: lol wait, you think psychotherapy is bad?

salixj asked something similar:

I don’t think psychotherapy is bad, I think it can be bad. In certain conditions, psychotherapy is harmful. Some form of psychotherapy are harmful and other are more likely to be harmful. A form of psychotherapy could produce a positive effect on a problem/disorder, but negative on others. Some kind of therapeutic relationships could be detrimental for some people. It’s quite a complex subject really.

My opinion is that psychotherapy is more likely to produce a negative effect when the therapist thinks the theory he embraces/the methods he uses is the best. When a psychoanalist (or CBT therapist or any kind of therapist) think psychoanalysis (or CBT or any other form of therapy) is the best of all, the probability of something going wrong increases a lot.

Let me give a simple example.

Critical Incident Stress Debriefing is a form of psychotherapy designed to prevent PTSD and related anxiety disorders among individuals exposed to extreme stressors. It’s administered in group within 24 to 72 hr of the traumatic event. The therapist talks about  the PTSD symptoms that the group members are eventually going to experience and encourage them to discuss and ‘‘process’’ their negative emotions. This is based on the assumption that to talk about the stressful experience and the associated emotions is good for you and it will prevent you to experience mental health problems.

That’s not true. The fact is, research shows the CISD can heighten risk for posttraumatic stress. So basically CISD produce the exact effect it is supposed to prevent. 

There are several reasons to why that could happen (for example, many people could be not ready to discuss their emotions, talk about your emotions is not always good.) But the main reason is that this program are thought to be useful to every person who had an extremely stressful experience because they’re expected to be more at risk, more in need for help, and when you’re stressed what’s better than talking about how you feel? Right?

No. Not always. Not for everyone.

So, the topic is complex and I don’t think I can explain it in details on tumblr, but, yes, psychotherapy can be bad. It’s not always bad. I think it can be very useful, really. But it can also be bad. That’s the truth.

Dangerous Confessions: violence in psychotherapy between reality and fantasy.

Dealing with anger and potentially violent behavior is certainly not easy. Even for psychotherapists managing the emergence of aggressive emotions or behaviour during a consultation may be difficult: the risk is that if such emotions are not recognized or adequately addressed, can have serious consequences. The fear of violence seems to be common among psychologists (Pope & Tabachnick, 1993), what’s very common: the fear that the client could attack them, that client could attack someone else, or that client could be attacked by someone else. Equally common is that psychologists feel angry about the behavior of the client towards someone else. Slightly less than 20% of the psychologists said he was assaulted by a client. About 60% of psychologists reported that a client has attacked someone else. Such behaviors frequently trigger psychologists’ fantasy of being attacked, and produce a series of reactions: from telling the client they’re scared, to report the thing to the police, to obtain a weapon for self-defence, to actually use the weapon (0.4 % of psychologists surveyed by Pope and Tabachnick).
According to Gately and Stabb (2005) between 35 and 40% of psychologists run the risk of being attacked by a client. through the examination of literature, and the conducting of a direct survey, they have suggested that mental health professionals do not feel equipped to deal with violent behavior by client. In their research 26% of psychologists in their sample had been verbally assaulted, and 10% physically assaulted.

Based on these data, Walfish, Barnett, Marly and Zielke (2010), conducted a study, interviewing a sample of 162 psychotherapists.

The results show that it is quite common in the career of a psychotherapist to have a client who confess to have: physically attacked someone (69%), or sexually assaulted someone (33%).

Although not common, it is not infrequent that a psychotherapist has had a client self-disclose to them during a session that he or she had murdered someone. In this sample a large majority, 135 (83%) indicated that they had never had this happen in their consultation room. However, 21 (13%) indicated that this had occurred at least once (4% did not respond to the survey question). Of these 21 clinicians, 12 indicated that they had only heard this once during their career, 4 had heard this twice, 3 had heard this four times, 1 had heard this six times, and 1 estimated having heard this from 15 different clients. Of these 21 psychologists only 5 had been told about the mur- der in the context of a forensic evaluation.

In addition to these data, 64.2% of therapists said they did not feel adequately prepared to deal with these confessions of violence.

The authors, comparing their results with those of Pope and Tabachnick (1993) who reported that as 9 out of 10 psychotherapists were afraid that a client could attack someone, reflected that this might be a realistic fear, at least regarding physical aggression.

Echoing the conclusions of several studies Walfish and his colleagues emphasize the importance of the way in which the therapist responds to the experience of the confession of violent acts by a client. They note that in their investigation, psychotherapists are equally split between those who argue that the revelation of the violence has had a negative effect on therapy and those who believed to have had a positive effect.
While it is certainly possible that counter-transference reactions by the therapist influence the assessment of the negativity of the event,  it’s also been proposed a model in which is proposed that client can benefit more from therapy, by keeping secrets (Kelly, 2000). The hypothesis is that revealing information that  the therapist could disapprove might help constructing an unwanted self-image.
The authors conclude that further research should investigate the reason that leads some therapists to consider these confessions negative for therapy, and others not.

The reaction of a psychotherapist dealing with a patient who admits violent acts can trigger powerful counter-transferal reactions, which if not managed will certainly have a negative effect on treatment. The authors wonder if the fear of the clinicians in these situations, is more or less realistic. Data from several studies (Tyron, 1986; Barnstein 1981, Gately & Stabb, 2005) suggest that the risks should not be underestimated. Not always the fear of psychotherapists is a counter-transferal reaction due to unresolved conflicts.

The authors conclude that although psychotherapists in the consultation room must be prepared to hear any type of material, whether  is it nice or not, and  even if this may also inclued unprosecuted violent crimes, they must still pay attention to three factors: their emotional reaction to this information, their need for security, and their ethical and legal obligations *.

This research highlights a particularly complex issue which might arise in clinical practice, but I believe that focusing on the therapist (how he reacts, what he should do), leaves aside the possibility that these confessed violent acts could be not real.

When Freud began the practice of psychoanalysis, initially he theorized that the cause of neurosis, was the experience of a childhood seduction, because he regularly heard that in the stories of his patients. Later, however, he diverged from this assumption, suggesting that the stories of childhood seduction were in fact the expression of unconscious fantasies of the patient.

Thus, the data from this research suggest at least some doubts: how likely is it that 33% of those who go in psychotherapy has committed a sexual assault that was not pursued by police? How likely is it that 13% of those who go in therapy has committed a murder for which he was not prosecuted? If it is possible to generalize the results of the study, we are talking about quite large numbers.

Without taking a definite position, it seems nevertheless useful to recall that the distinction between fantasy and reality in psychotherapy is at least problematic; psychotherapists, in front of a confession like that, rather than reacting as if it was immediately clear, obvious, that this is a true story, that is an unpunished crime, maybe they should carefully reflect on the meaning that the confession has as a communication in the context of therapy.

* The article by Walfish and his colleagues also contains a long close examination of the legal/ethics issues on the subject, since the law is different in the U.S. and in Italy I have not thought of bringing that part of the discussion.

[ Walfish, S., Barnet, J., Marlyere, K., & Zielke, R. (2010). “Doc, There’s Something I Have To Tell You”: Patient Disclosure To Their Psychotherapist of Unprosecuted Murder and Other Violence.  Ethics & Behaviour, 20 (5),  311-323. ]

[Italian Version]

This morning I was trying to imagine what  book I can read that can help me on my thesis. I’m writing about iatrogenic effects in psychotherapy, but for now I think I should better understand the process of psychotherapy in general. So I was searching for some influential book on this topic. I found an article “INFLUENTIAL PSYCHOTHERAPY FIGURES, AUTHORS, AND BOOKS: AN INTERNET SURVEY OF OVER 2,000 PSYCHOTHERAPISTS” that seems to have at least some answer to my questions. I want to share the list I found on this article:

Responses to the question: "Of all the prominent figures in the field of psychotherapy over the past 25 years, who are the contributors who have most influ- enced the way you practice today? Please list up to five"

Responses to the question : "What are the best psychother- apy books that you have read in the past 3 years? List up to five."

Now, I have to say that I have not read any of these books, and probably they are not right for the topic I’m studying at this moment, but, they may be of interest someone of my followers.

I want to share the books I’m actually reading right now: