Abstract
Berk and Parkers’ article ‘The elephant on the couch: side-effects of psychotherapy’ is a timely and much needed acknowledgement of the need to remember the hallowed medical rule primum non nocere [1]. All clinicians need to acknowledge that any treatment that has the capacity to greatly help the patient can also in equal measure have the potential to cause harm. One cannot acknowledge one without the other and so it is welcome that psychotherapy is openly described as helpful and efficacious. I am assuming that the term ‘psychotherapy’, as used by the authors, refers to dynamically informed treatments unless specifically noted otherwise.
The article, however, fails to make a vital distinction: that of differentiating the effects of a treatment that would occur regardless of the practitioner involved, from the impact of the individual clinician and their idiosyncrasies, upon the patients. Most of the effects of therapy described are implied to be the result of the former, while they are really under the rubric of the latter. A marked example is the category of sexual exploration of patients, including a description of a sexually predatory therapist. Rank abuse is just that, not a side-effect of psychotherapy. We would not after all consider a patient being touched sexually in the course of an operation as a side-effect of the surgery, but as a result of the surgeon's own disturbance.
Psychotherapy, whatever the orientation, is not suitable for all patients regardless of their condition and personality. This has been clearly recognized by Roth and Fonagy in ‘What works for whom’ [2]. Inappropriate matching of patient, therapist and therapy will only lead to disappointment and frustration for all concerned, but some difficulties are to be expected. Worsening of some symptoms during the course of the therapy is considered normal for deeper change to occur. Similarly, if the patient carries within them part of their parents’ unacknowledged difficulties, getting better for the patient can mean a family member getting worse.
It is not only for researchers to consider the effect of the therapist upon the patient, but for us as a profession and for the clinicians themselves. The side-effects described by Berk and Parker are caused by human factors, not an external agency such as the pharmaceutical substance. Poor assessment of the patient's suitability for specific treatment, inadequate technique, lack of understanding of the patient's experience of the therapist and collusion with parasitic wishes for excess dependency on the part of the patient, are not intrinsic to psychotherapy as a physical symptom is to a drug. They are deficiencies that can be addressed.
First, there needs to be adequate training of psychiatrists in psychotherapy, the ‘efficacious cornerstone of current practice’. More importantly, there also needs to be a recognition for all clinicians who see patients over a period of time, whether this is psychotherapy of a supportive kind or other, of the imperative to seek other's counsel. This can be a peer group or a senior colleague. The scourge of omnipotence, the belief that we should be able to handle all patients regardless of difficulty purely on our own, is a high price to pay, as has been well documented by Berk and Parker.