Comments on Making things worse through treatment: Iatrogenic psychological interventions

Michael and Joye Anestis commented on 'Making things worse through treatment: Iatrogenic psychological interventions'

2009-12-27T03:08:00Z

James -

I completely agree here. I generally hesitate to post comments like the one to which you replied and, when I do, I make immediate comments in reply that raise issue with the complete lack of empirical support for the claims made by the author. Ultimately, I end up deciding that it makes the most sense to publish the comment and let other readers see this discussion play out civilly on the site so they can make their own informed decisions, but it can be a bit frustrating at times when certain types of comments are made that distort or ignore research.

- Mike Anestis

James Claiborn Ph.D. ABPP commented on 'Making things worse through treatment: Iatrogenic psychological interventions'

2009-12-23T01:59:52Z

Diane Do you have references for research showing that exposure therapy is having a traumatizing effect on adults with a history of multiple traumatic events as children?

While your claim of a clear difference in PTSD may have face validity what evidence is there that there is some important difference in the disorder or it's response to treatment.

Michael and Joye Anestis commented on 'Making things worse through treatment: Iatrogenic psychological interventions'

2009-10-28T15:07:24Z

Nobody is saying it's all the same - not sure where you're going with that. Our intention is to discuss the evidence and if there are specific studies you can cite that point towards iatrogenic effects of particular treatments for particular populations, we will gladly cover that information.

This article - a review of Lilienfeld's discussion of particular iatrogenic treatments - is simply meant to be a summary of a particular set of data. Although we can not cover everything in every article, we can gladly follow-up on articles with additional information.

- Mike Anestis

diane commented on 'Making things worse through treatment: Iatrogenic psychological interventions'

2009-10-28T15:02:58Z

Exposure therapy for what kind of PTSD? It is clearly different if you are a veteran of a war versus an incest survivor. There is research beginning to show that exposure therapy can have a more traumatizing effect on adults who endured multiple traumatic events as children. Please, be specific when discussing PTSD. It's not all the same.

Mike Anestis commented on 'Making things worse through treatment: Iatrogenic psychological interventions'

2009-04-26T19:26:20Z

The comment was definitely intended to be a bit snarky if nothing else. I wanted to make sure it was clear that, even though a lot of popular therapies are not on the list of treatments that cause harm, many of those therapeutic approaches are still completely ineffective (at least relative to treatments that have empirical support).

I think your thought on why those treatments cause harm is a really good one. In the future, we plan to write quite a bit about an approach known as "motivational interviewing" that has a lot of support. This approach is very successful at using the client's own intrinsic motivation rather than attempting to push them into a corner. As popular as it is the "look what you're doing to your family!!" approach simply does not lead to sustained gains.

Also, some of the boot camp and scared straight interventions cause harm through another route. It turns out that group treatment for conduct disorder - essentially the childhood precursor to antisocial personality disorder - ends up reinforcing antisocial behavior because group members encourage and learn from one another's behaviors. Another one of those approaches that seems intuitively appealing but completely backfires in real world settings.

Alicia commented on 'Making things worse through treatment: Iatrogenic psychological interventions'

2009-04-26T19:02:29Z

"It is important to remember that this is not simply a list of treatments that are not effective. That list would be much longer." Ha! I don't know if you meant for that to be funny, but it made me laugh out loud :)

You're right - I was surprised by some of these. Particularly, the Scared Straight interventions, boot-camp interventions, and DARE programs. As I look at those three, I see they're all kind of related in a "grab you by the throat and force you to recognize and deal with what's going on" kind of way. I'm wondering if this could be why these methods are sometimes harmful to some people?

Mike Anestis commented on 'Making things worse through treatment: Iatrogenic psychological interventions'

2009-04-15T14:52:13Z

@Mia -

I'm so sorry to hear that you're dealing with such a difficult situation. I can not speak directly about the techniques your therapist is using because I do not have enough information to make that type of evaluation and I can not offer therapy myself in my response, but I hope I can answer your questions in a way that will be helpful.

The diagnosis of PTSD requires that at least a month transpire between the traumatic event and the diagnosis. The reason for this is that it is actually quite normal for us to respond severely in the moments and days immediately following trauma. When our symptoms linger for a month or longer, however, the theory is that this represents a significant, less typical response that would benefit from treatment. "Critical incident debriefing," which Lilienfeld refers to in his article, involves attempting to intervene immediately after a traumatic event occurs. When therapists do this, they are interrupting a normal stress response and the evidence is that this actually increases individuals' vulnerability to PTSD. Some time needs to transpire between trauma and treatment in order to ensure that treatment is needed (with the exception being when individuals meet criteria for acute stress disorder, which is marked by frequent dissociation). An example of this was when kind-hearted but misguided individuals attempted to "treat" groups of individuals immediately after Hurricane Katrina, which resulted in the opposite of the desired effects.

When therapists use empirically supported treatments for PTSD, like prolonged exposure and cognitive processing therapy, therapy involves a fair amount of discomfort on the part of the client, but only in the short term. These therapies ask the client to restructure the way they think, examining the evidence for and against their beliefs and testing them through behavioral experiments. For instance, if an attack victim has the thought "all men will attack me," she will be asked to examine the evidence for and against that belief. Have all men attacked her? What percentage of her interactions with men have resulted in attacks? Are there specific cues that might signal impending attack? The idea is that, when we are experiencing anxiety or depression, we tend to have skewed, inaccurate thoughts that impact our emotions and behaviors. Revising these thoughts so they are more accurate will decrease our discomfort. The exposure part of these therapies often involves writing detailed accounts of the traumatic event repeatedly, in detail, and reading those accounts in session or actually exposing the client to photos, people, or situations that mirror the trauma so that the client can feel their anxiety come and go and learn that they do not need to have so much fear and that their fear does not last forever. This is obviously uncomfortable, but the reason for it is to help the client habituate to their fear so that the fear response will diminish. Here's a good way to think about "habituation:" If I were to come up behind you and clap my hands loudly, you would likely jump. If I did it again, you might jump again. If I keep doing it, however, you will quickly learn that this sound does not represent a threat and you will no longer experience the psychological and physical symptoms of anxiety. This same principle is applied very successfully in the treatment of anxiety disorders, including PTSD. It might be that your exposure sessions are ending too early - that you end the exercise before your anxiety diminishes. If that happens, you are likely to become more sensitized to the stimulus, not less fearful. It might be that you are exposing yourself to something that is too frightening. In exposure, you want to rank your fears - a fear hierarchy - and always expose yourself to stimuli that are moderately frightening, not overly frightening. You repeatedly expose yourself to such things until they are no longer fear inducing, at which point you move up the hierarchy (and what was once incredibly frightening will now only be moderately frightening). It also might be that the cognitive restructuring element is missing from your treatment. Alternatively, it might be that your therapist is doing everything perfectly and that you simply need more time.

A good way for you to determine this would be to read the following resources:

(1) Read our articles on PTSD. Craig Bryan's article on PTSD in primary care military populations would be particularly relevant. Just click on the PTSD link in the categories section on our page and you'll find the article.
(2) Read Lora Rose Hunter's article on cognitive behavioral group therapy for social anxiety disorder. It's a different treatment for a different condition, but it explains exposure very well and might help you understand the goals of treatment.
(3) Here is the website for APA Division 12's description of PTSD and the empirically supported treatments for PTSD:

http://www.psychology.sunysb.edu/eklonsky-/division12/disorders/ptsd_main.php

This will give you more information on what the best treatments are for PTSD.

(4) Go to our EST Clinics link. There are locations in your area that offer empirically supported treatment for PTSD. If it turns out that this is not what you are currently receiving (and I do not know if that is the case), this list will help you find a clinic that will get you what you need.

(5) If you are feeling like you are in danger, please call 1-800-273-TALK. This resource is free, anonymous, and available 24/7. I highly recommend it when you feel like you're in a moment of crisis.

Best of luck and please feel free to ask us more questions. Hope this helps.

Mia Robertson commented on 'Making things worse through treatment: Iatrogenic psychological interventions'

2009-04-15T14:09:04Z

I have PTSD- and I am so glad that you posted this! It makes me feel a lot less crazy. I've been going to weekly therapy for two months now, and everyday we talk about my experience. We go into the details of it, my reactions, the triggers I have now, and discuss how all these things relate. Being a lowly undergraduate (and not in the psych field) I'm not sure if that is "Critical incident debriefing", but it sure feels like it to me. I found this article while googling 'harmful psychotherapy'- a search induced by another up coming session that threatens to send me into a tailspin for days. The last two months have been the worst I've had in awhile: I'm back to 'night terrors' and more frequent panic episodes. Again, not being an expert, I'm not sure if this is the kind of thing the paper is talking about, but it seems to fit the criteria. Glad to know that my refrains of "this is isn't working! It's making it worse!" are (hopefully) not the self-serving delusion of an admitted avoider. Any recommendations for broaching this subject with my nice, otherwise sweet psychiatrist?

Joye Anestis commented on 'Making things worse through treatment: Iatrogenic psychological interventions'

2009-04-14T20:17:01Z

This is one of my favorite articles of all time. I make my undergraduate class read it every semester, and it always prompts lively discussion. Inevitably, students are incredulous that there is not governmental body regulating psychotherapy. Lilienfeld makes the point in the conclusion of this article that perhaps identifying harmful treatments is more important than identifying effective/efficacious treatments. I find this a very provocative statement that prompts much debate. Is it more important to know what hurts than what helps?