THE ROUGH GUIDE TO PSYCHOLOGYcaused problems and tries to identify hot thoughts that precipitated
discomfort. An example might be a man with a social anxiety about
parties, who tends to think that everyone at the party is looking at him
or thinks he’s boring. The therapist will then help him question the
grounds for these thoughts and find new ways of seeing things in a more
positive light. Is it really his responsibility to be entertaining? Would the
person who asked for his phone number have done so if they thought
him boring? And so on. The therapist might also encourage the client to
try to shift his thinking and attentional focus – for example by consid-
ering more what he thinks of the other guests, rather than what they may
or may not think about him.
By the 1990s, behavioural and cognitive therapies were being routinely
merged to form Cognitive Behavioural Therapy, frequently abbreviated
When therapy causes harm
Finding out whether a treatment has caused harm is a methodological
minefield. If a client deteriorates, it doesn’t mean the therapy was
to blame – decline may have happened further and faster without
therapy. Similarly, improvement isn’t necessarily a sign that therapy
hasn’t been harmful because the client could have recovered more
quickly or smoothly without therapy. Whatever the reason, most
experts agree that five to ten percent of clients get worse after
therapy. Some approaches are more suspect than others, and Scott
Lilienfeld, a professor of psychology at Emory University, has called
for a list of potentially harmful therapies to be drawn up – a kind of
negative complement to the list of empirically supported treatments.
Candidates for the harmful list, according to Lilienfeld, represent the
“dark underbelly” of psychotherapy and include recovered-memory
techniques, boot camps for conduct disorder, and critical incident
stress debriefing.
One way that therapeutic harm can be averted is for clients to
fill out questionnaires after each session. The psychologist Michael
Lambert at Brigham Young University is a pioneer in this area. He sees
providing feedback on a session by session basis as the equivalent
to a medical doctor checking a patient’s blood pressure: “It’s simply
a mental health vital sign – it says whether it’s going in the right
direction or not.” This is important not least because clients who fare
worse than average in early sessions are at particular risk of ending
therapy in a deteriorated state (whereas early progress shown by
clients tends to be maintained). Raising the alarm about clients who
are off-track can cue the therapist to change tack or intensity, and get
the client back on course.