Are there any risks from engaging in psychotherapy?

Psychotherapy appears, on the surface, to be one of the most benign forms of medical therapies. There is no physical contact. No medications are prescribed. Only words are exchanged between people—nothing more.

However, never underestimate the power of words. There is a parable that may be recalled from childhood: "Sticks and stones may break my bones but names will never hurt me." Such a parable was created to provide comfort from the emotional wounds received from being called names. One would not need to recite such a parable if words did not hurt! Words carry power. Just as psychotherapy has the power to heal, it also has the power to harm. The harms vary from lack of progress to outright abuse. Most harm from psychotherapy comes from what are known as boundary violations between the therapist and the patient. The most obvious boundary violation stems from sexual or physical relationships that can develop between the therapist and patient. In many states this boundary violation is considered a criminal offense because the power differential between the patient and therapist is so great as to put the patient in a particularly vulnerable position.

Other boundary violations are not as obvious. Simple exchanges of personal information between the patient and therapist are often considered to be boundary violations and may or may not lead to more serious offenses on the part of the therapist. The potential dangers are that they may lead to friendly meetings that move beyond the office, and friendly meetings may turn more intimate. Although many patients may experience their therapists as friends, such feelings generated are known in therapy as transference. Transference[1] is an artificial relationship that the patient projects onto the therapist. In insight-oriented[2] or dynamic [3] (Freudian) psychotherapy, a transference relationship is intentionally created to allow the therapist to understand a patient's outside relationships better. This in turn allows the therapist to help a patient develop insight or greater understanding into the unconscious motives behind his or her relationships so that healthy interactions can be learned.

Therapists also develop transference relationships with their patients known as countertransference[4]. If the therapist is unaware of his or her countertransference, behavior toward patients reflects the therapist's own outside relationships. If such relationships are problematic, a patient may be made to feel that he or she is experiencing problems that are really the problems of the therapist. Patients often idolize their therapist, which makes patients particularly vulnerable to the influence of their therapist's words.

A notable example of the vulnerability patients can have in therapy occurred a few years ago when some cases were made public of patients believing through their therapists' suggestions that their parents sexually abused them. The process by which this occurred came about through the implantation of false memories on the part of their therapists. The therapists did not do this intentionally. However, in their zeal to associate certain symptoms that their patients presented with to a history of sexual abuse, they began to gradually convince their patients that they had repressed memories of abuse. Once they had convinced their patients of past abuse, false memories could easily be constructed by asking them to imagine being abused or by implanting false memories through hypnosis. "False memory syndrome" was coined, and several high-profile legal cases occurred in which patients sued their therapists for psychological damages as a result of the patients taking legal action against their parents based on their false memories.

How can one avoid such risks? One must rely primarily on referrals and word of mouth from friends as well as other professionals. Generally, one's primary care doctor has developed relationships with various therapists over the years and knows their work. Success in therapy is not dependent on the academic degree of the therapist as much as it is on the therapist's training and experience in treating patients. Secondarily, one needs to maintain an open mind to make changes if uncomfortable with a particular therapist, no matter how skilled he or she may be. Chemistry between patient and therapist is needed, and no amount of training provides that for any particular patient. Success in therapy depends on how one feels about the therapy sessions as well as the motivation from the therapist to "do the work" outside of therapy to make the changes needed.

  • [1] the unconscious assignment of feelings and attitudes to a therapist from previous important relationships in one's life (parents and siblings).The relationship follows the pattern of its prototype and can be either negative or positive. The transference relationship is a critical event for the progress of a patient in insight oriented or psycho-dynamic therapy.
  • [2] a form of psychotherapy that focuses on one's developmental history, interpersonal relationships with one's family of origin, and current relationships with friends, spouses, and others. Usually, such relationships are explored through the development of a transference relationship with one's therapist (see dynamic).
  • [3] referring to a type of therapy that focuses on one's interpersonal relationships, developmental experiences, and the transference relationship with his or her therapist. It is also known as insight oriented.
  • [4] the attitudes, opinions, and behaviors that a therapist attributes to his or her patient, not based on the true nature of the patient but rather the biased nature of the therapist because the patient reminds the therapist of his or her own past relationships.
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