Training Implications of Harmful Effects of Psychological Treatments
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Training Implications of Harmful Effects of Psychological Treatments Louis G. Castonguay and James F. Boswell Pennsylvania State University Michael J. Constantino University of Massachusetts at Amherst Marvin R. Goldfried Stony Brook University Clara E. Hill University of Maryland The goal of this article is to delineate training implications first systematic analysis of psychotherapy deterioration regarding harmful effects associated with psychotherapy. (Bergin, 1966; see also Lambert, Gurman, & Richards, in The authors strongly recommend that trainees be made press). Subsequently, several landmark publications have aware of (and encouraged to examine carefully) the poten- alerted the field to negative outcomes across different psy- tially harmful treatments that have been recently identified chotherapy approaches and diverse clinical populations (Lilienfeld, 2007). Consistent with a broad perspective on (e.g., Foa & Emmelkamp, 1983; Mays & Franks, 1985; evidence-based practice, it is also argued that additional Strupp, Hadley, & Gomez-Schwartz, 1977). More recently, guidelines for the prevention and repair of harmful impacts the potentially deleterious effect of psychotherapy has re- can be derived from psychotherapy research on process ceived renewed attention as a neglected but crucial aspect (technique and relationship) and participant (client and of evidence-based practice in psychology (Lilienfeld, therapist) variables. For example, rigid adherence to the 2007). Although the field has devoted considerable energy application of psychotherapy techniques can be a poten- to identifying empirically supported therapies (ESTs; tially harmful therapist behavior that necessitates careful Chambless & Hollon, 1998; Chambless & Ollendick, training on the nature and flexible use of interventions. 2001), Lilienfeld has cogently argued that more urgent Furthermore, the authors suggest that trainers and super- attention needs to be paid to identifying potentially harmful visors tentatively consider training implications linked to treatments (PHTs). clinical observations and theoretical assertions, such as However painful it may be, it is important for those of the premature use of clinical interpretations, with the as- us who are psychotherapists to recognize that we have all sumption that more confidence in such therapeutic guide- likely harmed one or more of our clients. To the extent that lines can be gained when they are supported by multiple a harmful effect in psychotherapy includes either a decel- knowledge sources (empirical, clinical, conceptual). Fi- erated rate of improvement that is the direct effect of the nally, training implications related to the monitoring of treatment or an opportunity cost reflected in participating in harmful effects in terms of treatment outcome and process an unhelpful or protracted versus a helpful and parsimoni- are demarcated. ous treatment (Lilienfeld, 2002, 2007), we would venture Keywords: training, psychotherapy, harmful effects to guess that all experienced psychotherapists have, at one point or another in their careers, failed to meet the most here is clear evidence that psychotherapy works. basic and ethically important principle guiding the profes- Research has demonstrated that individuals with var- sion: First, do no harm (American Psychological Associa- ious clinical problems will, on average, benefit more tion, 2002). T Considering the challenge and complexity of clinical from psychotherapy than from no treatment or a psycho- logical control treatment (Cooper, 2008; Lambert & Ogles, problems and the psychotherapy process, psychotherapists’ 2004). However, there is also evidence that some clients isolated missteps in clinical strategy and/or a momentary fail to benefit from psychotherapy and that some (approx- lack of attunement to a client’s needs are unavoidable. imately 5–10%) actually deteriorate during treatment However, what might be preventable—or at least attenu- (Lambert & Ogles, 2004). This deterioration rate is even ated—are systematic sources of harmful effects. Put differ- higher (approximately 10–15%) in substance abuse work ently, the fields of clinical and counseling psychology need (Lilienfeld, 2007). Although psychotherapists tend to underestimate the Louis G. Castonguay and James F. Boswell, Department of Psychology, occurrence of negative treatment outcomes (Boisvert & Pennsylvania State University; Michael J. Constantino, Department of Faust, 2006), deterioration in psychotherapy has long been Psychology, University of Massachusetts at Amherst; Marvin R. Gold- recognized as an alarming clinical reality. For example, fried, Psychology Department, Stony Brook University; Clara E. Hill, Department of Psychology, University of Maryland. Allen Bergin, who ironically provided one of the most Correspondence concerning this article should be addressed to Louis convincing rebuttals to Eysenck’s (1952) challenge of psy- G. Castonguay, 308 Moore, Department of Psychology, Pennsylvania chotherapy’s effectiveness (Bergin, 1971), also offered the State University, University Park, PA 16802. E-mail: [email protected] 34 January 2010 ● American Psychologist © 2010 American Psychological Association 0003-066X/10/$12.00 Vol. 65, No. 1, 34–49 DOI: 10.1037/a0017330 and/or have received empirical support) and clinical obser- vations (particularly if repeated over numerous occasions and contexts) may, at a minimum, alert psychotherapists to possible detrimental events and processes. Of course, con- fidence in the predictive ability of any training guideline would be increased if support was found across more than one knowledge source. Presently, we propose two clusters of clinical training guidelines. The first directly addresses the implementation of psychotherapy and the second focuses on the identifica- tion of harmful effects in psychotherapy. Needless to say, some of our proposed guidelines are already included in good training practices. We argue, however, that the more that these guidelines are integrated explicitly and system- atically across different phases of therapists’ training, the more likely it will be that training programs will produce psychotherapists who are effective in preventing harm and promoting therapeutic change. We also hasten to add that providing a comprehensive and detailed list of training guidelines pertaining to harmful Louis G. effects is beyond the scope of this article. Instead, our Castonguay intention is to raise trainers’ consciousness about the re- sponsibility to monitor, address, and ultimately prevent harmful effects and to convey that rich sources of empiri- cal, conceptual, and clinical knowledge can be tapped to to devote substantial attention to the factors that (across assist trainers in meeting this responsibility. Providing an numerous occasions and various situations) appear to en- exhaustive list of training guidelines, as well as suggesting hance the risk of or contribute directly to stagnation and new directions for their refinement, should be an evolving deterioration in psychotherapy. We also argue that an ex- and central focus in the field. plicit emphasis on such factors should occur at the very first step in the professional career of clinical and counseling Training Guidelines for the psychologists. Thus, we believe that one of the mandates of Implementation of Psychotherapy graduate training in clinical and counseling psychology The unavoidable reality that harm occurs in psychological should be to raise awareness of and to prevent, to the extent treatments should force graduate programs in clinical and possible, predictable sources of harm in psychotherapy. counseling psychology to recognize the need to train stu- Our goal in this article is to present what we view as dents not only about what to do but also about what not to central implications for psychotherapy training derived do in psychotherapy. Fortunately, research can help guide from the extant literature on potentially harmful effects in this imperative training mission. psychotherapy. These implications are not restricted to Empirical Guidelines PHTs. Inasmuch as ESTs should not be viewed as the exclusive source of evidence-based practices (see APA Outcome findings. By establishing and pub- Presidential Task Force on Evidence-Based Practice, lishing a list of empirically based PHTs, Lilienfeld (2007) 2006), one should recognize that specific techniques, rela- provided an invaluable service to the field. Similar to ESTs tionship factors, and participant characteristics and the in- (and, for that matter, the empirically supported therapy teractions among them can interfere with change or pro- relationships; see Norcross, 2002), students should be ex- mote harm. In fact, we focus on several variables that posed to the PHT list and kept abreast of its modification or Lilienfeld (2007) identified as potential contributors to expansion. Whereas ESTs might provide clinicians with a harmful effects; thus, the implications we advance in this first line of intervention for some specifically defined dis- article can be viewed as a set of complementary guidelines orders (e.g., when working with clients with generalized to PHTs with the common goal of preventing or repairing anxiety disorder, especially those without major interper- negative outcomes. Considering the current knowledge sonal problems, it is indicated to use cognitive–behavioral base regarding psychotherapy change processes, we also therapy; Newman, Castonguay, Borkovec, & Molnar, believe that training implications and guidelines