Potentially Dangerous Therapies AND Other Variables THAT Produce Iatrogeny IN Psychotherapy PDF

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The American Associationof Psychiatry defines iatrogenesis as “a disorder caused, aggravated or induced by the attitude of a professional when examining, formulating or putting into practice a certain treatment on a patient...

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POTENTIALLY DANGEROUS THERAPIES AND OTHER VARIABLES THAT PRODUCE IATROGENY IN PSYCHOTHERAPY The American Association of Psychiatry defines iatrogenesis as “a disorder caused, aggravated or induced by the attitude of a professional when examining, formulating or putting into practice a certain treatment on a patient” (Edgerton & Campbell, p. 103, 1994, cited in Boisvert & Faust, 2002). In general, this phenomenon has been associated with the effects of a drug or other interventions related to the field of medicine, such as, for example, when people who do not have any disease are converted into potential patients of the system, or when professionals health workers inoculate patients with the idea that they are responsible for their health, generating guilt in those with some pathology (Ortiz and Ibáñez, 2011). However, iatrogenesis is a phenomenon that can also occur in other fields such as Psychology (Bergin, 1980; Hadley & Strupp, 1976; Lambert & Bergin, 1994; Mays & Franks, 1985; Mohr, 1995; Sachs, 1983 cited in Boisvert & Faust, 2002). Although attempts to promote health, human well-being and human rights are inherent in all health professionals, including psychologists, harm or iatrogenesis may also occur in the field of psychotherapy (Walsh, 1988). In this way, the phenomenon of iatrogenesis in psychotherapy can be generated by the use of what authors such as Lilienfeld (2007) call potentially dangerous therapies, these being considered as “those that produce direct (psychological or physical) damage on patients or on third parties ”(Lilienfeld, 2007), as well as by the presence of other variables that surround an empirically validated psychological treatment. Carrying out a bibliographic review on this topic is relevant to the extent that there are studies that show that at least 10% of patients who receive therapy suffer some type of iatrogenic effect during it (Mohr, 1995, cited in Lilienfeld, 2007; Lambert & Bergin, 1994; Mohr, 1995, cited in Boisvert & Faust, 2002) and worsens after receiving psychotherapy (Hadley & Strupp, 1976, cited in Crown, 1983; Ortiz & Ibáñez, 2011). In the context of substance use, the iatrogenic effects are somewhat greater In the same way, Lilienfeld (2007) points out that, during 1990, 25% of psychotherapists used two or more memory retrieval techniques (hypnosis, guided imagery techniques ...) in order to reveal the sexual abuse suffered

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in childhood, when not all patients had had such an experience. For the Therefore, a motivation for the detection and knowledge of potentially dangerous therapies, as well as other variables that can generate harmful effects in psychotherapy, lies in reducing these percentages as soon as possible. In addition, Lilienfeld (2007) argues that detecting potentially dangerous therapies in time is especially important for several reasons: not to use them with patients, to inform people about those treatments that they should abandon, if they are involved in any, or to warn about those psychotherapies that they should always avoid. The importance of studying other variables that can generate iatrogenesis in psychotherapy lies in the fact that, on occasions, it is not the psychotherapeutic orientation or the treatment as such that generates damage in the patients, but variables related to the professional himself, the person who attends therapy or an interrelation of both (Lilienfeld, 2007), elements whose knowledge can help to avoid these foreign variables that destroy a treatment. Similarly, the importance of addressing this issue is that the APA has not yet been able to specify the specific evidence or indicators that make psychotherapy potentially harmful, despite the concern about the possible harmful effects that may arise from some treatments have spread among psychology professionals (Mash & Hunsley, 1993, cited in Lilienfeld, 2007). Finally, it is important to bear in mind that, although the objective of any psychological treatment is to increase the benefits and reduce the harm as much as possible, the fact of completely eliminating the negative effects that may arise in a psychological treatment is a utopia (Boisvert & Faust, 2002), since all treatment, even if it is effective, generates both curative and unwanted effects (Crown, 1983). 1. Differences between the iatrogenesis produced by potentially dangerous therapies and the negative effects generated by other variables in psychotherapy. A potentially dangerous therapy is what Lilienfeld (2007) considers as such: “those that produce direct harmful effects (psychological or physical) on a patient and / or third parties and whose harmful effects are so long-lasting that they cannot be

considered one mere exacerbation of symptoms during treatment ”(Lilienfeld, 2007). In this way, the author excludes other forms of damage whose origin is also in the use of a certain treatment (for example, the loss of time that is generated in a patient who is not being treated in the most appropriate way for his problem. ) (Lilienfeld, 2002, cited in Lilienfeld, 2007). Potentially dangerous therapies are treatments without proven scientific evidence (Lilienfeld, 2002, cited in Lilienfeld, Lynn & Lohr, 2015), whose mere application on people is known to generate, with greater or lesser capacity, a detrimental effect on them. To a lesser extent, Lilienfeld (2007) considers potentially dangerous therapies those empirically validated treatments that cause psychological or physical damage to a minority of patients. The damage that comes from potentially dangerous therapies is produced by the use of these treatments, and regardless of the presence or absence of other characteristics that surround the therapy that could also cause negative effects on patients. However, the phenomenon of iatrogenesis in psychotherapy is very extensive and complex to address. In this way, the damage produced by the therapy can also originate in treatments considered innocuous, that is, those whose effects are neutral and that produce indirect damages, such as opportunity costs, since, when chosen as the first option for the problem presented by the patient, do not allow the person to be treated in a more appropriate way (Lilienfeld, 2007). Furthermore, the use of empirically validated therapies can generate an iatrogenic effect when a certain technique is wrongly applied or chosen. In its extreme form, the Dodo bird paradigm consists in affirming that the therapeutic modalities (CognitiveBehavioral, Psychodynamic ...) chosen by professionals to treat patients are similar in efficacy (Wampold, Mondin, Moody, Stich, Benson & Ahn , 1997, cited in Lilienfeld, 2007), since the variability of the results in psychotherapy depends mainly on the variables of the therapist (empathy), patient variables or the interaction of both in the therapeutic relationship (Wampold, 2001, cited in Lilienfeld, 2007). Currently, there is knowledge that there are therapies that are more efficient than others for certain problems (Chambless & Ollendick, 2001; Hunsley & DiGuilio, 2002 cited in Lilienfeld, 2007), and that choosing as the first option a therapy that is not the most effective for the problems presented by the patient can generate iatrogenic effects. For example, using insight therapy to

A specific phobia, when gradual exposure or flooding is shown to be more effective, can lead to unnecessary anxiety states over time (Lilienfeld, 2007). On the other hand, the negative effects can also be produced by other variables that surround the treatment and that contribute to making it an iatrogenic experience for the patient (Parry, Crawford & Duggan, 2016), without the damage being necessarily due to the therapy or applied technique. Thus, variables that belong to the therapist, such as destroying the therapeutic relationship by negatively evaluating some aspect of the patient (Campell, 1992, cited in Boisvert & & Faust, 2002) or presenting difficulties in accepting that it is the treatment that is causing a worsening in the person (Bazilian, 1993, cited in Boisvert & Faust, 2002), among others, can generate iatrogenesis. Also, other variables belonging to the patient, for example, anchoring in the “sick role” to obtain care and attention (Ortiz & Ibáñez, 2011), or the interrelation of the therapist's variables with those of the patient, that is, those that belong to the therapeutic relationship, they can generate negative effects on the person. It is important to point out that the previous variables that contribute to generating an iatrogenic experience in treatment are manifested, above all, in contexts where the applied therapy is empirically validated, that is, in situations where the damage produced on the patient is not due to the treatment employed but to the presence of any of these variables during therapy (Lilienfeld, 2007). The iatrogenic effects that may result from the presence of one or more of these variables and, at the same time, the use of a therapy considered potentially dangerous, still needs to be investigated in greater depth (Lilienfeld, 2007), probably due to the difficulty in discriminating what produced the damage on the patient, if the iatrogenic therapy or the presence of any of these other variables in the treatment. Finally, it is important to add that the negative effects that may arise from the choice of a harmless therapy will not be included in the work, since, to cause harm to a patient is to harm him psychologically or physically, while performing a therapy with neutral effects is “ not solve the problem ”, but without necessarily making it worse in all cases (Dimidjian & Hollon, 2010). Nor will the iatrogenic effects that may arise from poorly selected empirically validated techniques be taken into account, since this would imply making a comparison between

efficacy of the different existing psychotherapies, moving the present work away from its main objectives (Lilienfeld, 2007).

2. Methodological difficulties in detecting potentially dangerous therapies and reasons for their existence. The methodological difficulties that complicate the detection of potentially dangerous therapies are multiple, which is why, in this work, only a compilation of what some authors consider as obstacles to locating iatrogenic treatments is offered, obstacles that, in turn, can function as an explanation for the maintenance of the use of this type of therapy. In this way, some problems to detect this type of therapy are: 1) Study deficit: There is no body or institution that studies or regulates the harmful effects that certain therapies can produce, which makes professionals responsible for personally monitoring their work (Ortiz & Ibáñez, 2011). As a consequence, a growing minority of clinicians prefer to base their therapies and practices on their clinical experience and subjective intuition, rather than on evidence from controlled trial studies (Lilienfeld, Lynn & Lohr, 2015), as many of them are skeptical about the need for evidence-based practice (Baker et al. 2008, cited in Lilienfeld, Lynn & Lohr, 2015). The devaluation of scientific evidence probably has negative effects on clients (Grove & Meehl, 1996, cited in Lilienfeld, Lynn & Lohr, 2015). 2) Question of data and percentages: Numerous studies only compare the data of people who finished treatment and do not take into account those who left or resigned it (Ortiz & Ibañez, 2011), so the reasons that led these people to abandon therapy are unknown. The reasons that prompted some people to give up treatment may be related to something about it that was harmful. In addition, probably among these people are young people or children who have suffered harmful effects during therapy and, as they are not asked directly about it, the corresponding data remain uncollected (Parry, Crawford & Duggan, 2016).

On the other hand, the percentages of the results on the harmful effects of a psychotherapy are not clearly established, since in some cases the harm is overestimated and in others it is underestimated (Lilienfeld, 2007). The harm that results from psychotherapy can be overestimated when people whose worsening is not related to the applied psychotherapy are included in the data, that is, these clients could have worsened even without treatment, and underestimated when those patients are included in the figures that improved with the treatment, but whose improvement would have been greater if the therapy had not been applied (Lilienfeld, 2007). In these cases, the therapy would produce damage by slowing down the natural improvement capacity in patients (Lilienfeld, 2007). 3) The difference in evidence between Potentially Dangerous Therapies: Like the therapies considered effective, the evidence provided by studies on treatments considered iatrogenic is different depending on the type of research carried out. Thus, the clearest evidence that a therapy is harmful would be that which comes from randomized controlled trials, followed by quasi-experimental studies that make comparisons between groups and, finally, that which comes from natural designs or multiple case reports (Ghaemi & Hsu , 2005, cited in Lilienfeld, 2007). 4) Ethics as a decisive factor for the abandonment of the detection of Potentially Dangerous Therapies: Another methodological problem is that, for the detection of the harmful effects of a potentially dangerous therapy to be correct, it is necessary to repeat it by independent researchers, with the aim of verifying whether they obtain the same results in different populations, and thus reduce the possibility that iatrogenic effects are due to chance (Lilienfeld, 2007). This situation leads to numerous ethical controversies, since professional ethics, of course, rejects the replication of studies of therapies that have been found to be potentially harmful to patients in previous research. According to Lilienfeld (2007), this situation leads us to a dead end loop, since, by not replicating the possible harmful effects of a therapy, Professionals lack the necessary knowledge to identify and intervene at the first signs of iatrogenic effects. In the same way, given the lack of knowledge about iatrogenic effects in therapy, in the field of research, those whose results during a treatment are positive are published, but not what is negative or could not be confirmed (Lilienfeld, 2007) .

5) The cost-benefit controversy: Sometimes it can happen that, as a result of the application of a specific therapy, certain symptoms improve and others worsen, making it difficult to determine the extent of the iatrogenic effect of certain therapies. According to Lilienfeld (2007), the professional who is in this situation should assess the costs and benefits of the treatment and deliberate together with the patient about the risks that may arise, even accepting the client's preferences with priority over scientific evidence ( APA, 2006, cited in Lilienfeld, 2007). 6) The broad meaning of the word therapeutic harm: Another difficulty in detecting or studying what is considered potentially dangerous therapy is the breadth in the meaning of the word therapeutic harm. In a psychotherapeutic treatment there are numerous ways of being damaged (generation of new symptoms, worsening of existing ones, among others) (Boisvert, 2003, cited in Lilienfeld, 2007); there are even psychological therapies that inflict physical harm (Mercer, Sarner & Rosa, 2003, cited in Lilienfeld, 2007). In addition, some authors suggest that a significant episode that occurs during or after treatment (for example, suicide, attempted suicide ...) and that is directly caused by the treatment could also be considered as damage (Parry, Crawford & Duggan, 2016) , which does not favor the unification of what is understood to be damaged within a therapy and increases the difficulty of detecting potentially dangerous therapies. 7) Damage to third parties: There are psychotherapeutic treatments that, being neutral for the patient or even positive, become harmful to third parties with whom he is related (Lilienfeld, 2007). For example, if an individual therapy is effective but causes harm to the partner of the subject who comes to therapy, should this therapy be considered potentially dangerous? As can be seen, this fact further complicates the establishment of a defined group of therapies that can be potentially dangerous (Lilienfeld, 2007). 8) The temporary problem in symptoms and pathologies: There are therapies that, being effective in the long term, temporarily exacerbate the magnitude of symptoms in the short term. For example, between 10% and 20% of patients with PTSD have an increase in

symptoms at the beginning of the exposure treatment, although, later, they will improve at the same speed as the people who did not present this increase (Foa, Zoellner, Feeny, Hembree, & Alvarez-Conrad, 2002; Tarrier et al., 1999 cited in Lilienfeld, 2007), and they will not present a greater deterioration than the rest of patients (Foa et al, 2002 cited in Dimidjian & Hollon, 2010). This methodological difficulty in detecting potentially dangerous therapies opens the door to the possibility that a therapy is iatrogenic for the patient, since when a therapy is really failing, the professional could use the excuse that the worsening is temporary and continue to use this treatment with harmful effects on patients. Conversely, a therapist could quickly abandon a treatment that is effective in the long term, but that in the short term is exacerbating the symptoms, which would also generate negative effects on the patient; For example, there are patients diagnosed with certain personality disorders who have never experienced anxiety and who begin to feel dysphoric emotions for the first time in treatment, which could be a sign that psychotherapy is helping them to enter into contact with their emotions (Crown, 1983). Some authors propose that the difference between an effective therapy that temporarily exacerbates symptoms and one that is harmful to patients lies in the amount of time the patient suffers from these negative symptoms (Crown, 1983). On the other hand, the question of time limits is related to the pathologies themselves; Thus, in those that remain constant over time, it is easy to detect the iatrogenic effects of a therapy, since the patient is worse than at the beginning, and any change in the pathology can be attributed to the therapy (Dimidjian & Hollon, 2010) . The problem occurs when these pathologies, naturally, tend to worsen or improve, since, then, it would be necessary to determine if the worsening is due to a natural process independent of the therapy or, on the contrary, the patient is worse that if he had not received treatment, and, therefore, the deterioration could be due to the applied psychotherapy (Dimidjian & Hollon, 2010). Sometimes, 9) Professional malpractice: There are empirically validated therapies, that is, adequate and effective for patients, which can be converted into therapies

potentially dangerous if the technique is applied wrongly (Shipley & Boudewyns, 1980; Stone & Borkovec, 1975 cited in Lilienfeld, 2007); Although this is not a methodological difficulty as such for the detection of iatrogenic therapies, it could be to the extent that malpractice or professional incompetence are not considered as an iatrogenic factor in a therapy (Dimidjian & Hollon, 2010). 10) The overgeneralization of therapeutic effectiveness: The paradigm of the Dodo bird, in its extreme form, consists in affirming that the therapeutic orientation (cognitive-behavioral, humanistic ...) is irrelevant, since the therapeutic results depend exclusively on the variables of the therapist, the patient and the therapeutic relationship (Wampold , 2001, cited in Lilienfeld, 2007), to the point that some professionals argue that making a list of empirically proven therapies is unnecessary because they all work correctly (Lundeen, 2005, cited in Lilienfeld, 2007), which may favor the continuation of the existence and proliferation of highly harmful therapies for patients. 11) The overestimation of therapeutic effects: Some potentially dangerous therapies may seem effective, since many professionals overestimate the prevalence of the appearance of negative effects if patie...