The March 2021 special issue of Clinical Psychology: Science and Practiceopens in new window focuses on existing evidence for treatments that may harm patients and addresses methodological issues related to identifying such treatments. Guest editors Dean McKay and Amanda Jensen-Doss discuss key takeaways.
What is the special issue about?
The goal of treatment is always to improve a patient’s health, but some treatments may do more harm than good. When treatments cause harm, they are called “iatrogenic”. The articles in this special issue focus on discussing existing evidence for treatments that may harm patients, as well as addressing methodological issues related to identifying harmful treatments.
What is the significance of the issue?
While the field has made significant progress in identifying effective, evidence-based psychosocial treatments, much less attention has been paid to the fact that some psychosocial treatments can also lead to harm. Although several authors have written about the potential for harm, there is little empirical data to help patients and clinicians know which treatments could be harmful.
Articles in this issue provide data and narratives about the harm that can result from ineffective or unethical treatments. Several articles pull together information about what is known about iatrogenic treatments for specific problem areas. A common theme across all of the articles is that current research is limited and difficult to interpret. Many of the articles also suggest how the field can improve its ability to measure and document harmful effects of treatment and help keep patients safe.
How did the issue come about?
The idea for this issue came out of a meeting of the Coalition for the Advancement and Application of Psychological Science (CAAPS). CAAPS is an umbrella organization that provides an opportunity for organizations committed to clinical science to work collaboratively on shared goals. Representatives from several CAAPS member organizations collaborated on a proposal for the issue that was submitted to Clinical Psychology: Science and Practice. One adult-focused and one child-focused member of the group served as the editors for the section; other committee members assisted with article reviews and wrote the issue’s discussion piece. We were particularly fortunate to have Scott Lilienfeld on our team before his death in September 2020.
Tell us about a few key takeaways.
One important takeaway from these articles is the evidence that some psychosocial treatments are harmful. For example, efforts to change sexual orientation or eliminate same-sex attraction are associated with depression, relationship dysfunction, and increased homonegativity in patients. There is also evidence for iatrogenic effects from critical incident stress debriefing for individuals exposed to trauma and Scared Straight-type interventions for adolescents with conduct disorders.
Another takeaway is that we need better methods for identifying and understanding iatrogenic treatments. For example, extensive anecdotal evidence as well as theory indicate that some attachment-based treatments and some approaches to treating obsessive-compulsive disorder are harmful. However, randomized controlled trials have not documented those harms, and it is likely that other types of evidence also need to be brought to bear on this topic.
A final takeaway is that the field could adopt specific methods and reporting practices to improve the ability to document iatrogenic effects. For example, standardizing definitions of harms and burdens and adequately powering trials to identify both benefits and harm would help move the field forward.
What are some practical implications of the articles featured in the issue?
Clinicians, patients, and families should be aware of the potential for some psychosocial treatments to cause harm. Clinicians should avoid practices like efforts to change sexual orientation because data indicate that they are harmful, as well as contrary to the APA Code of Ethics. In other cases, clinicians should regularly monitor client outcomes and potential iatrogenic effects to identify when clients are worsening in treatment. There is reason to believe that even some common practices, such as hospitalization for suicidal behavior, can be iatrogenic for some individuals; an individualized approach to monitoring patients is needed.
One of the articles notes that published psychopharmacology studies are 9 to 20 times more likely to report data on potential negative events than psychotherapy studies. Treatment researchers can increase the utility of their work by better tracking and reporting negative effects in their studies so the field can learn more about potentially iatrogenic treatments.
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