The Harmful Effects of Psychotherapy: When the Therapeutic Alliance Fails

Abstract

A good therapeutic alliance has been found to be the best predictor of outcome in psychotherapy, but psychotherapists also need to develop an understanding of the mechanisms by which that alliance is created and the factors that may damage that alliance and contribute to harmful effects of psychotherapy. I explore these factors in three contexts: the nature of the therapy itself, the characteristics of the therapist, and the dynamics of the patient-therapist relationship. I discuss the research that suggests that potentially harmful processes can be avoided by a dynamic-agentive systems model, which views psychotherapy as a conversation, in which turn-taking, rupture and repair, and perspectivetaking are the intersubjective tools that help to build the therapeutic alliance and that can be the focus for further study into the mechanisms by which psychotherapy is helpful or harmful. The neuroscience research that supports this model is summarized.

Jung's Platypus and Hamlet's Complaint: A Place for Wonder in the Consulting Room

“…In light of this, the centrality of cognitive knowledge and its rational articulation as a necessary condition for psychological understanding may be challenged – and has been seriously challenged in recent decades (Sterne et al ., ; Schore, ; Beebe & Lachmann, ; Fonagy et al ., ; Knox, ). My point though is that whether presented in interpretive form or otherwise, this kind of knowledge, while probably a rather vital part of the process, may prove of less value in the end for the person in therapy than a rather different kind of knowledge; one that heralds from a different kind of relational experience.…”