Doing Harm -- comparing medicine and psychotherapy

[Mary S]

Today I happened to hear this radio program: https://www.npr.org/sections/health-shots/2020/06/30/885186438/a-doctor-confronts-medical-errors-and-flaws-in-the-system-that-create-mistakes , that discusses a book called When We Do Harm, talking about mistakes made in  medical practice. I couldn't help comparing and contrasting with harm done in therapy. I appreciate the title, since it acknowledges that professionals can do harm. Among other things, the author  points out that measures intended to reduce harm sometimes actually open the door to harm. (Note: I think the transcript  in the link leaves out some things that I remember from listening to the program.)

[Eve B]

I think therapists do acknowledge that harm can happen in therapy when clients are given inappropriate treatment, but it seems like they, more often than not, point fingers at the faults of other therapists instead of looking at themselves and what they could be doing better. I agree with the following quote from Mary's link to be common among therapists who react defensively to client criticism: "the reporting of errors — including the "near misses" — is key to improving the system, but she says that shame and guilt prevent medical personnel from admitting their mistakes."  

How can therapists know when they're making mistakes with their clients before it's too late? Shouldn't strong client resistance be an obvious warning sign that therapy could be heading in a harmful direction?

[here today]

Thanks, Mary.  I'm going to quote a part of the article because I think there are some important implications for therapists:

Quote

 

On Ofri's experience of making a "near-miss" medical error when she was a new doctor

 I had a patient admitted for so-called "altered mental status." There was an elderly patient from a nursing home and they were sent in because someone there thought they looked a little more demented today than they looked yesterday. And of course, we were really busy. ... And the labs were fine. The radiology was fine. And so I just basically thought, "Let me get this patient back to the nursing home. It's all fine."

So I sent the patient to kind of an intermediate holding area to just wait until their bed opened up back at the nursing home. Well, it turns out that the patient was actually bleeding into their brain, but I missed it because I hadn't looked at the CAT scan myself. Somebody said to me, "radiology, fine." And so I took that at their word and didn't look at the scan myself as I should have.

Now, luckily, someone else saw the scan. The patient was whisked straight to the [operating room], had the blood drained and the patient did fine. So in fact, this was a near-miss error because the patient didn't get harmed. Her medical care went just as it should have. But, of course, it was still an error. It was error because I didn't do what I should have done. And had the patient gone home, they could have died. But, of course, this error never got reported, because the patient did OK. So we don't know. It never got studied or tallied. So it was missed, kind of, in the greater scheme of how we improve things.

On the effect of having made that 'near-miss error' on Ofri's subsequent judgment

In the short run, I think I was actually much worse, because my mind was in a fog. My soul was in a fog. I'm sure that many errors were committed by me in the weeks that followed because I wasn't really all there. I'm sure I missed the subtle signs of a wound infection. Maybe I missed a lab value that was amiss because my brain really wasn't fully focused and my emotions were just a wreck [after that serious near miss]. I was ready to quit. And so I'm sure I harmed more patients because of that.

Now that it's been some time, it's given me some perspective. I have some empathy for my younger self. And I recognize that the emotional part of medicine is so critical because it wasn't science that kept me [from reporting that near miss]. It was shame. It was guilt. It was all the emotions.

 

 

1. The error wasn't reported because somebody else caught the problem and the patient did fine.  This is too bad, as Ofri would acknowledge now, because others did not therefore get to learn from her mistake.  The quality or potential of people  "blaming" her for her mistake took over in her mind.  And perhaps that in fact WOULD have been the attitude of some in hospital had the error been reported.

2. The effects of shame and guilt put her mind in a fog so she wasn't as effective as she might otherwise have been.  The shame and guilt did NOT help her perform better.  The simple knowledge that she made a mistake was not able, therefore, to make her more alert for the future, as it might have with a more experienced doctor or a more experienced Ofri herself.  Except that now, with some mistakes under her belt, she is also less likely to make them.

3. Shame and guilt can be problems for clients too.  It may be that they come into therapy and have problems dealing with those emotions.  They impact their sense of self, which is necessary in order to function in society.  But the sense of self is affected by more than just shame and guilt and can be damaged in other ways, too. 

I believe that I went into my last therapy with a damaged sense of self already.  There are no tests for this that I know of, but I think my last therapist's observations that I was "narcissistically wounded and fragmented" were apt.  If I hadn't already had the damage I went into therapy with, the way the therapist behaved with me may in fact not have been very damaging.  For one thing, I might have had the ability to feel her slights and self-absorption and disapproving looks without taking those things personally.  BUT I DIDN"T.  That's part of why I had felt the depression and anxiety that led me to therapy in the first place.  Of course, I imagine that it is very disorienting for a therapist to begin to realize, if they even allow the idea into their awareness, that they may in fact be damaging to the client's sense of self.  And to say that I was already damaged, so it didn't matter -- no that's not right, either.  If a patient has a condition that the doctor exacerbates and makes worse with "treatment", then that is an iatrogenic treatment effect.  And those need to be observed and documented.  So that some day, maybe, therapists can get some better ideas how NOT to do those kinds of things for future clients.  If there clients and therapists in the future -- which I kind of hope not.  I hope that something better than therapy can be found.  And people who have been hurt in therapy could provide lots of potentially useful information and ideas for alternatives -- if anybody was interested.  Which, of course, at this point in history, they are not.

 

[Mary S]

5 hours ago, Eve B said:

How can therapists know when they're making mistakes with their clients before it's too late? Shouldn't strong client resistance be an obvious warning sign that therapy could be heading in a harmful direction?

I agree that strong client resistance should be considered a warning sign that therapy might be heading toward harm. But -- the reality seems to be that therapists use the concept of "resistance"  as a method to deflect attention from the possibility that the therapy doesn't fit the client/problem, or that the therapist isn't doing a good job, etc.. Another possible (and perhaps frequent) complication: Therapists may label the client as "resistant" when the goals of the therapy are determined by the therapist, without the agreement of the client. It's irrational to push a treatment on the client that the client doesn't it makes sense. Therapists so often seem to think of themselves as gurus, insightful, etc.-- when they look like The Emperor Who Has No Clothes to the client. (I wonder how many therapists have even considered the possibility that they may appear to the client as The Emperor Who Has No Clothes, or a bull in the china shop, or as just out of it; not in touch with the real world the client lives in. I doubt that many ever even think of these possibilities.)

[Mary S]

Here Today,

Thanks for your comments. You make several good points. In particular, the following seems spot-on:

"Of course, I imagine that it is very disorienting for a therapist to begin to realize, if they even allow the idea into their awareness, that they may in fact be damaging to the client's sense of self.  And to say that I was already damaged, so it didn't matter -- no that's not right, either.  If a patient has a condition that the doctor exacerbates and makes worse with "treatment", then that is an iatrogenic treatment effect.  And those need to be observed and documented.  So that some day, maybe, therapists can get some better ideas how NOT to do those kinds of things for future clients. "

This really summarizes something that should be an important part of therapists' training, but that I doubt is even brought up at all in that training.

 

[Mary S]

Repeating a quote from the article that Here Today' quoted upthread:

" I had a patient admitted for so-called "altered mental status." There was an elderly patient from a nursing home and they were sent in because someone there thought they looked a little more demented today than they looked yesterday. And of course, we were really busy. ... And the labs were fine. The radiology was fine. And so I just basically thought, "Let me get this patient back to the nursing home. It's all fine."

So I sent the patient to kind of an intermediate holding area to just wait until their bed opened up back at the nursing home. Well, it turns out that the patient was actually bleeding into their brain, but I missed it because I hadn't looked at the CAT scan myself. Somebody said to me, "radiology, fine." And so I took that at their word and didn't look at the scan myself as I should have.

Now, luckily, someone else saw the scan. The patient was whisked straight to the [operating room], had the blood drained and the patient did fine. So in fact, this was a near-miss error because the patient didn't get harmed. Her medical care went just as it should have. But, of course, it was still an error. It was error because I didn't do what I should have done. And had the patient gone home, they could have died. But, of course, this error never got reported, because the patient did OK. So we don't know. It never got studied or tallied. So it was missed, kind of, in the greater scheme of how we improve things."

Thinking about comparing and contrasting this with therapy:  In the situation in the  quote,  the actual CAT scan was available to be double-checked. In psychotherapy, there is nothing as concrete or objective as a CAT scan that could be double-checked. So the possibility of having mistakes persist (rather than being corrected) is much less than in medical treatments.  In other words, there is much less of a chance of discovering a "near miss" than in medical practice, and there is a greater chance of making serious mistakes that are not caught.

[Eve B]

On 7/4/2020 at 9:15 PM, Mary S said:

  In other words, there is much less of a chance of discovering a "near miss" than in medical practice, and there is a greater chance of making serious mistakes that are not caught.

How can near misses be caught in therapy at all when the sessions are private? Even if a therapist reviews a problematic case with a supervisor, it's still the therapist's version which can be different from the client's side of what actually occurred. 

[Eve B]

On 7/3/2020 at 5:45 PM, here today said:

I hope that something better than therapy can be found.  And people who have been hurt in therapy could provide lots of potentially useful information and ideas for alternatives -- if anybody was interested.  Which, of course, at this point in history, they are not.

I think artificial intelligence video game programs could be the future of therapy. Isn't it the human  emotional flaws of therapists that often cause client harm? Why couldn't virtual therapists be created that's specific to the needs of a client's issues? 

[Mary S]

3 hours ago, Eve B said:

How can near misses be caught in therapy at all when the sessions are private? Even if a therapist reviews a problematic case with a supervisor, it's still the therapist's version which can be different from the client's side of what actually occurred. 

Good point.

[Mary S]

3 hours ago, Eve B said:

I think artificial intelligence video game programs could be the future of therapy. Isn't it the human  emotional flaws of therapists that often cause client harm? Why couldn't virtual therapists be created that's specific to the needs of a client's issues? 

The problem with this is how "virtual" therapists could be created to be specific to the needs of a client's issues. It's not just the  human emotional flaws of therapists that cause client harm -- it's also therapists' ignorance and poor thinking skills. So no one but a perfect human would be able to create a good "virtual therapist". Virtual therapists would reflect the flaws of their creators.

[Eve B]

How about a program where clients could create their "perfect" virtual therapist by inputting certain preferences?

[Mary S]

7 hours ago, Eve B said:

How about a program where clients could create their "perfect" virtual therapist by inputting certain preferences?

To me, the idea of a "perfect" therapist just doesn't make sense. I find it hard to imagine a program where the selection of preferences to be input would result in a "good fit"  for all clients -- the list of possibilities might be adequate for many clients to create a good enough fit, but a list that was adequate for all clients to create a good enough fit seems very unlikely. (It might conceivably be possible to create an "adaptive" program, which would start with a list of preferences set by the developers, but then have an "adaptive" capability to ask prospective clients to suggest preferences not on the list, and then to incorporate these for future potential clients -- but I think this would be a very difficult undertaking that at the very least would take years to "learn" to give a good enough fit for even a simple majority of clients.

[Eve B]

Considering all the realistic video games out there now, I don't think it would be too hard creating an AI virtual therapist program (similar to those dating apps) that try to match compatible personality and treatment styles. The technology is available, but designing "good fit" metrics would be tricky.  The odds couldn't be worse than clients randomly picking therapists on their own without much clue what they're getting themselves into.

[zygomaticus]

I suppose the concept of harm differs from therapist to client, especially when there are methodologies designed to inflict short-term pain with a view to it being a 'corrective' stimulus. The practitioner may see this as healing pain, the client may simply experience it as pain, but the client's views are typically subordinated when it comes to the limited checks and balances that feed back into the professional practice and their dubious ethics. After all, clients allegedly have wonky, unreliable minds in the first place, they are one of the easiest groups in society to cast doubt upon, and, of course, therapists are well-trained in injecting doubt directly into the client if they do dare to voice discontent about how they're being treated by their therapist. So much so, that they can be spun into blaming themselves, instead.

Physical harm and negligence is so much easier to prove. In the privacy of a counselling room, a client is very much cut adrift from any grasp at advocacy or legal back-up. One person is adorned with certificates, the other is, by definition in the eyes of most, floundering and unreliable, psychologically speaking. Who has the upper hand? It's hard to prove psychological harm when the one making the claim can have their credibility undermined by the very person that caused it, and all in a social climate that, to a greater or lesser extent, contains a measure of taboo towards those seeking help rather than stoically coping without (obvious) crutches. Plus, it appears that in popular culture, mental states are typically treated as somewhat transitory, amorphous, impermanent and under the alleged executive control of a perfectly rational controller, the self... so long as it's someone else we're discussing. The individual, however, even if they won't admit it, knows how entrenched and deeply-rooted emotional woes and individual traits are. It's hard to acknowledge how daunting change truly is, but we want to have hope, and in its simplification and marketing of fool-proof systems, the therapy and self-help industry will endlessly exploit this need for hope. The disclaimer, routinely, is that it only works if the client makes it work. Faulty appliances get replaced. Faulty therapies come with no refunds, blame apportioned to clients, and a fat wedge of punishment, judgement and harm as a risk factor.

In terms of AI therapists, I recall speaking to someone working in AI who insisted that popular conceptions of it are distorted, that programming is ultimately the fulcrum and the AI is basically doing what the programmer wants it to do, albeit with a certain capacity for functional learning. If human therapists are drilled continuously to show 'fidelity to the model', which they very much are, both in training and supervision, why would we expect AI therapists to deviate from their programming when they have even less scope for creative or empathic thinking? They may not have the considerations of careerist individuals, or egos, but their programmers do. Do the venture capitalists behind the start-ups have any greater desire to be exposed to liability? Do the developers want to admit such flaws? Will concepts of 'personal responsibility', 'transference', 'resistance', 'lack of commitment/engagement' or 'non-compliance' not be abused in this techno-psychotherapeutic field? It's hard to imagine that it will.

There will always be markets to administer products in relation to our human ills, but they will always, ultimately, be self-serving, profit-making, and highly reluctant to admit liability for their failings. Those in need, desperate for a solution, will either be temporarily spell-bound, but ultimately disappointed, or stuck in an endless pursuit for the Baby Bear's porridge of a system perfectly attuned to their needs. When one 'fool-proof' system doesn't work, we're back perusing the shelves and listings for the next, because we're already hooked and conditioned.

Given the choice, though, at this point I'd probably pick AI over a human if I was forced to choose between the two. I might need to learn how to hack it, however. How's that for resistance?

[Eve B]

Maybe the AI program can just be a library of therapy information that can adapt to an input of client questions? I still believe an intuitive therapy app is possible, but there should be a clear disclaimer to use at one's own risk, like what should be included in any therapist's consent forms.