Why is the adverse side of the ledger neglected?
If these exemplars of omission and commission are accepted as potential cost risks to psychotherapy, why do we neglect this side of the ledger? First, it may be that we assume that the caveat emptor principle holds – that if a patient is referred to a psychotherapist who is clearly ineffective, exploitative or insensitive, they would choose not to return, thus preventing exposure to any distinct adverse event. For those who chose to stay, however, two processes may occur that, because they are neither overt nor clearly causal, may not be appreciated as generating adverse events. First, the ‘boiling frog’ principle, in which we adjust to stressors if they occur incrementally or slowly, and become accepting. Thus, when omission and commission concerns are less evident, blatant or immediate, a patient may continue with the psychotherapy despite a progressive smouldering enmeshment process that, because it unfolds slowly or subtly, builds to the boiling frog analogy. Examples include an unstructured meandering psychotherapy that fails to address the patient's problems, or the therapist subtly prioritizing their own needs. Worse, the patient may be unaware of the exploitation and, as one consequence of the confused agendas, even enjoy it. As Beddoe observed: ‘Within days Max's visits became the most anticipated event in my day’ [4].
A second contribution is that, while there is usually a clear-cut causal process in establishing a drug side-effect, it is less easy to argue any temporal causal link associated with psychotherapy. For example, if a depressed patient is commenced on an antidepressant drug, and they report immediate sedation and weight gain, the drug is the a priori causal agent. For a depressed patient receiving ineffective or inappropriate psychotherapy, negative consequences lack the immediacy of a distinctive drug side-effect. Even if the patient feels some discomfort about the psychotherapeutic approach and/or the psychotherapist themselves, there is a risk that such concerns will be rationalized (e.g. ‘I'm aware that therapy will take a long time’; ‘I'm not so sure about my therapist, but maybe that's my fault’) rather than being linked to something lacking or inappropriate in therapy.