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Chapter 1
Iatrogenesis
In 2006, I packed up everything I owned and moved from Washington, DC, to Los Angeles to be closer to my then boyfriend. I had only ever visited California once, a few months earlier, when I had flown out to meet his parents. Outside of my boyfriend and his family, every single person who could identify my body in the event of an untimely demise lived on the East Coast.
Then twenty-eight and having recently graduated from law school, I faced the unpleasantness of having become a lawyer. I was restless. My boyfriend had a business in Los Angeles. If I wanted things to work out with him, I needed to move.
But I also knew it was entirely possible that in this new life-his life-I would go crazy. My best friend, Vanessa, lived in DC. We'd both been hired by law firms, which meant long hours and an impossible time difference, as far as calls were concerned. I needed someone to listen to my worries and misgivings on my schedule. I needed a stand-in Vanessa, available every Thursday at six p.m. And for the first time in my life, I could afford one. I hired a therapist.
Every week, for a "fifty-minute hour," my therapist lent me her full attention. If I bored her with my repetition, she never complained. She was a pro. She never made me feel self-absorbed, even when I was. She let me vent. She let me cry. I often left her office feeling that some festering splinter of interpersonal interaction had been eased to the surface and plucked.
She helped me realize that I wasn't so bad. Most things were someone else's fault. Actually, many of the people around me were worse than I'd realized! Together, we diagnosed them freely. Who knew so many of my close relatives had narcissistic personality disorder? I found this solar plexus-level comforting. In quick order, my therapist became a really expensive friend, one who agreed with me about almost everything and liked to talk smack about people we (sort of) knew in common.
I had a great year. My boyfriend proposed marriage. I accepted. And then, a month before we were due to get married, my therapist dropped a bomb: "I'm not sure you two are ready to get married. We may need to do a little more work."
I felt the demoralizing shock of having walked into a plate-glass door.
My therapist was a formidable woman. She had at least fifteen years on me, a doctorate in psychology, and an apparently strong marriage of long duration. She dropped casual references to never missing Pilates. I once caught her at her spotless desk before our session, eating a protein bar she had carefully unwrapped, and marveled at her obvious self-mastery, the dignity she managed to bring to our silly modes of consumption. Maybe I should have been thrown into crisis by her pronouncement, but for whatever reason, I wasn't. For all her training, she was still human and fallible. I had already moved across the country by myself, set up a new life, and by then I knew: I didn't agree with her assessment, and I didn't need her permission, either. I left her a voicemail expressing my gratitude for her help. But, I said, I would be taking some time off.
A few years later, happily married, I resumed therapy with her. Then I tried therapy with a psychoanalyst for a year or so. Every experience I've had with therapy has fallen along a continuum from enlightening to unsettling. Occasionally, it rose to the level of "fun." Learning a little more about the workings of my own mind was at times helpful and often gratifying.
When I agreed with my therapist, I told her so. When I didn't, we talked about that. And when I felt I needed to move on, I did. Which is to say: I was an adult in therapy. I had swum life's choppy waters long enough to have gained some self-knowledge, some self-regard, and a sense of the accuracy of my own perceptions. I could pipe up with: "I think I gave you the wrong impression." Or, "Maybe we're placing a little too much blame on my mom?" Or even, "I've decided to terminate therapy."
Children and adolescents are not typically equipped to say these things. The power imbalance between child and therapist is too great. Children's and adolescents' sense of self is still developing. They cannot correct the interpretations or recommendations of a therapist. They cannot push back on a therapist's view of their families or of themselves because they have no Archimedean point; too little of life has gathered under their feet.
Nevertheless, parents my age have been signing up their kids and teens for therapy in astonishing numbers, even prophylactically. I talked to moms who hired therapists to help their kids adjust to preschool or to process the death of a beloved cat. One mom told me she put a therapist "on retainer" as soon as her two daughters reached middle school. "So they would have someone to talk to about all the things I never wanted to talk about with my mom."
A few moms told me, in roundabout verbiage, that they had hired a therapist to surveil their surly teen's thoughts and feelings. The therapist doesn't tell me what my daughter says exactly, the moms assured me, but she sort of lets me know everything's okay. And occasionally, I gathered, the therapist relayed to Mom specific information gleaned from the little prisoner of war.
If the notion of "therapy" here seems vague, that's largely to do with the experts. The American Academy of Child and Adolescent Psychiatry offers a tautology in place of a definition. What is "psycho therapy"? "A form of psychiatric treatment that involves therapeutic conversations and interactions between a therapist and a child or family." The American Psychological Association offers a similarly circular definition of psychotherapy: "any psychological service provided by a trained professional."
What's a "clock"? A device for measuring time. What's "time"? Something measured by a clock. Any conversation a therapist has with a patient counts as "therapy." But you get the idea: conversations about feelings and personal problems styled as medicine.
Parents often assume that therapy with a well-meaning professional can only help a child or adolescent's emotional development. Big mistake. Like any intervention with the potential to help, therapy can harm.
Iatrogenesis:
When the Healer Makes Things Worse
Any time a patient arrives at a doctor's office, she exposes herself to risk. Some risks arise through physician incompetence. A patient goes in to have a kidney removed, and the doctor extracts the wrong one. ("Wrong-site surgery" happens more often than you might think.) Or negligence: the surgeon loses track of a stray clamp or sponge in the patient's abdomen, then sews her up.
Or he "nicks" an organ. Or the operation proceeds swimmingly, but the patient develops an opportunistic infection at the surgical site. Or an allergic reaction to the anesthesia. Or bedsores, from lying in recovery too long. Or everything goes according to plan, but the entire treatment was based on a misapprehension of the problem.
"Iatrogenesis" is the word for all of it. From the Greek word iatros, meaning "healer," iatrogenesis literally means "originating with the healer" and refers to the phenomenon of a healer harming a patient in the course of treatment. Most often, it is not malpractice, though it can be. Much of iatrogenesis occurs not because a doctor is malicious or incompetent but because treatment exposes a patient to exogenous risks.
Iatrogenesis is everywhere-because all interventions carry risk. When a sick patient submits to treatment, the risks are typically worth it. When a well patient does, the risks often outweigh the potential for further improvement.
And here, what I'm calling an "intervention" is any sort of advice or corrective you would typically give only to someone with a deficiency or incapacity. So, telling kids to "eat vegetables" or "get plenty of sleep" or "spend time with friends" may be advice, but it isn't an intervention. We all need to do those things.
With interventions, a good rule of thumb is: Don't go in for an X-ray if you don't need one. Don't expose yourself to the germs of an ER just to say hello to your doctor friend. And-just maybe-don't send your kid off to therapy unless she absolutely requires it. Everyone knows the first two; it's the last one that may surprise you.
Psychotherapy Needs a Warning Label
For decades, the standard therapy proffered to victims of disaster-terrorist attack, combat, severe burn injury-was the "psychological debriefing." A therapist would invite victims of a tragedy into a group session in which participants were encouraged to "process" their negative emotions, learned to recognize the symptoms of post-traumatic stress disorder (PTSD), and discouraged from discontinuing therapy. Study after study has shown that this bare-bones process is sufficient to make PTSD symptoms worse.
Well-meaning therapists often act as though talking through your problems with a professional is good for everyone. That isn't so. Nor is it the case that as long as the therapist is following protocols, and has good intentions, the patient is bound to get better.
Any intervention potent enough to cure is also powerful enough to hurt. Therapy is no benign folk remedy. It can provide relief. It can also deliver unintended harm and does so in up to 20 percent of patients.
Therapy can lead a client to understand herself as sick and rearrange her self-understanding around a diagnosis. Therapy can encourage family estrangement-coming to realize that it's all Mom's fault and you never want to see her again. Therapy can exacerbate marital stress, compromise a patient's resilience, render a patient more traumatized, more depressed, and undermine her self-efficacy so she's less able to turn her life around. Therapy may lead a patient by degrees-sunk into a leather sofa, well-placed tissue box close at hand-to become overly dependent on her therapist.
This is true even for adults, who in general are much less easily led by other adults. These iatrogenic effects pose at least as great a risk, and likely much more, to children.
Police officers who responded to a plane crash and then underwent debriefing sessions exhibited more disaster-related hyperarousal symptoms eighteen months later than those who did not receive the treatment. Burn victims exhibited more anxiety after therapy than those left untreated. Breast cancer patients have left peer support groups feeling worse about their condition than those who opted out. And counseling sessions for normal bereavement often make it harder, not easier, for mourners to recover from loss. Some people who say they "just don't want to talk about it" know better than the experts what will help them: spending time with family; exercising; putting one foot in front of the other; gradually adjusting to the loss.
When it comes to our psyches, we're a lot more bespoke than mental health professionals often acknowledge or allow. And Tuesdays at four p.m. may not be when we're ready to confront our woes with a hired expert. Reminiscing with a friend, cracking a joke with your spouse you wouldn't dare make with anyone else, helping your cousin box up her apartment-without talking about your problems-often aids recovery far more than sitting around in a room full of sad people. Therapy can hijack our normal processes of resilience, interrupting our psyche's ability to heal itself, in its own way, at its own time.
Think of it this way: group therapy for those who experienced loss or disaster forces the coping to hang out with the sad. This may make the relatively resilient sadder and prompt the sad to stew. The most dejected steer the ship to Planet Misery, with everyone else trapped inside.
Individual therapy can intensify bad feelings, too. Psychiatrist Samantha Boardman wrote candidly about a patient who quit therapy after a few weeks of treatment. "All we do is talk about the bad stuff in my life," the patient told Boardman. "I sit in your office and complain for 45 minutes straight. Even if I am having a good day, coming here makes me think about all the negative things." Reading that, I remembered saving up emotional injuries to report to my therapist so that we would have something to talk about at our session-injuries I might have just let go.
Interestingly, even when patients' symptoms are made objectively worse by therapy, they tend to assume the therapy has helped. We rely largely on how "purged" we feel when we leave a therapist's office to justify our sense that the therapy is working. We rarely track objective markers, for example, the state of our career or relationships, before reaching a conclusion. Sometimes when our lives do improve, it's not because the therapy worked but because the motivation that led us to start therapy also led us to make other positive changes: spend more time with friends and family, reconnect with people we haven't heard from in a while, volunteer, eat better, exercise.
An embarrassing number of psychological interventions have little proven efficacy. They have nonetheless been applied with great élan to children and adolescents.
D.A.R.E. to Say "Yes" to Drugs
Picture it: 1992. Blue eyeliner, Doc Martens, and acid-washed jeans shot out at the knees. Into your high school assembly room tromps a uniformed officer in clodhoppers, keys jangling at the edge of a stiff black belt, armed with a jeremiad about the dangers of drugs.
This was the decades-long D.A.R.E. campaign, designed to raise awareness that drugs could ruin your life. Utilizing therapeutic techniques designed by Carl Rogers, one of the most influential psychotherapists of the twentieth century, D.A.R.E. counselors led students in a kind of group therapy. They entered schools and prompted kids to talk about their personal problems, confess their drug use, and role-play refusing drugs from each other.
Turns out, you can lead a teen to D.A.R.E., but it might make him wink. The program flopped like Vanilla Ice in his parachute pants, humiliating everyone involved. Not only was the campaign entirely ineffective, but follow-up studies revealed that D.A.R.E. may have actually increased substance and alcohol use among teens. Kewpie-faced Kirk Cameron pleaded, "You don't have to try 'em to be cool," but we sniffed a traitor, shilling for the Man. Kirk promised there were other avenues to cool, but teens who heard this message apparently figured drugs were quicker and more straightforward than most. Participating in group therapy to discuss a problem you didn't already have? That may be sufficient to introduce it.
Wanting to Help
Is Not the Same as Helping
Therapists almost always want to help, but sometimes they simply don't. And while some therapies have shown success in circumscribed areas-like cognitive behavioral therapy has in treating phobias-those who study the efficacy of therapies often point out that the results across treatment types are not terribly impressive.
