Like everyone who goes into therapy, Karen Masters hoped to come out a more confident and rounded individual. But a year later, she left her final session questioning what she had always thought was a strong relationship with her mother and having flashbacks of sexual abuse that she was astonished to discover ever happened. Her work suffered and her marriage broke down.
"I am in complete shock," says Masters, 31. "I went through counselling initially to deal with some bullying I had gone through as a child, but going into so much detail actually made me start to relive and remember things that were buried deep in my subconscious, which I had obviously made myself forget as a coping mechanism. Bringing it all to the surface has scared me into thinking what else could be buried. I am now seriously wishing that I had never embarked on the counselling."
Charlene Lunnon shares her concerns. Together with her friend Lisa Hoodless, she suffered abduction and rape nine years ago, aged 10, before escaping four days later. The girls recently appeared on a Channel 4 documentary, in which Lunnon seemed to be almost as troubled by the memory of therapy as she was by the abduction, complaining that time she wanted to be playing with friends was spent reliving an experience she wanted desperately to put behind her. "It was about the worst thing they could have put me through. No one understands how horrible that was," she said. Hoodless felt the same and her father allowed her to leave counselling after four months. Lunnon continued for 18 months.
Following the latest study showing that some anti-depressant drugs are of little clinical benefit for most patients, more and more individuals are likely to seek treatment through various forms of psychotherapy, which collectively have come to be known as "the talking cure". However, a recent article in the Psychologist journal, entitled When Therapy Causes Harm, cautions that approximately 10% of people get worse after starting therapy. "Yet the belief in the innocuousness of psychotherapy remains persistent and prevalent," says Christian Jarrett, the article's author and spokesman for the British Psychological Society.
High on the list of potentially counter-productive therapies, according to new research from King's College London, is immediate psychotherapy - or "debriefing" as it is often called - after traumatic events, as in Lunnon's case. "Debriefing can actually make it more likely for the individual to get post-traumatic stress disorder (PTSD)," says Peter Fonagy, professor of clinical psychology at University College London and a practising psychoanalyst. Reflecting this new caution, British military personnel who suffer trauma are now given at least a month to talk to family, friends and colleagues before professional help is suggested.
Fonagy is unsurprised by Lunnon's unhappiness about her time in counselling. He says that unless someone feels motivated to have therapy, with a specific issue they want to talk about, therapy can be like a repetition of the trauma - in effect, the person may be re-traumatised. "That doesn't mean that talking about a trauma, once you've had PTSD, is not helpful," he adds. But even then, therapy may fail. Fonagy is particularly sceptical of recovered-memory techniques. "I would strongly maintain that therapy can be enormously helpful in managing current relationships that have been affected by what is remembered. But there is no indication that recovering the memory of a trauma in the first place is helpful. Indeed, it can be very unpleasant. We forget these things for a reason."
Peter Saunders, chief executive of the National Association for People Abused in Childhood, says, "Callers sometimes ask whether we 'are counsellors' and when we say we are not the response is 'Thank God' or words to that effect. Far too many people come to us having had a very negative experience in counselling or therapy, although I think talking therapies can be very important."
Even group therapy, which is successful under most circumstances, can have negative outcomes for certain groups of people - notably adolescents with behavioural troubles. An American report published in the Journal for Studies on Alcohol and Drugs in 2002 found that one group-therapy programme led to increased alcohol abuse among participants because they were left with the impression that abusing cigarettes and alcohol is normal and widespread.
Scott Lilienfeld, professor of psychology at Emory University in Atlanta, Georgia, is sufficiently concerned about potentially harmful therapies to have drawn on current research to form a preliminary list of them, arguing that it should be possible to agree that some "should be avoided, or implemented only with caution". Featuring on his list are critical-incident debriefing; recovered-memory techniques; attachment therapy (an alternative practice, mostly for treating adopted or fostered children which can involve forcibly holding or lying on the child to induce cathartic rage at past maltreatment); identity disorder-oriented psychotherapy and grief counselling for normal bereavement. All these, says Lilienfeld, have led to a "dark underbelly" of clinical practice. It doesn't help, he adds, that many trials that find negative effects are never published - what's known as the "file-drawer" effect.
But even long-established and respected therapies don't always have the desired effects. Lucy Richards, an administrator in Buckinghamshire, believes that can be down to a number of factors, including how skilled the individual therapist is, and the number of sessions. "I've had four counselling experiences in the last 10 years [for relationship and health problems] and I haven't been particularly impressed by what's been on offer. In one case, the therapist was newly qualified and her responses were straight out of a textbook. It left me with my original problems, coupled with frustration. When I cried, she just sat there saying absolutely nothing. I found that weird and hurtful. Another time, I was offered four sessions on the NHS. It's almost like you get hooked in and bring all these experiences to the fore, but then what do you do with them?"
Masters says that even over the course of a year of therapy, she felt unequipped to cope outside the treatment room. "My mood altered completely and I became angry and negative. My biggest problem was that I didn't talk to anyone outside the counselling sessions."
David Purves, consultant counselling psychologist and principal lecturer in the department of psychology at London Metropolitan University, agrees that traditional therapies carry risks. "You talk about how bad you feel and the therapist doesn't necessarily give you a path out of that. Some therapies don't have focus either. Some psychoanalytic counselling, for instance, works on the principle that you talk about stuff and eventually you'll find the crux of the problem. It's slow and people can lose their way and while I'm not saying it can't work effectively - because it can - I think it has the potential to be detrimental."
He says that among the 400 therapies now available, there are more focused, positive techniques such as cognitive behavioural therapy (CBT). But Joanne Stubley, consultant psychotherapist and head of the adult trauma unit at the Tavistock and Portman NHS Foundation Trust, believes the issue is more complex. "If you take trauma as an example, CBT can work well for people who have intrusive symptoms like flashbacks or nightmares but it might not help others. It's not about which therapies work or don't, but about matching the right person with the right treatment."
She adds that people in therapy often feel worse before they feel better, particularly if they are dealing with a difficult issue, while Purves believes people should always leave a session feeling positive.
Some therapists are starting to use regular client feedback to avoid cases failing. The client fills in a form before each session, which alerts the therapist to any patients being "off-track". Lambert compares measuring client outcomes to measuring blood pressure in the health arena: "When you go to a physician you get your blood pressure checked. You don't say, 'I got it checked two months ago so there's no need to check it today'".
· Some names have been changed. National Association for People Abused in Childhood 0800 085 3330, British Psychological Society
