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Tuesday, 4 December 2012

Process: The Fallacy of Good Intentions

A few weeks ago I presented a workshop on some of the technical skills involved in conducting effective psychotherapy. One of the participants, a student in a training program, commented “I guess the most important thing is that your heart is in the right place.”
Nice idea, bad results.

I cautioned her that having a desire to help on the one hand, and actually helping on the other, are two separate things. But I realized afterwards that I was holding back in an effort to play nice. The truth is, I think that a belief in the power of good intentions is one of the most damaging elements of our field.

Going beyond what the student said, or perhaps intended, the idea seems to be that if one has a pure heart and wishes for the best interests of a client, then one will naturally choose actions and strategies that will lead in that direction. At minimum, the clinician will do no harm.

The type of therapy I do often involves working with a person to discover their underlying assumptions (about themselves, others, the world) for problematic ideas that might be leading them astray. The same idea can be applied to governments, cultures, and professions, including the profession of psychotherapy.

The belief in the benevolence of good intentions is a good example. It distorts by encouraging us to believe in what we are doing, and to lower our guard against potential harm. It relaxes the need for research evidence. After all, if our intent is positive, then we should at least do some good, shouldn’t we?

The field of mental health has unquestionably damaged a great many people over its history. The examples we hear about most are those in which the practitioner used the client for his or her own ends: sexual gratification, financial gain, a sense of power, or what have you.

But imagine that we could take all of the negative impacts that we have had and sort them into two categories: the product of bad intentions, and the product of good intentions. I believe that the damages caused by good intentions would easily dwarf those caused by evil or self-involved clinicians. Entire areas of practice would fall into the nice-try-bad-outcome category. Some examples:

  • The widespread use of lobotomy in past decades. It was believed that simply inserting a metal paddle into the prefrontal cortex and destroying it would result in better mental health. “I know it’s part of the brain, but we don’t really need it.” Egas Moniz was awarded the Nobel Prize for medicine in 1949 for this effort.
  • The near-universal implementation of critical incident stress debriefing, which appears to increase rather than decrease the likelihood of lasting post-traumatic effects. I took this training myself and felt a vague regret at never having the chance to use it - until I saw the data coming out on the effects.
  • The practice of putting individuals suffering subclinical depression on antidepressant medication, despite the absence of research evidence supporting the efficacy of these medications for this level of symptomatology (a recent study in British Columbia revealed that 20% of women were written a prescription for an antidepressant in one year alone).
  • The practice of so-called “reparative therapy” to turn gay men and lesbians into heterosexuals. This never seemed to work, damaged the lives of those so treated, and resulted in the leaders of the exgay organizations regularly coming out and denouncing their former efforts. (This practice was no more “effective,” it seems, than the former strategies of psychiatric hospitalization, electroconvulsive therapy, or, yes, lobotomy.) Yes, I know: This is more the bad-goal-worse-outcome sort of practice, but the practitioners' belief in the goals of their work helps it to fit.
  • The therapeutic fad of the 1980s and 1990s of taking vague symptoms of distress as indicators that clients had been abused by satanic cults. At its height, practitioners claimed (sans evidence) that thousands of people were being killed each year in these rituals. They weren’t, but thousands upon thousands of clients were being damaged by well-intentioned but gullible practitioners who jumped on the bandwagon.

It would be easy to go on. In every case, the intention was benevolent – cure people, prevent dysfunction, control illness, or secure a better seat in heaven. The means were promoted by well-intentioned people who genuinely believed that they were doing something positive. The results were disastrous. One can only wonder whether if the people involved believed just a little less in themselves and in the power of their good intentions, perhaps fewer people’s lives would have been ruined.

I’d like to see the belief in good intentions dragged out into the open – preferably in training programs – and subjected to the critical scrutiny it deserves. Like other distorted beliefs – and like vampires – the strong light of day might cause it to wither away.

And good riddance.


  1. Very good points! I will add one. I once worked with a client who received a "loan" from a previous therapist, whose intention was very positive, she wanted to help him get back on his feet. This client stopped seeing this therapist who he had seen for several years because he knew he would never be able to pay her back. Not only is this positive intentioned behavior by the therapist harmful to the client it is also unethical. Thank you for bringing up such an important topic.
    Gina Fricke, LCSW, NCGC II

  2. Ick! This is too true - so many therapists seem to think that simply being in their benevolent presence should be enough to 'cure' patients, sans any sort structured plan with measurable outcomes... I can't think of any other field where practitioners believe that 'a good heart' is enough to be competent - would you have a bone set by a doctor with minimal training but good intentions? Would you trust a financial adviser with dubious science but a great smile? Scary!

  3. When psychotherapy is damaging, its "failures" often seem dismissed with buzzwords like they have to want to change or they get out of it what they put into it or they're too severely damaged to repair, or they're simply disgruntled. The asymmetrical framework of therapy doesn't work for everyone.