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Thursday, 13 December 2012

Profession: Iatrogenic Fear of Emotion

Some fear is normal.

One of my interests in recent years has been the negative impacts of the mental health system. Although mental health services are intended to contribute toward mental health, unexamined assumptions often seem to result in unintended harm. A friend and colleague of mine once remarked that he felt the majority of his time was spent trying to undo the damage of previous mental health care.

In my last post I touched on one aspect of this issue – the belief amongst practitioners that having the best of intentions for our clients will contribute to better outcome.

It certainly does help to hold the best interests of our clients uppermost in mind. But we can’t use our intentions as a substitute for knowledge, training, an assessment of what the client really wants to achieve, or good old uncomfortable self-doubt. We should always be questioning what we are doing, rather than resting easy in the confidence that our good intentions will inevitably lead in a positive direction.

I remember a student at one point debating the relative merits of psychotherapy and pharmacotherapy and remarking “well, at least we don’t do any harm.” The assumption was that at worst psychotherapy will be ineffective, a null outcome, and holds the potential for significant gain. It took some effort to convince him that in fact psychotherapy, practiced incompetently, can be extremely damaging – I gave him some of the examples mentioned last week.

Treating Emotions by Making Them Scary

Clients often come to therapy because they are experiencing troubling emotional states: anxiety, depression, anger, guilt, shame, or what have you. They don’t like the discomfort (or the horror) and this is absolutely understandable.

In therapy we work with the person to develop strategies that will enable them to reduce the magnitude of these difficult emotions.  By gently venturing into the situations that frighten us, for example, we can reduce our fear in the long run. By pushing past the inertia that depression brings and reclaiming our lives, we can reduce depressive despair. And eventually what was a disabling state becomes a manageable and even helpful guide.

But there can be an unintentional message of therapy for difficult emotional states: “These are dangerous feelings and you are quite right to be frightened of them – we need to do all we can to stamp them out.”

On one level, this makes sense. Example: depression, left unchecked, may lead to job loss, relationship breakdown, and suicidality.

What is the impact, though, of labeling an emotional state as a threat – or as a disease? This removes any of the existing signal value the emotion may have. It no longer means “Hmm, working 16 hours a day at a job I hate may not be sustainable” and becomes “I’m mentally ill.” 

Further, by frantically steering the client away from the emotion, we emphasize that it is something to be feared. If fear is already the problem then we have just added to it.

An extreme example of this comes from recent announcements about the upcoming revision to the diagnostic manual used by most of North America, the DSM. DSM5 will remove an exclusion to depression diagnosis for individuals who are recently bereaved.

It’s easy to see the reasoning for this. Bereavement is an extreme emotional state that can be temporarily disabling in intensity. There is no requirement that the origin of a state be mysterious in order to be classed as a disorder. For example, we can diagnose caffeine intoxication even though it’s obvious why a person is experiencing it: they just drank a gallon of coffee. A bereaved person recently lost someone profoundly important to them, and as a result they are now experiencing symptoms very similar to clinical depression. No surprise.

But this makes normal grief a mental disorder. Rather than being a difficult, challenging, but normal-range life experience, grief becomes a mental illness.  And paradoxically, the failure to experience any grief when a person close to us dies is a non-disorder. The abnormal is normal, and the normal has been classed as abnormal – and therefore subject to intervention.

Do We Create the Problems We Treat?

The concern is that by labeling an increasing number of normal human experiences as mental disorders, or by declaring them treatable, we are narrowing the range of human emotion that our society deems acceptable.  The former highway of feeling that we may have been permitted begins to resemble a narrow sidewalk, or a tightrope.  Anyone outside these shrinking limits becomes disordered and in need of a pill or a Viennese couch.

I now frequently see people who have become discouraged during a difficult part of their lives. They have been told that the discouragement or lethargy they experience is a disorder, a disease of the mind. In some cases, they have been informed that they have a brain disease that will need medical treatment for the rest of their lives. Apart from being simply incorrect, this well-intentioned diagnosis can be profoundly damaging.

The mental health industry’s claim to ever-greater tracts of normal emotional territory seems likely to have effects beyond the consulting room. The taint leaks into the surrounding culture. When we leap forward and lecture on the emotional damage caused by natural disasters and improper diet, when we help create magazine quizzes (“Could YOU have social phobia?”), when we participate in the proliferation of diagnostic categories, we may be damaging the society we live in.

Although well-intentioned, our efforts may create more misery than they relieve.


  1. Does emotional freedom technique is included in your therapy? how does eft work for emotional, mental, depression and other physiological problems?

  2. The work we conduct at Changeways Clinic does not include EFT, as the evidence in its favour is largely lacking. EFT employs a variety of techniques but appears to rely to a great extent on the ideas of "energy medicine", in which the therapist manipulates invisible and mechanically undetectable energy fields around the client in order to enhance functioning. I can't speak for any others, but I don't believe in these fields, nor in the ability of professionals to manipulate them - through touch, near-touch (eg, therapeutic touch), or through bodily tapping procedures.

    1. A fascinating article, Dr. Paterson. It is astonishing that there seems so little acknowledgement of the dangers to which you point. I have tried to find discussions of this set of phenomena in the psychology literature but I have found nothing of any significant length or depth. My particular concern is that there may be increasing (Orwellian?) pressure to diagnose those who demonstrate an indifference (or abhorrence) to participation in normal, but unjust and/or otherwise morally undesirable, society, as abnormal, i.e. suffering from some sort of mental disorder. (It may be a slippery slope from ODD-type diagnoses in children to similar diagnoses in adults who--put somewhat hyperbolically--resist expectations to participate in an unjust society, etc.) I wonder whether you have any recommendations for books or papers that discuss this sort of topic at a more theoretical (philosophical or sociological) level?