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Iatrogenic Effect: A negative consequence brought forth by the healer.

August 31, 2014

While the concept of the iatrogenic effect is well known to medicine, it doesn’t receive much attention in the context of counseling. However and if we accept the counselor as a form of healer, emotional, psychological or psychiatric, then it does us well to ponder this concept as applied to counseling.

Counseling tends to be treated at best, something to help overcome emotional, personal or interpersonal problems. At worst, counseling appears to be viewed as innocuous; if not helpful, at least not harmful.

Rarely discussed though are those unintentional consequences, the negative outcomes of well-intended acts. Like any intervention, counseling too has its potential iatrogenic effects even while at some level being helpful.

As much as we rail against the stigma of mental illness and mental health services, it remains such that a stigma exists. As much as a person may be appropriately served and aided by mental health services such as counseling, there can remain a part of that person affected by the stigma merely from receipt of services. This can form a potential emotional/psychological weight, the antidote of which often deployed by the client, is secrecy. Secrecy, a withholding of personal information can provide a barrier to ones connection to others in intimate relationships. It can cause a person to feel less about him or herself, just for the mere attendance at counseling. Thus the intended goal of empowerment, getting along with others, or ameliorating emotional upset, can be offset by the unintended consequences produced from the weight of stigma.

Beyond the stigma often associated with mental health services, the process itself can produce unwanted consequences.

It is not uncommon for persons with relationship difficulties to seek counseling to address those difficulties. At times, the person seeks to address those difficulties unilaterally in individual counseling. While there may be a good rationale for doing so, an opposing concern would be the counselor inadvertently aligning with the client, particularly in the presence of a one-sided account of the relationship difficulties. Individual counseling for relationship issues also presumes the client to be an accurate historian of the issues presented. In the absence of meeting, knowing and assessing the context over and above of the person singularly, the counselor is at risk of providing counsel or at least inadvertently reinforcing issues or notions that are not actually reasonable to the circumstance. At once a person may feel better from an individual perspective yet have their relationship issues worsened. In some cases then, individual counseling for a relationship issue may worsen the relationship issue.

Notwithstanding the above and again in the context of relationship issues, seeing persons jointly can not only erode the well being of a person on an individual basis, but more-so may place a person at risk of physical harm. Such is the case in matters of domestic violence or intimate partner violence. When these matters are not surfaced prior to joint sessions, the target of the violent and/or otherwise controlling behavior may be at a disadvantage for disclosure of interpersonal issues for fear of reprisal or retribution. The iatrogenic effect of uncovering issues related to one side may put the other side at risk of harm. Herein is the case for an appraisal of individual issues or the context of relationship issues ahead of service.

In the context of helping separated parents untangle the intimate relationship from the ongoing parental relationship, both parents and children can be at risk of harm from well-intentioned but misguided counseling efforts. Children brought for counseling may feel a need to align with one or other parent for factors beyond the recognition of the counselor. This can skew the information derived from the counseling process, and then be subject to misuse in the context of settling parenting disputes. Just signing a child up for counseling in the absence of joint parental permission can itself escalate the parental conflict to which the child is exposed, yet requires respite from. To the uninitiated counselor, providing counseling services in the context of separated parents in dispute carries the risk of a multitude of iatrogenic effects, not just befalling the client, but the service provider too can be pulled into the vortex as a co-contributor to the parental conflict. The service provider can find him or herself at risk of reprisal from a disgruntled parent.

Counseling is anything but innocuous. It is a potent healing strategy aimed at repairing anything from the distraught to fractured psyche to tenuous and even dangerous relationships between individuals, intimate partners, parents and parents and children. Addressed in the counseling process are issues ranging from misplaced words creating emotional distress to despicable, horrific or traumatic acts that impact one’s ability to effectively meet the demands of life.

Just as the surgeon must examine the patient before surgery and may deploy far less intrusive measures, such as ex-rays, CT scans or MRIs, to make sure the cut is even necessary let alone well placed, the counselor is best advised to investigate the context and possible intervening variables that may need to be controlled for, prior to going straight form initial phone call to counseling appointment.

Referred to as “intake” many counselors rely solely upon an intake form or superficial questions posed by an “intake worker” to determine the appropriateness of the referral. However, many counselors themselves view counseling at worse as innocuous or may even put their need for a revenue stream or agency “numbers” ahead of determining the reasonableness of the referral, or ahead of determining the match between what is sought or needed and the skills or expertise of the counselor, or ahead of assessing safety or sobriety issues.

Counselors are well advised to review their intake processes to determine if their approach to intake mitigates or enables the potential for iatrogenic effects.

Counseling is not innocuous and not all counselors are suited to all issues. It behooves counselors to practice continuous professional development and to have structures in place to appropriately triage for service ahead of jumping into service. Intake procedures must provide for concern of and protection from iatrogenic effects. Intake is far more than obtaining contact information and scheduling an appointment.

Persons seeking counseling are well advised to assess their potential service provider, asking questions about qualifications, expertise and experience. Clients must be assured that the counselor has the requisite knowledge training and expertise to address the matter at hand. Whenever one places their well being into the hands of another for personal professional service, be mindful, counselors are not always helpful and even when helpful, counselors can inadvertently create iatrogenic effects. At times, both client and counselor must weigh the benefit of service against the potential for unintended negative consequences.

Counselor and client can choose more wisely and better attune the counseling process when the potential for iatrogenic effects is respected.

Here is a 10 minute radio interview on this issue where the interviewers are taken aback:



I am Gary Direnfeld and I am a social worker.

Gary Direnfeld, MSW, RSW

Gary Direnfeld is a social worker. Courts in Ontario, Canada, consider him an expert in social work, marital and family therapy, child development, parent-child relations and custody and access matters. Gary is the host of the TV reality show, Newlywed, Nearly Dead, parenting columnist for the Hamilton Spectator and author of Marriage Rescue: Overcoming the ten deadly sins in failing relationships. Gary maintains a private practice in Dundas Ontario, providing a range of services for people in distress. He speaks at conferences and workshops throughout North America.

If your relationship is faltering, then set it as your priority.

Read: Marriage Rescue: Overcoming ten deadly sins in failing relationships.

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  1. tallytowneades permalink

    You are so right.

  2. Gary, I agree with you. We have to consider any child’s counseling experience as a systematic type of work. The blowback that the child gets from a parent for consoling in a counselor can outweigh any possible benefits. I have been through situations where one parent had to negotiate a mutual agreement with the other, before I would even try to see the child at the office or school. The last thing I want is for anyone to associate counseling with grief from a family member.

    With every child client, I provide lots of explanation (to the guardian) of how goals are identified and processed. Most people have a huge misconception of the services anyway.

  3. Many excellent points Gary. I ran a long term residential treatment program for 20 years and trying to balance the issues of dully diagnosed traumatized kids from extremely complicated families, with caseworkers, probation officers, judges and referral sources from both before and after treatment placements often proved to be a nightmare full of potential for iatrogenic damage to the client. Often the matter was complicated these folks having vastly different ideas about what should happen both in treatment and afterwards. In many cases it was extremely difficult simply figuring out how best we could help the youth with the problems they were having. In residential treatment you have the proverbial village of helpers doctors, psychiatrists, nurses, therapists, case mangers and para professional staff which can add a whole new level not only to healing but for harm as well. I spent hours each week simply trying to manage iatrogenic effects through supervision and training. It amazed and scared me how easy it was for these effects to slip into the treatment dynamic. Bravo for raising this issue it is often a blind spot in people’s awareness.

  4. Reblogged this on WorkplaceWise and commented:
    I have long known that iatrogenic issues are present in the mental health field. I am regularly surprised at the courage of people to continue to try and find help through therapy despite some of the very damaging and/or traumatising experiences they’ve had.

  5. Thanks you for discussion some of the risks of counseling. I can think of many more: demeaning the client through the asymmetrical, contrived, subordinating relationship; fixation on flaws and defects; regression; stoking a removed, abstract world-view, immersion in a pseudo-world; creating unrealistic expectations, encouraging dependency; learned helplessness, pathologizing–interpreting normal behavior as illness, encouraging rumination rather than action, to name a few.

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