Research suggests that therapists have a long half-life and remain inside their clients for years, a fact we tend to forget in these days of problem-focused, symptom-based therapy. Writing in the April 2007 Psychiatric Times, psychiatrist Barbara Young reported on her personal project asking former clients how they’d internalized their therapy. A client from 20 years before, who told Young that she checks in daily with God about her decisions and feelings, suddenly looked at Young and exclaimed, “He talks to me just like you used to!” Another revealed that two years after therapy had ended, in the middle of hanging himself, he recalled her advice about doing little things to make things better, and he saved himself at the last second.

In the December 2009 Psychotherapy Theory, Research, Practice, Training, James Mosher of Miami University reported on a study about how former clients who’ve been in therapy for varying periods internalized their therapists over time. One client, who’d had eight sessions, described her therapist as a protective shell. “It was like being on Who Wants to be a Millionaire and using a lifeline,” said another short-term client. After a while, however, clients experienced the therapist’s presence as being inside. Therapy, said one longer-term client, became “something that was deepening in me.” A recovering addict, who’d relied on his therapist to keep him clean, reported, “Earlier, I needed to call on specific memories of things he said, but now they’re kind of in me.” In the final stage of internalization, Mosher speculates, the therapist’s voice may introduce new ways of thinking and act together with the client’s other internalized voices.

Psychotherapy researchers and theorists have contended that clients who internalize their therapists’ voices make more progress. Because this internalization takes place as therapy progresses, however, it isn’t clear whether clients do better because they internalize their therapists, or whether clients who can develop this capacity tend to stay in therapy longer. Because therapists who solicit regular feedback from clients generally have better outcomes, Mosher suggests that periodically asking clients whether and how they experience you between sessions may provide useful feedback about the nature of the therapeutic relationship and the client’s progress in therapy.

Harmful Therapy

Does therapy occasionally cause more harm than good? This isn’t a question many therapists or researchers like to think about, despite the fact that between 5 and 10 percent of the time, clients deteriorate during therapy. When researchers and therapists examine treatments or reflect upon how therapy is going, they usually attribute any null or negative effects to intractable symptoms, a deteriorating disorder, or unfortunate circumstances outside the office. Even when the worst things happen to clients—homicide, suicide, psychiatric hospitalization—we seldom consider that therapy itself may have had some harmful effect. That notion usually arises only when a therapist uses some untested and controversial therapy or grievously violates boundaries.

But writing in one of three articles in the January issue of American Psychologist addressing the possibility that therapy sometimes causes problems, Sona Dimidjian of the University of Colorado and Steven Hollon of Vanderbilt University contend, “If psychotherapy is powerful enough to do good, it may be powerful enough to do harm.” They describe various ways in which treatment can backfire. It may make the problem worse or cause harm in domains that aren’t the focus of therapy. A therapist may help release a client’s anger in session and the client may then cause a road-rage accident. A couple may be in therapy to work on communication issues, and then one of them may decide to leave the relationship. Harvard psychiatrist Richard Schwartz has wondered whether some people become so dependent upon therapists’ support that their social network deteriorates. Even empirically supported treatments may occasionally cause harm. For instance, exposure therapy makes some people’s anxiety worse, and some depressed people deteriorate with certain treatments.

Researchers are partly to blame for the underemphasis on harmful therapy, says Boston University psychologist David Barlow in a second article. He notes the irony that 40 years of increasing refinement of psychotherapy research has predominantly focused on finding positive results, best practices, and empirically supported treatments, with a concomitant underemphasis on harmful effects.

In an article by five therapists led by Louis Castonguay and James Boswell of Pennsylvania State University, the authors suggest that instead of focusing primarily on teaching empirically supported treatments and clinical techniques, training programs should also stress ways in which therapy can do damage. Knowing what’s empirically supported is important, but so is informing students that continuing to use a specific technique when it ­doesn’t work causes harm; clients can feel worse about themselves and become discouraged about seeking further help. A study led by Derek Hatfield and Lynn McCullough, reported in the January 2010 issue of Clinical Psychology & Psychotherapy, corroborates the dangers that arise when therapists haven’t been alerted to this possibility. It matched self-assessments of how they were doing in each therapy session from 70 clients with the therapists’ notes and found that therapists hadn’t noticed when their clients had been deteriorating.

Bringing into the open the issue of harmful therapy reflects one of the bedrock principles of therapy: ignoring a problem doesn’t make it go away, and may even make it worse.

Botox and Emotions

Smile, and the world smiles with you. Let a smile be your umbrella on a rainy day. If this advice is true, then encouraging depressed people to smile might be a quick, effective therapy. A widely cited study by dermatologist Eric Finzi of Chevy Chase, Maryland, in the May 2006 Dermatologic Surgery supports the wisdom of this adage. Finzi reported that 9 of 10 depressed women he treated said they felt significantly better after their frown muscles were deadened by Botox. The study, however, lacked a control group and objective measures of depression. Even if the “depressed” women felt better, it could have been due to self-image changes following Botox injections.

At first glance, a study by neuroscientist David Havas of the University of Wisconsin, Madison, in the forthcoming issue of Psychological Science seems to support Finzi’s contention. Havas found that when Botox deadened muscles involved in frowning, people’s comprehension response when they read angry or sad sentences was slower. They showed no delay in responding to happy sentences, however. Havas says there’s a bidirectional feedback loop between facial expressions and emotions: the brain, receiving a cue to register an emotion, sends a direction to appropriate facial muscles; the consequent physical act of, say, frowning, then sends a signal back to the brain, prolonging or intensifying the feeling. But, he says, his study also suggests a more complex relationship involving the translation of words into feelings. The delay of negative reactions in his study, he thinks, was partly caused by the brain’s difficulty in interpreting frown-inducing sentences when the brain–frown feedback loop was interrupted.

His study joins a growing body of research that finds links between physicality and emotions. In a review in the May 18, 2007, issue of Science, psychologist Paula Niedenthal of France’s Blaise Pascal University reports that people slouching when they receive praise respond less positively than people sitting straight. In another experiment, instructors subtly placed a pen on the table while people were instructed to either nod or shake their heads vigorously, ostensibly to test how their headphones fit. Later those who’d shaken their heads affirmatively reported more positive reactions to the pen than did people who shook their heads no.

Smiling may or may not alleviate depression—that research remains to be done—but Botox may actually increase feelings of disconnection from others by interrupting an interpersonal feedback loop. Facial expressions evoke emotional responses from others, and a split-second delay in showing a feeling, or showing less of that feeling, may impair or sever the emotional connection with others. Actress Meryl Streep has said she’d never use Botox because attention would be drawn to the part of her face that’s frozen. We rely on our inner selves and others for communicating truth and emotion and, says Havas, Botox just may create enough static to impair those essential human connections.

The Virtues of Fear

A new study reported in the January American Journal of Psychiatry finds that 3-year-olds whose brains don’t easily register fear are likelier to become criminals. A team of researchers, led by Yu Gao of the University of Pennsylvania, assessed 1,795 children by measuring their galvanic skin responses to a series of unpleasant tones. In addition, social workers paid home visits and assessed nine items of social adversity, such as an uneducated parent, teenage mother, overcrowded home, poor health of mother, or separation from parents. Twenty years later, a data search of the cohort’s criminal convictions for significant offenses located 137 of the same children as young adults. When they compared their data as 3-year-olds to 274 of the group who didn’t have criminal records, the only significant variable was that the criminally inclined lacked a fear response when they were 3. Gao thinks the results point to poor functioning of the amygdala.

Other studies provide indirect confirmation of the interplay between low-functioning amygdalas and later antisocial behavior. For instance, some have shown that children with callous or unemotional traits have hypoactive amygdalas. The amygdala of psychopaths are also less active when contemplating a moral decision than those of others in control groups.

Part of our primitive brain, the amygdala responds to danger before our consciousness recognizes it. It then communicates with the orbitofrontal cortex, which is involved in decision-making and expectations of reward and punishment. If the orbitofrontal cortex doesn’t receive accurate information about fear, it seems likely this would impede development of a conscience, which develops in response to a combination of fear and empathy.

Lack of fear may be one of the earliest markers for an antisocial trajectory. A September 2000 study led by Paul Hastings reported in Developmental Psychology finds that preschoolers with identified behavioral problems show the same amount of concern for others as do preschoolers without behavioral problems. But over the next two years, those whose behavioral problems remain the same or increase begin to show significantly less concern for others. The lesson of the Gao and Hastings studies isn’t that fear breeds respect for others, but that prosocial behavior should be encouraged. Hastings finds that the behavioral problems dissipated in many of those preschoolers who received nurturing over the next two years.

Both studies point to the importance of providing parents, especially those under­ financial or social stress, with enough support to tend to their children’s development. Between the ages of 3 and 5, says Gao, the amygdala and orbitofrontal cortex can be significantly influenced by good nutrition, exercise, empathic connection, and the kind of cognitive work we’ve known to be important for centuries. It’s especially important to help young children, says Gao, because it’s much harder to promote a good conscience in adults.

Outlawing Psychological Aggression in Couples

The French National Assembly has passed a bill that criminalizes “psychological violence” within couples. Under the bill, repeating actions or words that could “damage the victim’s life conditions, affect his/her rights and his/her dignity, or damage his/her physical or mental health” would be punishable by up to three years imprisonment and a fine of approximately $105,000. People under court order to stay away from their partners could be forced to wear electronic monitoring devices. The bill, which has both conservative and liberal support, will go to the French Senate this summer.

Emotional abuse specialist Steven Stosny of Washington, D.C., author of Love without Hurt, believes we need a similar law in the United States. “We already have laws to protect strangers and coworkers from harassment, intimidation, and verbal assault,” he says, “yet we exempt intimate partners from equal protection.” Taking a stand against psychological abuse would help define our legal and social norms, as well as increase couples’ safety, he says. Psychological abuse is often a prelude to physical abuse, and studies have shown that it can be more damaging than physical abuse because of the continual erosion of self-value and sense of control that it causes.

The United States Bureau of Justice Statistics reports that, in 2005, three women were murdered by an intimate partner every day—higher than the 2.2 women in France. The Centers for Disease Control (CDC) estimated in 2000 that 4.8 million women were victims of intimate partner physical assaults and rapes annually (compared to 2.9 million men who are victims of intimate partner physical assaults each year). It’s a safe bet that most of these victims also were subjected to psychological abuse.

Sociologist Patricia Tjaden, who’s researched violence in America for years, supports the passage of such a law in the United States, but points out the difficulty in defining psychological abuse. Proponents of the French bill argue that abusive or threatening text, e-mail, and voice messages meet a standard of psychological violence. Tjaden notes that the CDC wrestled with the problem of definition in 1999, concluding that psychological violence had to include an act or threat of physical or sexual violence within the previous year, and that the definition of psychological abuse could be partly determined by whether something felt abusive. Like the 20-year effort to criminalize stalking, Tjaden says, the CDC definition says that psychological abuse “manifests itself through a multitude of behaviors, at times idiosyncratic to the individual victim.” Therapists can easily accept such a standard—if something feels abusive to a client, they can accept it as abuse—but the law usually requires a more objective basis.

Are PsyDs “Psychology Lite”?

Last year’s controversial report for the American Psychological Society, coauthored by a team led by Timothy Baker of the University of Wisconsin, Madison, strongly criticized the American Psychological Association (APA) for its “prescientific” attitude toward scientific training and accreditation (see Clinician’s Digest, January/February 2010). The report singled out the proliferation of PsyD programs as an example of how psychologist education and training has gone wrong, noting with alarm the rapid growth in PsyD programs and degrees. That growth has outpaced the growth in psychology PhDs. Today, says Jessica Kohout of the APA’s Center for Workforce Studies, there are at least 73 APA accredited PsyD programs. The number of PsyD degrees awarded has increased annually since 1978 (with the exception of 2002–2003) and has recently surpassed the number of PhDs in clinical psychology. Approximately 26,000 PsyDs have been trained since 1978.

The PsyD was conceived as a practice-oriented, rather than an academic-oriented, degree. Eugene Shapiro, an early PsyD champion, and Jack Wiggins, a former APA president, have likened it to the emergence of the MD in the early 1900s, which was created to distinguish practicing physicians from their PhD colleagues who were more interested in studying and teaching the discipline than working with patients. Writing in the March 1994 American Psychologist they pointed out, “The use of the [psychology] PhD degree perpetuates the belief that ours is solely an academic-research profession. The PhD degree identifies the bearer as a scholar, a scientist, or an academician but fails to identify the holder as a professional [practicing] psychologist.”

PsyD programs are often perceived as “easier” than PhDs. Part of the reason is that it takes an average of five years to earn, as opposed to the six to seven years for a PhD. But Morgan Sammons, Dean of the California School of Professional Psychology, insists that PsyDs aren’t “psychology lite” degrees. Differences between PsyD and PhD programs are in focus, not quality or rigor, he maintains, noting that both the PsyD and PhD are science-based degrees. The PsyD teaches the science and research of understanding clients and therapy, whereas the PhD uses science and research to understand behavior and change. “Both are equally laudable and defensible goals,” Sammons insists.

Much of the disdain for one degree or the other may be related to the ever-present tension and gap between research and practice. Anyone examining the hundreds of abstracts in psychology journals will immediately notice how few of the studies have direct relevance to clinical practice. Even Baker admits that no research has demonstrated any association between therapists’ knowledge of the research and positive outcomes.


Voices: Psychiatric Times 24, no. 4 (April 1, 2007); Psychotherapy Theory, Research, Practice, Training 46, no. 4 (December 2009): 432-47. Harmful Therapy: American Psychologist 65, no. 1 (January 2010): 13-49; Clinical Psychology & Psychotherapy 17, no. 1 (January 2010): 25-32. Botox: Dermatolgic Surgery 32, no. 5 (May 2006): 645-50; Science 316 (May 18, 2007): 1002-05. Fear: American Journal of Psychiatry 167, no. 1 (January 2010): 56-60; Developmental Psychology 36, no. 5 (September 2000): 531-46. Outlawing Psychological Aggression: “France May Make Mental Violence a Crime” by Steven Erlanger, New York Times (February 25, 2010).


Garry Cooper

Garry Cooper, LCSW, is a therapist in Oak Park, Illinois.