On March 16, 2019, the esteemed international magazine The Economist published an article titled “Talk is Cheap: What Disasters Reveal About Mental-Health Care.” The article extolled the virtues of using lightly trained “psychotherapists” to deal with emotional problems in countries that have a shortage of mental health professionals. After highlighting the role of stressors such as natural disasters and civil wars, the piece went on to suggest the potential usefulness of “psychological first aid” that can be provided with minimal training by recruiting pastors, teachers, barbers and taxi drivers. The article went on to suggest that “non-specialists” could be trained in a few hours to treat mild-to-moderate depression and anxiety as well as posttraumatic stress disorders. In general, the piece brought to mind the quote often attributed to Renaissance scholar Erasmus: In the land of the blind, the one eyed man can be king. 

Particularly in the context of post-disaster settings where people are in distress but well-trained mental health professionals are not available, the idea that “doing something is better than doing nothing” has understandable appeal. Though it is common to observe that medications may produce harmful side-effects, verbal treatments, by contrast, are often presumed to be either helpful or innocuous. As Nutt and Sharpe (2008) observed, many assume that since psychotherapy is only talking …no possible harm can result from it. It may be advisable to be cautious, however, before applying the label of “psychotherapy” too broadly to the types of interventions such non-specialists can be quickly trained to administer effectively.

The psychotherapy research literature is at odds with the idea that talking therapy is consistently benign and incapable of producing negative effects. More than 50 years ago, Bergin (1966) introduced the term “deterioration effect” to describe the possibility that psychotherapy could lead people to becoming either better or worse adjusted.  Others have highlighted a number of studies showing the potential negative side-effects that psychotherapy might produce (e.g., Berk & Parker, 2009). Similarly, large numbers of studies have documented that some therapists are clearly better than others (Castonguay & Hill, 2017). Factors such as therapist adjustment (e.g., Fisher & Greenberg, 1985) and ability to establish a therapeutic alliance and demonstrate facilitative interpersonal skills are empirically linked to better outcomes (Boswell, Kraus, Constantino, Bugatti, & Castonguay, 2017; Greenberg, 2016; Wampold, Baldwin, Holtforth, & Imel, 2017). It is also true that novice; less experienced therapists are more likely to have clients who drop out of treatment before maximum benefits can be attained (Swift & Greenberg, 2015). 

In addition, some therapist qualities that directly produce harmful outcomes have been observed. For instance, Karon and VandenBos (1972) and VandenBos and Karon (1971) describe a variable they called “therapist pathogenesis.” This dimension measures the degree to which therapists use others who are dependent on them to meet their own needs. In a series of studies they were able to show that schizophrenic patient outcome deteriorated in direct proportion to the level of pathogenesis displayed by their therapist; the greater the level of pathogenesis, the worse the outcome for the patient.

Responding to disasters worldwide may, as the article in The Economist points out, require rethinking how to use available personnel and resources in ways that are creative and, ultimately, most helpful to those effected. Regardless of setting, however, the art and science of psychotherapy requires clinicians who are able to use empirically supported treatments in a way that is empathetic and attuned to the characteristics of the  person with whom they are working (Greenberg, 2018). Therapist style and ability to keep personal needs under control appears to be highly significant. Some people are clearly more adept at it than others who may turn out to be “psycho-noxious.” The literature suggests some caution should be employed in deciding on who will be chosen to provide emotional support for others and what level of instruction/training is needed to ensure reasonable outcomes. 

Whether it is being practiced in the United States or internationally, it is too simplistic to view psychotherapy as a benign enterprise that can do no harm since it is only based on words! Perhaps Rudyard Kipling, who won the Nobel Prize for Literature, was on to something when he said in a 1923 speech to the Royal College of Surgeons in London, “Words are, of course, the most powerful drug used by mankind.”

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Roger P. Greenberg, Ph.D.