The Adverse Behaviors in Clinicians (ABC-11) assessment tool
Just this month, researchers from the Scottish Mental Health Arts Festival, a “lived-experience collective” have published the results of a survey (N=251) and an assessment tool based on the findings.
This is the latest in a grassroots effort by mental health patients to bring attention to the various harms done by therapy or the therapists themselves. It’s deeply disheartening that the onus for proving harm lies with the patients who are already struggling, rather than the “professionals”.
It’s not exactly a secret that things we do can have unwanted side-effects, from medications, to fuel efficiency and the environment.
Psychotherapy is unique in that the practitioner is also the medicine. This may make them more likely to deny that the medicine itself could ever possibly be less than perfect.
Nearly every field except for psychology seems to have side effects, if one listens to “The Experts” anyway.
If survivor-led efforts at quantification fall short of whatever therapists and social workers consider “science”, it’s because their failure left an enormous gap in evidence.
There have long been popular explainations about why this field is so fucked, mostly surrounding the type of person that enters the field to begin with.
Popular epidemiology suggests that 40% of cops are domestic abusers; is it not reasonable to wonder what percentage of therapists are closeted abusers?
More research is definitely needed.
Survey Results
Researchers based their checklist on a resource for survivors of interpersonal abuse, created by EVA Psychology for NHS Scotland. I consider this a reasonable starting point for analyzing iatrogenic harm, particularly in the interpersonal context. The researchers then converted these criteria into a questionnaire form, using ChatGPT to ensure neutral wording and avoid leading questions.
Survey participants were mostly (48%) from the United States, 27% from the UK, 13% from the EU, 6.7% from Canada, and 4.8% Other.
Nearly 95% of participants (237 out of 251) reported encountering at least one of the adverse behavioral scenarios. Participants from “Other” saw the highest rate of adverse behaviors per participant, with an average of 9.10. Canada was the lowest at 5.29 adverse behaviors per participant, and the US, UK, and EU were in the middle, with 6.25, 6.47, and 6.78 “Yes” responses per participant, respectively.
The percentage of patients experiencing such behavior is described by Table 1:
| Q | Question Text | N | % | ||
|---|---|---|---|---|---|
| 8 | Have mental health professionals minimised, denied, or blamed you when their behaviour, medications or therapies are not helpful (or have been harmful to you) and so did not take your concerns seriously? | 193 | 76.89% | ||
| 4 | Have any mental health professionals disrespected you, interrupted you, not listened to your concerns, twisted your words, or criticised your friends or family? | 191 | 76.10% | ||
| 1 | Have you ever felt criticised or been verbally attacked by any mental health professionals? | 189 | 75.30% | ||
| 7 | Have any mental health professionals withheld emotional support, not expressed their own feelings or opinions to you, failed to provide support or compliments, or ignored your rights and feelings? | 185 | 73.71% | ||
| 2 | Have any mental health professionals used pressure tactics, guilt trips, or threats to influence your choices or decisions (including about treatments)? | 177 | 70.52% | ||
| 3 | Have you encountered any mental health professionals who abused their authority, consistently claimed to be ‘right’, told you what to do, or spoke negatively about you to other people? | 174 | 69.32% | ||
| 6 | Have any mental health professionals failed to follow through on agreements, broken their promises or prioritised their own plans over your needs and wellbeing? | 155 | 61.75% | ||
| 5 | Have you ever experienced breaches of trust by a mental health professional, such as them behaving in a way that is unexpected and hurtful towards you? | 152 | 60.56% | ||
| 10 | Have any mental health professionals ever made you feel isolated from your family, friends, other healthcare professionals or denied you access to other services or treatments? | 115 | 45.82% | ||
| 9 | Have any mental health professionals attempted to control your financial resources or decisions? | 57 | 22.71% | ||
| 11 | Have any mental health professionals engaged in harassing behaviour, such as making unwanted phone calls or visits? | 31 | 12.35% |
Discussion
Anyone who’s cared for psychiatric patients knows that there are frequently two sides to the story. It is entirely possible that, in many of these cases, the therapist was absolutely, objectively correct in their advice, but the patient didn’t want to hear it, and so they’re checking boxes like consistently claimed to be ‘right’, told you what to do, etc.
Other behaviors are far more alarming, like the double-digit number for stalking and harassing behavior, or the various types of deceptive, manipulative, or coercive control. These are indictments of individuals rather than the profession, but it does call to mind all the times I’ve heard people suggest that the field is attractive to a certain type of person.
Criticisms
This topic is personal to me and I’m definitely not a disinterested, dispassionate recorder of facts. I have thoughts, feelings, and opinions like every other human. But the idea that nearly every patient (~95%) experiences harm raises red flags for me for a number of reasons.
I’m not going to pick apart their methodology because A) it seems like an honest attempt to quantify this harm; and, B) we’re not PhD researchers here, so let’s not pretend to be. Instead, let’s stick to “common sense” and see how far that gets us.
To take the findings at face value, it would imply that basically everyone is harmed by therapy or therapists. I refuse to believe that, even though it tracks with basically everyone I know’s personal experience. The plural of anecdote is not “data”, so let’s move on.
A number this high is also explained by sourcing respondents from places in which “anti-Therapy” people are likely to hang out.
Asking everyone on r/TherapyFuckingSucks is obviously a good way to get a near-unanimous vote for “Therapy Bad”.
(But it’s also a form of selection bias to demonstrate that “Therapy Works” by selecting patients who keep coming back for more, or selecting patients from a healthcare setting, where they’re more likely than the general population to have severe cases. Generalizing these results to the wider population can make a problem seem more dire than it truly is.)
A third explaination I can offer is that the definitions for harm are too broad. Miscommunication happens all the time, and we should expect some during a therapeutic interaction. That is, people who hire others to call them out on their bullshit should not be surprised that their feelings sometimes get hurt.
There’s also the fact that a non-zero number of people are forced into therapy against their will, which can make even the best therapy in the world a deeply negative experience.
To compound the problem and dismiss or minimize the patients (76%+) that feel they’ve been ignored, interrputed, misunderstood, etc. and look only at the super-extra-alarming things like your therapist showing up at your house to steal your identity or somesuch, the numbers fall more in line with what I’d expect - 10%, 20%, maybe 40%.
I predict with high confidence that future studies will show a lower number, but I still think their core message is valid: that a significant number of patients have been harmed by the people who insist that therapy is all rainbows and unicorns.
As awareness of this grows and the taboo of being “anti-Therapy” fades, hopefully we’ll be able to strike a balance and get people the help they need.
But as long as we’re more worried about metrics like “dollars allocated”, “jobs created”, and “therapy sessions conducted” than patient outcomes, this something, something, more mental health movement will continue to misallocate resources and do more harm than good.