Iatrogenesis is unwanted or unintended damage, caused or provoked by medical or psychological treatment. In psychology, this term is usually associated with pseudoscientific procedures, but in reality iatrogenesis can be caused by a wide variety of factors associated with the therapy, the characteristics of the clients, the therapist, and the context.
Although we have known for years about the harm that therapy can cause, little is said about it in clinical training and therapists often overestimate the positive effects of therapy. Especially when talking about borderline personality disorder, a diagnosis that increases the risk of iatrogenesis as a result of emotional dysregulation (intensity and frequency of emotional conflicts) and deficiency in interpersonal skills.
To know more exactly what factors are associated with the harmful effects of therapy in BPD, Rodriguez Cahill’s team (2021) conducted a review of the iatrogenic factors related to BPD. The results were published in the journal and include some recommendations to reduce them. The review is psychodynamic in nature, but has many points in common with other more behavioral treatments, such as DBT.
Below I will present a synthesis of the aforementioned research and add some comments at the end about the commonalities I see with dialectical behavior therapy. If you want you can download the original article from .
What is iatrogenesis in therapy
Psychotherapists overestimate the positive effects of their therapies and overlook the risks to which patients are exposed. Research has shown that psychological treatments can be effective, but it has also been found that 5-10% of patients worsen during the process and more than 30% do not show clinically significant improvements.
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For several decades there has been talk about the problems adverse to psychological therapies; Still, research into its causes and prevention has stalled. There are different causes, but a very common one is that researchers use different terms to study adverse effects (exacerbation of symptoms, negative effects, treatment failure, clinical deterioration, negative reaction to therapy, etc.) making the data and the investigations are confusing.
To use a more specific definition, the review team proposes two types of iatrogenesis: positive iatrogenesis: that which arises as a result of an action harmful to the patient; and negative iatrogenesis: product of the absence of an adequate intervention (when a patient with self-harm receives, for example, family constellations instead of DBT). Which means that avoiding harm in interventions is not enough. Presenting insufficient service can also generate adverse effects. In patients diagnosed with BPD and their families, iatrogenic effects generate the belief that treatments do not work, that they are unlikely to change, and at the same time, self-efficacy in future treatments is reduced.
According to Fonagy and Allison (2014), people with this diagnosis are more susceptible to harm from interventions due to hyperactivation of their attachment system. Frequently, psychological interventions stimulate the attachment needs of these patients, but they do not provide the necessary structure nor are they carried out in the minimum conditions required to work on their difficulties. Which causes many patients to abandon treatment, require more emergency services, or increase the severity of self-harm.
Factors related to iatrogenesis
Factors that promote iatrogenesis. Image taken from Rodríguez Cahill, C., Ruiz Llavero, G., Martín Escudero, D., Garnelo Fernández, P., Sánchez Rodríguez, F., Casares García, MI and Morales González, K. (2021). Iatrogenesis in people diagnosed with borderline personality disorder. Contemporary Clinic, 12(3), Article e22. https://doi.org/10.5093/cc2021a21
The iatrogenic factors collected by the review:
Personality disorder concept
The very conceptualization of this diagnosis and the associated prejudices are usually iatrogenic. In 2017, Chartonas et al. 2017’s team replicated research from 1988 that showed that psychiatrists hold negative attitudes toward patients with a diagnosis of personality disorder and tend to feel that their work has less meaning when dealing with such patients. . Therefore, the diagnosis in this case can be stigmatizing. Which in turn produces overmedicalization and infantilization of people with this diagnosis. Resulting in the chronicification of their problems.
Clinical evaluation
Diagnostic labels are not realities but classifications that serve as a common language for mental health professionals. When diagnostic labels are not accompanied by an idiosyncratic analysis of the individual’s difficulties, characteristics, and strengths, they only generate more stigmatization and objectification. On this topic, data suggest that psychiatric diagnoses can worsen people’s clinical and social outcomes (Timimi 2014). Therefore, it is important to understand the individual and contextual variables of patients to provide adequate treatment.
The main causes of iatrogenicity in clinical evaluation are due to reductionist diagnostic models without a comprehensive reference model, ignoring diagnostic errors, overdiagnosis of problematic patient behaviors, and lack of dedication of sufficient time for a good evaluation. In 30-40 minutes they write a diagnosis.
Of course, the diagnosis can also be useful for patients and their families, as it can convey a sense that their suffering is something that has a name and is known by the community of specialists. But it must be explained carefully and taking into account all the characteristics of the person.
Intervention
The authors suggest that the most common mistake when treating people with personality problems is prioritizing pharmacological treatment over psychotherapeutic treatment. This position facilitates excessive medication and increases the risk of receiving poorly planned, inconsistent and improvised treatments. Which brings a lot of problems. Every time a patient does not receive treatment and does not benefit from it, hopelessness increases and they believe that it is not possible to change or have a better life.
Characteristics of iatrogenic treatments in patients diagnosed with BPD:
- Non-specific and inconsistent treatments.
- Lack of skills or training to work with these patients.
- Indicate psychotherapies or interventions not recommended for diagnosis.
- Carry out extemporaneous interventions that do not consider the timing of therapy due to the therapist’s impatience. The most concrete example is trying to do trauma treatment in the early stages of treatment when risk behaviors need to be stabilized.
- Use pseudoscientific treatments.
- Not paying attention to comorbidity (addiction, eating disorders, for example).
- Promote and maintain unrealistic expectations of success and instant professional competence. For example, assuming that the success of therapy only depends on the correct application of a technique.
- Fear of confrontation and difficulty managing the work relationship.
- Destroy the therapeutic relationship by negatively evaluating some aspect of the patient.
- Pathologization of the patient.
- Recurrent emergency admissions and absence of a crisis plan.
Treatments with scientific evidence, such as dialectical behavioral therapy, mentalization-based therapy, and transference-focused therapy, are manualized treatments that have proven to be effective in the treatment of people with borderline personality disorder. It is necessary that patients can receive adequate and precise treatment.
Bateman and Fonagy (2004) offer a list of characteristics and similarities that the treatments that have demonstrated evidence for this problem have:
- Treatments with a high level of structure.
- Implemented consistently and reliably.
- Theoretical coherence.
- They consider the difficulties in establishing relationships with these patients. And they include the importance of establishing a good therapeutic alliance
- Flexibility.
- Intensity according to the patient’s needs.
- Approach and personalized care.
- Good integration and coordination with other services that care for the patient.
Personal characteristics of the therapist
Working with people with borderline personality disorder involves dealing with high-level emotional content and significant relationship difficulties, risky behaviors, etc. This requires that professionals who work with this population be prepared to manage these characteristics. In therapy, the relational style and emotions that therapists experience are useful work tools, but they can also be a source of iatrogenicity. This means, according to the authors, that saving fantasies, therapeutic omnipotence, emotional withdrawal or subjection of the patient are sources of iatrogenesis and block any progress. Another factor is the therapist’s extreme adherence and rigidity to the application of techniques. With this population, the authors maintain that therapists must maintain an open attitude and flexible use of therapeutic tools.
People with BPD pose a special challenge to professionals, especially when they transgress the therapeutic framework and test the limits of the therapeutic relationship. The therapist must explain and maintain the conditions of the setting in order to be effective. On this topic, Rodríguez Cahil (2015) maintains that it is expected that patients with BPD will test the limits of therapy. This is not iatrogenic. What is harmful is that the therapist breaks the frame to satisfy his or her own needs, difficulties, economic or personal interests.
Management of the therapeutic alliance
The therapeutic alliance involves finding a balance in terms of distance and closeness, an especially difficult aspect with patients diagnosed with a personality disorder. People with BPD are often highly sensitive to intimate relationships. Therapists must be aware of this particularity and avoid iatrogenic interactions.
Patient-related factors
- Prolonged severe symptoms.
- Low motivation for change and therapy, external locus of control regarding their problem or difficulty with introspection and expression.
- Serious difficulties for…