Therapy is having a rough showing of late.
A recent Wall Street Journal article criticized therapists for encouraging family estrangement. Others have called out the dubious scientific claims behind popular modalities, the hypocrisy of therapy influencers, and the downsides of therapy.
And you know what?
It’s about time.
It’s about time we take therapy off the high horse we’ve put it on. The idea that therapy is a magical cure-all is misleading. Therapy is a means to an end that works, or doesn’t work, to varying degrees.
It is not for everybody. Not all therapy is helpful. And bad therapy is out there.
The first rule in medicine is do no harm, and it’s a strange thing that my field rarely talks about it. Our silence isn’t because we’ve rejected the principle. It’s the opposite: we don’t think of ourselves as capable of doing damage. We got into this work out of a sincere desire to help. We see ourselves as good, kind-hearted, hard-working people, and by and large that’s true. But that view blinds us to the harm we cause inadvertently and unknowingly.
Read any therapist’s website, mine included, and you’ll find claim after claim about inner transformation and lasting change. If we take those claims seriously — and I think we should — we have to take the other side seriously too. Anything potent enough to change your life for the better is also potent enough to change it for the worse.
That’s what this piece is about: how therapy goes wrong, and how you can spot it. If you’re thinking about starting therapy, or wondering whether the therapy you’re in is working, this is for you.
My Own Wake-Up Call
Many years ago, I worked with a couple for the better part of a year. After hitting a plateau, we ended the couples work on the understanding that one of the partners would pursue individual treatment.
Some months later, I received a thoughtful email from the other partner. In it, she shared her view that couples therapy was never going to work. She expressed her regret that I hadn’t seen that from the start — she wished I’d caught it, named it, and by doing so saved her time, money, energy, and heartache. In the end, she didn’t only see the couples therapy as ineffective. She saw it as harmful.
Sitting with her email, I had to face something: I had never been taught to investigate, much less consider, how and when therapy could be damaging. And that’s precisely the point I want to underline. When therapists aren’t introduced to the idea that therapy can be harmful, they aren’t able to see it.
I now go out of my way to tell clients that therapy isn’t always helpful and that it can do damage. I tell them what to look for, and I actively seek feedback about what is and isn’t working. Most therapists don’t do this, which is why you need to know what to watch for, too. Just as you’d expect to be told the side effects of a medication before taking it, you should know the potential side effects of therapy.
Where and Why and How Therapy Fails
Let’s begin by appreciating the nature of the therapeutic task.
One person — an immensely complicated, impressively dynamic human being — goes to another person for help with their mind and emotions. This other person, the therapist, is themselves dynamic and complicated. They are burdened by their own blind spots, their own history, their own idiosyncrasies, biases, assumptions, and defenses. To varying degrees, each person in the encounter lacks self-awareness. That is simply the human condition. And yet one is supposed to help the other.
It should be clear that pitfalls abound.
Every intervention carries risk, and ignoring that fact doesn’t make it go away. The opposite is more useful: the better you understand how therapy can hurt, the better your chance of catching it in real time.
Here’s what can go wrong, in three areas: your mental health, your relationships, and your self-understanding.
Your Mental Health
Ideally, therapy improves your mental health. That’s what it’s purported to do, anyway. Regrettably, that doesn’t always happen.
Your symptoms can get worse.
A 2018 study published in the British Journal of Psychiatry found that one in twenty people reported lasting bad effects from psychological treatment. That is not a rounding error. It’s a meaningful minority of people who came for help and left worse off.
New symptoms can arise that you didn’t have before.
Labels the therapist offers so you can understand yourself better such as neurodivergent, avoidant attachment, or rejection-sensitive can become a place to live. Clients arrive with a difficulty and leave with an identity. What started as a description of something they wanted to change becomes a description of who they are. Therapists contribute to this more than we admit. We hand over the vocabulary, and we’re pleased when a client picks it up, because it looks like insight. But rather than working to overcome these labels, clients sometimes take refuge in them, and the symptoms that make the categorization fit grow more pronounced as the therapy goes on.
You can become dependent on your therapist.
Therapy is meant to make itself unnecessary. You get better so that you don’t need it anymore. It doesn’t always go that way. A weekly hour with someone who listens carefully, never judges you, and attends entirely to your interior life is a rare thing in adult life, and it’s easy to come to feel you need it. Instead of dealing with things as they arise, you wait to process them on Thursday. You become dependent on the very thing meant to make you more confident, clear, and capable.
Therapy can drag on for years without noticeable improvement.
Costing you considerable time and money in the process. Most therapy has no built-in review point — the appointment renews itself, the relationship is pleasant, and the question of whether you’re actually better than you were eighteen months ago never quite gets asked.
Your Relationships
Your read on other people can get less accurate, not more.
As you discuss recurring interpersonal difficulties, you and your therapist may collude in painting others in a bad light. You may assign them a personality disorder or some other unflattering diagnosis. Gradually they’re reduced to a cold, narrow caricature of who they actually are. And you may experience that as insight rather than as loss.
Relationships might end that didn’t need to.
Estrangement — going no-contact with a parent, a sibling, a friend — is becoming more common, and therapy can move you toward that door too quickly. Sometimes it’s the right call. With abuse or danger, it may be the only call. But it should be, in the words of family therapist William Doherty, “the tragic exception rather than business as usual.”
Existing relationships can come under strain.
Marital and family conflict shows up consistently in the research as one of the most commonly reported negative effects of therapy. Some of that is unavoidable and necessary: if you start asking for things you never used to ask for, the people around you will feel it. But some of it is just destructive. A partner who has never met your therapist can end up feeling tried and convicted in a room he has no access to.
Boundaries can become a way of avoiding intimacy.
Intimacy isn’t always comfortable. It demands uncomfortable conversations and difficult feelings. At their worst, boundaries become an avoidance tool employed under the rubric of self-care. Because they sound like maturity — this is just my boundary — they can mask the fact that you’ve stopped doing the work intimacy requires.
Your Self-Understanding
You can lose the ability to just have your emotions.
Every feeling has to have an origin story, and the origin is usually childhood. You can’t simply have a bad day, because the bad day is a symptom, and the symptom has a history, and the history needs unpacking. Ordinary human discomfort — which everyone has and most people survive without assistance — becomes evidence of something serious requiring exploration.
You can analyze yourself into paralysis.
Introspection has diminishing returns. Past a certain point, examining every feeling and thought and reaction leads to exhaustion and second-guessing rather than clarity. When therapy encourages this, it has lost the plot.
You can collapse into victimhood.
This is the harshest thing in this section and I mean it. When you confront the difficulties of your past, there is a compelling pull toward seeing yourself as a victim — and therapy can hand you a version of your life in which everything that went wrong was done to you. That story is comfortable, and it’s often partly true, which is what makes it so hard to leave. But it renders you powerless.
You can trade your own self-knowledge for your therapist’s.
Your therapist’s read on your life can come to outrank your own. Rather than trusting yourself, you defer. Here’s a decent test: if you can’t say “I think you’ve got that wrong” out loud, in session, and have your therapist take it well, something has gone sideways.
Why It Happens
Some of the above is the result of bad therapy. Some therapists deliberately cross clear boundaries, and others are simply out of their depth. But most of what I’ve described happens in rooms run by decent, competent people who would be appalled to learn of the harm they’d caused. That’s the part worth understanding. If harm only came from obvious villains, it would be easy to avoid.
We can’t see what we were never taught to look for.
This is the one I ran into myself. Harm isn’t a topic in most training programs. It isn’t a standing question in supervision. A therapist can practice for thirty years and never once be prompted to ask whether he’s damaging someone.
We judge our own work by the least reliable evidence available.
Therapists mostly evaluate their effectiveness by whether the client seems better. That can be a terrible indicator.
We only ever hear one side.
Your therapist has never met your mother, your partner, or your coworkers. Everything we know about them comes from you. We are not neutral observers of your life. We’re working from a single account, and we risk forgetting that.
Without structure, therapy drifts toward venting.
If nobody is steering the sessions towards clear therapeutic goals, they risk becoming nothing more than a place you unload. That can feel good but get you nowhere. Worse, it can be a repetition of the very habits causing your troubles in the first place. When a client ruminates and the therapist joins in rather than interrupting, the hour reinforces the problem it was meant to treat.
Good intentions aren’t a skill set.
When therapists assume that a big heart and a sincere desire to help will be enough, they fall into incompetence without noticing. Rather than rigorously pursuing deep knowledge, they show up believing that “holding space” will get the job done. It won’t. The basic, painful truth is that wanting to help and being a good person are a far cry from the knowledge and skill that genuinely useful therapy requires.
And the incentives don’t help.
We get paid by the hour, which means I have no financial reason to ask whether we should stop. The solution is to be a ridiculously good therapist that clients pile in to see.
It’s Not All Bad News
I’ve spent this whole piece telling you how therapy can hurt you, so let me be equally direct about the other side.
Therapy works. Across decades of research, people who receive a bona fide psychotherapy do better on average than people who receive nothing. That finding is about as robust as anything in the field. The one-in-twenty figure I cited earlier means nineteen in twenty didn’t report lasting harm, and a great many of them got substantially better.
But notice that the argument for therapy and the argument against it are the same argument. Therapy can damage you because it is potent. A treatment too weak to hurt you would also be too weak to help. Nobody worries about the side effects of a placebo.
What follows from all this isn’t that you should avoid therapy. It’s that you should approach it the way you’d approach any other consequential intervention in your life: with your eyes open, with realistic expectations, and with some way of telling whether it’s working.
How to Protect Yourself
(If you’re still in the process of finding the right therapist, this guide covers what to look for, including the questions worth asking before you book.)
Know what you came for. Be able to say, in a sentence, what you want to be different. Vague goals produce vague therapy, and vague therapy is the kind most likely to drift for years.
Ask about risks before you start. Ask your therapist directly: what are the risks of this approach, and how will we know if it’s not working? The answer matters less than whether the question is welcome. A therapist who has never considered it is telling you something important.
If you want to understand the difference between therapy approaches before choosing one, this breakdown of therapeutic modalities is a practical starting point.
Track something outside the room. Not how you feel walking out, that’s the unreliable measure. Are you sleeping better? Fighting less? Working? Seeing your friends? Pick two or three real-world markers and check them every few months. Your life is the outcome measure, not the session.
Set a review date. Three months in, six months in, and then regularly: is this working? Would I recommend this to a friend in my situation? If the answer is no two reviews running, say so out loud.
Disagree with your therapist at least once. Not for sport, but so you find out what happens. A good therapist can hear “I don’t think that’s right” and get curious. If disagreeing feels dangerous or produces a lecture, you’ve learned something.
Be suspicious of certainty about people who aren’t in the room. Your therapist has never met them. Neither of you actually knows whether your mother has a personality disorder.
Notice if you’re getting smaller. The point of therapy is a larger life. That means more capacity, more relationships, more ability to handle what comes. If your world is narrowing, if the list of people you can’t deal with is growing, if therapy has become the main place you feel understood, something has gone wrong regardless of how good the sessions feel.
Leaving is allowed. You don’t need permission and you don’t owe an explanation. If it isn’t working, it isn’t working.
Trevor Brown is a licensed therapist working with expats, digital nomads, and intercultural couples online. He offers individual therapy as well as couples therapy. He’s based in Istanbul.
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