First, Do No Harm

The first principle of health care is to do no harm. Many of us can site examples where well intended care has injured others. As therapists we may forget that “talking” with someone has the potential for causing harm. Therapy by its nature is a process that encourages people to examine problems in their lives, look at ways that they may be undermining or sabotaging themselves, and look more closely at themselves, their feelings and their motives (all of which may not be consistently positive or uplifting).  Secondly, family and marriage therapy are potentially even more risky. If spouses, partners or family members confront each other about problems, bring out previously upspoken concerns, and challenge existing patterns there is a potentially significant risk that feelings may be hurt, relationships strained, and conflicts intensifed.

It is our obligation as therapists to remember that while the services we offer can help people in many ways,  often quite profoundly, that we can cause harm (emotional pain, family conflict etc).  Keeping this in mind when we consider various strategies and interventions is something we all need to be cognizant of. This is not to minimize or downplay the value of therapy. There is a clear and consistent body of research that supports the value of psychotherapy (see for a discussion of this issue and a list of article and studies supporting the value of psychotherapy). Rather, it is to highlight the importance letting those we are working with know that therapy, like all interventions, has risks and rewards.

Informed Consent: A paradigm for reducing risk 

It is also our obligation to let our clients know about these risks. For those who peruse the literature on risk management there is much discussion of the issue of informed consent. Many writers have stressed that informed consent should not be a static, one time proforma event, that it can be in some medical setting. I can think of a number of occasions where I was handed forms to sign, with no active encouragement to read them, but rather with the exceptation that I quickly sign and return them. For those of you who have ever had a stress test you realize that you are giving the hospital permission to perform a wide range of interventions (including heart surgery) if you encounter problems during that test. On other occasions I have had more positive experiences where I have been carefully warned about the potential risks and limits of a procedure. The challenge for all of us as health care professionals is to remember that we can bring about harm as well as benefit, and that it is our obligation to be clear with our clients and patients about this.

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