You do not currently have permission to view the full text for this document. Please sign in to an account with an active subscription or contact support.
In a JAP interview conducted by Warren Colman, it became clear that early in her career Jean Knox recognized that psychotherapists and analysts, mostly inadvertently, can harm their patients (Colman, 2019). Misunderstanding, rigid application of the wrong models and bad technique all impact negatively on patients we are trying to help. In this British Journal of Psychotherapy paper Knox underlines that it is insufficient to investigate good practice. We need also to ‘identify harmful aspects and define poor clinical practice’.
Knox begins by identifying three aspects, evidencing each. First, exploring the nature of the psychotherapy itself, she points to negative outcomes, under certain conditions, of a range of approaches, from Critical Incident Stress Debriefing to psychodynamic psychotherapy. Second, she tackles the characteristics of the therapist that may lead to deterioration in the patient. Examples of this are: being overly confrontative, lacking empathic warmth, relying defensively on theory. Knox also cites research showing that avoidant attachment styles in therapists are also associated with more negative outcomes. Third, the focus shifts to the dynamics of the patient-therapist relationship. Here, she highlights ways in which patients can feel confused, coerced or intruded upon and end up blaming themselves for not eliciting empathic responses, their sense of agency further undermined.
Avoiding the harmful effects of psychotherapy rests on the therapist's capacity for imaginative play, an interplay between associative and directed thinking. It includes the importance of affect regulation, mentalization and the emergence of epistemic trust. Interpersonal agency, resting on a strong therapeutic alliance is also key. In seeking further clarification on how these capacities develop, Knox helpfully looks to other disciplines which have already outlined intersubjective building blocks that can be related strongly to both positive and negative experiences of psy