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Sunday, August 16, 2015

APA and Torture: A More General "Nocere" Issue

People who are interested in psychology as a subject of study or as a profession can hardly have missed the recent brouhaha in the American Psychological Association, following public attention to the complicity of psychologists and the organization itself with the use of torture in the interrogation of prisoners at Guantanamo. This complicity of the organization included some shuffling of the ethical code to make it acceptable for psychologists to recommend “enhanced” interrogation techniques and thus to make themselves agreeable to the Department of Defense. (The American Psychiatric Association refused to do this, and they are most pleased with themselves--  which I acknowledge that they have every right to be.)

 At the recent APA (that’s the psychologists) annual convention  in Toronto, “town hall” meetings discussed the ethical issues concerned, and a resolution was passed, with only one dissenting vote. Among other things, the resolution stated that APA members should not be involved in national-security-related interrogations in any way, including supervising or advising on how other people do them. Members of APA were invited by e-mail to give feedback on this resolution, and I did so. Here is what I said:

“In my opinion, the resolution, with its focus on national security issues, completely misses the point. Psychologists should not employ or contribute to methods that are potentially harmful, whether the context is national security, domestic prisons, residential treatment centers, or outpatient treatment. In addition, there should be a clearly-stated ethical obligation for psychologists who become aware of such actions by other psychologists to call attention to them by reporting to APA or to licensing authorities. APA, in turn, needs to be responsive to such reports and to make public statements about substantiated reports even when the offending psychologist is not an APA member.”

Psychologists as a group have never adopted the principle of primum non nocere (first, do no harm). There has been a long-standing assumption that what psychologists do must be beneficial—why would we call it “therapy” if it isn’t good for you? Nocere has not been considered to be one of the options; in fact, when patients found treatments distressing, it was assumed that such distress was needed to motivate change or to overcome resistance, and that in the long term such unpleasant experiences were actually beneficial. This attitude was especially prevalent in the ‘70s, when bullying at Esalen was considered a viable intervention, when two practitioners in Flagstaff, AZ caused the death of an adult patient through physical methods, when Robert Zaslow lost his California psychology license after serious injuries to a patient, and John Rosen in Philadelphia apparently pushed a patient down a flight of stairs. Today, painful “psychotherapy” for adults is less common, but distressing methods for children, especially adoptees, are still advocated by some practitioners. These people may argue that just as chemotherapy for childhood cancer is painful but necessary, the treatments they use are similarly distressing but needed; unfortunately for their argument, they forget that there is good evidence for the efficacy of chemotherapy, but no such evidence for distressing psychological interventions.

In recent years, a small groundswell of disapproval for harmful behavior by psychologists has begun to appear. I can point to my own efforts to fight holding therapy by describing its distressing and physically harmful effects, beginning in 2001. Scott Lilienfeld in 2007 suggested the term “potentially harmful treatments” (PHTs) for interventions that have a history of doing harm or that could reasonably be expected to cause harm. The PHT designation provided a category whose existence indicated that nocere was in fact one of the options for psychologists—not all “therapies” were actually therapeutic. More recently, Michael Linden, a German psychiatrist, has put forward the concept of adverse events of various types that can accompany psychological interventions, just as they may occur with physical or pharmaceutical treatment. In a 2013 paper, Linden argued that feeling distress during psychological treatment should be considered an “emotional burden” and an unwanted side effect that should be avoided if at all possible.

These facts about psychological treatment and its potential for harm, in my opinion, need to be added to APA’s discussion of the harm done by psychologists who supervised torture. Simply to refrain from engagement with the Department of Defense provides only a small part of the solution to the problem. It is time for psychologists--  and not only psychologists, but other mental health workers—to recognize that there is a power for ill as well as good effects in our practices. It is time for us to stop passing by “on the other side”, like the priest and the Levite, when harm is caused to any person by the exercise of psychological skills. When APA recognizes this and builds awareness into the code of professional ethics, we may be able to move forward. As long as we point the finger only at the guilty parties at Guantanamo, we cannot.


  1. Thank you for shining a light on this broader problem. I am one of those people who just assumed that the APA would have long ago have considered the potential for harm in their code of ethics.

    How widely will you statement be seen? By all members, one would hope.

    1. No, I don't think most people associated with APA have given any thought to the potential for harm until recently. I would have thought that it would be realized that if something has the power to do good... well, you know what, but I guess not.

      I've posted this blog piece on two APA lists as well as sending it as feedback to APA. I had an interesting reply on one list, where someone said this should have gone into the APA casebook that was not published when it should have been--- I don't know what that's all about but will try to find out.

  2. A question: Does the APA have a statement about using science-based practices? It seems that would also serve to lessen harm to patients.

    1. Yes, for almost 20 years now the word has been that evidence-based treatments are to be supported and used when available. Unfortunately, this has not necessarily meant that APA continuing education materials have always concerned EBTs. Recently, I have noticed a tendency to call treatments or programs evidence-based when only one small part of a program is supported by strong empirical evidence.

      I recently had an e-mail discussion with a member of an APA division about posting information that showed that some treatments were potentially harmful. He asked whether there were randomized controlled trials that showed harm! I had to point out that people who do PHTs don't usually do RCTs.