Therapy is meant to help people heal, but can therapy cause harm? In some cases, yes. The concept of iatrogenesis in mental health care refers to unintentional harm caused during treatment. While therapy can be deeply healing, clinicians must also be willing to examine how harm in therapy happens and how ethical, thoughtful care can reduce that risk.

This month, our team discussed themes raised in Abigail Shrier’s book Bad Therapy. As therapists, I believe we should be willing to engage thoughtful criticism of our profession rather than dismiss it too quickly. Even when we disagree with a critic’s conclusions, there may still be value in examining the questions they raise.

My purpose here is not to review Shrier’s book. It is to reflect more broadly on a concern that should matter to every clinician, practice owner, and helping professional: Can therapy unintentionally cause harm?

That question is captured in the term iatrogenesis—the unintended creation of harm in the course of treatment.

It is a term more commonly associated with medicine, but it belongs in conversations about mental health care too. If we are serious about ethical practice, we cannot merely ask whether therapy helps. We must also ask when, how, and why it may harm.

The uncomfortable truth: good intentions are not enough

Most therapists enter the profession because they want to help people heal. But good intentions do not eliminate the possibility of poor outcomes. In fact, one of the greatest risks in any helping profession is the assumption that sincere care automatically protects us from causing damage.

It does not.

Therapeutic harm is not always dramatic, abusive, or obvious. Often it is subtle. It can emerge through misattunement, overconfidence, premature interpretation, excessive passivity, poor boundaries, misplaced affirmation, or an unexamined desire to lead the client where the therapist believes they should go.

When I asked members of our team what they would describe as “bad therapy,” their answers were strikingly consistent. They named therapy that is not focused on the client, therapy shaped more by the therapist’s goals than the client’s needs, therapy that retraumatizes, therapy that fails to address root issues, invalidation, poor listening, judgment, excessive advice-giving, and approaches that affirm emotion without grounding people in truth.

That list is worth sitting with.

Because the real leadership question is not whether we can identify bad therapy in theory. The real question is whether we are willing to ask how often those same dynamics can appear in our own work, often in quieter and more socially acceptable ways.

Therapy is never value-neutral

One of the great misconceptions about therapy is that it is a neutral, purely technical service. It is not.

Every therapist works from assumptions about human nature, suffering, change, responsibility, healing, and truth. Those assumptions shape what we notice, what we emphasize, what we challenge, what we validate, and what we believe the client most needs.

A cognitive behavioral therapist may view distorted thinking as central. A behavioral clinician may emphasize learned patterns and reinforcement. An EMDR therapist may focus on unresolved experiences and the beliefs formed around them. Family systems approaches, psychodynamic models, attachment-based work, somatic interventions—each framework highlights something real, but none offers a complete account of the human person.

That matters because the therapist’s theory of suffering becomes the therapist’s strategy for healing.

In other words, what we believe is wrong will inevitably shape what we do next.

This is one reason therapy can help profoundly—and also one reason it can go wrong.

The danger of clinical overconfidence

As a Christian EMDR therapist, I believe suffering is often shaped by an interplay of biology, psychology, relationships, lived experience, and spirituality. Human pain is rarely reducible to one cause. Nor is healing reducible to one technique.

That should make us humble.

I am trained in EMDR, an approach with a clear protocol and a meaningful structure. That structure matters. It provides direction, safety, and coherence. But even within a structured model, therapy is never mechanical. The work looks different depending on the person, the context, the readiness of the client, and what is emerging in the room.

The skill is not simply in knowing the model. It is in knowing how to use it with wisdom.

Yet clinical confidence can quietly harden into clinical overconfidence. We begin to assume we understand more than we do. We infer too quickly. We frame a complex relational problem through a single conceptual lens. We mistake one person’s report for the whole truth. We interpret before we have listened deeply enough.

And in doing so, we may unintentionally cause harm.

When therapy reinforces fragmentation instead of healing

One area where this concern feels especially relevant today is in the growing cultural vocabulary around narcissism, cutoff, estrangement, and no-contact relationships.

There are absolutely situations in which boundaries are necessary, distance is wise, and separation is protective. Some relationships are dangerous. Some patterns are destructive. Some clients need support in moving toward safety and clarity.

But we should be concerned when therapy begins to reinforce simplistic narratives of victim and villain based solely on one person’s perception, especially early in treatment. If clinicians prematurely encourage clients to sever relationships without careful discernment, contextual understanding, and meaningful exploration, we may be validating pain while bypassing truth.

That is not compassionate care. That is clinical carelessness dressed in therapeutic language.

The issue is not whether boundaries matter. They do. The issue is whether therapists are helping clients move toward wisdom, responsibility, discernment, and wholeness—or merely offering emotionally satisfying interpretations that deepen fragmentation.

A therapist who mistakes affirmation for wisdom may feel supportive while quietly increasing harm.

Therapy should be collaborative, not coercive

At its best, therapy is neither passive listening nor therapist-driven persuasion. It is a collaborative, intentional process in which the client participates in identifying goals, exploring patterns, tolerating truth, and practicing change.

There are moments when a therapist should challenge. There are moments when a therapist should encourage. There are moments to slow down, moments to interpret, moments to ask better questions, and moments to remain silent. No manual alone can tell us the right move in every moment.

That is why therapy requires more than technique. It requires judgment, self-awareness, emotional maturity, ethical restraint, and, I would argue, spiritual humility.

For those of us practicing from a Christian worldview, this humility is not optional. We can study theory, follow evidence, learn modalities, and refine our craft—but only God fully knows the human heart. Only God sees the whole story without distortion. The rest of us are working with partial knowledge.

That reality should never paralyze us. But it should keep us honest.

The leadership challenge for therapists and practices

If we want to lead well in mental health, we must create cultures where self-examination is normal, not threatening. The most dangerous therapeutic environments are not always the least skilled. Often they are the least reflective.

Thoughtful clinical leadership requires more than confidence in our methods. It requires the willingness to ask difficult questions:

• Where might our framework be too narrow?
• Where might our personal convictions be distorting our care?
• Where might we be reinforcing dependency, avoidance, or blame?
• Where might we be overidentifying with the client’s narrative without sufficient curiosity?
• Where might we be mistaking emotional validation for meaningful treatment?

These are not accusations. They are safeguards.

In healthcare, quality improves when professionals are willing to examine unintended consequences. Mental health should be no different. If iatrogenesis is possible in therapy—and I believe it is—then humility, consultation, ongoing training, and reflective practice are not extras. They are part of ethical care.

A final word

I do believe therapy can bring profound healing. I have seen it. I have been honored to witness people move toward freedom, integration, truth, and deeper connection with God and others.

I also believe therapists can cause harm, even when they mean well.

Holding both truths at once is not cynicism. It is maturity.

The future of good therapy will not be secured by defensiveness. It will be secured by humility, rigor, discernment, and the courage to examine ourselves honestly. If we want to serve people well, we must be willing to ask not only, “How do we help?” but also, “Where might we be hurting?”

That question is not a threat to our profession.

It is one of the ways we make it better.

FAQ

Can therapy cause harm?
Yes. Therapy can sometimes cause unintentional harm through poor boundaries, misattunement, premature advice, invalidation, or overly rigid clinical assumptions.

What is iatrogenesis in therapy?
Iatrogenesis in therapy refers to harm that occurs unintentionally during mental health treatment, even when the therapist intends to help.

What are signs of bad therapy?
Signs of bad therapy may include poor listening, therapist-centered goals, invalidation, excessive advice, retraumatization, or pushing clients toward major relational decisions too quickly.

How can therapists reduce harm?
Therapists can reduce harm through humility, reflective practice, supervision, ongoing training, careful assessment, and collaborative treatment planning.