Primum non nocere: Understanding the Role of Harm in Treatment for Youth Mental Health Concerns

Much of the extant literature supporting evidence-based treatments for mental health conditions has focused almost exclusively on salutary treatment effects, often measured via symptom reduction or improved functionality. Indeed, the American Psychological Association guidelines on empirically supported treatments (EST) uses rigorous studies demonstrating comparative efficacy of a proposed intervention compared to placebo or another treatment as the sole evaluative criteria for EST status. We certainly do not deny that symptom reduction and improved functionality are important outcomes in and of themselves. Nevertheless, potential iatrogenic or nonbeneficial effects of treatments for mental health conditions remain notably underexamined in both research and clinical settings, despite their insidious nature.

Potentially iatrogenic or nonbeneficial effects of treatments are complex in nature and can extend beyond clear cases of harm to patients (e.g., suffocation death due to rebirthing therapeutic techniques). For example, (a) use of ineffectual interventions (when efficacious ones are available) contributing to financial, time, and opportunity costs; (b) clinician failure to notice and correct for worsening/non-improving symptom course; and (c) a lack of critical assessment of reasons for patient drop out are all scenarios that could conceivably fall under the umbrella of intervention-related harm. At present, potentially harmful effects of treatment are typically considered only within the context of monitoring for imminent adverse effects in clinical research trials, with such monitoring being much more clearly explicated within pharmacological interventions compared to psychological ones. This results in greater difficulty in accurately drawing conclusions about the level of potential risk for harm within psychotherapy-based interventions compared to pharmacological ones.

Fortunately, there has been a growing line of conceptual and theoretical work explicating the importance of considering the potential iatrogenic or nonbeneficial effects of interventions for mental health concerns. However, much of this foundational work is often broad in nature, focusing less on specific disorders or populations, and more so on clarifying conceptual definitions of harm and applying this framework to mental health treatments on a general basis. More recently, a special issue in Clinical Psychology: Science and Practice (McKay & Jensen-Doss, 2021; https://psycnet.apa.org/PsycARTICLES/journal/cps/28/1) sought to move down the knowledge development funnel from broad to specific by commissioning a special issue on harmful treatments in psychotherapy, with articles devoted to potential iatrogenic treatments for specific psychological disorders, as well as empirical methods for identifying such harmful effects.

However, research endeavors within identifying potential harm in mental health treatments have predominantly focused almost exclusively on adult populations. As such, a glaring gap in the literature exists concerning our understanding of potentially harmful treatments for youth mental health issues. In terms of application, the process of downward adaptation of intervention principles from adult to child populations has served as a useful framework in clinical science. However, the intricacies of child mental health and unique developmental considerations mean that rote application of considerations for harmful treatments in adults to youth populations is likely insufficient. Additionally, several contextual factors unique to youth mental health, including the prominent role of parents and teachers in both youth psychopathology and treatment, may have significant implications for understanding potentially harmful intervention effects in this population. Indeed, harmful effects of interventions can conceivably extend beyond the patient themselves to include a detrimental impact on family members or other individuals close to the patient– an assertion that may be especially relevant for treatment of youth. Hence, greater attention to the role of harm in the treatment of youth mental health concerns is warranted, with such research offering potential to contribute substantially to the literature on child and adolescent mental health.

In this Collection, “Primum non nocere: Understanding the Role of Harm in Treatment for Youth Mental Health Concerns,” we will bring together a selection of original and rigorous theoretical/review, methodological, and empirical papers to further our understanding of potential for harm in treatments for youth mental health concerns. This will be accomplished by soliciting a collection of papers that explicate potential for harm or non-beneficence in treatment for specific youth psychological disorders, as well as offer practical suggestions for how to identify and address potential for harm in both research and clinical settings.

Guest Editors

Dean McKay, Ph.D. (Fordham University; mckay@fordham.edu)

Samuel D. Spencer, Ph.D. (University of North Texas; samuel.spencer@unt.edu)