When Validation Is Harmful

Commentary
Article

Validating some patients could lead to both clinician and patient harm.

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Permission to state the obvious: life has a tendency to be difficult. After all, 90% of Americans have lived through a traumatic event in their life.1 Naturally, many psychiatrists take a firm position validating individual trauma and providing a nurturing stance towards said traumatized individual. If life feels like an endless barrage of suffering, psychiatrists often define their practices as a place of safety and comfort. But we often wonder how far one should take this approach—how far should psychiatry promote this concept? Could it be counter-therapeutic? Has the field already taken a position where the risks outweigh the benefits?

The concept is as follows—if a patient were self-harming, validating him could entrench him in his maladaptive defense. Alternatively, if a patient failed to recognize how her behavior was harming others, validating her could protect the fraudulent facade. The concepts are evident and uncontroversial at face-value. Yet they are far from modern psychiatric practice.

When psychiatry was more focused on repairing developmental lacunas, the process was much clearer. Most parents are familiar with the limitations of endless praise and support. It would baffle anyone to encourage a toddler to experiment with fire. This concept is extended throughout the journey of a parent; being a parent can often resemble a repetitive exercise in forewarning and limit setting. When psychiatry was more interested in providing a milieu for psychological growth, the limitations of endless validation were apparent.

However, modern psychiatry has different interests. Recently, trainees have approached us with examples of such limitations in our modern conceptualization of treatment. Here is such an example.

Case Study

“Noah” is a 30-year-old nonbinary patient who was recently psychiatric hospitalized after endorsing suicidality. They were evaluated for a few days then referred to outpatient care. They joined a group of patients, who belong to a gender or sexual minority and have experienced trauma. One of the premises of the group is that it is “nontrauma” focused. Many treatments for past trauma deemphasize exposure therapy. Exposure therapy can be particularly emotionally difficult on a patient. Despite exposure therapy having solid scientific footings, many patients find themselves stuck and unable to process the exposures.

Eye movement desensitization and reprocessing (EMDR), for example, attempts to soften the difficulty in confronting exposures to past trauma by repeatedly interrupting the exposures with interventions aimed at reducing the emotional load. Seeking safety is a nontrauma focused therapy that focuses on finding comfort in one's current self rather than trying to reinterpret or change the past. This particular group had a rule for group members not to describe their past traumas in too much depth based on Seeking Safety principles and the concern that such reports may be triggering to other members.

Noah defied this rule and started their first visit by describing in gruesome detail a graphic past trauma. In response the group-leader, a trainee, interrupted Noah. She asked them to consider the impact their statements had. The group-leader hoped to start an important discussion about our desire to describe our past and the context of being mindful to others. However, Noah interpreted the intervention as an insult. They suggested that the provider assaulted them, the way they had been assaulted by prior abusers. They described being violated from their safety and robbed of their recovery by this single intervention.

After the group, Noah demanded to have a meeting with clinic management to complain about the group leader in front of her. Noah was allowed to yell at the group leader for an entire meeting. The idea behind this exercise was so that Noah could communicate their “truth”—a truth in which the group-leader was called discriminatory against sexual minorities, violent in her support of restricting victims from speaking, and insulting in her audacity to question the behavior of a patient.

The group-leader was not permitted to respond, at the request of Noah. In conclusion, the leadership team “thanked” Noah for their comment and “courage” without contesting their claims, in an effort “to meet the client where they are at.” The leadership team even spoke on behalf of the group-leader, allegedly knowing that said group-leader was satisfied that the patient was given this platform.

After the session, the trainee was distraught. She had been forced to sit through an hour of beratement. She had been called a bigot, destructive, and a bully. Through creative post-modernist prowess, leadership had accepted the patient’s version of reality, which was false, at the expense of the clinician. The provider had been rendered a mere object of this patient’s sadomasochistic fantasies and became an unwilling recipient to the patient’s narcissistic enactment.

Discussion

While this story contains many layers of modern malignancy in the mental health system, one bothers us in particular—it does not help the patient. It seems that this abused and traumatized patient was allowed to reenact their past, but in the role of an aggressor. They were allowed to inflict on a therapist a harm with which they are familiar. However, our concern is that this does not serve the patient. Our goal as providers is not to allow the patient to find confirmation in a new maladaptive defense; our goal is to provide patients with adaptive ways of handling their stressors.

We are rightfully concerned about the proliferation of victimization. We do not suggest that psychiatrists should turn themselves into the new victims of our patients. We suggest that psychiatrists should appropriately intervene when patients with past trauma use their victimhood to abuse others. Those stories are too common to stay silent. While administrators may come to the conclusion that appeasing and validating all who complain is the most judicious tool in their arsenal, let’s not fool ourselves into thinking that it is best for our patients.

Patients benefit from appropriate limitations. We do not think it is harmful to tell Noah that their group was a nontrauma group and not the appropriate setting for that particular form of sharing. It would be a good skill for Noah to learn that not all stories are appropriate in all settings and at all times. We do not think it is harmful to tell Noah that falsely berating and accusing a provider is not an act of courage but an act of harm. By intervening, we confirm that the solution of past harm is not new harm, but demonstrating resiliency, growth, and the development of wisdom.

Many excellent clinicians have left big institutions, in part, to not be subjected to such incidents. As a result, we may feel too out-of-touch or disconnected to comment on such incidents with our trainees. While we commend restraint, it is also our duty to inform trainees that in private practices and many other settings, providers throughout the country constantly provide adequate limitations to their patients in a healthy and productive way that is within the appropriate scope and skill of psychiatrists.

Dr Badre is a clinical and forensic psychiatrist in San Diego. He teaches medical education, psychopharmacology, ethics in psychiatry, and correctional care. Dr Badre can be reached at his website, BadreMD.com. Dr Lehman is a professor of psychiatry at the University of California, San Diego. He is codirector of all acute and intensive psychiatric treatment at the Veterans Affairs Medical Center in San Diego, where he practices clinical psychiatry.

Reference

1. Breslau N, Kessler RC, Chilcoat HD, et al. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Arch Gen Psychiatry. 1998;55(7):626-632.

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