How common are positive effects of psychotherapy? Very common, over 95% of patients report positive effects of psychotherapy (Moritz et al, 2019).

And how common are negative effects of psychotherapy? We know much less about negative effects than positive effects (Herzog et al, 2019). This data deficit will probably start to change as it becomes more evident that negative effects can and do occur from therapy. Given what we know, negative effects–depending on how you define them–are both common and uncommon. If understood as “side” or “adverse” effects, they may occur in over 50% of patients (Moritz et al, 2019). However, mediction adverse effects are also common, and their presence does not mean that the patient, if he or she could do it over, would avoid taking the medication nor does it mean that the patient develops lasting sequelae. But if we limit negative effects to “lasting bad effects,” then a large survey of patients in the UK who received psychotherapy through the National Health Service found that 5.2% endorsed these lasting bad effects (Crawford et al, 2016). Not a high percentage, but if this percentage holds for the US, and given the tens of millions of people in the US who are in or who have received psychotherapy in the past, the number of people negatively affected could be large indeed.

Given these statistics, some experts advise that the informed consent procedure for psychotherapy should warn patients of potential lasting and/or temporary negative effects (Crawford et al, 2016; Linden, 2013). In addition, all psychotherapists should be more cognizant of therapy’s potential for negative outcomes and for temporary but difficult thoughts and feelings the patient may have to address them regularly in therapy (Linden, 2013). Therapists can address the possibility of these upsetting events before they occur, as they are occurring, and at the end of therapy. The anticipation of therapy’s possible, but likely, challenges can partially inoculate patients against the negative effects of the common and normal responses they can have, such as experiencing emotional upheaval, a rupture in the clinician-patient relationship, or doubts as to the efficacy of the therapy or of their ability to benefit from it. Therapists should also address these challenges as they are occurring, not necessarily to abort or circumvent the patient’s responses, but to normalize them and guide the patient through making what are often difficult changes to make.

A conundrum faced by therapists and patients, as well as by researchers, is how to regard negative emotions and temporary declines in function and differentiate between, regarding them as unavoidable but welcome aspects of healthy growth and a search for solutions or as signs the therapy is harmful and damaging the patient’s wellbeing. One way to resolve this conundrum is for the therapist to explain the two sides to the discomfort or dysphoria that occurs within therapy and engage the patient in ongoing discussions about the meaning of these feelings and their potential longer-term effects. Once the topic is raised, patients can often tell whether the emotionally challenging periods in therapy are related to needed confrontations with a painful past and to setting the ground for growth versus the beginning of a decompensation. Sometimes, the best differentiator is function; if upsetting events are occurring in therapy but the patient’s function remains stable, that is often a good sign. Of course, if the patient’s function is worsening, that is a strong red flag. Prior to the ending of therapy therapists can review the process and experience of the therapy the patient underwent, answer concerns, reflect on their own missteps or shortcomings, and help the patient develop a post-therapy plan of action so that gains made are not lost over time.

Now, I’d now like to share with you the types of negative effects I’ve seen occur in therapy, both through my work with patients and through supervising residents and learning of their experiences.

  • Disappointment and shattered expectations: Some patients start therapy with high expectations of the benefit therapy will bring and expectations of how therapy is done; visions of therapy that they’ve learned from movies or from experiences related by friends. When patients start therapy, they may find the going to be much tougher, the benefits more elusive, and the process dramatically different than what they expected. The patient may drop from treatment, feel they are failing, and even end up feeling more hopeless and perhaps suicidal. It is wise for the therapist to query the patient on their expectations for change and their imaginings of what therapy will be like. The therapist should then educate the patient on the process and the concrete activities that occur in therapy.
  • Confusion: Some patients are not looking to start therapy but are instead prescribed therapy by their psychiatrist or other clinician. The patient may remain in the dark about the purpose, the activities, and the purported benefits of therapy. In therapy they may be asked to speak of highly personal topics and do assignments without understanding their purpose. This lack of adequate psychoeducation is not uncommon and not hard to fix. It only takes time and listening to the patient.
  • Distraction from making needed life changes: Some therapists will permit the patient to talk endlessly about their problems without ever pivoting to developing solutions. Talking out problems does sometimes allow a patient to develop enough insight and confidence from being validated that they develop solutions on their own. But the therapist should not count on this happening and, instead, share the mindset that understanding problems is important because it can lead—and needs to lead—to making concrete changes. Additionally, some forms of therapy, especially psychodynamic therapy, can encourage an over-focus on the self. This can lead to unhealthy self-preoccupation and heightened awareness and sensitivity to one’s emotional and cognitive reactions, resulting in increased rumination, emotional self-monitoring, and use of the psychological defenses of intellectualization and isolation of affect. All this talking can distract from making needed changes to behavior and cognitive habits.
  • Retraumatization: Exposure therapy is an opportunity to desensitize and develop a sense of mastery over traumatic memories, flashbacks, and trauma-related cues. When done poorly, as happens when it is forced and done without preparation, exposure can lead to further sensitization and decreased sense of control and mastery, the exact opposite of what is sought.
  • Damaged relationships with family and significant others: One effect therapy has —and that we wish it to have—is that it leads to healthy changes in awareness, emotional regulation, thinking, and behavior. This is the point of therapy after all. What can occur, however, is that the patient is rarely an isolated individual but rather a member of a family, couple, or friend group and the changes the patient undertakes and undergoes can disrupt these relationships and lead to their rupture. This relational aspect must be kept in mind and discussed throughout treatment. It sometimes makes sense to invite these important others into one or more therapy sessions with the patient. In the most dramatic and dangerous situation, a positive change—perhaps a greater sense of self-agency—in a patient in an unstable and potentially violent relationship may increase risk of intimate partner domestic violence. Again, this is an issue of which the therapist must remain cognizant and work with the patient to maintain the patient’s safety throughout.
  • Counter-therapeutic relationship with clinician: Patients will often, even if temporarily, idealize their therapist who may subtly encourage this idealization, may simply not be aware of it, or may choose not to address it. This idealization can lead the patient to experience anxiety about losing the therapist. The patient, overcome by the concurrent emotions of idealization and fear of loss, may drop out of treatment pre-emptively or act obsequiously to avoid rejection by the therapist. Eventually, the idealization gives way either to a healthier and balanced view of the therapist or to a severe disappointment with the therapist, perhaps feeling led on in their affections, which can turn into intense resentment and anger. Of course, the worst-case scenario occurs in cases in which the clinician identifies with the patient’s idealizing transference and acts on it, with actions ranging from subtle and deniable flirting to outright sexual relations with the patient. As always, therapists must remain on the lookout for various transference and counter-transference reactions and know when to bring them into explicit conversation and, of course, always maintain ethical and professional boundaries.

I’ll follow up more on patient-clinician issues in subsequent posts. Let me know if you wish me to discuss anything that is bothering you in your practice. I’ll do my best to address it.

Thanks,

Dr. Jack

Language Brief

“These are the times in which a genius would wish to live. It is not in the still calm of life, or the repose of a pacific station, that great characters are formed. The habits of a vigorous mind are formed in contending with difficulties. Great necessities call out great virtues.” – Abigail Adams

“The conflict between the will to deny horrible events and the will to proclaim them aloud is the central dialectic of psychological trauma.” – Judith Lewis Herman

“In my early professional years I was asking the question: How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship which this person may use for his own personal growth?” –Carl R. Rogers

“In Hollywood if you don’t have a shrink, people think you’re crazy.” – Johnny Carson