Understanding the Adverse Impacts of Psychotherapy: A Comprehensive Review

Recent research illuminates the often-overlooked negative facets of psychotherapy, revealing that adverse events are not uncommon and stem from various factors, including the therapeutic process itself, patient expectations, and clinician practices.

A review published in the Industrial Psychiatry Journal by Dushad Ram and colleagues highlights the significant number of individuals who encounter negative experiences in psychotherapy. Using a broad definition that includes general dissatisfaction, a substantial majority (95.6%) report such occurrences. These negative outcomes are categorized into three main types: predictable side effects (e.g., temporary emotional distress), adverse effects (unexpected and harmful results like new symptoms or worsening original ones), and severe malpractice or unethical treatment. Contributing factors range from therapist shortcomings, such as poor training or lack of empathy, to patient-therapist mismatches and cultural insensitivity. Young individuals, trauma survivors, and ethnic/cultural minorities are identified as particularly vulnerable groups. The authors advocate for improved monitoring, regular patient feedback, and enhanced therapist training to mitigate these issues.

Complementing this, Andrea W. M. Evers’ article in Current Opinion in Psychology examines the “nocebo effect” in psychotherapy, where negative expectations can lead to detrimental treatment outcomes. This effect is attributed to negative expectations, prior treatment experiences, therapist communication styles, social learning, and contextual factors. For instance, individuals may anticipate therapy to be challenging or ineffective, which can exacerbate anxiety and symptoms. Previous unfavorable experiences, particularly in chronic cases, reinforce these negative expectations. Social influences, like negative discussions about therapy, can also shape poor outlooks. To counteract the nocebo effect, Evers suggests managing patient expectations through clear, balanced communication, fostering strong therapeutic relationships, and utilizing screeners to identify patients prone to negative reactions. Reconditioning past negative treatment experiences is also recommended for those with deeply ingrained adverse perceptions.

Furthermore, two Dutch studies in Clinical Psychology & Psychotherapy, led by Sanne T. L. Houben, expose a concerning disconnect among clinicians regarding negative therapy effects. Many therapists consider outcomes like increased stress and worsening symptoms unavoidable, often failing to provide comprehensive informed consent. There’s also considerable disagreement among clinicians about what constitutes a negative effect and its avoidability. A significant portion tends to dismiss patient-reported adverse events, such as dependence on the therapist, as unrelated to therapy. For example, over half of clinicians considered worsening symptoms or increased stress as unavoidable. This highlights a critical need for standardized understanding and communication about potential negative impacts within the therapeutic community.

These findings underscore the importance of acknowledging, understanding, and addressing the negative aspects of psychotherapy to ensure ethical, effective, and patient-centered care. By integrating patient feedback, enhancing therapist training, and establishing clear communication about potential risks and benefits, the field can evolve to better serve those seeking mental health support, fostering environments where healing is prioritized and harm is minimized.