When Talking Doesn't Cure: Negative Outcomes In Therapy
Any technology that can heal can also injure.
Posted Mar 07, 2020
Therapy often works. But not always. At times, it may prove ineffective, and at other times even harmful. This should not be surprising. Any technology that has real power to clarify and heal, by definition also has the power to distort and harm. All interventions—medical, environmental, social, psychological, financial—have potential side effects and unintended consequences; all carry odds of failure and harm.
As a topic of research, the issue of negative psychotherapy outcomes remains insufficiently explored. Most clinicians are not trained to identify, measure, or address such negative effects. As Australian researchers Michael Berk and Gordon Parker note, the issue remains largely “the elephant on the couch,” generating too little attention and too few, and too narrowly focused, quantitative studies.
Estimates of the scope of the problem vary. Berk and Parker estimate that, “approximately 3-10% of patients become worse after psychotherapy, with slightly higher rates (7-15%) quantified for patients with substance abuse." Reviewing the literature, Michael Lambert of Brigham Young University, an authority on the issue of negative therapy outcomes, reported that a relatively consistent proportion of adults (5–10% in clinical trials and up to 14% in community settings) deteriorate after participating in treatment. The numbers for children are even higher.
German researchers Michael Linden and Marie-Luise Schermuly-Haupt, summarizing the literature on adverse outcomes, conclude that “There is an emerging consensus that unwanted events should be expected in about 5 to 20% of psychotherapy patients… They include treatment failure and deterioration of symptoms, emergence of new symptoms, suicidality, occupational problems or stigmatization, changes in the social network or strains in relationships, therapy dependence, or undermining of self‐efficacy."
To be fair, accurate numbers on this issue may be hard to come by, for several reasons.
First, the fact that deterioration happened during therapy does not mean it was caused by the therapy. People’s lives, after all, don’t stop when they are in therapy. And life can be damaging, as for example when a negative life event (like the loss of loved one or a new medical condition) occurs during or shortly after therapy. With multiple extra-therapeutic life variables consistently in play, determining that a certain negative effect is, in fact, an effect of therapy is not always easy or possible.
Second, given the subject matter of most psychotherapy, assigning valence to an outcome often involves a measure of subjective judgment. Certain therapy outcomes may not be easy to judge clearly as either positive or negative. For example, if a troubled couple divorces post-therapy, the outcome may be considered positive or negative, depending on whom you ask (the husband, wife, kids, etc.) and when (right after the divorce or years after it). In addition, unlike medication, which is usually measured only by symptom reduction (or lack thereof), psychotherapy effects may extend broadly into the client’s social life, where identifying and measuring them are more challenging tasks.
Scott Lilienfeld of Emory University, reviewing the literature on that matter, notes the multidimensional nature of these adverse effects, which may include, "symptom worsening, the appearance of new symptoms, heightened concern regarding extant symptoms, excessive dependency on therapists, reluctance to seek future treatment… and even physical harm… Some treatments may produce harm in the relatives or friends of clients in addition to, or instead of, clients themselves. For example, some treatments that are otherwise innocuous or even effective with clients could produce a heightened risk of false abuse allegations against family members."
Moreover, an unwanted negative outcome, even if it happens because of therapy, may happen in cases where the therapist acted appropriately or inappropriately. A client, for example, may have an adverse reaction to hearing both a correct and an incorrect diagnosis. But those outcomes should not necessarily be lumped together.
Similarly, the timing of measurement is an important factor in identifying negative outcomes, since a short-term setback may beget long-term improvement. Lilienfeld emphasizes the need to distinguish between short-term deterioration that may be a part of the path to long term success (like the worsening of PTSD symptoms during exposure sessions) and a long term deteriorating trajectory.
Likewise, negative outcomes for otherwise effective, empirically supported therapy interventions should not be lumped together with negative outcomes that result from fringe, quack, or empirically debunked interventions such as Critical Incident Stress Debriefing (a single-session group procedure administered shortly after the traumatic event, focused on discussing negative emotions) or Facilitated Communication (premised on the false notion that autistic children’s communication defects are attributable primarily to motor, not cognitive, problems).
That being said, recent research has attempted to identify the kinds of adverse effects legitimate therapy interventions may produce and how those may be predicted (and hence, perhaps, prevented). Some evidence suggests that negative outcomes (like positive outcomes) in therapy are not limited to one style of practice or theoretical orientation. A review of the literature by Michael Lambert (Brigham Young University) and Kara Harmon (Grand Junction VAMC) argued that: “Similar to client improvement, research shows the phenomenon of deterioration to be equivalent across theoretical orientations… Likewise, negative outcomes have been observed across all client populations, treatment interventions, and family and group therapies.”
However, the research on this issue is still young, and the measures used are often limited in scope and precision. Thus, this conclusion may lack nuance. Some evidence exists to suggest that certain therapies, and therapy situations, may be more prone than others to the risk of adversity.
For example, one survey (by Anton Leitner and colleagues at the University of Zurich) of clients’ perceptions found that risks for therapy-related “burdens” (such as feeling overwhelmed in therapy, being afraid of the therapist, or afraid of stigmatization) were higher in psychodynamic therapy compared to CBT, and in male therapist-female client dyads.
Looking at the potential predictors of adverse therapy outcomes, research has shown that both client and therapist variables may play a role.
On the client side, certain diagnoses and client characteristics are more difficult to treat successfully. For example, David Mohr of San Francisco University, in an early (1995) review of the literature, noted: “Patients who are borderline or obsessive‐compulsive, have severe interpersonal difficulties, are poorly motivated, or who expect psychotherapy to be painless have been found to be at risk for deterioration.”
Lambert and Harmon concur: “Severity of mental illness alone is predictive of unsuccessful outcome. Higher levels of interpersonal problems and a higher degree of seriousness in presenting problems also predict poor results. In addition, certain diagnoses and symptoms (e.g., borderline personality disorder, OCD, psychotic, schizophrenic, and bipolar) seem less amenable to psychotherapeutic intervention.”
In addition, the therapist’s characteristics and behavior may also contribute to treatment failure. Clinician competence and mastery vary. Not surprisingly, some therapists respond better to challenging patient presentations than others.
Mohr writes: “On the part of the therapist, lack of empathy, underestimation of the severity of the patient's problems, negative countertransference, poor technique, high concentrations of transference interpretations, and disagreement with the patient about the therapy process all have been associated with negative outcome.”
Lambert and Harmon write: “Studies focused on deterioration have found lack of empathy, underestimation of the severity of client concerns, and/or overestimation of client progress to be detrimental; multiple studies also underscore the destructiveness of therapist negative reactions toward the client that reflect irritation, hostility, and disappointment”
Berk and Parker write: “The therapist who is exploitative, overly narcissistic, patronizing, uncaring, inattentive (e.g. asleep during sessions or not remembering key details of the patient’s history), or unable to establish some congruence with the patient and their world, may be expected to create a lack of fit and an adverse outcome.”
Reviewing the literature on the therapist characteristics that may contribute to adverse client outcome, Gordon Parker suggests further that a lack of empathy was most commonly indicated, followed by the “preoccupied therapist, who made the patient feel alienated and powerless; the controlling therapist who encouraged dependency; and, finally, the passive therapist who was inactive, inexperienced or lacked credibility.”
Linden and Schermuly-Haupt conclude: “Despite the lack of sound empirical data, one can conclude that psychotherapy is not free of side effects. Negative consequences can concern not only symptoms, like an increase in anxiety, or course of illness, like enduring false memories, but also negative changes in family, occupation or general adjustment in life. Consequences like job loss or divorce can be lasting, costly and detrimental for the patient and his/her environment…As therapists and scientists alike are to some degree salesmen of “their” treatment, they are as trustworthy as pharmaceutical companies. They have good intentions and conflicts of interest as well. Like in pharmacotherapy, structures are needed to safeguard good clinical practice… As psychotherapy side effects are multifold and sometimes difficult to detect, good, practical and generally accepted assessment instruments are needed. Therapists should be trained in the recognition, evaluation, and documentation of side effects, and learn how to plan treatment taking possible negative consequences into account.”
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