If you are taking a medication, you can read about possible side effects in the package insert. Before an operation, patients are informed about what can go wrong. And even before psychotherapy, an explanation by the attending physician must take place – but side effects are rarely discussed. Is it because there are none? Or were they just not the focus of psychotherapy research?
Overall, the recognized procedures of psychotherapy show a high level of effectiveness. Unwanted effects occur more frequently than accepted for a long time.
Much of these side effects such as reduced well -being or growing fears are temporary and not completely avoidable. In the long term, however, the advantages usually predominate.
It is important to educate patients about possible side effects so that both they and those treating them can better recognize, classify and manage them.
For a long time it was assumed that psychotherapy can only do good and at most in some cases simply does not help. Numerous studies have now been able to show how promising the treatment for various mental disorders is. Psychotherapy relieves the symptoms of many sufferers, leads to an increased well-being and to a better quality of life and sometimes even causes a complete cure.
However, it has now been proven that the memory of bad experiences and talking about problems can trigger negative feelings. If you work through unsightly experiences, this sometimes leads to the fact that they are reminded more lively and more frequently and cause stronger reactions. Based on such a fact, it seems logical that psychotherapy can also have undesirable effects.
Already in the 1960s, the psychologist Allen E. Bergin, co-author of the famous "Handbook of Psychotherapy and Behavior Change", was able to show in an overview work that quite a few people benefited from psychological treatments. In addition, however, there were also those for whom nothing changed or who were worse off after the therapy than before. Comparisons with patients who had not received treatment suggest that these deteriorations were not infrequently related to the intervention itself. Despite these early findings, research, practice and education for decades completely ignored the fact that psychotherapy can have undesirable effects.
Patients have the right to be informed about the risks and possible side effects before treatment. This is the only way to consent to the treatment. It is also important that therapists know about unwanted effects, risks and contraindications in order to recognize them if necessary during the treatment and to counter them.
However, doctors can only give limited information about how often side effects occur in their clients. Because they underestimate their frequency, which is probably due, among other things, to the fact that unpleasant effects are primarily associated with mistakes or a failure of the therapist.
Distorted self -perception
Instead, therapists, possibly out of self-protection, tend to have a distorted self-perception in which they evaluate their performance more positively than it may be. They often do not recognize deteriorations in patients or attribute them to causes that have nothing to do with the treatment itself, such as lack of cooperation on the part of the patient. This is supported by a study published in 2005 by Corinne Hannan and colleagues from Brigham Young University. In it, 26 training candidates and 22 trained therapists were to predict the success of the treatment for each of their patients. Participants were informed in advance that symptoms are estimated to increase in around 8 percent of clients. Nevertheless, they considered a deterioration to be very unlikely and expected it only in 3 of the total of 550 patients (0.5 percent). In fact, 40 patients (7 percent) felt worse after therapy.
So many treating people are apparently not aware that side effects can occur during therapy. They find it correspondingly difficult to recognize them in their patients. This also helps that the training and further training still speaks too little about unwanted effects. A survey published in 2020 among prospective behavioral therapists showed that most people know about possible side effects of the treatment, but the risk of this tends to assess the risk of their own clients than others.
In the past 70 years of psychotherapy research, negative effects have only been addressed sporadically. Only a work by the American psychologist Scott Lilienfeld from 2007 finally brings more attention to the topic. He presented – as a counterpart to the proven effective therapies – a list of potentially harmful psychotherapeutic treatments.
A prominent example is group crisis interventions after a stressful event such as a killing spree or a serious traffic accident. With this so -called Critical Incident Stress Debriefing (CISD), those affected are encouraged immediately after a potentially traumatic experience, to talk about what they have experienced and the associated negative emotions, and sensitize it to possibly occurring post -traumatic symptoms. Lilienfeld leads various studies, according to which CISD - especially when people are pushed - cannot prevent post -traumatic symptoms, but on the contrary. In such cases, psychological intervention presumably hinders the natural healing process.
The Brain&Mind series "How Psychotherapy works" at a glance:
Part 1: What really helps (brain & spirit 4/2022)
Part 2: "The school dispute has long since been overtaken" (Brain&Mind 5/2022)
Part 3: On risks and side effects
In addition, Lilienfeld described other potentially harmful psychological treatments, such as the deterrence programs popular in the USA, in which young people are shown the hard prison life in order to deter them from committing crimes, or "rebirthing" methods in which people are supposed to process their alleged birth trauma. In doing so, he refuted the long–prevailing assumption that it is better to do something than nothing when it comes to mental health problems - and that, at worst, psychotherapy is simply ineffective.
Such a list of risky to potentially harmful therapy approaches is certainly helpful.
However, one has to take into account that some methods can be harmful under certain circumstances or in certain patients, but can definitely help others.
For example, relaxation techniques are considered effective in order to counteract early signs of unrest and are also used in various therapies.
Progressive muscle relaxation according to Jacobson and autogenic training are most common.
However, there is indications that some patients with anxiety diseases can trigger fears and panic attacks.
Nevertheless, they help a large part of the users.
Not only individual treatment approaches can have negative effects. Certain characteristics of the therapist or patient as well as the relationship of the two to each other can also stand in the way of relief or cause worsening. Studies have shown that this is mainly related to a less appreciative, even more hostile communication between patient and practitioner. Also, certain techniques such as exposure treatment for anxiety disorders (in which the patient is confronted with the anxiety-inducing stimulus) often increase anxiety, especially in the case of poor preparation or implementation. However, it is not so much the techniques themselves that are problematic, but rather their rigid, not very flexible use. In addition, studies suggest that some practitioners achieve worse therapy results than others and that some clients are more difficult to treat. Undesirable effects are often caused by the interaction of several of these different factors.
What exactly are side effects?
Lilienfeld's work has rekindled the discussion about negative therapy effects. A lot has happened in research since then. Scientists are working on defining side effects of therapies more precisely and developing suitable measuring instruments. This is an important prerequisite for recording the frequency of negative results.
Side effects are often understood as a deterioration in the symptoms of the disease, for example when fears or hopelessness increase. Psychotherapy does not work exclusively on the symptoms, but also aims to improve social skills and to cope with problems in the family or partnership. Accordingly, side effects can also occur in other areas. So it is conceivable that dealing with your own biography, for example, burdens the relationship with the parents. In the therapy, some people decide to separate from the partner. And a patient who has learned to say no more often is causing negative reactions in his environment (for example with partner or colleague).
In addition, psychotherapy can have other negative effects in life, for example, if it becomes more difficult to take out disability insurance or to become an official. In addition, there are clients who develop a dependence on their therapist and no longer feel able to make decisions without his support. Financial problems can also arise if the treatment itself is paid for.
All of these examples are events that are undesirable (since the treatment is not the goal) and occur in parallel with the therapy. If there were therapy that does not require such side effects, it would be preferred. But these are not always real side effects of psychotherapy.
An example: A patient is undergoing psychotherapeutic treatment for an anxiety disorder and is confronted with the anxiety-inducing situation in an exercise. The following week, his condition worsens. He reports increasing tension and increased feelings of anxiety. A few sessions later, he stops therapy.
Both the deterioration in symptoms and the termination of therapy are an undesirable event. Nevertheless, this is not necessarily to be regarded as a side effect of the treatment, because there are patients whose symptoms are therapy -resistant or in whom a deterioration occurs without having to do this with the therapy itself. Psychological complaints can also increase because the patient has lost a close person or his work. And some breaks off the therapy because it can no longer set it up due to a new job. In such cases, the undesirable result has nothing to do with the therapy itself and would not be classified as a side effect.
Adverse events in the course of therapy can also occur because the treating person makes mistakes or uses a procedure incorrectly. If a patient is not sufficiently prepared for an exercise, this can cause an increased anxiety reaction. However, this would not be considered as a side effect any more than an overdose of a drug.
How widespread are unwanted effects?
More recently, researchers have developed a classification of adverse effects that initially distinguishes according to whether the event was caused by psychotherapy or by other factors. If it is directly related to the therapy, it can be either the result of a correct or an incorrectly performed treatment. The undesirable result should only be classified as a side effect if it is directly related to the therapy that has been used correctly.
But how often do such side effects occur at all? The answer to this question largely depends on what and how detailed the question is asked for. Some international studies have found that 3 to 15 percent of patients feel worse after psychotherapy. If, in addition to the pure symptoms of illness, losses in other areas of life and function, such as in the partnership or at work, are included, the figures are much higher.
Researchers led by Winfried Rief from the University of Marburg have developed a German -language questionnaire that reviews 42 undesirable events in a shortened version 21. The proportion of patients surveyed who report at least a side effect by psychotherapy fluctuated in various studies between 45 and 94 percent . In contrast, with a single question among almost 15,000 participants in Great Britain, only 5 percent stated that they had experienced permanent negative effects of therapy. Probably more people report side effects if you ask them more detailed as well as about short-term consequences.
Based on such large differences, it is difficult to assess the prevalence of psychotherapeutic side effects. That is why we are currently conducting a nationwide survey at the University of Jena on experiences with psychotherapeutic treatments that focus on undesirable effects. It is intended to provide representative data for the first time. In an initial preliminary survey among 244 people, 57 percent reported at least one negative effect. Most often, the resurgence of old, unpleasant memories was described. Comparatively many respondents also mentioned sleep problems and an increased stress life.
According to current research results, side effects of psychotherapy are not uncommon. Unwanted events occur much more frequently during treatment than previously suspected. However, we need even more reliable data and meaningful samples in order to assess the frequency and long -term consequences of such effects and to be able to derive knowledge about risk factors and prevention options.
Literaturtipp
Linden, M., Strauß, B.: Risks and side effects of psychotherapy. Medical-Scientific Verlagsgesellschaft, 2nd edition, 2018
The growing awareness of problems among psychotherapists gives hope that in the future there will also be more talk about side effects in practice and training. In cooperation with many psychotherapy associations, the Patient Safety Action Alliance has published suggestions and recommendations for dealing with patient safety and side effects. It emphasizes that at the beginning of a therapy it is necessary to be informed about possible negative effects in principle. This information must be renewed again and again during the course of treatment, for example, before certain interventions. Such an education is not only required by law, but can also help to reduce the abortion rates and ensure a positive treatment result. Psychotherapy works better when patients know what to expect. However, there will hardly be a "package insert" for psychotherapies, given the individuality of the therapy process.
In addition, patients should know that they can contact neutral facilities at any time if they do not feel well treated in the therapy. Such a contact point offers, for example, the »Ethikverein e. V. - Ethics in psychotherapy «.
On the part of therapists, courage and self-reflection are needed above all to critically question one's own actions. The realization that psychotherapy can also be harmful should be conveyed more precisely in the training. In addition, prospective therapists must be trained to recognize and counteract undesirable effects of the therapy, for example through regular feedback. As a result, a negative course can be detected at an early stage. In view of the available data, it can be considered unethical if therapists do not regularly obtain feedback from their patients.
