Vybíral, Z., Ogles, B.M., Řiháček, T., Urbancová, B., & Gocieková, V. (2023) Negative experiences in psychotherapy from clients’ perspective: A qualitative meta-analysis, Psychotherapy Research, DOI: 10.1080/10503307.2023.2226813
Psychotherapy research tends to focus on positive patient outcomes – or patients who get better. More recently, psychotherapy researchers have focused on negative outcomes and client experiences of negative events in psychotherapy. Approximately 5% of clients get worse, 20% of clients in clinical trials drop out, and about 66% of clients do not recover by the end of treatment. All of this suggests that some clients have negative experiences during therapy that may interfere with their progress. One can learn a lot from studying processes that do not go well. Potentially, therapists can learn what not to do, how to avoid pitfalls, how to recognize when the client has a negative experience, and how to repair an error. In this qualitative meta-analysis, Vybiral and colleagues reviewed 51 studies that recorded client statements from post-treatment interviews. Through qualitative analysis, the authors reported four major clusters representing clients' negative experiences, specific therapist behaviours within each cluster, and the percentage of studies in which clients noted these specific behaviors. The first cluster was Therapist Misbehaviors including therapists not listening (17% of studies), therapists not understanding (37%), therapists perceived incompetence (37%), therapists devaluing clients (56%), therapists judging (33%), and therapists using the client for their own benefit (27%). The second cluster was Hindering Aspects of the Therapeutic Relationship including therapists’ lack of empathy (44%), lack of trust in the therapist (21%), clients experiencing confusion (23%), and poor interpersonal match (25%). The third cluster was Poor Treatment Fit including negative evaluation of the procedures or practical aspects of treatment (33%), unmet client expectations about therapy (33%), lack of fit with the interventions (65%), and dissatisfaction with how therapy ended (50%). The fourth cluster was Negative Impacts of Treatment including that therapy was unhelpful (46%), that problems increased (37%), fearing the therapy process (50%), loss of hope (23%), unpleasant feelings during therapy (60%), negative thoughts caused by therapy (35%).
This research indicates that the qualities of the therapist, the therapeutic relationship, the treatment provided, and the outcomes are key to clients’ perceptions of their therapy experience. A therapist's positive regard, genuineness, and empathy have long been considered necessary conditions for successful therapy. In addition, there is substantial research on the importance of the therapist and client developing a collaborative agreement on the goals of therapy and how therapy proceeds, that is – aspects of the therapeutic alliance. Therapists also must keep in mind that clients must develop realistic expectations of therapy like its duration, what gets discussed, and how therapy proceeds. Expectations are well-known predictors of client outcomes. Finally, therapists must monitor patient outcomes and processes, and modify what they are doing if the client experiences a precipitous increase in symptoms or a decrease in the alliance from one session to the next.