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Strauss, B., Gawlytta, R., Schleu, A., & Frenzl, D. (2021). Negative effects of psychotherapy: Estimating the prevalence in a random national sample. BJPsych Open, 7(6), E186.

The focus of psychotherapy research tends to be on establishing the effectiveness of psychotherapies for various disorders. Rarely do psychotherapy studies report negative effects or negative outcomes. Some researchers estimate that about 5% of patients experience worsening of symptoms by the end of psychotherapy. However, there are very few investigations of clients’ experiences of the negative impact of therapy and fewer still that ask clients in the general population who had a course of therapy. In this national survey of the general population, Strauss and colleagues asked 5562 individuals if they received psychotherapy in the past 6 years. Of the total sample, 244 indicated that they had or are currently in treatment. These individuals had characteristics similar to patients seen in treatment. The mean age was 55.1 years (SD = 15/2), 63.4% had shorter term therapy of less than a year, 41% reported an anxiety disorder and 77% had a mood disorder, 63.1% saw a female therapist, and 69.2% saw a psychologist. These individuals were asked a series of questions regarding their experiences as clients in therapy. Rates of positive change due to therapy varied by the problems that they noted. For example, 26.6% indicated that they had a better relationship with their parents due to therapy, whereas 67.7% experienced improved mood. On average 88.6% agreed that they had a positive working relationship with the therapist. However, about 19% dropped out of therapy and an additional 13.1% changed therapist during treatment, indicating negative experiences or outcomes. Patient problems that had the highest deterioration rates (i.e., worsened) were physical well-being (13.1%), ability to work (13.1%), vitality (11.1%), sexual problems (10.6%) and problems with self-esteem (10.3%). The most common negative effect attributed to specifically to the treatment was the resurfacing of unpleasant memories (57.8% in the total sample). Other such problems like sleep problems, stress, and unpleasant feelings were reported 27.9% to 36.9% of the time. Of the total sample, 56.6% reported having had at least one negative effect caused by their experience in psychotherapy. Boundary violations and malpractice were very rarely reported by this sample of patients.

Practice Implications

Much of the research and clinical writing of psychotherapy tends to focus on whether it is effective and to document its positive effects. However, an important minority of patients experience worsening of symptoms and/or unpleasant or negative effects of psychotherapy. Some might argue that painful feelings that emerge in some clients is a necessary process when the client works through conflicting feelings or perceptions of themselves and others. A collaborative agreement between therapist and client on how therapy might proceed, how it works, or the goals of therapy will go a long way to limit the negative impact of working through unpleasant feelings in therapy. Nevertheless, therapists should monitor dropout rates in their practice and worsening symptoms in their clients and adjust their therapy and interpersonal stances accordingly.

Knox, S., Miller, C., Twidwell, R.E., & Knowlton, G. (2022). Client perspectives on psychotherapy failure, Psychotherapy Research, online first publication

The research indicates that between 5% to 10% of patients get worse during psychotherapy, as many as 30% do not improve, and about 20% drop out of therapy. And so, despite the overall efficacy of psychotherapy, treatment failure (not improving, getting worse, and dropping out) is a big problem. Surprisingly, there is very little research to understand what happens when therapy is unsuccessful. Some of the research that exists asks therapists for their opinions, but we already know that therapists are not good at detecting patients who get worse, therapists overestimate patient satisfaction, and therapists often overestimate their effectiveness relative to peers. Very few studies have asked patients directly about their experience, their understanding, and the impact of psychotherapy not working for them. In this qualitative study, Knox and colleagues interviewed 13 adult patients who reported that their psychotherapy was a failure. The patients reported a variety of reasons for seeking therapy in the first place (depression, anxiety, trauma), and they received a median of 20 to 30 sessions of therapy. Of the therapists that patients saw, 62% were female whose average wage was in the 40s, from different professions (psychology, social work, counsellors), and different contexts (private practice, universities, community health clinics). Typically, patients defined a psychotherapy failure as one that negatively affected them (made them feel worse, did not meet their treatment goals, and characterized by problems in the therapeutic relationship). Often patients raised their concerns with the therapist prior to the final session, but the issue did not resolve. Patients also reported that after termination their symptoms worsened, they felt more hopeless regarding themselves, and they were less optimistic about therapy in the future. Patients noted that therapist behaviors contributed to the failure, such as: therapist insensitivity, apparent incompetence, not checking in with patients’ experiences of the therapy, not focusing on the patients’ goals, and not addressing concerns about the therapy raised by patients.

Practice Implications

Unfortunately, a non-trivial percentage of patients get worse or don’t benefit from therapy. There were immediate impacts (patients felt worse) and also longer-term impacts (patients’ symptoms continued to deteriorate and they were less optimistic about trying therapy again). Therapists should regularly check in with patients about how they are experiencing the therapy. If a patient expresses concern about how therapy is progressing, therapists must listen and non-defensively hear what the patient is saying while acknowledging that it is difficult for patients to speak up. Therapists who make an error should own the mistake and correct course if necessary or refer to another professional. Regular outcome monitoring (repeated measurement of patient symptoms) and process monitoring (repeated measurement of the therapeutic alliance) may help therapists to supplement their clinical judgement to determine if the patient’s symptoms are deteriorating or if they are dissatisfied.

Lutz, W., de Jong, K., Rubel, J.A., & Delgadillo, J. (2021). Measuring, predicting, and tracking change in psychotherapy. In M. Barkham, W. Lutz, and L.G. Castonguay (Eds.) Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (7^th ed.). Wiley. Chapter 4.

In this part of the chapter, Lutz and colleagues review research methods related to patients dropping out of psychotherapy. Drop outs represent an important problem. For the clinician, a patient who drops out may represent loss of income due to missed appointments, extra work, administrative costs, and a lower sense of professional self-efficacy. Not all patients who terminate therapy early have a poorer outcome. But the research indicates that overall, patients who drop out of treatment do have poorer outcomes, higher hospitalization rates, lower work productivity, and higher social costs than patients who complete treatment. Hence, when a patient drops out of therapy it should be defined as a failure of the treatment that could lead to further demoralization of the patient. Defining a drop out is tricky in that some studies indicate that if a patient does not attend a minimum number of sessions, then they have dropped out. However, a more realistic definition might be that if a patient unilaterally decides to end therapy against a therapist’s advice, then the patient can be considered to have dropped out. Estimates of patient drop out from therapy vary widely depending on the treatment context and patient characteristics. For example, highly controlled studies report dropout rates of about 19.7%, but less controlled studies that might be closer to real world practice report average dropout rates of 26%. But the range of dropout rates across studies was very wide from 0% to 74.2%. Patient characteristics that led to higher dropout rates included higher initial impairment, younger age, lower level of education, a personality disorder diagnosis, and negative expectations about treatment. Therapists had a significant impact on dropping out as well. Therapist effects accounted for 12.6% of the variance in dropping out – that is a moderate but important effect. That is, some therapists have higher dropout rates than others, and this is likely independent of patient characteristics. This is like therapist effects on patient outcomes, in which it is estimated that about 10.1% of patient deterioration is predicted by the therapist’s effect.

Practice Implications

Patients dropping out from psychotherapy is an important problem that negatively affects the patient, the therapist, and that has broader social, health, and economic consequences as well. Aligning the patient’s and therapist goals for the therapy, coming to a collaborative agreement on how therapy will work, and developing an emotional and empathic bond with the patient may be ways of reducing the number of dropouts from therapy. These are all elements of the therapeutic alliance that must be negotiated very early in therapy to forestall a negative outcome such as the patient dropping out.

Lilliengren, P., Johansson, R., Lindqvist, K., Mechler, J., & Andersson, G. (2016). Efficacy of experiential dynamic therapy for psychiatric conditions: A meta-analysis of randomized controlled trials. Psychotherapy, 53(1), 90-104.

There is growing research support for the efficacy of short-term psychodynamic psychotherapies to treat common mental health problems. A subtype of short-term psychodynamic psychotherapies is called experiential-dynamic therapy (EDT), which goes by a number of different names such as Fosha’s accelerated experiential-dynamic psychotherapy, and McCullough’s affect phobia therapy. A fundamental assumption of EDT is that conditions like depression, anxiety and personality disorders are by-products of an individual’s attempts to regulate strong emotions associated with adverse experiences in attachment relationships during childhood. When the attachment system and associated affects are re-awakened in current relationships, the individual may engage in maladaptive coping that leads to difficulties in relationships. While EDTs may focus on helping patients to understand how their attachment difficulties lead to inhibitory affects and maladaptive defenses, the treatment favors interventions that facilitate direct experience of underlying emotions in the here and now of the therapy. In this meta-analysis, Lilliengren and colleagues reviewed 28 studies with 1,782 adult patients who had a mood, anxiety, personality, or mixed disorder. Compared to inactive controls, EDT showed a moderate and significant effect at post-treatment (range: d = .39 to .65) and at follow-up assessments (range: d = .26 to .62), with largest effects for depression and anxiety. When researchers compared EDT to cognitive-behavioral therapy (CBT) in five studies, there were no significant effects at post-treatment (d = .02, 95% CI: -.24, .28) or follow-up (d = .07, 95% CI: -.22, .36). The average quality of EDT studies was good. In fact, studies with larger samples, that used blind randomization and assessments, and appropriate statistical tests showed larger effects for EDT. Drop-out rates for EDT (16.3%) were similar to other treatments.

Practice Implications

Experiential-dynamic therapy (EDT), which is a variant of short-term psychodynamic psychotherapy, was more effective than no-treatment and just as effective as evidence-based treatments like CBT. The findings are similar to those reported in many comparative outcome studies in which any bona-fide psychotherapy is effective for many disorders. The average quality of the EDT studies was quite good, suggesting that the findings were reliable and valid, and perhaps underestimating the true effects of EDT.

Author email: peter.lilliengren@psychology.su.se

Reich, C.M. & Berman, J.S. (2018). Are psychotherapies with more dropouts less effective? Psychotherapy Research. Online first publication.

The client dropout rate in clinical studies is about 20%, and almost double that in regular clinical practice. A dropout is a unilateral decision on the part of the patient to discontinue treatment after the first session. This is often viewed as a treatment failure, but it is possible that some patients feel better enough to not continue with therapy, and others may have practical constraints like transportation or childcare difficulties. In three meta analyses, Reich and Berman ask: (1) do those who drop out experience more distress than completers to begin with?, (2) do completers have better outcomes than drop outs?, and (3) do less effective treatments also have more drop outs? In general, the studies included different types of psychotherapy but most were CBT (~75%), most therapists had a masters or doctoral degree (~33%) but many studies also included student therapists (~25%), client problems included depression (~17%), anxiety (25%), or other disorders, and most studies were randomized controlled trials (~61%). To answer the first question the authors conducted a meta analysis of 76 studies. Clients who dropped out of therapy were in more distress prior to beginning treatment than individuals who completed the treatment (d= − 0.14, 95% CI [− 0.08, − 0.20], p < .001). The effect was small but significant. Younger and male clients tended to be in more distress at pre-treatment. To answer the second question, the authors conducted a meta analysis of 43 studies. Clients who dropped out of therapy were significantly more distressed following therapy than individuals who completed treatment (d = .0.56, 95% CI [.0.37, 0.70] p < .001). This was a moderately large and significant effect. To answer the third question, the authors completed a meta regression of data in 34 studies. Overall, treatments with more drop outs also had completers with worse outcomes at post treatment, β = -.37, SE = 0.17, p < .05. Also, when treatments were shorter in length, greater overall dropout was associated with even worse outcomes for treatment completers, β = − 1.28, SE = 0.35, p < .001.

Practice Implications

These meta analyses support the notion that on average those who drop out do so because they do not find the treatment to be helpful. Patients who drop out tend to be more distressed to begin with, and are more likely to be young and male. An intriguing finding was that those treatments with more drop outs also tended to be less effective for those who completed the therapy. In other words, effective treatments also tended to maintain more patients. Previously, writers suggested clinically useful methods to reduce premature termination from psychotherapy. These include: providing patients with information about duration of therapy and how change occurs, educating patients about therapist and patient roles, taking into account patient preferences when deciding on treatment methods and therapist stances, strengthening early hope, fostering the therapeutic alliance, and assessing and discussing treatment progress on an ongoing basis.

Foa, E., McLean, C.P., Zang, Y., Rosenfield, D., Yadin, E… Peterson, A. (2018). Effect of prolonged exposure therapy delivered over 2 weeks vs 8 weeks vs present-centered therapy on PTSD symptom severity in military personnel: A randomized clinical trial. Journal of the American Medical Association, 319, 354-364.

Post-traumatic stress disorder (PTSD) can affect 10% to 20% of military personnel returning from combat. PTSD is often chronic and debilitating, and is associated with symptoms that are distressing, that lower quality of life, and that negatively impact family and loved ones. Prolonged exposure therapy (PE) has been tested in the past, and researchers have claimed that it is an efficacious treatment in civilians and veterans. PE is a form of behavior therapy and cognitive behavioral therapy characterized by re-experiencing the most traumatic event through remembering it and engaging with, rather than avoiding reminders of the trauma. In their treatment guidelines, the American Psychological Association (APA) proposed PE as a recommended treatment for PTSD. In this randomized controlled trial, Foa and colleagues assess if providing PE in intensive short time frame (massed exposure; 10 sessions over 2 weeks) was as effective as standard exposure (10 sessions over 8 weeks) for 370 military personnel in the US with PTSD. That is, the authors were interested to see if providing the same amount of therapy based on exposure in a shorter time was just as effective. They also compared the two versions of PE (massed and standard exposure) to two control conditions: present centred therapy (PCT) that is largely supportive therapy that does not rely on exposure to the trauma, and a no treatment control condition. The main outcomes were reductions in level of PTSD symptoms and reductions in PTSD diagnoses at post-treatment and up to 6 months post-treatment. Massed and standard PE were equally effective in reducing symptoms and diagnoses of PTSD compared to no treatment. However, PE was not more effective than PCT in reducing symptoms and diagnoses, and PCT was more effective than no treatment. Overall, reductions in PTSD symptoms and reduction in PTSD diagnoses were modest. Drop out rates were high at about 50% for all conditions.

Practice Implications

Drop out rates were high and outcomes were modest for these short-term psychological treatments for PTSD in military personnel, such that over 60% still had a diagnosis of PTSD at 6 months follow up. And PE therapy did no better than a control condition (PCT) that simply provided support with no exposure to the trauma. These findings are similar to other research in this area. Psychotherapy for trauma may require more time to work, and perhaps different models of understanding and treating the disorder. As Shedler recently remarked, it takes at least 20 sessions/weeks before 50% of clients improve. So it may not be surprising that 2 or 8 weeks of therapy had only a small impact on PTSD symptoms.