The Psychotherapy Practice Research Network (PPRNet) blog began in 2013 in response to psychotherapy clinicians, researchers, and educators who expressed interest in receiving regular information about current practice-oriented psychotherapy research. It offers a monthly summary of two or three published psychotherapy research articles. Each summary is authored by Dr. Tasca and highlights practice implications of selected articles. Past blogs are available in the archives. This content is only available in English.
…I blog about CBT, negative effects of psychological interventions, and what people want from therapy.
Type of Research
- ALL Topics (clear)
- Alliance and Therapeutic Relationship
- Anxiety Disorders
- Attendance, Attrition, and Drop-Out
- Client Factors
- Client Preferences
- Cognitive Therapy (CT) and Cognitive-Behavioural Therapy (CBT)
- Combination Therapy
- Common Factors
- Depression and Depressive Symptoms
- Efficacy of Treatments
- Feedback and Progress Monitoring
- Group Psychotherapy
- Illness and Medical Comorbidities
- Interpersonal Psychotherapy (IPT)
- Long-term Outcomes
- Neuroscience and Brain
- Outcomes and Deterioration
- Personality Disorders
- Placebo Effect
- Practice-Based Research and Practice Research Networks
- Psychodynamic Therapy (PDT)
- Resistance and Reactance
- Self-Reflection and Awareness
- Suicide and Crisis Intervention
- Therapist Factors
- Transference and Countertransference
- Trauma and/or PTSD
- Treatment Length and Frequency
Negative Effects of Psychotherapy
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.
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.
Client Perspectives on Psychotherapy Failure
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.
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.
Predicting Not Starting and Dropping Out From Publicly Funded Psychotherapy
Andrzej Werbart & Mo Wang (2012). Predictors of not starting and dropping out from psychotherapy in Swedish public service settings, Nordic Psychology, 64, 128-146.
There are few empirical studies looking at patients who are offered but who do not take up psychotherapy. This is a particularly important issue in publicly funded psychotherapy programs in which large numbers of patients who need mental health services to not access the service or leave before receiving adequate treatment. Evidence from the Improving Access to Psychotherapy (IAPT) program in the United Kingdom suggests that about half of patients who are offered psychotherapy either do not take it up or drop out prematurely and unilaterally. Knowledge about what determines treatment rejection or dropping out is critical in designing and developing publicly funded psychotherapy so that not only access but also patient outcomes are improved. In this study from the national Swedish psychotherapy program that is publicly funded, Werbart and colleagues looked at data from 13 clinics in which 189 therapists treated almost 1400 patients. Therapists were experienced (median experience = 5 years), and most received advanced psychotherapy training. Patients had a wide array of problems and severity. Of the patients, 13.6% never started therapy even though they were referred and assessed for treatment, and of those who started 17.4% dropped out of treatment. So a total of 31% never received adequate treatment and did not benefit for psychotherapy. Patients who never started therapy tended to be younger, unemployed, and with higher levels of mental illness. Patients who remained in therapy once they started tended to be older, had more problems with trauma or loss, and had more severe illness although they were not a danger to themselves or others. Never starting treatment and dropping out were both associated with clinics that had greater institutional instability. Clinic instability was defined as a clinic with: unclear treatment goals and guidelines, not well adapted to providing psychotherapy, unclear policies around who and how therapy is conducted, less cooperation among professionals, and financial problems.
Jurisdictions around the world, including in Canada, are looking to offer publicly funded psychotherapy, yet there is little research to guide how to improve uptake and retention of patients within the system. Such systems might focus pre-therapy efforts to retain patients who are younger and with greater mental health problems. In particular, public systems need to pay attention to clinic and institutional stability. How patients experience the clinic environment (as welcoming and integrated), how treating professionals cooperate, the clarity and structure of treatment guidelines and goals, and the financial stability of a clinic all appear to have an impact on whether patients actually access and complete a course of psychotherapy.
Therapists’ Perspectives on Psychotherapy Termination
Westmacott, R. & Hunsley, J. (2017). Psychologists’ perspectives on therapy termination and the use of therapy engagement/retention strategies. Clinical Psychology and Psychotherapy, 24, 687–696.
The average psychotherapy client attends a median of about 3 to 5 sessions, which is substantially less than the number of sessions the average client needs to realize a clinically significant decline in symptoms. Premature termination (clients ending therapy unilaterally) occurs in 19% of cases in research trials and in as many as 38% of clients in community practices. And so premature termination is mental health problem for clients and an economic problem for therapists and agencies. Clients terminate therapy prematurely for a variety of reasons including: dissatisfaction with therapy or the therapist, achieving their goals, and practical barriers (appointment times, travel, cost). Therapists tend to underestimate the proportion of unilateral terminations from their practice, and underestimate negative outcomes and client negative perceptions of therapy and therapists. In this study, Westmacott and Hunsley, surveyed psychologists who provide psychotherapy (N=269) on their perspectives on their clients’ reasons for termination and the strategies they use to retain their clients in therapy. Therapists reported that 33.3% of their clients terminated prematurely, which is somewhat lower than the percentage reported in previous research. Most psychologists (65.7%) tended to attribute the most important reasons for premature termination before the third session to clients’ lack of motivation to change (rated as very important or important on a scale). A much smaller percentage (15.8%) attributed waiting too long for services as the most important reason for premature termination before session 3. The most important reason for premature termination after the third session was most often attributed to clients reaching their treatment goals (54.8%). Regarding strategies to retain clients - almost all psychologists (96.8%) indicated that they fostered a strong alliance, 74.3% indicated that they negotiated at treatment plan, 58.0% prepared clients for therapy, 38.7% used motivational enhancement strategies, 33.0% used client outcome monitoring, and 17.8% used appointment reminders.
This survey of psychologists suggests that psychotherapists may somewhat underestimate the number of clients who prematurely terminate therapy. Psychotherapists may also overly attribute dropping out to client-focused factors (low motivation, achieving outcomes), rather than therapist-focused factors (dissatisfaction with therapist or therapy), setting-focused factors (negative impression of the office and staff), or practically-focused factors (appointment times, cost). Many therapists reported using alliance-building and negotiating a treatment plan to retain clients. However, few therapists used other evidence-based methods like systematic outcome monitoring, and fewer still used appointment reminders. Therapists should consider therapist-focused and setting-focused reasons for client termination, and to use outcome monitoring and appointment reminders to reduce drop-outs from their practices.
Therapists Affect Patient Dropout and Deterioration
Saxon, D., Barkham, M., Foster, A., & Parry, G. (2016). The contribution of therapist effects to patient dropout and deterioration in the psychological therapies. Clinical Psychology and Psychotherapy. Advanced online publication, DOI: 10.1002/cpp.2028.
Outcomes for patients receiving psychotherapy are generally positive, but not always. For example, patients might drop out of therapy (i.e., unilaterally end therapy). In clinical trials, the average drop out rate is somewhere between 17% and 26% of patients. Also, patients might deteriorate during therapy (i.e., show a reliable negative change in symptoms from pre- to post-therapy). On average, about 8.2% of patients show a reliable deterioration after therapy. In this large study from a practice-based research network in the UK, Saxon and colleagues were interested in estimating the effect that therapists had on patient drop out and deterioration. Therapist effects refer to differences between therapists and the effects of this difference on patient outcomes. The authors were also interested in whether therapist effects predicted negative outcomes after controlling for therapist case-mix (i.e., patient variables like severity of symptoms, risk of self harm). Their study included 85 therapists who treated more than 10,000 adult patients over a 10-year period. Each therapist saw between 30 and 468 patients at one of 14 sites in the UK. About half of patients had moderate to severe depressive symptoms, and/or moderate to severe anxiety symptoms prior to starting therapy. Outcomes were measured with a reliable and valid psychometric instrument at pre- and post-treatment. The proportion of patients who dropped out of therapy was 33.8%. Patients who dropped out attended an average of 2.8 sessions (SD = 1.91), whereas treatment completers attended an average of 6.1 sessions (SD = 2.68). About 23.5% of therapists had drop out rates that were significantly worse than average. These below average therapists (n = 13) had 49% of their patients drop out, whereas above average therapists (n = 20) had only 12% of their patients drop out. Most patients who completed therapy improved (72.2%), but about 7.2% of patients deteriorated to some degree. The average therapist (i.e., 74% of therapists) had 4.6% of their patients who got worse, whereas below average therapists (i.e., 4.7% of therapists) had up to 14.9% of their patients who got worse. That is, almost 3 times as many patients deteriorated with below average therapists.
We know from previous studies that the type and amount of therapist training or theoretical orientation are not predictive of patient outcomes. However, previous research does suggest that therapists’ lack of empathy, negative countertransference, over-use of transference interpretations, and disagreement with patients about therapy process was associated with negative outcomes. Patient safety concerns might necessitate below average therapists to be identified and provided with greater support, supervision, and training.
Organizational Instability May be Related to Premature Termination from Psychotherapy
Werbarta, A., Andersson, H., & Sandell, R. (2014). Dropout revisited: Patient- and therapist-initiated discontinuation of psychotherapy as a function of organizational instability. Psychotherapy Research, Online first publication: DOI: 10.1080/10503307.2014.883087.
Premature termination of psychotherapy in mental health care is a problem both in terms of patient outcomes and in terms of financial consequences for providers. Drop out rates for psychotherapy in general range from 20% to 75% with an average of 50%. In my April, 2013 blog I reported on a meta analysis by Swift and Greenberg (2012) in which they reported an overall drop out rate of 20% in randomized control trials; but the average drop out rate could be up to 38% in randomized trials depending on how premature termination was defined (failure to complete a treatment, attending less than half of sessions, stopping attending, or therapist judgment). Drop outs are commonly believed to represent therapeutic failures. Much of the research to predict psychotherapy non-completion has focused on patient variables like age, gender, symptom severity and others. This implicitly puts the responsibility for dropping out on the patient. Swift and Greenberg (2012) found that on average young, male, single patients with a personality disorder diagnosis were more likely to drop out. Therapist variables are less frequently studied, and the only therapist variable related to lower drop out was greater experience. Therapeutic orientations were not related to more or less dropping out. Very few studies have examined work conditions or organizational variables as predictors of premature terminations. Werbata and colleagues (2014) conducted a large study in 8 clinics in Sweden with 750 patients treated by 140 therapists. The clinics were three psychiatry outpatient units, three specialized psychotherapy units, one young adult psychotherapy unit, and one primary care setting that provided psychotherapy. Drop out was defined as unilateral termination in which either the patient or therapist discontinued the treatment. Of the patients who started therapy, 66% completed treatment and 34% terminated prematurely (19.7% of patients terminated the therapy, 14.3% were terminated by therapists). On average, clients were in their mid-30s, and most had a psychiatric diagnosis. The most common therapy was psychodynamic (59.1%) followed by integrative (19.0%), and cognitive behavioral (17.1%). The authors looked at patient variables (e.g., symptom severity), therapist variables (e.g., age, gender, etc.), and organizational stability. Ratings of organizational stability of the clinic were based on: the transparency of the clinic structure, the suitability of the organization to provide psychotherapy, the clarity of rules and decision-making policies regarding providing psychotherapy, and the clinic’s financial stability. Client variables such as: older age, greater level of psychopathology, and tendency to act out were moderately predictive of dropping out. Receiving treatment at a less stable clinic made it almost four times more likely for patients to initiate dropping out than to remain in therapy. Organizational instability was more important than patient factors in accounting for premature termination.
Drop outs were almost four times higher in unstable clinics. Instability in organizations can create anxiety, cynicism, and disengagement in staff, which may have consequences for patient care. Financial and political problems within a clinic or institution, internal conflict related to treatment policy or disruptive administrative routines may affect the therapeutic relationship, which is generally more intimate and more important than in other health care contexts. Organizational instability can result in shortened or interrupted treatment, change in therapists, or therapists who are not fully engaged due to clinic stresses. For patients, these terminations may resemble earlier life losses or neglect that may have precipitated their need for therapy in the first place.