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Negative Effects of Psychotherapy

Cuijpers, P., Reijnders, M., Karyotaki, E., de Wit, L., & Ebert, D.D. (2018). Negative effects of psychotherapy for adult depression: A meta-analysis of deterioration rates. Journal of Affective Disorders, 239, 138-145.

Several types of psychotherapy are effective to treat depression, and there appears to be very little difference among the treatments in term of their effectiveness. Despite the documented effectiveness of psychotherapies to treat depression, there is also a growing interest in the clinical and research community about negative effects. Negative effects refer to the deterioration or worsening of depressive symptoms during treatment. Some may also refer to drop-out or non-response as a negative effect because these events are demoralizing and may prevent a patient from seeking more adequate care. Some researchers estimated that 5% to 10% of patients deteriorate during therapy. Deteriorations may not be due solely to the therapy itself, but instead may reflect the natural course of depression. In this meta-analysis, Cuijpers and colleagues examined studies in which a psychotherapy for depression was compared to a control condition in which patients did not receive an active treatment. In such studies, one might expect the control condition to represent what would happen in terms of symptoms if the patient received no treatment. Despite over 100 randomized controlled trials of a psychotherapy versus a non-active treatment control condition for depression, only 18 studies reported enough information to estimate negative effects. There was a median deterioration rate in the psychotherapy groups of about 4%, whereas the risk of deterioration in the control groups was about 11%. There were no differences in deterioration rates among types of psychotherapy (CBT vs others), treatment format (group vs individual), or type of control group (wait-list vs care as usual).

Practice Implications

Only 6.2% of research studies reported enough information to estimate negative effects, making it difficult to get a good estimate that represents all studies and patients. Nevertheless, receiving psychotherapy reduced deterioration rates by more than 61% compared to untreated control conditions, suggesting that psychotherapy can help some patients who might get worse with no treatment. Therapists should work to recognize and evaluate deterioration rates in therapy because they do occur for an important minority of patients. Some have suggested ongoing progress monitoring as a means of reducing the number of patients who might get worse during psychotherapy.

Adverse Events During Psychotherapy

Meister, R., Lanio, J., Fangmeier, T., Harter, M., Schramm, E., … Kriston, L. (2020). Adverse events during a disorder‐specific psychotherapy compared to a nonspecific psychotherapy in patients with chronic depression. Journal of Clinical Psychology, 76, 7-19.

Adverse events refer to negative or unwanted outcomes of psychotherapy that may be due to the therapy itself when delivered correctly, or to the application of the therapy when delivered incorrectly. For example, patients may report worsening of symptoms, relationship problems with partners or family, problems at work, stigma, and other disadvantages. Adverse events during pharmacologic treatment are well studied and are often considered when making treatment decisions. However, adverse events in psychotherapy are largely ignored in the research and clinical literature. A recent meta analysis reported that the median deterioration rates in psychotherapy studies is about 4%, which is likely less than half the rate of deterioration seen in regular clinical practice. In this study, Meister and colleagues look at deterioration rates in a randomized controlled trial comparing the Cognitive Behavioral Assessment System of Psychotherapy (CBASP) versus non-supportive psychotherapy (NSP). In that study that was previously summarized in this blog, 262 depressed patients were randomly assigned to receive 24 weeks of either CBASP or NSP. Participants who received CBASP were slightly better off than those who got NSP, and the drop-out rates were equivalent between conditions. Therapists asked patients at each session if the patient experienced an adverse event in the previous week. Patients reported an average of about 12 adverse events during the 24 weeks of psychotherapy, and there was no difference in the number of adverse events between CBASP and NSP. However, patients receiving CBASP reported more severe adverse events related to their personal life and work life compared to patients receiving NSP. Suicidal thoughts were infrequently reported by patients, and their frequency did not differ between CBASP and NSP.

Practice Implications

The study highlights that symptoms and interpersonal conflicts may temporarily increase as a result of being in psychotherapy. The authors argued that the increases in problems with work and personal relationships may be due to the specific interpersonal treatment elements of CBASP that require changes in the patient’s interpersonal behaviors that temporarily may be disruptive to their lives. Therapists may consider informing patients about the possible temporary negative effects of psychotherapy on their relationships or functioning. This preparation might help patients to make informed decisions about psychotherapy and to prepare them to cope with changes in their relationships.

Owen, J., Tao, K. W., Imel, Z. E., Wampold, B. E., & Rodolfa, E. (2014). Addressing racial and ethnic microaggressions in therapy. Professional Psychology: Research and Practice, 45(4), 283–290.

Overt forms of racism and prejudice still occur in society, and less overt forms are likely more prevalent. Microaggression are those less overt forms of racism and prejudice that may include direct and indirect insults, slights, and discriminatory messages. Specific types of microaggression are: microinvalidations (e.g., denying that racism exists), microassaults (e.g., direct racism but done in private), and microinsults (e.g., believing a group’s cultural norms are pathological). Microaggression are by definition ambiguous and subtle, and they may target culture, race, gender, sexual orientation, and other group identities. Microaggressions are associated with psychological distress in the recipient. Microaggressions can also occur in therapy if a patient perceives a therapist’s dismissing or negating messages about the patient’s culture, or if a therapist engages in culturally inappropriate interventions. Microaggressions represent a special type of therapeutic alliance rupture that could lead to negative patient outcomes. It is also possible that therapists and clients who address microaggressions after they occur are capable of repairing the alliance rupture and moving forward with a stronger relationship. However, there is very little research of the impact of client perceived microaggressions on the therapeutic alliance. In this unique study, Owen and colleagues asked 120 racial and ethnic minority university counselling centre patients treated by 33 different therapists (23 of whom were White) to rate their experience microaggressions, to indicate if the microaggression was discussed, and to rate the therapeutic alliance. In total, 53.3% of patients experienced a microaggression in therapy, and of those patients, 68.4% were treated by a racial or ethnic minority therapist. Clients who reported fewer microaggressions also reported stronger therapeutic alliances (r = .28, p = .01). Of the patients who reported a microaggression, only 24% (13 patients) reported that the microaggression was discussed by the therapist. Of these 13 patients, almost all (12 patients) reported that the discussion was successful. Therapist and patient dyads who successfully discussed the microaggression: (1) had alliance scores comparable to patients who did not experience a microaggression, and (2) had alliance scores that were significantly higher than dyads who experienced but did not discuss the microaggression.

Practice Implications

Microaggressions appear to be ubiquitous in daily life and in psychotherapy – no therapist is immune. More than 53% of patients in this study reported a microaggression, despite what was likely their therapists’ good intentions. Microaggression are a special case of therapeutic alliance ruptures, which are known to be associated with poor patient outcomes. Therapists must develop a strong multicultural orientation and take a culturally humble stance with clients from a different culture or group. This involves therapists being attuned to the possibility of committing a microaggression, inviting patients to alert the therapist should a microaggression occur, and being open to clarifying misunderstandings and owning missteps.

Mental Health Disorders Increase Health Care Utilization in Adults with Chronic Disease

Sporinova B, Manns B, Tonelli M, et al. (2019). Association of mental health disorders with health care utilization and costs among adults with chronic cisease. JAMA Network Open. Published online: 2(8):e199910. doi:10.1001/jamanetworkopen.2019.9910

Chronic diseases like diabetes, heart disease, chronic obstructive pulmonary disease (COPD), chronic kidney disease are common and represent a major burden on the individual and on society. So much so that chronic diseases represent about 60% of global disease burden. There is also a documented association between mental and physical health, such that mortality in cancer, diabetes, and following a heart attack is significantly higher in those with depression. The cost of chronic disease to the Canadian economy represents about 60% of the annual health care budget, and depression alone has a $32.3 billion impact on the Canadian economy. In this economic study, Sporinova and colleagues sought to quantify the impact of having a mental disorder on health care utilization and cost for those with chronic diseases. The study used a large data base of adults from Alberta, Canada who had at least one chronic disease including asthma, COPD, heart failure, myocardial infarction, diabetes, epilepsy, and chronic kidney disease. Mental disorders were defined as a concurrent diagnosis of depression, schizophrenia, or substance use disorder. Factors like sex, income, and rural residency were controlled in the analyses. Of the cohort with a chronic illness, 15.8% had a mental disorder, with depression as the most common mental disorder at 11.2%. People with chronic illness and a mental disorder tended to be younger, women, with a lower socio-economic status, and they tended to die at a higher rate during the study period. The mean total 3-year health costs of those with a chronic illness was $20,210 (95% CI: $19,674, $20,750) Canadian dollars, whereas for those with a concurrent mental disorder the cost was significantly higher at $38,250 (95% CI: $36,476, $39,935). Higher costs were driven by greater hospitalizations, prescription drug use, and physician visits. Costs were higher for older people, and for those with more than one mental disorder.

Practice Implications

The results clearly indicated that an important proportion of those with chronic illnesses were also diagnosed with a mental disorder. Further, a diagnosis of a mental disorder drove up the burden of the chronic illness significantly, both for the individual and for the health care system. Past research indicated improved medical outcomes when treating depression in medical patients. And so, although the physical symptoms of chronic illness may appear prominent, clinicians must treat mental health problems when they exist concurrently, if they want to improve patient medical and mental health outcomes.

Karver, M. S., De Nadai, A. S., Monahan, M., & Shirk, S. R. (2018). Meta-analysis of the prospective relation between alliance and outcome in child and adolescent psychotherapy. Psychotherapy, 55(4), 341-355.

Over the past decades there has been increasing research on the efficacy of psychotherapy for children and adolescents, but outcomes have not always been positive. Treatment of children and adolescents comes with challenges that are unique from those experienced in therapy of adults. For example, unlike most adults, children and adolescents may not be the ones to choose to attend therapy - that decision is often made by adults in their lives. Furthermore, psychotherapists must also develop and maintain a collaborative relationship with parents, on whom the therapist and child/adolescent rely in order to be able to engage in treatment. Because of the unique characteristics of working with children and adolescents, negotiating, developing, maintaining, and repairing the therapeutic alliance is potentially complex. The therapeutic alliance is defined as an agreement on tasks of therapy, an agreement on goals of therapy, and the relational bond between therapist and client. In this meta-analysis, Karver and colleagues reviewed 28 studies of psychotherapy with children and adolescents. The mean age was about 12 years, most children/adolescents had internalizing problems, but others had problems with externalizing behaviors, and substance abuse. Almost two thirds of the studies involved a version of behavior or cognitive behavioral therapy. The therapeutic alliance was measured from the perspective of the client, therapist, and/or the parent. The overall mean effect size of the alliance-outcome relationship was small to moderate: r = .19 (p < .01, 95% confidence interval [CI] [0.13, 0.25]). Larger effect sizes were seen in those therapies of children and adolescents with internalizing disorders (r = .19), and when the therapist – parent alliance was measured and correlated with outcomes (r = .30). In other words, a positive alliance was most important for internalizing disorders, and for the relationship between therapist and parent.

Practice Implications

The findings of this meta-analysis indicate that the therapeutic alliance, especially with the parent, is important to the outcomes of children and adolescents in psychotherapy. Clinicians should not only develop an alliance with the youth, but also with the parent/caregiver. Therapists should also consider measuring the alliance regularly during therapy as a means of heading off any ruptures (with the youth or the parent) that might endanger the therapy. The authors recommended using the Therapeutic Alliance Scale for Children – Revised with children/adolescents, and the Working Alliance Inventory with parents.

Lambert, M. J., Whipple, J. L., & Kleinstäuber, M. (2018). Collecting and delivering progress feedback: A meta-analysis of routine outcome monitoring. Psychotherapy, 55(4), 520-537.

Somewhere between 5% and 10% of adult clients in clinical trials of psychotherapy get worse, and the numbers are likely higher in regular clinical practice. In addition, some therapists are more effective than others, so that some therapists have few clients who get worse whereas others consistently have high rates of poor client outcomes. Unfortunately, therapists have a difficult time assessing their client outcomes. Many therapists are overly optimistic about their clients’ outcomes, and clinicians frequently do not identify when clients get worse. One likely reason for this erroneous assessment of client outcomes is that typically psychotherapists do not have quality information in order to make accurate decisions and predictions. Assessing client outcomes on a regular basis throughout treatment is a difficult and complicated endeavour, and one that is beyond the capacity of most people. So, like other professionals (pilots, air traffic controllers, engineers) psychotherapists can improve their predictions and decision-making if they have access to quality information about their clients’ functioning. One source of such information for psychotherapists could be from the use of routine outcome monitoring. Routine outcome monitoring involves assessing client mental health functioning with reliable psychometric scales throughout the course of treatment, and feeding this information back to therapists who can use the data to adjust what they are doing if necessary. The two most commonly used outcome monitoring tools are the Outcome Questionnaire-45 (OQ-45) which is part of the OQ Analyst Feedback System, and the Outcome Rating Scale (ORS) and Session Rating Scale (SRS) which are part of the Partners for Change Outcome Management System (PCOMS). In this meta-analysis, Lambert and colleagues assessed the effect of regular outcome monitoring with the OQ-45 and the ORS to improve client outcomes. In 15 studies with almost 8,500 participants, the OQ-45 outperformed treatment as usual but with a small effect (SMD = .14, 95% CI [.08, .21]). However, the positive effect of using the OQ-45 with feedback was larger for the 31.2% of clients who were not doing well in therapy (SMD = .33, 95% CI [.25, .41]). Among those studies that used the OQ standardized feedback system that provides recommendations to therapists, the effects were even larger (SMD = .49, 95% CI [.25, .73]). Similarly, in nine studies with over 2,000 participants, the effects of using the PCOMS system had a small to moderate positive effects on client outcomes (SMD = .40, 95% CI [.29, .51]).

Practice Implications

The research evidence supports the use of routine outcome monitoring with the OQ-45 or the PCOMS to improve client outcomes. Quality information that is fed back to clinicians can compensate for the limited capacity that any clinician has to accurately detect a client that is worsening in psychotherapy. The information provided to therapists with these feedback systems can highlight potential problems in the client and identify strain in the therapeutic alliance. This information can sensitise therapists to at-risk clients and situations, and encourage therapists to adjust their interventions or interpersonal stances accordingly.

Author email: lambert.michaelphd@gmail.com