Schermuly-Haupt, M. L., Linden, M., & Rush, A. J. (2018). Unwanted events and side effects in cognitive behavior therapy. Cognitive Therapy and Research, 42(3), 219-229.
Unwanted events are negative consequences for clients that may or may not be related to treatment (i.e., events outside of therapy or inside of therapy that may negatively affect clients). These might include: occupational problems, stigmatization, strains in personal relationships, changes in the social network, patients feeling overwhelmed, undermined self-efficacy, deterioration of symptoms, emergence of new symptoms, suicidality, and others. Side effects refer to negative reactions in clients directly related to appropriately delivered therapy. Research estimates that between 5% and 20% of patients report side effects of psychotherapy. One could argue that side effects may be inevitable even in well-delivered therapy, and therapists who are aware of the potential for side effects may be better equipped to help clients to manage. In this study, Schermuly-Haupt, interviewed 100 psychotherapists who provided CBT in outpatient clinics in Germany about side effects among their clients. All therapists were supervised as part of their work and so the authors assumed the therapy was appropriately delivered. Therapists had on average 5 years of experience and were trained to provide CBT. The interview asked therapists about their most recent treatment case in which the client attended at least 10 sessions. Clients typically had major depression, an anxiety disorder, or a personality disorder, and had attended 28 sessions of therapy on average. During the interview, therapists identified if an unwanted event occurred for a client from a standardized list, and then rated the duration and severity of the effects. They also rated the degree to which the unwanted event was directly related to therapy (i.e., a side effect). Prior to the interview, only 26% of therapists reported their client experienced side effects. However, the interview process found that almost all clients experienced an unwanted event (98%) that may or may have been related to therapy, and 43% experienced at least one side effect that was at least somewhat related to treatment. The most frequent side effects were: “negative wellbeing/distress” (27% of clients), “deterioration of symptoms” (9% of clients) and “strains in family relations” (6% of clients). Of the therapists, 46% rated the side effects as at least moderately severe, and 8.8% of side effects were rated as persistent (lasting more than a month).
Unwanted events outside of therapy are very common among our clients, but so are side effects from appropriately delivered treatment. Psychotherapy is not always harmless, and it may be best to acknowledge and prepare both clients and therapists for side effects. These may represent ruptures in the alliance that can be managed through alliance-focused therapy, for example. That is, side effects may be caused a mismatch between the goals of a therapist and client, or a disagreement on how to proceed in therapy given what a client needs at the time. Goals and tasks of therapy may need to be renegotiated following the experience of a side effect.