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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.

Cognitive Behavioral Analysis System of Psychotherapy (CBASP) for Chronic Depression

Schramm, E., Kriston, L., Zobel, I., Bailer, J., Wambach, K., …Harter, M. (2017). Effect of disorder-specific vs nonspecific psychotherapy for chronic depression: A randomized clinical trial. JAMA Psychiatry, 74, 233-242.

The lifetime prevalence of chronic depression is somewhere between 3% and 6% of the population. Chronic depression refers to depression that develops into a chronic course of more that 2 years. Compared to those with acute depression (< 2 years depressed), patients with chronic depression experience greater social, physical, and mental impairments. This large randomized controlled trial by Schramm and colleagues assessed the efficacy of the Cognitive Behavioral Analysis System (CBASP) compared to so-called non-specific psychotherapy (NSP), both delivered in 24 sessions. CBASP is a structured therapy that combines cognitive and interpersonal treatments focused on problems solving and learning the effects of one’s own behaviors on others. On the other hand, therapists delivering NSP were limited to reflective listening, empathy, and helping the client feel hopeful. Specific interventions associated with cognitive or interpersonal therapies were prohibited. A total of 262 patients with chronic depression were randomly assigned to receive 24 sessions of either CBASP or NSP. Main outcomes included indicators of “response” to treatment (a 50% reduction in a depression scale score) or “recovery” (a very low score on the scale at the end of treatment). Both CBASP and NSP resulted in a significant decline in depressive symptoms after 48 weeks. The CBASP condition was slightly more effective than simply providing NSP (d = 0.39, NNT = 5). About 38.7% responded to CBASP compared to 24.3% who responded to NSP (OR = 2.02; 95% CI, 1.09-3.73; p = .03; NNT = 5). In terms of remission, 21.8% recovered after CBASP compared to 12.6% in NSP (OR = 3.55; 95% CI, 1.61-7.85; p = .002; NNT = 4). Average drop-out rates were similar between the two treatments at about 22%.

Practice Implications

CBASP represents a highly structured integrative treatment for chronic depression. It did modestly better than NSP in which therapists were prohibited from engaging in any technical intervention. In the end, the longer-term rates of recovery for CBASP were also modest at about 21.8%. On the one hand, chronic depression is notoriously difficult to treat with psychotherapy or medications, so perhaps CBASP will provide relief for some. On the other hand, an average 21.8% recovery rate for CBASP was modest. CBASP was slightly better than providing active listening and empathy alone.

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.

Orlinsky, D.E., Ronnestad, M.H., Hartmann, A., Heinonen, E., & Willutzki, U. (2019). The personal self of psychotherapists: Dimensions, correlates, and relations with patients. Journal of Clinical Psychology. Online first: DOI: 10.1002/jclp.22876

What role does the psychotherapist’s personal self play in determining their interpersonal stances with patients? It is an intriguing question about the intersection between the personal self and the professional self of psychotherapists. Are we different in our personal lives compared to our professional lives? In this large survey of over 10,000 psychotherapists from Europe and North America, Orlinsky and colleagues examine the convergence of the personal and professional self of psychotherapists. The personal self was defined as therapists’ view of the self when engaging in personal relationships. This can include behaviors in close relationships, and also one’s temperament defined as innate sensitivities or proclivities in relationships. Previous research indicated that when relationships are satisfying, life typically feels rich and meaningful – but if personal relationships are limited or non-existent, life can feel empty and meaningless. The survey asked therapists a number of questions, including about how they describe themselves in close personal relationships, what their general proclivities are around affect expression, cognitive style, and expectations of relationships, and how they rated their life satisfaction. Half of the sample of psychotherapists were psychologists, and there was also a large representation of psychiatrists, counsellors, and social workers. Major theoretical orientations were represented (psychodynamic, CBT, humanistic), and therapists came from a number of countries mainly in Europe and North America. Most psychotherapists identified themselves as caring (friendly and warm: 85%) in close relationships, but some also reported being more forceful (authoritative: 37%) and reclusive (guarded: 27.6%). In terms of temperament most therapists were optimistic and intuitive (84% each), but some also indicated more pragmatic (72%) or skeptical (25%). Therapists who more caring and expressive also reported higher levels of personal life satisfaction. In general, therapists who were more caring in their personal relationships reported being more affirming with patients (r = .52), those who were more forceful in personal relationships tended to be more directive with patients (r = .48), and those who were more reclusive in personal relationships were more reserved with patients (r = .20).

Practice Implications

Not surprisingly, most therapists saw themselves as warm, affiliative, optimistic, and receptive in personal relationships. But, many therapists (35%) also described themselves in negative terms (reserved, guarded, skeptical) in close relationship. Although psychotherapists may see their personal relationships and their professional relationships as independent, this large multinational survey indicates otherwise. Personal relationship style and temperament has a moderate to large association with professional interpersonal style with patients. This may indicate that therapists generally are genuine (consistent with themselves) in their relationship with patients. But other therapists may have to reign in more negative aspects of their selves and social behaviors in order to be empathic and caring towards patients.

Kolden, G.G., Austin, S.A., Wang, C-C., Chang, Y., & Klein, M. (2018). Congurence/genuineness: A meta-analysis. Psychotherapy, 55, 424-433.

More than 60 years ago Carl Rogers first described congruence or genuineness in the psychotherapy relationship as one of the necessary conditions for patients to improve. Congruence has two components. The intrapersonal component refers to mindful genuineness, personal awareness, and authenticity in relationships. The interpersonal component refers to the capacity to express ones’ internal experiences to another person. Rogers argued that patients often experience incongruence with regard to their internal states (they may avoid or fear the experience or expression of what they think or feel). He also stated that therapists’ congruence in the relationship with a patient is a pre-requisite for positive regard and empathy toward the patient. In this meta-analysis, Kolden and colleagues do a systematic review of the relationship between therapist congruence and patient outcomes. The review included 21 studies representing 1,192 patients. The weighted effect size for congruence and psychotherapy outcome was r = .23 (95% CI: .13, .32), representing on average a moderately large effect. Theoretical orientation did not affect the congruence – outcome association. However older therapists with more experience showed a significantly stronger congruence – outcome relationship. Also, therapy with younger patients was associated with a larger congruence – outcome relationship.

Practice Implications

Research continues to support fundamental therapeutic factors defined by Rogers many decades ago. In this case, congruence/genuineness (or the therapist’s ability to know their internal experience and communicate it respectfully to patients) is positively related to patient outcomes. This is especially true for older therapists (who may have a greater capacity for genuineness) and for younger patients – (for whom therapist genuineness may be particularly important). Patients who may have a greater need for and expectation of genuineness are likely to develop a stronger therapeutic alliance with a highly congruent therapist. Patients in a congruent therapeutic relationship learn that it is a safe space, that they matter as a person, and that the therapist is committed and accepting. All of which are precursors to a successful therapy.

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.