Definition, assessment and rate of psychotherapy side effects
Open accessAbstract
Psychotherapy is often seen as a first line treatment, because patients and therapists consider this mode of treatment harmless in comparison, for instance, to drug treatment. This assumption is supported by the fact that there are only limited scientific reports on psychotherapy side effects 1, 2. There is, however, some evidence which suggests that psychotherapy can have frequent or serious negative consequences, like all effective treatments 3-5. There are several reasons why awareness of psychotherapy side effects is limited and research on this issue is insufficient. First, the psychotherapist is the "producer" of treatment and therefore responsible, if not liable, for all negative effects, which results in a perceptional bias towards positive rather than negative effects 6. Second, psychotherapy does not only focus on symptoms but also on social behavior, so that the spectrum of possible negative effects is much broader than in pharmacotherapy 7. Third, there is even no consensus on what to call negative: for instance, when evaluating a manuscript on psychotherapy side effects, a reviewer wrote: "a divorce can be both positive and negative, and crying in therapy can reflect a painful experience but can also be a positive and therapeutic event". Fourth, there is a lack of differentiation between side effects and therapy failure or deterioration of illness 8. Fifth, there are no generally accepted instruments for the assessment of psychotherapy side effects and no rules on how to plan scientific studies or monitor side effects in randomized controlled clinical trials 2. There are indeed some instruments for the assessment of negative psychotherapy effects, although they are not widely used. They include the Vanderbilt Negative Indicator Scale 9, the Inventory of Negative Effects 10, the Unwanted Events and Adverse Treatment Reaction Checklist for Psychotherapy 11, 12 and the Experience of Therapy Questionnaire 13. Learning from the assessment of side effects in pharmacotherapy, a distinction must be made between side effects, unwanted events, adverse treatment reactions, treatment failure, malpractice effects, side effect profile, and contraindications. The assessment of side effects must start with the recording of "unwanted events". These are events which occur parallel to or in the context of treatment and which are burdensome to the patient and/or his environment, independent of whether they are unavoidable or even necessary to reach a treatment goal. Scares in surgery or crying in psychotherapy may be unavoidable or even necessary, but if there is a new treatment without this burden to the patient, the old procedure may no longer be ethically appropriate. The UE-ATR checklist 11 provides a list of areas where to look for unwanted events (Table 1). "Adverse treatment reactions" are all unwanted events which are caused by the treatment. This requires the ascertainment of a causal relation between the unwanted events and the ongoing treatment. In many cases it will not be possible to make a final decision about the cause of an unwanted event. Therefore, a probability rating should be made: e.g., unrelated, probably unrelated, possibly related, probably related, definitely related to the treatment. Side effects are adverse reactions which are caused by a correct treatment, while malpractice effects are the consequence of an inappropriate treatment. Therefore, a decision must be made on the quality of treatment. Good treatment causes side effects, bad treatment malpractice effects, a distinction which is a prerequisite for the decriminalization of side effects. Side effects which occur routinely when applying a special type of treatment constitute the "side effect profile" of that treatment. These regularly occurring side effects must be taken into account in planning the therapy, and patients should be informed about the side effect profile before starting treatment. "Contraindications" are serious side effects which must be expected in special types of patients and which render not applicable that type of treatment in those patients. Finally, the clinical impact of side effects must be assessed. Based on intensity, duration and patient's impairment, a rating of severity is needed. For instance: mild, without consequences; moderate, distressing; severe, in need of countermeasures; very severe, lasting negative consequences; extremely severe, hospitalization required; or life threatening. A suicide would be "extremely severe"; a lay off at work "very severe"; an increase in anxiety "severe"; discussions with one's spouse "moderate"; crying in therapy "mild". At present, it is not possible to report precise data on the rate and type of side effects of different forms of psychotherapy. Only very few papers were found when searching in PsycINFO and PubMed, from 1954 until now, for journal articles which have in their title the key word "psychotherapy" in combination with "side effects" (PsycInfo: 12, PubMe
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Trauma-focused therapy has safety concerns in clinical practice, such as symptoms worsening and patients ending treatment prematurely.
“and there are some safety concerns in clinical practice (eg, symptoms worsening and patients ending treatment prematurely).24 25”
Some adverse effects are expected in psychotherapy trials, including new symptoms and strains in the patient-therapist relationship, but few psychotherapy trials report data on adverse events and suicidality.
“Some of the adverse effects would also be expected in psychotherapy trials, including the emergence of new symptoms and strains in the patienttherapist relationship, 43 however, few psychotherapy trials report data on adverse events and suicidality.44”
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“Harm can be considered as any of the broad array of events that are considered AEs (e.g., deterioration of symptoms, emergence of new symptoms, interpersonal impairment; Lilienfeld, 2007; Linden & Schermuly-Haupt, 2014).”
Should rTMS be considered a first-line treatment for major depressive episodes in adults?
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Research-Informed Practice of Systemic Therapy
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“21 However, trauma-focused therapy can be difficult for some therapists to implement,(22) 23 and there are some safety concerns in clinical practice (eg, symptoms worsening and patients ending treatment prematurely).(24) 25 Two recent trials that directly compared TF-CBT with non-TF-CBT alternatives reported that both…”
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Self-citationThe preliminary development and psychometric properties of the Psychotherapy Side Effects Scale
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- Authors
- Linden, M., & Schermuly-Haupt, M.-L.
- Affiliations
- Stiftung Charité (DE)
- Research Group Psychosomatic Rehabilitation; Charité University Medicine Berlin; Department of Behavioral Medicine, Rehabilitation Centre Seehof; Lichterfelder Allee 35 14513 Teltow Germany
- ORCID
- Linden, Michael
- Venue
- World Psychiatry
- Publisher
- Wiley
- Published
- 2014-10
- Volume
- 13
- Issue
- 3
- Pages
- 306-309
- ISSN
- 1723-8617 (ISSN-L)
- PMC
- PMC4219072
- OpenAlex
- W2155424421
- Cited by
- 220
- References
- 23
- Citations by year
- 2026: 22 · 2025: 29 · 2024: 37 · 2023: 18 · 2022: 23 · 2021: 19 · 2020: 21 · 2019: 14 · 2018: 22 · 2017: 6 · 2016: 6 · 2015: 3
- FWCI
- 5.92
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- World Psychiatry (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
- Health Sciences › Medicine › Psychiatry and Mental health › Schizophrenia research and treatment
- Keywords
- unwanted events, treatment failure, side effect profile, contraindications, psychotherapist liability, randomized controlled trials, adverse event reporting, psychotherapy ethics, school dropout prevention
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