Research roundup: Potential harms and burdens of psychotherapy

This issue reviews recent studies on potential harms and burdens of psychotherapy and possible implications for treatment.

According to Section 3.04 (Avoiding Harm) of the APA Ethical Principles of Psychologists and Code of Conduct, psychologists must “take reasonable steps to avoid harming their clients/patients, students, supervisees, research participants, organizational clients and others with whom they work, and to minimize harm where it is foreseeable and unavoidable.” Compared to research on the positive effects of psychotherapy, the negative effects have not been as thoroughly studied. In the fields of medicine and psychopharmacology, the study of negative effects is commonplace. A lack of knowledge in this area may not only risk the well-being of patients, but may hurt the integrity of the field of psychotherapy. 

In addition to reviewing the following research summaries, psychologists are encouraged to explore the literature more completely to determine what may be useful to them in practice. 

Moyers, T.B. & Miller, W. R. (2013). Is low therapist empathy toxic? Psychology of Addictive Behaviors, 27(3) 878-884. Doi: 10.1037/a0030274


The interpersonal skills of clinicians play an integral role in patient outcomes. This study examined the importance of “accurate empathy,” a specific therapeutic skill that includes a commitment to understanding the client’s personal frame of reference and the ability to convey this heard meaning back to the client via reflective listening, in evidence-based addiction treatments. 

Effect sizes for four studies examining the connection between therapist empathy and outcomes of substance abuse treatments were computed and yielded the finding that empathy is a moderately strong predictor. However, the authors note that the findings don’t necessarily mean empathy causes improved client outcomes; rather, other factors such as client motivation may contribute to outcome as well as empathy of the therapist.

The authors attempted to determine whether therapists could be screened for empathy. They found that 68 candidates demonstrated the capacity to listen empathetically and an additional ten “passed” after a second try.   

The authors used this to determine if those who prescreened for empathy would demonstrate greater levels of empathy later. They conducted two randomized controlled trials (RCTs), training substance abuse therapists in motivational interviewing. In both RCTs, therapists submitted a baseline tape of themselves performing addiction treatment as they normally would. 

The therapists were then trained in motivational interviewing (MI). Afterwards, they submitted tapes of themselves using MI at 4, 8 and 12 months post-training. Although all participants were trained in MI (which has an aspect of empathy), those therapists with higher empathy scores pre-training continued to show higher empathy post-training.

Practical Implications

“Accurate empathy” in psychotherapy has been linked to better patient outcomes, including among providers of substance abuse treatment. Obtaining training in accurate empathy or otherwise enhancing one’s skills, regardless of therapeutic orientation, might have a positive impact on psychologists’ clients’ outcome, especially in addiction treatment.

Linden, M. (2013). How to define, find and classify side effects in psychotherapy: From unwanted events to adverse treatment reactions. Clinical Psychology and Psychotherapy, 20, 286-296. Doi: 10.1002/cpp.1765


This article examines the importance of identifying and classifying the various types of side effects that can result from psychotherapy. First, unwanted events (UE) are defined as “all negative events that occur parallel or in the wake of treatment.” These can be related to treatment (but don’t have to be) and include negative somatic or psychological symptoms that are not a desired effect of the particular treatment chosen for the patient. 

Research suggests therapists often don’t recognize potential treatment failures and other problems with treatment. This author recommends that therapists consider all UEs treatment-related unless and until the clinician can prove otherwise. The authors assert that “any UE that is probably caused by incorrect or improperly applied treatment” would be the responsibility of the clinician.

Further, the authors state that “any UE that is probably caused by correct treatment” would be an ‘adverse treatment reaction’ (ATR). While they may be inescapable, or even necessary, it’s important for clinicians to apprise their patients of risks at the start of therapy. Therapeutic risks (TRs) are “all ATRs that are known. Patients have the right to be informed about severe or frequent or impairing TRs as this is the basis for giving their informed consent for treatment.”

Once a side effect of treatment is identified, clinicians can determine how the therapeutic process lead to that particular therapeutic effect(s). The author describes how diagnostic procedures, theoretical orientations, selection of treatment focus, treatment procedures, sensitization processes, disinhibition processes, direct treatment effects, and therapist-patient relationship could all possibly contribute to side effects in therapy.

The author provided a list of possible UE based on clinical experiences and pharmacotherapy research that includes symptoms and complaints, the well-being of the patient, the therapeutic relationship, other treatments, the relation of the patient to other persons, family relations, work status, or any other changes in the life circumstances of the patient. The UE list is meant to function not only for the purpose of classification, but as a checklist when scanning for UEs while conducting psychotherapy.

Practical Implications

Regularly examining the therapeutic relationship for both positive benefits and negative side effects affords psychologists the opportunity to course correct and improve care. Greater attention to possible adverse treatment reflects due diligence on the part of the psychologist.  

Parker, G., Fletcher, K., Berk, M. & Paterson, A. (2013). Development of a measure quantifying adverse psychotherapeutic ingredients: The Experiences of Therapy Questionnaire (ETQ). Psychiatry Research, 206 293-301.


Based on a review of the literature on psychotherapeutic factors that impact therapy, the authors developed the Experiences of Therapy Questionnaire (ETQ), an experiential measure for psychotherapy evaluation studies. An independent study established high test-retest reliability for ETQ along with five factors. Scores were compared for a sample of 360 respondents currently receiving therapy and 356 respondents who had received therapy in the past. Higher scores for the factors “negative therapist,” “pre-occupying therapy,” “idealization of therapist” and “passive therapist” indicated a more negative view of therapy, while a higher score on the factor “beneficial therapy” indicated a more positive view of therapy. Research suggests that attributes signifying a negative or passive therapist, pre-occupation with therapy and idealization of therapy contribute to poorer therapy.

Factor 1, labeled “Negative Therapist,” was characterized by lack of empathy, intrusiveness and not seeming to have the patient’s best interest at heart. Respondents in the “past therapy” sample indicated that age, therapist type and medication status significantly influenced scale scores. Younger respondents had a more negative view of their therapist. A greater number of negative ratings were seen for psychiatrists than psychologists and counselors. 

Factor 2, labeled “Pre-occupying Therapy,” was characterized by the patient becoming excessively inwardly focused/pre-occupied with therapy or feeling alienated/powerless. Younger respondents in both “past” and “current” therapy samples reported higher scale scores. The number of sessions received, therapist type, diagnosis and medication status greatly influenced ratings for “past” therapy participants. 

Scores increased as more therapy sessions were received. Scores for psychiatrists were much higher than for psychologists and counselors. Participants receiving medication yielded higher scores than those not on medications.

Factor 3, labeled “Beneficial Therapy,” was characterized by improved quality of life/coping, symptom reduction and increased insight. In the “current” therapy sample, CBT and long-term psychotherapy were rated as more beneficial than “general” counseling. The “past” therapy sample rated psychiatrists as less beneficial than psychologists and counselors. 

Factor 4, labeled “Idealization of Therapist,” was characterized by patient feeling dependent on therapist, and boundary issues. Females in the “current” therapy sample were more likely to idealize their therapist. In both samples, more frequent sessions were associated with higher ratings and those receiving current therapy on a biweekly basis had higher ratings as well. In the “past” therapy sample, psychiatrists were more idealized than psychologists. Participants receiving medication yielded higher scores than those not receiving medication.   

Factor 5, labeled “Passive Therapist,” was characterized by therapist perceived as inactive, inexperienced, or lacking credibility. Younger respondents in “current” therapy were more likely to score their therapist higher. 

Practical Implications

Use of the ETQ in treatment studies could begin to uncover how different attributes of therapy relate to treatment outcomes. Those psychologists who opt to use such a tool in practice would likely learn more about how their patients perceive them and therapy. This feedback could be useful for possibly modifying interventions in order to improve patient benefits. 

Leitner, A., Martens, M., Koschier, A., Gerlich, K., Liegel, G., Hinterwallner, H. & Schnyder, U. (2013). Patients’ perceptions of risky developments during psychotherapy. Journal of Contemporary Psychotherapy, 43 95-105


In a preliminary study, the authors examined six dimensions of personal therapy in an online questionnaire completed by 1,357 participants. 

Three dimensions were associated with risky developments during psychotherapy:

  1. Perceived quality of the therapeutic relationship (accounting for 73.4 percent of total variance, Cronbach’s Alpha = 0.94), which was measured by the following statements: “I was satisfied with my therapist,” “I feel that my therapist understands me,” “I could trust my therapist” and “My therapist takes me seriously.” 
  2. Dependency and isolation (accounting for 10 percent of the total variance, Cronbach’s Alpha = 0.56), measured by the following statements: “I feel my therapist is the most important person in my life,” “I feel that my therapist is the only person that listens to me” and “I do not get help and support from my social network beyond psychotherapy.” 
  3. Burden caused by psychotherapy (accounting for 8 percent of the total variance, Cronbach’s Alpha = 0.64), measured by the following statements: “I feel overwhelmed in therapy,” I’d be afraid of the reaction of my therapist, if I would tell him/her that I want to end the therapy” and “I’m afraid someone could notice that I’m in psychotherapy.” 

Of the 1,357 participants, 459 (22.3 percent) viewed their therapeutic relationship as poor. 

A poor therapeutic relationship can have a profound effect on the success of psychotherapy. Overall life satisfaction can decline during the course of therapy when a mediocre relationship between patient and therapist exists.

A total of 367 patients (17.9 percent of the total sample) felt highly dependent and/or isolated. The combination of male therapist-female patient was found much more frequently among highly isolated patients (109 of 357 patients; 29.7 percent).

The more dependent a patient becomes on his or her therapist, the greater likelihood there is for risky conditions, and ultimately, a negative therapy development.

Two hundred and sixty-seven patients (13 percent of the total sample) indicated high levels of burden caused by therapy. Patients can experience burden connected to unwanted life changes in the social environment or from fear of disappointing their therapist. 

Additionally, the authors also identified premature termination of psychotherapy as having the potential to lead to negative effects.

Practical Implications

Regardless of psychotherapeutic approach, fostering a positive therapeutic relationship is critical to successful treatment. Strategies for evaluating the quality of the relationship and adjusting the relationship could serve to enhance the work of psychologists. 

Strategies to reduce patient dependency, such as increasing the degree of a patient’s input throughout the course of treatment by discussing the optimal number of sessions and when therapy should end, may also reduce risky therapy conditions. Anticipating how patient change might alter the patient’s environment or relationships might reduce patient perception of therapeutic burden, which could reduce the risk of poorer outcomes.