Here is What Clinicians Should Know About Side Effects of Psychotherapy – Dr Sanil Rege MBBS, MRCPsych, FRANZCP – July 24, 2017
In conditions such as depression and anxiety, the beneficial effects of psychotherapy are often comparable with evidence-based pharmacotherapy options in terms of symptom reduction and protection against relapse.
While discussion about side effects, risks and benefits are an important part of psychotropic medication prescribing, the same cannot be said for psychological treatments.
All pharmacological medications come with relevant or absolute contraindications, and yet the common assumption is that talking therapies are risk-free or come with little risk at all.
It is important to recognise that psychotherapy is not free from side effects with a range of potentially negative patient outcomes in the context of treatment .
The study of negative effects in psychotherapy research is under-represented, and this is due to several reasons:
- There is an inherent difficulty in differentiating between side effects and unavoidable negative effects.
- A therapist has a legal responsibility and may face malpractice if the reported side effects were caused by incorrect therapist behavior rather than perhaps just aberrant patient behaviour.
- Lack of consensus on the terminology of side effects
THE OSHEROFF CASE
Dr Osheroff was a 42-year-old physician who was admitted to Chestnut lodge in 1979 with depression and agitation. Although Chestnut lodge recorded the symptoms of major depression, they attempted to treat him with psychotherapeutic techniques designed to regress him.
During the seven months that Mr Osheroff was in Chestnut lodge, his condition deteriorated, and his family took him out of Chestnut lodge and admitted him to another psychiatric hospital where he was treated with medication and his condition rapidly improved within a matter of weeks.
However, the delay in treatment led to a loss of his practising license, loss of his relationship and loss of his practice.
Dr Osheroff subsequently sued for malpractice on the basis that he should have been treated with medication of demonstrable efficacy as opposed to intensive psychotherapy which was not indicated for his type and severity of depression. You can read the case in more detail here.
DEFINING AND ASSESSING PSYCHOTHERAPY SIDE EFFECTS
A review published in Clinical Psychology and Psychotherapy in 2012 aimed to provide a well-defined classification system of psychotherapy side effects . These are divided into Treatment Emergent Reactions (TER) and Adverse Treatment Reactions. (ATR)
A treatment-emergent reaction (TER) is an unwanted negative event directly caused by the treatment itself.
This could be due to treatment not being applied correctly, such as in the case of malpractice, or it could alternatively be attributed to being a side effect of adequately applied treatment.
2. Adverse-Treatment Reactions
An adverse-treatment reaction (ATR) is an unwanted event caused by the correct treatment. Adverse-treatment reactions are therefore side effects that are inherently unavoidable and are not due to malpractice.
Often, known ATRs are instead classified as therapeutic risks such as those qualified contraindications that are included when considering pharmacotherapy.
If a therapeutic risk is not made clear before commencing therapy, this is likely to constitute malpractice.
PREVALENCE OF PSYCHOTHERAPY SIDE EFFECTS
Any side effect could instead just be a negative development of the illness rather than caused by the treatment itself. With psychiatric disorders there are natural fluctuations in symptomatology that can make treatment cause and effect difficult to determine.
A cross-sectional survey of over 14,000 patients receiving psychological interventions showed that 5.2% reported lasting negative side effects .
This study did not explore the nature of these negative side effects and instead used multivariate statistical analyses to cover demographic factors and the type and form of therapy.
Other studies have shown that approx. 3-10% of patients become worse after psychotherapy with higher rates (7-15%) for patients with substance misuse.
NEGATIVE EFFECTS OF PSYCHOTHERAPY
The emergence of new symptoms, which includes the development of interpersonal difficulties or issues within the family or at work are possible signs of a negative impact of psychotherapy.
Furthermore, the negative impact of psychotherapy may cause a significant decline or deterioration in existing symptoms.
It is, therefore, reasonable to assume that assessment of negative changes should be implemented as routine assessment even when providing evidence-based care .
TREAMENT SPECIFIC NEGATIVE EFFECTS
A review of RCTs in the literature from 1954 to 2014 shows there are only 132 eligible trials for which only 21% reported side effects. Furthermore, only 3% recorded these side effects .
Cuijpers et al., conducted a meta-analysis of trials comparing psychotherapies in adult depression with control conditions that report deterioration rates. They found that although psychological treatments of adult depression may reduce the risk for deterioration, only 6% of all trials comparing psychotherapy with a control condition reported deterioration rates.
Key risks of psychotherapy to the patient include
- Excessive self –absorption at the expense of important external demands. (Work, family etc.)
- Externalised locus of control may lead to the adoption of a victim role.
- Decreased capacity to make independent judgements
Side-effects of psychotherapy.
Classification of Side Effects in Psychotherapy
Linden M, How to define, find and classify side effects in psychotherapy: from unwanted events to adverse treatment reactions. Clinical Psychology and Psychotherapy. 2012
Patient experience of negative effects of psychological treatment
Crawford M et al., Patient experience of negative effects of psychological treatment: results of a national survey. British Journal of Psychiatry. 2016
Negative effects from psychological treatments
Barlow D, Negative effects from psychological treatments: a perspective. American Psychologist. 2010
Definition, assessment and rate of psychotherapy side effects
Linden M and Haupt M, Definition, assessment and rate of psychotherapy side effects. World Psychiatry. 2014
Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in three-through six year-old children
Scheeringa M et al., Trauma-focused cognitive-behavioral therapy for posttraumatic stress disorder in three-through six year-old children: a randomized clinical trial. Journal of Child Psychology and Psychiatry. 2011
Author: Dr. Sanil Rege is a Consultant Psychiatrist and founder of Psych Scene and Vita Healthcare. He has lived and worked on 5 continents and currently lives on the Mornington Peninsula.