Interviews with 100 CBT-therapists reveal 43 per cent of clients experience unwanted side-effects from therapy

GettyImages-690819948.jpgBy Christian Jarrett

The structured nature of Cognitive Behavioural Therapy/CBT and its clearly defined principles (based on the links between thoughts, feelings and behaviours) make it relatively easy to train practitioners, to ensure standardised delivery and to measure outcomes. Consequently, CBT has revolutionised mental health care, allowing psychologists to alchemize therapy from an art into a science. For many mental health conditions, there is now considerable evidence that CBT is as, or more, effective than drug treatments. Yet, just like any form of psychotherapy, CBT is not without the risk of unwanted adverse effects.

A recent paper in Cognitive Therapy and Research outlines the nature and prevalence of these unwanted effects, based on structured interviews with 100 CBT-trained psychotherapists. “This is what therapists should know about when informing their patients about the upcoming merits and risks of treatment,” write Marie-Luise Schermuly-Haupt and her colleagues.

The researchers asked each CBT-therapist (78 per cent were female, average age 32, with an average of 5 years experience) to recall their most recent client who had taken part in at least 10 sessions of CBT. The chosen clients (51 per cent were female, average age 38) mostly had diagnoses of depression, anxiety or personality disorder, in the mild to moderate range.

The interviewer – an experienced clinical psychologist trained in CBT – followed the Unwanted Events-Adverse Treatment Reactions checklist, asking each therapist whether their client had experienced any of 17 possible unwanted events during therapy, such as deterioration, new symptoms, distress, strains in family relations, or stigma.

The therapists, who work at outpatient clinics in Germany, reported an average of 3.7 unwanted events per client. Based on the therapists’ descriptions, the interviewer then rated the likelihood of each unwanted event being directly attributable to the therapeutic process – making them a true side-effect (only those rated as “definitely related to treatment” were categorised as such).

Following this process, the researchers estimated that 43 per cent of clients had experienced at least one unwanted side-effect from CBT, equating to an average of .57 per client (one client had four, the maximum allowed by the research methodology): most often distress, deterioration and strains in family relations. Over 40 per cent of side-effects were rated as severe or very severe, and over 25 per cent lasted weeks or months, though the majority were mild or moderate and transient. “Psychotherapy is not harmless,” the researchers said. There was no evidence that any of the side-effects were due to unethical practice.

Examples of severe side-effects included: “suicidality, breakups, negative feedback from family members, withdrawal from relatives, feelings of shame or guilt, or intensive crying and emotional disturbance during sessions.”

Such effects are not so surprising when you consider that CBT can involve exposure therapy (i.e. gradual exposure to situations that provoke anxiety); discussing and focusing on one’s problems; reflecting on the sources of one’s stress, such as difficult relationships; frustration at lack of progress; and feelings of growing dependency on a therapist’s support.

The longer that a client had been in therapy, the more likely they were to have experienced one or more side-effects. Also, and against expectations, clients with milder symptoms were more likely to experience side-effects, perhaps because more serious symptoms mask such effects.

Interestingly, before the structured interviews, the therapists were asked off the top of their heads whether they felt their client had had any unwanted effects – in this case 74 per cent said they had not. Often it was only when prompted to think through the different examples of potential side-effects that they became aware of their prevalence. This chimes with earlier research that’s documented the biases that can lead therapists to believe therapy has been successful when it hasn’t.

Schermuly-Haupt and her colleagues said a conundrum raised by their findings was whether unpleasant reactions that may be an unavoidable aspect of the therapeutic process should be considered side-effects. “We argue that they are side-effects although they may be unavoidable, justified, or even needed and intended,” they said. “If there were an equally effective treatment that did not promote anxiety in the patient, the present form of exposure treatment would become unethical as it is a burden to the patient.”

There are reasons to treat the new findings with caution: the results depended on the therapists’ recall (an in-the-moment or diary-based methodology could overcome this problem), and about half the clients were also on psychoactive medication, so it’s possible some adverse effects could be attributable to the drugs rather than the therapy (even though this was not the interviewer’s judgment, and remember the researchers used a conservative estimate of side-effects, only considering those that were “definitely” related to therapy by their estimation, and ignoring those that they considered “rather” or “most probably” related).

The researchers concluded that “An awareness and recognition of unwanted events and side effects in all therapies will benefit patients, improve therapy or reduce attrition, analogous to the benefit of measurement-based monitoring of treatment progress.”

Unwanted Events and Side Effects in Cognitive Behavior Therapy

Christian Jarrett (@Psych_Writer) is Editor of BPS Research Digest


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23 thoughts on “Interviews with 100 CBT-therapists reveal 43 per cent of clients experience unwanted side-effects from therapy”

  1. Everything that happens to us in life has side effects. Every single thing – here are some examples: going to the gym, not getting what we want, getting what we want, hanging out with friends, getting old, going on a big trip, etc. – the list can go on and on.
    I think what is important to investigate is whether something does more good than bad for a particular person (based on the client’s evaluation only).

    1. Absolutely agree Dayane. Life has side effects – wanted and unwanted. It’s how we learn to deal with them that matters, and that has to evolve over time. As we change we often surface shame, guilt, tears, anxiety, joy, hope, possibility – it’s part of the complete experience of life. I’d be interested to see the stats for other therapies – there’s no such thing as a consequence free change process.

      1. Thank you for your reply. Since these issues are ultimately experienced as troublesome emotions, etc., mindfulness practices can go a long way in the healing process. Please see the other comment (on mindfulness) I posted just now.

  2. As mentioned in your article but should be emphasized, not every side effect is a negative, psychoactive medication is a big factor to consider and should we not be surveying the patient as well?

  3. I think often relationships can become strained because the client is finally addressing problems in those relationships or changing their behaviors in a way to better the relationship. But the other member of the relationship may not be wanting or expecting that change, especially if is an unhealthy/abusive relationship, so there is a strain or potentially break up.

  4. The nasty side effects that come from psychiatric medicines often cannot be reversed – it can also make people drug dependent for life with dire consequences. With CBT, however, things come and go. Even if a side-effect such as a break up might be hard to endure for a while, after sometime, the person might feel glad that it happened. Negative feedback from relatives can also be overcome through family interventions (that have been proven to be very effective). Suicidal thoughts can come and go as well, even when one does not go for therapy.

  5. People don’t understand that CBT means identifying how your inter and intrapersonal beliefs are causing negative behaviors and/or thoughts then altering those beliefs to reflect a positive outlook. Changing the core of your being like this gives you a different perspective on life, a perspective that might cause you to realize things you thought were ‘positive’ were just enabling your negative behavior or just find fulfillment in different things. It’s naive to expect everything to remain the same when the goal of CBT is to change the very basis of your thought process.

    1. is the therapist any better at living life than the average person? probably not – long before psychotherapy we have had an entire history of human beings harming and helping each other – but now after around 100 years of modern psychology, psychiatry, psychopharmacology are we seeing a rise in wellbeing. mental health and human thriving? NO in fact its the exact opposite suffering grows year in year out and we are encouraged to see more and more systemic causes of suffering as personal problems or disorders.

      What do the critics of psychotherapy research tell us? that its largely rubbish and the entire industry is completely oversold but is nonetheless now embedded within the culture and reinforced through self interest and self promotion and the cult of self.

      I think of equal importance for any ‘therapist’ is to read the critics and be very humble about what they believe they can achieve from a few hours of talking to someone in distress from the isolated confines of a therapy room, imbued with power imbalance, largely devoid of context with both parties operating from their own bias, blind spots and ignorance.

      Human beings are in constant dynamic interaction with self and world both of which we have only a sliver of awareness about – we are also contained within vast powers of economy, ideology, media, education, class – all of this and more and we think a few hours of talking/exploring/homework/techniques is going to be anything other than a temporary fleeting offer of comfort, clarification and encouragement?

      It seems clear we have significant cultural level or systemic disorders that are shaping us all and cause our distress but we have mental (ill) health systems that re-frame this as personal distress and heaps the person with responsibility to change themselves so they can continue to simply get on with it – how about we strive as David Smail suggested not for empty insight but outsight and seek to change the world to make it a place fit for human thriving not just struggling to get buying.

      If you are a therapist working in primary or secondary care in the UK you will likely to be stressed through the overwhelming work load and focus on meaningless targets linked to equally pointless outcome measures.

      this chap has done a thorough review of the research

      there are other critics a good summary can be found here – The Therapy Industry: The Irresistible Rise of the Talking Cure, and Why It Doesn’t Work, Paul Maloney.

      and anything by David Smail is a must

      1. Let me rebut the entirety of your comment with one point: The macro-scale dynamics of the world influence and acculminate in the micro-scale realities, psyches, and experiences of the individual. But they do not substitute them – and this was where you made your mistake. Due to the fact that they do not substitute them, your argument here, falls apart. I am not denying the presence of large macro-scale patterns and structures that influence and help to shape our experiences and our lives, who we are, but I am also not denying the micro-scale.

        If a person is dropped in a family or upbringing where for example, theft, was socially syntonic – and also socially natural – but then led to the person later in life developing habits of impersistence and lack of diligence which then led to chronic lack of achievement or underachievement, and THEN therefore led to feelings of, say, emptiness and lack of fulfillment just to name one of the things that the person may feel, would you *then* say that that person is doomed like that, forever, until some god-willed social dynamic or force from some god-forsaken impetus changes his conditions, and therefore changes the person? I think you, or anyone, would agree that that’s a dubious claim to argue at best. People can change beyond the social forces that surround, and yes, do help to shape them. And change is precisely what psychotherapy wants – to evoke and elicit deep and fundamental intrapersonal change with the person.

  6. As I see it, unless one includes a significant component of mindfulness into CBT, this therapy wouldn’t be all that useful for people. This study had used a convenient sample of therapists, and doesn’t even mention mindfulness. The reason why a mindfulness component is very important is because many psychological issues that people face cannot be overcome through mere logical reasoning alone (since these issues together with various beliefs, etc., are ingrained through past conditioning). Mindfulness interventions gradually teach individuals techniques like how to become aware of thoughts and emotions (that happen as a result of past conditioning influences), and to observe how they come and go in the present moment. These strategies gradually enable an individual to not get overwhelmed by emotions even when they come up.

    1. My usual response for those advocating more “mindfulness in CBT” is that CBT when done well incorporates mindfulness interventions. It’s a component of CBT, as is Motivational Interviewing – these are not standalone therapies, IMHO. Moreover, to call well-done CBT “talk therapy” to differentiate it from other approaches neglects the all-important “B” part. In some respects, therapists still use 1960s style CBT esp when it comes to exposure-based programs which utilise SUDS as the primary outcome measure.

  7. The study gives me the impression that the clients or the writers think therapy is the sole cause of all the negative/difficult events. Painful or difficult experiences aren’t “bad side effects”; they are often the result of YOU making progress in therapy. It’s not like your therapist is sitting at the dinner table with you and your emotionally abusive parents, for example, and decides to get the family into a big fight. YOU’RE the one working on your self-efficacy in therapy, and if you have a good therapist, YOU’RE the one who decides to stand up to your family members. The therapist isn’t making the decisions for you.

    Sometimes the consequences of therapeutic progress are downright unpleasant. But then again, the consequences of staying the same may be more damaging over the long run.

    Also, I see that the majority of the clients in this study suffered from depression, anxiety, and mild/moderate personality disorders. I would hope their therapists work on emotional mindfulness and emotional regulation with them, especially for those with personality disorders. Some of the so-called “side effects” may be due to the therapists not attending to the clients’ emotional regulation.

    1. Yes. I have the same issues with this ‘study’.

      “suicidality, breakups, negative feedback from family members, withdrawal from relatives, feelings of shame or guilt, or intensive crying and emotional disturbance during sessions.”

      Not one of those events looks like an effect of the therapy itself – at least, not as I experienced rational-emotive behaviour therapy. I’d want to know if any of these things were happening:
      a- more or less in the general population not in any form of therapy;
      b- more or less in people undergoing different forms of therapy;
      c- whether the recall of these events during the interview might have been influenced/affected by the wording of the questions asked, and so on.

      As you note, therapy that acts on how one thinks about things as a means of changing one’s behaviour brings about change: that’s the whole point of it. And some people with whom one deals outwith therapy are not going to like that change: a domineering person being refused that place in someone’s life is going to react negatively towards that change. That’s not a side/unwanted effect of therapy – that’s an effect of someone else’s view of the person in therapy being challenged by that person! Feelings of shame or guilt can come about because of having learned a new way of looking at past behaviour – well, much as those emotions are uncomfortable, they tell us something about our changing attitudes towards our own previous behaviour and how far we’ve come in understanding that as a means for prompting behaviour change in the future … and part of the therapeutic process is learning how to deal with those emotions appropriately; so, even if they arise from therapy, they are not automatically a bad thing. If one is going through a therapy that relies on exposure and response prevention, the crying and emotional disturbance during sessions is to be expected: the emotional disturbance comes from the client’s beliefs about the thing being feared and the whole point of this part of therapy is to learn that those emotional responses eventually will dissipate because one gets used to them and learns to regulate them. That is not a lesson learned on a purely theoretical basis!

      You say: “The study gives me the impression that the clients or the writers think therapy is the sole cause of all the negative/difficult events.”

      The impression I get from the study is worse, to be honest: i think that the authors of it were looking for anything they could latch onto as something negative to pin on cognitive-behavioural therapies generally, because of an ulterior motive – are the people who authored it psychoanalysts? Are they in the anti-psychiatry movement? I don’t know the answers to these questions, but these things could be part of why this ‘study’ was done. I couldn’t get to the article itself but basing the study on recall rather than clinical notes does not seem very scientifically rigorous to me.

      David N. Andrews M. Ed., C. P. S. E.
      psycho-educational consultant

  8. I found cbt to be actually the worst therapy experience I had – it was all useless but cbt was actively harmful. Therapists need to be a lot more open about the harmful risks of therapy.

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