“I am now in therapy for my depression for two months, but I have the idea that things are only getting worse. Is it possible that therapy has negative effects?”
A blind spot in the field
It has been thought for a long time that therapy cannot cause harm, because it is “just talking”. That is also the reason that for a long time studies examining the effects of therapies have not reported adverse and negative effects. That is slowly changing now. Many researchers and clinicians now believe that negative effects do occur and that it is important to examine them better. But there are still quite a lot of gaps in the knowledge about negative effects and hardly any research on methods to prevent or reduce negative effects.
What counts as a “negative effect”?
One major problem is that there is no clear definition of what a ‘negative’ effect exactly is. It is clear that significant deterioration of symptoms can be a negative effect. Serious adverse events, such as suicide attempts, are also potential negative effects. But there are many other outcomes that can be considered to be a negative effect. Other negative effects that are sometimes reported by clients are for example:
- Treatment dissatisfaction
- Lack of a good working relation with the therapist
- Anxiety or rumination about therapy
- Emergence of new symptoms that were previously not present
- Stigmatization
- Perceived negative effects of treatment on family/friends
Because there is no consensus on what a negative effect exactly is, few studies have used consistent measures. This means that at this moment there is no clear overview of the different negative effects and how often they happen during therapy.
What the data say about deterioration
One type of negative effect that has been examined better in research is symptom deterioration during therapy. That means that the client feels that the symptoms are getting worse considerably. This happens for example in about 5% of clients who receive therapy for depression.
However, in the studies examining these negative effects, there are also control groups who do not get therapy. These control groups are necessary to examine how effective the therapy is compared to not getting therapy. In these control groups it was found that 13% of clients deteriorated in the same period.
This means that some clients can deteriorate during therapy, but the chance to deteriorate would have been higher if they would not have had therapy.
So in reality, therapy has prevented deterioration in some clients, but has not been able to prevent it in other clients. In these clients, the deterioration would probably also have happened if they would not have been in therapy and it is not ‘caused’ by the therapy.
What to do if you feel worse
When you feel that things are getting worse during therapy, there are a few things that you need to keep in mind.
First, therapy can stir things up and maybe the fact that you are getting worse is part of the process and necessary to get better at the longer term.
It is also possible that the deterioration is not caused by the therapy, but would have happened anyway.
In any case, it is important to discuss this with your therapist. Then you can discuss the goals and focus of therapy, and whether the current approach is a good fit for you and your current situation. It is possible that the fit with your therapist is not right and that you for example don’t feel understood or respected.
It is always important to take your experiences seriously and discuss them with your therapist.
Pim Cuijpers is professor emeritus of clinical psychology and scientific director of Metapsy. He has been involved in more than 1,100 scientific studies, mostly on psychological treatments of mental health problems. This is one of a series of evidence summaries in which Prof. Cuijpers tries to answer questions from patients and clinicians, based on what is known in science about treatments. The knowledge is mostly drawn from collective work of the Metapsy collaboration of at least 15 years. Do you have other questions you would like Prof. Cuijpers to discuss? Feel free to contact us.
Literature
- Cuijpers P. (2021). Research on negative effects of psychotherapies: The next steps. Clinical Psychology: Science and Practice, 28, 142–144.
- Cuijpers P, Reijnders M, Karyotaki E, et al. (2018). Negative effects of psychotherapies for adult depression: A meta-analysis of deterioration rates. Journal of Affective Disorders, 239, 138–145.
- Rozental A, Andersson G, Boettcher J, et al. (2014). Consensus statement on defining and measuring negative effects of Internet interventions. Internet Interventions, 1, 12–19.
- Cuijpers P, Karyotaki E, Ciharova M, et al. (2021). The effects of psychotherapies for depression on response, remission, reliable change, and deterioration: A meta-analysis. Acta Psychiatrica Scandinavica, 144(3), 288–299.
- Cuijpers P, Karyotaki E, Ciharova M, et al. (2023). The effects of psychological treatments of depression in children and adolescents on response, reliable change, and deterioration: a systematic review and meta-analysis. European Child and Adolescent Psychiatry, 32(1), 177–192.