Abstract
Side effects (SEs) are negative reactions to an appropriately delivered treatment, which must be discriminated from unwanted events (UEs) or consequences of inadequate treatment. One hundred CBT therapists were interviewed for UEs and SEs in one of their current outpatients. Therapists reported 372 UEs in 98 patients and SEs in 43 patients. Most frequent were "negative wellbeing/distress" (27% of patients), "worsening of symptoms" (9%), "strains in family relations" (6%); 21% of patients suffered from severe or very severe and 5% from persistent SEs. SEs are unavoidable and frequent also in well-delivered CBT. They include both symptoms and the impairment of social life. Knowledge about the side effect profile can improve early recognition of SEs, safeguard patients, and enhance therapy outcome.
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Notes
The interview is available from michael.linden@charite.de.
References
Anderson, E. M., & Lambert, M. J. (2001). A survival analysis of clinically significant change in outpatient psychotherapy. Journal of Clinical Psychology, 57(7), 875–888.
Barlow, D. H. (2010). Negative Effects from psychological treatments. A perspective. American Psychologist, 65(1), 13–20. https://doi.org/10.1037/a0015643.
Bergin, A. E. (1963). The effects of psychotherapy: Negative results revisited. Journal of Consulting Psychology, 10, 244–250.
Berk, M., & Parker, G. (2009). The elephant on the couch: Side effects of psychotherapy. Australian & New Zealand Journal of Psychiatry, 43(9), 787–794. https://doi.org/10.1080/00048670903107559.
Brainerd, C. J., & Reyna, V. F. (2005). The science of false memory. New York: Oxford University Press.
Buckley, P., Karasu, T. B., & Charles, E. (1981). Psychotherapists view their personal therapy. Psychotherapy: Theory, Research & Practice, 18(3), 299–305. https://doi.org/10.1037/h0088377.
Castonguay, L. G., Boswell, J. F., Constantino, M. J., Goldfried, M. R., & Hill, C. E. (2010). Training implications of harmful effects of psychological treatments. American Psychologist, 65(1), 34–49. https://doi.org/10.1037/a0017330.
Creed, T. A., Wolk, C. B., Feinberg, B., Evans, A. C., & Beck, A. T. (2014). Beyond the Label: Relationship Between Community Therapists’ Self-Report of a Cognitive Behavioral Therapy Orientation and Observed Skills. Administration and Policy in Mental Health and Mental Health Services Research, 43(1), 1–8. https://doi.org/10.1007/s10488-014-0618-5.
Crits-Christoph, P., Baranackie, K., Kurcias, J., Beck, A., Carroll, K., Perry, K., Luborsky, L., McLellan, A., Woody, G., Thompson, L., Gallagher, D., & Zitrin, C. (1991). Meta-analysis of therapist effects in psychotherapy outcome studies. Psychotherapy Research, 1(2), 81–91.
Dilling, H. (2011). Internationale Klassifikation psychischer Störungen: ICD-10 Kapitel V (F); klinisch-diagnostische Leitlinien (8., überarb. Aufl. unter Berücksichtigung der Änderungen entsprechend ICD-10-GM 2011.). Bern: Huber.
Fischer-Cornelssen, K. A., & Berchier, P. (1982). Validität und Reliabilität einer Symptom-Checkliste (FSCL): Anwendung in der Psychogeriatrie. Zeitschrift für Gerontologie und Geriatrie, 15, 31–37.
Fisher, P. L., & Durham, R. C. (1990). Recovery rates in generalized anxiety disorder following psychological therapy: An analysis of clinically significant change in the STAI-T across outcome studies since 1990. Psychological Medicine, 29(6), 1425–1434.
Foa, E. B., Zoellner, L. A., Feeny, N. C., Hembree, E. A., & Alvarez-Conrad, J. (2002). Does imaginal exposure exacerbate PTSD symptoms? Journal of Consulting Clinical Psychology, 70(4), 1022–1028.
Hafner, R. J. (1984). The marital repercussions of behavior therapy for agoraphobia. Psychotherapy: Theory, Research, Practice, Training, 21(4), 530–542. https://doi.org/10.1037/h0085999.
Hamilton, K. E., & Dobson, K. S. (2002). Cognitive therapy of depression: Pretreatment patient predictors of outcome. Clinical Psychology Review, 22(6), 875–893.
Hannan, C., Lambert, M. J., Harmon, C., Nielsen, S. L., Smart, D. W., Shimokawa, K., & Sutton, S. W. (2005). A lab test and algorithms for identifying clients at risk for treatment failure. Journal of Clinical Psychology, 61(2), 155–163. https://doi.org/10.1002/jclp.20108.
Harnett, P., O´Donovan, A., & Lambert, M. J. (2010). The dose response relationship in psychotherapy: Implications for social policy. Clinical Psychology, 14(2), 39–44. https://doi.org/10.1080/13284207.2010.500309.
Hatfield, D., McCullough, L., Frantz, S. H., & Krieger, K. (2010). Do we know when our clients get worse? An investigation of therapists’ ability to detect negative client change. Clinical Psychology and Psychotherapy, 17(1), 25–32. https://doi.org/10.1002/cpp.656.
Henry, W. P., Strupp, H. H., Butler, S. F., Schacht, T. E., & Binder, J. L. (1993). Effects of training in time-limited dynamic psychotherapy: Changes in therapist behavior. Journal of consulting and clinical psychology, 61(3), 434–440.
Hoffmann, S. O., Rudolf, G., & Strauß, B. (2008). Unerwünschte und schädliche Wirkungen von Psychotherapie. Der Psychotherapeut, 53, 4–16.
Jonsson, U., Alaie, I., Parling, T., & Arnberg, F. K. (2014). Reporting of harms in randomized controlled trials of psychological interventions for mental and behavioral disorders: A review of current practice. Contemporary Clinical Trials, 38(1), 1–8. https://doi.org/10.1016/j.cct.2014.02.005.
Lambert, M. J. (2010). Predicting negative treatment outcome: Methods and estimates of accuracy. In M. J. Lambert (Ed.), Prevention of treatment failure: The use of measuring, monitoring, and feedback in clinical practice (pp. 83–105). Washington, DC: American Psychological Association.
Lambert, M. J. (2011). What have we learned about treatment failure in empirically supported treatments? Some suggestions for practice. Cognitive and Behavioral Practice, 18(3), 413–420. https://doi.org/10.1016/j.cbpra.2011.02.002.
Lambert, M. J., & Ogles, B. M. (2004). The efficacy and effectiveness of psychotherapy. In M. J. Lambert (Ed.), Bergin & Garfield’s handbook of psychotherapy and behavior change (5th edn., pp. 139–193). New York: Wiley.
Leitner, A., Märtens, M., Koschier, A., Gerlich, K., Liegl, G., Hinterwallner, H., & Schnyder, U. (2013). Patients’ perceptions of risky developments during psychotherapy. Journal of Contemporary Psychotherapy, 43(2), 95–105. https://doi.org/10.1007/s10879-012-9215-7.
Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2(1), 53–70. https://doi.org/10.1111/j.1745-6916.2007.00029.x.
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(4), 286–296. https://doi.org/10.1002/cpp.1765.
Linden, M., & Schermuly-Haupt, M. L. (2014). Definition, assessment and rate of psychotherapy side effects. World Psychiatry, 13(3), 306–309. https://doi.org/10.1002/wps.20153.
Linden, M., & Strauß, B. (2013). Risiken und Nebenwirkungen von Psychotherapie. Erfassung, Bewältigung, Risikovermeidung. Berlin: Medizinisch-Wissenschaftliche Verlagsgesellschaft.
Macaskill, N. (1992). Psychotherapists-in-training evaluate their personal therapy: Results of a UK Survey. British Journal of Psychotherapy, 9(2), 133–138. https://doi.org/10.1111/j.1752-0118.1992.tb01211.x.
Mayou, R. A., Ehlers, A., & Hobbs, M. (2000). Psychological debriefing for road traffic accident victims: Three-year follow-up of a randomized controlled trial. British Journal of Psychiatry, 176(6), 589–593. https://doi.org/10.1192/bjp.176.6.589.
Milton, F., & Hafner, R. J. (1979). The outcome of behavior therapy for agoraphobia in relation to marital adjustment. Archives of General Psychiatry, 36(7), 807–811.
Nolan, S. A., Strassle, C. G., Roback, H. B., & Binder, J. L. (2004). Negative treatment effects in dyadic psychotherapy: A focus on prevention and intervention strategies. Journal of Contemporary Psychotherapy, 34(4), 311–330. https://doi.org/10.1007/s10879-004-2526-6.
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(2–3), 293–301. https://doi.org/10.1016/j.psychres.2012.11.026.
Roback, H. B. (2000). Adverse outcomes in group psychotherapy. Risk factors, prevention, and research directions. Journal of Psychotherapy Practice Research, 9(3), 113–122.
Rose, S. C., Bisson, J., Churchill, R., & Wessely, S. (2002). Psychological debriefing for preventing post traumatic stress disorder (PTSD). The Cochrane database of systematic reviews, 2002(2), 1–47. https://doi.org/10.1002/14651858.CD000560.
Rosen, M. I., Rounsaville, B. J., Ablondi, K., Black, A. C., & Rosenheck, R. A. (2010). Advisor-teller money manager (ATM) therapy for substance use disorders. Psychiatry Services, 61(7), 707–713. https://doi.org/10.1176/appi.ps.61.7.707.
Scheeringa, M. S., Weems, C. F., Cohen, J. A., Amaya-Jackson, L., & Guthrie, D. (2011). 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, 52(8), 853–860. https://doi.org/10.1111/j.1469-7610.2010.02354.x.
Shrout, P. E., & Fleiss, J. L. (1979). Intraclass correlations: Uses in assessing rater reliability. Psychology Bulletin, 86(2), 420–428.
Sijbrandij, M., Olff, M., Reitsma, J. B., Carlier, I. V. E., & Gersons, B. P. R. (2006). Emotional or educational debriefing after psychological trauma. Randomised controlled trial. British Journal of Psychiatry, 189, 150–155. https://doi.org/10.1192/bjp.bp.105.021121.
Smith, S. R., Hilsenroth, M. J., Baity, M. R., & Knowles, E. S. (2003). Assessment of patient and therapist perspectives of process: A revision of the Vanderbilt Psychotherapy Process Scale. American Journal of Psychotherapy, 57(2), 195–205.
Sotsky, S. M., Glass, D. R., Shea, M. T., Pilkonis, P. A., Collins, J. F., Elkin, I., Watkins, J. T., Imber, S. D., Leber, W. R., Moyer, J., & Oliveri, M. E. (1991). Patient predictors of response to psychotherapy and pharmacotherapy: Findings in the NIMH Treatment of Depression Collaborative Research Program. American Journal of Psychiatry, 148(8), 997–1008. https://doi.org/10.1176/ajp.148.8.997.
Tarrier, N., Pilgrim, H., Sommerfield, C., Faragher, B., Reynolds, M., Graham, E., & Barrowclough, C. (1999). A randomized trial of cognitive therapy and imaginal exposure in the treatment of chronic posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 67(1), 13–18.
Tomba, E., Tecuta, L., Schumann, R., & Balladini, D. (2017). Does psychological well-being change following treatment? An exploratory study on outpatients with eating disorders. Comprehensive Psychiatry, 74, 61–69. https://doi.org/10.1016/j.comppsych.2017.01.001.
Wirtz, M. A., & Caspar, F. (2002). Beurteilerübereinstimmung und Beurteilerreliabilität: Methoden zur Bestimmung und Verbesserung der Zuverlässigkeit von Einschätzungen mittels Kategoriensystemen und Ratingskalen. Göttingen: Hogrefe.
Acknowledgements
The authors thank the Institute for Behavior Therapy Berlin, the Centre for Psychotherapy at the Humboldt-University Berlin and the Institute for Behavior Therapy Brandenburg for participating in the study. We would also like to acknowledge the editorial assistance of Jon Kilner, MS, MA (Pittsburgh, PA).
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Marie-Luise Schermuly-Haupt, Michael Linden and A. John Rush declare that they have no conflict of interest.
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Schermuly-Haupt, ML., Linden, M. & Rush, A.J. Unwanted Events and Side Effects in Cognitive Behavior Therapy. Cogn Ther Res 42, 219–229 (2018). https://doi.org/10.1007/s10608-018-9904-y
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DOI: https://doi.org/10.1007/s10608-018-9904-y