Research Finds Youth Often Have Negative Experiences of Psychotherapy

Youth do not report negative experiences in psychotherapy to their therapists.

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A new article published in the Journal of Child and Family Studies finds that negative experiences of psychotherapy are common for adolescents, but these negative experiences are rarely reported to therapists. This research, headed by Priya Watson from the University of Toronto, also finds that youth may interpret these negative experiences as ineffective treatment, which can lead to discontinuation of therapy.

Watson and her colleagues write:

“Youth have negative experiences in psychotherapy at high rates, but do not report them to their therapists. Negative experiences associated with psychotherapy need to be systematically anticipated, measured and addressed by therapists, or they may be interpreted by youth as symptom worsening or ineffective treatment, leading to treatment discontinuation. Using principles of ‘youth friendliness’ to inform service provision could improve psychotherapy uptake and retention and decrease negative experiences.”

Unhappy girl listening to psychologist at meeting. Doctor consulting stressed teen at counselling therapy session. Little patient sitting on couch at office or home, thinking about her problemsThe goal of the current research was to explore youth’s negative experiences of psychotherapy. To accomplish this goal, the researchers recruited participants from the Research and Action for Teens project, a longitudinal study of mental health issues in young people. To be eligible for inclusion in the current study, participants had to self-report mood or anxiety issues and have some previous experience in psychotherapy.

The current research included self-report surveys completed by 45 participants. Researchers also interviewed 33 participants, one of whom reported no negative experiences in psychotherapy and was subsequently excluded from the study. The participants had an average age of 19.13 years. The majority of the sample was female (36) and Caucasian (35).

As part of the study, the participants were asked to complete four different self-report questionnaires. These questionnaires were designed to measure different aspects of their mental health and well-being. The Negative Effects Questionnaire was used to assess any negative effects experienced by the participants during psychotherapy. This included whether the participants attributed these negative effects to “the treatment I received” or “other circumstances.” The Global Appraisal of Individual Needs-Short Screener was used to assess mental health and substance use. The Center for Epidemiologic Diseases Scale-12 was used to assess depression, while the Difficulties in Emotion Regulation Scale was used to assess emotional regulation. For those participants who agreed to an interview, open-ended questions were asked about various topics related to their therapy experiences. This included the type of psychotherapy they received, the number and frequency of sessions, any stigma experienced, the relationship with their therapist, activities recommended by the therapist, as well as any positive or negative effects of therapy.

According to the surveys conducted, 66.7% of the participants reported experiencing at least one negative effect of their psychotherapy. Among them, 37.8% experienced increased stress, with 20% attributing it to their therapy. Likewise, 37.8% reported an increase in unpleasant memories, with 29.8% attributing it to psychotherapy. In addition, 31.1% experienced an increased perception that their problem would not improve, with 26.7% attributing it to therapy. Another negative effect reported was decreased self-esteem, with 20% attributing it to their treatment. The study authors have noted that while increased symptoms such as anxiety, sadness, and sleep problems were the most commonly reported negative effects, the increased perception that their problem would not improve was rated as the most severe.

A significant number of participants expressed dissatisfaction with the quality of their psychotherapy. Specifically, 42.2% reported that the treatment did not produce the expected results, with 35.6% attributing this problem to the therapy itself. Additionally, 20% of the participants reported that the quality of their treatment was poor, and all of them attributed this problem to the therapy. Furthermore, 40% of the participants lacked confidence in the therapy they received, with 26.7% attributing this issue to the treatment. Many participants also reported difficulty understanding their therapy, with 40% indicating that they did not understand the treatment and 33.3% attributing this issue to the therapy.

Using data from the interviews, the authors identified 4 main themes involving negative experiences of psychotherapy: barriers experienced in psychotherapy, concerns about the therapist, concerns about therapy sessions, and negative experiences as part of the therapeutic process.

The barriers experienced in therapy theme was made up of two subthemes: access and stigma. Participants talked about problems with access in terms of finding therapy, the financial costs, and the limited hours and services offered. Some participants also mentioned age as a barrier to access. With some services tailored to adolescents and people under the age of 18, participants were aware of their impending end of therapy as they approached these cutoffs. Many participants also reported worrying about the stigma associated with going to therapy. They worried that they would be perceived as “delicate,” “dependent,” or “weak.” They were also concerned that people around them could become “overly supportive” or “nosey” and that their issues may be dismissed as “attention seeking.”

Concerns about the therapist contained 3 subthemes: identity, communication/rapport problems, and therapist stance. Participants reported being concerned with their therapist’s identity in terms of preferring women (who they perceived as “safer”) and people from their own cultural backgrounds. Many participants took issue with their therapist’s stance, which they described as “too textbook” and “too vague and not individualized.” Communication/rapport problems were the most commonly reported issue from the interview data. The lack of communication often became an issue around homework assigned by the therapist without explaining its purpose or real-life applicability. Participants also reported that their therapy did not conform to their needs. The authors write:

“Youth conveyed how therapy became less effective as it became clear that these unexpressed wishes would remain unmet, and treatments were not adjusted in response to their elicited needs and concerns.”

Concerns about therapy contained 2 subthemes: therapy process and clinical environment. Participants reported having difficulty with the process of therapy, such as disclosing sensitive information. These personal disclosures were often accompanied by increased stress. Issues with the clinical environment included being treated rudely by staff and sessions taking place in drab environments with no natural lighting.

The last theme, negative experiences as part of the therapeutic process, involved participants who saw their negative experiences in therapy as important for their recovery. This theme contained 3 subthemes: tolerating distress with a desire to recover, strong therapeutic alliance, and improvements over time. Some participants reported tolerating distress during their session because it would lead to them feeling better and more positive afterward. Many participants reported that while it was uncomfortable venting to someone about their problems, it was worth it when the therapist conveyed genuine concern and understanding. This often led to a strong therapeutic alliance. Participants also reported that sessions improved over time as they built rapport with their therapist.

The authors acknowledge several limitations to the current work. The inclusion criteria were broad, limiting the number of factors that could be analyzed. As the data was self-reported, participants could have misremembered their experiences. The sample size was small, which limited the quantitative analysis and the ability of the researchers to investigate how demographic info such as race, gender, etc., could effect the negative experience of psychotherapy.

Previous research has found that psychotherapy is often effective when drugs are not. Psychotherapy is also likely safer and less expensive than drug treatment.

Unfortunately, research has also found that psychotherapy is less effective and less accessible for people living in poverty. One study found racial and class discrimination to be relatively common in psychotherapy. A large meta-analysis also found that psychotherapy in children has lackluster long-term results.

 

 

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Watson, P., Leroux, E. J., Chowdhury, M., Mehra, K., Henderson, J., Szatmári, P., & Hawke, L. D. (2022). Unexpressed Wishes and Unmet Needs: a Mixed Methods Study of Youth Negative Experiences in Psychotherapy. Journal of Child and Family Studies32(2), 424–437. https://doi.org/10.1007/s10826-022-02431-w (Link)

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Richard Sears
Richard Sears teaches psychology at West Georgia Technical College and is studying to receive a PhD in consciousness and society from the University of West Georgia. He has previously worked in crisis stabilization units as an intake assessor and crisis line operator. His current research interests include the delineation between institutions and the individuals that make them up, dehumanization and its relationship to exaltation, and natural substitutes for potentially harmful psychopharmacological interventions.

8 COMMENTS

  1. Not just youth!

    I still don’t get why therapists arent just more explicit about what they think is supposed to happen in therapy. Especially with youth. Why do they assume that teenagers know what to expect and how to engage in therapy?

    Especially because voluntary participation is suspect and content of therapy can be shared with parents. Like, who is surprised that teens may not share everything and feel and not meet their needs?

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    • At least in the state where I work, we cannot report details to the parents w/o client consent after the age of 13 (age of consent). I get consent for younger kids too even though it is not required, it’s just good manners…

      I can only remember one case where I did not get consent because it was required by law that I report. The client called me a ‘dick’, but he’s still alive so it was worth it.

      I do think talk therapy 1 on 1 with kids is very difficult for them in most cases. I try to get my kids outside to the skatepark or doing art, or playing games. It’s hard to tell them what to expect in therapy, because some times I don’t even know what to expect. Therapy does not generally follow the medical model. What is supposed to happen in therapy is often up to the client. We try not to be the authority or the expert.

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      • Only, in my experience, clinical psychologists and psychiatrists never asked for an informed consent when disclosing information to relatives or acquiring information from them.

        I have even asked specifically what kind of information they want to share or acquire, what wil be the use of that, the justification, and I never had complete accurate information in that regard.

        They, in my personal opinion, ask for blanket permission to do as they see fit, without legal orders to do so. As an adult.

        In teenagers, it will be worse, given the greater asymetry between an adult and a minor…

        Most parents and relatives have no clue, not even minimal, on what privacy and respect actually means. And if they did have enough, effective idea, relatives and parents, even partners, can be “scared” into buying, acquiescencing, even praising!, false justifications for privacy, and protected information disclosure.

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      • Pretty sure parents only send you their children to treat because they believe you are an authority and expert. I’ll remember that what happens in therapy is up to me the next time I’m told that in an informed consent process.

        Therapy should definitely be covered by public or private insurance if it is not considered an intervention like any other. Scam rich parents to go skateboarding with their kids all you want. But I am aghast by your cavalier notion that somehow you are not the “expert,” but only get paid because you are.

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  2. “…leading to treatment discontinuation.”, reformulated says young persons going to psychotherapy need to COMPLY BETTER. Just like psychiatrical rethoric. At least this review does not mention they called teenagers insigh lackers. But it does question, apparently their self report as a caveat, they might misremember their negative experiences.

    Right…

    Just like their OTHER memories of child abuse…

    So many youth having negative emotions when the results of the treatment are not good, and the good outcomes reported are inflated, by among other things selective reporting and statistical massage of the results, sounds akin, a light version of TORTURE: induce suffering to claim afterwards that it’s for their own good.

    Right…

    That’s not paternalistic/patriarcal/autoritarian, it’s TORTURING…

    Not suprising, given the APA-psychology has been involved in the cover up of the negative influence social media has on teenagers. Recently addressed by actually suing social media, META, by 33 district attorneys:

    https://arstechnica.com/tech-policy/2023/10/41-states-sue-meta-for-allegedly-addicting-kids-to-facebook-and-instagram/

    and :

    https://www.washingtonpost.com/technology/2023/10/24/meta-lawsuit-facebook-instagram-children-mental-health/

    From the WaPo:

    ‘But a report by the American Psychological Association found that social media use “is not inherently beneficial or harmful to young people”’

    Right…

    They became professional obfuscators of harm by companies, just like the ideological proapaganda to defend fire arms, tobacco, Big Pharma and climate change.

    And that has parallels with psychotherapy in minors: claim it’s not clear, there is doubt, it could go either way. But!, there are benefits!.

    Right…

    Just, if there are, don’t last, apparently beyond 12 months, for depression:

    https://www.madinamerica.com/2021/10/meta-analysis-psychotherapy-children-finds-lackluster-long-term-results/

    Just this study, excellently review by RS, shows the dramatism, the suffering minors are exposed to when going “only” to the psychotherapists office.

    Just the despair kinda feeling that things won’t improve has to be shocking…

    I suspect they will try to minimize the harm, the suffering and claim it is FOR THEIR OWN GOOD, after all, they don’t comply enough with the treatment. Despite some of them shut off their mouths and keep going to therapy when they probably feel awefull when they go. And get at least unfulfilled expectations of benefit…

    Right…

    And the linked articles at the last two paragraphs are great references too. It can give context for parents/guardians/carers of youth to make shared informed decisions about the REAL value and SUFFERING of/by psychotherapy for youths/minors.

    This review was very needed, particularly because there are complaints about the lack of access to psychotherapy for minors. Which if expanded will lead to negative emotions, for benefits that won’t last long, at least for depression.

    Right?…

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