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.”
The 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.
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 Studies, 32(2), 424–437. https://doi.org/10.1007/s10826-022-02431-w (Link)