This week, Mad in America examines three articles related to negative effects of psychotherapy. The first reviews the literature around negative effects in therapy, including prevalence, causes, and susceptible populations. The second examines the “nocebo” effect in therapy and how bad expectations can translate to poorer outcomes. The third finds that clinicians disagree about negative effects of therapy, commonly dismiss patient-reported negative effects as not related to therapy, and believe worsening symptoms and stress are unavoidable.
Negative Events in Psychotherapy
A new narrative review published in the Industrial Psychiatry Journal explores the prevalence and causes of negative events in psychotherapy. The authors, led by Dushad Ram from Shaqra University in Saudi Arabia, reports that significant numbers of patients and service users experience adverse events and negative effects of psychotherapy. When using a broad definition of “adverse events” that includes things like unmet expectations and general dissatisfaction, an overwhelming majority (95.6%) of patients and service users report such experiences.
The overall prevalence of adverse events in psychotherapy is difficult to assess due to a lack of standardized definitions. The authors also note that underreporting of such events is common, further complicating prevalence numbers. Negative outcomes of therapy generally fall into three distinct categories. First, predictable side effects are unintended but negative experiences that occur as a result of correctly applied treatment. This could include things like temporary emotional distress after a session or a rise in anxiety during exposure therapy. These negative events are common, reported by 33% to 41% of patients and service users.
Second, adverse effects describe unexpected and harmful results of therapy. This can include things like new symptoms, deterioration of original symptoms, strained family relationships, or feeling a complete loss of control. These events are more rare, with 5% – 10% of patients and service users reporting adverse effects.
Third, malpractice and unethical treatment includes things like misdiagnoses, boundary crossing, sexual harassment, and inappropriate therapist-client dynamics. Two point six percent of patients and service users report severe malpractice.
The authors identify multiple factors that contribute to negative events in psychotherapy. Therapist factors such as poor training, inflexibility, lack of empathy, misdiagnosis, weak therapeutic alliance, unresolved ruptures in therapy, incorrect or rushed interventions, failing to monitor progress and negative effects, and failure to provide adequate informed consent can lead to preventable side effects, adverse effects, and possible malpractice. Patient-therapist mismatch, like forcing cognitive-behavioral approaches for someone that wants psychoanalysis or therapists being culturally insensitive, also contribute to negative events. Some patient factors like high anxiety, severe depression, and low self-reflection are linked to more negative events in therapy. External factors, such as negative life events, can also lead to poor therapeutic outcomes.
The authors point to three groups that are most likely to experience negative events in therapy. Young people are more likely to report weak therapeutic alliance and symptom exacerbation during therapy. Trauma survivors can be highly vulnerable to severe emotional distress when therapy is rushed or the topic of their trauma is addressed insensitively. Ethnic and cultural minorities experience higher rates of harm from therapy as a result of therapists lacking cultural competence and using westernized models that do not fit with patients’ and service users’ cultural values.
The authors recommend standardized monitoring of adverse events, regularly asking patients and service users about their experience of therapy, and better training for therapists to minimize negative events in therapy.
The Nocebo Effect in Psychotherapy
The “nocebo effect” describes when a treatment has negative effects due to patient or service user expectations, clinician communication, or therapeutic context. A new article published in Current Opinion in Psychology explores the nocebo effect in psychotherapy. The author, Andrea W. M. Evers from Leiden University in the Netherlands, argues that the nocebo effect in psychotherapy has five key causes: negative expectations, previous treatment experiences, therapist communication and training, social learning, and contextual factors.
Negative expectations that psychotherapy will be painful, confrontational, or ineffective can lead to anxiety, an increase in symptoms, and reduced adherence. Previous negative experiences of therapy, especially in chronic cases, can establish negative expectations of future therapy. According to the author, an “evolutionary bias” in human beings prioritizes negative experiences over positive ones. This means past negative experiences of therapy are extremely difficult to overcome and may result in poorer current therapy outcomes.
Social learning, such as hearing bad things about therapy from family, friends, or social media, may lead to negative expectations and a worse experience in therapy. Contextual factors, such as being placed on a long waiting list, can result in negative emotions and symptom deterioration before therapy even begins.
The way that therapists communicate may also provoke distress and lead to poorer therapeutic outcomes. This can happen through overemphisizing the difficulty of making progress or during discussions of possible negative effects of therapy. Inability to establish a strong therapeutic alliance and a lack of empathy on the therapists part may cause negative effects in therapy, as can a poor explanation for treatment rationale.
The author notes that there are several tools designed to assess the negative effects in psychotherpay, but some of them risk priming participants for remembering more adverse effects due to focusing on the negative effects encountered in therapy. The Positive and Negative Experiences in Psychotherapy survey is a newer measure of harmful impacts in therapy which avoids negative priming by asking about both positive and negative effects.
Evers presents four strategies that can mitigate and possibly reverse the nocebo effect in therapy. Managing patient expectations through providing clear and comprehensive explanations for the rationale behind treatment as well as a balanced framing around potential positive and negative effects of therapy can reduce service user anxiety. Optimizing the the therapeutic relationship through warmth, empathy, and positive environments that make the patient feel safe and reduce negative effects.
Using self-report screeners to identify service users that experience excessive worry about therapy or have had negative experiences of therapy in the past can allow the clinician to tailor the treatment to avoid specific nocebo triggers. In cases where negative expectations are deeply ingrained in the service user or patient, the author recommends reconditioning of past traumatic or negative treatment experiences as part of therapy to minimize the nocebo effect.
Clinicians Disagree About Negative Effects of Therapy, Commonly Dismiss Patient-Reported Side-Effects as Unrelated, and Believe Worsening Symptoms and Stress are Unavoidable
A pair of new Dutch studies published in Clinical Psychology & Psychotherapy finds that many therapists consider negative effects such as increased stress and worsening symptoms unavoidable in therapy, fail to provide informed consent, and often disagree on both what counts as a negative effect of therapy and whether these effects are avoidable. This research, led by Sanne T. L. Houben from Maastricht University in the Netherlands, also finds that a significant number of clinicians dismiss patient-reported negative effects such as dependence on the therapist as not caused by therapy.
The goal of this research was to evaluate Dutch clinicians’ familiarity with negative effects of therapy, how they conceptualize and define negative effects, and the frequency and manner clinicians use to disclose possible negative effects of therapy to patients and service users.
This article reports on two separate studies conducted by the authors. Both used online surveys to collect data from Dutch clinical psychologists and psychotherapists. The first study, including 58 participants, examined general awareness, baseline knowledge, and conceptual definitions of negative effects in psychotherapy. The second, including 64 participants, asked clinicians to classify patient- and service user-endorsed negative effects of therapy as avoidable, unavoidable, or non-existent (meaning not caused by the therapy).
Notably, a significant portion of clinicians believed the following negative effects of therapy were unavoidable, meaning that when they occur no action by the clinician could prevent them:
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Worsening of the symptom that caused the patient to seek therapy (54.8%)
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Increased stress (71%)
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Not reducing symptoms the therapy was meant to treat (69.7%)
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Feeling worse overall (51.6%)
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Trouble sleeping (41.9%)
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Feeling gloomy (38.7%)
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Feeling more anxious (32.3)
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Suicidal thoughts (19.4%)
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Worsening relationships with family and friends (36.4%)
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Increased conflicts with partner (48.5%)
Between 51% (study 1) to 61% (study 2) of participants reported being familiar with negative effects of therapy. Just 70% of those that were familiar with negative effects of therapy actively discussed those negative effects with clients. Only 32.1% of clinicians with little familiarity of the negative effects of therapy reported discussing adverse effects with their clients. This means a significant portion of therapists are failing to provide informed consent around possible negative effects of therapy.
There was considerable disagreement regarding what constitutes a negative effect of therapy and which negative effects were avoidable. Clinicians also commonly dismissed negative effects reported by patients and service users as not related to therapy. For example, in study 2 51.6% of participants believed the patient feeling worse was a negative effect of therapy, compared to 48.8% that dismissed this as not related. Fear of stigma if people found out they were in therapy was acknowledged as a negative effect by 51.6% of participants and dismissed by 48.5%. Having fewer opportunities in the labor market as a result of going to therapy was seen as a negative effect by 51.5% of participants and dismissed by 48.5%.
Feeling gloomy was viewed as an unavoidable negative effect of therapy by 38.7% of participants and avoidable by an identical 38.7%. Worsening relationships with family and friends was seen as an unavoidable consequence of therapy by 36.4% of participants compared to 45.5% that believed it was avoidable. Causing the patient to think about themselves too much was believed to be an unavoidable negative effect of therapy for 43.3% of participants compared to 36.7% that saw it as avoidable.
This means that clinicians largely disagreed with both their peers and clients about negative effects in therapy.
This research had three key limitations. The self-report nature of the surveys means that the data was susceptible to clinicians reporting what was desirable rather than what was true. The sample size for both studies was small. The data came entirely from Dutch clinicians, limiting generalizability to other populations.
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Evers, A. W. M. (2026). The nocebo effect in psychotherapy. Current Opinion in Psychology, 69, 102274. (Link)
Houben, S. T. L., Backus, A. C. P., Merckelbach, H., & Dandachi‐FitzGerald, B. (2026). Exploring the overlooked: Dutch clinicians’ perspectives on side effects of psychological interventions. Clinical Psychology & Psychotherapy, 33(1). (Link)
Ram, D., Manjunatha, N., & Bada Math, S. (2026). Negative events in Psychotherapy: A narrative review. Industrial Psychiatry Journal, 35(1), 15–24. (Link)
Why even bother to call it “therapy” if it isn’t therapeutic?
And you can’t really measure that with a medical test; you have to go with how the patient feels about the experience.
Calling most of these actions “treatments” is at least more accurate, if not more palliative.
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“Therapy” basically amounts to hiring a person to talk with. It is not medical, nor scientific.
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I don’t like to think like this.
There are therapies that really work. Most “professionals” don’t use them as they tend to be a bit unconventional.
I don’t care that much about medicine or “science,” if the treatment has a good track record. Many don’t, even though they are supposedly based in “science.” That word is being used today as a propaganda tool. But that doesn’t mean we have to give up on the concept of real therapy.
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Give me an example of an unconventional therapy that works.
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Steve Burgess uses “hypnotic” regression, which has been quite effective. Hubbard’s therapies use non-hypnotic techniques and are also quite effective. Objectives and New Era Dianetics are the best-known sub-classes of his therapies.
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Turns out that psychotherapists have equivalent — or worse — mental health than the general population: https://totalmentalhealth.info/should-you-get-a-therapist-for-your-therapist/
So, should any of this be surprising?
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“The world seems to be full of intelligent idiots. The examples are endless.
There was a recent study that asked 30 behavioral scientists to predict which interventions would motivate people to go to the gym more often. Keep in mind that these are people who study human behavior for a living, and they were simply being asked to predict what will change human behavior.
Not only were their predictions horribly wrong, but they were worse than the random guesses of a person on the street… or a coin flip.
But this result is not unprecedented. Back in the 1980s, there was a debate within clinical psychology of which therapeutic modalities was most effective. As a result, researchers spent years collecting data on thousands of patients and dozens of modalities. The goal was to determine, once and for all, which form of therapy would rule them all.
But the study found that all forms of therapy barely work at all. In fact, it found that trained clinical therapists do not, on average, produce better outcomes than talking about your problems with a random person. And, in fact, even more surprisingly, giving therapists more training does not improve the outcomes of their patients at all. The entire field of clinical psychology, one could argue, was a marginal upgrade, at best, from having a beer and an honest chat with a friend.
Or consider the fact that a Harvard Business Review study found that over 75% of corporate training actually makes employees less productive.
Or the recent studies that have found that diversity and racism training actually makes people more racist, rather than less.
What the hell is going on here? What are all of these ‘smart’ people actually doing?”
“Intellectuals are F*cking Idiots – Why the Smartest People Get Trapped by Their Own Minds”, by Mark Manson on Substack
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You’ve got a lot of good information here.
I am not quite so cynical. If someone is really smart, they probably won’t try to act like they are. Such people can be very helpful.
But life on Earth is a real circus. Most of us can’t read each others’ minds, and that results in endless deceit. You have to be able to LOOK at someone and tell whether they are deceiving you or not, and that takes training and practice that most people don’t have.
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The therapist is the stranger that you talk to. They become familiar because the person sees and talks to the same stranger.
The therapist is supposedly the steady, stable person to relate to who provides unconditional positive regard, non-judgement, to show that relationships can be safe (no rejection, no abandonment). This interpersonal meeting, is meant to transform the negative and harsh years of unfavorable childhood experiences, so that they no longer dominate in interactions.
For example:
Doesn’t really help when a spouse is hostile, abusive, aggressive, to reflect on how one’s childhood experiences created a situation where one chose to marry such a person. Maybe what is needed is real time functional supports? Therapists don’t do real time supports. They sit, and listen, maybe talk a few words here and there, book the next session, and on and on it goes, until the person works things out (hopefully) for themselves. Weeks. Months. Years.
So choose your therapist carefully and wisely.
Therapy in private practice is costly – time, travel, finances, thinking, processing, filtering, safety, comfort, trust.
We should not tolerate inferior therapy. We should be given information by PUBLIC services providers, on who to expect as a therapist (their exact qualifications and years of practice and what they specialise in) prior to booking an appointment that has been long waited for because of the systems in place. If trainees need prac. hours and experience, these should be directly supervised by a fully and appropriately qualified therapist. Otherwise, the whole process is a con from the beginning.
Basically, the public mental systems put people on waiting lists and keep them waiting according to the services’ money making priorities.
Emergencies go to services that cater for acute crises.
Maybe talking to the seagulls at the beach, seaside, might be more healing. Especially on a sunny day. Take some chips – seaguls love chips (yep, not all that good for them).
The sun is always shining, even when the clouds and rain and bad weather decide to appear.
Rhichard Sears, would you provide the full research papers for all three of the examples that you shared?
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“This means that clinicians largely disagreed with both their peers and clients about negative effects of therapy.
This research had three key limitations. The self-report nature of the surveys means that the data was susceptible to clinicians reporting what was desirable rather than what was true.” Richard Sears
What? Only three key limitations? How about simply naming some indisputable facts?
“Intellectuals create models of the world. In theory, these models reflect and measure reality in a way that allows us to quantify progress and predict the future.
The problem is, you can’t measure everything. It’s impossible. And if it turns out that the immeasurable factors are far more important than what’s measurable, well, then like McNamara, you’re screwed.” Mark Manson
Thank you, Mark Manson, for words to live by.
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“But here’s the problem… Intellectuals forget that models are just models. They begin to believe their models are actual reality. And the consequences are often catastrophic.
Reality always wins.
But intellectuals are rewarded for their models, not reality. And the data and analysis that looks elegant on paper is often disastrous on the ground. Yet, when their models are contradicted by reality, most intellectuals don’t have the courage to accept the reality, instead they double down on their models…
… and this is what turns them into idiots.” — Mark Manson
More words to live by — from someone not trapped inside the model.
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There are no pay cheques, without the research, science, theories, hypotheses, models, “evidence”, “best practice”, and that is how an alternate reality is created and chosen. Money talks.
Strangely, falsifiability is not required. Consensus will do.
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When a therapist defames a person to their spouse, and within two appointments ships a person off to be neurotoxic poisoned by a psychiatrist, “therapy makes things worse.”
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If faculties – capacity, are maintained, you are being shipped off against your will and without fully informed consent or without being told the options of alternative modes of healing and care.
Spouse is not a legal guardian. Or are they?
Therapists are trained to not give too much weight to what family, relatives, “loved ones”, spouses, have to say.
How did this happen without you contributing to the discussion?
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Hi Richard Sears,
What are your thoughts on:
“Gaslighting, the Double Whammy, Interrogation and Other Methods of Covert Control in Psychotherapy and Analysis, psychiatrist Theo L. Dorpat” ??
When people are not given solid foundations for grounding and coping skills, and the therapist allows dysregulation to continue (months, years) – is this not a therapist thing? Of course it is.
Since therapists are not meeting the needs of the person, it is almost guaranteed that they, the person, will either implode – seek relief in other ways, or explode – displace.
However, the therapist puts the fault and blame onto and into the person seeking “help”. So exactly which of the two in the dyad has the pathology?
More harsh realities perhaps?
The dyad is a power imbalance to start with. There are no witnesses. There are vulnerabilities (whatever that means at the time).
Most people do not front up to therapy per se to share their good news and joy.
When people are demeaned, sworn at, criticised, humilated, disliked, not guided to see things better – and yet their money is freely taken from them, and the next appointment is booked via a leading “when do you want to come in again same time next week or there is a earlier/later time, what suits you” question, all while the person is probably drugged with often polypharmacy, is this not also abuse?
“Failing” to see the harms of prescribed drugs.
“Failing” to see and acknowledge the person’s reality and experiences. This is appearing to be calculated neglect (conscious, subconscious, “unintended”).
If, no, since the therapist can get away with doing harms (short of someone dying which may or may not be investigated, depending on the “professional” contemporaneous notes and the therapists’ reliance on good standing), what protections are in place to minimise and or eliminate these poor practices?
It shouldn’t matter what the person brings to the therapy session (sans violence). If it’s not a comfortable fit for the therapist, they need to speak up as soon as they notice their own inner discomforts.
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Richard Sears:
Oh. And what right do therapists have to interfere negatively in other people’s lives (other than mandatory reporting and or declared threats and or sudden lack of capacity)? Taking sides. Using family sessions to share private and confidential information. Using family sessions to discuss the person but not include the person in the conversation. Belittling the person in front of their family. Is that what family sessions are for? No!
The therapist has undermined and blindsided the person who sought their care.
Talking the talk seems to exclude professional codes, ethics, standards, once behind closed doors. Therapists know the legal boundaries and ensure flying just under them.
Success stories belong to the person, the situation they brought with them and not so much with the therapist.
It is well known that the majority of therapists in private practice pick and choose who they will see.
The public system is a matter for the person on the waiting list of not drawing the short straw. Allocated by urgency (supposedly) or described need (filled in form), the person may be seen by an unsupervised trainee.
The above examples in the body of “When Therapy Makes Things Worse” does not disclose who provided the therapy, what the therapy was for (day-to-day life, crisis, … ), who supervised the therapist, and what guidance the therapist received along with their own self-reflection.
These three stories read to be cut and paste – incomplete.
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Hi Richard Sears,
Just spotted the references to the three examples.
Many thanks for providing them.
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