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Clinicians' Perspectives on NegativeEffects of Psychological TreatmentsSamuel Bystedta, Alexander Rozentala, Gerhard Anderssonbcd,Johanna Boettchere & Per Carlbringa

a Division of Clinical Psychology, Department of Psychology,Stockholm University, Stockholm, Swedenb Department of Behavioural Sciences and Learning, LinköpingUniversity, Linköping, Swedenc Swedish Institute for Disability Research, Linköping University,Linköping, Swedend Division of Psychiatry, Department of Clinical Neuroscience,Karolinska Institutet, Stockholm, Swedene Department of Clinical Psychology and Psychotherapy, FreieUniversität Berlin, GermanyPublished online: 09 Sep 2014.

To cite this article: Samuel Bystedt, Alexander Rozental, Gerhard Andersson, Johanna Boettcher& Per Carlbring (2014): Clinicians' Perspectives on Negative Effects of Psychological Treatments,Cognitive Behaviour Therapy

To link to this article: http://dx.doi.org/10.1080/16506073.2014.939593

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Clinicians’ Perspectives on Negative Effects ofPsychological Treatments

Samuel Bystedt1, Alexander Rozental1, Gerhard Andersson2,3,4,Johanna Boettcher5 and Per Carlbring1

1Division of Clinical Psychology, Department of Psychology, Stockholm University,Stockholm, Sweden; 2Department of Behavioural Sciences and Learning, LinkopingUniversity, Linkoping, Sweden; 3Swedish Institute for Disability Research, Linkoping

University, Linkoping, Sweden; 4Division of Psychiatry, Department of ClinicalNeuroscience, Karolinska Institutet, Stockholm, Sweden; 5Department of Clinical Psychology

and Psychotherapy, Freie Universitat Berlin, Germany

Abstract. Negative effects of psychological treatments is a fairly unexplored area of clinical research.Previous investigations have indicated that a portion of all patients experience negative effects interms of deterioration and various adverse events. Meanwhile, evidence suggests that many cliniciansare untrained in identifying negative effects and unaware of the current research findings. Theobjective of the current study is thus to investigate clinicians’ own perspectives and experiences ofpossible negative effects of psychological treatments. An invitation to participate in an anonymousonline survey consisting of 14 open-ended questions was distributed via three mailing lists used byclinicians that primarily identify themselves as cognitive behavior therapists. The responses wereanalyzed using a qualitative method based on thematic analysis. In total, 74 participants completedthe survey. A majority agreed that negative effects of psychological treatments exist and pose aproblem, and many reported having experienced both deterioration and adverse events amongpatients in their own practice. The thematic analysis resulted in three core themes: characteristics ofnegative effects, causal factors, as well as methods and criteria for evaluating negative effects. Theclinicians recognize that negative effects exist, but many are unaware of the current research findingsand are unfamiliar with methods and criteria for identifying and preventing deterioration and adverseevents. The results provide evidence for further dissemination of the present knowledge regardingnegative effects, particularly during basic clinical training, as well as the need for raising awareness ofthe available methods for identifying and preventing negative effects. Key words: negative effects;adverse events; Cognitive Behavior Therapy; online survey; thematic analysis.

Received 14 April 2014; Accepted 25 June 2014

Correspondence address: Per Carlbring, Division of Clinical Psychology, Department of Psychology,Stockholm University, Frescati Hagvag 8, Stockholm 106 91, Sweden. Tel:þ46 8 16 38 71. Fax:þ46 815 93 42. Email: per@carlbring.se

Introduction

Psychological treatments have primarily beenevaluated with regard to their potential forpreventing and alleviating mental distress(Boisvert, 2010). Meanwhile, little is knownabout the occurrence and characteristics ofpossible negative effects, reflecting a majorshortcoming in clinical research (Nutt &Sharpe, 2008). Investigations of negativeeffects have almost exclusively focused onthe so-called fringe psychotherapies, e.g.,

rebirthing and recovered memory techniques,while paying less attention to negative effectsthat might be associated with evidence-basedcare (Barlow, 2010). However, recent findingssuggest that many patients experiencedeterioration and adverse events despitereceiving psychological treatments that havebeen validated and are properly performed(Berk & Parker, 2009). Foulkes (2010) statesthat any intervention with the potency ofrelieving mental distress also carries with itthe risk of eliciting negative effects. Similarly,

q 2014 The Authors. Published by Routledge.This is anOpenAccess article distributed under the terms of theCreativeCommonsAttributionLicense (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited. The moral rights of the named authors have been asserted.

Cognitive Behaviour Therapy, 2014

http://dx.doi.org/10.1080/16506073.2014.939593

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Castonguay, Boswell, Constantino, Goldfried,& Hill (2010) argue that clinicians shouldacknowledge the probability of inadvertentlyhaving induced negative effects to one or morepatients during the course of psychologicaltreatment, and that clinicians as well asresearchers should become more aware ofhow to monitor and manage situations thatmay have a negative impact on the therapeuticprocess and treatment outcome.To what extent negative effects exist and

pose a problem in psychological treatments is,however, a topic of great debate with a longhistory in clinical research (Boisvert, 2010;Rozental et al., 2014). The first empiricalevidence of negative effects is often assumed tobe the Cambridge-Somerville delinquencyprevention study (Powers & Witmer, 1951),although it was not until a review of a numberof outcome studies by Bergin (1966) thatsparked the interest of whether psychologicaltreatments can produce negative effects.Referring to it as the deterioration effect,Bergin (1996) proposed that apart from thepatients that benefit from psychological treat-ments, there are also those who do not profitat all, and a small proportion who becomeworse. Albeit criticized by May (1971) andRachman (1973) on account of the difficultyto prove a cause-effect relationship betweenpsychological treatments and deterioration,several recent outcome studies have providedevidence that between 5% and 10% of allpatients receiving psychological treatmentsdeteriorate (Hannan et al., 2005; Hatfield,McCullough, Frantz, & Krieger, 2010; Heinset al., 2010; Lambert et al., 2002). However,deterioration might not be the only type ofnegative effect that exist (Boisvert & Faust,2002). Strupp and Hadley (1976) investigatedhow a number of influential clinicians andresearchers perceived negative effects, andpresented a tripartite model in which negativeeffects should be assessed from the perspectiveof patient, the clinician, and society,suggesting that mental distress and personalwell-being largely depend on the eye of thebeholder (Strupp, Hadley, & Gomes-Schwartz, 1977). Instead of using the defi-nition deterioration effect, Strupp and Hadley(1976) put forward the idea of negative effects,assuming that it comprises more than justdeterioration, e.g. novel symptoms, misuse ofpsychological treatments and undertaking

unrealistic tasks and goals. A similar conceptwas proposed by Mays and Franks (1980)using the term negative outcome:

A Negative Outcome is a significant decline inone or more areas of a patient’s functioning,between the onset of psychotherapy andtermination of therapy (and for controls, overan equivalent period of time), which persists fora substantial period of time beyond terminationof therapy. The term Negative Outcome is notrestricted to those negative changes which aretherapy-induced, and usage of the term doesnot therefore imply that the therapist isnecessarily responsible for the negative change.

Negative outcome thus included bothdeterioration as well as other types of negativeeffects, but did not presume that the negativeeffects were necessarily related to psychologi-cal treatments per se (Mays & Franks, 1985).It is for instance plausible that some patientsmay experience negative effects because ofevents that occur in their everyday life, andthat some patients might actually havedeteriorated to a greater degree had they notreceived any help at all (Mays & Franks,1980). The natural fluctuation of mentaldistress also obfuscates the idea of negativeeffects, making it difficult to distinguish whatis caused by psychological treatments andwhat is part of an ongoing psychiatriccondition (Rachman & Wilson, 1980). Fur-thermore, nonresponse, drop-out, interperso-nal difficulties, dependency, and socialstigmatization have all been recognized asnegative effects that might interfere or preventthe patient to benefit from psychologicaltreatments (Crown, 1983; Foa & Emmelkamp,1983; Dimidjian & Hollon, 2010). Determin-ing what constitute negative effects is thereforecomplicated, but a number of suggestions onhow to monitor and report negative effectshave lately been presented (Peterson, Roache,Raj, & Young-McCaughan, 2013). Linden(2013) provided a comprehensive checklistthat divide negative effects into a number ofdifferent categories, e.g., events and reactionsunrelated to the interventions in use, non-response, and deterioration of illness. Inaddition, Parker, Fletcher, Berk, and Paterson(2013) have developed a questionnaireintended to probe for negative effects amongpatients undergoing psychological treatments.Nestoriuc and Rief (2012) have also putforward an inventory for assessing negative

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changes in various life domains, and Dimid-jian and Hollon (2010) have suggested thatclinicians and researchers should implementboth quantitative and qualitative methods toexamine the occurrence and characteristics ofnegative effects. It is therefore reasonably toassume that the investigation of negativeeffects will become more common in clinicalresearch, and that it can help prevent patientsfrom experiencing deterioration and adverseevents despite receiving evidence-based care(Barlow, 2010).

Despite the recent interest in negative effectsof psychological treatments among research-ers, clinicians might not be as aware and up todate regarding the debate on how to monitorand report negative effects (Castonguay et al.,2010). Investigations of how clinicians per-ceive and experience negative effects in theirclinical practice are scarce, but there are someindications that they may not acknowledgethat some patients fare worse and encounteradverse events (Boisvert & Faust, 2003).Strupp and Hadley (1976) distributed a surveyon negative effects to 150 researchers andclinicians, of whom 70 responded, with amajority agreeing that negative effects con-stitute a significant problem in psychologicaltreatments. However, the participants wereselected based on their expertise and extensiveknowledge in clinical research, making itdifficult to extend the results to clinicians ingeneral. Similarly, Boisvert and Faust (2003)explored the understanding of psychotherapyresearch findings, including the occurrence ofnegative effects, among 25 prominentresearchers, of whom 12 responded andconfirmed that about 10% of all patientsdeteriorate during psychological treatments.The only examination to date of ordinaryclinicians comprehension of negative effects is,however, a survey by Boisvert and Faust(2006) that replicated their previous investi-gation of psychotherapy research findings, butinvolved 500 randomly selected clinical psy-chologists of the American PsychologicalAssociation. The findings indicated that ofthe 181 participants whom responded, 28%were unaware that a considerable portion ofall patients seems to experience negativeeffects. This can be seen as particularlyalarming when considering the results ofHatfield et al. (2010), exploring 14 clinicians’ability to detect whether one of their patients

were about to deteriorate using only theirclinical judgement. In only 21% of the caseswere the participants able to recognize when apatient had deteriorated, while less than 9% ofthe cases were detected in terms of non-response. Hatfield et al. (2010) found similarevidence when using a survey that wasadministered to 300 randomly selected clinicalpsychologist of the American PsychologicalAssociation, of whom 36 responded, implyingthat clinical judgment alone does not seem tobe sufficient in order to apprehend negativeeffects in psychological treatments. Hatfieldet al. (2010) concluded that clinicians seem tobe overly optimistic with respect to their ownperformance, lending support for a systematicevaluation of treatment progress, e.g. theTreatment Outcome Package (TOP; Kraus,Seligman, & Jordan, 2005) and the OutcomeQuestionnaire-45 (OQ-45; Lambert et al.,2003).

The purpose of the current study was toextend the previous investigations of howclinicians perceive and experience negativeeffects in their clinical practice, as well as toexamine their knowledge of the availableresearch findings regarding negative effects inpsychological treatments. The current studyalso seeks to explore whether clinicians wereinformed about negative effects in their basicclinical training, by what criteria they wouldjudge a patient as having been exposed tonegative effects, which factors might beconsidered responsible for negative effects,and whether there exist certain patient groupsat risk of deterioration or adverse events. Theoverall aim of the current study was thus toprovide valuable knowledge of how cliniciansregard negative effects of psychological treat-ments, as well as to further the understandingof how clinicians themselves apprehend anddeal with negative effects in their everydayclinical practice.

Methods

ProcedureAn invitation to participate in an onlinesurvey concerning negative effects of psycho-logical treatments was sent out to a selectgroup of individuals in order to conduct apilot test. After minor revisions regarding thewording of the questions, the survey wasdistributed via email to the Swedish Society

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for Behavior Therapy (consisting of approxi-mately 1000 members), the Section forCognitive Behavior Therapy within the Swed-ish Psychological Association (consisting ofapproximately 350 members), as well asstudents attending the psychotherapist pro-gram with a cognitive behavioral orientationat the Department of Psychology at Stock-holm University (consisting of approximately50 students). The survey consisted of 14 open-ended questions (see Appendix), of which 3were adapted from an earlier investigation ofnegative effects of psychological treatmentamong practicing clinicians and researchers(Hadley & Strupp, 1976; Strupp, Hadley, &Gomes-Schwartz, 1977). Participants wereguaranteed anonymity and that no meta-data, i.e., IP-addresses, would be logged by thewebsite hosting the online survey or availableto the authors of the current study. Nofinancial compensation was offered to thosewho chose to participate in the survey, exceptfor the students attending the psychotherapistprogram who were able to receive a book onanxiety upon completion. The survey wasaccessible for two weeks, during whichadditional reminders were sent out to theparticipants. Information with regard to thepurpose of the current study, the principalinvestigators, as well as the possibility toreceive a final copy of the results, was includedin the invitation.

ParticipantsIn total, 74 clinicians participated in thesurvey, of which 45 (60.8%) were women and28 (37.8%) were men, while one (1.4%)individual choose not to disclose his/hergender. The mean age of the participants was45.52 years (SD ¼ 10.36), ranging from 26 to67 years. The mean number of years workingas a clinician was 11.98 years (SD ¼ 8.71),ranging from 1 to 39 years. In terms oftherapeutic orientation, 63 (85%) of theparticipants described themselves as CognitiveBehavior Therapists (CBT), 6 (8%) as CBTwith a strong influence from Acceptance andCommitment Therapy (ACT), 10 (13.5%)portrayed themselves as Behavior Therapists(BT), and 3 (4%) stated that they were BTusing ACT. In addition, one (1.4%) partici-pant identified herself as a Cognitive Thera-pist, and one (1.4%) participant reported

using integrative methods combining BT andtheories of attachment.In Sweden, the title psychotherapist is a

licence regulated by the National Board ofHealth and Welfare (Socialstyrelsen), and canonly be obtained by documenting an adequateuniversity degree and sufficient clinical train-ing. Essentially, there are two ways ofbecoming a psychotherapist: either the indi-vidual is a licenced psychologist and completesa three-year education and clinical trainingwithin the psychotherapist program, or theindividual has a different background inhealth care or social work that includes basicclinical training which allows application tothe psychotherapist program, e.g., licencednurse, licenced physiotherapist, licenced psy-chiatrist, licenced social worker, or clericalworker. Hence, it is not uncommon in Swedento have two separate licences, i.e., licencedpsychologist and licenced psychotherapist.A full description of the participants’occupation is illustrated in Table 1.

AnalysisThe data-set from the survey consisted of17.406 words that were explored usingthematic analysis. Because the responseswere imputed directly by the participant,neither transcription or further processingwas warranted in order to proceed with theinvestigation of the material. A qualitativemethod based on thematic analysis was usedbecause of its ability to examine a specificconcept through the unique perspective of theparticipants (Braun & Clarke, 2006). The-

Table 1. Description of the participants’ currentoccupation

Occupation

Licencsed psychologist 38 (51.4)Licencsed psychologist and licencsedpsychotherapist

23 (31)

Licencsed social worker 5 (6.7)Licencsed social worker andlicencsed psychotherapist

3 (4)

Licencsed psychotherapist (basic clinicaltraining unspecified)

2 (2.7)

Licencsed physiotherapist 1 (1.4)Licencsed psychiatrist and licencsedpsychotherapist

1 (1.4)

Basic clinical training (occupationunspecified)

1 (1.4)

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matic analysis is particularly useful as aninductive approach, identifying recurrentthemes that are rooted in the data withouthaving to fit it into a pre existing theoreticalframework. This allows the researcher toexamine the participants’ own comprehensionof a given concept, in this case, negative effectsof psychological treatments. Thematic anal-ysis has, for instance, previously beenemployed in relation to patients’ experiencesof Internet-based Cognitive Behavior Therapyfor Bulimia Nervosa (McClay, Waters,McHale, Schmidt, & Williams, 2013), as wellas adolescents’ perception of diagnosticevaluation in psychotherapy (Binder, Moltu,Sagen, Hummelsund, & Holgersen, 2013), andis a common qualitative method used foranalyzing large data-sets in medical and socialsciences (Willig, 2013).

The thematic analysis was conducted by themain author of the current study in accord-ance with the steps proposed by Braun andClarke (2006): (1) the data were read andreread to get an overview of the material andits content; (2) each response to the open-ended questions was coded using its semanticcontent, i.e., the meaning of the actual wordswritten, so that all responses carrying similarcontent would be identified within the data-set. All codes were then named after thesemantic content in the responses, forinstance, a response concerning the thera-peutic alliance received the code “alliance”.Responses that consisted of several semanticcontents were given multiple codes and (3)codes were structured into groups with theirrespective headlines, each describing themeaning of each group. Each code was alsogiven an identification number representingthe specific participant, 1–74, and a letterrepresenting the response to a question, a–n;(4) themes were generated in an iterativeprocess using both the data-set and the groupsof codes, that is, each group was tested againstthe actual content of the data-set a number oftimes by returning to the data and rereadingand reformulating the themes; (5) the themeswere congregated into core themes and, whereapplicable, sub-themes. Formulation of thefinal themes in the current study wasperformed using the semantic meaning of theactual words in the data-set; (6) the resultsfrom the thematic analysis was used toinvestigate the material, relate it to prior

research, and discuss the main theoreticalfindings. In the event of methodological issuesor difficulties related to the analytic procedureor investigation of the results, the co-authorswere consulted. Furthermore, the themes andformulations of themes were reviewed by thesecond author in order to dissolve anydisagreement and increase reliability.

In addition to the thematic analysis, theresponses to the questions 1–6, as well as11–13, were used to provide descriptivestatistics, while the responses to questions 5and 11 were used both in the thematic analysisand as descriptive statistics. Question 12 onlyallowed a dichotomous yes or no response towhether or not the participants had receivedinformation concerning negative effects duringtheir basic clinical training.

Results

Descriptive statisticsIn terms of whether the participants believedthat negative effects of psychological treat-ment exist and pose a problem, 73 of 74participants responded, with 63 participants(94.5%) stating that they agreed. The four(5.5%) participants who disagreed hadbetween 13 and 30 years of clinical practice,and did not differ from the rest of theparticipants in any significant way. Overall,55 (75%) participants described that they hadclinical experience of negative effects, andeight (11%) responded to having receivedinformation about negative effects duringtheir basic clinical training.

Thematic analysisThe thematic analysis of the data-set revealed3 distinct core themes and 12 sub-themes,which are illustrated in Table 2: characteristicsof negative effects, causal factors, as well asmethods and criteria for evaluating negativeeffects.

Characteristics of negative effectsShort-term negative effects. Many of theparticipants described how psychologicaltreatment has the potential of evoking strongbut temporary feelings of discomfort. Forexample, a patient performing exposurein vivo will most likely experience an increasein anxiety, even though it is presumed to bebeneficial in the long run. A short-term

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increase in discomfort was referred to by theparticipants as an unavoidable part of manyinterventions, but patients are not always beprepared for this and might choose to endtreatment prematurely, which in turn couldmake them less inclined to seek help for theirdifficulties in the future. One participant wrotethe following:

The patient does absolutely experience aversiveevents because of treatment, in the short run. Ifthey have the strength and patience to bear withit, they will be empowered by this. However, ifthey are not prepared, the aversive effects canprove to be long lasting. (Licenced socialworker, 47 years old)

No treatment effect. Entering treatment andnot experiencing any positive results wereperceived by some of the participants as anegative effect, particularly because it cangenerate feelings of hopelessness and lead tothe perception of oneself as being damagedbeyond repair. One participant described thisprocess as attributing the lack of treatmenteffect to personal deficiencies:

Yes, for example, if there is no treatmenteffects, the patient, depending on how oneinterprets the lack of results, might gain astronger belief in its own negative self-image(it’s my own fault that therapy did not work) ora negative experience of the possibility toreceive help from others (there is no help to get,others can’t help me). (Licenced psychologist,44 years old)

Another participant described the experi-ences of meeting patients with a history of

failed treatments and the feelings of hope-lessness that sometimes follow:

For me, it’s not unusual to see patients, whodescribe previously failed treatments (this mightnot qualify as negative effects – but one canview the lack of a treatment effect as somethingnegative, if this represents a lost opportunity toparticipate in a different and more effectivetreatment). In my view, lack of treatment effectsseems to add to an already existing sense ofhopelessness in patients. (Licenced psychologistand licenced psychotherapist, 38 years old)

Deterioration. Several participants mentioneddeterioration of illness as a negative effect,describing how some patients might fare worsefrom entering treatment than they would havewithout it. In addition, several participantsalso regarded the emergence of new symp-toms, e.g., insomnia, low self-esteem, and themanifestation of a sick role, as other examplesof negative effects. One of the participantswrote about reinforcement of behaviors thatare not in the best interest of the patient:

Escalating suicidal tendencies (within thetherapeutic contact) different kinds ofreinforcing consequences contingent upon self-harm. Then there are of course a lot of examplesof how treatment professionals, motivated bygood intentions, have been encouragingavoidance of anxiety at any costs, etc.(Licenced psychologist, 32 years old)

Dependency. A few participants illustratedhow patients sometimes become dependent onthe therapist or on therapy in general, and thattherapists often fail to see the treatment as a

Table 2. Themes and sub-themes in the data-set

Themes Sub-themes

Characteristics of negative effects Short-term negative effectsNo treatment effectDeteriorationDependencyImpact on other life domains

Causal factors Incompetence and inadequately applied methodsPotentially harmful treatmentsInsufficient therapeutic allianceFailed ethical judgment and professional conductDiscontinuing treatmentExternal factorsPatients at higher risk of suffering from negative effects

Methods and criteria for evaluatingnegative effects

None

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means of increasing the patient’s ability ofbecoming self-reliant. Particularly, long-termtreatments were referred to by the participantsas a great risk factor for developing depen-dency. One participant wrote explicitly abouthow some patients gain positive effects and atthe same time they lose their independence as aresult of undergoing treatment:

Sometimes patients can get less independent asa result of participating in treatment. In otherwords, they can’t do things on their own, thatending therapy would be negative because thenthe problems would return. (Licencedpsychologist, 40 years old)

Impact on other life domains. The impact oftreatment on other domains of life wasportrayed by some of the participants as apotential negative effect, particularly withreference to the loss of time for social activitiesor work. A number of participants mentionedthat treatment might require the patient to beon sick-leave from work in order to manage anextensive treatment, e.g., exposure withresponse prevention for severe obsessivecompulsive disorder. One participant wroteabout how the path to recovery sometimes isboth difficult and invasive:

During more intense and time-consumingtreatments such as intensive exposuretreatment of OCD, patients might be forcedto cut down on other activities, and sometimesthey might even need to take sick leave toreserve time for the treatment, whichpotentially can have aversive effects in otherareas of life. (Licenced psychologist, 27 yearsold)

Causal factorsIncompetence and inadequately appliedmethods. Many participants in the studyperceived incompetence or inadequatelyapplied methods as potential causes ofnegative effects, highlighting the need forsufficient clinical practice and opportunitiesfor further training among therapists. Severalof the participants emphasized the responsi-bility of the clinician to ensure that skills andknowledge are up to date, as well as the needto acknowledge one’s own limitations. Atherapist should be aware which patients totreat and which to refer to others. Oneparticipant wrote the following about thera-pist behavior and the necessity to obtain as

much information as possible before thetreatment is initiated:

Different therapist behaviors: lack ofresponsiveness, lack of competence byapplying treatment methods, lack of time,lacking maintenance program and follow-up. Not checking up on the patient regardingfor example homework. But also that the clientdid not provide all the necessary backgroundinformation that might have an impact ontreatment outcome (e.g. information onprevious episodes of depression). (Licencedpsychologist and licenced psychotherapist,51 years old)

Another participant wrote about identifyingimportant markers of treatment failure, thatis, the lack of behavior change, and the factthat both the therapist and the patient mayreinforce each others’ avoidance behaviors:

The biggest problem I see is if there is no changein the patient’s behavior as a result of thetherapy, or if there is a gradual increase inavoidance behavior, which you are unable toreverse. The patient might feel comfortable tostart treatment and simply talk and experience asense of relief after each session, and at the sametime reinforces the therapist’s sense ofimportance. The problem is that thisreinforces the behavior of going to therapy totalk, which becomes yet another avoidancebehavior. (Licenced psychologist, 59 years old)

Potentially harmful treatments. A few partici-pants described potentially harmful treat-ments as responsible for negative effects,similar to those referred to by Lilienfeld(2007), e.g., rebirthing, grief counseling forpatients with normal bereavement reactions,and scared straight interventions. Only oneparticipant explicitly mentioned Lilienfeld’s(2007) paper, but some participants wereaware of some of the potentially harmfultreatments that are mentioned. One partici-pant wrote about repressed memory tech-niques and critical incident stress debriefing:

Some examples that are highly relevant at themoment is to confess crimes that you did notcommit, report false traumatic memories.Another treatment that comes to mind isetching in traumatic memories duringdebriefing. (Licenced psychologist, 39 years old)

Insufficient therapeutic alliance. Failing toestablish a strong therapeutic alliance betweenthe therapist and patient was declared a

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potential risk factor for treatment failure byseveral participants. It was for instance statedthat the patient needs to understand thetreatment rationale, the explicit goals oftreatment, and what it means to achievethose goals in terms of time and commitment.One participant wrote:

Lacking a relationship, lacking an understandingof what the purpose of the treatment is, lackingthe ability tomeet the patient at the right level, orlowmotivation to change. All of these are factorsthat are important for both the therapist andthe patient, that is, we as therapists need to adaptour behaviors to the patient’s level in relationto several different parameters. (Licencedpsychologist, 45 years old)

Failed ethical judgment and professionalconduct. Other aspects of therapist behaviorthat were mentioned by many participantswere failure to uphold the ethical standardsand professional conduct that is expected by apracticing clinician. Particularly, violating orusing your patient, as well as abusing yourpower as a therapist was considered to resultin negative effects. One of the participantswrote about the obligation to adhere to ethicalguidelines and to know your own limits as atherapist:

Unethical therapist behavior, disregardingprofessional and ethical guidelines. Or whenthe therapist takes on assignments within areaswhere the therapist in question lacks thenecessary competence (which is also part ofthe professional responsibility to be able todetermine). (Licenced psychologist, 55 yearsold)

Another participant wrote about meetingpatients with a history of feeling misunder-stood by their therapists and the negativeconsequences that may arise thereof:

I have seen quite a few patients, who have feltthat they were not understood or validated, oreven violated, and patients, who have beentreated in such a way that they did notunderstand what the treatment was intendedfor. This in turn has led to more depression,anxiety, mistrust, etc.(Licenced psychologist,45 years old)

Discontinuing treatment. Several participantsdiscussed discontinued treatment as a poten-tial risk factor for negative effects. Treatmentscan end prematurely by either the therapist orthe patient. A number of participants

described short-term negative effects as apotential cause for patients to leave treatment,but also unexpected attrition. A few partici-pants also mentioned that some patients mightnot be able to pay for treatment. Oneparticipant wrote the following about makingmistakes when having to end an ongoingtreatment:

I myself have ended treatments in a clumsy waywhen I switched from one workplace toanother, which led to disappointment whichthe patient had a hard time coping with. That is,thoughtlessness or carelessly administeredinterventions by therapists can createfrustration, which overshadows the potentialgood that the therapist might haveaccomplished.—Licenced psychologist, 39years old

Another participant wrote about how somepatients leave treatment prematurely as aresult of not being able to cope with theemotional stress and increase in anxiety thatoften accompany many interventions:

On a short term basis in the treatment ofanxiety disorders: feelings of discomfort,increased levels of anxiety, and in certaincases the patient might not overcome thatthreshold and thus leave the treatmentprematurely taking only negative experienceswith her/him. (Licenced psychologist andlicenced psychotherapist, 55 years old)

External factors. External factors were per-ceived by some participants as an importantfactor that might interfere with the quality andoutcome of treatment, most notably the lackof funds to pay for the number of sessionsrequired in order to benefit. Other types ofexternal factors that might have a negativeeffect were the institution in which thetherapist works, e.g., lack of support for theinterventions that are deemed necessary,inadequate training, or financial restraints.One participant described experiencing finan-cial pressures that affected the time allocatedto psychological treatment in an outpatientcare setting:

To rush through a treatment, to cut costs, it’slike a surgeon sewing a patient back togetherwith sloppy stitches. The surgery is done but thewound might not heal very beautifully. In myexperience the outpatient care setting oftenstruggles with demands of taking on high case-loads, which can result in shorter treatments,

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despite the evidence regarding how manysessions that are usually required to achieve asignificant result. (Licenced psychologist,52 years old)

Patients at higher risk of suffering fromnegative effects. In terms of patients thatmay have a higher risk of experiencingnegative effects, none of the participantswere able to distinguish any specific group ordiagnosis. However, several participants men-tioned patients with comorbid disorders asbeing more difficult to treat in general, andthus more likely to result in treatment failureor encountering negative effects. Some par-ticipants also believed that patients with acombination of personality disorders andanxiety disorders, or patients with lowcognitive abilities and anxiety disorders,experience negative effects to a greater degree.One participant wrote about the delicatenature of treating individuals with personalitydisorders related to their lack of insights intotheir own responsibility in causing difficultieswith others:

Individuals with a victim-mentality (everyone ismean to me and I have no impact on whathappens in my life) often with personalitydisorders, are often discontent, they might evenfeel more violated and mistreated when you arenot able to help them (since we often are notable to work directly with their home and socialenvironment and only with the individual inquestion). They are often very upset if yousuggest that they themselves might be part oftheir ongoing problem. (Licenced psychologistand licenced psychotherapist, 55 years old)

Another participant wrote about how youshould address an anxiety disorder when thereis an underlying personality disorder leftuntreated, which might make things worse:

If there is for example a personality disorderunderneath and the treatment is aimed at panicdisorder and/or depression, severe features ofthe personality disorder might be enhanced, inmy experience. (Licenced psychologist, 52 yearsold)

Another participant wrote about the diffi-culties in providing the best interventionpossible for individuals with varying capabili-ties and cognitive impairments, and how CBTmight not always be the best choice:

The patients I see (an outpatient clinic fortreating patients with psychosis) often have a

history of failures or experiences of notachieving their treatment goals. To initiatepsychological treatment when the patient mightnot have the capacity to carry out the tasks(I am specifically thinking of CBT because thatis what I am trained to administer) might in thelong run be less advantageous for the patientthan for example counseling. The patient mightlack the cognitive capacity, strength, andexecutive capability to carry out homework orother activities, which might cause thetreatment to never really get off the ground orrender any positive results. (Licencedpsychologist, 26 years old)

Criteria and methods for assessingnegative effectsParticipants were asked to propose specificcriteria for assessing whether or not a patienthad suffered from negative effects of psycho-logical treatments. This was seemingly difficultto answer, and many of the participantsdiscussed methods for assessing negativeeffects rather than defining specific criteria, e.g., therapist andpatient assessment, qualitativedata in the form of a patient’s verbal account ofthe treatment and its perceived outcome, andthe clinician’s overall judgment of the patient’scondition and development during treatment.However, a few participants mentioned acombination of measures concerning deterio-ration of illness, collection of qualitative datathrough clinical interviews, clinical judgment,as well as the systematic use of differentoutcome measures. One participant also men-tioned the OQ-45 (Lambert, 2013) as a methodfor detecting negative effects during treatment.In addition, one participant highlighted theimportance of considering the patient’s ownunique perspective:

I would first of all take into account what theindividual tells me about her experiences of thetreatment and how it has affected her/him. I’mnot sure how to interpret ’criteria’. These wouldhave to be based on the patient deteriorating, oron lack of treatment effects (that could havebeen obtained by another more effectivetreatment), and also on the notion that thetreatment in question is faulty. (Licencedpsychologist, 39 years old)

Furthermore, another participant wroteabout taking the patient’s perspective intoaccount, as well as summarizing several

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different outcome measures in an overalljudgment of the treatment outcome:

I usually evaluate treatments usingmeasurements of symptoms, for exampledifferent scales and instruments, and oftenmeasurements of behavioral change, forexample by registering target behaviors.Evaluation is also done verbally usingquestions about the patient’s experiences oftreatment and if any progress has been made.A clinical judgment about how the patient isdoing after treatment has ended. I am lackingspecific measurements of negative effects, but Ithink that if a significant deterioration hasoccurred, the methods mentioned above wouldmake this easy to distinguish. (Licencedpsychologist and licenced psychotherapist,61 years old)

Discussion

The purpose of the current study was toinvestigate how clinicians perceive and experi-ence negative effects in their clinical practice,as well as to examine their knowledge of theavailable research findings regarding negativeeffects in psychological treatments. The resultsreveal that a majority of the participantsagreed that negative effects of psychologicaltreatments exist and pose a problem, andmany were also able to recount incidenceswhere their patients had either deteriorated orencountered adverse events. In addition, theresults suggest that there is a lack of consensusregarding how and by what criteria negativeeffects should be determined. Most of theparticipants responded by discussing measure-ment issues rather than to provide a definitionof negative effects, e.g., to use clinicaljudgement or rely on validated outcomemeasures, as well as presenting various typesof negative effects, e.g., short-term negativeeffects, no treatment effect, and impact onother life domains. This finding is, however, inline with prior research where the conceptu-alization of negative effects ranges fromdeterioration to misuse of psychologicaltreatments, novel symptoms, social stigmati-zation, interpersonal difficulties, and loweredself-esteem (Dimidjian & Hollon, 2010;Lilienfeld, 2007; Boisvert & Faust, 2003),while the criteria for assessing negative effectsare still unclear, making it complicated forclinicians to distinguish negative effects in

clinical practice (Peterson et al., 2013). Hence,a more uniform classification for definingnegative effects could become valuable inorder to raise the awareness among cliniciansof what negative effects that can occur.Likewise, the different suggestions on how tomonitor negative effects that recently havebeen proposed may facilitate the investigationof deterioration and adverse events byproviding useful measures and questionnairesto clinicians and researchers (Linden, 2013;Nestoriuc & Rief, 2012; Parker et al., 2013).The results of the current study also showed

that the participants were able to discuss anumber of factors that are presumed to berelated with the occurrence of negative effectsin psychological treatments, e.g., the thera-peutic relationship, the importance of amutual agreement, certain patient groups, aswell as adequate competence and properapplication of interventions. Although thecausality of psychological treatments andnegative effects is difficult to examine, similarfactors are discussed by Castonguay et al.(2010), suggesting that the clinician’s beha-vior, rigid application of a therapeutic model,and specific patient characteristics might resultin a greater incidence of negative effects.Understanding what factors could be associ-ated with deterioration and adverse events isdeemed important, and should help cliniciansprevent and manage negative effects in theirclinical practice. However, this warrants anincreased acknowledgement of negative effectsduring basic clinical training, which thecurrent study indicates might not be the case.Only a small portion of the participantsresponded to having received information ofnegative effects through literature andresearch, and when considering the range inage and years of clinical practice among theparticipants, this is assumed to be lacking still.Castonguay et al. (2010) have presented anumber of guidelines in order to introduce theidea of negative effects to clinicians in Spe,e.g., clinical supervision focusing on how todetermine lack of improvement, systematicevaluation of treatment progress, as well asknowledge of the therapeutic variables andpatient characteristics that can contribute todeterioration and adverse events, and mayhelp to improve the awareness of negativeeffects in basic clinical training.

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The current study has several methodologi-cal limitations that need to be consideredwhen reviewing the results. First, of theapproximately 1400 potential participantswho received an emailed invitation to partici-pate, only 74 completed the survey, generatinga response rate of no more than 5%. Thesurvey might therefore have been affected byresponse bias, which can in turn impact thegeneralizability of the results. However, this isin line with the response rate of similarinvestigations, e.g., 12% for Hatfield et al.,(2010), even though Boisvert and Faust (2006)did manage to increase their response rate to36% by using additional reminders that weresent out by post cards. The use of email in thecurrent study could be a possible explanationfor the small number of participants complet-ing the survey, but it is also unclear how manyof the 1400 potential participants activelyreceive email from their respective affiliation.Furthermore, the deadline for the survey wasonly two weeks, and no financial compen-sation was offered, which might have influ-enced the motivation to participate. Second,the use of a survey and not an interview mighthave restricted the type of responses that thecurrent study was able to collect. Theparticipants were for instance unable toelaborate their responses after submission,and no follow-up questions were feasible,ruling out the possibility to probe foradditional information. Third, the thematicanalysis was conducted entirely by the firstauthor of the current study, and no reliabilityestimate such as inter-rater reliability byassessing Cohen’s kappa or percentage agree-ment was used. This may have affected thecoding of the results and increased the risk ofperforming human errors. However, meth-odological issues and difficulties related to theanalytic procedure were discussed togetherwith the co-authors, and the themes andformulations of themes were also reviewed bythe second author. In addition, by providingfacts on how the participants were recruited,their occupation and theoretical orientation,and the process of analyzing the data, greatertransparency has been achieved in the currentstudy, thus enhancing the credibility andtransferability of the results (Sandelowski,2000). Recommendations for future researchis to use an interview in order to furtherexplore the perception and experiences of

negative effects among clinicians, as well as toinvestigate what measures and criteria thatcan be used to identify patients at risk ofdeterioration or adverse events.

Acknowledgements

This work was supported by FORTE - theSwedish Research Council for Health, Work-ing Life and Welfare [grant number 2013-1107].Disclosure statement: The authors havedeclared that no conflict of interest exists.

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Appendix

1. Age2. Gender3. I practice psychological treatment as part

of... (what occupation)?4. Please describe your basic clinical

training5. My main therapeutic orientation, that is,

the theoretical perspective I rely on whenpracticing psychological treatment, is...

6. How many years have you been practi-cing psychological treatment?

7. Is there a problem of negative effects, i.e.,can we legitimately speak of a patientgetting worse or experiencing adverseevents as a result of psychological

treatment?8. If so, what would constitute a negative

effect in psychological treatment?9. By what criteria would one judge a

patient as having experienced negativeeffects as a result of psychologicaltreatment?

10. While any therapy outcome is obviously afunction of many factors, which factorswould you associate with, or considerresponsible for, a negative effect?

11. In your opinion, is there a particularpatient group that might experiencenegative effects of psychological treat-ment to a greater degree?

12. Did you during your basic clinicaltraining receive information about, orcome in contact with any literature orresearch that concerns negative effects ofpsychological treatments?

13. Do you have any clinical experience ofnegative effects of psychological treat-ments?

14. Is there anything else you would like toadd?

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