Negative events in psychotherapy: A narrative review

Abstract

While psychotherapy is effective for numerous mental health conditions, it may also result in undesirable effects, such as mild emotional distress, symptom exacerbation, dependency, and, in certain cases, ethical violations by therapists, which are frequently underreported. This narrative review synthesizes existing literature to evaluate the prevalence, underlying mechanisms, ethical implications, and prevention strategies for negative events in psychotherapy, including side effects, adverse effects, and therapist-related harm. The incidence of negative effects varies significantly due to inconsistent definitions and research methodologies. Factors such as weak therapeutic alliances, therapist incompetence, cultural mismatches, and systemic deficiencies contribute to the development of negative effects. Additionally, vulnerable groups, including youth, trauma survivors, and ethnic minorities, are also affected. Current assessment tools, such as the Inventory for the Assessment of Negative Effects of Psychotherapy and the Negative Effects Questionnaire, fail to fully capture the complexity of harm, while ethical issues such as inadequate informed consent persist. To enhance safety, psychotherapy requires standardized harm monitoring, comprehensive therapist training, culturally tailored approaches to meet diverse client needs, and routine outcome tracking to detect and address negative events early. The lack of comprehensive tools impedes transparent risk communication, intensifying ethical challenges such as inadequate informed consent. Clear definitions and comprehensive assessment tools are essential to provide safer, more ethical, and effective care.

In recent years, the global incidence of mental disorders has risen, with both pharmacological and non-pharmacological treatments remaining primary care strategies.[1] Although safety concerns related to pharmacotherapy are well documented, there is an increasing preference among patients for psychological treatments,[2] supported by evidence-based methods designed to overcome accessibility challenges.[3] In 2024, the World Health Organization revised its guidelines to prioritize manually guided psychotherapies.[3] However, accumulating evidence suggests that clients undergoing therapy may experience unintended effects, highlighting the urgent need for standardized methods to identify and address these potential negative effects. This article advocates for transparency in acknowledging both the benefits and risks of psychotherapy, thereby empowering clients, enhancing practice, and advancing research toward comprehensive outcome assessments. In India, this issue is particularly critical as a mix of trained and untrained professionals, many of whom are unlicensed, engage in, or claim to practice psychotherapy and counseling. Furthermore, the preamble of the Mental Healthcare Act, 2017, clearly aims to ensure the provision of mental healthcare and services for individuals with mental illness for protecting, promoting, and fulfilling their rights during the delivery of such care and services. Although the effectiveness of psychotherapy is well established, data on its safety are limited. In this context, this narrative review synthesizes existing literature to evaluate the prevalence, underlying mechanisms, ethical implications, and prevention strategies for negative events in psychotherapy, including side effects, adverse effects, and therapist-related harm.

PSYCHOTHERAPY- CONTEXT AND RELEVANCE

Psychotherapy is a mental health intervention that addresses cognitive, emotional, and behavioral issues through a collaborative therapist-patient relationship, where negative events may arise from therapeutic processes or therapist actions.[4] Psychotherapy is effective in treating mental health conditions, with meta-analyses indicating improved outcomes.[5] A combination of in-person and online therapy enhances results.[6] CBT shows a 40%–50% response rate for MDD,[7,8] while CPT and EMDR are effective in reducing PTSD,[9] and DBT decreases self-harm in BPD.[9] The treatment success varies depending on the type of therapy and patient factors. CBT is effective for acute depression and anxiety, whereas psychodynamic therapy is more suitable for chronic conditions,[7] and acceptance and commitment therapy reduces distress. Brief interventions are beneficial for younger patients, while older adults may require longer treatment.[10] Culturally adapted programs are advantageous for minorities.[11] Therapeutic alliance significantly impacts outcomes.[12] The challenges include access and cost. Improvements in depression can last 24–36 months, with severe cases requiring follow-up.[13] However, cost-effectiveness data remains limited.[14] While psychotherapy is effective for various conditions, its benefits are not universal, and adverse events (AEs) can undermine outcomes, particularly in vulnerable populations.[7] Understanding the potential for harm in psychotherapy is crucial for enhancing its safety and efficacy, especially in diverse settings such as India, where unregulated practices increase risks.[15]

Conceptual aspects of negative effects in psychotherapy

The terminology employed to describe undesirable outcomes in psychotherapy is varied and differs across disciplines. Unwanted events (UEs) encompass all negative incidents occurring during or after treatment, whereas treatment-emergent reactions are UEs directly attributable to therapy. Adverse treatment reactions refer to UEs likely resulting from appropriate therapy, while adverse effects are undesired outcomes of therapy, and side effects are unintended consequences beyond the intended therapeutic goal.[16] Negative effects serve as an overarching term encompassing AEs, side effects, malpractice, and unethical behavior.[17] McIntosh et al. (2019)[18] categorize these into temporary discomfort, beneficial long-term effects, harms outweighing gains, or issues arising from therapy cessation. To ensure clarity, this review uses “negative events” to encompass side effects, adverse effects, UEs, and ethical violations. These distinctions are detailed in Table 1. Although predictable, side effects are unintended, such as emotional distress, occurring in 33%–41% of clients, with young adults frequently reporting symptom exacerbation.[19] Adverse effects are unexpected and harmful, often involving tension with therapists or family issues.[20] All adverse effects fall under the broader category of negative effects and affect up to 95.6% of patients using a broad definition, in outpatient psychotherapy settings, including issues such as unmet expectations or stigmatization.[21] Use of narrower definitions (e.g., symptom exacerbation) yields lower prevalence rates, ranging from 5% to 10%.[22] The high prevalence may reflect outpatient-specific factors, such as less intensive monitoring compared with inpatient settings, highlighting the need for standardized harm assessment across contexts.[21]

Table 1.

On various definitions – Side effects, adverse effects, and negative effects

Type of Negative Event	Definition	Risk Factors/Notes
1. Unwanted Event (UE)	Any negative event occurring during or after therapy	Broadest category; may not be treatment-related
2. Treatment-Emergent Reaction/Side effects (TER)	A UE caused by the treatment	Usually expected with some interventions; it may require monitoring, should be part of informed consent
3. Adverse Treatment Reaction (ATR)	A TER is likely caused by the correct application of therapy	Often unexpected side effects
4. Malpractice Reaction (MPR)	A TER is likely caused by incorrect or poorly applied treatment	Includes incompetence and poor fit
5. Treatment Non-Response (TNR)	No clinical improvement despite the treatment	Often unrecognized; can contribute to dropout or hopelessness
6. Deterioration of Illness (DOI)	Worsening of symptoms during or after treatment	Can occur naturally or be treatment-induced; high clinical relevance
7. Therapeutic Risk (TR)	Known ATRs that patients must be informed about	Informed consent must include TR to support autonomy
8. Contraindications	Patient-specific conditions increasing the risk of severe ATRs	The ethical obligation to screen and adapt therapy accordingly
9. Boundary Violation Reaction (BVR)	Reactions emerged due to boundary violation	Both sexual and non-sexual boundary violations, causing mental agony

Adverse treatment reactions may arise from therapy or the actions of therapists; however, not all adverse effects can be directly attributed to therapists. UEs, such as concurrent life crises, may not originate from therapy but can exacerbate distress or perceived inefficacy, potentially worsening mental health without being therapy-driven. Classifying these effects is challenging due to the subjective nature of psychological experiences. Unlike pharmacotherapy, the impact of psychotherapy extends beyond symptom flare-ups to family, social, occupational, and behavioral domains, blurring the lines between treatment harm, illness progression, and external stressors.[23] Therapist actions often complicate accountability during disease progression or life events, with unclear definitions and no unified classification system.[16] Previous studies have inconsistently reported AEs and assessment methods.[24] While tools such as the Positive and Negative Effects of Psychotherapy Scale (PANEPS) aim to address this issue, their application remains limited.[20] The lack of consensus has impeded robust harm monitoring.[25]

Side effects are causally linked to the severity of the illness, the emotional impact of therapy, and patient characteristics such as interpersonal difficulties.[26] Adverse effects often result from the improper application of therapeutic techniques, the choice of inappropriate therapy, unstable therapeutic alliances, malpractice, and unethical practices.[26,27] Negative effects frequently arise from inflexible therapists, breakdowns in the therapeutic alliance, and unmet client expectations, with a perceived loss of control over treatment being a significant factor.[28] Additionally, compassion fatigue, unresolved conflicts, and therapists’ past traumas play crucial yet frequently overlooked roles in modern psychotherapy. Historically, these issues were addressed by therapists under the guidance of a senior professional, a practice that has largely diminished in the current era.

Prevalence of side, adverse, and negative effects

Determining the prevalence of side effects, adverse effects, and negative effects presents challenges due to the ambiguity in defining these terms, as researchers often use them interchangeably [Table 1]. Reported rates of negative effects vary significantly, ranging from 5.2% to 95.6% of clients, contingent upon the context and definition employed.[17] Systematic reviews have identified underreporting of negative effects, with only 30% of 1,430 psychotherapy studies acknowledging negative outcomes, and merely 57 studies actively monitoring them.[29] This underreporting is attributed to inconsistent definitions, lack of standardized reporting protocols, and reliance on voluntary reporting by therapists or patients, who may underreport due to stigma or lack of awareness.[24] Side effects impact 33%–41% of clients, with young adults being disproportionately affected.[19] Negative events were observed in 52.6% of patients with depression,[20] whereas broader negative effects, such as unmet expectations or stigmatization, affected up to 95.6% of outpatients.[30] Common issues include emotional distress (30.3%), symptom exacerbation (9%), and unpleasant memories (57.8%), although underreporting remains prevalent; only 21% of trials report harm data, and only 3% detail the method.[31] Vulnerable populations, such as ethnic/sexual minorities and individuals with severe baseline symptoms (e.g., anxiety and chronic pain), are at heightened risk.[32] Meta-analyses estimate the prevalence of adverse effects to range between 5% and 10%.[22,33] Typical issues include misunderstood treatment goals, stigmatization, and dependency concerns, affecting patients in the Cognitive Behavioral Analysis System of Psychotherapy.[34] Severe AEs include malpractice, with 2.6% of inpatients reporting sexual harassment and 34% reporting premature termination due to AEs.[35] The risks associated with these interventions vary. Cognitive behavioral therapy and humanistic approaches generally exhibit fewer negative effects than psychoanalysis.[36] In CBT, 43% of patients reported side effects, such as distress (27%) and symptom worsening (9%), with inpatients (37.3%) being more affected than outpatients (15.2%).[27] Group psychotherapy presents higher risks, with AEs occurring in 60%–65% of inpatients; CBT-based groups reported 41.9% compared to 28.9% in recreational groups.[37] Digital CBT for adolescent chronic pain elicited negative reactions in 9% of users, particularly in those with high baseline anxiety.[38] Trauma-focused CBT, however, demonstrated lower AE rates (0%–5%) than non-trauma therapies.[33] Substance use interventions are associated with 7%–15% iatrogenic harm, linked to younger age and severe substance use.[39]

Expecting negative effects of psychotherapy

Adverse effects of psychotherapy may arise during the therapeutic process. Clients might experience heightened emotional distress, including anxiety, sadness, and vulnerability, as well as therapeutic discomfort when confronting challenging issues. Exposure therapy can temporarily increase anxiety levels. Trauma survivors are particularly susceptible to re-experiencing their symptoms. During mid-therapy, individuals may encounter emotional exhaustion due to intensive emotional work and potential therapeutic dependence, coupled with frustration over perceived slow progress. The termination phase can induce separation anxiety or grief, and some individuals may experience temporary symptom exacerbations or emotional instability, particularly a fear of abandonment. Vulnerable populations, such as those with personality disorders, may exhibit intense emotional reactions, including anger and impulsivity, in response to perceived rejection or boundary setting. Boundary violations invariably lead to negative outcomes.

Negative outcomes in psychotherapy result from the intricate interaction of patient vulnerabilities, therapist practices, treatment methodologies, and external influences. Key mechanisms include therapy-induced UEs and treatment-emergent reactions, which may arise from poorly matched interventions, malpractice, inherent therapy risks, contraindications, dropout or non-response, countertransference, client fragility and unrealistic expectations, excessive focus on pathology, resistance, external life events, symptom exacerbation, cultural insensitivity, therapist incompetence, and group dynamics.[40,41,42] These mechanisms are aligned with broader determinants and are categorized as follows:

1. Therapist Factors: Misdiagnoses, cultural insensitivity, or inflexible approaches (e.g., confrontational role-playing) adversely affected 45.2% of patients.[28,41] Training deficiencies, as observed in Gestalt therapy, are associated with higher deterioration rates, and deficits in empathy or skills increase the risk.[28]

2. Patient Factors: Elevated baseline anxiety, depression, and pain increase risk. Trauma survivors and traits such as low self-reflection or alexithymia are more likely to experience negative outcomes.[40]

3. Patient–Therapist Mismatch: This occurs when a therapist’s skills, therapeutic approach, or cultural competence do not align with the patient’s needs, preferences, or clinical presentation. For instance, a patient with trauma-related symptoms may disengage from a therapist employing confrontational techniques unsuitable for trauma processing. Mismatches can lead to disengagement, dropout, or symptom exacerbation, with studies indicating that poor fit contributes to 20%–30% of therapy terminations.[41,43] Factors include mismatched therapy modalities (e.g., CBT for a patient preferring psychodynamic therapy), cultural insensitivity (e.g., ignoring ethnic values), and inadequate therapist training for specific disorders (e.g., personality disorders). A poor fit between patient needs and therapist skills or services leads to disengagement.[40,41]

4. Therapeutic Alliance: Weak bonds, particularly in adolescent therapy, contribute to dropouts.[44] Unresolved ruptures due to poor communication or empathy exacerbate symptoms, with 34% of inpatients prematurely discontinuing group therapy.[35] Power imbalances or inadequate feedback increase distress.[45]

5. Treatment Processes: Inappropriate interventions or lack of monitoring can provoke emotional reactions and symptom decline.[16,24] Internet therapies, such as ABM+iCBT, have adverse effects, and behavioral interventions for adolescents may increase the thinness drive in females.[43] Premature trauma exposure risks re-traumatization, and culturally invalid methods harm minorities.[46,47]

6. Service Delivery Framework: Limited information provided to patients regarding services and processes, coupled with restricted patient engagement in therapy (such as expressing concerns, preferences, or feedback), may exacerbate their experiences.[41] Furthermore, inconsistent and inadequate monitoring of AEs leaves potential harm unaddressed.[48]

7. External Factors: Life events and symptom worsening influence outcomes, with inpatients reporting more side effects (e.g., family strain) than outpatients.[27] Negative events vary in severity and impact physical, psychological, and social well-being. The extent of harm depends on the intensity, duration, and impact of treatment adjustments.

THE LIMITATIONS OF SAFETY DATA ON ADVERSE EVENTS IN PSYCHOTHERAPY

The availability of safety data on AEs in psychotherapy is constrained by widespread underreporting and inconsistent methodologies. Incomplete data results in selection bias and skewed outcomes, which subsequently lead to suboptimal results and impede risk evaluation.[49] The field faces challenges arising from inconsistent definitions and reporting of AEs. A systematic review found that only 60% of psychotherapy trials explicitly reported harm, with considerable variation in methodologies.[24] Another review of trials involving behavioral, lifestyle, and psychological therapies revealed that 63% mentioned documenting AEs, while 59% noted serious AEs.[50] However, trials supported by organizations such as the National Institute for Health Research often omit AE reporting.[51] Monitoring is less common in studies involving children and adolescents than in those involving adults.[52] Frameworks adapted from pharmacotherapy trials fail to capture the nuances of psychological treatments, exacerbating inconsistencies.[53] The safety of therapy extends beyond the clinical setting. A strong therapeutic alliance enhances patient security.[54] However, societal factors such as disparities in policing disproportionately affect marginalized groups, necessitating ethically grounded safety measures. The assumption that psychotherapy is inherently safer than pharmacotherapy for depression and anxiety is being questioned, prompting a comprehensive reassessment of the risk-benefit balance.[55] Currently, there is no universal mechanism for reporting the negative effects of psychotherapy. Clinical trials may use tools such as UE-ATR or INEP; however, routine practice often lacks structured reporting systems. Patients may report harm to therapists or ethics boards, but underreporting persists due to power imbalances or fear of stigma.[32]

TOOLS FOR ASSESSING SIDE EFFECTS, ADVERSE EFFECTS, AND NEGATIVE EFFECTS IN PSYCHOTHERAPY

A comprehensive understanding of the domains associated with negative events is essential for an effective psychotherapy assessment [Table 2]. These domainsencompass stigma, therapeutic misconduct, symptom deterioration or emergence, therapy quality, therapeutic relationship (e.g., dependency and idealization), treatment expectations, response to therapy, intrapersonal changes, life strains (e.g., work, family, and relationships), desired effects, therapy setting, interactions with other patients, overall experience, hopelessness, patient well-being, noncompliance, and treatment prolongation.[17] As no single tool addresses all these domains, multiple instruments are often necessary for a thorough evaluation [Table 3]. The adverse effects of psychotherapy can range from mild to severe, impacting physical, emotional, and social functioning. The severity and duration of these effects determine the extent of harm and influence the required treatment adjustments.[56] Establishing standardized definitions for AEs, including side effects, malpractice, and unethical conduct, is crucial.[57]

Table 2.

On negative impact of psychotherapy on various domains

	Domain	CBT	Psychoanalysis/Psychodynamic	Humanistic/Existential	DBT/ACT	Systemic/Family Therapy	Exposure-based therapies (ERP, PE)
1.	Stigma	May reinforce “problem-focused” labels	Long treatment may increase the perceived severity	Often de-emphasizes pathology, less stigma	Moderate; mindfulness may reduce stigma	Stigma from family blame	It can feel stigmatizing due to the direct confrontation of fears
2.	Therapeutic misconduct	Rare, but protocol misuse can feel invalidating	Power imbalance; blurred boundaries risk	Risk of inappropriate self-disclosure	Less likely, structured	Inadvertent coercion of family members	Risk of pushing too fast without consent
3.	Deterioration/symptom emergence	May worsen due to confronting thoughts	Uncovering trauma may worsen symptoms	Idealization may delay insight, trigger disillusionment	Emotional dysregulation may initially increase	Interpersonal conflict may increase at first	Symptom spikes common before improvement
4.	Quality of therapy	High variance across therapists	Depending on the therapist’s insight, fit	Risk of superficial work or boundary confusion	Protocol rigidness may not fit all	Variable based on family dynamics	Therapist skill critical; poor delivery=harm
5.	Therapeutic relationship	Risk of being overly “technique-driven”	Risk of dependency/transference complications	High empathy; risk of idealization	Skillful therapists foster alliance	Potential triangulation/scapegoating	May strain alliance due to distress intensity
6.	Expectations toward therapy	Can create “quick-fix” expectations	May expect deep life changes over the long term	Overestimation of change through “to being heard”	Unrealistic hope for emotional regulation	Expectations may clash among members	May expect full fear removal—unrealistic
7.	Treatment response	Moderate to strong, but 10% worsen	Slower; not for acute crises	Mixed; may not address core symptoms	Effective, but the dropout risk is high	Often depends on buy-in from all members	Effective; high distress may cause dropout
8.	Intrapersonal changes	Can over-intellectualize; emotions not always processed	Insight without behavioral change	Encourages self-exploration; may evoke confusion	Identity shifts may cause instability	Shifts in roles may cause internal conflict	Increased emotional flooding at first
9.	Strains in life areas	Changes in cognition may lead to interpersonal conflict	Disruption from re-examining past	Self-focus may affect external relationships	Assertiveness may cause pushback	Restructuring dynamics may increase short-term conflict	Fear activation may cause avoidance of social/pro-work
10.	Wanted effects (benefit)	Often achieved but not sustained without homework	Insightful gains may not translate into behavior	Supportive; but not symptom-specific	Effective if retained; risk if misunderstood	System change is hard to maintain	Achieved through persistence; dropout risk
11.	Therapy setting	Often rigid, office-based	Traditional settings may feel intimidating	Flexible but sometimes less structured	Standardized; can be perceived as clinical	It may involve multiple settings (home, clinic)	In-clinic only; limited for remote clients
12.	Relationship to other patients	Usually 1:1, no effect	Same as CBT	Group formats rare	Group DBT may create peer dependency	Sibling dynamics or alliances may form	Group settings may provoke comparison, shame
13.	Global experience	Can feel manualized or dry if misapplied	Deep but slow; frustration common	Often affirming but lacking structure	Empowering but overwhelming	Dynamic; can be chaotic	Emotionally taxing but often transformative
14.	Hopelessness	If tools fail, may blame self	Long delays in progress may lead to demoralization	Feeling “unfixed” despite empathy may lead to despair	Failure to regulate may lead to shame	Family resistance may leave the client hopeless	Failed exposures can feel like defeat
15.	Patient well-being	Can improve greatly or worsen with rigid delivery	Risk of old trauma resurfaces without support	Initially supportive, but lack of direction can frustrate	Self-awareness may increase distress	Conflict exposure may increase stress	Anxiety may spike before improvement
16.	Noncompliance to treatment	Homework non-adherence is common	Dropout due to time/financial demands	Inconsistent attendance due to low structure	High dropout if distress is high	Family resistance common	Avoidance of tasks common
17.	Prolongation of treatment	Protocols are short, but extensions are common	Treatment may last years	Ongoing, if not goal-directed	Long-term possible in chronic cases	Repeat sessions if patterns persist	It may require long exposure to see gains

Table 3.

On various scales to measure side-effects

Tool	Merits	Demerits/Limitations	Best Suited For	Less Suited/Contraindicated
1. Vanderbilt Negative Indicators Scale (VNIS)	Structured identification of negative therapeutic indicators during sessions; focuses on process-related red flags	Outdated (developed in 1970s); lacks psychometric standardization; clinician-rated only	Clinician supervision; early detection of countertherapeutic processes	Research requiring client self-report; precision evaluation of side effects
2. Unwanted Effects–Adverse Treatment Reaction Checklist (UE-ATR)	Differentiates between unwanted effects and adverse reactions; good face validity	Limited empirical validation; lacks subscale differentiation; may conflate therapist error with inherent effects	Routine clinical monitoring, therapist reflection	Longitudinal outcomes; structured research studies
3. Inventory for the Assessment of Negative Effects of Psychotherapy (INEP)	Covers ethical violations, dependency, stigmatization; strong psychometric support; retrospective format	Requires recall after therapy ends; potential recall bias	Post-therapy research, therapist training audits	Real-time adverse event monitoring; brief clinical screening
4. Experiences of Therapy Questionnaire (ETQ)	Captures patient-perceived harmful therapist behaviors; includes six dimensions (e.g., criticism, exploitation)	May conflate discomfort with harm; lacks detailed adverse effect classification	Identifying therapist-related misconduct or rupture	Measuring symptom-based adverse reactions or side effects
5. Negative Effects Questionnaire (NEQ)	Well-validated; separates symptom deterioration, stigma, and dependency; includes attribution of harm	Subject to social desirability bias; self-report only	Clinical trials, psychotherapy outcome research	Use in populations with severe cognitive deficits or low insight
6. UE-G (Group-specific UE–ATR)	Tailored for group therapy; distinguishes social/interpersonal harms	Limited generalizability to individual therapy; relatively newer tool with less widespread use	Group psychotherapy settings; interpersonal harm analysis	Individual therapy assessment; generalized side effect tracking
7. Side Effects of Psychotherapy Scale (SEPS)	Provides gradation of side effects from mild to severe; addresses intensity and frequency	Still under development in some regions; less common in practice	Real-time adverse effect screening; symptom tracking	Ethical or boundary violation detection
8. Exploitation Index (EI)	Focused specifically on unethical therapist behavior (e.g., boundary violations, financial abuse)	Very narrow scope; not designed for general side effect screening	Ethics boards, supervision, training in misconduct awareness	Broad psychotherapy outcome or effectiveness research
9. Positive and Negative Effects of Psychotherapy Scale (PANEPS)	Captures both benefits and harms; dual valence scoring promotes a balanced view	Relatively limited validation; less known in clinical use	Program evaluation, client feedback in routine care	Detailed adverse event classification or attribution studies

Mixed-method tools, which incorporate both self- and observer-rated assessments, provide a comprehensive perspective, while mobile applications and telehealth facilitate real-time monitoring.[48] Context-specific tools, such as those for COVID-19, and longitudinal studies, such as those focusing on dependency or stigma, are essential for tracking post-treatment effects.

A systematic review identified nine assessment tools for evaluating the side effects, AEs, and negative effects of psychotherapy, each with distinct domains and psychometric properties, yet revealed a lack of consensus.[58]

1. The Vanderbilt Negative Indicators Scale (VNIS) is a 42-item instrument[59] designed to assess patient-therapist interactions, unrealistic expectations, poor commitment, rigid techniques, and relationship issues. It does not address psychiatric symptoms, positive outcomes, and external stressors, and its psychometric data and scope are limited.

2. The Exploitation Index (EI), a 32-item tool, identifies boundary violations through therapist behaviors and patient experiences, excluding general negative effects, efficacy, and patient factors.[60]

3. The Unwanted Effects–Adverse Treatment Reaction Checklist (UE-ATR) is a 16-item tool that evaluates new symptoms, symptom worsening, lack of progress, treatment prolongation, noncompliance, therapy dependency, and life strain.[16] It does not consider therapist behaviors, patient satisfaction, and cultural factors and is time-intensive.

4. The Inventory for the Assessment of Negative Effects of Psychotherapy (INEP) is a 21-item scale that measures intrapersonal changes, stigma, relationships, emotional well-being, work performance, and malpractice, offering strong reliability.[61]

5. The Experiences of Therapy Questionnaire (ETQ) is a 63-item tool that assesses negative therapist behaviors, therapy preoccupation, idealization, passivity, and benefits of therapy.[62]

6. The Negative Effects Questionnaire (NEQ), developed by Rozental et al. (2019),[63] targets symptom increase, quality issues, dependency, stigma, and hopelessness and is particularly suited for internet-based therapies, although it omits misconduct and temporal factors.

7. Unwanted Events and Adverse Treatment Reactions in Group Psychotherapy (UE-G) is a 46-item tool for group settings, covering symptoms, treatment progress, dependency, and life changes.[64]

8. The Side Effects of Psychotherapy Scale (SEPS) is a 147-item scale that assesses negative emotions, dependency, stigma, symptom changes, and interpersonal conflicts with robust psychometric properties but excludes malpractice and external events.[65]

9. The Positive and Negative Effects of Psychotherapy Scale (PANEPS) is a 43-item tool that evaluates both benefits (e.g., symptom relief and growth) and harm (e.g., side effects and malpractice), providing a balanced perspective.[20]

Psychometrically, the INEP, NEQ, and PANEPS demonstrate good validity and consistency, whereas the UE-ATR functions as a checklist without formal evaluation. Administration varies: VNIS, UE-ATR, and EI are therapist-rated; INEP, ETQ, NEQ, SEPS, and PANEPS are patient-rated; and UE-G is specific to group settings. There is domain overlap (e.g., misconduct and symptom worsening); however, each tool has distinct strengths: INEP excels in intrapersonal changes, NEQ in dependency, PANEPS in misconduct, and SEPS in emotional distress. Despite their strengths, these tools often fail to capture nuanced domains such as cultural stigma, long-term dependency, and subtle therapist misconduct due to their limited scope or reliance on self-reporting.[17]

Ethical and clinical implications of negative outcomes in psychotherapy

The ethical and clinical implications of negative outcomes in psychotherapy present significant challenges that necessitate a careful balance between efficacy and safety. Ethically, informed consent is often inadequate; 45.2% of patients in therapies such as the Cognitive Behavioral Analysis System of Psychotherapy (CBASP) express concerns about dependency, which is associated with weak therapeutic alliances, cultural insensitivity, and therapist rigidity.[28] Ethical breaches, including boundary violations and sexual harassment, result from therapist actions rather than the therapeutic process itself, yet their occurrence in psychotherapy underscores the need for robust ethical oversight.[60] Many therapists fail to discuss potential risks, thereby undermining patient autonomy and beneficence, often due to fear of increasing patient anxiety and their own lack of knowledge.[66] Clinically, misinterpreting resistance as a drug related instead of a therapeutic mismatch requires nuanced judgment to uphold care standards.[45]

Research indicates a higher incidence of early dropout in less-structured therapeutic modalities, such as Gestalt therapy. However, this may be attributed to specific variables related to individual therapists or clients rather than the therapeutic modality itself.[67] Long-term consequences include persistent distress, strained interpersonal relationships, and stigma.[68] Patients frequently feel disempowered by inflexible or culturally insensitive therapeutic approaches, with 2.6% reporting severe malpractice, including sexual harassment.[28] Risks arise from patient-related factors, such as severe mental illness and alexithymia, and therapist-related issues, including countertransference and a lack of empathy. Specific therapeutic modalities present distinct hazards, as evidenced by the 16.5% adverse effect rate in internet-based therapies for social anxiety and harm associated with confrontational methods.[69]

STRATEGIES TO MITIGATE AND PREVENT NEGATIVE EFFECTS IN PSYCHOTHERAPY

While psychotherapy is generally effective, it can occasionally lead to negative effects, such as emotional distress and a perceived loss of control over treatment decisions.[19,63,65] Implementing comprehensive strategies is essential to ensure client safety, enhance outcomes, and minimize harm [Table 4]. Presented below are evidence basedapproaches to mitigate and prevent adverse effects by integrating pre-therapy preparation, ongoing monitoring, therapist training, and systemic adjustments. Implementing comprehensive strategies is essential to ensure client safety, enhance outcomes, and minimize harm. Presented below are evidence-based approaches to mitigate and prevent adverse effects by integrating pre-therapy preparation, ongoing monitoring, therapist training, and systemic adjustments.

Table 4.

On strategies to mitigate the negative effects of psychotherapy

	Negative Event	Mitigation Strategy	Scientific/Clinical Basis
1.	Stigma	Normalize therapy, use strength-based language, and incorporate psychoeducation	Reduces internalized stigma; enhances treatment engagement (Corrigan, 2004)[75]
2.	Therapeutic misconduct	Ongoing ethics training, supervision, informed consent, and client feedback tools	Prevents boundary violations; builds accountability (ACA Code of Ethics, 2014)[76]
3.	Deterioration/Symptom Emergence	Routine outcome monitoring (ROM), crisis planning, pacing exposure-based work	Early detection and adjustment reduce dropout and harm (Lambert, 2013)[71]
4.	Quality of therapy	Use evidence-based modalities, assess therapist competence, and include client-rated alliance measures	Therapist quality is one of the strongest predictors of outcome (Wampold, 2015)[77]
5.	Therapeutic relationship	Gathering feedback at the end of each psychotherapy session is crucial and also maintain boundaries	A strong alliance mitigates risks such as dependency and dropout (Safran & Muran, 2000)[78]
6.	Expectations toward therapy	Discuss realistic goals and limitations in early sessions	Prevents disappointment and disengagement (Swift et al., 2011)[79]
7.	Treatment response	Use measurement-based care, adjust modalities based on progress, and consider pharmacotherapy when indicated	Personalized adjustments improve response rates (Trivedi et al., 2006)[80]
8.	Intrapersonal changes	Prepare clients for identity shifts, enhance emotional regulation skills	Sudden self-concept changes can destabilize clients without support (Hayes et al., 2007)[81]
9.	Strains in life areas	Include systemic/contextual work, involve family/support when appropriate	Reduces isolation and external conflicts arising from internal changes (Nichols, 2012)[82]
10.	Wanted effects (benefit)	Align goals with client values, revisit progress often, and use client-defined outcomes	Enhances motivation and perceived value of therapy (Norcross, 2011)[14]
11.	Therapy setting	Create a safe, accessible, and private environment; offer hybrid/telehealth options	Environment impacts safety perception and willingness to engage (Norcross, 2011)[14]
12.	Relationship to other patients	Screen for group readiness, establish norms, and monitor peer dynamics in group therapy	Prevents retraumatization and conflict (Yalom & Leszcz, 2020)[83]
13.	Global experience	Invite meta-feedback about the therapy process and impact, and validate mixed feelings	Improves satisfaction and helps address micro-ruptures (Hill et al., 1996)[84]
14.	Hopelessness	Use strength-based approaches, track and reflect micro-improvements	Counteracts despair and reinforces self-efficacy (Beck et al., 2024)[85]
15.	Patient well-being	Holistic case conceptualization integrates wellness and coping outside sessions	Promotes general life functioning, not just symptom relief (APA, 2018)[86]
16.	Noncompliance to treatment	Collaboratively tailor interventions, explore ambivalence, and address barriers	Enhances adherence through motivational interviewing and flexibility (Galvani, 2021)[87]
17	Prolongation of treatment	Use time-limited approaches when indicated, and define clear goals and milestones	Reduces dependency and maintains focus (Budman & Gurman, 2022)[88]

Pre-Therapy Preparation: Conducting a thorough pre-therapy assessment of the client’s psychological, physical, and social history is instrumental in identifying vulnerabilities, thereby allowing for tailored interventions.[41] Informed consent, which clearly outlines potential challenges such as temporary symptom worsening and emotional discomfort, sets realistic expectations without causing nocebo effects.[27] Collaborative goal setting empowers clients, reduces feelings of disempowerment, and fosters trust.[41]

Ongoing Monitoring and Feedback: Regular client feedback at the conclusion of sessions, combined with standardized tools such as the Unwanted Event to Adverse Treatment Reaction (UE-ATR) checklist, INEP,[16] and PSES, facilitates the early detection of adverse reactions.[70] Routine outcome monitoring (ROM) using tools such as the UE-ATR checklist or PANEPS enables the early identification of adverse reactions, such as symptom exacerbation or alliance ruptures, allowing therapists to promptly adjust interventions.[71] Studies indicate that ROM can reduce deterioration rates by up to 15% in outpatient settings.[58] Periodic harm-benefit reviews, as proposed by Klatte et al. (2023),[48] enhance transparency and accountability. Implementing mandatory AE reporting systems, akin to those in pharmacotherapy, could address underreporting by standardizing data collection across clinical settings.[24]

Therapist Competencies and Training: Therapists’ empathy and sensitivity are crucial in building trust and minimizing harm, particularly for vulnerable clients.[72] Training in metacommunication aids in repairing alliance ruptures, while regular clinical supervision addresses countertransference and refines judgment.[73] Ongoing skill development through continuing education ensures that therapists remain updated on best practices and safety protocols.[50] Strict adherence to ethical boundaries, avoidance of dual relationships, and management of countertransference further safeguard clients.[73]

Systemic and Client-Centered Adjustments: Aligning therapy with client needs, such as cultural preferences or trauma history, prevents mismatches and reduces dropout rates.[41] Culturally tailored interventions, such as adapting therapy to align with clients’ ethnic, linguistic, and social values, reduce negative events by minimizing cultural insensitivity and miscommunication, which can lead to disengagement or distress.[41] Adjusting session frequency and ensuring timely referrals to specialized care for severe reactions, such as suicidal ideation, can mitigate risks.[74] Structured AE reporting enhances systemic accountability.[48] By integrating comprehensive assessments, regular monitoring, therapist training, and client-centered systemic adjustments, psychotherapy can balance its efficacy and safety. These strategies empower clients, reduce adverse outcomes, uphold ethical care, and ensure equitable and effective treatment.[25,41]

CONCLUSIONS

Psychotherapy, while demonstrably effective across a range of mental health conditions, is not devoid of risks. A significant proportion of clients experience negative effects, including emotional distress, symptom exacerbation, and therapist-related harm, which are often underrecognized and underreported. These effects are influenced by complex interactions among patient characteristics, therapist competencies, the quality of the therapeutic alliance, and systemic factors. Current research is impeded by definitional inconsistencies, inadequate methodological frameworks, and limited use of standardized assessment tools. Despite the ethical imperatives of transparency and safety, adverse outcomes remain insufficiently addressed in routine clinical practice and research protocols. There is an urgent need to establish clear taxonomies of negative events, implement robust monitoring systems, and integrate safety measures into psychotherapeutic training and service delivery. Enhancing clinician awareness, improving informed consent procedures, and tailoring interventions to individual and cultural needs are essential to reduce harm and ensure ethical, patient-centered care.

Authors’ contributions

All the authors have equal contributions.

Data availability statement

The data generated and analyzed in this study are available upon reasonable request from the corresponding author.

Ethical statement

In accordance with established research ethics guidelines for secondary data analysis, this study does not require formal ethical approval from an Institutional Review Board or ethics committee.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.