Thanks for your effort in documenting this information. I think it's especially important for therapists to realize that an intervention can cause harm and consider that if a client is getting worse or complains about increased symptoms. I recall being in an introductory class on CBT taught by Dr. Christine Padesky when I was in training. She said if a client did not do well with an intervention it was most likely not "resistance" which I had been taught by my psychoanalytic teachers. She said the reasons needed to be explored and could be things like the wrong intervention, the client misunderstood the intervention, the intervention would help but at a later point in treatment, ...
Was impressed that a couple of references came from an Australian Journal... I'm trying to think how anj adverse effects study would be done that correlates with the way side effects are reported in med studies... Do think that the illusion of therapy as an absolute good is misguided. Would it be difficult to tease out a counter therapeutic effect (made the original condition worse) from an adverse effect? I'm hinking that gets classed as an adverse effect/side effect? I suspect that one of the weaknesses of a RCT design... That if a treatment alleviates X (target condition) more than it causes X, it'll come out as alleviating X in the analysis, even if it did cause some cases of X. And that as the targets of therapy often includes a broad range of psychological functioning, there's often not much leftover to rank as a side effect, rather than getting subsumed by the treatment effect...
Mind you the long term efficacy of manualised therapies is often woeful, so if that was when adverse effects were assessed, they may be more likely to show up.
Not sure if I'm making sense or if my logic is reasonable
Great article! I too was impressed to find Gerd Rudolf and Bernhard Strauß among the sources! Hopefully I found another German Psychotherapist here! I do agree with the main message of the article and found your take on Karen Horney particularly interesting:
You wrote Karen Horney questioned Freud’s view on the negative therapeutic reaction resulting from unconscious guilt. She argued that it often reflects injured pride—the patient’s feeling of “humiliation” when interpretations are “perceived not as help but as an attack”. My intention to comment was to first agree with Horney as shame has a more malignant quality - withdrawal, devaluation, lying etc. But the more I think about it, the more I doubt it. We all want find that one superb answer, but the true answer does lie in the core of our profession. We are unique and therapists ought to find out what is the particular reason for these effects in this particular patient. Adverse effects might be found in different areas, but I think three processes - if not worked through - are crucial for the development:
1. Transference Resistance, when the patients treats us the same way they were treated.
2. Transference Neurosis, when we enact a relationship with the patient similar to an important past figure. We treat the patient the same way they were treated
3. Projective Anxiety: Where patients project aggressive impulses, guilt or will onto us and want to withdraw
Thank you for your kind comment! You may or may not have correctly deduced that I work and live in a German-speaking country. ;-) Welcome here, too! I look forward to seeing how successful you can be writing about psychotherapy in German on that platform. Good luck!
I have some questions about your position. First, I'm not sure if Horney is right, but I agree that shame is a powerful emotion, and we unconsciously make great efforts to avoid changing our self-image (the principle of homeostasis).
I'm also not sure whether I agree that we all want to find one superb answer, whether such an answer exists, or whether it lies at the core of our profession. As therapists, I think we tend to overestimate our own intelligence and importance.
I'm not a psychodynamic therapist, so I don't use the exact wording of your points 1–3, but I think those effects are important to acknowledge in mental disorders or problems with a significant interpersonal component. However, I wouldn't call them immune to adverse effects or omnipresent and important in every therapy.
Just like other human beings, we tend to overestimate our intelligence and importance. You are absolutely right! I am quite surprised that you are not a psychodynamic therapist—Freud, the unconscious, Gerd Rudolf… I might even have deduced that you are a psychoanalyst.
I think my last point may have been lost in translation. I believe there are many reasons for adverse effects in psychotherapy. However, these three—at least for me—are the most crucial ones, because they tend to amplify shame, guilt, rage, and anxiety in direct contact with the therapist. This can be a great opportunity for change on the one hand, but if not handled well, it can also become a pitfall.
Thank you for this piece, the algorithm Gods are working with me.
It has somehow articulated the issues I’m experiencing with the BACP, and now I have references for the concerns I knew I had - and some I didn’t know I had. . .
Yup. When a human wants to edit the first word in a comment - it is approximately 2mm from the send button 🤣
I ranted for so long that I bored myself. I’d say I tick two or three of the unintended consequences of extended therapy. . .
I’ve recently reviewed the BACP Public Protection Committee’s report, the latest is from 2023. Complaints doubled, and despite assurances in that document, the complaints process seems to have collapsed.
In the study conducted by my friend and colleague, the psychologist Ľuboš Chvála, the negative experiences with psychotherapy are highlighted in a patient who underwent psychotherapeutic treatment for 15 years. He encountered major difficulties getting the work published, as it was repeatedly rejected. As he told me in private communication, journal editors were concerned that it might cast an excessively negative light on psychotherapy, and these journals did not want to contribute to its discreditation. Here is a study of my friend: https://ceskoslovenskapsychologie.cz/index.php/csps/article/view/279
Thanks for your effort in documenting this information. I think it's especially important for therapists to realize that an intervention can cause harm and consider that if a client is getting worse or complains about increased symptoms. I recall being in an introductory class on CBT taught by Dr. Christine Padesky when I was in training. She said if a client did not do well with an intervention it was most likely not "resistance" which I had been taught by my psychoanalytic teachers. She said the reasons needed to be explored and could be things like the wrong intervention, the client misunderstood the intervention, the intervention would help but at a later point in treatment, ...
Was impressed that a couple of references came from an Australian Journal... I'm trying to think how anj adverse effects study would be done that correlates with the way side effects are reported in med studies... Do think that the illusion of therapy as an absolute good is misguided. Would it be difficult to tease out a counter therapeutic effect (made the original condition worse) from an adverse effect? I'm hinking that gets classed as an adverse effect/side effect? I suspect that one of the weaknesses of a RCT design... That if a treatment alleviates X (target condition) more than it causes X, it'll come out as alleviating X in the analysis, even if it did cause some cases of X. And that as the targets of therapy often includes a broad range of psychological functioning, there's often not much leftover to rank as a side effect, rather than getting subsumed by the treatment effect...
Mind you the long term efficacy of manualised therapies is often woeful, so if that was when adverse effects were assessed, they may be more likely to show up.
Not sure if I'm making sense or if my logic is reasonable
Great article! I too was impressed to find Gerd Rudolf and Bernhard Strauß among the sources! Hopefully I found another German Psychotherapist here! I do agree with the main message of the article and found your take on Karen Horney particularly interesting:
You wrote Karen Horney questioned Freud’s view on the negative therapeutic reaction resulting from unconscious guilt. She argued that it often reflects injured pride—the patient’s feeling of “humiliation” when interpretations are “perceived not as help but as an attack”. My intention to comment was to first agree with Horney as shame has a more malignant quality - withdrawal, devaluation, lying etc. But the more I think about it, the more I doubt it. We all want find that one superb answer, but the true answer does lie in the core of our profession. We are unique and therapists ought to find out what is the particular reason for these effects in this particular patient. Adverse effects might be found in different areas, but I think three processes - if not worked through - are crucial for the development:
1. Transference Resistance, when the patients treats us the same way they were treated.
2. Transference Neurosis, when we enact a relationship with the patient similar to an important past figure. We treat the patient the same way they were treated
3. Projective Anxiety: Where patients project aggressive impulses, guilt or will onto us and want to withdraw
Best from Germany!
Dear Psychosomatiker,
Thank you for your kind comment! You may or may not have correctly deduced that I work and live in a German-speaking country. ;-) Welcome here, too! I look forward to seeing how successful you can be writing about psychotherapy in German on that platform. Good luck!
I have some questions about your position. First, I'm not sure if Horney is right, but I agree that shame is a powerful emotion, and we unconsciously make great efforts to avoid changing our self-image (the principle of homeostasis).
I'm also not sure whether I agree that we all want to find one superb answer, whether such an answer exists, or whether it lies at the core of our profession. As therapists, I think we tend to overestimate our own intelligence and importance.
I'm not a psychodynamic therapist, so I don't use the exact wording of your points 1–3, but I think those effects are important to acknowledge in mental disorders or problems with a significant interpersonal component. However, I wouldn't call them immune to adverse effects or omnipresent and important in every therapy.
What do you think?
Kind regards!
Just like other human beings, we tend to overestimate our intelligence and importance. You are absolutely right! I am quite surprised that you are not a psychodynamic therapist—Freud, the unconscious, Gerd Rudolf… I might even have deduced that you are a psychoanalyst.
I think my last point may have been lost in translation. I believe there are many reasons for adverse effects in psychotherapy. However, these three—at least for me—are the most crucial ones, because they tend to amplify shame, guilt, rage, and anxiety in direct contact with the therapist. This can be a great opportunity for change on the one hand, but if not handled well, it can also become a pitfall.
Thank you for this piece, the algorithm Gods are working with me.
It has somehow articulated the issues I’m experiencing with the BACP, and now I have references for the concerns I knew I had - and some I didn’t know I had. . .
Unfortunately, your comment is incomplete. The sentence stops in the middle.
Yup. When a human wants to edit the first word in a comment - it is approximately 2mm from the send button 🤣
I ranted for so long that I bored myself. I’d say I tick two or three of the unintended consequences of extended therapy. . .
I’ve recently reviewed the BACP Public Protection Committee’s report, the latest is from 2023. Complaints doubled, and despite assurances in that document, the complaints process seems to have collapsed.
But I’m off again . . .
In the study conducted by my friend and colleague, the psychologist Ľuboš Chvála, the negative experiences with psychotherapy are highlighted in a patient who underwent psychotherapeutic treatment for 15 years. He encountered major difficulties getting the work published, as it was repeatedly rejected. As he told me in private communication, journal editors were concerned that it might cast an excessively negative light on psychotherapy, and these journals did not want to contribute to its discreditation. Here is a study of my friend: https://ceskoslovenskapsychologie.cz/index.php/csps/article/view/279