Negative effects of psychotherapy: estimating the prevalence in a random national sample. Bernhard Strauss, Romina Gawlytta, Andrea Schleu and Dominique Frenzl. BJPsych Open, Volume 7, Issue 6, November 2021 , e186. https://doi.org/10.1192/bjo.2021.1025
Abstract
Background: Negative or adverse effects of psychological treatments are increasingly a focus of psychotherapy research. Yet, we still know little about the prevalence of these effects.
Aims: Starting from a representative national sample, the prevalence of negative effects and malpractice was determined in a subsample of individuals reporting psychotherapy currently or during the past 6 years.
Method: Out of an initial representative sample of 5562 individuals, 244 were determined to have had psychotherapy within the past 6 years. Besides answering questions related to treatment, its effects and the therapists, patients filled out the Negative Effects Questionnaire, items of the Inventory of Negative Effects of Psychotherapy reflecting malpractice and the Helping Alliance Questionnaire, and rated psychotherapeutic changes in different areas.
Results: Rates of positive changes related to therapy varied between 26.6% (relationship to parents) and 67.7% (improvement in depressed mood). Deteriorations were most commonly related to physical well-being (13.1%), ability to work (13.1%) and vitality (11.1%). Although patients generally reported a positive helping alliance, many of them reported high rates of negative effects (though not always linked to treatment). This was especially true of the experience of unpleasant memories (57.8%), unpleasant feelings (30.3%) and a lack of understanding of the treatment/therapist (19.3/18.4%). Indicators of malpractice were less common, with the exception that 16.8% felt violated by statements of their therapist.
Conclusions: This study helps to better estimate aspects of negative effects in psychotherapy ranging from deteriorations, specific effects and issues of malpractice that should be replicated and specified in future studies.
Discussion
Based upon the conclusion that our knowledge about negative effects of psychotherapy is still limited,1–6 one of the unmet needs is sufficient study of the type and quantity of negative effects of psychotherapy under naturalistic conditions. There are several approaches to reach the goal of acquiring more detailed data concerning negative effects. For example, Crawford5 approached psychotherapeutic services in England and Wales to survey patients receiving treatment within these services. Although this approach might result in a population close to being representative of psychotherapy patients in a specific health system, it would not be representative of the wider population.
Another approach would be to start by drawing a random sample from a national population and to filter those individuals who had received psychotherapeutic treatment in a certain time period. The latter approach was chosen in a study of Albani et al18–20 related to the German population. In contrast to our survey, that study focused on formal characteristics of psychotherapies, patients’ experiences with choosing and finding a therapist, and general figures related to the effectiveness of psychotherapy from the patients’ perspective. In their survey, Albani et al asked only a very small number of questions related to general opinions about the patients’ psychotherapists and did not explicitly focus on negative effects. The sampling method of the Albani et al study probably did not yield a sample representative of psychotherapy patients in Germany. On the other hand, by avoiding direct selection of these patients, the procedure likely resulted in an unbiased sample from which patient experiences could be derived.
So far, data related to the prevalence of psychotherapeutic change, change rates and the occurrence of negative effects are quite variable and do not allow aggregation owing to the different data sources and measures. To add data from a representative population, our study followed the model of Albani et al, selecting individuals from a random national sample of the German population and determining which had been treated with psychotherapy. This resulted in a sample of 244 individuals who were interviewed in detail – in contrast to Albani et al – with a focus on effectiveness, helping alliance and a description of negative effects.
In fact, the resulting sample had quite similar characteristics to those of the German population. The ratio of males to females appeared to be more balanced in our sample than in the Albani study and closer to the distribution of the national population. In a large clinical sample of German out-patients,30 the percentage of female patients was much higher than in Albani's study19,20 (77%), showing that the general population is different from the population using the psychotherapeutic system. Individuals in the under-45 age group were underrepresented whereas those of 45 to 65 years of age were overrepresented in our sample, compared with the general population. Compared with the national population, individuals in our sample had a higher educational level. This probably reflects selective mechanisms of patients’ access to the psychotherapeutic system.31
Of the initial sample, 7.44% indicated experiences with psychotherapy during the prior 6 years. Although there are no exact estimates of the proportion of individuals seeking psychotherapeutic treatment in Germany, there are some figures for this percentage that can be used to for comparison. Rommel et al32 reported that 11.3% of German females and 8.1% of males over 18 years of age sought psychotherapeutic or psychiatric help over the course of 1 year (Survey Health in Germany). A study of adult health in Germany33 reported that 5.3% of females and 3.2% of males between 18 and 79 years of age made use of psychotherapy in the public health system (i.e. attending licensed therapists with reimbursement of the costs by health insurance). Based on these comparative figures, we think that our sample reflects a realistic proportion of psychotherapy users.
Based on the data obtained in our interview study with the final sample of 244 (former) psychotherapy patients, we found a relatively positive evaluation of the therapeutic relationship using the HAQ,22 which was comparable to that found by other studies. The reports of our sample were generally positive regarding the quality of the working alliance and trust in the therapeutic relationship. At least 80% of all individuals agreed at least to some extent with the positive formulations of the HAQ.
On the other hand, there were some indicators of problems in the therapeutic relationship. One of the most prominent indicators was the report that at least 19% thought that the treatment would not help and ended their therapy prematurely. Also of relevance is the finding that in 24.2% of those cases, the end of treatment was a proposal of the therapist. Although we have no information on whether these were negotiated or unilateral decisions, this finding raises concerns about the lack of participatory decision-making about when to end therapy.
Although we did not use standardised scales that are commonly used to assess treatment outcomes, our data suggest that ‘direct measurements’ of different fields susceptible to psychotherapeutic change indicate improvement rates between 26.6% and 67.6%. The improvement rates of common outcomes (i.e. interactions with others, improvement in depressed mood, personal development), reported by more than 60% of the individuals, particularly demonstrate that the sample might be representative of psychotherapy patients, as similar rates are reported in the research literature.12
The improvement rates in our sample are also similar to those reported by Albani et al, with respect to both change rates and rates of deterioration as well as differences between single areas of change. However, the improvement rates in the Albani study (with a larger sample) were somewhat higher than those in our sample. For example, an improvement in depressed mood was reported by 67.6% of our sample and by 78.6% in the Albani study. The general evaluations of the treatments were also in line with those reported by Albani et al.
The primary focus of our study was an estimation of negative effects (or side-effects as negative effects paralleling correct treatment in the sense of Linden's classification3) of psychotherapies, with the NEQ as the core instrument. Twenty different negative effects could be attributed to the treatment or to other causes.
The survey results reported in our sample are comparable with those reported in different clinical samples with the NEQ; we found similar results to those of other studies using this method in different samples and psychotherapeutic settings. In a recent study, Rozental et al2 reported: ‘As for the rate of negative effects, the number of participants reporting negative effects in the current study was 50.9%, consistent with 58.7% among patients in a psychiatric setting who responded to the INEP’.34 However, this number varies significantly between investigations, with rates as high as 92.9% among patients with obsessive–compulsive disorder assessed with the Side-effects of Psychotherapy Scale in a study by Moritz et al,35 and as low as 5.2% in a national survey by Crawford et al5 probing for ‘lasting bad effects from the treatment’. Hence, different studies assess a range of negative effects, from transient ‘side-effects’ to lasting harm, making it difficult to compare ratios directly. Even within a subtype of negative effect, different methods of assessment will yield different results, so accurate estimates are not yet available.
Finally, since we had limited resources, we restricted our investigation of malpractice and boundary violations in psychotherapy in this study to only the six items of the INEP. These items form a subscale of the instrument mainly developed to cover side-effects of psychotherapeutic interventions. In general, in our sample, the rates of boundary violations were very low, even lower than one would have estimated from the specific studies in this field. For example, Becker-Fischer and Fischer36 reported rates of sexual boundary violations in psychotherapies that were much higher than 5%, whereas in our sample such violations occurred in three of the 244 cases (1.2%).
Strengths and limitations
The main strength of this study was clearly the sampling procedure, which started with a large (>5000) sample representative of the German population and then sought to find individuals disclosing experience with psychotherapy in the German health system, currently or during the past 6 years. We used some of the items from a former survey focusing on more general aspects of psychotherapy and added (parts of) instruments specifically developed to capture negative effects (NEQ) or malpractice (INEP). These additions have shown good psychometric qualities in this and other studies and allow comparisons with other studies or sampling procedures. Compared with other studies, e.g. the Crawford et al5 survey, we obtained much more detailed results on negative effects as opposed to global ‘lasting bad effects’.
Despite our best efforts, the final sample of 244 was rather small, although it was within the expected range for the use of psychotherapy in the population. Another limitation was the fact that 98 of the 244 participants were surveyed, on average, 2.63 years after completion of their psychotherapy. Of the 244, 139 had already completed their psychotherapy, among whom 98 provided the date of the end of therapy. Thus, the results may have been biased by recall effects. More specifically, there may have been a tendency to only remember adverse aspects of the treatment and neglect the positive ones, or to forget certain unwanted events that occurred several years ago. However, comparisons between those currently undergoing psychological treatment and those remembering their treatment retrospectively yielded only minor differences with respect to both general evaluations of psychotherapy and negative effects.
Moreover, as only 65% of eligible participants accepted the invitation to the interview, the results could be open to selection bias. For example, participants who were unhappy about their treatment might be more (or less) likely to respond to a study on the effects of psychotherapy or might exaggerate negative effects experienced during psychotherapy.
A comparison of demographic data from the recruited sample and the final sample revealed some minor differences regarding age distribution and educational level. However, participants were not recruited only on the basis of potential experiences of negative effects, as positive aspects of treatments were evaluated as well, limiting the risk of selection bias. Also, the response rate in our study was similar to those of other studies on negative effects of psychotherapy, which found rates of 59%6 and 61%29; it was even much higher than the rate of 19% found in one study.5
Our results related to problematic issues such as boundary violations should encourage a detailed examination of patient complaints. So far, these have been mainly reported by certain institutions who serve as receiving agencies for psychotherapy-related complaints.37,38
In the future, more research on the prevalence of negative effects would be useful. This would include a more systematic assessment of these effects in clinical trials.8 It would be interesting to try to recruit a similar sample as that used in our study to estimate the occurrence of more subtle violations of borders and other problematic issues in psychotherapy. According to the studies relating to such complaints, these are much more common than severe ethical problems such as a sexual assault in the treatment room. Addressing such violations and intensifying the more general focus on negative effects would eventually enrich training, supervision and clinical practice with the goal of avoiding harm in psychotherapy.
Posts
No comments:
Post a Comment