A sample of 32 research studies with data on adverse process and adverse effects was obtained. A sample of 26 studies on the helpful effects of psychotherapy was obtained to aid discrimination some of these were the same as they covered both helpful and hindering factors. A sample of 27 sources of service user testimony reporting adverse processes was obtained.
A further 16 accounts of helpful therapy were used to inform the discrimination of adverse effects. Details of referenced sources on which the data extraction was based are given in Supplementary Data Sheet S1. For qualitative research papers, data on the publication, research method, type of psychotherapy, the phase of therapy, specific adverse process and adverse effects of studies were extracted by one of two researchers, who then compared their results for the sample overall to establish consistency.
For service user testimony, the data extracted centered on first person accounts of psychotherapy, as well as contextual features of the events and the account. Quality of the reporting of the testimony was completed using a checklist informed by one developed by the Joanna Briggs Institute The first stage in extracting empirical categories was to identify an adverse process marker.
Then adverse effects were identified, which needed to be as a consequence of the task marker, experienced directly by the research participant and negatively evaluated implicitly or explicitly. Codes were applied to the extracted data with reference to the processes identified in the rational model. If the process did not correspond to any rational model code, the study authors' themes were retained for evaluation and synthesis later.
For service user testimonies codes were applied to the textual data units. The extracted data from testimony were explored and coded, either using the rational model, or where the data did not appear in the rational model, according to the researchers' understanding of the service users' experience, consulting with a service user member of the project steering group.
The resulting categories were constructed into an empirical model of service user experiences of adverse processes of psychotherapy. This resulted in the specification of key themes across several areas, and an overarching theme.
A matrix of regularities in relationships between specific adverse processes, or themes and adverse effects, where they existed, was constructed. The contribution of each research paper and service user testimony is provided in Supplementary Tables S1 , S2 , from which two empirical models were developed available from the authors. The synthesis of the research findings involved construction of a rational-empirical model of adverse processes which incorporated evidence from both empirical models.
Two researchers independently reviewed all of the coding for each adverse process reported at each phase of therapy and developed initial ideas for ways of describing the key themes that uniquely distinguish adverse processes in psychotherapy.
Empirical themes from both research and testimony were successively compared with the descriptions suggested in the rational model, which was refined, modified and extended, adapting the rational model to fit the empirical data. The themes were placed into the model, and further overarching themes derived to account for regularities in adverse processes across stages of therapy.
The validation phase usually involves looking at whether the model discriminates between therapy events, such as unresolved and resolved moments in therapy. This comparative method is problematic when considering a whole therapy experience; we therefore adapted this step to include a comparison with a thematic analysis of risk factors for negative experiences of therapy that was developed by the same research group in parallel but with different members undertaking it, blind to the task analysis.
Therefore, the results used for validation purposes are entirely independent of the task analysis study. The risk factors in the validation study were developed using the thematic analysis of therapist and patient interviews and questionnaires see Hardy et al. The validation process involved three of the authors JC, GP, and GH separately comparing the themes of the rational-empirical model to the themes from the qualitative study, noting similarities and differences.
Agreement was then reached through discussion, noting which task analytic themes were present in or absent from the thematic analysis. The final synthesized rational-empirical model is described below. As before, the Domains overarching themes in the Synthesized Model are given in bold , and the subordinate themes in italics.
The final synthesized rational-empirical model contained 51 themes subsumed under the eight Domains that were identified in the rational model of adverse processes, plus two additional Domains, What to do and Adverse effects. Nineteen of the subordinate themes were part of the original rational model these are indicated in Figure 3 and were confirmed in either service user testimonies Venue, Narrow options, Poor information, Deference, Money, Blaming, Over adherence , qualitative research Demographic identity not attended to , and Suddenly left high and dry or both Cultural validity of therapy, Professional lack of knowledge, Negative relationship patterns, Misuse of power, Goals not being met, The wrong therapy, Helpful experienced as unhelpful, Malpractice, Personality , and Money.
The remaining themes came from either or both of the empirical models but not the Rational Model see Figure 3. Figure 3. The final model includes the following themes that have been linked to adverse effects.
These themes include the Cultural validity of therapy , which refers to the ways in which therapy and therapists are represented and understood, as suggested by the quote:. We've all been told that this baloney somehow is on the same par with medical services. They've been trained and validated by prestigious institutions. Much of what we watch and read tell us these are serious, qualified, responsible people who will improve our lives if we follow their program Service User Testimony 1.
Participants in both studies highlighted a range of deficits in conventional services that left them expressing feelings of desperation and powerlessness in a system that appeared to undermine access to effective care Bee et al.
Some survivors also seemed to believe that living in certain areas affected their access to services Chouliara et al. The tendency for health professionals to address symptoms rather than causes led to what many respondents believed was an over-emphasis on a medical model of care and a sole reliance on pharmacological treatments Bee et al. The theme Client experience and expectations was developed from clients' experiences of previous therapy good and bad , and covers client expectations on the nature and structure of therapy and their own role in the process.
Negative feelings seemed to occur because of the clients' feelings that their expectations for therapist behavior were breached Rhodes et al. Several relationship factors were identified. An important theme that was present in both sets of literature were the derived and directly experienced Negative patterns in therapy relationships that were described in several ways:.
Experience of an impersonal therapist Poulsen et al. Distant and Rigid Therapeutic Relationships Grunebaum, , p. The Misuse of power theme refers to the ways in which people felt disempowered in the relationship, as indicated in:. At the same time, he felt pushed by the therapist to pursue a treatment goal that he did not share and by which he felt restricted Qureshi, , p.
So long as there was a payment and revelations were not mutual, the therapist always had huge power over me, the troubled client Service User Testimony 3, p. Clients reported Not being heard or understood and Conditional conditions refers to the impact of what might be considered the standard, typical or core conditions of therapy may be experienced adversely in some contexts, as suggested by the following:.
Negotiating Distance: A sense of professional caring is needed, or the therapist is experienced as too distant, defensive, or un-attuned to clients' emotions.
However, caring is too intense if the therapist is experienced as jealous, controlling, or pitying Levitt et al. Ruptures that were maintained or not attended to also were seen as leading to adverse effects. The theme Goals not being met was developed from themes evident in both sets of literature:. All of the patients experienced a conflict between a wish for more simple, functional help in contrast to the intensive therapy they had been given Wilson and Sperlinger, , p.
So it's like a lottery, only you can either gain big, lose big or land anywhere in between Service User Testimony 5. The theme Vulnerability of clients was present only in the patient testimony and refers to the reported experience of seeking therapy at particularly vulnerable times, exemplified by:.
Particularly after my divorce I felt unattractive and unwanted. I wished to be seen as a viable woman who was worthy of love. I desperately needed to know if Dr.
A could see me in such a light. Not to act on it but just to know that he could see those qualities in me Service user testimony 6. Although lack of attention to Demographic identity of the client could be related to therapist factors or behavior it is in this overarching theme to emphasize the importance of this theme to the client, where failure to address issues such as race, spirituality, or culture led to adverse events.
Certain processes relating to the therapy that clients went through were associated with adverse experiences. Being in the Wrong therapy was developed from clients' descriptions that they did not agree with the techniques or model of therapy. In helpful events, this new story line was perceived as empowering and emancipating. By contrast, in some hindering events, the new story line was regarded as threatening, painful, or untimely p.
Amongst the several therapist factors the client's perception of the therapist's Personal characteristics and or personality adversely affects the therapy process for example:. Therapists described by their patients and having great difficulty dealing with their patients in ordinary human ways and often in a cold or Inflexible manner Grunebaum, When I went to therapy, I was looking in large part for a role model, someone who set a good example.
What I found was quite the opposite. I didn't know where else to turn Service User Testimony 1. None of the patients in the Emotionally Seductive group thought that their therapists had helped them sufficiently to work on their feelings that had been aroused Grunebaum, Beyond the suggested specific characteristics of therapists, themes around how therapists behaved in ways that led to adverse events were developed.
As well as writing secretly, we began texting. Some of his texts became very sexually explicit Service User Testimony 13, p. For example, the client may have felt pressured into participating in certain exercises, engaging in non-sexual touch, remembering past experiences, disclosing the abuse to others, talking about certain topics, or engaging in some behavior outside of the therapy setting for which she did not feel ready.
She viewed the counselor as being controlling, rigid, and violating or minimizing her boundaries, and she may even have felt re-abused Koehn, , p. They also related to less overt, but still problematic and aversive behaviors.
For example, therapists were sometimes seen as Devaluing or Blaming the client. Therapists were also reported to be too confrontational or characterized as too passive, vague and silent. These behaviors were related to the theme Involvement :. It was noted that the therapist did good work but exercised too much control over the direction it took Service User Testimony 8. The ending of therapy, including where clients choose to end therapy unilaterally or when they felt Suddenly left high and dry , and the ways in which it was handled and processed contributed to the overall experience of therapy Knox et al.
Particularly after my divorce I felt unattractive and unwanted. I wished to be seen as a viable woman who was worthy of love. I desperately needed to know if Dr. A could see me in such a light. Not to act on it but just to know that he could see those qualities in me Service user testimony 6. Although lack of attention to Demographic identity of the client could be related to therapist factors or behavior it is in this overarching theme to emphasize the importance of this theme to the client, where failure to address issues such as race, spirituality, or culture led to adverse events.
Certain processes relating to the therapy that clients went through were associated with adverse experiences. Being in the Wrong therapy was developed from clients' descriptions that they did not agree with the techniques or model of therapy. In helpful events, this new story line was perceived as empowering and emancipating. By contrast, in some hindering events, the new story line was regarded as threatening, painful, or untimely p. Amongst the several therapist factors the client's perception of the therapist's Personal characteristics and or personality adversely affects the therapy process for example:.
Therapists described by their patients and having great difficulty dealing with their patients in ordinary human ways and often in a cold or Inflexible manner Grunebaum, When I went to therapy, I was looking in large part for a role model, someone who set a good example. What I found was quite the opposite. I didn't know where else to turn Service User Testimony 1. None of the patients in the Emotionally Seductive group thought that their therapists had helped them sufficiently to work on their feelings that had been aroused Grunebaum, Beyond the suggested specific characteristics of therapists, themes around how therapists behaved in ways that led to adverse events were developed.
As well as writing secretly, we began texting. Some of his texts became very sexually explicit Service User Testimony 13, p. For example, the client may have felt pressured into participating in certain exercises, engaging in non-sexual touch, remembering past experiences, disclosing the abuse to others, talking about certain topics, or engaging in some behavior outside of the therapy setting for which she did not feel ready. She viewed the counselor as being controlling, rigid, and violating or minimizing her boundaries, and she may even have felt re-abused Koehn, , p.
They also related to less overt, but still problematic and aversive behaviors. For example, therapists were sometimes seen as Devaluing or Blaming the client. Therapists were also reported to be too confrontational or characterized as too passive, vague and silent.
These behaviors were related to the theme Involvement :. It was noted that the therapist did good work but exercised too much control over the direction it took Service User Testimony 8.
The ending of therapy, including where clients choose to end therapy unilaterally or when they felt Suddenly left high and dry , and the ways in which it was handled and processed contributed to the overall experience of therapy Knox et al. This was characterized by:. No expression of termination related emotion, No review of therapy or client growth, Unplanned termination and No discussion of post-termination plan Knox et al. Four specific themes were developed from the service user testimony in which people reporting adverse effects had provided accounts of actions they had taken to address or resolve these consequences, and were therefore encouraging other to do the same.
One suggestion is to Choose wisely :. I would say ask for recommendations if you can, and if the person's not right for you, say so, and ask if there's someone else you can see Service User Testimony 9. I am lucky to have had a good support network. My husband has been a safe haven of love and support. I have had mental health care providers who understand how to help victims of trauma and sexual abuse. This theme also includes the client telling the therapist about their experiences of therapy.
Writing a complaint helped me put the blame where it belongs. My therapist was entirely responsible for what had happened between us. I had done nothing wrong by holding him accountable for his actions Service User Testimony This Domain was derived from the qualitative literature.
All themes except one, No return on investment were observed in both the qualitative literature and patient testimonies and included Feeling worse, Negative feelings, Stops, and impairs life patients , Stops and impairs therapy qualitative literature , and Thoughts after therapy. These themes were evidenced by the strong negative feelings expressed by patients:. I was confused about the nature of our relationship and this confusion resulted in a profound trauma that I am still trying to heal Service User Testimony Impeding involvement—feelings of vulnerability led to desire to disengage Audeta and Everall, Therapy has always tended to reduce my experience of life to monochrome Service User Testimony 3.
Although most of the Domains identified in the rational model were confirmed in both the qualitative and service user literature, the themes described above often came from the empirical models. Fifty-eight themes from the task analytic model were examined in terms of whether they matched themes from the validation study Supplementary Table S3.
Of the 58 themes coded, 53 matched themes in the validation study 24 were fully matched independently, 29 were partially matched and agreed by consensus. Only 5 remained unmatched. Three themes present in the task analysis were not found in the validation study: the negative therapeutic relationship pattern where an earlier relationship is re-enacted in therapy transference and counter-transference , the theme on what clients can do to prevent or escape from negative experiences, and a range of difficulties over ending therapy.
From the client's point of view, ending could be premature, abrupt, and emotionally unmanageable or conversely, therapy could be difficult to escape from, or to end against the therapist's advice. Consistent with the method of task analysis, each adverse process theme was contrasted and compared with data, themes or descriptions of helpful processes, using the within-study data for those studies that had examined both adverse and helpful processes.
Trauma focused work was largely seen as challenging by some survivors and professionals alike. The challenges by survivors centered mainly on choosing appropriate timing and depth of such work, which may differ for each survivor. Being prepared for the process and being given the option to opt out when it feels too much were important caveats emphasized by survivors Chouliara et al.
The refinement of the adverse process themes from the service user testimony involved a similar process of comparison. For example, within the Negative Relationship Patterns theme, patients reported relationship patterns which were helpful; these helpful processes were absent in the adverse accounts:.
Someone who I feel has the time for me and knows where I'm coming from someone who I feel I can relate to and understands me, being able to face up to painful aspects of myself and memories with support forming a relationship, albeit with a therapist, where I feel safe Patient testimony The use of a task analysis paradigm to synthesize two types of qualitative evidence about adverse effects of psychological therapies is innovative. We believe this study demonstrates that it is a feasible and productive method.
However, it can be argued that other qualitative systematic review techniques would serve this purpose just as well, for example, realist synthesis Pawson, Dixon-Woods et al. It is in this spirit that we used task analysis, as we considered it particularly well-suited to the systematic integration of both qualitative research findings and patients' testimony.
In common with realist synthesis, it uses iterative and heterogeneous processes to produce a review of evidence, and, as an interpretive review, uses theoretically derived sampling in a complex field. However, in task analysis these processes are fully explicit and the method is transparent and reproducible rather than opaque and idiosyncratic.
This study has methodological limitations. The literature search preceded the lengthy process of empirical refinement, which preceded the study used as validation, and so is not contemporary. However, there is no reason to believe that people's experiences of therapy have fundamentally altered during this time period; indeed more recent reports confirm that very similar issues continue to be raised Werbart et al. Our verification results were encouraging, although we did not proceed to the final stage of verification, which would require testing whether the model can distinguish between beneficial and adverse therapies in a new, prospective study.
Each of these factors has the capacity to influence the others. The findings suggest that contextual issues, such as lack of cultural validity and limited therapy options, together with unmet client expectations, fed into negative therapeutic processes.
Examples of negative process include unresolved alliance ruptures and client disengagement. These involved a range of unhelpful therapist behaviors, such as rigidity, over-control, boundary violations and lack of knowledge, which in turn were associated with clients feeling disempowered, silenced, or devalued. From the service user's point of view, these were coupled with issues of misuse of power and being blamed.
To a surprising extent, many of the themes in the rational model failed to find empirical evidence in their support from the qualitative research sample or the service user testimony. Whilst this may be attributable to the selected sample, it does emphasize the difference in views between professionals, researchers, and clients about adverse process and effects.
We found a similar disparity in the views of therapists and clients in a UK survey of their experiences of failed therapies. Patients generally reported their negative experiences as more harmful, whereas therapists with failed therapies rated them as less harmful for their patients Hardy et al. A discrepancy between the views of professionals and their patients or clients is not unique to psychotherapists, and has long been noted in other disciplines Robinson, The service user perspective reveals there are potentially harmful factors at each stage of the therapy journey, rather than simply negative reactions to therapy itself, which require remedial action.
There are several implications of this for practice. First is the importance of methods for ensuring the client's voice is enabled to be heard, so that the therapist-client relationship is not enacted within a closed system. This involves the wider system within which therapy is offered, so that client expectations, cultural validity and therapy choices are actively managed prior to therapy starting. The principle of informed consent requires that risks as well as potential benefits of therapy are clearly explained before therapy starts, and there should be explicit guidelines for both therapist and client on how they can address the problems outlined here.
There is a balance to be struck between protecting the framework of the therapy relationship so that it remains safe, confidential and well-boundaried, whilst allowing and empowering the client to find support, if it deteriorates into a negative, potentially harmful state. Suitable methods might be routine consultation with clients independent of the therapist on how therapy is progressing, providing clients with pre-therapy information explaining what to expect in therapy and how to know if therapy is causing harm.
This could also give details of who to contact if therapy is going badly, and emphasizing that a change of therapist may be necessary in these circumstances. Any of these policy initiatives would need evaluation.
Another important area of practice improvement concerns the training, accreditation and supervision of competence in therapists, all of which could be improved. Currently there is little education in therapy trainings on the potential for harm, the prevalence of negative effects, the importance of informed consent which explains risks as well as benefits, and developing skills in noticing the signs of a negative process and knowing how to address them.
Accreditation is usually offered on the basis of completing a course of study and supervised practice rather than on monitored outcomes including negative outcomes. Although many psychotherapy courses routinely use audio or video recordings of sessions in supervision and appraisal, in others supervision is only based on the therapist's account of their client's presentation, the session process and the therapist's feelings and difficulties.
Psychotherapies, such as cognitive behaviour therapy or dynamic psychotherapy, are all developed with an underlying logic and possess powerful specific ingredients. Cognitive behaviour therapy, for instance, challenges faulty thinking patterns that cause people to view themselves, their future, and the world negatively.
While dynamic psychotherapy, which is derived from psychoanalysis, is designed to identify the early formative events that led the individual to develop psychological problems. But all psychotherapies also contain non-specific therapeutic ingredients that may — when present in some circumstances, or absent in others — benefit or harm the patient.
These include the therapist being empathic, and providing a clear therapeutic rationale in a healing and restorative setting. But all effective medication is accompanied by risk and the same holds for talking therapies. In , a colleague and I published an overview of reported harmful effects from talking therapies, examining scenarios such as the insensitive, critical, voyeuristic or sexually exploitative therapist, and their prevalence. Some therapists had a lot more clients whose state of mind deteriorated than others although, Parry pointed out, that could be because they had more difficult cases.
And some may have got worse whether they had therapy or not. But, said Parry, both therapists and clients need to be more aware of the potential dangers and those who feel they are getting worse need more help.
Her team have used the findings from the research project to set up a website to help people going through any form of psychological counselling called supporting safe therapy , which offers guidance on what to expect and advice if things go wrong.
There have been widespread reports of "transgressive behaviour" by therapists who abuse the trust of their clients, but less so about poor quality support.
If airline pilots said we get some people who crash, we'd all be worried about it.
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