Many psychotherapists are unaware

The idea that psychotherapy may have side effects has long been a topic of discussion among experts, “but the debate has only been had in a systematic and substantial way over the last five years or so,” explains Linden.

Along with his colleague Bernhard Strauß, at the University of Jena in Germany, and a small group of fellow psychologists and psychotherapists, Linden is one of the pioneers in this area of research in Germany. He says that not every therapist is aware of the phenomenon, let alone the wider public and lawmakers. “And there is still a lot to be done in terms of research.” However, there have been a range of studies – in Europe, the U.S. and Australia.

The common belief that “talking can’t hurt” is not true.

The debate about the efficacy — and side effects — of psychotherapy is almost as old as the discipline itself, says Gary Burlingame from Brigham Young University in Utah, U.S. “There has always been a debate about whether psychotherapy has any measurable impact, beyond the placebo effect.”

In the early 1990s, Burlingame and his colleague Michael Lambert developed a questionnaire for patients, which was used to empirically measure the efficacy of therapy – “the vital signs of mental health”, as he calls it. The Outcome Questionnaire is now a standard tool used by psychotherapists in the U.S.

The efficacy of psychotherapy is now beyond doubt, says Moria Smoski, a clinical psychologist at Duke University in North Carolina. “But recognizing this means that experts now expect psychotherapy to be evaluated according to a medical model” – in clinical studies that analyze working methods, risks, side effects and interactions.

Such analysis clearly shows that the common belief that “talking can’t hurt” is not true. “Anyone who undergoes psychotherapy will feel unwell,” explains Smoski. “This is about serious, painful, long-lasting things, about examining memories that people try to avoid.”

In order to identify and classify the side effects of psychotherapy, we need a clear definition, says Berlin-based psychotherapist Linden. “In medicine as a whole and also in psychotherapy, side effects are defined as negative and unintended effects of a correctly administered treatment.” That does not include mistakes by the therapist, such as exhibiting a dominant or condescending attitude, or downplaying the significance of a patient’s suicidal thoughts. Serious, illegal misconduct such as sexual abuse of patients does not fall under side effects.

False memories

Unintended side effects vary according to the kind of psychotherapy treatment, says Linden – whether it’s behavioral therapy; psychodynamic therapy, which developed out of psychoanalysis; or systemic therapy, which focuses on social contexts. So a subset of cognitive behavioral therapy – exposure therapy used to overcome anxiety, where the therapist gradually confronts the patient with the cause of their anxiety – can also go wrong.

Linden recalls a patient who was suffering from agoraphobia. Unlike claustrophobia (fear of enclosed spaces), this patient had panic attacks in open spaces and was increasingly retreating to his apartment. Through his treatment he learned to take short walks to the street corner. But on a car ride with his therapist he suffered an unexplained panic attack, after which he stopped leaving the house and going to therapy.

Another side effect is the creation of false memories. Linden says that can sometimes occur early on, when a therapist is taking a patient’s medical history. The therapist asks about the patient’s childhood and their relationship with their parents – and the patient, seeking an explanation for their mental state and potentially susceptible to suggestion, remembers things that never happened, for example sexual abuse.

In the 1990s, there were multiple cases of false memories in the U.S. In Germany, the organization False Memory Deutschland advises people accused of abuse on the basis of false memories.

Dissociative disorders

Treating serious trauma such as post-traumatic stress syndrome can involve particular risks explains psychotherapist Smoski. “Having to repeatedly confront the traumatizing experiences can trigger extreme reactions.”

In serious cases, patients can develop dissociative disorders, splitting off specific memories of traumatic experiences or whole swathes of their personality that are associated with these experiences. Symptoms range from amnesia to perceptual disorders and paresthesia, seizures and paralysis.

These side effects are more common among war veterans, says Smoski, “simply because the level of trauma and the severity of the psychological damage is often greater”.

Therapy as a potential ego trip

Group therapy also has its own risks, Linden explains. Patients listen to other people’s dramatic stories and instead of drawing strength from hearing about these shared experiences, they feel demoralized. “There is a kind of infection risk,” says Linden.

For some patients, psychotherapy treatment becomes a kind of ego trip. Through therapy, they learn – often for the first time in their lives – to pay attention to their own needs. In Michael Linden’s recently published book Risks and Side Effects of Psychotherapy, experts describe patients who became so focused on themselves after having therapy that they began to struggle with “coping at work and at home”.

As a therapist you mustn’t be afraid of side effects.

They separated from partners, resigned from their jobs and broke off contact with family and friends; in short, they developed signs of a narcissistic personality.

As with all treatments, in psychotherapy there are also interactions – between psychotherapy and medicines, as well as between different types of therapy, says Smoski. So in some cases she advises patients suffering from anxiety not to take sedatives in the benzodiazepine class when they have panic attacks. “Because it has an effect on the efficacy of psychotherapy,” she says. It interferes with a patient’s emotional life and memory.

Therapists' responsibility

Sometimes it is difficult to choose the best form of therapy for a patient, Smoski says. She recalls one patient who she was treating for post-traumatic stress disorder, depression, sleep disorders and prescription drug addiction. She decided to start with sleep therapy – “because research shows that addressing sleep problems often leads to more successful outcomes in treating depression”.

But then it became clear that the patient couldn’t sleep because he was experiencing severe nightmares as a result of his trauma. “I had chosen the wrong kind of treatment – and I changed my therapy plan,” says Smoski.

Therapists are responsible for explaining to patients what the possible side effects might be, recognizing them when they occur during therapy, and adapting treatment accordingly, says Linden. Their experience should allow them to predict possible reactions, sometimes as early as taking the patient’s medical history.

For example, if a patient has an anxious-dependent personality, they are likely to form a close attachment to their therapist. A patient showing signs of borderline personality disorder, who tends towards impulsivity, unpredictable emotions and fluctuating moods, will be more susceptible to false memories. And special care should be taken when using exposure therapy to treat patients suffering from anxiety.

The greatest challenge faced by those researching side effects is the lack of data, says Lynn Bufka, a clinical psychologist from the American Psychological Association (APA). So far there has been almost no systematic data from which to draw conclusions about “whether a negative effect is a consequence of treatment or a symptom of the illness being treated”. Since 2018, the APA has required authors of scientific articles about therapy to list potential risks and side effects.

However, although this research is necessary, Linden advises all his colleagues: “As a therapist you mustn’t be afraid of side effects.” Medical doctors are not afraid of prescribing antibiotics, as the benefit is greater than the possible damage. “Any therapist who doesn’t see any side effects has probably just failed to notice them.”