The Unspoken Risks of Psychotherapy

You start psychotherapy hoping for a change.

This hope is justified.

We know psychological treatments are highly effective for most mental health disorders. Hundreds of studies back this up.

But this positive picture isn’t the whole story.

Improvement rates could be much higher. For major depression, remission rates can be as low as 43%.

For some, therapy doesn’t just not work—it makes things worse. This is one of the most common adverse experiences.

A new review article summarizes decades of research to ask: Where do we stand on therapy’s negative effects?

The authors synthesized data from clinical trials , patient complaints , and large public surveys to get a clearer picture.

A Problem of Definition

For decades, this topic received little attention.

Part of the problem is confusion. Terms like “deterioration,” “harm,” and “adverse effects” are often used interchangeably.

We need a clearer framework.

Think of it like this: Did the negative event happen because of the treatment? Or was it just a critical life event that happened at the same time?

Side Effect or Malpractice?

If the treatment is related, we must ask another question.

Was the therapy applied incorrectly? This includes treatment errors, wrong indications, or unethical behavior.

This is “malpractice”.

Or, was the therapy applied correctly, but still caused a negative outcome?

This is a “side effect”.

Just like medicine, a correctly-applied treatment can still have unwanted effects.

Untangling these is complex, but vital for patient safety.

Sifting Through the Evidence

Researchers pull from many sources to estimate how common these problems are. Each source tells a different part of the story.

1. Clinical Trials (RCTs) Randomized controlled trials (RCTs) are our gold standard.

A systematic review of 85 RCTs found adverse events in over 10% of patients. Serious events, like hospitalization or suicidality, occurred in 1 in 21 patients.

But there’s a huge gap.

The studies often failed to report if the therapy caused the harm.

In fact, numerous major reviews find that most studies don’t report safety data at all.

2. Patient Complaints Formal complaints paint a different picture, often highlighting malpractice.

One analysis of 1482 complaints in Germany provided a breakdown.

Violating formal agreements (like session length) was cited in 29.8% of cases.

More serious issues included social boundary violations (30.0%) and sexual boundary violations (22.8%).

3. Patient & Public Surveys When you ask patients directly, the numbers jump.

Surveys using specific questionnaires find negative effect rates from 20% all the way to 94%, depending on the sample.

A large UK survey of 14,587 people found 5% reported “long lasting ‘bad effects'” from therapy.

A German study of the general population was even more striking. 57% of those with therapy experience reported at least one negative effect.

The most common? Recurring unpleasant memories (58%), stress, and increased worry. A replication found 76% reported at least one negative effect.

However, in that study, only 2.5% said the effects were long-lasting.

Why It Matters

This research isn’t meant to scare people away from a treatment that helps millions. It’s about honesty and improvement.

The data suggests that temporary adverse experiences are “very common side effects of any psychotherapy”.

Feeling distressed or recalling bad memories might be a normal, temporary part of the healing process for many.

We must get better at tracking these events in clinical studies.

More importantly, we must talk about them.

Patients need to be informed that therapy isn’t risk-free and empowered to “reflect adversities during the treatment process”.

Therapists need better training to recognize and minimize these risks, right from the start.

Understanding therapy’s downsides is the only way to make it safer and more effective for everyone.