The structured nature of Cognitive Behavioral Therapy (CBT) and its clearly defined principles—based on links between thoughts, feelings and behaviors—make it relatively easy to train practitioners, ensure standardized delivery, and measure outcomes.
Consequently, CBT has revolutionized mental health care, allowing psychologists to alchemize therapy from an art into a science. For many mental health conditions, there is now considerable evidence that CBT is as effective—or more effective—than drug treatments. Yet just like any form of psychotherapy, CBT is not without the risk of unwanted adverse effects.
A recent paper outlines the nature and prevalence of these unwanted effects based on interviews with 100 CBT-trained psychotherapists. The researchers asked each CBT therapist (78 percent of whom were female, with an average of five years experience) to recall their most recent client who had taken part in at least 10 sessions of CBT. The clients chosen mostly had diagnoses of depression, anxiety, or personality disorder in the mild to moderate range.
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The interviewer—an experienced clinical psychologist trained in CBT—followed what's known as the Unwanted Events-Adverse Treatment Reactions checklist, asking each therapist whether their client had experienced any of 17 possible unwanted effects from therapy such as new symptoms, distress, strains in family relations, or stigma.
The therapists, who worked at outpatient clinics in Germany, reported an average of 3.7 unwanted events per client. Based on the therapists’ descriptions, the interviewer then rated the likelihood of each unwanted event being directly attributable to the therapeutic process, making them a true side effect. (Only those rated as “definitely related to treatment” were categorized as such.)
Following this process, the researchers estimated that 43 percent of clients had experienced at least one unwanted side effect from CBT, equating to an average of .57 per client. (One client had four, the maximum allowed by the research methodology.) The side effects most frequently cited were distress, deterioration, and strains in family relations.
More than 40 percent of side effects were rated as severe or very severe, and more than 25 percent lasted for weeks or months, though the majority were rated mild, moderate, or transient. (There was no evidence that any of the side effects were due to unethical practices.) Examples of severe side effects included suicidality, breakups, negative feedback from family members, withdrawal from relatives, feelings of shame or guilt, or intensive crying and emotional disturbance during sessions.
Such effects are not surprising when you consider that CBT can involve exposure therapy, which can take the form of gradual exposure to situations that provoke anxiety, discussing and focusing on one’s problems, reflecting on the sources of one’s stress—such as difficult relationships, frustration at lack of progress, and feelings of growing dependency on a therapist’s support.
The longer that a client had been in therapy, the more likely they were to have experienced one or more side effects. Also, and against expectations, clients with milder symptoms were more likely to experience side effects, perhaps because more serious symptoms mask such effects.
Interestingly, before the structured interviews, the therapists were asked off the top of their heads whether they felt their client had had any unwanted effects. In this case, 74 percent said they had not. Often, it was only when prompted to think through the different examples of potential side effects that they became aware of their prevalence. This aligns with earlier research documenting the biases that can lead therapists to believe therapy has been successful when it hasn’t.
Another conundrum raised by the findings, the researchers reported, was whether unpleasant reactions that may be an unavoidable aspect of the therapeutic process should be considered side effects. “We argue that they are side effects, although they may be unavoidable, justified, or even needed and intended,” they said. “If there were an equally effective treatment that did not promote anxiety in the patient, the present form of exposure treatment would become unethical as it is a burden to the patient.”
There are reasons to treat the new findings with caution: The results depended on the therapists’ recall (an in-the-moment or diary-based methodology could overcome this problem), and about half of the clients were also on psychoactive medication. That means it's possible some adverse effects could be attributable to the drugs, rather than the therapy.