1. By:
Prof. Hani Hamed Dessoki, M.D. Psychiatry
Prof. Psychiatry
Acting Head, Psychiatry Department
Beni Suef University
2013

2. Agenda
 History
 Introduction
 Prospectives on
psychotherapy
 Suicide and Psychotherapy
 How could psychotherapy
ever be harmful?
 Negative effects of
psychotherapy

3. Definition of Psychotherapy
 A classic definition of psychotherapy is use
of interpersonal influence skills and
psychological techniques by trained
professionals toward the goal of relieving
the signs and symptoms of psychiatric
disorder.
 Psychotherapy is defined as a “procedure,”
similar to that of a medical procedure.

4. History
 The possibility of treatment-induced
deterioration among psychiatric patients
was first observed nearly 7 decades ago
(Masserman & Carmichael, 1938).
 Psychotherapy can sometimes be harmful:
(a) deterioration effects and (b) negative
effect

5. Introduction
 Effective treatment causes side effects; this
applies for medical interventions and
psychotherapy alike.
 Due to its specific setting it is unusual to
focus on risks and damages within
psychotherapy.

6. Introduction
 When ascertaining negative effects from
treatment, one might look for slower
response, less remission or recovery, higher
rates of relapse or recurrence, or some
combination of these.

7. Introduction
 Every guideline for management of
psychiatric disorders in the world contains
the suggestion and recommendation to
include psychotherapeutic intervention.
 Cognitive-behavioral therapy is probably the
most researched and best-established
treatment method in this respect.

8. Introduction
 In contrast to all the pharmacotherapy
studies, there is precious little information
about the safety of psychotherapeutic
interventions -- which are also, in some
patients and in some instances, associated
with adverse events that need to be noted.
 These may include undue stress and
potential overstimulation.
 Both of these issues may contribute to the
potential for symptom exacerbation.

9. Perspectives on Psychotherapy
The Bottom Line: Does Psychotherapy Work?
The Benefits of Psychotherapy
 Based on the results of 475 studies (Smith et al., 1980),
the average psychotherapy client shows more
improvement than 80% of those in the no-treatment
Psychology, 4/e by Saul
control group.
Kassin ©2004 Prentice Hall

10. Perspectives on Psychotherapy
What is the Future of Psychotherapy?
Orientations of Psychotherapists
Eclectic: Borrowing ideas and techniques from different approaches
Psychology, 4/e by Saul Kassin ©2004 Prentice Hall

11. Prroblems
 Empirical research on the negative effects of
psychotherapy is insufficient, partly
because there is a lack of theoretical
concept on how to define, classify and
assess psychotherapy side effects.

12. Introduction
 Most clinical studies reported a complete
lack of side effects of psychotherapy and
related therapies, like cognitive-behavioural
treatments, also in schizophrenia,
behavioural treatments, hypnotherapy,
hypnosis, alcoholics anonymous.

13. Paradoxal findings: Psychotherapy
diminishes side effects
 A number of the studies found associated
paradoxically psychotherapy to the
reduction of side effects of other treatments.
 This indicates that psychotherapy in general
is balancing the patient and helping the
patient with physical, mental, existential and
sexual problems.

14. Suicide and Psychotherapy
 Suicide is normal in the mentally ill
population, but there is no documentation
that psychotherapy provokes suicide; quite
contrary it seems therapy with intimacy and
closeness between therapist and patient can
prevent suicide.

15. Suicide and Psychotherapy
 Sometimes, although rarely, mentally
patients did commit suicide during
psychotherapeutic treatment caused by their
mental illness not their therapy.
 In comparison, psychiatric treatment with
drugs is known to provoke suicide in 2% in
the beginning of treatment .

16. How could psychotherapy ever be
harmful?
 Negative side effects for a therapeutic
technique is the use of breathing retraining
and relaxation procedures during exposurebased procedures for individuals with panic
disorder with agoraphobia.
 Just because a therapeutic technique is
useful in one situation — outside of
exposure procedures, for instance, to help
reduce anxiety or tension — doesn’t mean it
might not be harmful in other situations.

17. How could psychotherapy ever be
harmful?
 In addition, there have been increased
reports of family conflicts, with aggressive
or suicidal behavior in people undergoing
various psychotherapeutic interventions.

18. Psychotherapy among patients with
OCD
 Although very effective for reducing the frequency
and severity of OCD symptoms, many people
undergoing psychotherapy, such as cognitive
behavior therapy (CBT) and exposure and response
prevention (ERP), notice that a side effect of
treatment is that their anxiety actually increases in
the beginning stages of therapy.

19. “Side effects” of psychotherapy are
unpredictable
 In psychotherapy, you never know what to
expect.
 Any behaviour modification technique can be
misused or misapplied.
 "positive thinking" can actually have a negative
impact on the mental health of some people
(and this has been known for years in regard to
trauma counselling and sexual assault
counselling).

20. The negative effects of psychotherapy
 Psychotherapy can lead to the occurrence of
new symptoms or problems which are not
themselves resolved in the course
of management.

21. The negative effects of psychotherapy
 The clients will go through a period of feeling
worse as their old habits of coping are replaced
with new strategies and ways of thinking.
 This process can temporarily highten anxiety
and insecurity and negative thoughts, feelings
of helplessness, hopelessness etc.

22. The negative effects of psychotherapy
 Acquiring new symptoms
 Worsening of symptoms (3-10%) and
regression
 Depdendence
 False memories
 Superficial insight (acquiring empty
language)
 Iatrogenic malingering

23. Causes of negative effects of
psychotherapy
 Negative effects may be due to techniques,
client variables, therapist variables, or some
combination of these.

24. Psychotherapy and Informed
Consent
 Informing clients about the potential risks
and benefits of psychotherapy is a
fundamental component of obtaining
informed consent, analogous to a
physician’s informing a patient about the
risks and benefits of medication or
treatment.

25. Difficulties
 The lack of consensus in existing literature related
to what constitutes negative effects of
psychotherapy reflects the conceptual complexities
in this area.
 One classic definition states that negative effects
occur “when there is no meaningful positive change
in a client due to some aspect of the treatment
process”.
 The most extreme negative effect is related to
“client deterioration in functioning that is attributed
to the course of therapy”.

26. Indicators of Potential Deterioration
 The five indicators for “potential deterioration,” as a
result of interaction between therapeutic
techniques, psychotherapists, and clients include,
(a) the role of anticipation of emotional pain and
therapeutically induced arousal
(b) client suspiciousness toward the therapist and
therapist empathy
(c) level of interpersonal functioning and the focus
of treatment
(d) diagnosis and treatment modality
(e) relaxation therapy and clients’ need for control

27. Termination
 Over 4-6 monthly sessions
 Review patient success
 Discuss potential vulnerabilities
– Identify strategies for management of
interpersonal difficulties and symptom relapses
 Encouragement about ability to use
strategies independently

28. Psychotherapy and Pharmaceutical
Companies
 Drug companies have been sold on the idea
that their troubles stem from a "chemical
imbalance," the solution to which, of course,
involves rebalancing their chemicals, just
like diabetics taking insulin.

29. Biopsychosocial model
 The biopsychosocial model (abbreviated "BPS") is a
general model or approach positing that biological,
psychological (which entails thoughts, emotions,
and behaviors), and social factors, all play a
significant role in human functioning in the context
of disease or illness.
 Indeed, health is best understood in terms of a
combination of biological, psychological, and social
factors rather than purely in biological terms

30. Biopsychosocial model in
depression
Effective treatment of severe or chronic
unipolar depression requires the combination
of pharmacological and psychotherapeutic
interventions.
The model stresses the self-evident integration of
biological
and
psychological
therapeutic
interventions that need to focus on symptom
reduction and on relapse prevention.
Schotte et al., 2006;23(5):312-24

31. Psychotherapy
 Psychotherapy focuses on the therapeutic
relationship with the client / patient as well
as their social environment.
 The healing process is dialogical and
polylogical as well as vulnerable throughout
all schools of psychotherapy.
 The quality of the therapeutic relationship is
central to a cure.

32. Take Home Massage
 Recognition of adverse treatment
effects is a characteristic of
good therapists and treatments.
 Psychotherapists should be
sensitive for negative effects.
 The detection and management
of adverse treatment effects is
not a sign of bad but of good
clinical practice.

33. Stress reduction