When therapy is harmful: A qualitative study of our clients’ negative experiences of therapy

As therapists we often formally and informally identify our negative experiences of therapy - 

what worked for us, how we handled the sessions, and where things felt difficult.  We explore these with our peers and supervisors.

It is not at all easy for us to gain any insight into what our clients’ negative experiences of our therapy might be.  Yet, the therapy is for the client, and the clients’ experience is priority.  So we really do need to have some understanding of the negatives.  There are a lot of things that get in the way of finding this information out.  Not least, asking the client about their negative experiences will introduce a dynamic into the sessions which may not be in the client’s best interest, and  dynamic into the therapy.  Another is that as their therapist we are necessarily too involved with our clients to have sufficient objectivity for such an evaluation.   It was this issue that Vybíral, Ogles, Řiháček, Urbancová & Gocieková (2023) set out to address.  They wanted to find out more about the negative experiences of therapy that clients might have had, and to provide us therapists with some of that valuable insight into our clients’ worlds.  

Their research strategy was to carry out a qualitative meta-analysis of these negative client experiences.  In other words, conducting a review of all the published research on this issue and summarising or synthesising them.

The researchers carried out a database search in order to find relevant studies, and these were then summarised by themes.  In total the researchers managed to amass a total of 936 statements from 51 different studies.  These were then summarised into 21 themes which were then divided into subthemes. The 21 themes identified 4 overarching themes in clients’ negative experiences: therapists’ misbehaviour, hindering aspects of the relationship, poor treatment fit, and negative impacts of treatment.  Each will be discussed in turn:

Therapist’s behaviour:  negative evaluations  of  therapists’  personal  qualities  and behaviours.  This refers to perceptions of the therapists’  competence or the manner in which the therapist approached the client (such as not listening/understanding, being disrespectful, judging, and abusing the client).

This is reminiscent of Rogers’ warning that we should enshrine an atmosphere of positive regard for the client, and the consequences if that crumbles.  The antidote to this category of negative experience is, it seems therapists’ empathy, positive regard,  and  genuineness as consistent predictors of outcome. 

Hindering  aspects  of  the  relationship mostly corresponded to issues around the  therapeutic  alliance  and  alliance  rupture, but is extended a little beyond the more formal alliance to include the emotional bond and goal/task consensus.  Negative therapeutic relationships were reported by clients in terms of distance,  lack  of support, insecurity, and confusion.

Poor treatment fit referred to experiences of the therapist or therapeutic process not meeting  the client’s  expectations  or  needs.  This echoes the finding that by accommodating the client’s treatment preferences, we simultaneously increase the chances of better outcomes and lower dropout rates. There was also sensitivity to the ending, in clients’ negative experiences, emphasising the need for therapists to more carefully consider endings.

Negative impacts of treatment included clients’ reports of unsatisfactory outcomes (in other words, little or no change over the course of the therapy, and at times a deterioration). This insight highlights the need for some kind of outcome monitoring, so that therapists can know if the therapy is not improving and make adjustments to address this.  Some of the negative outcomes included the client feeling a loss of motivation or hope when they feel that therapy did not work, feeling angry that the therapy did not work despite all that the client invested, feeling a sense of dependency on the therapist, and adopting an attitude of self-accusation and self- blaming.

In conclusion, it may be stated that as therapists we need to consider the negative, the shadowy, and the harmful dimensions to our clients’ experiences of therapy.  This study offers some insight, but much more is needed.

Zbyněk Vybíral, Benjamin M. Ogles, Tomáš Řiháček, Barbora Urbancová & Veronika Gocieková (2023) Negative experiences in psychotherapy from clients’ perspective: A qualitative meta-analysis, Psychotherapy Research