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Psychotherapy is not harmless: on the side effects of CBT
The structured nature of cognitive behavioural therapy (CBT) and its clearly defined principles (based on the links between thoughts, feelings and behaviours) make it relatively easy to train practitioners, ensure standardised delivery and measure outcomes. Consequently, CBT has revolutionised mental-health care, allowing psychologists to alchemise therapy from an art into a science. For many mental-health conditions, there is now considerable evidence that CBT is as, 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 in Cognitive Therapy and Research outlines the nature and prevalence of these unwanted effects, based on structured interviews with 100 CBT-trained psychotherapists. 'This is what therapists should know about when informing their patients about the upcoming merits and risks of treatment,' write Marie-Luise Schermuly-Haupt of the Charité University of Medicine in Berlin and her colleagues.
The researchers asked each CBT therapist (78 per cent of whom were female, average age 32, 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 chosen clients mostly had diagnoses of depression, anxiety or personality disorder, in the mild to moderate range.
The interviewer – an experienced clinical psychologist trained in CBT – followed the checklist of unwanted events and adverse treatment outcomes, asking each therapist whether the client had experienced any of 17 possible unwanted effects from therapy, such as deterioration, new symptoms, distress, strains in family relations or stigma.
The therapists 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 it a true side effect (only those rated as 'definitely related to treatment' were categorised as such).
Following this process, the researchers estimated that 43 per cent of clients had experienced at least one unwanted side effect from CBT, equating to an average of 0.57 per client (one client had four, the maximum allowed by the research methodology): most often distress, deterioration and strains in family relations. More than 40 per cent of side effects were rated as severe or very severe, and more than a quarter lasted weeks or months, though the majority were mild or moderate and transient. 'Psychotherapy is not harmless,' the researchers said. There was no evidence that any of the side effects were due to unethical practice.
Examples of severe side effects included: 'suicidality, breakups, negative feedback from family members, withdrawal from relatives, feelings of shame and guilt, or intensive crying and emotional disturbance during sessions'.
Such effects are not so surprising when you consider that CBT can involve exposure therapy (ie, 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 she was 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 to say, off the top of their heads, whether they felt that their client had had any unwanted effects – in this case, 74 per cent said they had not. Often it was only when prompted to think through the different examples of potential side effects that therapists became aware of their prevalence. This chimes with earlier research that's documented the biases which can lead therapists to believe that therapy has been successful when it hasn't.
Schermuly-Haupt and her colleagues said a conundrum raised by their findings was whether unpleasant reactions that might 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 the clients were also on psychoactive medication, so it's possible that some adverse effects could be attributable to the drugs rather than the therapy (even though this was not the interviewer's judgment). At the same time, though, remember that the researchers used a conservative estimate of side effects, only considering those that were 'definitely' related to therapy by their estimation, and ignoring those that they considered 'rather' or 'most probably' related.
The researchers concluded that: 'An awareness and recognition of unwanted events and side effects in all therapies will benefit patients, improve therapy or reduce attrition, analogous to the benefit of measurement-based monitoring of treatment progress.'
This is an adaptation of an article originally published by The British Psychological Society’s Research Digest.
This article was originally published at Aeon and has been republished under Creative Commons.
Educators and administrators must build new supports for faculty and student success in a world where the classroom might become virtual in the blink of an eye.
- If you or someone you know is attending school remotely, you are more than likely learning through emergency remote instruction, which is not the same as online learning, write Rich DeMillo and Steve Harmon.
- Education institutions must properly define and understand the difference between a course that is designed from inception to be taught in an online format and a course that has been rapidly converted to be offered to remote students.
- In a future involving more online instruction than any of us ever imagined, it will be crucial to meticulously design factors like learner navigation, interactive recordings, feedback loops, exams and office hours in order to maximize learning potential within the virtual environment.
A leading British space scientist thinks there is life under the ice sheets of Europa.
- A British scientist named Professor Monica Grady recently came out in support of extraterrestrial life on Europa.
- Europa, the sixth largest moon in the solar system, may have favorable conditions for life under its miles of ice.
- The moon is one of Jupiter's 79.
Neil deGrasse Tyson wants to go ice fishing on Europa<div class="rm-shortcode" data-media_id="GLGsRX7e" data-player_id="FvQKszTI" data-rm-shortcode-id="f4790eb8f0515e036b24c4195299df28"> <div id="botr_GLGsRX7e_FvQKszTI_div" class="jwplayer-media" data-jwplayer-video-src="https://content.jwplatform.com/players/GLGsRX7e-FvQKszTI.js"> <img src="https://cdn.jwplayer.com/thumbs/GLGsRX7e-1920.jpg" class="jwplayer-media-preview" /> </div> <script src="https://content.jwplatform.com/players/GLGsRX7e-FvQKszTI.js"></script> </div>
Water Vapor Above Europa’s Surface Deteced for First Time<span style="display:block;position:relative;padding-top:56.25%;" class="rm-shortcode" data-rm-shortcode-id="9c4abc8473e1b89170cc8941beeb1f2d"><iframe type="lazy-iframe" data-runner-src="https://www.youtube.com/embed/WQ-E1lnSOzc?rel=0" width="100%" height="auto" frameborder="0" scrolling="no" style="position:absolute;top:0;left:0;width:100%;height:100%;"></iframe></span>
New study shows white dwarf stars create an essential component of life.
- White dwarf stars create carbon atoms in the Milky Way galaxy, shows new study.
- Carbon is an essential component of life.
- White dwarfs make carbon in their hot insides before the stars die.
What Are White Dwarf Stars?<span style="display:block;position:relative;padding-top:56.25%;" class="rm-shortcode" data-rm-shortcode-id="7b046e546ce994682b2553a8c978eb32"><iframe type="lazy-iframe" data-runner-src="https://www.youtube.com/embed/77a1KSxfaR0?rel=0" width="100%" height="auto" frameborder="0" scrolling="no" style="position:absolute;top:0;left:0;width:100%;height:100%;"></iframe></span>
Master negotiator Chris Voss breaks down how to get what you want during negotiations.
- Former FBI negotiator Chris Voss explains how forced empathy is a powerful negotiating tactic.
- The key is starting a sentence with "What" or "How," causing the other person to look at the situation through your eyes.
- What appears to signal weakness is turned into a strength when using this tactic.
3 Tips on Negotiations, with FBI Negotiator Chris Voss | Best of '16 | Big Think<span style="display:block;position:relative;padding-top:56.25%;" class="rm-shortcode" data-rm-shortcode-id="b86d518e9f0c9f9d7a7c686e07798152"><iframe type="lazy-iframe" data-runner-src="https://www.youtube.com/embed/-FLlBchonwM?rel=0" width="100%" height="auto" frameborder="0" scrolling="no" style="position:absolute;top:0;left:0;width:100%;height:100%;"></iframe></span><p>This question forces a response, but—and this is key—the other person has to consider your side of the argument. They have to look at the situation from your perspective if they hope to offer a solution.</p><p>Offering a real-world example, Voss mentions coaching a high-end real estate agent. They were leasing an expensive home in the Hollywood Hills. The first time the negotiators asked the "how" question, the leasing agent relented on a number of terms. A little while later, they asked again. This time, the agent said, "If you want the house you're going to have to do it," signaling that the end of negotiations had been reached. </p><p>Voss says that "how" is not the only word that works. "What" is also a powerful entry into negotiations, such as "What am I supposed to do?" Again, you're forcing the other person to empathize. </p><p>This is a particularly tricky skill during a time when most conversations are online. Nuance is impossible without the immediacy of pantomimes and vocal fluctuations. Whataboutism is too easy an escape. </p>
Aikido Morihei Ueshiba (1883 - 1969, standing, centre left), founder of the Japanese martial art of aikido, demonstrating his art with a follower, at the opening ceremony of the newly-opened aikido headquarters, Hombu Dojo, in Shinjuku, Tokyo, 1967.
(Photo by Keystone/Hulton Archive/Getty Images)<p>Online debates often amount to little more than frustrated individuals pulling out their hair. In his book, "Against Empathy," Yale psychology professor Paul Bloom writes that effective altruists are able to focus on what really matters in everyday life.</p><p>For example, he compares politics to sports. Rooting for your favorite team isn't based in rationality. If you're a Red Sox fan, Yankees stats don't matter. You just want to destroy them. This, he believes, is how most people treat politics. "They don't care about truth because, for them, it's not really about truth."</p><p>Bloom writes that if his son believed our ancestors rode dinosaurs, it would horrify him, but "I can't think of a view that matters less for everyday life." We have to strive for rationality when the stakes are high. When involved in real decision-making processes that will affect their life, people are better able to express ideas and make arguments, and are more receptive to opposing ideas. </p><p>Because we "become inured to problems that seem unrelenting," it's imperative to make the problem seem immediate. As Voss says, giving the other side "the illusion of control" is one way of accomplishing this, as it forces them to take action. When people feel out of control, negotiations are impossible. People dig their heels in and refuse to budge. </p><p>What seems to be weakness is actually a strength. To borrow another martial arts metaphor, negotiations are like aikido: using your opponent's force against them while also protecting them from injury. Forcing empathy is one way to accomplish this task. You may get more than you ask for without the other side ever realizing they surrendered anything.</p><p>--</p><p><em>Stay in touch with Derek on <a href="http://www.twitter.com/derekberes" target="_blank">Twitter</a>, <a href="https://www.facebook.com/DerekBeresdotcom" target="_blank">Facebook</a> and <a href="https://derekberes.substack.com/" target="_blank">Substack</a>. His next book is</em> "<em>Hero's Dose: The Case For Psychedelics in Ritual and Therapy."</em></p>