Psychotherapy Is Not Harmless: These Are the Side Effects of CBT

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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,’ writes 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 percent 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 percent 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.’

Source: Aeon


  1. I don’t think CBT would help me much with my issues. In fact, exposure can do more harm than good as it can cause more trauma on top of trauma that just makes it harder and I often never fully heal.

    • Thank you for leaving a comment. Definitely exposure is not for everybody and does more harm than good. It is so important to recognise if this is the case for you as you have. Exposure therapy has to be done by an expert therapist. All the best for the future. Erin

    • Thank you for commenting. I appreciate it. It is always good to get feedback. All the best Erin

  2. Thanks for this Erin. I saw CBT takeover the NHS where I worked for ten years. It was being promoted for the treatment of virtually every form of mental distress, as well as discreet physical and neurological problems, including ME/ CFS (since then the ‘evidence’ produced by the CBT movement has not held up to scrutiny and has been shown to worsen patients’ symptoms in many cases rather than alleviating them).

    I think there is a political movement behind CBT, driven by money and in the case of the NHS in the UK, the desire for simple easy-to-teach therapies, easy to present statistics, and budget-driven time-limited support for patients. I’m personally not a fan of CBT and I don’t like the reductionist psychology that underpins it. It’s take-over in the NHS was, in my view, not unlike settler colonialism, with similar effects upon non-CBT psychotherapists and a reinforcement of a Victorian culture of making distressed people responsible for their suffering by focussing entirely on the causes of problems being the result of personal habits and thoughts. In the CBT model we need only readjust ourselves back into the dysfunctional world to be ‘ok’ again.

    • Hi Stephen there is a ‘take-over’ here of CBT in the Prive Clinic system as well in Group Thereapy. It’s mandatory to attend group therapy sessions if you go into a private clinic and it’s 9/10 CBT. Not much good for DID or PTSD. I agree with everything you’ve said. I’m very lucky to be with a psychotherapist who practices EMDR and I am making good though slow progress with her. CBT was a complete waste of time and just made me feel responsible for the abuse. All the best Erin

      • That’s pretty much my experience of CBT from a professional standpoint too. I started a Masters Degree in CBT and hated it so much I quit before the end of the first semester!

      • Wow that speaks volumes in its self. I am very lucky that the Clinic I attend as an inpatient doesn’t use CBT. They use EMDR and other modalities. They speciliase in trauma and PTSD/CPTSD so I am very lucky to have access to it. Unfortunately we have to travel two hours to go there but it’s worth it. My psychotherapist is only 45mins away which is great. She like you offers out of hours contact like I mentioned. People like you and her are like hens teeth. Gold dust. All the best Erin

      • Oh thank you Erin. That’s very kind. It’s the first time I’ve been described as being like a hen’s tooth too! Fantastic. It would be good to hear about your experiences and what has really helped you and how. If you have any posts on that maybe you could point me to them. Take care

      • Hi Stephen,
        The psychiatrist/psychotherapist I see uses EMDR. It’s very effective with processing my trauma which is childhood sexual abuse for fourteen years at the hands of a paedophile ring organised by my parents in Ireland in the 60s/70s. You can type in EMDR in the search engine on the blog and entries will come up. This entry, in particular, may be of interest where she is using another technique as well to cope with the alters (I have Dissociative Identity Disorder due to the abuse) I have responded very well to this treatment and have achieved integration of three of my alters which is fantastic. Unfortunately, we have been unable to achieve anything with the hostile alters who cause the suicidality and self-harm and that is what we are working towards now. I am going into the Clinic on Monday for two weeks intensive treatment and respite as the hostile alters have been very active and she wants to avert any self-harm before it happens. All the best Erin

      • Hi Erin. It’s incredible what you’ve survived. I can’t imagine how horrific it must have been for you. Thank you for those links and for sharing your experiences so openly. All the best, Stephen

      • Thanks Stephen. Hope you find the links useful. Sharing my experiences has proven beneficial to others through the blog so it’s been worth it. Hard to write but good to get it out of my system. All the best Erin

      • Hi Stephen, this is good, really good. I really enjoyed reading it and got a lot out of it. I could relate to a lot of the strategies especially the ones relating to pets and nature (camping). I have a therapy dog and horses, chickens, geeese etc so animals area huge part of my life and give me great solace. The routine of caring for them is very beneficial to me too. I related and agreed very strongly too with having a loving partner and soul mate in your life and walking together, something myself and my partner to all the time on the beach with the dog. Bliss and a great place to solve problems. I share with you, your concerns about world and local problems and am active in lobbying and am involved with GetUp and Greenpeace. I wonder would you consider being a guest blogger with this article on my blog. All credit would go to you and a direct link would feed back to your blog. I think it would be of enormous benefit to my readers. Looking forward to hearing from you. All the best Erin

      • Hi Erin, I’m so pleased that you relate to to this. And yes I’d be honoured to be a guest blogger. You have my email, so let me know.

        Likewise, please post your last comment on that post when you get the chance. Take care for now, Stephen

      • Hi Stephen I can’t find your email address. I have left the commentary on your website and have published the article on the site today. It’s receiving decent volume of traffic already. Thanks for being a guest blogger. All the best Erin

  3. So far as I can recall, when I did CBT in NY, we always let clients know that ANY change in behavior or attitude — even if it was in a healthy direction — could trigger negative reactions among one’s friends and family. A wife becomes more self-assured and assertive — a domineering husband will typically not really like that! A drug or alcohol or gambling addict who typically hangs out with others may often find that their company is less welcome when they become un-addicted. A person who starts addressing their problems at work constructively can easily not “fit in” so well with their peer group if that group just likes to complain without doing anything about it. Anyway, thanks for the post! I guess my approach was to work with clients to anticipate such things and to do some planning around it and in some cases do some role-playing.

    • That’s awesome that you prepare your clients to expect changes such as those you’ve mentioned and that you do role plays. Your clients are lucky to have such a good therapist. All the best Erin

I would love to hear from you so please leave a comment. All feedback is much appreciated. Thank you. Erin

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