Negative Effekte von Psychotherapie – Ein Mixed-Methods Ansatz

While there is ample evidence of the positive influence of psychotherapy, its potential negative effects have seldom been the subject of scientific research (Jacobi, 2002; Margraf, 2009; Märtens & Petzold, 2002). It was the aim of this dissertation to investigate the frequency of and factors influencing the negative effects from psychotherapy in standard health care by applying quantitative and qualitative methods. With deeper understanding about when and how psychotherapy can trigger negative effects, psychotherapeutic interventions could be evaluated in greater depth. That would also mean that treatment decisions could be made more autonomously and with patients informed consent, factors very much in harmony with the laws addressing patients’ rights. To this end I will refer to three publications in my cumulative dissertation. In Study I, a standardized questionnaire was developed to capture negative effects of psychotherapy and malpractice/unethical behavior. To that end, an item pool created by a committee of experts via online collection of data from N=195 former psychotherapy patients was evaluated. From that, an Inventory for the assessment of Negative Effects after Psychotherapy (INEP) containing 21 items was drafted. The participants were queried as to any negative effects in various respects (worsening symptoms, the appearance of novel symptoms, being overly dependent on the therapist, conflicts with their partner, family or circle of friends, conflicts at work, and stigmatization due to therapy). My aim thereafter was to subject the new instrument to further assessment and thereby enable deeper insight into the factors influencing the negative effects of psychotherapy and their frequency in different therapeutic settings. In so doing, patients in an outpatient setting (N=182, cross-sectional) as well as an inpatient setting (N=118, longitudinal) were asked after their treatment whether they had experienced any negative effects, malpractice, or unethical behavior. What became evident was that outpatients most frequently report having trouble getting their health insurance, while inpatients most often report that their symptoms have worsened. When asked about malpractice or unethical behavior on their therapist‘s behalf, patients in both settings most often reported having been hurt by something the therapist had said and by having been forced to do therapeutic interventions they did not want to do. At the same time, most patients reported having experienced positive effects from their psychotherapy. Predictor analyses revealed that negative effects from psychotherapy and malpractice or unethical behavior are more likely to be reported by patients who have already undergone psychotherapy, and by negative expectations and a negative therapeutic relationship. Qualitative data was collected in addition to collecting quantitative data. To that end, a total of N=24 previous psychotherapy patients were queried as to their negative experiences with psychotherapy in an interview I designed and structured. Via qualitative analyses I investigated those aspects of life in which negative effects arose and the causes the patients held responsible for them. These demonstrated that a substantial number of the causes could be attributed to factors outside the therapeutic relationship, eg, conditions in the clinic and an inflexible healthcare system. In conducting this research I was able to draft a new questionnaire capturing the negative effects of psychotherapy from the patient’s perspective – an economical instrument with which to systematically investigate negative effects. Moreover, I have been able to contribute to the knowledge about the factors that favor the perception of negative effects and malpractice. Previous experience with therapy and pessimistic expectations are particular risk factors in that context. I also deliver qualitative data that give us deeper insight into how negative effects come about from the patient’s perspective.