How Does Therapy Harm? A Model of Adverse Process Using Task Analysis in the Meta-Synthesis of Service Users' Experience

Abstract

Background: Despite repeated discussion of treatment safety, there remains little quantitative research directly addressing the potential of therapy to harm. In contrast, there are numerous sources of qualitative evidence on clients' negative experience of psychotherapy, which they report as harmful.Objective: To derive a model of process factors potentially leading to negative or harmful effects of therapy, from the clients' perspective, based on a systematic narrative synthesis of evidence on negative experiences and effects of psychotherapy from (a) qualitative research findings and (b) participants' testimony.Method: We adapted Greenberg (2007) task analysis as a discovery-oriented method for the systematic synthesis of qualitative research and service user testimony. A rational model of adverse processes in psychotherapy was empirically refined in two separate analyses, which were then compared and incorporated into a rational-empirical model. This was then validated against an independent qualitative study of negative effects.Results: Over 90% of the themes in the rational-empirical model were supported in the validation study. Contextual issues, such as lack of cultural validity and therapy options together with unmet client expectations fed into negative therapeutic processes (e.g., unresolved alliance ruptures). These involved a range of unhelpful therapist behaviors (e.g., rigidity, over-control, lack of knowledge) associated with clients feeling disempowered, silenced, or devalued. These were coupled with issues of power and blame.Conclusions: Task analysis can be adapted to extract meaning from large quantities of qualitative data, in different formats. The service user perspective reveals there are potentially harmful factors at each stage of the therapy journey which require remedial action. Implications of these findings for practice improvement are discussed.

Exploring harm in psychotherapy: Perspectives of clinicians working with children and young people

“…Additionally, exploration with children, young people and parents around harm is also needed, particularly as there is a lack of congruence between them around the types of mental health difficulties and treatment options (Yeh & Weisz, 2001). This may allow for the identification of harmful experiences which remain out of the awareness of particular stakeholder groups, especially since patients’ and therapists’ understanding of negative effects are divergent (Curran et al., 2019).…”

A systematic review of the effectiveness of art therapy delivered in school-based settings to children aged 5–12 years

“…These findings raise the issue of whether longer durations of treatment are indeed more beneficial than shorter. One possibility is that during extended number of sessions, children become more aware of their emotions, which often comes with greater amount of distress, or fear of separation when arts therapies come to an end (Curran et al, 2019). Providing information such as, the art therapist background and experience, or the participants' preference for art therapy could shed light to this question.…”

Preventing harm related to CBT supervision: a theoretical review and preliminary framework

“…Ellis et al, 2014;Ladany, 2014), with definitions of harm in the therapy literature (e.g. Curran et al, 2019;Klatte et al, 2018;Schermuly-Haupt et al, 2018), and on those within the 'client safety' literature (e.g. World Health Organization, 2009).…”

“…Table 1 also incorporates valuable concepts from the literature on the harm that therapy can cause to clients (e.g. Curran et al, 2019;Hardy et al, 2017;Klatte et al, 2018), in addition to examples of the systemic harm that can be done to supervisors and supervisees within organizations. This ensures that the key roles related to supervision are each accorded due emphasis: the supervisors, supervisees (therapists), clients and service managers.…”