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Risk factors for negative experiences during psychotherapy

Hardy, Gillian E.; Bishop-Edwards, Lindsey; Chambers, Eleni; Connell, Janice; Dent-Brown, Kim; Kothari, Gemma; O’Hara, Rachel; Parry, Glenys D.


Gillian E. Hardy

Lindsey Bishop-Edwards

Eleni Chambers

Janice Connell

Gemma Kothari

Rachel O’Hara

Glenys D. Parry


Background: It is estimated that between 3% and 15% of patients have a negative experience of psychotherapy, but little is understood about this. Aims: The aim of this study was to investigate the factors associated with patients’ negative therapy experiences. Method: The data comprised 185 patient and 304 therapist questionnaires, 20 patient and 20 therapist interviews. Patients reported on an unhelpful or harmful experience of therapy, and therapists on a therapy where they thought the patient they were working with had a poor or harmful experience. These were transcribed and analysed using thematic analysis. Results: There was a Lack of fit between Patient needs, Therapist skills, and Service structures. This could result in Fault Lines, a tension between Safety and containment and Power and control. This tension led to Strain and Poor Engagement, which led to Consequences following the negative therapy experience. Conclusions: Patients require clear information, choice, involvement in decision-making, explicit contracting and clarity about sessions and progress. Opportunities for patient feedback should be the norm, where the therapist and service are vigilant for signs of deterioration and solutions considered.Clinical and methodological significance of this article: Estimates of “unwanted effects,” including long-lasting effects, of psychotherapy have ranged from 3% to 15%. Few empirical studies have been conducted in this area. This study aimed to address this gap and provide clinicians with a model of risk factors for negative therapy effects. The findings of this study indicate the importance of providing patients with a supportive service structure that offers clear information, choice and involvement in decision-making. Explicit contracting at the beginning of therapy and clarity about sessions and progress are also important in managing patient expectations throughout. Opportunities for patient feedback should be provided.


Hardy, G. E., Bishop-Edwards, L., Chambers, E., Connell, J., Dent-Brown, K., Kothari, G., …Parry, G. D. (2017). Risk factors for negative experiences during psychotherapy. Psychotherapy Research, 29(3), 404-414.

Journal Article Type Article
Acceptance Date Oct 9, 2017
Online Publication Date Oct 27, 2017
Publication Date Oct 27, 2017
Deposit Date Oct 30, 2017
Publicly Available Date Oct 31, 2018
Journal Psychotherapy research
Print ISSN 1050-3307
Electronic ISSN 1468-4381
Publisher Routledge
Peer Reviewed Peer Reviewed
Volume 29
Issue 3
Pages 404-414
Keywords Risk factors; Negative therapy experiences
Public URL
Publisher URL
Additional Information This is the accepted manuscript of an article published in Psychotherapy research. The version of record is available at the DOI link in this record.


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