Negative events in psychotherapy: A narrative review

While psychotherapy is effective for numerous mental health conditions, it may also result in undesirable effects, such as mild emotional distress, symptom exacerbation, dependency, and, in certain cases, ethical violations by therapists, which are frequently underreported. This narrative review synthesizes existing literature to evaluate the prevalence, underlying mechanisms, ethical implications, and prevention strategies for negative events in psychotherapy, including side effects, adverse effects, and therapist-related harm. The incidence of negative effects varies significantly due to inconsistent definitions and research methodologies. Factors such as weak therapeutic alliances, therapist incompetence, cultural mismatches, and systemic deficiencies contribute to the development of negative effects. Additionally, vulnerable groups, including youth, trauma survivors, and ethnic minorities, are also affected. Current assessment tools, such as the Inventory for the Assessment of Negative Effects of Psychotherapy and the Negative Effects Questionnaire, fail to fully capture the complexity of harm, while ethical issues such as inadequate informed consent persist. To enhance safety, psychotherapy requires standardized harm monitoring, comprehensive therapist training, culturally tailored approaches to meet diverse client needs, and routine outcome tracking to detect and address negative events early. The lack of comprehensive tools impedes transparent risk communication, intensifying ethical challenges such as inadequate informed consent. Clear definitions and comprehensive assessment tools are essential to provide safer, more ethical, and effective care.