Opening the Black Box of Negative and Positive Unintended Experiences in Psychotherapy

Abstract

Background: Psychotherapy has been shown to produce effective outcomes for a range of psychological difficulties. Besides its intended benefits, psychotherapy may also have unintended effects during or after treatment, which remain underexplored in clinical practice and scientific research. These unintended effects are defined as experiences that fall outside the goals of therapy and may be either negative or positive. We investigated which unintended experiences former patients and clinicians had encountered and how these experiences were interpreted.

Method: Five former patients and six clinicians, including psychotherapists and psychologists with post-master’s specialist training in mental healthcare, participated in semi-structured focus group interviews about their personal therapy experiences. The narratives were analysed using reflexive thematic analysis with an inductive approach.

Results: The following themes emerged: (1) negative unintended experiences, such as the worsening of existing symptoms or the emergence of new symptoms; (2) positive unintended experiences, such as increased autonomy or remoralization; and (3) uncertainty regarding the classification and determinants of unintended experiences, such as where to draw the line between an intended therapeutic goal and an unintended experience. While some experiences were mentioned by both former patients and clinicians, others appeared to be role-specific. For example, only former patients shared experiences related to not feeling heard or seen, or receiving insufficient psychoeducation.

Discussion: Our study highlights notable differences in the concrete experiences shared by former patients and clinicians, as well as in the ways unintended experiences were explained. Former patients prioritized the nature and subjective impact of these experiences, whereas clinicians emphasized underlying mechanisms and therapeutic rationale. This points to a gap between the two perspectives. In terms of clinical practice, it is essential to narrow this gap, for example through the systematic and concurrent monitoring of experiences and the facilitation of open dialogue between both parties. Importantly, monitoring should be designed in a nuanced way that captures both negative and positive experiences. By explicitly discussing both types of experiences, a more balanced view of therapy can emerge, allowing clinicians to intervene in a timely manner when unwanted experiences occur.