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How to Define, Find and Classify Side Effects in Psychotherapy: From

Unwanted Events to Adverse Treatment Reactions

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Clinical Psychology and Psychotherapy
Clin. Psychol. Psychother. 20, 286–296 (2013)
Published online 18 January 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/cpp.1765

How to Define, Find and Classify Side Effects in

Psychotherapy: From Unwanted Events to Adverse
Treatment Reactions
Michael Linden1,2*
1
Research Group Psychosomatic Rehabilitation, Charité University Medicine Berlin, Berlin, Germany
2
Department of Behavioural and Psychosomatic Medicine, Rehabilitation Centre Seehof, Teltow/Berlin, Germany

Objective: Empirical research on the negative effects of psychotherapy is insufficient, partly

because there is a lack of theoretical concept on how to define, classify and assess psychotherapy side
effects. This paper proposes a model for the definition, classification and assessment of psychotherapy
side effects.
Method: Definitions are provided for ‘unwanted events’, ‘treatment-emergent reactions’, ‘adverse
treatment reactions’, ‘malpractice reactions’, ‘treatment non-response’, ‘deterioration of illness’,
‘therapeutic risks’ and ‘contraindications’. We describe processes analysing the causality of negative
events and the correctness of treatment.
Result: A procedural model on how to find, classify and evaluate negative events is described, the un-
wanted event to adverse treatment reaction (UE–ATR) checklist.
Conclusion: Recognition of adverse treatment effects is a characteristic of good therapists and treat-
ments. Psychotherapists should be sensitive for negative effects. This can help improve the quality of
treatment. The UE–ATR checklist can be used in psychotherapy trials, quality assurance, clinical prac-
tice and training of psychotherapists.Copyright © 2012 John Wiley & Sons, Ltd.

Key Practitioner Message:

• If you do not find adverse treatment effects, then ask yourself why and do not assume that there are no
side effects.
• The detection and management of adverse treatment effects is not a sign of bad but of good clinical
practice.

Keywords: psychotherapy, unwanted events, side effects, adverse treatment reactions, malpractice, quality
assurance

DIFFICULTIES TO RECOGNIZE UNWANTED effects and others in psychotherapy or behaviour therapy

EFFECTS IN PSYCHOTHERAPY
Psychotherapy is sometimes seen as a mode of treatment
with good effects and only limited risks and side effects
(Nutt & Sharpe, 2008). But estimates are that the rate of
unwanted effects is between 3% and 15% of the cases,
which is similar to that of pharmacotherapy (Mays &
Franks, 1985; Mohr, 1995; Roback, 2000; Moos, 2005;
Boisvert & Faust, 2007; Jarrett, 2007; Berk & Parker,
2009). There is ample research on the positive effects of
psychotherapy (Bandelow and Broocks, 2002; Barnes,
2003), while research and empirical data on the side effects
could still be better (Barlow, 2010). Searches in PubMed
and PsycInfo by using the key words side effects, negative
*Correspondence to: Prof. Dr Michael Linden, Research Group
Psychosomatic Rehabilitation, Charité University Medicine Berlin,
Lichterfelder Allee 55, 14513 Teltow, Germany.
E-mail: michael.linden@charite.de
from 1964 to 2011 resulted in less than a dozen citations,
and empirical data are even more seldom.
Side effects in psychotherapy are difficult to recognize
and study (Dimidjian & Hollon, 2010; Hatfield et al.,
2010). This is due to several reasons.
1. Side effects of psychotherapy are different from side
effects of drugs, as they are often related to actions of
a therapist who is therefore held responsible for
what happened (Sachs, 1983). It has been shown that
therapists have problems in predicting treatment
course, failure and deterioration (Levenson et al.,
2010). So it must be even more difficult to recognize
side effects. Instead, it can be assumed that there is
rather a tendency to repress the recognition of
side effects or to attribute them to patient behaviour
(Eaton et al., 1993).
2. Because of their relation to therapist actions, side
effects in psychotherapy are not only a therapeutic

Copyright © 2012 John Wiley & Sons, Ltd.

Side Effects in Psychotherapy: The UE–ATR Checklist
problem but also a legal problem and raise the
question of malpractice. This makes it almost
mandatory for a therapist to cover up side effects, as
a measure of self-defence.
3. The differentiation between side effects and unavoid-
able negative developments of the illness or negative
life events is, in many cases, difficult to make (e.g.,
when is the experience of panic during exposure
therapy a side effect?).
4. It is even difficult to differentiate between positive
and negative effects (e.g., is an emotional arousal or
a divorce a negative or a positive treatment effect?).
5. In psychotherapy, there are only limited procedural
standards. Therefore, it is difficult to say whether
side effects occurred in the context of correct or
incorrect therapist behaviour, i.e., whether this has
been a side effect of correct treatment or a consequence
of an inadequate intervention.
6. Different from drug trials, adverse event monitoring is
not mandatory and is often missing in psychotherapy
trials (Hoffmann et al., 2008; Märtens and Petzold,
2002; Märtens, 2005; Wittmund, 2007; Nutt & Sharpe,
2008; Berk & Parker, 2009).
7. The recognition of side effects requires definitions and
a system of classification. There is until now no con-
sensus in this respect. Therefore, the basic requirement
for a systematic research on side effects is missing.
Given this background, the goals of the present paper
were (a) to give a conceptual framework for side effects
different from treatment failure or malpractice, (b) to
describe typical modes of how psychotherapy can
produce side effects, (c) to present a classification system
for psychotherapy-related side effects, (d) to propose a
system for the recognition of side effects in research or
clinical practice and (e) to give recommendations for
future research and training of therapists. This paper is a
theoretical background paper that has been developed in
an ongoing research project on psychotherapy side effects.
DEFINITION OF SIDE EFFECTS
When talking about side effects, first, a clarification of
concept is needed. Side effects must be discriminated from
treatment non-response, deterioration of illness or results
of malpractice. For this, it is helpful to turn to pharmaco-
therapy, where there is a longstanding scientific tradition
with respect to the definition and monitoring of side
effects, with the involvement of scientists, practitioners,
epidemiologists and even government agencies. Although
there are still some problems unsolved, important lessons
can be learned and used for psychotherapy (Doll, 1969;
Skegg & Doll, 1977; Inman, 1981; Nilsson, 1990; Brown,
2002; Barnes, 2003; Bahri & Tsintis, 2005; Wysowski &
Copyright © 2012 John Wiley & Sons, Ltd.
287
Swartz, 2005, Vallano et al., 2010). Guiding principles
are (a) the distinction between unwanted events (UEs)
and side effects, (b) the need of a coding system of events,
(c) the knowledge about the processes that lead to
side effects, (d) the judgement on the appropriateness of
treatment and (e) the judgement on the severity and the
consequences of side effects. Finally, (f) there should be
structured ways of assessment and (g) guidelines on
how to educate therapists. Table 1 gives an overview of
the terms and phenomena that must be kept apart.
‘Unwanted events’ are all events that occur parallel to
treatment in relation to the patient (Skegg & Doll, 1977;
Wysowski & Swartz, 2005). This includes somatic or
psychological symptoms and well-being of the patient
and also his or her social or occupational performance
(Linden & Westram, 2010). UEs are unwanted because of
their negative quality and because they are not intended
by the treatment. Crying of the patient during therapy
may be unavoidable, or a divorce may even be helpful
in the long run. But this will not be the goal of treatment,
and if there would be another therapeutic approach
without this burden to the patient, this would be better;
the burdensome treatment would become obsolete if
not unethical. UEs are collected without aetiological
assumptions or interpretations by collecting events on a
descriptive level without early theoretical ‘explanations’
or ‘excuses’ that can cloud the observation. UE should
be collected even if it may be improbable on first
sight that this could be related to the treatment, as on a
second look this may be very different. In general, a high
rate of under-recognition and under-reporting must be
assumed (Skegg & Doll, 1977; Inman, 1981; Nilsson,
1990). Therefore, a rule could be that every event that is
not definitively positive per se should be collected as UE.
Unwanted events can be related to the treatment or not.
To make a causality judgement, it must be clarified in
which context the UE emerged and how it developed.
This can be guided by looking at diagnostic procedures,
theoretical orientation of therapy, treatment focus,
treatment procedures, sensitization processes, disinhib-
ition processes, direct treatment effects or therapist–
patient relationship. After clarification of how the UE
has developed, a judgement should be possible whether
this UE is treatment related. These UEs can be called
‘treatment-emergent reactions’ (TERs).
Examples of UE that can or cannot be treatment-related
are non-response or deterioration of illness. If a treatment
does not show the expected results, then this is a UE; but
it can well be the result of illness characteristics and
not related to the treatment. No therapist can be held
responsible if an illness cannot be cured. The same is
true for the deterioration of illness. This would be a side
effect only if there is a good reason to assume that lack
of improvement or deterioration of illness is caused by
the treatment.
Clin. Psychol. Psychother. 20, 286–296 (2013)
288 M. Linden

Table 1. Definition of side effects different from treatment failure, deterioration and malpractice

Side effects Definition

Unwanted event (UE)
Treatment-emergent reactions (TER)
Adverse treatment reactions (ATR)
Malpractice reaction (MPR)
Treatment non-response (TNR)
Deterioration of illness (DOI)
Therapeutic risk (TR)
Contraindications
All negative events that occur parallel or in the wake of treatment
Any UE that is caused by the treatment
Any UE that is probably caused by correct treatment
Any UE that is probably caused by incorrect or improperly applied treatment
Lack of improvement in spite of treatment. It is a UE; it can be or cannot be an ATR or an MPR
Worsening of illness during therapy or any other time in the course of illness. It is not
necessarily a UE; it can be a UE and can be or cannot be an ATR or an MPR
All ATRs that are known. Patients have the right to be informed about severe or frequent or
impairing TR as this is the basis for giving their informed consent for treatment
Conditions of the individual case, which make severe ATR highly probable. An ATR of
treatment in spite of given contraindications are one form of MPR

Given a general bias of therapists against the recognition
that a UE is treatment related, a rule could be not to prove
that it is caused by treatment but that it is not caused
by treatment (Barnes, 2003). All UEs should be taken as
treatment related unless it has convincingly been shown
that they are not. Furthermore, therapists must be aware
that some treatment effects are ambiguous in quality, i.e.,
they are therapeutic and negative at the same time,
but these should still be recognized as UE. An example
is emotional turmoil in the patient during treatment,
independent of the fact that it is unavoidable or may even
turn out to be positive in the long run. Some therapists,
such as emotion-focused therapists, suggest that eliciting
of emotional outbursts may be needed in some patients
as a way to induce change. Examples are ‘episodes of
temporary destabilization’, which can ‘represent a precon-
dition for abrupt changes within the therapeutic process’
(Gumz et al., 2010). In spite of the possible positive effects,
such emotional burdens are first of all negative because
they put strain on the patient, similarly to hurting a
patient when doing surgery. Nobody would ever say that
making patients cry and feel bad could be a goal of
psychotherapy. There may at present be no other way to
help. But the very moment that there is another treatment
option, which has the same positive effects without
burdening the patient, it would be clearly unethical to
proceed in such a way. Furthermore, the induction of high
emotional arousal can also result in further negative
outcome, such as inducing a persistent negative emotional
state or increasing alcohol intake (Dishion, McCord &
Poulin, 1999; Moos 2005; Finset et al., 2011).
Treatment-emergent reactions can be side effects or
malpractice reactions. When treatment is not correctly
applied, this is malpractice, and negative results cannot
be attributed to the treatment as such (similar to over-
doses and poisoning in drug treatment). They should be
called ‘malpractice reactions’ (MPRs). Different from this
are unwanted effects of adequate treatment. This requires
a judgement about the correctness of treatment. This
judgement can be based on the same analyses of the
therapeutic process, which have been necessary to come
up to a conclusion on the causality. In summary, these types
of side effects are (a) unwanted events (b) caused by treat-
ment, which (c) has been applied according to the rules,
and they are termed ‘adverse treatment reactions’ (ATRs).
It is important to discriminate UE from TER as these
are very different phenomena. Treatment non-response,
illness deterioration, job loss and divorce are undoubtedly
negative events. But they can be part of the illness process
and fully independent of the therapeutic process. This will
then not characterize nor qualify treatment.
It is also important to discriminate ATRs from MPRs.
MPRs are the direct fault of the therapist who can be held
accountable. The incorrect application of therapy and all
negative consequences can lead to liability claims or
even criminal prosecution. Different from that, ATRs are
treatment-inherent effects. They may be unavoidable or
even necessary, such as crying or divorce, in spite of their
negative quality. They are still important as treatment
should be guided both by the goal to achieve improve-
ment and by the goal to avoid burdens. The recognition
of ATR can therefore be an important driving force to look
for treatment improvements. ATR can also be expected to
some degree, and it is an important duty of therapists to
inform their patients about therapeutic risks and make
this part of the informed consent process.
Known ATRs are called ‘therapeutic risks’ (TR). Condi-
tions of the individual case that make severe ATR highly
probable define contraindications. ATRs of treatment in
spite of given contraindications are one form of MPR.
TREATMENT-EMERGENT REACTIONS
IN THE CONTEXT OF DIFFERENT
PSYCHOTHERAPEUTIC PROCESSES
Given the above definitions of side effects, concepts about
how therapeutic processes lead to therapeutic effects are
needed. This is similar to other treatment areas where
the identification of side effects is carried out in reference

Copyright © 2012 John Wiley & Sons, Ltd. Clin. Psychol. Psychother. 20, 286–296 (2013)
Side Effects in Psychotherapy: The UE–ATR Checklist
to knowledge about actions of the treatment (Doll, 1969).
For example, pharmacodynamic knowledge allows to
discriminate general complaints of a patient from such
symptoms that are, with high probability, caused by the
treatment. Similarly, one can refer to psychotherapeutic
processes and actions when trying to define side effects
(Roback, 2000). As mentioned above, this includes diag-
nostic procedures, theoretical orientations, selection of
the treatment focus, treatment procedures, sensitization
processes, disinhibition processes, direct treatment effects
and therapist–patient relationship. For illustrative pur-
poses, we refer to little prototypical case vignettes that
we have taken from clinical practice or supervision of
psychotherapists in training. Each case depicts a special
problem in the assessment of side effects, which will be
explained in detail.
Treatment-emergent Reactions in the Context
of Diagnosis
Psychotherapy is based on diagnostic information includ-
ing the history of the patient, the description of the
personality, the present symptoms, the somatic status,
and functional or psychodynamic analyses. Assessment
and diagnosis are guided by theoretical concepts of the
therapists (Langwieler & Linden, 1993; Garb, 1998). This
can lead to side effects because of non-recognition of
important aspects of the illness or treatment alternatives.
Treatment-emergent reactions due to diagnostic
procedures: A 55-year-old patient complains about sleep-
lessness, overtaxation, exhaustion and concentration
problems. He thinks that the workload is too high. The
psychotherapist endorses this view and focuses on stress
management as the problem seemed to be clear. In the
course of the treatment, the patient gives up his work, as
this is what seemingly makes him ill. After almost a year
of psychotherapy, a multi-infarct dementia is diagnosed.
One year of causal and preventive treatment is passed
because of psychotherapy.
This example shows that the assessment of negative
effects has to take into account aspects of the illness that
are beyond the area of psychotherapy, as well as other
potentially more effective treatments, be it other forms
of psychotherapy, or pharmacotherapy, or other modes
of treatment, which could have been hindered (Nutt
& Sharpe, 2008, Berk & Parker, 2009).
This case vignette is also an illustration of the close ties
between side effects and malpractice in psychotherapy. If
it is a laboratory test that does not catch the illness and
leads to the wrong treatment, then this is bad fate. If a
therapist does not catch the true problem, then this can
be seen as a malpractice. The question is when this TER
Copyright © 2012 John Wiley & Sons, Ltd.
289
would be an ATR or an MPR. This would be dependent
on the setting. If the psychotherapist has seen this patient
in his or her office, taken a proper history and not seen any
signs that may have suggested further investigations, then
this is not an MPR, as no psychotherapist has to arrange
for an X-ray of the brain if there is no indication. Still, it
is an ATR, as the psychotherapy has kept the patient from
seeing a doctor.
Treatment-emergent Reactions in the Context of
Theoretical Explanations
Psychotherapists must develop theoretical models and
explanations of the problem at hand, which they also have
to convey to the patient. This includes assumptions about
the development of a disorder and how it can be changed.
Such theoretical models can be individual illness concepts
and also schools of psychotherapy, such as behaviour
therapy or psychodynamic psychotherapy. They can
cause side effects (see below), and there may even be risk
profiles for different schools of psychotherapy, such as
regression in psychodynamic psychotherapy.
Treatment-emergent reactions in the context of theoret-
ical orientations: A 29-year-old patient with personality
disorder asks for psychotherapy because of her many
problems with other people, including her family, friends
and workmates. Her mother is the only reliable person
left in her social net. She is a humble, friendly and non-
neurotic person who already, in childhood and during
school, has realized that her daughter has special pro-
blems and who has always tried to care for her daughter
to the best of her capacity. She, at present, takes care of
her grandchild whenever needed. She helps out in critical
financial situations. She is the only one who tolerates all
the critical behaviour of her daughter and is always at
hand when help is needed. During psychotherapy, the pa-
tient is told and gets the notion that the cause of her dis-
order is wrong parenting and that her mother is
responsible for all her problems. The patient accuses her
mother, and finally, the mother separates from her daugh-
ter who is now without support so that, in the end, even
her child is taken away from her.
The example shows that explanations are one thing and
that conclusions from these explanations are another.
Also, explanations and concepts of the therapist and of
the patient may not be the same. In this case, the therapist
has been right, but the patient concluded the wrong thing,
which she would not have done without therapy. This is
an ATR. It even would be an ATR if the patient would
benefit from insulting her mother.
A special problem in this context is false memories that
are induced by theoretical explanations. An example is
Clin. Psychol. Psychother. 20, 286–296 (2013)
290
exaggerating or even false memories of childhood sexual
abuse (Weisberg, 1993; Marchewka, 1996; Lilienfeld 2007;
Linden & Zehner, 2007; Nutt & Sharpe, 2008). Theoretical
assumptions can easily become convictions and, in the
end, even ‘memories’.
Treatment-emergent Reactions in the Context of
Selecting a Treatment Focus
What is the focus of treatment is the result of an
agreement between the patient and the therapist. Still,
in the end, it is primarily the responsibility of the
psychotherapist to know what is needed in the treatment
of the present disorder (Garb, 1998). Negative develop-
ments can occur if a treatment focus is chosen that does
not help to solve the problem but makes it worse.
Treatment-emergent reactions in the context of select-
ing a treatment focus: A 39-year-old patient complains
about being bullied at work. He also shows narcissistic
tendencies. The therapist focuses on solving the problem
and helping the patient to defend himself and find his
right. As the narcissistic attitude of the patient causes
negative reactions to peers and superiors, even when he
is legally right in his demands, this problem-solving
approach turns out to result in even more negative
reactions at the workplace so that, in the end, the patient
is laid off.
This is an example that shows how difficult it can be to
recognize side effects in the context of psychotherapy. It
is right to fight for one’s right, and it is true that the
others have been unfair so that the patient can even feel
confirmed in his view by the course of events. Still, the
aggravation of the problem has been due to the psychotherapy.
In a more general perspective, the problem of treat-
ment selection is also related to the question of contra-
indications. Which type of patient is eligible for a certain
treatment, be it pharmacotherapy, psychotherapy or
different modes of psychotherapy? Obsessive patients
could be a contraindication for very structured behaviour
therapy interventions, intellectual patients for cognitive
interventions, or patients with dependent personalities
for psychodynamic long-term treatment (Crown, 1983).
Research on this question is rare.
Treatment-emergent Reactions in the Context of
Treatment Procedures
As stated earlier, side effects are the result of correct
treatment. An example can be exposure treatment, which
is recommended as the first choice in the treatment of
Copyright © 2012 John Wiley & Sons, Ltd.
M. Linden
phobic anxiety (Nutt & Sharpe, 2008; Bonchek, 2009,
Pence et al., 2010) but still can also increase anxiety.
Treatment-emergent reactions in the context of treat-
ment procedures: A 32-year-old patient suffers from
agoraphobia with panic. She has been in cognitive
behaviour therapy for 20 sessions. The therapist has
carried out extensive exposure treatment including
guided practice. Yet, avoidance behaviour has rather
increased than decreased. The patient now declares that
she will never do exposure treatment again as this is too
frightening. When analysing what has happened, it
becomes evident that a ‘stimulus exposure’, instead of a
‘reaction exposure’ or an ‘anxiety management training’,
had been carried out. The patient had been confronted
with anxiety-provoking situations without having been
taught the skills to cope effectively with these situations
and her anxiety reactions. As a consequence, feelings of
helplessness and personal insufficiency increased, and an
‘anxiety learning process’ was induced.
This example shows how difficult it is to ascertain
correctness of treatment and to discriminate between
unavoidable side effects, avoidable side effects and mal-
practice effects. One could argue that the deterioration
has been the consequence of inappropriate treatment as,
instead of reaction exposure with anxiety management,
a stimulus exposure occurred. This would then be an
MPR. The difference between correct and incorrect psy-
chotherapeutic technical procedures is in psychotherapy,
similar to surgery, often very small (Linden et al., 2007;
Linden & Hautzinger, 2011). To see that something wrong
is going on needs very good professional knowledge and
also a close monitoring of events. In such cases, it can
happen that neither the therapist nor the patient is aware
that the way how treatment was applied has caused the
negative outcome. Still, this case vignette is an example
of an ATR. The therapist has intended the right thing
and proceeded according to the rules. It can happen that
the therapeutic process gets out of hand.
Treatment-emergent Reactions in the Context of
Sensitization Processes
All psychotherapists talk with their patients about
problems, be it problematic experiences, problems in the
environment or problems in the patients themselves.
Being reminded of problems inevitably causes negative
feelings. In a study by Poepel (2006), test persons were
asked to remember situations in which they had prob-
lems. Then, half of them were asked to go on and think
about what had happened and how they had behaved.
The other half was asked to stop thinking and instead
solve other tasks that were unrelated to the critical event.
Clin. Psychol. Psychother. 20, 286–296 (2013)
Side Effects in Psychotherapy: The UE–ATR Checklist
Negative feelings and mood impairment considerably
increased in the remembering group, whereas it improved
in the distracted group. This shows that psychothera-
peutic encounters as such almost inevitably deteriorate
the status of the patient. This is similar to many treatments
in medicine that are inevitably associated with UE, such as
surgeons and scars.
Treatment-emergent reactions in the context of
memory or sensitization processes: A 42-year-old patient
had no psychological trouble in her life up to the day,
18 months ago, when several colleagues of her department
died in a car accident. She was neither a witness of the
accident nor had any of the deceased been very close to
hear. She did not react to this event in any special way.
The company decided that all employees who had been
working together with the deceased should get psycho-
therapeutic help in order to ‘work through the trauma’
and prevent the development of post-traumatic stress dis-
order. In the group sessions, the therapist focused on what
had happened. The accident was discussed in all details,
the meaning of dying, the consequences for the relatives,
the company and oneself, and how oneself would react
to the dying of a near one. The patient step by step devel-
oped vivid fantasies of the accident, became anxious
about what could happen to her, became insecure when
driving a car and experienced recurrent intrusive images
of the accident or possible accidents of family members.
The example above is indisputably a TER. Such
sensitization processes can already occur with simple
psychoeducation (van Gent and Zwart, 1991) when
patients ‘learn more’ about their many symptoms and
problems, which they did not know until then. This can
be even more so when the primary treatment focus is on
remembering negative or traumatic experiences (Bisson
et al., 1997; Mayou et al., 2000; Bledsoe, 2003; Nutt &
Sharpe, 2008). This can result in a sensitization process
with lasting negative results up to the point that a new
state of illness is induced.
Treatment-emergent Reactions in the Context of
Disinhibition Processes
Any treatment can stimulate behaviour that is, in the end,
detrimental to the patient or to his or her environment.
Examples are suicidal acts, which can be stimulated by
antidepressant drugs through the improvement of drive.
Similarly, psychotherapy can, in many ways, disinhibit
problematic behaviour (Bridge et al., 2005). Treatment
can increase drive and reduce inhibition and, by that, also
the drive to act according to depressive despair. It can
intensify the psychological pain of the patient when look-
ing at his or her present problems and, by this, stimulate
Copyright © 2012 John Wiley & Sons, Ltd.
291
acts of hopelessness or revenge. It can focus on events or
persons that are held responsible for the present problems
and thus lead to disruptive behaviour, such as insults or
even physical attacks against the spouse.
Treatment-emergent reactions in the context of disin-
hibition processes: A 52-year-old patient came because of
continuous quarrels with his wife and impending divorce.
Part of the problem was alcohol abuse. The patient
believed that his wife will forgive and come back, on his
promise that in the future everything will become better.
When analysing the problem in psychotherapy, it became
apparent to the patient that his wife wanted a divorce
without any chance of coming back. This intensified the
anger of the patient and his aggression so that he attacked
and hurt his wife.
The example above shows the problem that side effects
do not only emerge in the direct therapeutic encounter
or in respect to symptoms of the patient but can also affect
social or occupational role functioning and conditions of
life at large (Lambert, 2007).
Treatment-emergent Reactions in the Context of
Treatment Effects
From pharmacotherapy, it is well known that many side
effects are main effects, e.g., sedation, but in the wrong
intensity, at the wrong time or in the wrong patient. This
can also be the case in psychotherapy. Psychotherapy
induces changes in patient behaviour and teaches skills
such as assertiveness, reframing of events or emotional
control. The more patients learn and the more they change
their view of the world, their way of feeling and their
behaviour, the more psychotherapy is seen as effective.
But therapeutically wanted effects can nevertheless also
cause problems. More is not necessarily better but can as
well be too much. This can, e.g., be the case when the
treatment target is assertiveness or self care, which can
have adverse effects on the environment (Santisleban
et al., 2003; Szapocznik et al., 2004). The development of
selected skills may also open new avenues in the behav-
iour of the patient, which then can require additional
skills. If these are not given, then treatment success can
result in new problems.
Treatment-emergent reactions in the context of treat-
ment efficacy: A 29-year-old patient had forever been a
rather anxious person. He asked for psychotherapy
because he had problems to express himself or speak out
in groups. The therapist started assertiveness training
and taught the patient ‘to say no’. The treatment was
effective insofar as the patient learned to delineate himself
from others. When doing so, this caused irritation on the
side of his colleagues, resentment, exclusion and bullying.
Clin. Psychol. Psychother. 20, 286–296 (2013)
292
When analysing what had happened, it turned out that
the treatment had been correctly applied, that the patient
had learned assertiveness and also had behaved in the
boundaries of socially normal behaviour. But others, espe-
cially his boss, reacted with irritation as they were not
used to this new behaviour and the patient did not have
the additional skill of consoling his peers and superiors.
The example above shows the multidimensionality of
treatment effects and also side effects. Single outcome
measures, such as, in this case, an assertiveness scale,
cannot tell whether the treatment has been beneficial or
harmful.
Treatment-emergent Reactions in the Context of the
Therapist–Patient Relationship
All psychotherapies are based on a close and trustworthy
personal relation between the patient and the therapist.
Some authors see this even as a prerequisite for any treat-
ment success (Ackerman & Hilsenroth, 2001; Fitzpatrick
et al., 2009). But the therapeutic relationship is inevitably
an asymmetric one (Langhoff et al., 2008). The therapist,
and not the patient, knows the details of the life of the
other, and the therapist has special knowledge. This
unavoidably dominant position of the therapist is one
reason why psychotherapists work under legal regulations
in order to prevent patient abuse. Sexual contacts with a
patient are therefore seen as abuse of a dependent person, a
criminal offence and a malpractice (Gartrell et al., 1986;
Morrison & Morrison, 2001; Rüger, 2004; Nutt & Sharpe,
2008), and detrimental consequences are not ATRs but MPRs.
Still, correct therapeutic relationships can also cause ATR.
Treatment-emergent reactions in the context of the
therapist–patient relationship: A 51-year-old patient ori-
ginally came into psychotherapy because of problems in
adjusting after her divorce. She was a somewhat insecure
person but not to a pathological degree. The psychother-
apist started treatment and provided 80 sessions, which
is the maximum the health insurance will pay. After this,
the patient wanted additional sessions and support from
the health insurance. She had the feeling that she needed
further treatment because the therapist had become her
guide through life. It became evident that a focus of
treatment had been her insufficiencies, which intensified
her feeling that she was a person in need of help and that
the therapist was the very person to know how to solve
the problems in her life. The original problems after her
divorce were meanwhile history and no topic anymore.
The example above shows that patient ratings on
the quality of psychotherapy can well be misleading.
Dependent patients will see prolonged treatment as a
Copyright © 2012 John Wiley & Sons, Ltd.
M. Linden
reflection of special therapeutic attention and be unable
to see the dependency problem. Similarly, it may be
unavoidable that a therapist takes over responsibility for
patient behaviour or living conditions by controlling or
dominating the patient. Still, this can cause dependency
on the side of the patient and even lead to withdrawal
symptoms like in some drugs (Horowitz, 2000; Rüger,
2004; Nutt & Sharpe, 2008; Berk & Parker, 2009).
Side effects in the context of the therapeutic rela-
tionship can also be caused by pathological behaviour
of patients and countertransference processes, which
can infect the therapist and lead to negative therapist
reactions. In such cases, it can happen that the patient
is criticized, is belittled or becomes a goal of hostile
therapist actions in reaction to similar patient behav-
iour (Lieberei & Linden, 2008; von der Lippe, Monsen,
Rønnestad & Eilertsen, 2008). Even if this could be
called an interaction in lack of some professionalism,
this would not be enough to talk about MPR but
would still be counted as ATR.
CLASSIFICATION AND ASSESSMENT OF
UNWANTED EFFECTS AND ADVERSE
TREATMENT REACTIONS
The case vignettes show how difficult it is to recognize
and diagnose side effects, which can include symptoms
as well as living conditions at large. To help with the rec-
ognition of UE, we recommend a coding system. This
can guide the attention of the assessors and also allow
comparisons across different studies (Brown, 2002,
Bahri & Tsintis, 2005, Wysowski & Swartz, 2005).
Table 2 provides a list of UE classes that are relevant
for psychotherapy. This list is a proposal based on clin-
ical experiences and psychotherapy as well as pharma-
cotherapy research. To recognize and find UE requires
a rather broad perspective on negative events. Accord-
ing to the definition of UE, this list covers symptoms
and complaints, the well-being of the patient, the
therapeutic relation, other treatments, the relation of
the patient to other persons, family relations, the work
status or any other changes in the life circumstances of
the patient. The list of UE in Table 2 can serve as a
classification if not a checklist in the monitoring of UE
in psychotherapy.
After finding UEs, the causality and the treatment con-
text must be evaluated. This includes judgement about
the correctness of treatment. This can be guided by refer-
ring to the same psychotherapeutic processes as described
above. As there is in many cases no definite way of saying
what has been caused by what, a probability rating is
required. This allows, also to include cases of doubt.
We recommend a simple five-step rating ranging from
unrelated to related (Table 2).
Clin. Psychol. Psychother. 20, 286–296 (2013)
Side Effects in Psychotherapy: The UE–ATR Checklist
Table 2. Checklist for the assessment of psychotherapy unwanted event and adverse treatment reaction (UE–ATR checklist)
Finally, it is important to say how severe the ATR has
been. This is important not only for therapeutic reac-
tions to the event but also for the evaluation of treat-
ments as such. Treatments with frequent but mild
ATR are less problematic than treatments with rare
but severe ATR. Therefore, also the severity of the
event must be coded. Table 2 gives a recommendation
on how to classify the severity of ATR. It ranges from
mild to very severe, depending on the type and conse-
quences of the ATR. A criterion for judgements on the
severity is the consequences of the event. ATR without
any consequence can be called mild. An example
would be a patient who is crying during therapy.
Moderately severe ATRs are distressing, such as
increased dissonance with co-workers. Severe ATRs
are in need of countermeasures, such as plans to step
down from work; very severe ATRs result in lasting
negative consequences, such as divorce or losing the
job; and extremely severe ATRs are life threatening or
require intensive measures, such as hospitalization.
THE UE–ATR CHECKLIST
The assessment of ATR requires that therapists and
scientists are aware of the problem and know how to find
side effects (Inman, 1981, Bahri & Tsintis, 2005). The
Copyright © 2012 John Wiley & Sons, Ltd.
293
course of treatment has to be monitored closely and sys-
tematically (Lambert et al., 2007). It is even recommended
that therapists should get special training in this respect
and use standardized methodologies in order to avoid
judgement biases (Doll, 1969; Vallano et al., 2010). Table 2
can be used as such an instrument and rating form in the
search for side effects of psychotherapy and help in the as-
sessment and classification of UE, the diagnosis of the
context of their development, the rating on the relation
to treatment and on the severity of ATR. Therapists, super-
visors and researchers are encouraged to take such a scale
and monitor the ongoing treatment on a regular basis.
The detection of side effects is always a fact-finding and
later on a fact validation process. The UE–ATR checklist is
therefore no scale with psychometric properties. As the
name says, it is a checklist and an attention-guiding in-
strument. For clinical practice, it is important to encourage
a side effect orientation of therapists so that in case of
doubt they take into account rather more than less events.
The UE–ATR checklist can guide the recognition as it tells
where to look for UE and how to decide whether this is an
ATR. It is recommended to fill in the UE–ATR checklist in
fixed intervals.
In supervision and training, the question for UE
should be a regular exercise in order to teach the novices
side effect awareness and orientation. This includes the
Clin. Psychol. Psychother. 20, 286–296 (2013)
294
notion that finding side effects is not a sign of a bad but
rather of a good therapist. In our own practice, we ask
the trainees in reference to the UE–ATR checklist systema-
tically for UE and then teach them to do the secondary
appraisals. They also have to learn that there remains
always some degree of uncertainty. In psychotherapy
research, standardized instruments for the assessment of
side effects should be made mandatory. The UE–ATR
checklist could be an option. A UE–ATR scale should be
filled in at every assessment point.
CONCLUSIONS
Psychotherapy is not free of risks. There can be negative
consequences. In dealing with side effects of psychother-
apy, several general conclusions and recommendations
can be drawn.
1. In psychotherapy, like in any other mode of treat-
ment, it is as important, if not even more important,
to avoid an ATR than to get positive treatment
effects. The first rule in all treatments is not to harm
the patient.
2. For psychotherapists and their patients, it can be
difficult to recognize side effects, and they are some-
times even reattributed as reflecting good treatment
results. So feeling secure does not mean being on
the safe side.
3. Psychotherapists should always look for UE even
without special reason. Therapists should be aware
that treatments that work must have ATR.
4. Psychotherapists should be aware that they have a
bias not to see UE nor ATR, to reattribute UE as
normal developments or to even interpret them as
the result of patient behaviour. Therefore, they should
look twice before being sure that everything is okay.
5. Asking for UE should be a regular part of supervi-
sion, intervision and therapeutic self-monitoring.
6. An important part of education of psychotherapists
should be to train therapists to ask for UE, learn to
recognize, describe, classify and prevent UE, and how
to make a rational judgement on ATR (Castonguay
et al., 2010).
7. ATR does not mean MPR. Good therapists recognize
ATR. A general rule is that only after a therapist has
identified UE and ATR he or she can be content.
8. The checklists in Table 2 allow to classify UE and
ATR of psychotherapy on the dimensions event/
context/relation/severity (UE–ATR checklist).
9. An UE–ATR checklist should be added to all patient
record forms in psychotherapy trials. This would not
only stimulate systematic research on UE in
psychotherapy but also allow to compare UE lists
across different treatment trials and treatments.
Copyright © 2012 John Wiley & Sons, Ltd.
M. Linden
10. UE and ATR assessments, possibly based on the
UE–ATR checklist, should be part of any quality man-
agement system in psychotherapy and clinical care.
11. In general, more research and more publications on
UE and ATR in psychotherapy are needed to keep
the subject in the minds and hearts of the profession.
Scientific and professional journals should do more
in this direction.
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