Harm, deterioration and dropout

Between 5% and 10% of adults are worse at the end of psychotherapy than at the start. For children and adolescents estimates run higher, to around 14%. These figures come from routine outcome data rather than from trials, which frequently do not report deterioration at all.

Sources of harm

Treatment-specific harm

Debriefing after trauma, which increases PTSD risk; Scared Straight programmes, which increase offending; some grief interventions for uncomplicated bereavement.

Iatrogenic memory

Suggestive techniques producing confident false memories, with consequences beyond the consulting room.

Boundary violations

Sexual and non-sexual, with well-documented severe harm.

Missed or wrong problem

Treating depression while missing a medical cause, an eating disorder, or ongoing abuse.

Dependency and deskilling

Long treatments that erode the patient’s sense of their own capacity.

Cultural harm

Pathologising accurate appraisals of discrimination, or requiring a patient to adopt the therapist’s values.

Opportunity cost

Two years of a treatment that does not work is two years not spent on one that might.

Dropout

Roughly 20% of adults drop out of psychotherapy, with wide variation by setting and population. Dropout is predicted better by alliance and by unmet expectations than by symptom severity, and it is substantially reduced by accommodating patient preferences and by explicit orientation to what treatment involves.