Can psychotherapy have side effects? Michael Linden believes it can. He launched some of the key studies that shed light on this under-appreciated phenomenon, and discusses them in this podcast-interview.
Opening
So far, no one has had an allergy to psychotherapy, but psychotherapy can cause side effects, even when it’s done correctly.
Chris Aiken, MD 
Kellie Newsome, PMH-NP
Podcast Text
KELLIE NEWSOME: I was excited to see that the Carlat Report chose psychotherapy as this month’s foxus. But I have to say I found this interview on psychotherapy side effects, well, rather challenging.
CHRIS AIKEN: How so?
KELLIE NEWSOME: One thing that patients struggle in psychotherapy is that they avoid pain, so when I practice psychotherapy I’m often trying to get them to move toward that pain instead of away from it. This might be in exposure therapies – like when I work with trauma or phobias, or with depression – depressed patients will often stay in bed and avoid doing anything because it makes them uncomfortable or anxious. So, the way I see it, psychotherapy is difficult, and it ought to be difficult because that’s what makes it work. So why is Dr. Linden calling that a side effect?
CHRIS AIKEN: You’re not alone in that Kellie. Judging from the reader feedback a lot of people were challenged by Dr. Linden’s ideas. Here’s what I think is going on. We have a bias in our field about psychotherapy – and perhaps about life – and Dr. Linden is coming at this work without that particular bias – which is unsettling. The bias is something like what you just said – it’s the idea that the only way to grow in life is through difficulty – and it’s imbedded in a lot of our idioms – “no pain, no gain;” “every rose has its thorns;” “what doesn’t kill you makes you stronger.”
KELLIE NEWSOME: Or like a therapist said to me once, “The patient has to get worse before they can get better.” So Dr. Linden believes you don’t need to suffer to get better?
CHRIS AIKEN: We’ll he’s also a realist, and he sees “side effects” as a somewhat inevitable consequence of psychotherapy – in fact of any medical treatment. He’s just trying to call it what it is, because for many years we’ve been glorifying them as the royal road to recovery. In other fields of medicine, we don’t do that. When patients have memory loss on ECT we don’t say, “This is part of the cure, you need to forget the pain that is making you depressed.”
KELLIE NEWSOME: Well wait I have heard this said in psychopharmacology. Like with mood stabilizers. Some doctors warn patients that they may feel flat or dull on the mood stabilizer, but that this is an inevitable part of treating the extreme highs of mania. Or with SSRIs – sometimes patients feel emotionally numb on them and their doctor will tell them this is because the alternative is to feel anxious and overly reactive.
CHRIS AIKEN: That’s true we do say that sometimes… and perhaps we shouldn’t. I think what’s happened here is that we’ve been so busy trying to get patients to stick with treatment – whether psychotherapy or medication – that we’ve created this mythology around the negative aspects of treatment – the side effects – as though they were inevitable or even necessary to the cure. But really – we can treat anxiety or neurosis without causing apathy like the SSRIs do – there’s bupropion, buspirone, even EMSAM and SAMe – and these don’t tend to make people emotionally numb. And sedation and affective flattening are not inevitable consequences of mood stabilizer treatment. If they were, then anything that makes you feel tired and out of it would treat bipolar disorder. These are side effects to mood stabilizers, not part of the cure.
Dr. Linden: “Well, you know in pharmacotherapy, the assessment of side effects has a long tradition meanwhile. In the early days, it didn’t have a tradition also. But then people learned, and especially regulators were forced to have a closer look at side effects. And since then side effects in pharmacotherapy are a major aspect of whether a company will market a drug or not. So marketing is very much dependent on side effects. And therefore if you have a drug which is having major or many side effects, will just not be on the market, so there is a limit. For example, amitriptyline, an old antidepressant which is still available, would nowadays never be marketed.
So that’s why you have a little bit of time on the topic in pharmacotherapy, while in psychotherapy up to now, there is no such tradition. And so everybody who has a nice thought creates a new psychotherapy, and whether that’s helpful or not well, it’s an interesting question”
Staying with the Anxiety
KELLIE NEWSOME: OK so back to psychotherapy. Let’s talk about exposure therapy – I understand Dr. Linden is himself a CBT therapist and has done a lot of exposure work. So I thought it was necessary for phobic patients to experience anxiety in order to overcome their phobias. Exposure therapy does this, and so do the third-wave behavior therapies like Mindfulness and Acceptance & Commitment Therapy – these all encourage the patient to “be with” the anxious feeling instead of running away from it.
CHRIS AIKEN: You’re right – all of those therapies cause anxiety, and on the other side they all work to improve anxiety disorders. So I can understand how you’d come to believe that – as you put it – you have to go….
KELLIE NEWSOME: Yes you have to go through the anxiety to get to the other side of it.
CHRIS AIKEN: Well, Dr. Linden is suggesting we stop calling this a necessary step in therapy and call it what it is: A side effect.
KELLIE NEWSOME: That makes it sound like there’s something wrong, like exposure is a bad therapy.
CHRIS AIKEN: No – this is another part of his work where it helps to put our biases aside to understand what he’s saying. Dr. Linden defines “Side effects” as unwanted effects of good therapy – these aren’t therapeutic mistakes like boundary violations, and they aren’t the result of bad therapy either. Again, it’s just like with medication. When sertraline causes nausea or sweating, we don’t say that it’s a bad medicine, or that I’m a bad doctor for prescribing it. It’s a side effect.
KELLIE NEWSOME: OK I think I’m starting to get it. Exposure therapy is a valid therapy – it’s one of the best we have for phobic anxiety. But it causes a side effect – particularly in the beginning – in that it makes the patient feel worse. In fact they feel more anxiety – the very thing they’ve come to us to overcome.
CHRIS AIKEN: Yes and if they get more anxious during the therapy there are several ways it could turn out. They might get better – if the therapy works – and come out with less anxiety than ever before. But exposure therapy doesn’t work. It could cause flooding – where it makes them anxious beyond the point that they can tolerate and they give up on therapy. Or they might go through all the hard work of exposure and not get better. Or they might even go through exposure therapy – with all the anxiety that entails – and come out feeling worse – in other words their condition could get worse during therapy. Now it’s hard to prove that any of those results are caused by the therapy, just as it’s hard to prove that any given side effect is caused by a medication. But we at least need to think about these possibilities.
Dr. Linden: “In behavior therapy if you are treating anxiety we do exposure treatment. We want to have the patient confront anxiety in order then to learn how to cope with anxiety, and if it’s really a good treatment, in the end, to be able, for example, to go to the subway without any anxiety anymore. To get to that end, you have to expose the patient to situations which are frightening for the patient. Well, if everything comes out fine, the patient will lose the anxiety. But I’ve seen dozens of patients who after that have more anxiety than before, so this can happen.”
What’s in a Name
KELLIE NEWSOME: So we need to think of anxiety as a side effect, rather than a good part of the therapy. But how does that change things? You’re just calling it by a different name.
CHRIS AIKEN: In practice, it shifts us more toward the patient’s experience, because it forces us to recognize aspects of therapy that are negative for the patient. So it’s more compassionate. Like I’ve said, as professionals we tend to venerate some of these side effects – imbuing them with hidden therapeutic mechanisms as though they are necessary for recovery. But patients don’t see it that way. And we also tend to be blind to problems we’re causing with our treatments. Whether you’re a primary care physician or a psychotherapist, it’s easier to see the good we’re doing then then harm. We’re only human. So Dr. Linden’s idea is that we need to intentionally watch for side effects, and even engage the patient in that. He believes in informed consent – he’ll warn patients that they may experience negative effects during therapy. In that way he’s helping them to make rational decisions about their treatment, which is ultimatel y what they need to do in life. Few of the choices we have available to us in life are perfect – they do some good, they do some harm, and we try to follow the path that works best on balance. Why should psychotherapy be any different?
KELLIE NEWSOME: So I’m guessing Dr. Linden wouldn’t agree with the idea that everyone should be in psychotherapy.
CHRIS AIKEN: Well, he’d at least want them to consider the risks and benefits. One thing he said that has changed my practice is that even the act of gathering a history has side effects.
Dr. Linden: “Well, let’s start at the beginning. You see a psychotherapist; the first thing is he’ll start with the anamnesis – so with the history taking, right. And then he starts asking you how you feel about your mother and your father and your spouse, and so on and so forth. And just by talking about all the negative events which you experienced in your life, this may already start to have negative impact on you because all of a sudden you get the feeling your life has been possibly a whole mess.”
Painful Histories
I think of a few patients I’ve seen who literally refused to let me take a psychiatric history. They weren’t paranoid. They just didn’t want to think about the past – the depressions and psychiatric hospitalizations – it was too painful to talk about. And from my point of view as a doctor I thought this was irrational – How could I help them without taking a history? But after talking with Dr. Linden I see it more compassionately. Essentially, they were telling me, “Yes I know your medicine can help – and taking a history is part of that medicine – but it causes side effects that I don’t want to experience right now. And I need to be in charge of my own experience.”
KELLIE NEWSOME: So did you ever get that history?
CHRIS AIKEN: Not really. I had to piece it together – you know – over time, talking to the family and gathering records. But the patient never went through it with me. And I’ve come to appreciate their honesty as well. A lot of patients aren’t assertive enough to tell us that they don’t want to go through their history, so they instead they give us a history that’s vague and inaccurate, and we may end up believing they’ve never had a suicide attempt or a manic episode. These patients were at least alerting me to the fact that there was something big in their psychiatric history – even if they didn’t want to talk about it.
Side Effects Are Common
Dr. Linden: “Group therapy by itself has a high rate of side effects just to start with. sit in the group and listen to all of the problems of the other patients. This is burdening. And if you then have to think whether what you hear from the others may also be true for yourself, there is demoralization as we call it. You have maybe, for example, maybe an anxiety disorder. You hope that it will become better. And then there is in the group another person who tells you ‘Well, at your point I had been years ago, and it will not go away.’ Okay, that’s demoralization.”
KELLIE NEWSOME: One thing Dr. Linden says that struck me is that nearly every psychotherapy has side effects. He started doing research on this in the early 2000s, and since then others have followed in his footsteps – and in some of the studies they’ve done 90-100% of people have side effects during psychotherapy. Only about 10% of these are significant or lasting however, but that’s still a lot. So even good therapy has side effects, but what about bad therapy – aren’t there therapies that we just don’t do anymore because they nearly always cause harm?
CHRIS AIKEN: Yes, but it’s not about being good or bad. If we’re going to innovate in psychotherapy and try new things we’re going to run into some blunders that do more harm than good. But if we look at them fully from the get go – and research their side effects as well as their benefits – then we can catch these things before they spread too far.
Problematic Therapies
KELLIE NEWSOME: OK last week we talked about a medication that got taken off the market – zimeltidine, the first SSRI. So what are some therapies that have been taken “off the market” – so to speak?
CHRIS AIKEN: The most notorious was recovered memory therapy. This was popular in the 1980’s and 1990’s. The therapist would suggest that the patient may have repressed memories of abuse as a child, and the patient would start to uncover these memories even if they’d never recalled them before. Often the remembered abusers were people close to them, like their parents, and this split up families and even lead to false accusations in court. Then the law suits started to go in the other direction, and some of the aggrieved families starting suing therapists for planting these misperceptions in the patient’s minds. Eventually the courts, and later many professional organizations came out against this kind of therapy, but it hasn’t been pulled from the market. You can’t take away a psychotherapy like you can a drug.
Dr. Linden: “So the therapist tries to answer questions like that. And then he tries to remember. And in the end there will be induction of false memories, just by asking, and if you a patient who is sensitive to that. This is very quick. There is a whole bunch of literature on false memories which can be induced just by asking a patient the history. So this can be a major side effect.”
KELLIE NEWSOME: Does recovered memory therapy still go on?
CHRIS AIKEN: Yes. In 2018 there was a survey of over 1,000 U.S. adults who had undergone psychotherapy in the past few decades. 1 in 5 respondents said that the therapist had suggested that they might have repressed memories of childhood abuse. Those suggestions peaked in the 1990’s, up to 27%, but they have stayed between 15-20% in the decades since. And it has a definite effect. True or not, half of the people who received that suggestion ended up recovering memories during their therapy (Patihis L, Pendergrast MH, Clin Psych Sci 2019, 7;1:3-21). We could do a whole podcast on the false memory debate, but let’s just keep it short today and say there is research proving that false memories can be implanted, and that even when people experience a real traumatic event they often have distorted memories about that event.
Affective Avoidance
KELLIE NEWSOME: OK So let’s get back to research. What evidence do we have that psychotherapy can cause harm?
CHRIS AIKEN: One possibility that Dr. Linden brought up is that focusing too much on negative events can be demoralizing. He told me about a study where they asked a group of people to recall a time when they had problems. Then, half of them were asked to go on and think about what had happened during that difficult time. The other half was asked to stop thinking about it and instead solve other, unrelated tasks. At the end, mood symptoms got worse in the people who spent their time remembering a difficult time in their life, but mood improved in the ones who were distracted by another task were (Poepel N, DGPPN-Kongress Berlin, 2006).
KELLIE NEWSOME: That is something I hear a lot from patients with depression. They say they don’t want to do therapy because it makes them more depressed to talk about their past or their problems. How do you work with that in therapy?
CHRIS AIKEN: To start with you need to understand that what the patient is saying is true – it does make them more depressed! I see this a lot and I call it affective avoidance. People with mood disorders often don’t want to be reminded of their past depressions. They may avoid songs, people, even entire cities that remind them of what they’ve been through. They have strong emotional associations – and are understandably worried that revisiting those memories will send them back in to a depressed episode. So to start this we need to believe them and handle it carefully. We can’t assume it’s the same type of avoidance as PTSD – people with PTSD avoid traumatic memories for different reasons than this affective avoidance.
KELLIE NEWSOME: So is that healthy avoidance or not?
CHRIS AIKEN: It can be both. One way to tell is if the patient ruminates a lot about the very memories that they want to forget. Rumination itself is a form of avoidance – it often involves asking “why” questions like “Why did this happen to me?” and approaching painful memories from an overly logical perspective, intellectualizing and rationalizing into abstractions… and all of this is a way to avoid feeling the pain of that memory. So in rumination focused CBT the therapist carefully guides them through a kind of imaginal exposure therapy where they sit with the full details of the memory and allow the feelings to come and go instead of fighting them. So, yes, there may be times when it’s helpful to work on painful memories in depression like this, but it’s difficult work and there are definitely side effects with it. And there are other times where it’s best to let sleeping dogs lie.
Remembering Trauma
KELLIE NEWSOME: That reminds me of critical incident debriefing. This therapy was developed to help people who recently went through a traumatic event, like burns or car accidents. Like in the study you just quoted, they would talk about the trauma in this debriefing session. The problem is that – in the studies – the people who got this debriefing had more PTSD and anxiety when they were followed up down the road.
TCPR: Yes. And this doesn’t mean that debriefing is bad therapy – it just has this negative side effect in people who were recently traumatized. Focusing on the trauma at that point only causes the memory to set in deeper. But a few months later, in someone with real PTSD, it’s a different story, and that’s when careful exposure to the traumatic memory can be curative. What people need in the immediate aftermath of a trauma is support and help getting back into their lives – community, housing, food, necessities, and reassurance.
Too Much Education
KELLIE NEWSOME: Another place where psychotherapy can backfire is in psychoeducation. Dr. Linden found that out in a study he conducted that compared two forms of CBT – one was conducted as regular CBT therapy with a therapist and patient, and in the other the therapist was encouraged to add written educational materials in to the therapy. It was a large study of 377 patients in a hospital unit with various disorders, mainly depression and anxiety. After 5-6 weeks, the ones who got the additional written materials were more knowledgeable about their health, but they were less satisfied with therapy and had worse outcomes on many psychological measures. They had poorer self-esteem, well-being, and family relationships (Linden M et al, Cogent Psychology 2019, 6:1612825 They were standard CBT materials about schemas, cognitions, and coping skills, all written at the level of an easy-to-read newspaper. The idea was that these leaflets would support the therapy and allow more time for other discussions in session. But it had the opposite effect. Patients read the materials, and then spent the session asking questions about the what they read instead of doing the treatment. It was more information than the patients could absorb and it ended up making them feel overwhelmed and insecure.
CHRIS AIKEN: Yes. Donna Sudak makes a similar point in the other interview in this issue. She says that many patients receive psychoeducation when they are in severe episodes, such as in the hospital. They’re not likely to remember that later because their cognition was impaired when they got it, so she always makes a point to revisit it down the road and ask what they know about their illness.
KELLIE NEWSOME: And we’ll close with one more example of psychotherapy side effects, a particularly important one. In a 2001 study from Edinburgh, Scotland, they tested whether a video education program could help people with schizophrenia. There were 114 patients, and half were randomized watch this brief video about schizophrenia as they left the hospital. When they were followed up a few months later, the ones who saw the video were 4 times more likely to have suicidal thoughts.
CHRIS AIKEN: That doesn’t mean that you shouldn’t teach people with schizophrenia about their condition. It just needs to be done carefully, and with a human touch). Suicidality goes down in schizophrenia when the same psychoeducation is delivered as part of a therapy program that teaches skills to cope with the illness, rather than an impersonal video (Donker T et al, BMC Psychol 2013;1(1):6).
Dr. Linden: “Well, the first thing it’s good to know that there can be side effects. The second thing is it’s even better when you know which specific side effects can occur with each technique. For example, exposure treatment – every therapist should be aware that exposure treatment can result in anxiety learning, so he has to monitor that and maybe intervene if he gets the idea that this is going in the wrong direction.
Or every therapist should know that psychoeducation can result in terrible misunderstandings, so I have to check what the patient has understood.
So there is a side effect-guided treatment. It’s very simple. And, well, one general phrase is: Side effects are negative effects of good treatment. If the therapist does not see side effects, it can’t be a good treatment. A good therapist sees side effects.”
About Dr. Linden
Michael Linden is a German psychiatrist and professor of psychiatry, psychosomatic medicine and psychotherapy in the Charité University Hospital in Berlin. He helped developed the concept of on Post-traumatic embitterment disorders, as well as a therapy for this disorder: Wisdom therapy. He has served as editor of the journals Primary Care Psychiatry, Rehabilitation, Pharmacopsychiatry and the Journal of Cognitive Psychotherapy. In 1997 he was the recipient of the Research Award in Psychogeriatrics of the International Psychogeriatric Association.
Word of the Day: QT Interval
KELLIE NEWSOME: And now for the word of the day…. QT Interval
CHRIS AIKEN: One of the most important measurements on an electrocardiogram or ECG is distance between the start of the Q wave and the end of the T wave – the QT interval. It represents the time it takes for the ventricles of the heart to depolarize and repolarize, or to contract and relax. In other words, it’s the thump-thump of the heart beat. The QT interval is longer when the heart rate is slower and shorter when the heart rate is faster, so you’ll usually see corrected for the heart rate, in which case it’s called the QTc: C for corrected. A long QT interval can cause a potentially fatal ventricular arrhythmia called torsades de pointes.
Many psychiatric medications can prolong the QT, including antidepressants, antipsychotics, and stimulants. But a lot of other medications prolong it as well. Electrolyte disturbances – including those caused by bulimia or anorexia – are another cause. It can also be hereditary; some patients are born with a prolonged QT. All of these risk factors can stack up in an additive way, so a psych med that prolongs the QT just a little could be the straw that broke the camel’s back if there are enough other risk factors going on.
So how long is too long? Anything above 450 is long, and anything longer than 500 is dangerous.
Closing
Join us next week for a special child psychiatry edition to the podcast. You can read the full interview with Dr. Linden – which includes a table of common psychotherapy side effects –
At the CarlatReport.com, where we have a special offer for our podcast listeners – you can get $30 off your first year’s subscription with the promo code PODCAST. Subscriptions include CME credits, so log on and knock out a dozen of them before 2020 is over. And to all those who celebrate Thanksgiving, we wish you a safe and happy one.