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Psychotherapy is generally effective (APA, 2012). The most effective therapists invite the patient’s problematic patterns of relating into the therapy sessions, where the therapist can work on them directly (Shedler, 2010).
The negative side effects of psychotherapy are fairly well-known (Szapocznik & Prado, 2007; Herzog et al., 2019). These include, mainly, emotional upheaval and disrupted relationships. Good therapists cause pain because they welcome that which has been marginalized, and it was marginalized for a reason.
Therapy can disrupt relationships that have adapted to the patient’s problematic patterns, because when those change, the patient’s friends and colleagues may have grown used to the old ways. Relationships are also disrupted by bad therapists who villainize and demean other people in the patient’s life.
Psychotherapy also has positive side effects, or secondary gains (Hoyer, 2016). Just as an exercise regimen developed to restore functioning after a broken leg can provide the benefits of overall physical fitness, therapy to attain specific behavioral goals, such as deepening relationships or reducing anxiety, can provide other, more general benefits. Some of the benefits associated with a particular school of therapy, such as acceptance and commitment therapy (ACT; Hayes et al., 1999), are found in all therapy.
Just talking things over with a neutral, curious observer has beneficial effects, promoting emotional intelligence. When the therapist wonders why the patient’s mind went to a particular topic, rather than just diving in on the topic, the patient learns to observe their own behavior, thoughts, and feelings.
ACT therapists recognize these secondary benefits. Acceptance, a key concept in ACT, is learning to treat one’s own thoughts and feelings as the therapist does: neutrally and nonjudgmentally. ACT calls the benefit of keeping words and concepts from reification defusion; this follows in most therapies from wondering about specific examples instead of taking the patient’s words as known entities.
Mediocre therapists focus on things outside the therapy space; the best therapists emphasize the function of a story or a memory in its occasioning environment, which is the present situation. ACT calls the ensuing benefits contact with the present moment. Therapists who explore and interpret what is going on in the therapy itself teach patients the advantages of contacting the present moment.
ACT emphasizes the utility of self-as-context, or identifying with one’s observing self rather than with only one or a few of the elements of the self. This has been called psychological-mindedness: the warm but neutral welcoming of all aspects of the self. Good therapists produce this effect in all patients by observing their patients with welcoming curiosity, with warm neutrality.
Good therapists of all stripes also engage in what ACT calls value work. This is not a series of flashcards or moral discussions; it’s a secondary benefit of having a neutral space in which patients can discover what is really important to them.
There are other benefits to patients that come from being treated by their therapists in a way that no one else treats them, in a way that they would do well to emulate in their treatment of themselves. Many patients have never been in a genuinely collaborative relationship, and they mess these up when they have a chance to collaborate.
Good therapy is above all a collaboration, and patients can learn not to mess up collaborations by working with a therapist who doesn’t take it personally when patients make their usual mistakes in the therapy collaboration.
Patients, like most people, are conflict-avoidant, which makes it much harder to resolve conflicts both interpersonal and intrapsychic. Good therapists approach conflict, and patients learn from them the advantages of approaching conflict with themselves and with others.
Many patients have been hurt in close personal relationships, and many of their life problems can be described as overreacting with fear and anger when someone tries to get close to them. Therapy is itself a close personal relationship, but one with certain guarantees of safety. Regardless of the reason for therapy, patients can learn to be more comfortable in intimate encounters by letting their therapists get close to them.
Lastly, good therapy teaches patients that their feelings are not a good guide to what is going on. We often feel things not because of what is happening now but because of our often erroneous perceptions of what is going on or our incorrect expectations of what will happen next.
Discussing feelings as something other than the truth teaches patients not to overly rely on their emotions. Many therapists fail at this when they discuss the patient’s friends and family—these therapists tend to be conflict avoiders themselves, so they concur with the patient to avoid conflict. Therapists who explore, rather than evaluate, their patients’ reactions provide the benefits of circumspection and fallibility, reflection and wonder—you might call it wisdom.
References
American Psychological Association. (2012). Recognition of psychotherapy effectiveness. Retrieved from http://www.apa.org/about/policy/resolution-psychotherapy.aspx.
Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. The American Psychologist, 65(2), 98-109.
Hoyer, J. (2016). “Positive Nebenwirkungen” von Psychotherapie. Zeitschrift für Klinische Psychologie und Psychotherapie, 45(3), 163–173. https://doi.org/10.1026/1616-3443/a000370
Szapocznik, J., & Prado, G. (2007). Negative effects on family functioning from psychosocial treatments: A recommendation for expanded safety monitoring. Journal of Family Psychology, 21(3), 468–478. https://doi.org/10.1037/0893-3200.21.3.468
Herzog, P, Lauff, S, Rief, W, Brakemeier, E-L. Assessing the unwanted: A systematic review of instruments used to assess negative effects of psychotherapy. Brain Behav. 2019; 9:e01447. https://doi.org/10.1002/brb3.1447
Hayes, S.C., Strosahl, K.D., & Wilson, K.G. (1999). Acceptance and commitment therapy: An experiential approach to behavior change. New York: Guilford.
