Clients' narratives of healing and harm in psychotherapy: A qualitative method

Purpose

For decades, researchers have acknowledged the potential for negative effects in psychotherapy, highlighting the need for further investigation. However, a clear understanding of the nature and definition of harm within this context has remained elusive. Efforts were made to clarify terminology such as ‘side effects’ and ‘negative effects’, but a consensus on the extent and definition of harm has continued to evade the field. Notably, existing research on negative effects has often prioritised expert and therapist perspectives, neglecting the crucial insights offered by the client's subjective experience of harm.

Method

This study adopted an exploratory approach, employing qualitative research methods. To uncover and illuminate past experiences of harm within the therapeutic context, semi-structured interviews were conducted with 21 participants (15 female, 6 male) who reported perceiving their psychotherapy sessions as harmful. Data analysis utilised the theoretical framework of Strauss and Corbin's grounded theory approach, facilitated by the MAXQDA2020 software.

Results

The study results offered a comprehensive examination of factors contributing to client-perceived harm in psychotherapy, categorised as both client-related and therapist-related. Additionally, the definition of harm was explored through the lens of emotional and cognitive experiences. The client's reaction to perceived harm (submission, avoidance and compensation) and the therapist's course of action vs. the client's reaction (corrective and justifying) respectively, can cause consequences (strengthening the therapeutic alliance and the client's healing or individual and interpersonal impacts) from the client's perspective.

Conclusion

A significant finding was the lack of attention paid to the interpersonal nature of psychotherapy in past understandings of harm. The results highlight the potential for harm in any therapeutic relationship, regardless of the therapist. This potential appears to be particularly heightened when therapists display a lack of responsiveness to clients' internal experiences, especially through justifying comments in response to client-reported negative experiences within the therapeutic relationship. Based on these findings, the study offers clinical recommendations for therapists to enhance their responsiveness and mitigate potential harm.