The side effects of psychotherapy might include negative consequences despite appropriate treatment. Patients may experience heightened anxiety, increased symptoms, or relationship conflict because of going through a treatment process. Side effects may not be caused by malpractice, but may be simply a byproduct of some phases of therapy. The frequency of side effects from psychotherapy can be as high as 94%. Although side effects are perhaps unavoidable, clinicians should minimize them to reduce harm, improve outcomes, and limit their negative impact on the therapeutic alliance. There are several potential causes of side effects, including the type of treatment, the patient's diagnosis, and the patient's level of personality functioning. In this study, Kempe and colleagues asked 45 patients to self-report side effects from their psychotherapy. They were asked to indicated if they experienced one or more of 17 possible side-effects, including new or worsening symptoms, feeling uncomfortable, tension with the therapist, and conflict with the family of origin or the current family. Patients in the study were diagnosed with an affective or somatoform disorder. They received CBT (n=15), psychodynamic (n=15), or psychoanalytic (n=15) psychotherapy on an outpatient basis. The aim of the study was to investigate whether the frequency and intensity of psychotherapy-related side effects may be due to treatment type and level of personality functioning. Level of personality functioning was defined by three self-report scales: (1) self-perception (how the person views and understands themselves, including identity), (2) interpersonal contact (how the person interacts with others and communicates feelings), and (3) relationship model (recurring relationship themes of how a person expects others to behave and how they attach to others). All but one patient (97.8%) reported at least one side effect across the 17 side-effect domains. CBT, psychodynamic, and psychoanalytic therapies resulted in similar frequencies and intensities of side effects. Even after controlling for demographic variables (age and education), the number of therapy sessions, and the type of therapy, lower levels of personality functioning significantly predicted more frequent side effects. Impairment in personality functioning (i.e., problems with self-perception, difficulty communicating emotions, and recurring maladaptive relationship patterns) was most strongly associated with the following side effects: new symptoms, worsening symptoms, conflicts with family of origin, and conflicts with current family.
Practice Implications
Psychotherapy side effects may negatively affect the therapeutic alliance and patient outcomes. Mental health professionals who treat patients with lower levels of personality functioning, regardless of diagnosis and type of treatment, need to consider the management of side effects as a substantial component of treatment. This may mean closely monitoring side effects, such as new or worsening symptoms and conflicts with the family of origin and the current family.
Kempe, S., Blomert, E., Linden, M., & Wittmann, L. (2026). Side effects in cognitive–behavioral, psychodynamic, and psychoanalytic outpatient psychotherapy are associated with the level of personality functioning. Journal of Psychotherapy Integration. Advance online publication. https://dx.doi.org/10.1037/int0000405
The director of the Psychotherapy Practice Research Network (PPRNet) is Dr. Giorgio Tasca. Dr. Tasca is an Associate Professor with the School of Psychology, in the Faculty of Social Sciences at the University of Ottawa. His research is centered around psychotherapy process, mechanisms of change, and outcomes, as well as eating disorders.
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PPRNet Clinical summary: Level of Personality Functioning and Side Effects Across Different Therapies
The side effects of psychotherapy might include negative consequences despite appropriate treatment. Patients may experience heightened anxiety, increased symptoms, or relationship conflict because of going through a treatment process. Side effects may not be caused by malpractice, but may be simply a byproduct of some phases of therapy. The frequency of side effects from psychotherapy can be as high as 94%. Although side effects are perhaps unavoidable, clinicians should minimize them to reduce harm, improve outcomes, and limit their negative impact on the therapeutic alliance. There are several potential causes of side effects, including the type of treatment, the patient's diagnosis, and the patient's level of personality functioning. In this study, Kempe and colleagues asked 45 patients to self-report side effects from their psychotherapy. They were asked to indicated if they experienced one or more of 17 possible side-effects, including new or worsening symptoms, feeling uncomfortable, tension with the therapist, and conflict with the family of origin or the current family. Patients in the study were diagnosed with an affective or somatoform disorder. They received CBT (n=15), psychodynamic (n=15), or psychoanalytic (n=15) psychotherapy on an outpatient basis. The aim of the study was to investigate whether the frequency and intensity of psychotherapy-related side effects may be due to treatment type and level of personality functioning. Level of personality functioning was defined by three self-report scales: (1) self-perception (how the person views and understands themselves, including identity), (2) interpersonal contact (how the person interacts with others and communicates feelings), and (3) relationship model (recurring relationship themes of how a person expects others to behave and how they attach to others). All but one patient (97.8%) reported at least one side effect across the 17 side-effect domains. CBT, psychodynamic, and psychoanalytic therapies resulted in similar frequencies and intensities of side effects. Even after controlling for demographic variables (age and education), the number of therapy sessions, and the type of therapy, lower levels of personality functioning significantly predicted more frequent side effects. Impairment in personality functioning (i.e., problems with self-perception, difficulty communicating emotions, and recurring maladaptive relationship patterns) was most strongly associated with the following side effects: new symptoms, worsening symptoms, conflicts with family of origin, and conflicts with current family.
Practice Implications
Psychotherapy side effects may negatively affect the therapeutic alliance and patient outcomes. Mental health professionals who treat patients with lower levels of personality functioning, regardless of diagnosis and type of treatment, need to consider the management of side effects as a substantial component of treatment. This may mean closely monitoring side effects, such as new or worsening symptoms and conflicts with the family of origin and the current family.
Kempe, S., Blomert, E., Linden, M., & Wittmann, L. (2026). Side effects in cognitive–behavioral, psychodynamic, and psychoanalytic outpatient psychotherapy are associated with the level of personality functioning. Journal of Psychotherapy Integration. Advance online publication. https://dx.doi.org/10.1037/int0000405
By Dr. Giorgio Tasca
The director of the Psychotherapy Practice Research Network (PPRNet) is Dr. Giorgio Tasca. Dr. Tasca is an Associate Professor with the School of Psychology, in the Faculty of Social Sciences at the University of Ottawa. His research is centered around psychotherapy process, mechanisms of change, and outcomes, as well as eating disorders.Also Read