Friday 28 April 2017

Side effects of psychological therapies

Patricia Casey

The mantra "tablets bad, talking good" stalks mental health professionals with a tenacity that is nearly impossible to divert. The belief that medications for the treatment of mental illnesses are riddled with side effects is almost universal, while the possibility that talking treatments may also have side effects is almost never alluded to.

When I suggest medication, patients invariably ask if they will become dependent on them, but when I am recommending a talking therapy, I am rarely asked if it has any drawbacks. There is an assumption that talking is harmless.

A range of evidence-based psychological interventions have now become mainstream in medicine, and not just for mental health problems, but as adjuncts to physical treatments in areas as diverse as cancer and heart surgery. And so, assessing side effects as well as benefits is crucial - it is naive to expect talking therapies to be psychoactive yet harmless.

One of the reasons for the impression that there is an absence of side effects from psychological therapies is that, unlike pharmacological treatments, which are policed by the Medicines Board in Ireland, no such independent body exists for psychological treatments. The Medicines Board regularly publicises the hazards of medications, resulting in high levels of information reaching the general population. However, it falls to the professions of psychology and psychiatry to evaluate the risks and benefits of the various talking therapies used by its practitioners.

This month's issue of the British Journal of Psychiatry includes two editorials and a study of negative experiences of talking therapy. The study by Prof Mike Crawford of the Royal College of Psychiatrists, London, was based on survey data collected from those attending 184 psychological treatment services in England and Wales for the treatment of depression and/or anxiety.

It involved over 14,500 attendees who were sent questionnaires about the type of psychological therapy they received, the information they were provided with before it commenced, and if they considered they experienced any negative effects - just over 5pc considered they had lasting ill-effects.

Particularly affected were those under 65, those from ethnic and sexual minorities, people unsure of the type of therapy they received, those undergoing psychodynamic therapy and those who felt they were not given sufficient information before commencement.

This study did not explore the nature of the side effects, but other studies have identified several. These include: dependence on the therapist, making the completion of therapy particularly painful for the patient; loss of self-confidence with prolonged therapy; self-harm when painful issues are raised, such as abuse or childhood separations; and worsening of the symptoms for which they were referred.

How does psychotherapy lead to side effects? Unlike the taking of a tablet, the therapist is part of the active ingredient in psychotherapy and so, the skill with which the intervention is delivered is crucial.

In her editorial accompanying the above study, Prof Glenys Perry (a psychologist) from Sheffield University, points out that in this regard, delivering talking therapy more closely resembles surgery. In addition to the skill, the talking therapist must show fidelity to the therapy that is intended. For example, there are some who call themselves cognitive therapists but who deviate from what was developed originally.

Also, if there is a poor fit between the patient and therapist so that there is tension, mistrust or even animosity, then the danger of lasting side effects become very real. The patient also plays a role and some may be unsuitable for talking therapies, such as those who are excessively dependent and may transfer this need to the therapist.

Despite concerns, some therapies with clearly recognised side effects are still popular in some organisations. Critical incident stress debriefing is one such intervention that is used after major incidents such as fires and hurricanes. Routine use has been shown to increase the risk of post-traumatic stress disorder. Another popular intervention is bereavement counselling for those with normal bereavement reactions. There is evidence that this can induce prolonged and complex grief reactions. Most people resolve grief with the support of family and friends, and counselling should be reserved for those with protracted symptoms, worsening over time. Recovered memory techniques may induce false memories of abuse and as a result may cause distress and harm to others.

The way forward is to provide a framework for routinely measuring the side effects of psychological treatments in the same way that pharmacological agents are monitored. Trials of psychological treatments should be mandated to measure side effects and to detail them in final reports and published papers. Clinical audits, routinely carried out a local level, should monitor disengagement from psychological treatments along with evaluation of the reasons.

Psychological interventions have come of age and with this, the responsibility to monitor not only their benefits but also their side effects, is required for pharmacological or surgical intervention. Informed consent and patient well-being demands no less.

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