When Therapy Doesn’t Work | Psychology Today

Therapy has been called a gift. For many, it’s a path to greater fulfillment and meaning—even liberation. But therapy can also have a shadow side. Research has revealed that not everyone who engages in treatment is better off for it.

What are the most common negative experiences in therapy? This question was at the center of a meta-analytic study led by psychologist Zbyněk Vybíral of Masaryk University in the Czech Republic. More specifically, given the substantial concerns around harm in therapy, he and his team wanted to identify negative experiences in therapy from the perspective of clients.

To that end, the investigators searched the psychology databases for qualitative studies about negative therapy experiences. The studies were conducted around the world, including the United Kingdom, the United States, South Africa, Israel, and Chile. In total, Vybíral and his collaborators culled 936 statements from 51 studies for analysis.

The results were striking. The researchers identified four broad clusters, each containing “meta-categories.” In total, the findings yielded 21 areas where clients report negative experiences in therapy.

Cluster I: Therapists’ Misbehavior

• Therapist not listening: Some clients wondered whether their therapist cared or was sincerely interested in them. Some even harbored doubts about whether their therapists were listening. One client expressed: “My God, is she listening to me at all?”
• Therapist not understanding: Clients shared that they felt misunderstood, even if their therapist was listening. One participant described “saying something and having the counselor summarize it differently than what I want.”
• Therapist perceived as incompetent: Participants felt unease with clinicians they felt were incompetent or inexperienced, and questioned whether they could “handle” the work. This was true with respect to cultural competency as well. One client reported that their therapist seemed to draw from stereotypes: “She had made up her mind from the way we are usually shown on TV as Arab or Muslim men, as basically being female oppressors; […] she just simply seemed to have this negative view.”
• Therapist devaluing the client: Some respondents described feeling rejected, disrespected, humiliated, and having their therapists’ values imposed on them. One participant described their provider as having an “air of superiority,” while another recalled: “It was a negative turn off for me. It was like, ‘I can’t help you’ kind of thing.”
• Therapist judging: Some clients felt their therapist was judgmental when it came to religion. One recollection stated: “Therapist told the client that she was ‘too Catholic,’ which made the client feel bad.” The same was true for sexual preference and sexual identity. Trans clients cited concerns over heterosexism, sexism, pathologizing biases, and hostility.
• Therapist using client for own benefit: Participants reported therapists’ sexual involvement, such as unwanted compliments or touch, and leeriness. Relatedly, there were instances of boundary violations, including dual relationships. Therapists also revealed intimate sexual details from their own lives, breached confidentiality, and made disclosures for their own benefit.
• Other inappropriate verbal reactions: Clients recalled arrogance, unsuitable notes, or vulgarity on the part of their therapist. A client shared: “He lectured me and yelled at me loudly during the whole session.”

Cluster II: Hindering Aspects of the Relationship

• Experiencing distance and/or lack of empathy: Clients recalled their therapist as detached or disconnected from the therapy and the client. This surfaced as pathologizing diagnostic labels, wanting more sensitivity, and viewing the therapist as lacking collaborativeness. One client remarked: “I don’t trust him anymore in fact I feel really uncomfortable with him.”
• Experiencing confusion or uncertainty: Some clients were confused, annoyed, or upset because of their therapy. They also recalled not understanding why they felt that way. One client shared: “I didn’t understand the game. I didn’t understand the rules.”
• Experiencing a poor interpersonal match with the therapist: Participants reflected on a lack of chemistry and not having a shared understanding with their therapist. Some were locked in a “negative interactional pattern” that seemed unlikely to change.

Cluster III: Poor Treatment Fit

• Negative evaluation of practical aspects of therapy: Clients had concerns about some of the practicalities of treatment, such as length, fee increases, not accommodating work hours, undergoing treatments they didn’t want, and therapists accepting phone calls during sessions.
• Unmet expectations: Some clients reported unmet expectations or violations. One person shared: “I found the therapy too focused on food […] as opposed to exploring feeling and behaviors. I would have liked to explore why I do this to myself.”
• Lack of fit with the intervention: Some clients found therapy too structured, with respect to rigid approaches, therapist over-directing, or the therapist imposing a treatment modality either coercively or confrontationally.
• On the flip side, some people felt their therapy was too unstructured, and their therapist too quiet and passive (this was mostly found in psychoanalytic psychotherapy). Some clients felt that their treatment was not solution-focused enough, and wanted to gain more tools and strategies. One client remarked: “I needed the structure. I needed someone to say: ‘Don’t do this. Do that!’”
• Dissatisfaction with therapy ending: Some respondents felt that termination of treatment created vulnerability, which led to an inappropriate or “misprocessed” end. Loss, abandonment, pain, and sorrow were also reported. Others felt that their treatment ended prematurely, and were left with the fear that “I will not be able to spread my wings and fly without my therapist.”

Cluster IV: Negative Impacts of Treatment

• Change or insufficient change: Some clients felt their therapy wasn’t helpful, describing it as a “waste,” a “lost opportunity,” “going two steps forward, three steps back,” and “spinning one’s wheels.”
• Increased problems after therapy: Unfortunately, there was a subset of participants who got worse as a result of therapy despite their motivation to change, leading to feelings of confusion. One respondent reflected: “It can’t be possible that I voluntarily wanted to get better and I got even worse in the end.”
• Feeling fear of the therapy process: Clients reported fear and felt threatened by the loss of control in the treatment process. This led to them holding back in therapy and undermined their trust in the process.
• Loss of motivation or hope; resignation: Because of bad experiences in therapy, some clients were less likely to continue or seek help from another provider. One person remarked: “To be honest with you, I could not sit down now and go through all what I went through again.”
• Unpleasant feelings during therapy: Clients reported five dimensions of this meta-category: arousal without resolution and being overwhelmed, feeling hurt (e.g., desperate, retraumatized, broke), feeling angry or resentful toward their therapist, feeling dependent on therapy or therapists, and additional unpleasant feelings (e.g., hate, disgust, and paranoia).
• Negative cognitions aroused in therapy: Participants expressed bad feelings about their treatments, including self-accusation and self-blame for the therapy’s lack of success. The feeling that they had done something wrong was also cited. Some were self-critical, while others justified the therapist’s behavior: “It could have been a lot better if I’d tried harder.”

While therapy can be a life-changing experience for the better, and discomfort and negative feelings are bound to occur when confronting pain, it is helpful for prospective and current clients to understand that there can be pitfalls to look out for and address.