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DOI: 10.1037/a0020078

Negative Treatment Effects: Is

It Time for a Black Box
Warning?
Charles M. Boisvert
Rhode Island College and
Rhode Island Center for Cognitive
Behavioral Therapy, Inc.
I read the special section in the January
2010 American Psychologist on Negative
Effects of Psychotherapy with much anticipation and interest. Addressing negative
treatment effects in the psychotherapy field
is long overdue. Barlow (2010) provided a
historical perspective of clinical psychologys long-standing interest in studying the
positive effects of psychotherapy, and he
indicated that although negative treatment
effects have long been identified, little attention has been paid to them. Dimidjian
and Hollon (2010) brought methodological
awareness to these issues by recommending various investigational methods for detecting negative treatment effects. Castonguay, Boswell, Constantino, Goldfried, and
Hill (2010) brought the issue of negative
effects more directly into the therapy session by recommending several training
strategies to help therapists minimize negative treatment effects. In a previous work,
Lilienfeld (2007) also contributed to these
efforts by suggesting a system for classifying potentially harmful treatments (PHTs).
As I read the articles, the authors certainly
raised my scientific sensibilities to the issue
of negative treatment effects. As a practicing therapist and an academic, I toggled
back and forth between sinking my teeth
into the scientific discussion of these issues
and reflecting on the practice implications
that may lie therein. After reading the articles, the academic side of me said, These
articles should go on next semesters reading list for my clinical practicum course.
The therapist side of me asked, Is there
something different I should do with my
new client tomorrow afternoon at 3:00
p.m.?

680

I decided to reread the articles. Castonguay et al. (2010, p. 45) presented an

extensive list of training recommendations
to reduce negative effects. I carefully reviewed the list. Much of the list (e.g., establish and maintain a good therapy alliance, express empathy, monitor change,
and be aware that certain clients may or
may not benefit from certain treatments or
therapeutic styles) looked strikingly similar
to what the literature has said about ways to
enhance positive treatment effects. I trust
that most therapists already are making efforts to implement many of these recommendations. What became evident to me
was the absence of any specific recommendations as to how this knowledge of negative treatment effects should be part of an
informed consent discussion. Maybe this
should not be surprising. Barnett, JohnsonGreene, Wise, and Bucky (2007) indicated
that unfortunately, informed consent is
not uniformly applied, and confusion appears to exist concerning the specifics of
informed consent. Challenges exist for psychologists including knowing just what information to share and in how much detail
(p. 180). I began to wonder, To what
extent do therapists accept the concept of
negative treatment effects, and what are the
practice implications one can distill from
these articles? Although negative treatment effects have long been recognized as
a possible treatment outcome (Bergin,
1963), and may be all too obvious to the
astute researcher and the community of
psychotherapy researchers (Barlow, 2010),
one wonders about the extent to which this
phenomenon has actually permeated into
the belief system of the average practitioner. In fact, research has shown that a significant number of practitioners may either
underestimate the occurrence of negative
treatment effects or not realize that they
can occur (Boisvert & Faust, 2006). Maybe
this fact warrants adding a recommendation to Castonguay et al.s (2010) working
list: Help the trainee have a discussion
with his or her clients about the possibility
that therapy may lead to some negative
effects. Then I began wondering, Is it
time simply for a black box warning?

I wondered what such a warning

would actually say. Would it contain a list
of possible negative treatment effects such
as a possible increase in symptoms, development of new symptoms, development of
dependency on the therapy relationship, or
an increase in negative ruminations as a
result of exploring emotionally laden issues? Would it possibly contain a list of
PHTs (Lilienfeld, 2007)? I then wondered
what the discussion with clients would look
like if all informed consents contained such
a black box warning. Would it be akin to a
doctor reviewing the possible side effects
of a medication, answering the clients
questions, and reassuring the client that the
benefits of treatment outweigh the risks?
How would we integrate this warning into
our discussion of the risks and benefits of
therapy? Would we tell clients that therapy
necessarily leads to a mix of both positive
and negative effects, such as an increase in
self-esteem and assertiveness accompanied
by rejection from coworkers or spouses,
who may feel threatened by these changes?
Would we talk about the more subtle mechanisms through which negative effects may
occur, as in, for example, clients possibly
being vulnerable to negative impressions
conveyed by a therapist who uses a pathology-oriented belief system that emphasizes
deficits over strengths (Boisvert & Faust,
2002)?
Then I thought, How would a client
respond to such a warning? Would a black
box warning be helpful? Would imparting
this knowledge to clients make them more
likely to consider the possibility that their
deterioration in therapy could actually be
caused by the therapy itself? And would
this subsequently make them more inclined
to discuss with their therapists possible
ways to adjust the therapy or conclude the
therapy? Moreover, although therapists in
general may be disinclined to suggest that
they have contributed to their clients deterioration in therapy, I wonder if a shared
knowledge of the concept of negative treatment effects may even make therapists
more open to examining how they may be
worsening their clients conditions and enable them to remain open to their clients

October 2010 American Psychologist

2010 American Psychological Association 0003-066X/10/$12.00
Vol. 65, No. 7, 680 681

This document is copyrighted by the American Psychological Association or one of its allied publishers.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

feedback. Interestingly, Lamberts research

has shown that consistently soliciting feedback from clients about their perceived
progress in therapy has enabled therapists
to take action and improve their chances of
correcting a deteriorating course of treatment (Lambert, Hansen, & Finch, 2001).
Dimidjian and Hollon (2010) similarly recommended developing a more systematic
method for measuring therapy outcome by
using more structured self-report measures
at each session as a way to more carefully
monitor client progress. They suggested
that the use of such measures in an ongoing fashion helps to monitor whether the
clients target problem has worsened
(Dimidjian & Hollon, 2010, p. 26). Could a
black box warning also be helpful by creating a degree of skepticism in clients who
are ambivalent about therapy? That is,
would such a warning appropriately dissuade from participating in a treatment
those clients who simply would have been
made worse by the treatment or, stated
differently, those clients who would simply
end up doing better by electing not to participate in therapy? Would a black box
warning be a way out for clients who may
experience anxiety by having to negotiate
their decision to forgo therapy with an
overly enthusiastic therapist who may be
overselling therapy?
But could a black box warning also be
potentially harmful? Suppose in the discussion of this warning, one misrepresented
the actual risk benefit ratio to the client
and undersold the therapy? Could the client
now get worse because she decided to
forgo treatment, which could have improved her functioning or at least prevented
further deterioration? Could the warning
make the client more likely to prematurely
terminate therapy by misattributing his increased distress to the therapy (which incidentally was slowing the rate of deterioration) and not to a naturally deteriorating
course of symptoms?
I decided to see if the APA Ethics
Code (American Psychological Association, 2002) might provide some guidance
about what degree of warning about therapy in general would be appropriate, so I
reviewed Ethical Standard 10.01, Informed
Consent to Therapy. There is some general
guidance about informing clients about
the nature and anticipated course of therapy (p. 1072) and a statement that psychologists inform clients about the potential risks involved in therapy for which

October 2010 American Psychologist

generally recognized techniques and procedures have not been established (p. 1072).
I wondered what that phrase for which
generally recognized techniques and procedures have not been established meant,
but I decided not to go there, at least for
now! I could not find anything that explicitly said one needed to review a particular
list of negative treatments, impart the
knowledge of negative treatment effects
in any specific way, or discuss in any particular way how therapy may be harmful.
So, how do we best use this knowledge about negative treatment effects to
inform practice and to inform clients? Do
we wait for the scientific community to
more clearly distill the best ways to detect
these effects (Dimidjian & Hollon, 2010),
practice more universal training procedures
to help minimize these effects (Castonguay
et al., 2010), or maybe work toward developing a scientifically grounded list of PHTs
(Lilienfeld, 2007) akin to ESTs (empirically supported treatments)? Any and all of
these approaches may help. However, despite some of these efforts in, for example,
identifying PHTs (Lilienfeld, 2007), such
as rebirthing methods, critical incident debriefing methods, and some types of groups
for conduct-disordered clients, many of
these interventions or treatments are still
practiced even though there is scientific
evidence that argues against their use. How
can and does this science of negative treatment effects then best guide practice? Barlow (2010) recommended a greater emphasis on more idiographic approaches to
studying negative effects. He further added
that this would be best carried out in the
context of a strong collaboration among
frontline clinicians and clinical scientists
(Barlow, 2010, p. 13). I would argue that
this may best be carried out between frontline clinicians and their clients. So the science that we use may not be clinical mandates prohibiting, for example, certain
treatments but may simply be the sharing
of our scientific knowledge about clinical
possibilities so as to better inform clients
about the treatment they are considering.
Of course, this would be contingent on
practitioners themselves having knowledge
that therapy can lead to negative effects
and displaying a willingness to enter into a
more focused discussion about this with
their clients.
As for that black box warning, maybe
after all, it is not just for clients. In fact,
these three articles may have just served

that very purpose. They should go on next

semesters reading list. And as for my new
client tomorrow afternoon, Im still not
sure if it is time for a black box warning. Is
it? And what should it say?
REFERENCES

American Psychological Association. (2002).

Ethical principles of psychologists and code
of conduct. American Psychologist, 57, 1060
1073. doi:10.1037/0003-066X.57.12.1060
Barlow, D. H. (2010). Negative effects from
psychological treatments: A perspective.
American Psychologist, 65, 1320. doi:
10.1037/a0015643
Barnett, J. E., Johnson-Greene, D., Wise, E. H.,
& Bucky, S. F. (2007). Informed consent: Too
much of a good thing or not enough? Professional Psychology: Research and Practice,
38, 179 186. doi:10.1037/0735-7028.38.2.179
Bergin, A. E. (1963). The effects of psychotherapy: Negative results revisited. Journal of
Counseling Psychology, 10, 244 250. doi:
10.1037/h0043353
Boisvert, C. M., & Faust, D. (2002). Iatrogenic
symptoms in psychotherapy: A theoretical exploration of the potential impact of labels,
language, and belief systems. American Journal of Psychotherapy, 56, 244 259.
Boisvert, C. M., & Faust, D. (2006). Practicing
psychologists knowledge of general psychotherapy research findings: Implications for
sciencepractice relations. Professional Psychology: Research and Practice, 37, 708
716. doi:10.1037/0735-7028.37.6.708
Castonguay, L. G., Boswell, J. F., Constantino,
M. J., Goldfried, M. R., & Hill, C. E. (2010).
Training implications of harmful effects of
psychological treatments. American Psychologist, 65, 34 49. doi:10.1037/a0017330
Dimidjian, S., & Hollon, S. D. (2010). How
would we know if psychotherapy were harmful? American Psychologist, 65, 2133. doi:
10.1037/a0017299
Lambert, M. J., Hansen, N. B., & Finch, A. E.
(2001). Patient-focused research: Using patient outcome data to enhance treatment effects. Journal of Consulting and Clinical Psychology, 69, 159 172. doi:10.1037/0022006X.69.2.159
Lilienfeld, S. O. (2007). Psychological treatments that cause harm. Perspectives on Psychological Science, 2, 5370. doi:10.1111/
j.1745-6916.2007.00029.x

Correspondence concerning this comment

should be addressed to Charles M. Boisvert,
Department of Counseling, Educational Leadership, and School Psychology, Rhode Island College, 600 Mt. Pleasant Avenue, Providence, RI
02908-1991. E-mail: cboisvert@ric.edu

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