‘Get help and get happy!” runs a tagline for one of the new generation of e-counselling services, offering psychotherapy by text, phone and video chat. Except it turns out that getting happy is by no means guaranteed to be therapy’s only outcome. One recent paper (which I found via the excellent Research Digest blog) estimates that, when it comes to cognitive behavioural therapy, 43% of clients will experience unwanted side-effects like distress, a deterioration in their symptoms, or strained family relations. “Psychotherapy is not harmless,” the paper’s authors conclude. It’s useful research. But that conclusion highlights a widespread belief about therapy that gets stranger the longer you dwell on it: why on earth would anyone assume it was harmless in the first place?

There are echoes, here, of the surprise that greets media revelations that mindfulness meditation – another seemingly guaranteed path to happiness – has its perils. Beginners, especially if they’ve experienced trauma, sometimes report emotional “flooding”: once they turn their attention inwards, and follow the instructions to notice their emotions without judgment, they’re engulfed by thoughts and feelings they’d previously been keeping in check. (Repression may not be the healthiest technique for dealing with trauma, but it can be a practical way to get through the day.) Advanced meditators, meanwhile, occasionally report distressing experiences of panic or meaninglessness known as the “dark night”, a result of fundamentally rewiring their perception of reality.

Yet if therapy and meditation weren’t potent enough to have such effects, would they be any use at all? A hammer strong enough to drive a nail into a wall must also be capable of crushing your thumb. It’s not that the benefits of these psychological interventions are exaggerated; rather, it’s that they depend on their reaching deep inside your mind and making significant positive changes there – which means they could make negative ones, too.

Nobody doubts this when it comes to chemical interventions: the fact that antidepressants can be transformative for many people is inseparable from the fact that for some they make things worse. Likewise, changing your diet can bring a big boost in happiness – or a big decrease, if you switch to junk food and vodka. It’s only with directly psychological interventions, apparently, that we’re astonished to discover the upside has a downside.

One final conundrum, the study’s authors observe, is what should count as a negative side-effect anyway. According to many models of both therapy and meditation, some degree of distress proves the process is working – as Robert Frost put it, there is “no way out but through”. Confronting psychological pain is, well, painful. (The study even included upsetting relationship breakups as a side-effect, but it’s easy to imagine cases where a breakup would be a great result.) This in turn suggests that maybe “getting happy” isn’t the best way to think about the aim here. Maybe confronting life as it really is – even when that’s no cause for celebration – is the path to meaning.

I remain partial to Sigmund Freud’s remark that his goal was changing “neurotic misery into ordinary unhappiness”, a tagline I don’t expect to see gracing an e-therapy website anytime soon.

Read this

Talk Is Not Enough: How Therapy Really Works, a 2001 book by US psychotherapist Willard Gaylin, is an insider’s account of why the process works – and sometimes doesn’t.