The benefits of a range of psychotherapies have been widely examined. Far less research has investigated whether such treatments can have negative effects. This research seeks to better understand negative outcomes by reviewing extant literature and exploring stakeholder perspectives. The aims of this thesis are to examine personal, interpersonal, and contextual factors that are associated with negative outcomes, and to explore how they occur, what constitutes this type of outcome, and how people recover from these experiences.

The thesis combines two iterative phases: a systematic literature review, and a qualitative study of patient and therapist therapeutic experiences. I used a Constructivist Grounded Theory framework to address the research aims and generate conceptual models.

The review confirmed the absence of substantial research examining patient- and therapist- identified harm. Most previous research focused on deterioration, and only two papers incorporated qualitative data. Findings from the qualitative component suggest that therapists are ambivalent about negative outcomes, and uncertain about how they should be identified and responded to. This contributes to additional findings of an apparent ‘distorted lens’, which appears to prevent detection of harm. The data indicated that therapists gauge these outcomes by extreme cases, particularly formal complaints. Patients reported difficulties in disclosing negative experiences to therapists. The data revealed a pertinent distinction between patient’s hopes and their negative expectations for therapy, which contribute to an apparent ‘breach’ of faith that occurs in therapy. The findings generated a substantive grounded theory, which tentatively suggests a disconcerting culture of minimising harm in various ways, particularly through individual and service level silence, repudiation, and protection.

This research makes an original contribution to the understanding of negative outcomes. It moves forward issues surrounding identification of harm, elucidating prior conceptual anomalies. In addition, it provides insights into the potential for recovery from these effects.