Dr Denman’s presentation of the adverse effects of psychotherapy was novel and welcome (Reference DenmanDenman 2011). The topic is under-researched in comparison to the wealth of data on the side-effects of medication. However, the list of adverse effects presented in the article is not complete. Although I am a frequent advocate of psychotherapy for patients, I would venture to suggest three very important additional adverse effects: inappropriate or missed diagnoses, psychological dependence and withdrawal, and boundary violations leading to sexual abuse or financial manipulation.

Sexual boundary violations during therapy crop up regularly at regulatory body hearings for psychiatrists, psychologists, psychiatric nurses and mental health social workers. Adjustment disorders, post-traumatic stress disorder and relationship breakdowns can ensue for the victims and these surely are unwanted and major adverse effects of psychotherapy.

Being launched into therapy without a correct diagnosis is dangerous. As psychiatrists, we may all have come across patients with organic illness (e.g. hyperthyroidism) who have had months of anxiety therapy when all they required was the correct investigations and treatment.

Similarly, we will all have encountered self-funding psychotherapy patients whose ‘time-limited’ therapy has elongated into an unlimited assault on their time and pockets. They have become psychologically dependent on their therapists and their therapists have become financially dependent on them.

I would suggest that therapists have a duty to advise about the potential adverse effects of psychotherapy before it begins, just as doctors have a duty to advise patients about the side-effects of the drugs they prescribe. This is an example of seeking informed consent. Being open about such adverse effects at the start of therapy and discussing their features might prevent their development.