Negative Effects Questionnaire (NEQ)

Psychological treatments can be beneficial in relation to a number of psychiatric disorders, both in terms of alleviating mental distress and improving well-being (c.f., Cuijpers et al., 2013). However, far less attention has been given to the possibility of inadvertently causing negative effects, with few studies reporting their incidence (Jonsson, Alaie, Parling, & Arnberg, 2014). Several prominent researchers and clinicians have therefore urged that more investigations should be performed in order to better understand their occurrence and characteristics (Lilienfeld, 2007; Barlow, 2010; Dimidjian & Hollon, 2010). Lately, findings from various naturalistic investigations show that 5-10% of all patients undergoing psychological treatments deteriorate (c.f., Hatfield, McCullough, Frantz, & Krieger, 2010), and similar estimates have been found in randomized controlled trials of Internet-based psychological treatments (Rozental et al., 2017), suggesting that negative effects occur and need to be monitored.

Meanwhile, other types of negative effects have also been proposed, such as adverse and unwanted events occurring during the course of treatment (c.f., Linden & Schermuly-Haup, 2014). This might involve new symptoms, social stigma, and interpersonal difficulties that affect the patient negatively, some being related to the treatment interventions being delivered, others having an association with circumstances in the patient’s life (Strupp & Hadley, 1977). These negative effects have, however, been yet even less explored, with a few notable and important exceptions (Parker, Fletcher, Berk, & Paterson, 2013; Linden, 2013; Ludwig, Rief, & Nestoriuc, 2014). Thus, not much is currently known about what these negative effects are and how the may influence the patient or the ongoing treatment, warranting further research.

With the intention of examining these potentially adverse and unwanted events in psychological treatments, a novel self-report measure was therefore created, the Negative Effects Questionnaire (NEQ). Using the results from a consensus statement (Rozental et al., 2014), a pilot study investigating negative effects (Boettcher et al., 2014), a qualitative analysis of the patients’ own experiences of adverse and unwanted events (Rozental et al., 2015), as well as a literature review, it was developed and evaluated on a sample of 653 patients. The self-report measure is presently available in eleven different languages and can be downloaded and used for free. It contains 32 items that are scored on a five point Likert-scale (0-4) and differentiates between negative effects that are attributed to treatment and those possibly caused by other circumstances, as well as one open-ended question.


Turkish versions (32 + 20) now available (Translation by Samet Baş & Gizem Bozyel).

New and improved scoring help with this Excel-file: NEQ_scoring_matrix_(2022-02-10).xlsm

[ New paper ] Rozental, A., Kottorp, A., Forsström, D., Månsson, K., Boettcher, J., Andersson, G., Furmark, T., & Carlbring, P. (2019). The Negative Effects Questionnaire: Psychometric properties of an instrument for assessing adverse and unwanted events in psychological treatments. Behavioural and Cognitive Psychotherapy, 47(5), 559-572. doi:10.1017/S1352465819000018

The NEQ is now available in Czech, Greek, and Polish.

A shorter version (20 items) of the NEQ is now available. For more information on its psychometric properties please see the reference below. .


Main Developers and Curators

  • Alexander Rozental is a Licensed Psychologist and Post Doctoral Researcher at the Department of Clinical Neuroscience at Karolinska Institutet, as well as an Honorary Senior Lecturer at the Institute of Child Health at University College London.
  • Per Carlbring is a Licensed Psychologist, Licensed Psychotherapist, Board Certified Specialist in Clinical Psychology, and Professor in clinical psychology the Department of Psychology at Stockholm University.

Associate Developers

  • Anders Kottorp is a Licensed Occupational Therapist, Professor in occupational therapy, and Dean of the Faculty of Health and Society at Malmö University.
  • Johanna Boettcher is a Licensed Psychologist and PhD at the Department of Clinical Psychology and Psychotherapy at Freie Universität Berlin
  • Gerhard Andersson is a Licensed Psychologist, Licensed Psychotherapist, Board Certified Specialist in Clinical Psychology, and Professor in clinical psychology at the Department of Behavioural Sciences and Learning at Linköping University, as well as the Department of Clinical Neuroscience at Karolinska Institutet.

Download & Scoring


The Negative Effects Questionnaire (NEQ) has currently been translated into fourteen different languages. Most of the translations are made by an authorized translator and in accordance with the coordinated framework agreements in Sweden, thereby ensuring a high standard, satisfactory reliability, and that each translation is made in compliance with the quality certification ISO 9001:2008. If not, the translations have been made by an experienced clinical psychologist or researcher in clinical psychology and been back-translated to ensure that it is correct. Furthermore, each translation has also been reviewed by clinical psychologists with the given language as their native tongue in order to make sure that the translation is easy to comprehend, feels unsophisticated, and does not include words or expressions that are unfamiliar to most people.


The self-report measure consists of three parts. First, respondents endorse specific items in case they have occurred or not during treatment, yes/no (dummy coded as a variable: 1/0). Second, the respondents rate how negatively the negative effect was on four-point Likert-scale, ranging from ”Not at all” to ”Extremely”, 0-4 (”0” being minimum and ”4” being maximum). Third, the respondents attribute the negative effect to ”The treatment I received” (1) or ”Other circumstances” (0) (dummy coded as a variable: 1/0).

The items can be summed together in order to get a frequency measure of the number of negative effects the respondents have experienced, divided by treatment or other circumstances. The mean and standard deviation of their average negative impact for the full self-report measure can also be presented. Finally, the individual factors can be examined in terms of their means and standard deviations.

To facilitate investigations using the self-report measure, the following spreadsheet can also be used: scoring matrix.

There is currently no consensus on how to interpret scores from a self-report measure on negative effects of psychological treatments. However, summing up the frequencies and providing information on means and standard deviations can help with comparisons between different samples. For more information, please see the references.


The self-report measure is free to download and free to use in both clinical and research settings. If implemented in clinical trials or similar studies, please include a reference to its original evaluation.

NEQ Czech 20 Items
NEQ Czech 32 Items
NEQ Danish 20 Items
NEQ Danish 32 Items
NEQ Dutch 20 Items
NEQ Dutch 32 Items
NEQ English 20 Items
NEQ English 32 Items
NEQ Finnish 20 Items
NEQ Finnish 32 Items
NEQ French 20 Items
NEQ French 32 Items
NEQ German 20 Items
NEQ German 32 Items
NEQ Greek 20 Items
NEQ Greek 32 Items
NEQ Italian 20 Items
NEQ Italian 32 Items
NEQ Japanese 20 Items
NEQ Japanese 32 Items
NEQ Lithuanian 20 Items
NEQ Lithuanian 32 Items
NEQ Norwegian 20 Items
NEQ Norwegian 32 Items
NEQ Polish 20 Items
NEQ Polish 32 Items
NEQ Spanish 20 Items
NEQ Spanish 32 Items
NEQ Swedish 20 Items
NEQ Swedish 32 Items
NEQ Turkish 20 Items
NEQ Turkish 32 Items



The Negative Effects Questionnaire (NEQ) has currently been evaluated in terms of its reliability and factor structure in articles published in the peer-reviewed journals PLoS One and Behavioral and Cognitive Psychotherapy. Moreover, in accordance with idea of providing important and interesting research for free, the articles are available for everyone through so-called open access – just click on the title below to read it online or download to your computer, tablet, or smartphone.

Additional references
(in reverse chronological order)

For additional articles related to the research of negative effects of psychological treatments in general, and for Internet-based treatment interventions in particular, please consult some of the references below.

Rozental, A., Castonguay, L., Dimidjian, S., Lambert, M., Shafran, R., Andersson, G., & Carlbring, P. (2018). Negative effects in psychotherapy: Commentary and recommendations for future research and clinical practiceBJPsych Open, 4(4), 307-312. doi:10.1192/bjo.2018.42

Rozental, A., Magnusson, K., Boettcher, J., Andersson, G., & Carlbring, P. (2017). For better or worse: An individual patient data meta-analysis of deterioration among participants receiving Internet-based cognitive behavior therapyJournal of Consulting and Clinical Psychology, 85(2), 160-177.

Ebert, D. D., Donkin, L., Andersson, G., Andrews, G., Berger, T., Carlbring, P., Rozental, A., Choi, I., Laferton, J. A. C., Johansson, R., Kleiboer, A., Lange, A., Lehr, D., Reins, J.A., Funk, B., Newby, J., Perini, S., Riper, H., Ruwaard, J., Sheeber, L., Snoek, F. J., Titov, N., Ünlü Ince, B., van Bastelaar, K., Vernmark, K., van Straten, A., Warmerdam, L., Salsman, N. and Cuijpers, P. (2016). Does Internet-based guided-self-help for depression cause harm? An individual participant data meta-analysis on deterioration rates and its moderators in randomized controlled trialsPsychological Medicine, 46(13), 2679-2693. doi:

Rozental, A., Boettcher, J., Andersson, G., Schmidt, B., & Carlbring, P. (2015). Negative effects of Internet interventions: A qualitative content analysis of patients’ experiences with treatments delivered onlineCognitive Behaviour Therapy, 44(3), 223-236. doi:

Bystedt, S., Rozental, A., Andersson, G., Boettcher, J., & Carlbring, P. (2014). Clinicians’ perspectives on negative effects of psychological treatmentsCognitive Behaviour Therapy, 43(4), 319-331. doi:

Rozental, A., Andersson, G., Boettcher, J., Ebert, D. D., Cuijpers, P., Knaevelsrud, C., Brjánn Ljótsson, B., Kaldo, V., Titov, N., & Carlbring, P. (2014). Consensus statement on defining and measuring negative effects of Internet interventionsInternet Interventions, 1(1), 12-19. doi:

Boettcher, J., Rozental, A., Andersson, G., & Carlbring, P. (2014). Side effects in Internet-based Interventions for social anxiety disorderInternet Interventions, 1(1), 3-11. doi: