Internet Editor’s Note: Dr. Lambert recently published an article titled “Progress Feedback and the OQ-System: The Past and the Future” in Psychotherapy. You can access a free copy of their journal article here .

Introduction

In the course of a program of research aimed at preventing treatment failure our research group at Brigham Young University has had the opportunity to track the session-by-session treatment progress of clients undergoing psychotherapy. These clients have received treatment in a wide variety of clinics and in private practice as well as inpatient care. Outcomes have been measured with the Outcome Questionnaire, a self-report measure that asks questions about functioning over the last week. The thousands of clients whose functioning has been assessed were treated by hundreds of therapists practicing a wide variety of treatments and modalities. Here are a few of the important and somewhat surprising findings.

1. Improvement is Rapid

Many patients who show lasting change improve dramatically and rapidly, often in the first five sessions. This occurs across disorders and across treatment orientations.

2. Clients Rarely Get Worse Before They Get Better

The road to final recovery is improvement in response to sessions. It is rare for individuals to reliably worsen before they improve.

3. Reliable Improvement

Fifty percent of patients reliably improve after 8 sessions of treatment.

It takes closer to 18 sessions of treatment for 50% of clients to re-enter the ranks of normal functioning as established with scores from normative samples.

4. Lasting Change Is More Often Characterized by Sudden Dramatic Improvement Rather Than Incremental, Session-By-Session Improvement

It’s as if a reorganization of the self occurs as opposed to rather than individuals learning a skill that takes steady practice. Something much deeper than mere symptomatic change occurs for many individuals.

5. Some Therapists’ Clients Are Consistently Faster at Fostering Improvement in Their Clients, While Other Therapists Produce a Greater Amount of Change

The speed and amount of overall change appear to be unrelated to the kind of psychotherapy clinicians claim to be practicing. Trainees, in general, create change more slowly and their clients experience a “rougher road” to recovery than experienced clinicians-- but are not less effective.

6. Therapist Exaggerations of Their Impact

Therapists seriously overestimate their positive impact on clients compared to measured impact. Thus, therapists’ estimate about 85% of their caseload improves whereas controlled research (clinical trials) find 2/3 improve and in routine care it appears that only 1/3 improve!

7. Therapist Avoidance of Noticing Client Decline

More important, therapists are woefully challenged when it comes to identifying which of their clients will leave treatment worse off than when they entered. Thus, I have learned that therapists fail to record in their case notes that client functioning has declined (compared to measured functioning) even when the decline in functioning is dramatic. Ratings were gathered at the end of each therapy session and not only involved therapist prediction of final negative outcome, but the status of the client at the current session compared to their status at intake (i.e., Is the client functioning more poorly today than when they started treatment?).

After clients (n=550) had completed treatment, 7.6% had deteriorated. Therapists were specifically asked to predict which of their clients they believed were likely to be among the 8%; experienced clinicians made few predictions, trainees faired no better than professionals, and both groups fell way short of actuarial methods. The licensed professionals did not identify a single client who deteriorated and the trainees identified a single case. In contrast, the computer algorithms identified 85% of those who eventually deteriorated.

8. Mental Health Lab Test

We can create a reliable and valid assessment of patient mental health functioning (internal pain, interpersonal functioning, life functioning, and well being) that can be completed in 5-minutes. Clients find it perfectly acceptable to complete it on a weekly basis before each treatment session.

9. Therapists Can Be Alerted

The measure can be completed on-line or in the office before the treatment session, scored instantaneously, and a report generated for the clinician (or client) in seconds.

10. Therapists Can Reduce Treatment Failure If They Are Alerted

Over the years we conducted numerous clinical trials. Our basic methodology involved asking clinicians to practice as they usually do with half their cases (no formal session-by-session measurement of mental health functioning) and to examine reports of clients’ progress before every treatment session with the other half of their cases (randomly assigned). As expected progress feedback in the form of graphs was NOT helpful in the majority of cases. It was helpful specifically for clients who were predicted to be treatment failures. The portion of treated individuals who were predicted to have negative outcome varied from clinic to clinic (from about 18% to more than 40%).

When therapists were alerted to possible treatment failure, it resulted in reduced deterioration rates in at-risk cases by 1/3 to 2/3 depending on the methods we used. The more disturbed the clientele within a clinic the higher the likelihood of deteriorating in psychotherapy, and the greater the need to measure and monitor mental health functioning.

The key to reducing deterioration appears to be alerting therapists and helping them organize their problem-solving strategies.

Conclusion

Clients frequently tell therapists some of their most private thoughts and feelings and therefore therapists, more than most people, are in a unique position to understand clients’ suffering and change over time. The problem with clinical judgment in the treatment setting is both time and method. Clinicians do not have time to routinely and thoroughly assess client functioning across all the domains of interest. With few exceptions, therapists do not routinely employ reliable assessments at each visit so that precision in assessment is lacking. Most therapists do not use modern actuarial methods that can accurately predict treatment failure and thus never become aware that the treatment is not working. Therapists in general are happy to treat clients in the absence of “lab” test data. This situation (practice without monitoring and alerting) has a long tradition in psychotherapy practice, training, and supervision, but one that is no longer justified in the age of advanced statistical modeling, computers, and appropriate software.

Who wants to be treated for high blood pressure by a physician who does not bother to measure it? Who wants to have their diabetes managed without tracking the consequences of various interventions aimed at reducing AC1 levels? Likewise, how can we most effectively help clients improve their mental health if we do not actually measure the effects of our interventions on mental health throughout the course of therapy? Enough evidence has accumulated at this point in time to make clear that practicing in the absence of formally tracking client mental health is not in our patients’ or society’s best interests.