When I raise the topic of treatment failure in therapy with colleagues, the most frequent response is: “There is always something that can be done… We can't give up on people… Failure is not an appropriate term in our field. You can't even talk of ‘failure’.” This is backed up by metaphors of therapy as a journey of discovery, and the demand that everyone has a right to receive help. The aim is to help, and compassion demands ongoing attempts with no checks other than resource. The conversation often turns to the inadequacy of current measurement of impact—perhaps what feels like a failure has long-term positive effects later in life that have not yet been measured accurately; perhaps someone not being worse, or just being alive, could be counted as successes. This might relate to the deep need to help that so many drawn to the caring professions feel.

Yet by every metric currently available, it is clear that not everyone is “better” at the end of even the most rigorously controlled and best provided treatment, or indeed in long-term follow-up studies. Even for the most robust interventions in the most selected populations, such as cognitive behavioural therapy for panic, 30% of those completing the treatment are not better at the end. And for more challenging difficulties, such as eating disorders, fewer than 50% achieve full recovery, with overall deterioration rates of 5–10% for adults, as Lambert pointed out in his thought-provoking piece on treatment failure in 2011 ( appendix ). For children and young people it would appear the failure rates might be even higher; in their 2010 study, Warren and colleagues documented findings from routine care in community services in the USA of 19% deterioration, 33% no reliable change, 32% improvement, 30% recovery, and 1% subclinical deterioration.

Despite these statistics, the issue of what should be done with those who have not recovered is almost nowhere addressed in the academic or practice literature. My colleagues and I have recently made some suggestions for how to conceptualise this group for child mental health services, focusing particularly on young people who are not better after therapy, but who cannot be discharged from services because they are seen as being at risk to themselves or others. In the THRIVE model for child and adolescent mental health services, we argue that these young people should be offered “risk support” in collaboration with social care, and explicitly not offered more therapy. In the main, however, the academic literature that considers the limitation of current treatment focuses exclusively on how to make clinicians better at their jobs—whether that is being better at spotting signs of patients being “off-track” and thus likely to disengage, receiving improved training in how to gather and respond to different data sources, or placing a greater emphasis on deliberate practice (eg, the work of Castonguay et al, 2010, and Chow et al, 2015). These are all important and valuable approaches, but none of them addresses in detail what is to be done when the person is not able to be helped. Indeed, I would argue that this question is not even possible within their conceptual framework.

This largely unchallenged shared belief that everyone can potentially be helped is a powerful disincentive to genuine learning and service development. Where is the incentive for therapists to rigorously examine who they do or don't help, if any data that show less than 100% success are going to be worse than current internal and external expectations? Moreover, the assumption conveyed to service users that treatment failure rarely occurs might lead to unhelpfully raised expectations, deprive therapists of a language to talk honestly about the limits of help, and leave those accessing services who find they are not “better” blaming themselves. I would argue that stopping the provision of ineffective intervention does not equate to stopping caring.

A very common riposte to my attempts to raise the issue of treatment failure as a necessary topic for study is: “You are focusing on the wrong thing. The real issue is lack of access to help. Not everyone can get the help they deserve. If you talk about treatment failure you will play into the hands of those who want to further cut services and limit access even more.” Numerous authors have estimated a global under-provision of mental health support relative to need. For example, results from the last UK epidemiological study of child mental health, done by Howard Meltzer and colleagues in 2000, suggested that at that time, fewer than 25% of those deemed “in need” accessed specialist mental health support. The situation is likely to have worsened with economic recession in high-income countries. There is undoubtable harm caused by lack of access to effective interventions, and it is right to focus energy on research and practice in relation to this issue. However, if all energies are directed here, with the implicit assumption that with access all will be helped, this can have the paradoxical effect of further limiting access to those who might be helped while those who are not being helped might be over-treated and potentially even harmed. Initiatives such as Choosing Wisely that aim to highlight the dangers of too much of the wrong thing may point the way forward. While it is important to consider harm from lack of access, it is crucial to consider harm from ongoing ineffective or iatrogenic practices once accessed. Considering and capturing any adverse events of psychological therapy is an under-researched area; suggestions for how to define and address such adverse events have only recently begun to be considered (eg, by Michael Linden). Welcome developments include the UK Adverse Effects of Psychological Therapies (AdEPT) project, which looks at negative effects of talking therapies for adults, and the recent call by Scott and Hague for psychotherapies to be assessed for harm as well as benefit.

Perhaps the most difficult objection to rebut in relation to the consideration of treatment failure is the argument that raising issues of limitations directly with service users might be anti-therapeutic and even harmful. As one colleague put it to me, “I would not talk of failure and limitations of treatment to a vulnerable and distressed service user, and certainly not at the outset of treatment. This is counter-therapeutic. Part of our role is to instil hope and be there for people. Saying I might not be able to help them would just be cruel and unhelpful.” Researchers such as Bruce Wampold suggest that optimism and hope might be important factors in treatment effectiveness. There is also reasonable concern about the ability of, for example, severely depressed patients or younger children to process or understand this information.

I would counter this argument by saying that these are empirical questions and we simply do not yet have the evidence base to answer this properly. Authenticity and trust may also be powerful positive therapeutic factors; it may be that if therapists were more honest with clients about the parameters and limitations of treatment and the possibility of failure, then this could actually help therapeutic outcomes rather than hinder them. There might also be ways of being realistically optimistic and sharing information. While many therapists recoil at the idea of explicitly saying to someone seeking their help—for example, for an eating disorder, for which “only half of people” get better—who is really being protected by not sharing this information? As alluded to above, not sharing these statistics might leave service users feeling responsible and blamed that they have not succeeded in therapy when the assumption is that recovery is the norm.

There is evidence that a new language and approaches are tentatively emerging in some areas. Interesting work on using probabilistic approaches to consider potential outcomes with individual clients are being pioneered particularly in relation to anxiety difficulties. There are some radical suggestions—for example, models of palliative care in which very severely ill individuals with anorexia are no longer treated but are offered palliative care, acknowledging that they will in likelihood die from their disorder. These are not uncontroversial and reflect wider controversies across physical health about how best to work with people in whom cure may be unlikely. As yet, no clear training exists for practitioners as to how to discuss treatment limits and failure in mental health. In physical health, there is a newfound interest as to how to have conversations about what success and failure might look like for individual patients in the light of what makes their life meaningful, as described in Atul Gawande's bestseller Being Mortal, and there may well be useful lessons to share in this regard.

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Therapists may need to learn how to be more explicit about endings from the start. “In my beginning is my end” may be the mantra to be adopted, with a focus on self-management from the start and an emphasis on endings. One could imagine conversations at the early stage of an intervention along the lines of “My job is to try and help as much as I can, but the focus is really on you finding ways to draw on your own strengths to manage your own life and finding a balance that is right for you.” Or “Given the difficulties you are experiencing and your context, you have a x% chance of being completely better (or completely meeting your goals) and a y% chance of being much improved (or partially meeting your goals.” Or “I would expect x change on measure y by z date. It is important to note that research shows that even without help a specific percentage of people will get better with time anyway. We can discuss the pros and cons of different types of help, and also agree when it looks like you may be better off managing things yourself, or if there is nothing else I can usefully suggest.” Or “Not everyone is helped by this treatment, but people do find ways to live with these difficulties. If what we have agreed to try first doesn't seem to help you, then you might try x and y, but even if that does not help we find that people can live with these difficulties using strategies such as a and b.” It might be that one way to discuss these issues is to talk about the way people manage to live positively with ongoing difficulties: “Some of our most productive members of society live with ongoing challenges of bipolar disorder, obsessive-compulsive disorder, self-harm, and anorexia, for example. Some would even argue that it provides them with a wisdom and perspective they might otherwise not have.”

I believe that there is an ethical imperative to be more explicit in our communal recognition of the limits of treatment, and on the definition of treatment failure and appropriate response to it. Being unrealistic with service users about possibilities of treatment failure may mean that all too many are left feeling to blame for not having succeeded in therapy. Remaining silent on the levels of treatment failure stops service-level discussion of what should be done for these individuals. It reduces rational use of resources, stunts service development, and might contribute to forms of both therapist-blaming and patient-blaming. For these reasons, I would argue that there is a pressing need for greater research into and discussion of the limits of treatment and treatment failure, which I hope this Essay might play some part in stimulating.

The opinions expressed in this Essay are the author's own and do not necessarily represent the views of UCL (University College London), the Anna Freud Centre, Child Outcomes Research Consortium, or any other organisation or body with which the author is associated

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Supplementary Material Supplementary appendix