Knox, S., Miller, C., Twidwell, R.E., & Knowlton, G. (2022). Client perspectives on psychotherapy failure, Psychotherapy Research, online first publication
The research indicates that between 5% to 10% of patients get worse during psychotherapy, as many as 30% do not improve, and about 20% drop out of therapy. And so, despite the overall efficacy of psychotherapy, treatment failure (not improving, getting worse, and dropping out) is a big problem. Surprisingly, there is very little research to understand what happens when therapy is unsuccessful. Some of the research that exists asks therapists for their opinions, but we already know that therapists are not good at detecting patients who get worse, therapists overestimate patient satisfaction, and therapists often overestimate their effectiveness relative to peers. Very few studies have asked patients directly about their experience, their understanding, and the impact of psychotherapy not working for them. In this qualitative study, Knox and colleagues interviewed 13 adult patients who reported that their psychotherapy was a failure. The patients reported a variety of reasons for seeking therapy in the first place (depression, anxiety, trauma), and they received a median of 20 to 30 sessions of therapy. Of the therapists that patients saw, 62% were female whose average wage was in the 40s, from different professions (psychology, social work, counsellors), and different contexts (private practice, universities, community health clinics). Typically, patients defined a psychotherapy failure as one that negatively affected them (made them feel worse, did not meet their treatment goals, and characterized by problems in the therapeutic relationship). Often patients raised their concerns with the therapist prior to the final session, but the issue did not resolve. Patients also reported that after termination their symptoms worsened, they felt more hopeless regarding themselves, and they were less optimistic about therapy in the future. Patients noted that therapist behaviors contributed to the failure, such as: therapist insensitivity, apparent incompetence, not checking in with patients’ experiences of the therapy, not focusing on the patients’ goals, and not addressing concerns about the therapy raised by patients.
Unfortunately, a non-trivial percentage of patients get worse or don’t benefit from therapy. There were immediate impacts (patients felt worse) and also longer-term impacts (patients’ symptoms continued to deteriorate and they were less optimistic about trying therapy again). Therapists should regularly check in with patients about how they are experiencing the therapy. If a patient expresses concern about how therapy is progressing, therapists must listen and non-defensively hear what the patient is saying while acknowledging that it is difficult for patients to speak up. Therapists who make an error should own the mistake and correct course if necessary or refer to another professional. Regular outcome monitoring (repeated measurement of patient symptoms) and process monitoring (repeated measurement of the therapeutic alliance) may help therapists to supplement their clinical judgement to determine if the patient’s symptoms are deteriorating or if they are dissatisfied.