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Lambert, M. J. (2012). Helping clinicians to use and learn from research-based systems: The OQ-analyst. Psychotherapy, 49(2), 109.

One of the more interesting and clinically relevant trends in psychotherapy research and practice in the past 10 years is the emergence of research on continuous progress monitoring. Continuous progress monitoring occurs when a patient is given a standardized self report measure before a session and the results of patient functioning are fed back to the therapist. (This is distinct from a clinician asking a patient for a verbal account of how he or she is doing this week). The standardized self report assessment is often done repeatedly, sometimes before every session or every fixed number of sessions. Measures, such as the Outcome Questionnaire (OQ) for adults or youths, was specifically designed for this purpose. The OQ assesses symptoms, interpersonal functioning, and life functioning, and clients are identified as improving (i.e., on course), or at risk of deteriorating. Recently, a small meta analysis of 3 to 4 studies representing 454 to 558 clients on the effects of progress monitoring found a moderate relationship between monitoring plus feedback and client outcomes. The method is particularly effective in changing the course of outcomes for patients who are deteriorating. Large research reviews of evidence based treatments in randomized controlled trials show that about 40% to 60% of patients improve or recover from psychotherapy, 30% to 50% may not benefit, and 3% to 14% deteriorate (see my March 2013 blog). These proportions are likely less positive in everyday practice in which clients are not highly screened to meet research inclusion criteria. Unfortunately, clinicians’ views of their own client outcomes are unrealistically positive. In one survey, clinicians in routine practice reported that about 85% of their clients improved or recovered. About 90% of therapists rated themselves in the upper quartile and none rated themselves as below average (50^th percentile). Also there is serious doubt about the ability of clinicians to identify clients during the course of therapy, who ultimately deteriorate. In the paper by Lambert on the use of the Outcome Questionnaire (OQ), he reviewed several studies on continuous progress monitoring in everyday practice. Each therapist was asked to practice as they routinely do with half their usual caseload. With the other half of their caseload clients completed the OQ and the therapist received feedback before every session about patient progress. The feedback did not make a difference for clients who made steady progress (i.e., on track) from week to week. However, continuous progress monitoring did make a difference for the 20% to 30% who showed some sign of deteriorating at some point in treatment. Notifying therapists that these patients were in trouble reduced the rate of deterioration from 20.1% to 5.5%, and monitoring and feedback increased positive outcomes from 22.3% to 55.5%.

Practice Implications

Lambert reported that clinicians in these “practice as usual” studies were initially skeptical but quite surprised at the outcomes related to continuous progress monitoring. Standardized assessments appear to get around the problem of clinician over-estimation of their patients’ positive outcomes. Clinicians were able to more accurately identify clients at risk of deteriorating likely resulting in the therapist doing something different to forestall the negative consequences. Lambert argues that it is in the best interest of at-risk patients to have their symptoms, interpersonal functioning, and life functioning formally monitored throughout treatment. However, clinicians are likely to resist doing so because they believe that they are already highly successful, and even more so than the typical outcomes produced by clinical trials. Formal monitoring of client outcomes has little downside for clinicians (it is inexpensive and requires little training), and it has many upsides for clients, especially those who are at risk for deteriorating.

Author email: michael_lambert@byu.edu

Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month in the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses. If you are interested, the Handbook table of content can be viewed on Amazon.

Lambert, M.J. (2013). The efficacy and effectiveness of psychotherapy. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6^th ed.), pp. 169-218. Hoboken, N.J.: Wiley.

An important issue for patients, therapists, and agencies is the optimal dosage of psychotherapy that is necessary to reduce impairment and improve life functioning. In this part of the Handbook chapter on Efficacy and Effectiveness of Psychotherapy, Lambert tackles the issue of the psychotherapy dose-response relationship by reviewing the existing literature. That literature tends to focus on naturalistic national (U.S.) samples of patients (often N > 6,000) receiving routine care in Health Maintenance Organizations, Employee Assistance Programs, and Community Mental Health Clinics. Outcomes tend to be assessed by patient self report, and can include symptoms, character traits, quality of life, and interpersonal functioning, among others. Lambert defines “improved” patients as those who reliably changed but still are within the dysfunctional range on a measure, and he defines “recovered” patients as those who both reliably improved and were no longer in the dysfunctional range. He concluded that on average 50% of patients who begin treatment in the dysfunctional range achieve recovery following 21 sessions of psychotherapy. On the flip side, half of patients do not achieve recovery after 21 sessions. Almost 50 sessions are necessary for 75% of patients to recover. In other words, there is a rapid rate of recovery in which half of patients recover after 21 sessions, but then the rate of recovery slows down so that it takes up to 50 sessions for an additional 25% of patients to recover. The rates of recovery also differ depending on what is measured. Symptoms (depression, anxiety, etc.) tend to recover more quickly than characterological or interpersonal problems. Further, some patients experience sudden symptom gains in therapy that are long lasting. Between 17% and 50% of patients experience the majority of their symptom improvements within 7 sessions, and these early changes accounted for 50% of total symptom gains in therapy.

Practice Implications

The question of how much therapy is enough is important for practical and theoretical reasons. Research on this topic can help patients, therapists, and agencies make decisions about treatment planning. Research suggests that a sizeable proportion of patients (50%) reliably improve after 7 sessions and a similar percentage recover after 21 sessions. However, limiting treatment to less than 20 sessions will mean that about half of patients will not achieve a substantial benefit from therapy. Session limits need to be assessed carefully depending on how the patient is doing and what outcomes are important or valued. Agencies or clinicians that firmly set limits on the number of psychotherapy sessions that are too low will have the majority of their patients showing some improvement but not recovering.

Swift, J.K., Greenberg, R.P., Whipple, J.L., & Kominiak, N. (2012). Practice recommendations for reducing premature termination in therapy. Professional Psychology, 43, 379-387.

As discussed in a previous blog entry, Swift and Greenberg (2012) found that almost 20% of adult individual therapy patients drop out of therapy. Dropping out is generally defined as clients unilaterally terminating psychotherapy prior to benefitting fully and against their therapist recommendation. In this paper, Swift and colleagues review five methods with the best research evidence to reduce premature termination. (1) Providing education about duration and course of therapy. Research indicates that 25% of clients expect to recover after only two sessions of therapy, 44% after four sessions, and 62% expect to recover after 8 sessions. However the research literature indicates that it takes 13 to 18 sessions for 50% of clients to recover. Further, although some clients improve quickly and maintain that, some clients may feel worse before they get better, especially if the symptoms are related to painful feelings or events. So aligning client expectations about the length of treatment and the course of treatment may reduce dropping out. This education should be research based to increase the credibility of the information. (2) Providing role induction. Clients who are naıve to therapy may start not knowing what behaviors or roles are most appropriate on their part and could feel lost or like they are doing things wrong. Role induction refers to providing clients with some pre-treatment education or orientation about appropriate therapy behaviors. This could be done by video, verbally, or in writing. A meta analysis found that pre-therapy role induction increases attendance and reduces drop outs. (3) Incorporating client preferences. Client preferences include wants or desires concerning the type of treatment that is to be used, the type of therapist one would like to work with, and the roles and behaviors that are to take place in therapy. A recent meta analysis found that clients who had their preferences accommodated were almost half as likely to drop out of treatment prematurely compared with clients whose preferences were not taken into account. (4) Strengthening early hope. Although it is important that clients do not hold unrealistic expectations (i.e., recovery after only two sessions), it is also important that they have a general hope that therapy can help them get better. Research evidence shows that expectations for change explain as much as 15% of the variance in therapy outcomes. (5) Fostering the therapeutic alliance. The therapeutic alliance involves agreeing on goals and tasks of therapy, and a positive bond between client and therapist. A rupture in the alliance has been associated with dropping out of therapy, and a previous meta analysis found that a stronger alliance was associated with fewer drop outs.

Practice Implications

Therapists can do 5 things that are research supported to reduce patient drop outs. (1) Provide education about duration and course of therapy.  Practicing clinicians can help their clients to develop realistic expectations about duration and recovery prior to the start of therapy. Clinicians working with a more severely disturbed population or working from an orientation that espouses longer treatment durations may want to alter the education they provide to better fit their clients. (2) Provide role induction. Clinicians can provide education about the “jobs” of both the client and the therapist, such as who is expected to do most of the talking and who will be responsible for structuring or directing sessions. This type of induction should also include a discussion of the rationale for the approach that will be used. (3) Incorporate client preferences. Accommodating client preferences does not mean the therapist should automatically use the client’s preferred methods. Often clients are unaware of what treatment options are available or best suited for their particular problems. Instead, therapists should consider sharing their knowledge about the particular disorder and the nature of different approaches to the treatment of those problems with clients. Clients can then share their preferences regarding those treatment options with the therapist and work collaboratively toward a decision about which approach might be best. (4) Strengthen early hope. Therapists should express confidence that the therapy will work for their patient. Knowing the research evidence on the efficacy of psychotherapy will increase the therapist’s credibility in making such statements. (5) Foster a therapeutic alliance. Efforts to foster the therapeutic alliance should occur early on in therapy when the risk of premature termination is high, and as also therapy progresses. Early efforts should focus on making sure there is an agreement on the goals and tasks before jumping to treatment interventions.

Author email: Joshua.Keith.Swift@gmail.com

Handbook of Psychotherapy and Behavior Change: The Handbook of Psychotherapy and Behavior Change is perhaps the most important compendium of psychotherapy research covering a large number of research areas. The Handbook is updated approximately every 10 years, and the most recent 6^th edition was published in January 2013. In the coming months I will review one chapter a month in addition to commenting on psychotherapy research articles. Book chapters have more restrictive copy right rules about distributing content, so I will not provide author email addresses for these chapters. If you are interested, you can view the table of contents on Amazon.

Lambert, M.J. (2013). The efficacy and effectiveness of psychotherapy. In M.J. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behaviour change (6^th ed.), pp169-218. Hoboken, N.J.: Wiley.

This comprehensive chapter in the Handbook reviews research on the efficacy and effectiveness of psychotherapy. Lambert’s reviews focus on meta-analyses, which is a way of summarizing effect sizes in a research area. The bottom line is that psychotherapy is effective so that 40% to 60% of clients show substantial benefit in controlled research trials, though the effect is likely smaller in routine practice.  Concurrently, a consistent proportion of adults (5% to 10%) deteriorate during psychotherapy. Patients who receive formal treatment are better off than those who receive no treatment, and bona fide treatments are superior to control conditions that provide only some aspects of effective treatment. When psychotherapy is offered by skilful therapists, on average clients experience appreciable gains and return to normal functioning. Fifty percent of patients achieve clinically significant gains after 8 sessions, and 50% achieve recovery after about 20 sessions of psychotherapy. The effects of psychotherapy tend to be long lasting. For example, only 25% treated depressed patients relapse, whereas 50% of those who receive antidepressants relapse. Research continues to support those therapies that have been rigorously tested, and differences in effectiveness between therapy types (e.g., cognitive behavioural therapy (CBT), psychodynamic, interpersonal, etc.) tend to be small or negligible for many disorders. Cognitive behavioural therapy is still the most tested therapy modality, though other treatments are also accumulating evidence of efficacy. Treatment is likely facilitated by a therapeutic relationship that is characterized by trust, understanding, acceptance, kindness, and warmth. The effect of the therapist providing the therapy is at least as large as the effect of different therapy techniques. That is, some therapists are unusually effective, whereas others may not help the majority of patients who seek their services. Continuous monitoring of outcomes and providing regular feedback to the therapist improves the therapy’s effectiveness.

Practice Implications

Providers and patients can be assured that a broad range of formally defined and tested psychotherapies when provided by skilful therapists are likely to result in appreciable gains in clients including a return to normal functioning. Therapy relationships characterized by trust, understanding, acceptance, and warmth can greatly facilitate change in depression, anxiety, inadequacy, and inner conflicts. When making a decision about which therapy to choose, clients would be wise to consider the therapist as a person at least as much as the type of therapy being offered. Treatment efforts should be based on the best evidence available for treatment types, therapist behaviors, and relationship factors. Routinely monitoring the effects of therapy with each patient will give the therapist ongoing information about their effectiveness and may improve their patients’ outcomes.