Better Living Through Psychology

Many clients wonder why I so frequently ask them questions about how the session was, whether we are on the right track, whether there’s anything I did or said that didn’t work for them, and so on. Some also wonder whether it’s really worth the effort to record their session ratings. (I use a session rating scale that gives me feedback on whether the person felt heard, whether we are talking about what is important, etc. If you are a therapist you can obtain this instrument from www.talkingcure.com)

I appreciate you may feel these questions and the rating scales are burdensome and unnecessary. After all, you’ve come to see me to get help with your problems, not to help me learn how to do therapy better. That is quite a valid point of view, however recent research at Brigham Young University showed how seeking this feedback can at least help protect you from ‘bad’ therapy. Richard Friedman discussed this research in New York Times article. His advice for seeking a good therapist is worth quoting:

In a study published last month in the journal Psychotherapy Research, Michael J. Lambert and Cory Harmon, psychologists at Brigham Young University, gave psychotherapy patients a questionnaire about how they were feeling and functioning. They randomly gave feedback from the questionnaires to half the patients’ therapists; the other half received strengthened feedback, which included patient self-assessment plus specific information about how the patients viewed their therapists and their social supports. These two groups were compared with a control group of patients whose therapists received no feedback.

The researchers found that giving feedback to therapists clearly improved treatment outcome: When therapists received no feedback, 21 percent of their patients deteriorated. With therapists who received regular feedback, 13 percent of patients deteriorated; with strengthened feedback, 7 percent of patients deteriorated.

The clear implication is that therapists are not always the best judge of how their patients are doing, perhaps because they are blinded by their own optimism and determination to succeed.

Some therapists might even view worsening during treatment as a sign of progress — a misguided “no pain, no gain” view of psychotherapy.

It’s probably easier to say what is bad psychotherapy than what is good, but there are qualities that all good therapies share. You should feel that you are understood as an individual, and that your therapist is compassionate and nonjudgmental. Good therapists should be able to explain the nature of your problem, and which of several treatments might help you.

Protecting you from treatment deterioration is important. There is a medical principle called primum non nocere - first do no harm. In other words if you come to counselling for help, you should expect at least not to be any worse off. However, like any treatment, psychotherapy has its treatment failures.

Most studies in this area show that, depending on the therapist, negative treatment outcomes are likely in an average of 10% of cases. Which therapists have the worst outcomes? The ones who don’t ask for feedback from their clients.

Of course, I’m not so naive or arrogant as to think I won’t have treatment failures like anybody else. But if that is going to happen, I want to find out as soon as possible so that I can change my approach or refer that person to someone more suitable.