Better Living Through Psychology

What does your doctor do when you tell her or him that you’re not getting better? What would you do if her response was “more of the same”?

I dare say you’d at least leave and see another doctor. That would make sense and it happens rarely because good doctors pay attention to signs of improvement – and their absence. Certainly if your condition worsened you’d expect the doctor to notice at least.

Unfortunately this is far from common practice when it comes to psychotherapy and counselling. Exactly how bad the average therapist is at this essential assessment task was recently revealed in an intriguing real-world study by Derek Hatfield and colleagues published in Clinical Psychology & Psychotherapy.

Hatfield’s group combed a database of over 4000 clients at a university counselling centre to identify cases where the client’s condition had deteriorated. All of these clients had attended at least two sessions where they were assessed with a standard test of psychological health. The researchers were only interested though in cases that met these two criteria:

1. Their intake score on the measure was in the clinical range and at some point in the course of therapy had deteriorated significantly, and;
2. They had only seen the one therapist during the course of the treatment in which the deterioration had occurred.

The first criterion ensured that the clients who were the subject of the study were not deteriorating through statistical artefact – otherwise known as regression to the mean. We all have ups and downs in life and “regression to the mean” describes a situation where someone who is functioning exceptionally well shows a deterioration that is simply due to these “normal” variations – what goes up has to come down, if you will. This criterion is also important because the most demanding, and therefore expensive-to-treat, clients are those whose status is the poorest during treatment.

The second criterion was important because it allowed the researchers to draw conclusions about the perceptiveness of individual counsellors.

Hatfield’s group examined the progress notes of a random selection of 70 clients who met these two criteria. Only 30% of the therapists in these situations referred to the client’s deterioration in their progress notes.

It’s hard to solve a problem you’re not aware of.

Why does this matter? There is a wealth of research on psychotherapy outcomes that shows that early gains in the course of therapy are a good basis for continued gains. Conversely, if a client is deteriorating the therapist may be able to alter the client’s trajectory by changing their treatment or recommending another therapist.

These courses of action have been found to improve the overall outcomes of individual counsellors as long as they have access to objective feedback (i.e. psychological test results) about the client’s progress. Many psychologists and other therapists do not use any form of psychological testing to determine progress. But even with the presence of test scores in the Hatfield et al study, only around 10% of counsellors even mentioned the change in scores in their notes.

So here’s the reason I ask my clients how they are going, and do it using a standardised measure of outcome: my perception of the client’s progress may be incorrect, it’s unlikely though that the client’s will be.

One thing I know I can count on – and Hatfield’s study backs this up – like every therapist, I am going to get a small proportion of clients whose condition fails to improve or actually worsens under my care. In the study, 9% of the original sample deteriorated significantly.

I have been measuring client outcomes since 2003. Combined with asking questions like “How was this session for you? What was missing from the session? Is this approach helping?” and then acting on the answers to improve the treatment for the client, this has enabled me to produce outcomes that are better than over 70% of therapists in standardised samples.