Psychotherapy is effective in helping patients to reduce their symptoms. However, approximately 5% to 14% of patients report worsening symptoms after completing psychotherapy, and about 20% drop out of therapy. It would be very useful if therapists could identify these patients quickly so that the therapy or therapist behaviors can be modified to reduce the possibility of worsening symptoms or dropping out. Three studies have investigated whether therapists can identify deteriorating patients, and the results are not promising. In one study, 49 therapists were told to expect that about 8% of patients get worse from therapy. Despite that information, therapists identified only 3 of 40 patients who deteriorated. Surprisingly, experienced therapists performed no better than trainees at identifying those patients who got worse, suggesting that therapist experience level was not a helpful factor. In this study, Ostergard and colleagues replicated the research on therapists’ ability to estimate client change in each session and at the end of therapy. Therapists were asked to systematically estimate patient change after each session compared to intake and predict client outcomes at the end of treatment. Therapists rated if the patient improved, stayed the same, or got worse based on their clinical judgement. Patients completed validated self-report questionnaires about symptoms at the end of each session and at post-treatment. The study had 53 trainee psychotherapists, most of whom treated two adult patients in weekly individual psychotherapy. Eight of the 96 patients (8.3%) showed deterioration after therapy. Therapists correctly identified only 1 of these patients, thus failing to detect 7 (87.5%) of patients who deteriorated. When asked to rate symptoms after each session, therapists identified only 6 (7.2%) sessions in which a patient had worsening symptoms. In 27 cases (32.5%) where a patient reported worsening symptoms after a session, therapists incorrectly estimated that patients had improved.
It can be challenging for therapists to identify and predict patients who deteriorate. Determining a patient’s symptom status involves identifying their current state relative to intake, judging if a symptom change is clinically meaningful, and deciding if symptom severity is significantly above the norm. These are highly complex decisions, and human information processing has its limitations. Further, people are generally subject to confirmation bias (selectively considering evidence to support their position and disregarding opposing evidence). To overcome this challenge, therapists can use outcome monitoring alongside clinical judgement to assess patient progress and outcome. Outcome monitoring (measuring patient progress and psychotherapy processes repeatedly during therapy with a validated instrument) can augment clinical decision-making.
Ostergard, O.K., Gronnebaek, L., & Nilsson, K.K. (2024). Do therapists know when their clients deteriorate? An investigation of therapists' ability to estimate and predict client change during and after psychotherapy. Clinical Psychology and Psychotherapy, 31, e70015. https://doi.org/10.1002/cpp.70015.