How Feedback Can Improve Psychotherapy Treatment

A new study published in Psychotherapy and Psychosomatics examines previous findings on the tendency for therapists to overestimate their progress with clients, and presents the efficacy of alternatively using client self-report of feedback throughout therapy.

“Clinicians appear to be overly optimistic about patient benefits compared to measured outcome. Failure to recognize that a patient is not responding to treatment is a serious problem in routine care and one that appears to be made worse by the clinicians’ confidence in their clinical judgment and unique healing gifts.”

Michael Lambert, a professor at Brigham Young University, summarized the results of 12 clinical trials that measured and monitored patient progress and feedback throughout the course of therapy and observed the effect of feedback on treatment outcomes.

Previous literature has found that approximately 20-40% of patients fail to respond to treatment in clinical trials, and prospects are even worse in child or adolescent samples. This is despite deliberate attempts to provide evidence-based treatment from demonstrably successful therapists after patients with the same “disorder” have been carefully screened.

Furthermore, clinicians tend to overestimate their abilities and the progress of their clients. One in four therapists rate themselves within the top 10% of therapists, and none had the impression that they were below average, one study found. It may be this false perception that one is exceptionally qualified to provide effective services that also prevents therapists from being able to assess client progress accurately.

“Unfortunately, the clinicians’ view of their own patients’ outcome is much more positive than the measured outcome using self-report scales. In their survey of clinicians, Walfish et al. suggest that they estimate about 85% of their patients improve or recover, an estimate that far exceeds estimates based on measured outcomes in clinical trials and routine care. The discrepancy between clinician estimates of success and measured success suggests the need for formally measuring and monitoring treatment response.”

Lambert suggests that this discrepancy between clinicians’ ability to discern client progress and their realistic state of progress may be underlying issues in psychotherapy treatment including patient deterioration, treatment failure, and client dropout.  It is not as though clients at-risk of deterioration are necessarily difficult to detect, either. Rather, studies demonstrate that patients at risk of deterioration can often be identified after just the first few sessions.

Lambert summarizes additional research suggesting the ways in which feedback can improve therapist performance. The greater the discrepancy between therapist perception of progress and measured progress, the more likely it is that feedback will be beneficial. Other researchers have conceptualized a theory to determine how feedback is most useful, and found it is most effective when therapists are committed to improving, if they are made aware of the discrepancy between their views and measured progress, the source of the feedback is deemed credible, and when feedback is timely, simple, and offers concrete suggestions to improve.

“Clinicians could benefit from employing formal mental health vital sign tracking systems because of their proven accuracy in identifying treatment failure and thereby overcoming a clinician’s overly optimistic estimates of their patients’ treatment responses and because of their inability to predict treatment failure, specifically negative change.”

In this study, Lambert observed the usefulness of feedback through two measures, the Outcome Questionnaire (OQ) and the Youth Outcome Questionnaire (Y-OQ), which can be recorded with a computer tracking system. As the founder and partial owner of OQMeasures, the owner and distributor of the OQ, Lambert reports the potential for conflict of interest within this study and acknowledges limitations of the measures within the limitations section of this report.

The primary research question was whether or not clients have better outcomes when therapists are receiving feedback and monitoring of client self-reported progress. A secondary question is if so, then to what degree is it more useful relative to outcomes in clients receiving care from therapists who did not receive feedback?

Lambert’s summary indicates that feedback was helpful for some clients more than others. Most clients who receive psychotherapy tend to progress at a relatively steady rate. For those clients, feedback did not make a significant difference in their rate of progress.

For the other 20-40% of clients at risk of deterioration or dropout, feedback significantly and positively altered the course of their treatment such that deterioration rates were reduced from 21% to 13%, and recovery rates increased from 20% to 35%. When concrete strategies for improvement accompanied this feedback, deterioration rates were further reduced to 6%, and recovery rates further increased to approximately 50%.

While therapist qualities and skills are not solely responsible for barriers in treatment progress, monitoring treatment and identifying improvement strategies may serve to direct therapists’ attention to other therapeutic factors, prompting them to carefully attend to the client-therapist relationship, consider social supports, develop greater attunement toward client readiness to change, and other components.

Yet, sometimes, Lambert notes, monitoring the course of psychotherapy is unfortunately imposed on therapists by systems of care in a manner which might elicit resistance of what feels like external control and management. “Nevertheless,” he writes, “it appears that this research-based innovation (formal monitoring and problem-solving) has little downside for clinicians (it is cheap and effective) and large upsides for patients.”

It is important to consider that there was a limited range of studies reviewed by Lambert which featured a small variety of researchers using client self-report measures of progress and outcome. Finally, Lambert warns against the reliance on feedback tools and processes, rather than interpersonal attunement and skill, to improve outcomes:

“Mental health self-report data cannot capture the full range of psychological functioning any more than a thermometer can detect cancer, diabetes, or heart disease. Furthermore, collecting such data cannot cure mental illness any more than sticking a thermometer in a patient’s mouth can cure the flu. Feedback data themselves are not helpful unless clinicians know how to use the data to improve treatment.”

****

Lambert, M. J. (2017). Maximizing Psychotherapy Outcome beyond Evidence-Based Medicine. Psychotherapy and psychosomatics, 86(2), 80-89. doi: 10.1159/000455170 (Abstract)