Last week, my inbox started filling with emails from colleagues about a new study. Working with a real world sample, researchers compared dynamic therapy to cognitive therapy and found…
(drum roll please)
NO DIFFERENCE IN OUTCOME!
Long ago, psychologist Saul Rosenzweig dubbed the equivalence in outcome between competing brands of psychotherapy, “The Dodo Verdict.” 
(I’m the one on the right)
What’s surprising is all the attention the study has been getting. After all, the “Dodo verdict” is one of the most robust findings in the treatment literature. And yet, it remains a subject of controversy. For obvious reasons, those who advocate that certain therapies are more effective than others dislike the Dodo intensely. In fact, as I’ve reported several times on this blog, that group is forever claiming they’ve found the single study that proves it wrong.
Ultimately, however, the Dodo provides strong empirical support for something practitioners have long known: nothing works for everyone. To find the right path, therapists, and the people they serve, need choice.
Personally, I believe a much more important, yet under reported, finding of the study is the number of people who dropped out after a single visit with their therapist. In this carefully controlled and executed study, 26% of people in both treatment conditions did not return for a second session. Slightly more than half—50%–attended 5 sessions or less. This after having endured a selection and recruitment process that retained only 5% of those initially screened for participation!
Beyond the impact on those seeking service (e.g., inadequate and ineffective care, longer waiting lists, etc.), unilateral client discontinuation and no shows, available evidence shows, “exact a significant financial burden in terms of staff salaries, overhead, and lost revenue, in addition to personnel losses resulting from low morale and high staff turnover.”
What can be done?
Three evidence-based ideas:
- Setting aside time at the outset of treatment specifically aimed at making people feel welcome and comfortable has consistently been shown to improve attendance. Known variously as “role preparation/indunction,” it’s similar to how you would treat a guest in your home, either formally or informally explaining the therapeutic process, addressing any concerns/apprehensions/misconceptions, and creating an expectation of success.
- Actively seek negative feedback about the therapeutic relationship. Clients rarely report negative reactions until they’ve already decided to quit (Horvath, 2001). Measuring and discussing the status of the working relationship has been shown to improve both retention and outcome.
- Monitor progress. Not surprisingly, a felt lack of improvement is predictive of service discontinuation. Clients whose therapists use measures to identify those not making progress or worsening stay longer and improve more than those who do not.
Learn more about how to create a culture of feedback and formally monitor the progress and the therapeutic relationship in this free article from the newly published book, Quality Improvement in Behavioral Health.
Join me for an in-depth training by registering for our upcoming Fall Webinar. Over the course of four, 1-hour, online sessions, you will learn to use formal client feedback to track and improve client retention and clinical effectiveness. Click here to register or for more detailed information. And yes, CE’s are available!
Until next time,
Scott
Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
What do you make of the Cochrane conclusion that there is not sufficient evidence for using patient reported outcomes. I note that an author, DeJong, who was at UPenn evaluated these systems including the OQ45.
Here is the Cochrane conclusion:
We found insufficient evidence to support the use of routine outcome monitoring using PROMs in the treatment of CMHDs, in terms of improving patient outcomes or in improving management. The findings are subject to considerable uncertainty however, due to the high risk of bias in the large majority of trials meeting the inclusion criteria, which means further research is very likely to have an important impact on the estimate of effect and is likely to change the estimate. More research of better quality is therefore required, particularly in primary care where most CMHDs are treated.
see http://www.cochrane.org/CD011119/DEPRESSN_using-patient-reported-outcome-measures-monitor-progress-among-adults-common-mental-health-disorders
Can you give the references of the study (psychodynamic vs cognitive) you mention in this article.
Thanks!
I remember hearing from Moshe Talmon many years ago about his research into what he thought was treatment dropout, but turned out to be client satisfaction with a single session. I think this is worth bearing in mind when thinking about dropout rates – especially after one session.
Yes agreed. I for us brief effective interventionist 1 session is fine, 2 -5, fine too.
As an engineer-turned-hypnotherapist, I’m often surprised at the way people put together trials of therapeutic effectiveness. The dodo-bird verdict is exactly the result you’d expect given the way most experiments are put together. If you take a bunch of therapists and average their results, there’s a strong tendency for the results to look like average therapy.
But I think the dodo-bird verdict is correct that modality and techniques are of secondary importance: perhaps largely as an aid to practice, like training wheels. Take hypnosis, which in theory is a very distinct modality. Many hypnotists, starting with Bernheim in the 1880’s, found that eventually they were getting the results that, before, they could only achieve with formal hypnosis, but now they could do it without the hypnosis.
Couldn’t agree more about the “wrapper” around the therapy. People are far more responsive to social and environmental cues than we generally realize, and the more different ways we can honestly reinforce their desire and belief to get better (and to stick around long enough for it to happen, and to place enough trust in us that it can happen) the better.
Robert
Hi Geoffrey,
I’ll see your Cochrane, and raise you 14 years of my own practice-based client feedback, anchored within the PCOMS framework.
Click on “Practice feedback” on the above website.
Nothing uncertain about the results my clients record as being secured by service.
If you want to see the results of a Practice that is way, way better than me in terms of formal client outcome recording however, check these guys out:
Who knew that the Cochrane Collaboration was capable of a “hit piece”?