You are not going to believe me when I say it. Fifty percent. It’s true. Even in studies where carefully selected therapists who receive copious amounts of training, support, and supervision, and treat clients with a single diagnosis or problem, between 5 and 10% get worse and 35-40% experience no benefit whatsoever! That’s half, or more.
What happens to these people?
Well, as readers of this blog know, if the therapist formally and routinely solicits feedback regarding the quality of the relationship and progress in care, drop out and deterioration rates fall, and outcome improves.
Still, a significant percentage of people do not improve—as many as 25%! What can we do? The ethical standards for all of the professional mental health organizations require clinicians both monitor and end ineffective treatments as well as suggest helpful alternatives to clients (ACA [C2.d], APA [10.10]). But what?
Enter Lynn D. Johnson, Ph.D., a psychologist whose work and thinking is always a step ahead. I’ve known Lynn for 30 years, met him when I was a graduate student. As I blogged previously about, it was Lynn who in 1996 first suggested routinely measuring outcomes. He is also responsible for the creation of the original Session Rating Scale–a 10-item version that I later shortened to four. For several years, Lynn pushed me to do research on top performing therapists, believing they held clues to improving the practice of psychotherapy in general.
Well, my long time colleague and mentor is at it again, once more seeing “over the horizon.” Based on the latest findings on “human flourishing,” he says that lifestyles provide a pathway to health for the non-responders. True to form, he’s freely sharing what he knows, offering online courses on “Lifestyle secrets of the happy and healthy.”
Click here if you are you interested in learning more. Lynn claims that these ideas and techniques are the next thing in both physical medicine and psychotherapy. Let me know what you think.
Until next time, wishing you a healthy and happy life,
Scott
Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
Thanks Scott. I’m a bit confused though .. I thought that from the ‘therapy works’ research, 8 out of 10 people get better with treatment. How does that square with this ‘50% don’t’ finding?
Cheers
Andrew
Hi Andrew. Great question. When you compare treated versus untreated clients, meta-analytic studies show that those receiving care are better off than 80% of those who do not. The figure I cite in my most recent blog is the percentage of clients who achieve a reliable change/improvement. Two different stats. Two different comparisons.
Very interesting, Scott, as always… Still wish I could get more of the clinic here to actually embrace FIT but perhaps if more outside pressure from 3rd-party payers and others builds over time to incorporate outcomes it may happen. Of course, I would rather have it come from a genuine interest in client welfare and effectiveness versus those other factors!
Nate…come hang out with us this summer at one of our three intensives. You’d be perfect for the professional development course. We will be use the latest research on top performing therapists to help participants develop an evidence based plan for improving engagement and effectiveness.
Hi Scott,
Thanks for the interesting info on failure rates. My question is more on FIT outcomes. I know that FIT enhances outcomes and decreases drop out rates across different modalities of therapy. How long do these improvements in therapist efficacy last? Is there a bump up when FIT starts and then it goes back to normal or does it stay improved? Similarly, do therapists who use FIT keep improving showing that experience does predict excellence when you add FIT?
thanks,
stephen
Interesting and important question. We know that therapists do not learn merely by receiving feedback. The tools function like a GPS, pointing the way and alerting us when we are off course. If one wants to learn the geography (keeping with the GPS analogy), an additional step is required: reflection and practice. Go to my publication list and read the two articles, “Supershrinks” and “The Road to Mastery” for a review.
Hi Scott,
Thanks for your feedback. I did read the articles and have a few questions/comments. Given yours and other’s work on the ineffectiveness of techniques and training, “reflection and practice” are no longer simple topics to understand or work with. “Reflecting” on how my family systems or cognitive behavioral intervention helped this last client isn’t likely to make me a better therapist. And you have written quite extensively on the futility of emulating or reflecting on a “common factors” approach; thinking about how I really listened to that client or supported her goals is also unlikely to make me more effective.
Ericsson’s recommendations regarding reflection and deliberate practice seem solid to me but only when we are working in a field where mastery of techniques improves outcome. Constructionists and Narrative Therapists argue that psychology is not such a field; instead of operating in fundamental reality—where techniques work—we are operating in constructed reality—where change occurs through other mechanisms. If enhanced therapeutic efficacy comes from reflection and practice, then your experience with de Shazar—which had huge amounts of reflection and practice—should have improved outcome. But you report that not only did that reflection and practice (which occurred at levels far above the norm) fail to enhance outcome, surprisingly the most effective therapists were two graduate students! In sum, following a recommendation about reflection and practice is much more challenging when operating in constructed reality.
I suspect that FIT works by enhancing listening and enhancing motivation—at least for a time. I think your graduate students at the BFTC were outstanding because they were trying harder—they were highly motivated to demonstrate they could help clients change, more motivated than the more experienced therapists who had already proved they could help clients change.
This leads back to my original question about whether there is any research yet about whether the improvements caused by FIT are sustained over time and whether they are cumulative (the therapist continues to improve). I don’t know if there are any early results in this area but such research could shed important light on the theoretical speculation above.
Thanks,
Stephen Bacon
Stephen:
Take a look at the work we’ve just finished looking at top performing therapists. The key is not to focus on the level of technique applied to clients by therapists in general but rather looking at what happens when individual therapists identify the edge of what they do well and push from there. We’ve got a number of studies now showing that clinicians can improve engagement, retention, and their outcomes.
Does you research also include clients who have received psychotherapy and improved/got better but would have got better/improved without any psychotherapy? I would think this would be hard to know?
Most comparisons of psychotherapy to no treatment find in favor of treatment. Changes from psychotherapy are greater, faster, and more enduring. However, the present study was looking at the failure rate WHEN people receive treatment.
The failure rate is much higher than that. The mental health issues in our society are a byproduct of our society. You can continue to treat individuals but until the field of psychology decides to address the real issues the failure rates will never improve.
Look at it this way. In a dysfunctional family you will normally find one individual who demonstrates that dysfunction. This individual is the one most effected. In order for long term results the family has to be addressed. Now apply systems theory. Our society is the family. The same patterns on a grander scale. For any lasting and significant change the real issues must be addressed. We live in an increasingly unhealthy society. Poor mental health is a byproduct of that society. It really is that simple. Healing our society however isn’t so simple.
You’re right. I couldn’t believe it’s 50%, and I still don’t.
There’s no way it’s as high as 50% success rate. Nor do I believe the percentage of those worse off is as a low as 5-10%. I’d suspect that if more realistic measures of success and worse off were presented to respondents, you’d find percentages more like:
Success: 10%
Nothing: 50%
Worse off: 40%
Your statement of 50% success and failure is inaccurate, at best misleading. To say that people who were helped somewhat, mild to moderately improved, did not count as success, is grossly mistaken. The suffering that people go through without treatment/before treatment, as compared to after “mild to moderate” improvement, cannot be measured in dollars. It is very important. The most extensive study of psychotherapy ever done was by Consumer Reports in 1994 and found psychotherapy to be 90% effective, as rated by the consumers themselves. That 54% of respondents found therapy “helped a great deal” is staggering. To put your view in perspective, using the same standard of effectiveness would place psychiatric medications at about 33% effective, since in numerous studies it was observed that roughly a third of patients were helped extremely, a third were helped moderately, and a third felt the medication had little to no effect. Psychotherapy has been found by researchers to be just as beneficial as psychiatric medications alone, or as in at least one study, a close second, and medication and psychotherapy together have repeatedly been found to be more effective than either one alone. The verdict is in: psychotherapy works.
Dear Gregory:
Thanks for taking the time to reply. When assessing the effectiveness of therapy, it is important to separate change that is due to chance, the passage of time, the use of repeated measures, and measurement error from the actual effect of therapy. In our work, and in all clinical trials, researchers report both “reliable change” and “clinically significant” change. It is one of the most important advances in the assessment of psychotherapy outcomes of the last three decades. Such figures, derived from standardized formulas, allow us to determine when the change is actually due to treatment versus other (“noise”) factors. To our clients, change is change. It doesn’t matter what caused it. To therapist, it is essential to know what contribution they uniquely make to the change process so that we can improve the effectiveness of care. We do not and should not take credit for the changes that happen WHILE people are in care but that are not attributable to it. The most recent studies of the most researched treatment method (CBT) confirm the 50% figure. The study you cite is interesting. It was published in 1995. If you google it, you’ll be able to read scores of commentaries about the methods used in the study (survey, from a limited, highly select sample, etc.). No researcher takes the 90% figure seriously. Our own measures, applied by 10’s of 1000’s of therapists worldwide indicate that approximately 64% of people experience a reliable improvement (e.g., better than chance, maturation, and error)–a figure that is high compared to many medical procedures, and which simultaneously shows there is much room for improvement.
Also there are a lot of useless treatments in the field of phsycotherapy, treatments that are said to be highly effective, yet prove completely ineffective when actually employed. I would say 80% of treatments are bunkum. There is no way that hypnotherapy or affirmations are going to change anything about any disorder.They do nothing and achieve nothing. They are rubbish treatments, yet “highly effective” at the same time.
Actually, hypnotherapy –although not a treatment in and of itself — has compared favorably to other methods. And again, no one method has proven worse or better than any other.
Could I get your opinion on the Hansen, Lambert and Forman (2002) metaanalysis of psychotherapy in naturalistic settings? In it, the authors conclude that cirka 65% did not experience significant change, much less clinically significant change, or deteriorated. For us working in community care, is this a stat that we can refer to as a base-line? I have seen some studys citing 50% clinically significant change when settings are more structured. What can we refer to a baseline in community care settings, when it comes to expected RCI and SCS? Thanks agains Scott!
Hi Scott. I attended a training you conducted several years ago at Oregon Counseling Association’s conference in Portland. I recalled you asked the question regarding how long into their practice do counselors use their counseling skills or sometime similar to it. You gave the answer like 40 or 60 hours into their practice, counselors would stop using their skills (learned in school?). I found it alarming for sure. Just want to make sure I heard you right. Could you provide me with the research study that found that stats？ I wasn’t able to locate it. Thank you in advance.
Thanks for your comment Kok-Mun Ng! I wonder what, after all the time that has passed, caused you to reach out at this time? Let me know when you have a moment. It’s always interesting to me to know why certain ideas stick…
In any event, there is no single study. Rather, the figure is derived from studies conducted on other subjects, for example, studies comparing students or paraprofessionals with professionals. These routinely find that minimal training (less than 50 hours) results in outcomes equivalent to those of professionals (generally with years of training).
That said, the preponderance of the literature finds little or no difference in outcome between students/peers and professionals and that professionals’ outcomes deteriorate slowly with time and experience. These latter results I’ve blogged about multiple times over the years.
Hope this helps.
Thanks for your response. Here’s my follow-up:
1. Why it took so long for me to reach out after so long? I’ve always had the inkling that therapists quit doing “therapy” not long after they left school and revert back to what they’ve always done in life, which is to dispense advice and telling clients what is wrong with them and what they need to do to fix their problems. I’ve seen that happened, heard that happened. and often myself fallen into that trap. Many reasons, I supposed. One of it is probably due to us not being well-trained to truly believe in what we’ve learned in class about what works and why we do counseling. In a sense, counseling and its philosophy has not been interiorized by us, counselors. So, when you mentioned 50 (or 40) hours in the conference, I was shocked that it was so short. I remember giving an answer of 6 months. So, that answer always stuck in my mind because it sort of confirmed my inkling as well as lit an alarm in my mind so that I’ll have to caution my students against complacency.
Apparently, I might have remember or gotten your question inaccurately. Perhaps, you were asking, “How many hours of training is needed for trainees to be able to perform like experienced practitioners?”, rather than the question “How many hours (how long) before a therapist would revert back to practicing at the skill level of a trainee?” My doubt about my memory of your question came when I read your response to my question.
Perhaps, you can clarify for me which accurately represents what you were referring to with the number of 50 hours or less– training hour or hours/length of time into one’s practice upon graduation? Or, they really don’t matter.
2. Why now? I’ve been discussing and earnestly warning my students and myself against complacency ever since I attended your training. And, one of the students recently asked me for the research support for that notion. And, I couldn’t find it. So, I decided to go back to the source -> Dr. Miller.
In any case, I’ve been incorporating the idea of deliberate practice in my own work – therapy, supervision, as well as teaching. One thing that helps me to apply such concept in my own professional practice is my own insecurity or self-doubt. This of course supports what studies have found on why and how ppl improve, like what you’ve blogged.
Another thing is the attitude of humility. The field has talked much about cultural humility, etc. What about practice humility? Practitioners who subscribe to post-modern paradigms talk about “maintaining a not-knowing” stance, we should then be serious about practice with humility…..
Appreciate your time.
Thanks for replying again. Always happy to continue to dialogue and clarify. My statement in workshops is, “How long does it take before therapists’ effectiveness begins to level off?” The answer, we know from our recent study is, therapists begin to decline in effectiveness the minute they begin to practice! However, in my workshops, I always cite around 50 hours, as we can see little evidence of improvement beyond 50 hours in studies comparing the outcomes of minimally trained from those with professional degrees.
The issue, however, is SO WHAT? What does this mean? In my opinion, it means we need a different training model as well as a change of paradigms. Our model-driven training does not work to enhance therapist effectiveness. Deliberate practice provides a hopeful alternative.
Thanks for the clarification. I agree with the implications you draw. Cheers.
Seems about right. My therapist abandoned me 8 months ago, and it has for sure traumatized me and heavily affects day to day life even today. I almost killed myself because of it. I have interacted with about a dozen therapists since then, and with every one of them I either saw no change or got worse. It got so bad that I had to go to an inpatient facility a few months ago. That would have never been something that would have even been considered before I started therapy. I have friends who are in therapy right now and even the ones who have a good therapist now had to sift through a few bad ones before they found a good fit. All that to say, from my experience, the numbers line up, and, honestly, it might even be worse now. Hope you have a good day.