It happens. Our client turns up faithfully every week but doesn’t seem to be progressing. Worse, we’re not aware that we’re stuck and one week, they simply don’t turn up. Can we anticipate these situations? And if we can, how can we get moving again?
This blog was prompted by a recent publication that crossed my line of sight. The paper, by Lutz et al [i] outlines the development of a clinical feedback system designed to help therapists identify and address factors that may be preventing some clients making progress.
It got me thinking about what we know already about client engagement and dropout and the factors associated with them. Is there a way, I wonder, that we can systematically attend to those factors in a way that makes a difference to individual clients’ outcomes?
What do we know about progress and dropout?
Therapy research over several decades has pointed to a number of ‘truths’ in terms of patterns of client change and the factors that contribute to successful therapy. Many of these I’ve written about in a previous blog. Key among them are:
There appear to be typical trajectories of change that can be identified for ‘typical’ clients, or typical groups of clients. The greatest degree of change (again typically) occurs in the earlier stages of therapy.
Not all clients are typical. Some do not follow this typical pattern of change. These are clients that are at risk of a poor outcome or of dropping out. We need to pay them particularly close attention.
Early change in therapy, and the client’s rating of the therapeutic alliance, are among the strongest predictors of a successful outcome to therapy.
We perform poorly in comparison to computer-based algorithms at predicting which clients will have positive outcomes and which not.
Using measures of outcome during therapy can help us to identify which clients are not progressing and are therefore at risk of a poor outcome or dropout. Armed with this information, we can collaboratively review our work with them and adjust our focus as necessary.
The key message from all this is clear: if there is obvious evidence of progress, do more of the same. If there is not, be prepared to adjust. But feedback that clients are not making progress is only helpful if we are prepared to pay attention and do something with it. But where should we start?
Basing action on evidence
Even if we are aware that clients don’t seem to be making progress as we would hope, the reasons why are not always evident. Given that there is a significant body of evidence about the factors that may lead to dropout, however, it would seem to make sense to start here.
Two studies, one from 2003, and the more recent one already mentioned by Lutz et al, help to illustrate how we might systematically approach our work with clients who are not progressing.
The study from 2003, by Whipple et al [ii] built on earlier research reported by Lambert and colleagues.[iii] This had demonstrated that simply giving feedback to therapists about clients that were ‘not on track’ (NOT) boosted their improvement rates over treatment as usual (TAU) from 18% to 32%. Deterioration rates decreased from 23% to 18%. Despite this improvement, however, there remained a significant proportion of clients that still did not benefit from their therapists receiving feedback about their NOT status.
Whipple et al surmised that providing therapists of NOT clients with strengthened feedback might further boost improvement rates. To this end, therapists were provided with a problem-solving strategy and three additional questionnaires to use with NOT clients. The questionnaires assessed: (1) the strength of the therapeutic alliance, (2) the client’s readiness to change, and (3) the strength of their social support system. A manual provided the therapist with a decision tree (see below), and suggestions for interventions based on the client’s responses to the various questionnaires.
The specific questionnaires used were as follows:
The Helping Alliance Questionnaire (HAq-II)
An 11 item measure, with each item rated on a six point Likert scale, covering three key alliance domains: (1) the strength of the bond between therapist and client, (2) agreement on the goals of therapy, and (3) agreement on the therapeutic tasks within the session.
The Stages of Change Scale (SCS)
The SCS assesses clients’ state of readiness to make changes in their lives that will benefit them. Using the five stages of change outlined by Prochaska and Norcross [iv] of (1) Precontemplation, (2) Contemplation, (3) Preparation, (4) Action, and (5) Maintenance, the SCS identifies clients scoring in the precontemplation or contemplation stages as having unfavourable readiness for change.
The Multidimensional Scale of Perceived Social Support (MSPSS)
The MSPSS is a 12-point self-report measure that assesses the client’s level of social support from friends, family and significant others. Adequacy of social support may be an important factor in the development and severity of a client’s symptoms and further, may help or hinder the client in negotiating stressful life events.
As shown in the decision support tree, if the client reports no significant problems with the therapeutic alliance, is clearly motivated, and has adequate social support, then reassessing the current therapeutic strategy is encouraged, and, in the final analysis, the option of considering medication.
The provision of the clinical support tools (CSTs) in this study proved to be highly effective. Clients of therapists using the CST’s achieved a recovery rate of 49%, compared with 25% for clients that received treatment as usual.
The state of the art: Personalised prediction and therapy adaptation
The study by Lutz et al is one of those that can really test where you sit on the therapy as ‘art versus science’ spectrum. Findings are yet to be reported, but essentially the study is a randomised controlled trial based at the psychotherapy clinic at the University of Trier and will involve about 420 clients receiving CBT for a depressive and/or anxiety disorder. Three intervention groups are involved in the study:
The control group (CG). The progress of clients in this group will be monitored session by session (see below) as they move through therapy, but no progress feedback will be given to their therapists.
Intervention group 1 (IG1). Therapists of clients assigned to this group are given feedback on their clients’ self-reported progress via a computer-based feedback portal.
Intervention group 2 (IG2). Therapists of clients in this group will receive the same feedback as those in IG1, plus a range of CST’s and a personalised treatment approach recommendation based on clients with similar profiles that have achieved positive outcomes.
As well as the general effects of feedback and use of CST’s on outcomes, the study will explore a range of variables that may mediate these effects: treatment length, frequency of feedback use, therapist effects, therapist attitude towards feedback and congruence of therapist and client evaluation regarding progress.
As can be seen from the schedule below, the measurement load on clients is considerable. After an initial structured clinical interview to establish diagnosis, clients complete a short symptom checklist and the Global Assessment of Functioning at every session. Every fifth session, they complete a further range of measures including a short (30 item) version of the Outcome Questionnaire (OQ-30), the Assessment for Signal Clients (ASC), the Affective Style Questionnaire, the PHQ-9 and GAD-7.
The Assessment for Signal Clients and the Affective Style Questionnaire are of particular interest here in terms of their role in providing feedback to therapists. The ASC contains four subscales that measure therapeutic alliance, motivation, social support and life events, indeed many of the variables assessed in the Whipple study. The ASQ is used a marker for the extent to which the client’s capacity for emotional regulation may support or hinder progress.
In contrast with the Whipple study, however, where alliance, motivation and social support were measured only when the client was NOT (and then at the discretion of the therapist) the ASC and ASQ are routinely administered at every fifth session. Time will tell if the more routine collection of these data proves to have a greater impact on outcomes than the model used in the Whipple study.
System feedback to therapists
The image below shows the full summary feedback that is available through the computer-based system. The graph on the left shows the client’s session by session progress (irregular line) against their expected treatment response (curved line) based on similar clients. In the example shown the severity of the client’s symptoms is increasing, and they are very clearly not progressing as might be hoped.
For clients that are identified as being NOT, orange or green (light or dark grey in the image below) signals are shown on the right that display the general course of symptom change, as well as information on five further domains: (1) Risk/ Suicidality, (2) Motivation/ Treatment Goals, (3) Therapeutic Relationship, (4) Social Support/ Critical Life Event, (5) Emotion Regulation. The signals for each of these are based on cut-off values for each of the four ASC subscales and the ASQ and are designed to alert therapists to areas of potential concern.
Therapists in the IG1 intervention group are given feedback on their clients’ self-reported progress only, but not its relationship to their expected treatment response. Those in the IG2 intervention group also receive progress feedback, but additionally have access to information about the client’s expected treatment response, as well as the other CST’s (as shown above). Where a domain shows an orange signal, the therapist is able to click on that signal and access range of further resources that include written, audio and video material for that domain.
In this way the system can guide the therapist to particular areas of concern that may be impeding progress and support them by suggesting ways in which their therapeutic focus might be enhanced or changed.
Love it or loathe it?
There is much more within this study that I could write about, but I’ve described here the essence of the system as it relates to providing tools to help adapt therapeutic focus when clients are not progressing. Based on what I’ve written, you may either love it or loathe it. Assuming that you’ve got this far, I suspect that you may have one of three possible responses:
I’m doing a lot of this already without the fancy kit
I’m able to gauge the therapeutic alliance well enough without measures, and the same applies to my clients’ levels of motivation. Assessing clients’ levels of social support is something I cover routinely in assessment. If there’s a problem in any of these areas, I can identify and address it.
My clients are a special case
The profile of my clients and the issues that they struggle with means that the early patterns of change described here can’t be expected. Basically, we’re in it for the long haul, and it may be a very long time before any real change becomes apparent.
Where can I get my hands on one of these?
I can see this technology having the potential to make a real difference to the way I work with clients when we’re stick, and in giving me evidence-based ideas about how I might work differently at times. Where and when will this shiny bauble be available, and for how much?
I’ve given up getting into arguments with therapists over the ‘my experience’ versus the actual evidence, so if your response is one of the first two I’ll simply make two brief points.
Maybe you do have the ability to unerringly know early on which of your clients are headed for good outcomes and which not, without the need for any progress measures or clinical support tools. Assuming that you’ve checked your own dropout rates, as I did in a recent blog, then savour your good fortune, as the evidence suggests that you’re in a small minority.
The studies that I referred to earlier, that have shown patterns of early and relatively predicable patterns of improvement, hold true across most problem types and settings. That is not to deny that for some clients achieving a significant level of change is a bigger task than for others, and one that may take relatively longer.
If you’d simply like to get your hands on the system that enables this feedback and its clinical support tools, part of the project is concerned with the adaptation of the software to provide a cost-free version after the end of the project. The bad news is that you’ll need to be part of an ‘interested research group’ to have access to it.
However, if you’re interested in the principles behind the system and believe that its tools may have something to offer to your practice, there’s plenty that you can do without a Rolls-Royce piece of software and a library full of measures.
Routinely monitor your client’s initial problem and symptom severity, and use a brief measure, such as CORE-10, the Outcome Rating Scale (ORS), or GAD-7/PHQ-9 at every session. You may also choose to use (if you don’t already), a sessional measure of the therapeutic alliance such as the HAqII, Working Alliance Inventory or the Session Rating Scale.
Thoroughly explore your clients’ level and quality of social support at assessment. Bear in mind that the therapeutic relationship is no substitute for ‘real world’ relationships, and where social support is deficient explore with the client how it may be enhanced.
If your client is showing early signs of positive improvement, then allowing for the odd ‘blip’ now and again, keep on doing more of what you’re doing.
If your client is showing no signs of some early improvement in the first six or so sessions, consider systematically exploring potential barriers to progress. Start with an assessment of the therapeutic alliance if you’re not already measuring it. After that, consider the client’s level of motivation for change, including what might be their investment in not changing. Visit, or revisit if necessary, the adequacy of the client’s social support in enabling them to sustain the level of change they may be seeking to make.
Remember that the therapeutic alliance comprises goal, task and bond elements. Even with a well-motivated client who has good social support, and with whom you have a strong bond, if the goals and tasks of therapy are poorly conceived, then progress will be hampered. In the absence of other obvious obstacles to progress, revisit and revise as necessary the goals and tasks that you and your client have established.
We thrive on feedback, so please let us know what you think about what you’ve read in the comment section below. Only the name you use to identify yourself will be shown publicly. Thank you!
[i] Lutz W et al. 2017. Randomized controlled trial to evaluate the effects of personalized prediction and adaptation tools on treatment outcome in outpatient psychotherapy: study protocol. BMC Psychiatry 17:306. DOI 10.1186/s12888-017-1464-2
[ii] Whipple J et al. 2003. Improving the Effects of Psychotherapy: The Use of Early Identification of Treatment Failure and Problem-Solving Strategies in Routine Practice. Journal of Counseling Psychology. Vol. 50, No. 1, 59–68
[iii] Lambert MJ et al. 2002. Enhancing psychotherapy outcomes via providing feedback on client progress: A replication. Clinical Psychology and Psychotherapy, 9, 91–103.
[iv] Prochaska JO & Norcross JC. 1999. Stages of change. In J.C. Norcross (Ed.), Psychotherapy relationships that work. New York: Oxford University Press