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Many branches of medicine rely heavily on lab tests to monitor client treatment response and use this information to modify their treatment. By contrast, those who offer psychological interventions seldom rely on formal assessments (lab tests) to monitor their clients' response to treatment. Data are presented that demonstrate that clinicians rarely accurately predict who will not benefit from psychotherapy. This finding is contrasted with the use of a questionnaire (lab test data) and decision rules on the basis of a client's expected progress. Results have indicated that formal methods of monitoring were able to identify 100% of the patients whose condition had deteriorated at termination, and 85% by the time they had attended three treatment sessions. Practitioners are encouraged to consider formal methods of identifying the deteriorating client. Keywords: deterioration; negative outcomes; Outcome Questionnaire-45; identification of treatment failure; outcomes management; psychotherapy outcome

Background: Early dramatic treatment response suggests a subset of patients who respond to treatment before most of it has been offered. These early responders tend to be over represented among those who are well at termination and at follow-up. Early response patterns in psychotherapy have been investigated only for a few of mental disorders so far. The main aim of the current study was to examine early response after five therapypreparing sessions of a cognitive behavior therapy (CBT) for syndromes of medically unexplained symptoms (MUS). Methods: In the context of a randomized, waiting-list controlled trial 48 patients who suffered from ≥3 MUS over ≥6 months received 5 therapy-preparing sessions and 20 sessions of CBT for somatoform disorders. They completed self-report scales of somatic symptom severity (SOMS-7 T), depression (BDI-II), anxiety (BSI), illness anxiety and behavior (IAS) at pre-treatment, after 5 therapy-preparing sessions (FU-5P) and at therapy termination (FU-20 T). Results: The current analyses are based on data from the treatment arm only. Repeated measure ANOVAs revealed a significant decrease of depression (d = 0.34), anxiety (d = 0.60), illness anxiety (d = 0.38) and illness behavior (d = 0.42), but no change of somatic symptom severity (d = -0.03) between pre-treatment and FU-5P. Hierarchical linear multiple regression analyses showed that symptom improvements between pre-treatment and FU-5P predict a better outcome at therapy termination for depression and illness anxiety, after controlling for pre-treatment scores. Mixed-effect ANOVAs revealed significant group*time interaction effects indicating differences in the course of symptom improvement over the therapy between patients who fulfilled a reliable change (i.e., early response) during the 5 therapy-preparing sessions and patients who did not reach an early reliable change. Demographic or clinical variables at pre-treatment were not significantly correlated with differential scores between pre-treatment and FU-5P (-.23 ≤ r ≤ .23). Conclusions: Due to several limitations (e.g., small sample size, lack of a control group) the results of this study have to be interpreted cautiously. Our findings show that reliable changes in regard to affective-cognitive and behavioral variables can take place very early in CBT of patients with distressing MUS. These early changes seem to be predictive of the outcome at therapy termination. Future studies are needed in order to replicate our results, and to identify mechanisms of these early response patterns in somatoform patients. [ABSTRACT FROM AUTHOR]

Abstract: Objectives: Although psychosomatic in-patient treatment is effective, 5–10% of the patients deteriorate. Providing patient progress feedback and clinical support tools to therapists improves the outcome for patients at risk of deterioration in counseling, outpatient psychotherapy, and substance abuse treatment. This study investigated the effects of feedback on psychosomatically treated in-patients at risk of treatment failure. Methods: At intake, all patients of two psychosomatic clinics were randomized either into the experimental group or the treatment-as-usual control group. Both groups were tracked weekly with the “Outcome Questionnaire” (OQ-45) measuring patient progress and with the clinical support tool “Assessment of Signal Cases” (ASC). Therapists received feedback from both instruments for all their experimental group patients. “Patients at risk” were defined as patients who deviated from expected recovery curves by at least one standard deviation. Of 252 patients, 43 patients were at risk: 23 belonged to the experimental group, 20 to the control group. The feedback effect was analyzed using a level-2-model for discontinuous change, effect size (d), reliable change index (RCI), and odds ratio for reliable deterioration. Results: For patients at risk, the experimental group showed an improved outcome on the OQ-45 total scale compared to the control group (p<0.05, d=0.54). By providing feedback, the rate of reliably deteriorated patients at risk was reduced from 25.0% (control group) to 8.7% (experimental group) — odds ratio=0.29. All reliably improved patients at risk belonged to the experimental group. Conclusion: Feedback improves the outcome of patients at risk undergoing psychosomatic in-patient treatment. [Copyright &y& Elsevier]

Some practical problems are highlighted with regard to studying the outcomes of individual therapists, including the long and inconsistent success in finding therapist variables that explain differential client treatment response. Research on the individual therapist makes it clear that considerable variability in outcome exists at the extreme ends of the normal distribution of therapist effects. Much less is known about the variability of client outcomes within specific therapists’ clients. We encourage further research on therapist effects, but concede that such research is not likely to provide actionable information for routine clinical care. In the meantime, client treatment response needs to be monitored if positive outcomes are to be maximized. [ABSTRACT FROM AUTHOR]

Recent research has found that measuring, monitoring and providing therapists with feedback about their clients' treatment progress improves treatment outcome. This study assessed the level of agreement between two outcome measures used to measure and monitor treatment progress. The Outcome Questionnaire (OQ-45) was compared with a shorter, derivative measure, the OQ-30. Each measure has an associated feedback system, which provides therapists with feedback about their clients' treatment progress. The OQ-45 and the OQ-30 demonstrated high levels of agreement in measurement of client outcome. The OQ-45 feedback system emerged as the most accurate and clinically useful method for providing therapists with feedback about their clients' predicted treatment outcomes. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Empirical methods have been found to be superior to clinical judgment for the purpose of correctly identifying patients at risk for treatment failure and, hence, to enhance psychotherapy outcomes. The development and evaluation of an empirical approach aimed at supporting clinical decisions during the course of psychotherapy is described. The tool provides predictions based on a patient-specific sampling strategy called the nearest neighbors method and on growth curve approaches to model an expected treatment course for each patient. Using session-by-session data from an outpatient center in the US (N = 4365), this new empirically derived decision model was evaluated and compared with a clinically based approach loosely based on an adaptation of clinically significant change concepts. The empirically derived decision system was found to be superior to the rational clinically based one in almost all measures of prediction accuracy, indicating its potential to identify patients at risk for treatment failure. Copyright © 2006 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

An emerging practice-based research strategy attempts to monitor ongoing patient treatment response for the purpose of improving psychotherapy outcomes. This body of research uses information about patient improvement and declines to prompt psychotherapists about the possible need to modify their treatment approach, step up or step down the intensity of interventions, attend to relationship ruptures, or even make referrals to other providers. Within this research paradigm, all systems use statistical methods that attempt to predict the final outcome of psychotherapy. In this study, the dependence and homogeneity of session-by-session responses to psychotherapy were explored with data from 3 clinical settings (N=608). The results suggest that dependence (i.e., early change predicts later change) and nonhomogeneity (i.e., decelerating improvement courses) cannot be taken for granted. An outcome-monitoring strategy is recommended that takes these findings into account. [ABSTRACT FROM AUTHOR]

Evidence is presented demonstrating that placebo control groups benefit more from psychotherapy than no-treatment control groups but less than patients who receive theory-driven treatments. Through a brief review of the results of comparative outcome studies, studies which compare patient outcomes for those seen by trainees or paraprofessionals versus professional therapists and those which show an early response of a sizable portion of patients, a case is made for the powerful effects of common factors in psychotherapy. The early response phenomenon has proposed another challenge to the unique effects of specific psychotherapies and to the wisdom of emphasizing the causative effects of specific techniques in the treatment of specific disorders. © 2005 Wiley Periodicals, Inc. J Clin Psychol 61: 855–869, 2005. [ABSTRACT FROM AUTHOR]

Psychotherapy outcome can be enhanced by early identification of potential treatment failures before they leave treatment. In adults, compelling data are emerging that provide evidence that an early warning system that identifies potential treatment failures can be developed and applied to enhance outcome. The present study reports an analysis of early warning algorithms to identify treatment failures among child/adolescent patients (ages 3–18). The progress of 300 patients who had completed treatment was analyzed to see if algorithms could identify those children who ultimately had a negative outcome. Results indicated that the rationally derived method had a 77% success rate for identifying child/adolescent patients who were reliably worse or had deteriorated by the time that therapy was terminated. [ABSTRACT FROM AUTHOR]

This article introduces the issue of Journal of Clinical Psychology/In Session devoted to the need for, and value of, providing psychotherapists with feedback about client progress during the course of treatment. After an introduction that sets articles in the series in the context of improving psychotherapy outcome, the seven articles in this special issue are briefly summarized. The articles that follow this introduction provide general principles for effective feedback, highlight therapist difficulties in predicting treatment failure, provide “lab tests” for recognition of poorly responding clients, and demonstrate the powerful effects of providing therapists with feedback on client progress. The articles argue that coupling of statistical modeling techniques with currently available information technology is an innovation to routine clinical practice that clinicians can ill afford to overlook. © 2004 Wiley Periodicals, Inc. J Clin Psychol/In Session. [ABSTRACT FROM AUTHOR]

We describe and illustrate our system to measure, monitor, and feed back information about patient treatment. This clinical innovation relies on research-based clinical decision tools that provide psychotherapists with timely warnings when a patient's deviation from an expected treatment response foretells possible treatment failure. We summarize the results of four controlled studies using this methodology; the collective results suggest that measuring, monitoring, and predicting treatment failure (feedback) enhance treatment outcomes for patients who have a negative response. Clinicians are encouraged to employ these methods in routine practice despite their confidence in their own ability to predict patient outcome. © 2004 Wiley Periodicals, Inc. J Clin Psychol/In Session. [ABSTRACT FROM AUTHOR]

We present two methods of enhancing outcome and preventing treatment failure in psychotherapy. The first involves providing therapists with a decision tree and several assessment measures for clients who are not having a positive response to psychotherapy. The organization of the decision tree and the selection of measures were based on results from psychotherapy outcome studies. The second method involves providing clients with feedback on their progress throughout the course of treatment. Both methods of providing feedback enhanced treatment outcomes and representative studies are reviewed. Use of these methods is recommended for application in routine practice. © 2004 Wiley Periodicals, Inc. J Clin Psychol/In Session. [ABSTRACT FROM AUTHOR]

To date, few studies have been published on the dose–response relationship in psychotherapy. The current study addresses limitations of previous research by using (1) clinical significance methodology to address the meaningfulness of patient change, (2) survival analysis to assess change across time, (3) assessment of patient change on a session-by-session basis, and (4) a large data set representing a variety of treatment settings. A total of 4,761 patients representing standard treatment settings in the United States were tracked at each session of therapy. A survival analysis of this data reveals that between 15 and 19 sessions of therapy are required for a 50% recovery rate using clinical significance methodology. The results of this study provide a useful overview of time-to-change in naturalistic settings that can be used to estimate reliable treatment expectations and as a baseline for comparison when modifications are made within treatment delivery systems. [ABSTRACT FROM AUTHOR]

Comments on the article 'A Multidimensional Meta-Analysis of Treatments for Depression, Panic, and Generalized Anxiety Disorder: An Empirical Examination of the Status of Empirically Supported Therapies,' by Drew Westen and Kate Morrison, published in the December 2001 issue of 'Journal of Consulting and Clinical Psychology.' Meta-analysis of psychotherapy; Status of empirically supported therapies.

The results of the development of expected recovery curves for an empirically driven patient profiling system are presented. Patients undergoing a course of psychotherapy (N = 11 492) repeatedly took the Outcome Questionnaire-45 (OQ-45). Scores across all patients were combined into an aggregate dataset for use in generating expected recovery curves based on severity of symptoms at intake. SAS PROC MIXED was used to create a mixed linear model of recovery curves based on OQ-45 scores across sessions and the log transformation of session number. Mean estimates were established for each session from one to 20. Tolerance intervals were then created around each estimated mean score. Expected recovery curves were combined with tolerance intervals to create an early warning system capable of identifying patients whose slow progress suggests that they might be expected to have a negative therapy outcome (terminate treatment prior to obtaining a clinically significant benefit). Current efforts to establish a systematic quality improvement procedure using these curves are discussed. Charts of expected recovery values are plotted, and a straightforward system of patient profiling, early identification of treatment failures, and feedback to clinicians is described. Copyright © 2001 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The article replies to criticisms made by Professor Michael Shepherd against psychotherapy. According to the author, the type of criticism of psychotherapy leveled by Shepherd is regarded as tantamount to a regression to the Eysenckian period of the 1950s. The author claims that little purpose can be served by a pessimistic and rather destructive critical approach. He adds that psychotherapy demands a commitment to its intelligent study, as well as the exploration of paradigms for research.

T.E. Schacht and W.P. Henry view the scheme proposed by M.J. Lambert, B.M. Ogles and K.S. Masters as a limited heuristic giving some categorical structure but no specific guidance for selecting particular outcome measures to reflect the changes that result from psychotherapy. They suggest the need for researchers and practitioners to consider additional issues beyond those offered in the scheme. They emphasize issues that will encourage research that is theoretically meaningful. A minor point, however, seems worth noting. Should researchers use outcome measures and link theory with "problem," "process," and "outcome"? Researchers committed to a theoretical position should attempt to show that changes in clients can be observed by a variety of sources, across a variety of content areas, through numerous technologies. With regard to contextual background for interpretation of results, we believe and hope that the scheme with its emphasis on using multiple sources and multiple technologies will require researchers to consider the limitations of relying on one technology or one source.

Psychotherapy clients often experience intake therapist discontinuity: meeting first with an intake therapist, then entering therapy with a different treating therapist. The authors compared such discontinuity clients at a university's counseling center (55.6% of 15,137 clients) with continuity clients, who continued therapy with their intake therapists. Discontinuity clients were twice as likely as continuity clients to terminate by missing the appointment after intake. Improvement among discontinuity clients lagged behind improvement among continuity clients at Sessions 2 and 3. Though more likely to terminate by missing Session 2, discontinuity clients attended 2 sessions more than continuity clients, on average, making treatment of discontinuity clients 19% more expensive than treatment of continuity clients in terms of sessions attended. The extra sessions attended by discontinuity clients did not yield overall better outcomes. Intake therapist discontinuity appeared to disrupt the beginning of psychotherapy, dissuading some clients from returning after intake, slowing early improvement among those who did return, and unproductively lengthening their treatment. [ABSTRACT FROM AUTHOR]