The Failure Rate of Psychotherapy: What it is and what we can do?

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, 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?

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Enter Lynn D. Johnson, Ph.D., a psychologist whose work and thinking is always a step ahead.  I’ve known Lynn for decades, 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.

19 responses to “The Failure Rate of Psychotherapy: What it is and what we can do?”

  1. Andrew Sedger Avatar
    Andrew Sedger

    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

    Reply
    1. scottdm Avatar
      scottdm

      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.

      Reply
  2. Nate Avatar
    Nate

    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!

    Reply
    1. scottdm Avatar
      scottdm

      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.

      Reply
  3. Home | therapeutic alliance in family therapy

    […] A good therapeutic alliance in family therapy : What it is and what we can do? […]

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  4. Stephen Bacon Avatar
    Stephen Bacon

    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

    Reply
    1. scottdm Avatar
      scottdm

      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.

      Reply
  5. Cristalexi Avatar
    Cristalexi

    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?

    Reply
    1. scottdm Avatar
      scottdm

      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.

      Reply
  6. David Avatar
    David

    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.

    Reply
  7. K Avatar
    K

    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%

    Reply
  8. Gregory Avatar
    Gregory

    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.

    Reply
    1. scottdm Avatar
      scottdm

      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.

      Reply
  9. Kok-Mun Ng Avatar
    Kok-Mun Ng

    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.

    Reply
    1. scottdm Avatar
      scottdm

      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.

      Reply

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