What if psychotherapy doesn't work? - Part 1

Deterioration and non-response rates in psychotherapy: frequency and possible reasons

What we already know (and what not)

Psychotherapy in general and cognitive behaviour therapy (CBT) in particular are the first line of treatment for most mental health diagnoses in the majority of western countries (APA, n.d; WHO, 1996) and they have also been shown to be on average as efficient as other medical treatments (Lambert, 2013). However, there might be significant variations in effectiveness depending on type of problems and treatment setting. In addition, there has been worryingly little research on the potential negative effects and problems in psychotherapy, with most studies focusing only on symptom improvements achieved with different forms of treatment. This results in an imbalance in our knowledge on the effects of psychotherapy, where the possibility, that some patients may not experience any changes during treatment or might even report negative or harmful effects is largely unexplored.

Thus, in this two part blog series we would like to

1. focus on studies which look at cases where psychotherapy is not successful and shed light on the potential reasons for non-response or deterioration,

2. and present some conclusions from our own focus group interviews and suggest possible ways to improve treatment outcomes.

Deterioration and non-response rate in psychotherapy

Deterioration is usually defined based on the Reliable Change Index – an indicator showing if symptom change in treatment is larger than what would be expected from measurement error -, where negative change scores larger than a pre-defined threshold (e.g. 1.96 standard deviations, Christensen and Mendoza, 1986) are classified as deteriorated. Those few studies which looked at the number of patients faring worse with treatment have repeatedly shown that around 5-10% of patients report more severe symptoms after than before therapy, which is true for both face-to-face (e.g. Hansen et al, 2002) and internet based (e.g. Rozental, 2016) treatments. Thus, research seems to support that psychotherapy can have detrimental effects, even if just for a small proportion of patients.

However, deterioration of symptoms is not the only way that therapy can have worse than expected effects. Assuming that most patients seeking psychotherapy hope for symptom relief or at least improvement, it can also have a significant negative effect on patients’ wellbeing, motivation and engagement if weeks or even months of treatment fail to achieve this goal. Studies looking at non-response rates in psychotherapy across various disorders and settings (e.g. Hofman et al, 2012; Hansen et al, 2002; Mechler and Holmqvist, 2016) found that between 45.6 and 66% of patients do not show improvements as a result of treatment (with slightly lower non-response rates in primary care compared to psychiatric settings). This number increases even more when looking at patients who experience relapse in the months after treatment. The rate of patients who do not achieve remission after psychotherapy was found to be as high as 60-80% (Brakemeier and Herpetz, 2018). Thus, it seems that on average around half of patients do not show clinically significant improvements at the end of treatment and even more fall back into old patterns in the follow-up period.

Problems and hindering factors in psychotherapy

DeSmet et al (2019) applied a qualitative approach to examine the experience of treatment non-responders by interviewing 19 patients who did not show reliable symptom improvements after cognitive behavioural or psychodynamic psychotherapy. They found that treatment non-responders described their state after the end of therapy as “being stuck between knowing and doing”. They felt that they have achieved some improvements in terms of insight, self-understanding, and mental stability, however, they were unable to act based on these new skills in everyday life and in difficult situations. Thus, even though they experienced some changes in their mindset due to therapy, they were not able to overcome core problems on a practical level. They felt that both them and therapy hit their limits, for example because treatment mismatched their needs and expectations, they had difficulties with opening up or they were reluctant to do certain exercises.

Similar and other reasons were mentioned in studies looking at reasons why patients drop out of therapy, which can be seen as one possible response to negative and hindering experiences in treatment and happens in up to 1/3 of cases (Fernandez et al, 2015). McLeod et al (2013) found that the most common reasons for non-recovered patients to discontinue treatment were dissatisfaction with specific therapy procedures (e.g. due to the mismatch between patients’ beliefs and the assumptions of the therapeutic approach), lack of credibility and cultural fit, communication difficulties, cost, timing, travel to therapy and change in living situation.

But even if patients complete treatment or get better, this does not mean that they do not have negative experiences during therapy. A study by Moritz et al (2015) on patients treated with obsessive-compulsive disorder for example found that the majority of patients (92.9%) experienced some form of negative or adverse events, with most negative events being related to deterioration, emergence of new symptoms, disappointment about outcome or stigma. When looking at negative effects of internet-based CBT Rozental et al (2016) found that the most common problems reported by patients were negative feelings due to unpleasant memories, increased stress, poor treatment quality and the feeling that the issue they were looking for help for got worse.

Conclusion

In summary, research seems to suggest that it is relatively common that patients do not improve, or even fare worse during psychotherapy. Findings show that 5-10% of patients deteriorate during treatment and approximately half of patients do not show improvements by the end of therapy and fall back into old patterns long term. The most common hindering factors that might explain these cases are related to not being able to implement new knowledge and skills learnt in difficult situations, increased feelings of stress and negative emotions during therapy and dissatisfaction with treatment.

In our next blog post we will extend these findings by summarizing conclusions from our own focus group interviews and using the findings above to suggest ways how treatment response could be improved.

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References:

American Psychological Association (n.d). Clinical Practice Guidelines https://www.psychiatry.org/psychiatrists/practice/clinical-practice-guidelines

Brakemeier, E. L., & Herpertz, S. C. (2019). Innovative Psychotherapieforschung: auf dem Weg zu einer evidenz-und prozessbasierten individualisierten und modularen Psychotherapie. Der Nervenarzt, 90(11).

Christensen, L., & Mendoza, J. L. (1986). A method of assessing change in a single subject - An alteration of the RC index. Behavior Therapy, 17(3), 305-308.

De Smet, M. M., Meganck, R., Van Nieuwenhove, K., Truijens, F. L., & Desmet, M. (2019). No change? A grounded theory analysis of depressed patients' perspectives on non-improvement in psychotherapy. Frontiers in Psychology, 10, 588.

Fernandez, E., Salem, D., Swift, J. K., & Ramtahal, N. (2015). Meta-analysis of dropout from cognitive behavioral therapy: Magnitude, timing, and moderators. Journal of consulting and clinical psychology, 83(6), 1108.

Hansen, N. B., Lambert, M. J., & Forman, E. M. (2002). The psychotherapy dose-response effect and its implications for treatment delivery services. Clinical Psychology: Science and Practice, 9(3), 329-343.

Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427-440.

Lambert, M. (2013) The efficacy and effectiveness of psychotherapy. In: Lambert MJ (Hrsg) Bergin and Garfield’s handbook of psychotherapy and behavior change. Wiley,NewYork

McLeod, J. (2013). “Qualitative research. Methods and contributions,” in Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, 6th Edn. M. J. Lambert (New York, NY: JohnWiley and Sons), 49–84.

Mechler, J., & Holmqvist, R. (2016). Deteriorated and unchanged patients in psychological treatment in Swedish primary care and psychiatry. Nordic Journal of Psychiatry, 70(1), 16-23

Moritz, S., Fieker, M., Hottenrott, B., Seeralan, T., Cludius, B., Kolbeck, K., . . . Nestoriuc, Y. (2015). No pain, no gain? Adverse effects of psychotherapy in obsessive-compulsive disorder and its relationship to treatment gains. Journal of Obsessive-Compulsive and Related Disorders, 5, 61-66.

Rozental, A. (2016). Negative effects of Internet-based cognitive behavior therapy : Monitoring and reporting deterioration and adverse and unwanted events (PhD dissertation, Department of Psychology, Stockholm University). Retrieved from http://urn.kb.se/resolve?urn=urn:nbn:se:su:diva-135382