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What if therapy doesn’t work? - Part 2

Updated: Jun 19, 2023

Findings from our focus groups and how to improve treatment outcomes


In our previous blog post we summarized research findings on deterioration and non-response rates in psychotherapy and looked at potential hindering factors in treatment which might explain these outcomes. Now we would like to summarize some of our own findings from focus group interviews and look at recommendations on how treatment success could be improved.

Conclusions from our focus groups

Within our research and development activities we also conducted focus groups ourselves with current and previous patients in psychotherapy. We asked them about their experiences with treatment, including potential difficulties, with particular focus on homework, and identified three important hindering factors that are relevant for psychotherapy in general. Firstly, patients mentioned as problematic, that they often did not see the purpose of certain exercises in psychotherapy, which decreased their motivation, engagement and adherence. Therapist often did not explain in enough detail why certain tasks are necessary and what their benefits are. Secondly, even if the therapist gave a rationale for the exercises, they often felt too burdensome or tedious, and patients did not find enough time or energy to complete them between sessions. And lastly, patients also reported not getting enough feedback on their treatment progress and homework. They would have liked to have more profound feedback about what they did well and how they could improve, what the assignment was good for and how it relates to other elements of therapy. Such an evaluation could give patients a better sense of their therapy progress and put the different tasks in context, which would increase their motivation in the future

Recommendations and what we at Zeeds do to improve treatment

Rozental (2016) recommended the continuous monitoring of patients’ symptoms as a potential measure to mitigate deterioration and improve treatment response. Using regular self-report symptom measures to follow patients’ progress (or non-progress) would enable therapists to detect and react if a patient diverges from the expected treatment trajectory. Based on this they could then modify or intensify treatment to meet the needs and individual problems of the patients. Lambert et al (2002) found that patients who completed weekly measures on their symptoms deteriorated on a lower rate (15.2%) than patients who were not monitored (23.2%). This number improved even further (8.5%) when clinicians also received recommendations on how to adopt treatment based on the monitoring (Whipple et al, 2003). Interestingly, continuous symptom measurement did not affect the improvement rates for treatment responders (Lambert et al, 2002). Thus, monitoring seems to be a method specifically benefiting patients who deteriorate or do not respond to treatment. This approach can be implemented in the form of a stepped care model where patients who show early signs of non-response or deterioration get more intense interventions, while those who improve complete a less resource (and time) intensive treatment and are released after clinically significant improvements have been achieved. It also highlights the importance of individualising treatment content to the needs and preferences of patients, for example within a modular treatment program (for more on this see the individualization of treatment section of our blog post "Why we need digitalization in psychotherapy - Part 2" post).

We at Zeeds follow this recommendation by including a regular, short symptoms monitoring form into our patient application (PHQ-2, Kroenke et al, 2003), which patients are asked to fill out on average on every fifth login. The data from these measurements is sent to the therapists’ data portal in real time and plotted against time and patients’ activity levels (frequency of performing certain behaviours). This way therapists can follow patients progress throughout treatment in real time and also draw parallels between patients’ symptoms and performed behaviours.

In addition, its mobile, app-based format and ease of use makes Zeeds a useful tool to help patients implement the knowledge and skills learnt in treatment sessions in everyday life and use them in difficult situations (helping them to overcome the feeling of being stuck between knowing the doing mentioned above). This is because a large proportion of exercises in CBT is based on replacing negative reactions with positive and adaptive behaviours or thought patterns, which requires replacing old or building new habits. For this, it is necessary to bring the adaptive actions as close to the relevant, problematic situation as possible to support habit formation (Lally and Gardner, 2013). With a mobile solution, patients can perform the exercises exactly at the time when they are most needed (e.g. short breathing exercise in an anxiety provoking situation) and remind themselves of the different steps and strategies related to their “positive” behaviours on spot.

Overall summary

In summary, there is currently only little research looking at cases in which psychotherapy has no or even negative effects. However, the few studies addressing these questions seem to indicate that these outcomes are relatively common with 5-10% of patients deteriorating during treatment and approximately half of patients not showing improvements by the end of treatment and falling back into old patterns long term. Thus, research should focus more on examining the possible reasons for why psychotherapy only helps around 50% of the patient population and based on that improve current treatment methods and protocols. Relying on the findings we summarized above, it seems likely that continuous symptom monitoring, individualisation of treatment and easy-to-implement exercises have the potential to mitigate deterioration in therapy and improve treatment response.

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Kroenke, K., Spitzer, R. L., & Williams, J. B. (2003). The Patient Health Questionnaire-2: validity of a two-item depression screener. Medical care, 1284-1292.

Lally, P., & Gardner, B. (2013). Promoting habit formation. Health psychology review, 7(sup1), S137-S158.

Lambert, M., Whipple, J. L., Vermeersch, D. A., Smart, D. W., Hawkins, E. J., Nielsen, S. L., & Goates, M. (2002). Enhancing psychotherapy outcomes via providing feedback on client progress: A replication. Clinical Psychology & Psychotherapy, 9(2), 91-103.

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

Rozental, A., Kottorp, A., Boettcher, J., Andersson, G., & Carlbring, P. (2016). Negative effects of psychological treatments: An exploratory factor analysis of the Negative Effects Questionnaire for monitoring and reporting adverse and unwanted events. PLoS ONE, 11(6), e0157503.

Whipple, J. L., Lambert, M. J., Vermeersch, D. A., Smart, D. W., Nielsen, S. L., & Hawkins, E. J. (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, 50(1), 59-68.

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