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Unread September 29th, 2011, 02:02 PM
James Pretzer James Pretzer is offline
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Default What can we learn when empirically-supported treatments fail?

It would be great if CBT always worked wonderfully but that's not always the case. The overall effectiveness of of empirically-supported treatments (not all of which are CBT) has been estimated as 57%-67% recovered or improved after an average of 12-13 sessions of treatment. This isn't bad at all, but some clients drop out of treatment before much is accomplished, sometimes treatment is ineffective, and sometimes clients get worse over the course of treatment. The August, 2011 edition of Cognitive and Behavioral Practice is a special issue exploring what we can learn when empirically-supported treatments fail. The articles in the series cover a broad range of empirically-supported CBT treatments for a broad range of problems including depression, anxiety disorders, eating disorders, and borderline personality disorder. I recommend it highly.

In discussing the articles' findings, Michael Lambert points out a number of things:

1. A number of client factors have been implicated such as lack of motivation, non-compliance, and co-morbid substance abuse or personality disorders. This doesn't mean that clients with these issues can't be treated effectively, but that these are challenges that therapists need to be able to deal with. Lambert points out that one of the best predictors of final treatment outcome is early response to treatment. If a client shows a poor initial response to treatment, don't just plow ahead adhering to the protocol, modify the treatment approach to address the difficulties that are being encountered.

2. By paying attention to treatment failures we can identify the shortcomings of our current treatment approaches and improve them, by adding interventions designed to address the short comings of our protocols, by identifying individuals who need a more individualized approach to treatment, or by identifying sub-groups of clients who need a different treatment approach.

3. Sometimes treatment is ineffective because it is being delivered poorly. Adequate training, supervision, consultation, and feedback can do a lot to improve treatment outcomes. (This is especially true when therapists are expected to read a manual or book and teach themselves how to provide a treatment.)

What can practitioners do? Lambert's suggestion is that the most effective thing we can do is to monitor each client's progress in therapy, notice when the client's initial response to treatment is poor, and promptly try to address poor initial response to treatment. There's quite a bit of research showing that if therapists are simply provided with feedback when clients are responding to treatment more slowly than usual, the rate of treatment failure is reduced substantially.
Lambert, M.J. (2011) What have we learned about treatment failure in empirically supported treatments? Some suggestions for practice. Cognitive and Behavioral Practice, 18, 413-420.
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