Can therapists tell when their clients have deteriorated?

About five to ten per cent of the time, people in therapy get worse instead of better. What should psychotherapists do in such cases? Hang on a minute. There's no point answering that question unless therapists can recognise that a client has deteriorated in the first place. A new study tackles this precise issue, finding, rather alarmingly, that the vast majority of therapists appear blind to client deterioration.

Derek Hatfield and colleagues took advantage of therapy outcome data gathered at a student counselling centre where clients provided symptom feedback prior to each weekly session. Although placed on record, this outcome data wasn't fed back to the therapists in a systematic way and there was no alert in place to signal symptom deterioration (as an aside, past research shows such systems hugely improve therapy outcomes). Rather, the therapists, the majority of whom had PhDs or were in doctoral training, had to rely on their own judgment.

Hatfield's team identified 70 clients who at one particular session were in significantly worse shape compared with their state before entering therapy, prior to the very first session. The researchers then scrutinised clinical notes made by the therapists after each session to see if, at the appropriate session, they'd made any reference to their clients' worsened state. Here's the shocker: in only 15 of these 70 cases had the therapists made a clinical note after the relevant session suggesting they had noticed a deterioration.

Therapists often have massive case loads and in some cases the deterioration could have occurred some weeks after the opening session. Perhaps it is no wonder that most therapists had struggled to notice negative change. To make things easier, Hatfield and his co-workers returned to the database and focused on just those cases where a client had shown a huge deterioration from one session to the next. Unfortunately, it's still bad news. Of these 41 cases, therapist notes suggested they noticed only 13.

The question of what psychotherapists should do when a client deteriorates is for fuller discussion another day. However, Hatfield did touch on this. On those occasions that therapists had noted a client deterioration, Hatfield's team looked to see what the noted course of action had been. The most common choices were drug referral and continue as usual. Hatfield then surveyed hundreds of APA-registered psychological therapists about what they would do, hypothetically speaking, if they had a client who'd deteriorated. Revealingly, among those 36 who replied, popular answers included 'discuss the deterioration with the client' and 'increase therapy sessions'. Worryingly perhaps, these suggestions were noticeably absent from the real life case notes.

This research comes with a major caveat - dependence on therapists' clinical notes is a far from perfect indicator of whether or not they noticed client deterioration. Still, you'd expect a significant worsening, if noticed, to be noted. The researchers said: 'It is hoped that therapists will be open to the idea that additional information concerning client progress will enhance their clinical judgment, particularly concerning potential client deterioration.'
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Hatfield, D., McCullough, L., Frantz, S., & Krieger, K. (2009). Do we know when our clients get worse? An investigation of therapists' ability to detect negative client change. Clinical Psychology & Psychotherapy DOI: 10.1002/cpp.656

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