Does Therapy Work?

In general, psychotherapy works. There have been hundreds of studies on whether psychotherapy works to resolve emotional problems. One study summarized 475 studies of the outcome of therapy. It found the average person who completed therapy was better off than 80% of the people who did not receive therapy. Many other studies agree with this finding. This level of effectiveness is equal to having a pacemaker installed, to prevent fainting from heart malfunciton. Psychotherapy is 6 times more effective than using beta-blockers to prevent being re-admitted to the hospital for heart failure. It is 3 times more effective than bone-marrow transplants to prevent relapse or death from leukemia. It is 59 times more effective than taking aspirin to prevent a major cardiovascular event. In short, psychotherapy is as effective, or far more effective, than many well-known medical procedures.

However, these results do not count the number of people who do not complete therapy. Up to 47% of people only attend one session. They also do not count the number of people who attend a couple of sessions, do not improve, and drop out early.

FIT (Feedback Improved Therapy) changes all of that. When it is used, clients are less likely to drop out early because of lack of improvement, because progress is being measured and discussed each session. They feel more free to give feedback on what is and is not working in therapy. When clients are not on track to improve, they have one-third the risk of deterioration in therapy, compared to when FIT is not used. Not only are they far less likely to deteriorate, they are twice as likely to improve.

This finding of being twice as likely to improve has been found across multiple studies. In a very large study of 75 therapists, who treated 6,424 clients, the researchers looked at effectiveness before and after FIT was introduced. After FIT was brought in, effectiveness increased by 120%. This effect has been found in other studies. One researcher found that when FIT was not used, the treatment gain was 5 points on a scale of psychological distress. On the other hand, when FIT was used with clients, they reported a treatment gain of 10.8 points. This was replicated in another study, where the treatment gain was 6.8 points without FIT, and 12.7 points with FIT. Again, this shows that FIT doubled the effectiveness of psychotherapy.

The huge increase in effectiveness also has been found in research with couples. A large study of 410 couples who entered marriage therapy has just been completed. The marriage therapists did not use FIT on half of the couples who they worked with. They used FIT on the other half of the couples. The results were amazing. When FIT was used, couples were 378% more likely to report that they had no significant distress by the end of marriage therapy, compared to when it was not used. The differences showed up in the long term. Only 9% of the couples divorced when FIT was used, compared to 25% divorced when it was not used. This is an increase in effectiveness of 278%.

Why does FIT (Feedback Improved Therapy) work so well?

There are several theories to account for the stunning increase in effectiveness. The first is very simple, that feedback improves performance. When an athlete trains for the Olympics, the coach videotapes the athlete’s every move. Then, the coach and athlete sit and watch the videotapes, freezing frames, and studying every move. The coach will tell the athlete that they need to rotate their hip by 2 degrees, or kick their foot a centimeter further. This continuous feedback improves the performance of the athlete. The same is true in FIT. The therapist is getting feedback from the client on whether therapy is helping, and what needs to be changed. Then, the therapist can adjust therapy to fit better with what works for the client. This process of continuous feedback improves therapy.

The second theory is that FIT explicitly gives clients an opportunity to give feedback. People enter therapy because they are hurting and overwhelmed, and need help. When people are in that state, it is harder to say, “This approach is not working that well.” But, when clients fill in the form that asks if the therapist’s approach is a good fit, it gives them much more permission to give feedback. When I first started using FIT with some clients I had seen for 18 months, I was amazed at how it gave them more opportunity to tell me what needed to be adjusted in therapy. We made the changes, and they showed clear progress. Even though they had been improving before, the pace of change picked up quickly.

References

Smith ML, Glass GV, Miller TI. (1980). The benefits of psychotherapy. Baltimore: John Hopkins University Press.
Lipsey MW, & Wilson DB. (1993) The efficacy of psychological, educational, and behavioral treatment: Confirmation from meta-analysis. Amer Psychologist: 48 1181-1209 http://www.cebm.utoronto.ca/glossary/nnts.htm#table Effectiveness is calculated by comparing the Number Needed to Treat for psychotherapy, compared to the NNT of selected medical interventions.
Harmon, S.C., Lambert, M.J., Smart, D.M., Hawkins, E., Nielsen, S.L., Slade, K., & Lutz, W. (2007) Enhancing outcome for potential treatment failures: Therapist-client feedback and clinical support tools. Psychotherapy Research, 17, 379-392.
Miller, S..D., Duncan, B.L., Brown, J., Sorrell, R., & Chalk, M.J. (2006). Using formal client feedback to improve retention and outcome: Making ongoing, real-time assessment feasible. Journal of Brief Therapy, 5, 5-22.
Reese, R.J., Norsworthy, L., & Rowlands, S. (2008) Does a continuous feedback model improve psychotherapy outcome? Unpublished anuscript, University of Kentucky.
Anker, Duncan, & Sparks (2008) Using Client Feedback to Improve Couple Therapy Outcomes: A Randomized Clinical Trial in a Naturalistic Setting, Unpublished manuscript, Institute for the Study of Therapeutic Change.

Graph references

Brown, G.S., Lambert, M.J., Jones, E.R., & Minami, T. (2005). Identifying highly effective psychotherapists in a managed care environment. American Journal of Managed Care, 11(8), 513-520.
Harmon, S.C., Lambert, M.J., Smart, D.M., Hawkins, E., Nielsen, S.L., Slade, K., & Lutz, W. (2007). Enhancing outcome for potential treatment failures: Therapist-client feedback and clinical support tools. Psychotherapy Research, 17(4), 379-392.
Hawkins, E.J., Lambert, M.J., Vermeersch, D.A., Slade, K.L., & Tuttle, K.C. (2004). The therapeutic effects of providing patient progress information to therapists and patients. Psychotherapy Research, 14(3), 308-327.
Miller, S.D., Duncan, B.L., Brown, J., Sparks, J.A., & Claud, D.A. (2003). The Outcome Rating Scale: A preliminary study of the reliability, validity, and feasibility of a brief visual analog measure. Journal of Brief Therapy, 2(2), 91-100.