Those of you who are CDOI Members: http://heartandsoulofchange.com/training/cdoi-members/  know that I just did a webinar of the same title as this blog. For the first time, members were able to download the actual PowerPoint slides from the presentation so that they could influence the decision makers where they work. Here are the slides in pdf format: 

GoodBadUglyWebinarSlides

Here is a brief video I did that covers the main points:

And here is a narrative account excerpted from new book, On Becoming a Better Therapist:
The good news is that the efficacy of psychotherapy is very good—the average treated person is better off than about 80% of the untreated sample (Duncan, Miller, Wampold, & Hubble, 2010), translating to an effect size (ES) of about 0.8. Moreover, these substantial benefits apparently extend from the laboratory to everyday practice. For example, a real world study in the UK (Stiles, Barkham, Twigg, Mellor-Clark, & Cooper, 2006) comparing cognitive behavioral therapy (CBT), psychodynamic therapy (PDT), and person centered therapy (PCT) as routinely practiced reported a pre-post ES of around 1.30. In short, there is a lot to feel proud about our profession: psychotherapy works.

But there’s more to the story. The bad news is two-fold: First, drop outs are a significant problem in the delivery of mental health and substance abuse services, averaging at least 47% (Wierzbicki & Pekarik, 1993). When drops outs are considered, a hard rain falls on psychotherapy’s efficacy parade, both in randomized clinical trials (RCT) and in clinical settings. Second, despite the fact that the general efficacy is consistently good, not everyone benefits. Hansen, Lambert, and Foreman (2002), using a national data base of over 6000 clients, reported a sobering picture of routine clinical care in which only 20% of clients improved as compared to the 57-67% rates typical of RCTs. Whichever rate is accepted as more representative of actual practice, the fact remains that a substantial portion of clients go home without help.

And the ugly: Explaining part of the volatile results, variability among therapists is the rule rather than the exception. Not surprisingly, although rarely discussed, some therapists are much better at securing positive results than others. In fact, therapist effectiveness ranges from 20-70%! Moreover, even very effective clinicians seem to be poor at identifying deteriorating clients. Hannan et al. (2005) compared therapist predictions of client deterioration to actuarial methods. Though therapists were aware of the study’s purpose, familiar with the outcome measure used, and informed that the base rate was likely to be 8%, they accurately predicted deterioration in only one out of 550 cases; psychotherapists did not identify 39 out of the 40 clients who deteriorated. In contrast, the actuarial method correctly predicted 36 of the 40.

So despite the overall efficacy and effectiveness of psychotherapy, drop outs are a substantial problem, many clients do not benefit, therapists vary significantly in effectiveness, and are poor judges of client deterioration. Most of us provide an invaluable service to our clients, but sadly most of us don’t know how effective we really are—we don’t know who will drop out or who will ultimately not benefit or even deteriorate. Do you know how effective you are? With drop outs considered, how many of your clients leave your office absent of benefit? Which clients in your practice now are at risk for drop out or negative outcome?

And what is the answer to these problems? You know! Practice based evidence. Continuous client feedback individualizes psychotherapy based on treatment response, provides an early warning system that identifies at risk clients thereby preventing drop-outs and negative outcomes, and suggests a tried and true solution to the problem of therapist variability—namely that feedback necessarily improves performance and quickens the pace of your development.