Michael Lambert on Preventing Treatment Failures (and Why You're Not as Good as You Think)
Dr. Michael Lambert's groundbreaking work on tracking client outcomes has revealed a huge blindspot for psychotherapists: We don't notice when our patients are getting worse. But he's got the solution if you're willing to try something new.
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The Blind Spot
|Tony Rousmaniere:||Let’s jump right in. You’re a leading researcher in the field of helping clinicians track their clients’ outcomes.|
|TR:||Despite a quickly growing body of evidence that tracking outcomes can really help clinical practice, there are still many clinicians who don’t do it or who don’t want to do it. How would you make the case to these clinicians that tracking outcomes can be beneficial for their practice and for their clients?|
|ML:||Well, the system we developed, the OQ (outcome questionnaire) Analyst, essentially monitors people’s mental health by asking 45 questions about their mental health. Clinicians can’t do that on a weekly basis because it takes too much time to do it, so the best way to do it is through a client self-report measure that asks very specific questions about different areas of functioning. It’s important to use a self-report measure and to tap into a broad range of symptoms that wouldn’t normally come up in a session, since sessions usually focus on what happened last week. It’s like taking a patient’s blood pressure and checking their vital signs for each visit. It gives you a much more precise measure of how they’re doing over time.|
We developed the measure essentially to reduce treatment failure. It came out of the problem of managed care bothering clinicians with management bureaucracy around cases they knew nothing about. And so the idea was to stop managed care from managing all the patients in the clinician’s caseload and to focus on the management of patients not responding to treatment. So it’s not for all patients. It’s not necessary for the majority of the patients, actually—but it is necessary for patients who are not progressing or are getting worse.
About 8 percent of adult patients actually deteriorate at the time they leave treatment, and with kids it’s double that at least. So 15—24 percent of adolescent child clients actually leave treatment worse off than when they started.
Our estimate is that about 8 percent of adult patients actually deteriorate at the time they leave treatment, and with kids it’s double that at least. So 15—24 percent of adolescent child clients actually leave treatment worse off than when they started, which doesn’t include people who simply aren’t improving. But in our survey with clinicians we asked what percent of their patients were improving in psychotherapy, and they estimated 85 percent. This is a major blind spot for clinicians. They’re not good at identifying cases where patients are not progressing or are getting worse. Even in clinical trials where you’re delivering evidenced based psychotherapy and get well trained clinicians who are following protocol, etc., you’re only getting about two-thirds of those patients responding to treatment. And then in routine care, the percentage of responders is closer to one-third. So clinicians’ estimates are way overstated.
In many ways, I think it’s a necessary distortion for clinicians; in order for us to remain optimistic and dedicated and committed and engaged, we have to look for the silver lining even when patients are overall not changing or outright worsening. It’s kind of a defensive posture, and it serves clients well generally and it serves clinicians well generally because the more success we see in our patients the happier we are in our jobs. But the downside is for the subset of patients who are not on track for a positive outcome. The distortion doesn’t work in their favor.
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Michael J. Lambert, PhD is a professor of Psychology at Brigham Young University and has been in private practice as a psychotherapist throughout his career. His research spans 30 years and has emphasized psychotherapy outcome, process and the measurement of change. He has edited, authored, or co-authored nine academic research based books, and 40 book chapters, while publishing over 150 scientific articles on treatment outcomes. He is the co-author of the Outcome Questionnaire, a measure of treatment effects that is growing in popularity. Tony Rousmaniere, PsyD, is a psychologist in private practice in Seattle and Clinical Faculty at the University of Washington. He is the editor of the forthcoming edited volume The Cycle of Expertise: Using Deliberate Practice in Supervision, Training, and Independent Practice (with co-editors Rod Goodyear, Scott Miller, and Bruce Wampold; Wiley Press), author of the forthcoming book Deliberate Practice for Psychotherapists: A Guide to Improving Clinical Effectiveness (Taylor & Francis), and co-editor of Using Technology for Clinical Supervision: A Practical Handbook (ACA Press). Dr. Rousmaniere provides clinical training and supervision to therapists around the world, with an emphasis on using deliberate practice to improve the effectiveness of clinical skill development. www.drtonyr.com
Hi dr lambert, i agree that at times measurements are needed. We should always question ourselves and others to get or be our best we can be. In other fields measurements are used as an assessment of us to get to a better level why not here? This is an opportunity for both parties to grow.
Hi Tony, thanks for the interesting interview. I was pleasantly surprised at the end to read your bio and see that you are working at UAF. I'm from Fairbanks and graduated several years ago with my Master's in Counseling from UAF. Hope you're enjoying Alaska and good luck with the students!
I'm of that band of therapists who question the often limited applications of institutional measurements (deriving from my past experience of working for institutions.) Reading this article from my personal perspective, I'm left with questions: What is measured against what? … The role of adults is often to go to work and do their job and get raises and advance their careers. If you’re a student, it’s succeeding in college or some training program … What if the client is doing a job or study they unconsciously sabotage because it does not fulfil an unacknowledged desire? Using statistic measurement … … Innovations are a hard sell. Unfortunately, the way most clinicians get exposed to this is through administrators who make them do it, and then their general attitude is distrust of the way the information is being used. Clinicians passively-aggressively don’t participate, and as a result they sabotage the whole effort. It ends up being a power struggle between clinicians and administrators … This seems to mirror an ineffective therapist/client relationship. Aren't there reasons, often valid ones, for resisting coercion? How are they honoured? … The practice of medicine is a good analogy. I don’t think my doctor is any better at guessing my blood pressure after measuring everybody’s blood pressure and getting feedback. I just don’t think he can operate without a lab test … Isn't any single measurement of body symptoms as fractured as a psychological one? And misleading if used in isolation of the whole system, including the interconnected relationship between the two systems – of body and psyche?
This is quite an interesting article. I am interested in this tool. Maybe I missed it, but did the article mention how/if clinicians can go about trying this out?
CE credits: 1
- Describe the origin and purpose of the Outcome Questionnaire Analyst and why it is important for clinicians to track patient outcomes
- Identify the key elements of treatment failures
- Explore possible blindspots in your own work with clients
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