Interview With Michael J. Lambert
Interviewer [Male Voice]: In your recent book Prevention of Treatment Failure you talked about the fact that some patients do get worse in the course of psychotherapy. How common is the problem, what are the causes?
Michael Lambert: In adults who enter treatment, the rate is about 5–10 percent. In children and adolescents who seek treatment, the rate is about 15–25 percent. So it's relatively rare in adults but all too common in children. And the major causes are external events that set people back like a divorce or a death or loss of a job, so it's environmental. And then within the therapy itself, it's usually related to some kind of rejection that the person experiences while they are working with their therapist. It's usually not related to specific therapy techniques but to relationship factors where the patient feels misunderstood, uncared for, or neglected in some way.
Interviewer: Why aren't therapists more aware that clients are at risk for failure?
Michael Lambert: We did a survey in which we looked at therapist perception of what the percentage of their patients is that improved and therapists guessed that about 85 percent of their patients improved. If we look at research studies, clinical trials, then the rates are somewhere between 40 and 60 percent. So therapists have a very positive attitude about their effects on people and since the people come in with various levels of disturbance and various problems sometimes that they are in control of, sometimes not, it's very difficult for therapists to achieve high levels of success because mainly what determines the outcome of psychological treatments is the patient, not the therapist or not the therapy.
And so in the face of the difficulties, therapists look for silver linings. And so they are almost always interpreting any sign of positive gain as a positive gain and so it's very disheartening for them, in a way they would lose their confidence, they would lose their commitment to the patient if they saw little gain or if they were pessimistic about the effects of treatment. So we see things with this silver lining that keeps us working hard in the face of great difficulty and little control over patient's lives and patient's behaviors. It's true in all the professions, medical doctors, and it's true in trades, carpenters, electricians, engineers; all have very positive views of their own effects on patients or their subject matter and most see themselves as much better than the average. So it's almost sort of a self assessment bias that keeps us looking for evidence that supports what we're doing is working. It's a universal phenomenon.
Interviewer: What can therapists do to improve their success rate with challenging clients?
Michael Lambert: Well the therapists are looking at the treatment and out of necessity viewing it as being successful; they need some kind of outside source. So in medicine we would have lab tests based on white blood cell counts. So one of the things practitioners can do is they can start using lab test data. In the case of what we proposed is psychological test data, standardized test data, based on client's self report of their functioning instead of relying on their clinical intuition which is way too positive and particularly overlooks negative change because it's threatening and disheartening to therapists so they — in order to keep going and keep committed. So we have to have a measure, I think, of mental health vital signs, and that measure needs to be given throughout the course of psychotherapy to monitor whether people are improving, staying the same, or, in fact, worsening. And it's not something that the individual therapist can interpret — it's something that we use statistics, computer models, statistical modeling, so that we can get a scientific view and a quantitative view that's not biased by our filters of wanting things to work out and ignoring the fact that they're not working out.
Interviewer: Do you have a specific test or battery of tests that you recommend for measuring success?
Michael Lambert: Yes, it's probably not very wise to start with a battery of tests because whatever kinds of tests you use needs to take about five minutes of patient time. So you can't give a whole battery because you are intending to do it every week or every session that's held. So it needs to be about five minutes, it needs to be based on the patient's perception, not the treating person's perception, and it probably needs to cover the most important aspects of functioning. With adults, that's mood, anxiety, somatic complaints, interpersonal problems and social role functioning like work, or performance in school, or performance as a homemaker. So we created a test called the OQ45 that has 45 items that tries to tap into those areas of functioning.
So in five minutes, every week, you can get people to report whether they are having a problem or not a problem, or the degree in which something is a problem, and this is something that psychotherapists can't do. You can't sit down with a patient and ask them 45 questions every time you see them, because it takes — it would take 20 minutes and you've only got usually 50 minutes. So we want to turn the task over to a self report instrument and then what you need is a software that can score that patient's responses and compare those responses to other patients that are in treatment, to know whether the patient is responding to treatment the way other people do, or whether they're off track.
So it's not just a test, it's actually a warning system. Because what we're trying to do is warn therapists that this particular patient is not responding as expected, in fact they're way off track, and we can predict that they will deteriorate by the time they leave treatment if something doesn't change in the psychotherapy. So we call that a mental health vital sign, we're just measuring a vital sign, giving that information to clinicians in the form of warning signals if there's a problem, just like you would get a warning for blood pressure if it was above a certain level, we would say "Well if it's 160, it needs management," and we measured again and see if what we're doing to manage it is lowering it sufficiently, if it's not, we would modify the treatment or the program until we can see that we've managed it.
So we propose that mental health providers start to use these lab tests, information, routinely, systematically at every session. If we want to find out if our treatment is working we need to measure the mental health function of our patients as they undergo our treatments.
Interviewer: When therapists get a warning sign, what do they do? Stop treatment? Start doing a different therapy? What?
Michael Lambert: The first thing is they probably need to reflect on why that might be, but the best thing probably to do is to ask the patient. The patient is recording more symptoms than they were when they came in and the therapist has probably got to have a discussion. "You're reporting more disturbance than you were when you very first came in. What do you think is happening? How come it's going in the wrong direction, is there some reason for that?" So what it does is it prompts a dialogue between the patient and the therapist about treatment progress. And that's a little bit difficult to just introduce out of the blue but when you have lab test data coming from the patient's self report, it's a much easier discussion to have.
So it needs to be a discussion, and it also needs to probably be a message that goes to therapist amygdala rather than their cortex. So if you want to get therapists to take some action, you probably need a color like red that's an alarm signal, so that they immediately, within a second, can look at patient progress and see if it's on track, which is green, or if it's off track, which is going to be red, so that you get an emotional reaction from the therapist that says things are not right. If you give therapists numbers, standard deviations and means, that sort of thing, you're going to get therapists to think about numbers and get into their cortex.
Why we think this helps patients is because it actually activates therapists emotionally to pay attention to this information. So once they pay attention to it, they can start to problem solve, but if they ignore it and they don't know it, because they usually function with a sort of silver lining, they are looking for evidence of progress and instead of evidence of negative change, they can't solve the problem. So the method simply raises the therapist's awareness of things not being as they are for most patients.