Duration of Therapy & Dropout Rate

Clients who had reliable clinical change achieved it by the 3^rd or 4^th session, on average, and had an average of 10 total therapy sessions (the range was 2 to 45).  Clients who did not achieve reliable clinical change had an average of 6 sessions (the range was 2 to 12).  96% of my clients returned after their first visit.   18% dropped out of treatment due to reasons other than achieving their clinical goals.  The industry-wide dropout average has been estimated to be between 30% and 60%.  

* range = 2 to 45 ** range =  2 to 12  *** reliable change = 5 or more points on ORS  

Deterioration Rate

Two (5%) of my clients had reliable clinical deterioration in therapy (a loss of 5 or more points on the ORS).  The average deterioration rate in therapy is about 8%.

Client Population

In 2011 I had two part time private practices: one in San Francisco and one in Palo Alto.   Most clients paid $150 per session (out of pocket).  Nine (24%) were on a sliding scale, which ranged from $5 to $110 per session.  I had a limited client schedule because I also taught clinical psychology courses and ran a training program (practicum) for graduate students.   The number of clients I saw in 2011 was also limited because I closed my practice in November (to move to Alaska) and thus stopped taking in new clients in August. 

• 29% of my clients were women, 71% were men.
• 74% were Caucasian, 3% were African-American, 8% were Latino/Hispanic, 16% were Asian.
• The age range of my clients was early 20s to late 50s.  Most of my clients were ages 30 to 40.
• 89% were heterosexual and 11% were gay/lesbian/bisexual.  I had no transgender clients 2011.   
• I work with both individual adults and couples.  81% of my clients were individuals, and 19% were couples.  Four of my clients started in individual therapy and then transferred to couples therapy, while one client started in couples therapy and then did individual therapy.
• 66% of my clients started therapy with a high level of distress (below the clinical cutoff) and 34% started with a low level of distress (above the clinical cutoff).
• The most common issues I helped clients with were depression, anxiety, relationship problems, substance abuse/dependence, sexual problems, impulse control, self-harm/suicidality, sexual assault (childhood and adult), other traumas, and grief.  Less commonly, I helped clients with physical pain & somatic symptoms, eating disorders, brief problems, and ADHD.   All but one (2%) of my clients presented with symptoms of multiple issues.  58% of my clients had experienced significant symptoms since childhood, 26% a few years, and 16% less than a year.  11% were on psychiatric medications.   None of my clients had psychotic symptoms.   

 

About the Data

The data are based on a sample of 38 clients.  This is 81% of my entire clinical case load (47 clients) from a part-time practice in 2011.  I do not have data on four clients who only had one session (two were referred for a single session treatment by an insurance provider and two dropped out after one session).   I do not have data for five clients due to errors in my record keeping (3), or because the client declined to complete outcome measures (2).  

I began tracking outcomes on January 1^st, 2011.  Ten (26%) of my clients in the dataset had already been in treatment before that time.  For this reason, it is very likely that those clients had already improved in therapy, and the outcome data from those clients do not represent the full range of their improvement.

How I Practice

The therapeutic modalities I primarily use are Intensive Short-Term Dynamic Psychotherapy (ISTDP), Experiential/Humanistic Psychotherapy, Cognitive Behavioral Therapy (CBT), and Eye Movement Desensitization Reprocessing (EMDR). 

In 2011 I did over 30 one-way-mirror live supervisions (via Skype) with Jon Frederickson, an expert in Intensive Short-Term Dynamic Psychotherapy (ISTDP), with 10 clients (7 in my data set).  I think Jon’s help contributed significantly to my effectiveness and low dropout rate, although the sample is too small to examine quantitatively.

 

Outcome Measurement and Client Response

I use the Outcome Rating System (ORS) to track outcomes.  The ORS is an ultra-brief measure that is free to use.  Information about the ORS is here and here.   Clients completed the ORS at the beginning of each session, on my laptop computer.  It takes about 30 to 60 seconds to complete. 

After reviewing my cases, I consider the ORS results to be valid for 84% of my cases.  For a few  cases I think it underrepresented the amount of positive change, especially for clients who started treatment with less clinical distress.  For a few clients the ORS overrepresented the amount of positive change.

I use the MyOutcomes.com software package to collect and organize outcome data.  It costs $150 per year for a clinician in private practice.   I found the software to be helpful in collecting data, but it displays formula-based feedback immediately to the client, which can be inappropriate for some clients and has the risk of harming the therapeutic alliance.   I may discontinue use of MyOutcomes in 2012 for this reason. 

Consent for tracking outcomes is obtained at the beginning of treatment.  This is voluntary for clients, and two clients refused consent.  Consent includes agreement for the outcomes to be used for research and publication, after being de-identified.

When I asked clients their thoughts about the outcome measurement, most clients were curious about their results but said they gave more weight to my subjective clinical impression of their case.  A few clients were skeptical of the validity of standardized outcome measurements, and two clients refused to complete the measures because of this concern.   In studies, clinicians have reported that a leading reason for not collecting outcome data is that clients do not want to, or concerns about harming the therapeutic alliance.  I did not find this to be the case, but rather found that discussing outcomes with some clients strengthened the therapeutic alliance.  My guess is that clinician attitudes towards the outcome measures strongly affect clients’ reactions to the measures.

What About Change for "Low-Distress" Clients?

There are no outcome measures that are good at assessing the amount of change in psychotherapy for clients who start therapy with low levels of distress.  (Clients who start therapy above the clinical cutoff of 25 points on the ORS).  For this reason, I do not have reliable quantitative data on the amount of change for low-distress clients, which were 34% of my clients.  If you know of a measure that is good for assessing change for low-distress clients, please email me at trousmaniere@yahoo.com

Limitations of the Data and Outcome Measurement

These data are preliminary.  My sample size of 38 clients is just over the minimum of 30 required for reliable analysis of ORS data.   Likewise, the data are drawn from only 11 months of practice.  Furthermore, it is hard to know how strong these results are, because all of the previous studies using the ORS had client populations different from those I worked with at my practice (e.g. low-fee community mental health).  It is possible that the $150 out-of-pocket fee most of my clients paid for therapy increased their motivation for change, thereby boosting the outcome data.   Another validity concern is that I do not yet have follow-up data for this sample, so I do not yet know if gains will be lasting. Therapy outcome measures are not perfect.  I had multiple clients report negative change on outcome measures when in fact their symptoms improved.  Likewise, paper forms can never describe the rich complexities of growth and healing in therapy.  Given these limitations, I still think it is important for therapists to track their clients' outcomes with unbiased measures.  While the measures should never be used alone for clinical decisions, they are an important source of information regarding client progress or deterioration, and are essential for assessing overall therapist effectiveness.

Effect Size

An "effect size" is a statistical tool to compare the effectiveness of therapists or type of therapy.  The goal for posting my outcome data online is to inform potential clients.  I do not list my effect size prominently on this website because (A) there are no industry standards on what type of effect size to use and (B) none of the studies of psychotherapy effectiveness provide accurate comparisons for my treatment population.  For these reasons, comparing my effect size to research studies could be misleading to potential clients.  For researchers looking for practice-based-evidence, you are welcome to use my data in aggregate form:  pre-tx std dev=6.14, mean intake ORS=22.27, mean last session ORS=29.79, n=38  (Cohen's D effect size: 1.22).   

  

References

Outcome Rating Scale:  

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.

Client Dropout Rates: 

Wierzbicki, M. & Pekarik, G. (1993). A Meta-Analysis of Psychotherapy Dropout. Professional Psychology: Research and Practice, 24(2), 190-195.

Client Deterioration Rates: 

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.

Duration of Therapy: 

Hansen, N.B., Lambert, M.J., & Forman, E.M. (2002). The psychotherapy dose-response effect and its implications for treatment delivery services. Clinical Psychology Science and Practice, 9(3), 329-343.

Effect Size:

Wampold, B.E. (2001). The Great Psychotherapy Debate: Models, Methods, and Findings.  Routledge.