1 of 34

On Failure

103-12-13

2 of 34

�

The Analysis of Failure: An Investigation of Failed Cases in Psychoanalysis and Psychotherapy, by Arnold Goldberg, Routledge, 2011

3 of 34

Prevention of Treatment Failure: The Use of Measuring, Monitoring, and Feedback in Clinical Practice, by Michael J. Lambert, APA, 2010

4 of 34

Book review (Goldberg, 2011)

The bulk of the book is based on qualitative data from Goldberg’s ‘Failure Project’ [a Kafka-esque title if ever there was one], which was prompted by the plaintive query of a psychoanalytical colleague who noted that his peers always presented case studies that went well, or had a minor problem, easily corrected in hindsight, but never cases that utterly failed.

Radlett, Marty (2014) The Analysis of Failure: An Investigation of Failed Cases in Psychoanalysis and Psychotherapy. Existential Analysis. 25 (1), pp. 170-172

5 of 34

Equally Kafkaesque was Goldberg’s difficulty in recruiting participants to his project: some simply laughed, were insulted or shocked.

6 of 34

Why don’t we ever discuss our failures? The silence that greeted this suggestion was deafening. Is failure the dirty little secret of our profession?

7 of 34

Therapists of all persuasions are vulnerable to rescue fantasies; or more bluntly: a ‘…grandiose fantasy of cure’.

Therefore, ‘failure lurks in the shadow of every rescue attempt’; and when it occurs, we feel it as a blow to our self-esteem.

8 of 34

The ubiquity of failure across all therapeutic methods is the result of rigid adherence to a theoretical model, coupled with ignorance of and/or contempt for alternative ways of working.
Rather than a ‘one size fits all’ stance, he challenges professionals to consider when/whether another methodology might be more helpful/suitable/appropriate.

9 of 34

a taxonomy of failure

[1] cases that never ‘launch’;
[2] cases that are interrupted and felt to be unfinished by therapist or client. These interruptions may be external, i.e. money problems; client moves. Or they may be internal: someone [therapist, client, client’s significant other] feels psychologically threatened;
[3] cases that ‘go bad’ [client becomes angry/upset/suddenly quits]; and
[4] cases that go on and on without obvious improvement.

10 of 34

By analysing failure, we expose the pitfall of only discussing success; for by only focussing on successful cases, ‘…there is no great need to learn anything new… [success] …can well become a prison house of limited knowledge’.

11 of 34

The pioneer of client feedback

Prevention of Treatment Failure: The Use of Measuring, Monitoring, and Feedback in Clinical Practice, by Michael J. Lambert, American Psychological Association, 2010

12 of 34

Tony Rousmaniere Interview with Lambert (2013)

About 8% of adult patients actually deteriorate at the time they leave treatment, and with kids it’s double that at least.
So 15-24% of adolescent child clients actually leave treatment worse off than when they started.

http://www.psychotherapy.net/interview/preventing-treatment-failures-lambert

13 of 34

clinicians’ estimates are way overstated

In our survey with clinicians we asked what percent of their patients were improving in psychotherapy, and they estimated 85%.
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 2/3 of those patients responding to treatment.
In routine care, the percentage of responders is closer to 1/3. �

14 of 34

It’s been true since it was first studied in the 1970s that individual private practice clinicians are overestimating treatment effects.

15 of 34

90% of us think we’re above the 75th percentile.
And none of us in our survey saw any clinician who rated themselves below average compared to their peers.
So we live in this world where we not only think our patients are having excellent success, but we think we’re having greater success than our peers.

16 of 34

In the study we did we asked 20 clinicians, doctoral level psychologists, and 20 trainees getting doctorate degrees to identify the cases they were treating where patients were getting worse and who they predicted would leave treatment worse off.
The patients answered a questionnaire at the end of every session and we identified 40 out of about 350 patients who got worse over the course of their treatment.
Of the clinicians in the study, one trainee identified one of those 40 as being worse at the end of the treatment. The licensed professionals didn’t identify a single case.

17 of 34

You’ve got to measure it. You’ve got to identify the problems because you can’t solve the problem unless you can identify the problem.
In our statistical algorithms, we look for the 10 percent of clients that are furthest off track and then we tell clinicians, “This patient is not on track.” That’s what clinicians can't do on their own. That’s information they need.

18 of 34

ASC

The second part in what we developed was a clinical support tool for identifying what might be going on that’s causing the deterioration.
We have a 40-item measure, the ASC, the Assessment for Single Cases, that measures generic problems in psychotherapy like the therapeutic alliance, negative life events, social support outside of therapy and motivation.
And there’s a prompt to consider referral for medication.
And there’s a prompt for change in therapy tactics, like delivering a more structured psychotherapy—you start increasing the directiveness of the therapy for the off track cases.

19 of 34

Another blind spot for clinicians is the therapeutic alliance. Clinicians tend to overrate it as positive, but it really does correlate with outcome if it’s based on client self-report.
We’ve looked at studies where clients are interviewed about the course of therapy and in that case they lie to protect their therapists. But when they take a self-report measure, they’re inclined to give a more honest appraisal.

20 of 34

We actually find that about half the dropouts are completely satisfied with treatment. So they quit because they felt better. And that can happen really fast, so not all dropouts are a bad thing; about half of them are.

21 of 34

OQ45

There are three subscales. There’s the symptom distress subscale that’s mainly anxiety and depression with some physical anxiety symptoms. Then there’s one on interpersonal relations and one on social role functioning.
OQ45.2-English-Sample-2006July11.pdf
oq45_scoring.doc

22 of 34

We find clinicians tend to underestimate the problems people have with substances.

They’re under reported, but when they are reported it’s often not addressed because people underestimate the negative consequences of substance use.

23 of 34

With suicide, no clinician asks patients at every session how suicidal they were this last week, but that can spike quickly.

A patient can go from not thinking of suicide much at all to thinking of it almost daily over the last week.

24 of 34

When I see a client and I give them the OQ45, it gives me right off the bat a gauge of just how unhappy they are, but I don’t find it a rich diagnostic instrument. It’s more like a blood pressure test.

25 of 34

If there’s a discrepancy between the score on the test and your own intuition, then that tells you the patient may be too ashamed or distrustful to tell you.

26 of 34

Psychodynamic therapists are usually overly confident in their clinical judgment, so they see defenses at work everywhere and don’t trust self-report measures.

But I think underneath all of that is that once we get into a routine and we develop confidence, we think there is no reason to give new interventions a try.

27 of 34

Our student therapists do as well as our licensed, supervising professionals. That’s very disturbing [laughs].
The only thing we can find is that when you see somebody with a lot of experience, their patients get better faster. But the overall outcome is the same.

28 of 34

Feedback helps when it’s novel, when it’s giving you information that you didn’t know about.

29 of 34

章目

I. Foundations and Contexts for a New Paradigm
II. Measuring and Predicting Treatment Outcome
III. The Evidence Base
IV. Illustrations of Practice-Based Evidence for Outcomes Management at the System Level

30 of 34

Introduction

Focus on reducing treatment failures by identifying persons at risk of deterioration and providing timely feedback to clinicians so that they may take effective action.

31 of 34

The underlying assumption of this book is that this task can be done most effectively by formally measuring a client’s mental health and using changes in mental health functioning to predict the final outcomes of treatment.

32 of 34

It calls for changes in routine practice.

33 of 34

mental health vital signs

Systematically monitoring client mental health vital signs (i.e., client treatment response), much as is done in medical practice to manage physical disease.