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Deterioration in Psychotherapy: A Summary of Research by Jorgen Flor
This qualitative study explores 10 Norwegian psychologists thoughts about patients'
deterioration in psychotherapy. Data are analyzed using systematic text condensation, and
discussed in the light of existing research literature. The results show a lack of common
terminology, little knowledge and great variation in how informants understand patients'
deterioration. Psychologists underestimate the occurrence of deterioration in their own
practice, they experience to a small extent a culture where these issues can be discussed
and several reports that theme is uncomfortable. Informants have gotten little or no
teaching, guidance or training on the topic, although they express a desire for this.
The study shows how little awareness of patients' deterioration in education and research
propagates to the practical professional practices. This study is not appropriate to say
something about the findings is representative of psychologists in general. Further research
should collect data on negative outcomes from both patients and therapists using
The purpose of this work has been to explore how psychologists think about
negative outcome, and contribute to a better basis for quantitative work with the same
questions. This study shows that quantitative surveys has methodological challenges with
respect to validity. One can not assume that negative outcome is interpreted equally. This
underpins the assessments that were made in advance and which led to the choice of
method and formulation of research questions.
Informants in this study have difficulties both to define and identify patients' deterioration.
Although everyone recognizes that deterioration may occur, their explanations as to why,
how and when this occurs is incongruent. A main finding is therefore a lack of common
terminology about negative outcome. This may be because none of the psychologists have
received adequate instruction or guidance about patients' deterioration, neither during
education, through continuing education nor in the workplace in general. The consequence
is that their responses emerges as educated guesses withouth basis in evidence-based
knowledge. They speculate that patients' deterioration often are temporary, that it is due
therapists mistakes or that there is a marginal phenomenon in his own practice. Such
arbitrary and haphazard understanding is reinforced by the absence of a culture at the
workplace where these questions are subject to systematic thematization. Their workplace
seem to lack a psychological safe environment that enables this thematization. The
difficulties of adopting a self-critical attitude to their own practice is enhanced by personal
discomfort and negative feelings relating to patient deterioration.
Little knowledge of negative outcomes, considerable variation in how to measure treatment
outcomes, lack of culture in the workplace to address these questions and a personal
discomfort related to their role creates a major obstacle to thematises patients'
deterioration. This study can counteract this tendency by creating more awareness of the
negative outcome in psychotherapy.
Some excerpts fromthe discussion
Measuring the effect of psychological interventions is essential
When the psychologists state that few or none of their patients has deteriorated, they build
this on our own clinical judgment assessments. No displays of data, statistics or other
sources. These judgments are influenced by a range of cognitive fallacies, complicating
efforts to identify, explain and deal with patients' deterioration. When therapists interpret
the therapy process, they should avoid relying entirely on their own clinical judgment.
A precise conceptual framework is a prerequisite to talksoberly about worsening
This study reveals great variety and lack of precision in how psychologists describe patients'
deterioration. If one is to be able to talk about negative outcomes, we need a recognizable
and understandable terminology for it. This study indicates that such a conceptual
framework is not in place by the informants.
Concepts such as "harmful therapy" and "harmful therapists" implies that the therapist
blame for patients' deterioration. Such discussion can stand in the way of a sober
understanding of negative outcomes, inhibit survey of patients' deterioration and affect
therapist's assessment of their own skills.
Treatment-induced deterioration until the opposite is proven?
However, there is an important difference between having the responsibility to detect and
deal with negative outcomes, and getting blamed for it happening. The results of this
study suggest that many psychologists may experience the latter, and that this can come at
the expense of work with the first. Both the therapist and the therapist system is part of the
must-have-responsibility for the measures necessary for the negative outcomes to be
identified. Therapists should also have that basically that any deterioration caused
processing, and look for evidence to the contrary. Thus the therapy or therapist "guilty" until
From transient to persistent deterioration - the therapist's responsibility eitherway?
The difficulties in defining what negative outcomes are frequently associated with the
assumption that patients become worse before they get better. The term deterioration is
equally hazy when used to describe temporary deterioration as it is when used to
characterize lasting deterioration. The question of when a determination that a patient has
deteriorated becomes even harder. This vagueness associated with a symptom exacerbation
can probably be solved by means of a clearer conceptual framework about negative
outcome. It absolutely overriding premise is that if the patient becomes worse during
therapy, the therapist must clarify why.
Some clinical implications
One of the main conclusions of this study is that a good knowledge on negative outcome is
necessary for clinicians to identify patients' deterioration. Today, this seems to be scarce,
and one should therefore ensure that future psychologists are taught about negative
outcomes. In addition, one should update todays clinicians using courses and guidance. This
study indicates that experience of psychological security is too poor for more jobs. It is of
serious concern that psychologists report discomfort, shame, guilt and negative feelings
related to this topic. In light of this, one should consider doing surveys specificially aimed at
psychologists' experience of doing "Wrong" to their patients. A good working environment is
a prerequisite to talk about the difficult questions related to negative outcome.