3 - (SYM 122) When Progress Monitoring Gives You Lemons, Make Lemonade! Symptom Deterioration and Recovery During Naturalistic Outpatient Cognitive Behavior Therapy

Background: Psychotherapists are notoriously poor at identifying  and responding to patient symptom deterioration. This oversight is mirrored in the empirical literature, which has only recently begun to investigate negative effects in therapy. We used a large, naturalistic dataset of adults who received individual cognitive behavior therapy for mood and anxiety disorders in an outpatient private practice setting to investigate the relation between deterioration and clinical outcomes (e.g., dropout, end-of-treatment symptom severity) and therapist use of decision support tools (e.g., case formulation, plot of progress data).

Method: The dataset included 786 patients who completed the Beck Depression Inventory and/or the Burns Anxiety Inventory at each session to monitor progress. We defined deterioration as a symptom increase resulting in a progress monitoring score worse than the intake score according to the reliable change index. Each deterioration was coded as resolved (any subsequent progress monitoring score was not reliably worse than the intake score) or not resolved. We analyzed the data using generalized hierarchical linear modeling.

Results: Analyses for this study are on-going. Initial results indicate that 19% of patients experienced a deterioration during treatment, and 5% ended treatment in an unresolved deterioration. Having a deterioration was not by itself associated with increased likelihood of dropout, but failing to resolve the deterioration was associated with dropout. Having a deterioration during treatment was associated with worse end-of-treatment symptom severity. However, resolving a deterioration during treatment was associated with better end-of-treatment symptom severity, and the positive effect of resolving the deterioration was greater than the negative effect of having the deterioration. Therapist use of a plot of progress data and a written case formulation were each associated with a higher likelihood of resolving deteriorations.

Conclusion: These results suggest that deterioration is not uncommon in a naturalistic outpatient setting. If successfully detected using progress monitoring, these episodes may present therapists with opportunities to make lemonade out of lemons by building collaboration, fine tuning case formulations, and revising treatment plans, yielding greater symptom improvement in the long run.