A Starting Place for Preventing Treatment Failure

All counseling efforts contain elements of success and other elements of failure (Bugental, 1988). In the effort to preserve optimism and hope, it can be beneficial to acknowledge seemingly minor breakthroughs where clients implement new behaviors or ways of thinking in situations that would have previously resulted in difficulty. At the same time, as Meehl (1973) warned almost 40 years ago, celebrating breakthroughs is not the same as “rewarding everything – gold and garbage alike” (p. 227-228). Along the same lines, it is also important not to be lulled into a false sense of positive complacency that just because a client comes every week that they are receiving maximum benefit (Lambert, 2000). The challenge for practitioners is to find the balance between maintaining, as Pedrotti, Edwards, and Lopez (2008) reminded, the therapeutic benefits of hope while properly safe-guarding against treatment failure.

Brief Case Example

A number of years ago, I worked with an adolescent who experienced a great deal of conflict with her mother. The student identified the communication freeze that had been in place between the two of them as a critical issue to resolve so that constructive dialogue could take place. Following several sessions with the daughter followed by a session with both the mother and daughter together, the possibility to hold conversation between the two of them had been re-established to a degree.

While the initial goal of the treatment plan had occurred in the presence of a mediator, both daughter and mother acknowledged a need to further address their communication difficulties. According to the initial case conceptualization, core beliefs and behavioral patterns remained that would in all likelihood continue to confound their relationship. In spite of compelling reasons to continue to work on these issues with professional assistance, the family elected to stop treatment and work on these issues on their own.

I will never know whether the treatment actually resulted in helping the family achieve greater health or well-being. At the same time it would not properly value the important and courageous first step the mother and daughter took that day to consider the treatment a failure. However, that they elected to prematurely terminate support before seeing the treatment plan to fruition indicates that, for whatever reason, the family did not see the benefit in continuing.

Use of Assessment

As a relevant resource, Persons and Mikami (2002) developed an algorithm for successfully handling treatment failure that utilizes assessment at varying points through work with a client to prevent, identify, overcome, and make a referral following acceptance of failure. While perhaps easy to take for granted, an important initial assessment to make in preventing failure, including premature termination, is the client’s stage regarding readiness for change (Prochaska, DiClemente & Norcross, 1992).

With regard to the case described above and other cases where treatment either fails to begin effectively or runs the risk of premature termination, as a first step, McConnaughy, Prochaska and Velicer’s (1983) assessment regarding readiness for change may help practitioners approach case formulations in a way that helps anticipate and prevent early treatment failure.

As one additional resource for approaching cases where my initial assessment suggests the case conceptualization would benefit from further information regarding readiness to change, I have adapted the University of Rhode Island’s Change Assessment for my site and population. If this is of use to you and your work please see the references below and feel free to use my model as a basis for whatever you create. This is a non-validated measure but scoring information can be found here – AC

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Adam Clark is a school counselor at Yokohama International School in Yokohama, Japan. Find out more here.

References

Bugental, J. T. (1988). What is “failure” in psychotherapy?. Psychotherapy: Theory, Research, Practice, Training, 25(4), 532-535. doi:10.1037/h0085378

Cancer Prevention Research Center, Initials. (n.d.). Other: URICA (long form) (University of Rhode Island Change Assessment). Retrieved from http://www.uri.edu/research/cprc/Measures/urica.htm

Lambert, M. J. (2000, August). Promise and problems of evaluating clinical practice in everyday clinical settings. In J. A. Carter & G. K. Lampropoulos (Chairs), Reprioritizing the role of science in the scientist-practitioner model in psychotherapy. Symposium conducted at the 108th Annual Convention of the American Psychological Association, Washington, DC.

McConnaughy, E.N., Prochaska, J.O., & Velicer, W.F. (1983). Stages of change in psychotherapy: Measurement and sample profiles. Psychotherapy: Theory, Research and Practice, 20, 368-375.

Pedrotti, J., Edwards, L., & Lopez, S. (2008). Promoting Hope: Suggestions for School Counselors. Professional School Counseling, 12(2), 100. Retrieved from MasterFILE Premier database.

Persons, J. B., & Mikami, A. (2002). Strategies for handling treatment failure successfully. Psychotherapy: Theory, Research, Practice, Training, 39(2), 139-151. doi:10.1037/0033-3204.39.2.139

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