Therapist Blind Spots

Introduction

If therapy is not helping you, or is quietly making things worse, both you and your therapist want to know early.

Early is when there is still time to change course: to adjust the approach, to talk openly about what is not working, or to consider a different kind of help.

The difficulty is that the research suggests your therapist may not notice on their own. In the studies that tested this directly, therapists identified very few of the clients who were getting worse.

Introduction

What the Research Found

One of the clearest tests comes from Hannan and colleagues (2005), at a university clinic.

Forty-eight therapists were asked to predict which of their clients would end treatment worse off than when they started.

The therapists had been told beforehand that the clinic's deterioration rate was about 8%. They knew that some clients get worse. Yet, as the next slide shows, they rarely recognized it in the clients they were seeing.

What the Research Found

What the Research Found

By contrast, a formal, algorithm-based method tested in the same study identified 100% of the deteriorated clients at termination, and 85% of them by the third session, according to the study's abstract.

The pattern has shown up again more recently. Østergård and colleagues (2024) found that 53 trainee therapists identified 1 of 8 clients who had deteriorated by the end of therapy.

These are small studies in single settings. Together, they suggest that a therapist's impression, on its own, is not a reliable way to spot a client who is getting worse.

Why It May Happen

If therapists miss deterioration, the next question is why. Part of the answer may lie in how clinicians see themselves.

In a survey of mental health professionals, Walfish and colleagues (2012) found that 25% rated their own skill at the 90th percentile or higher, and none rated themselves below average.

The same clinicians also overestimated how much their clients improve and underestimated how often clients deteriorate, compared with published rates.

This was a self-report survey, compared with published rates rather than the clinicians' own outcomes.

Why It May Happen

Experience Does Not Close the Gap

It might seem that experience corrects this. The evidence suggests otherwise.

Goldberg and colleagues (2016) followed 170 therapists and 6,591 clients in one clinical setting over time.

On average, client outcomes did not improve as therapists gained experience. In fact, there was a very small but statistically significant decline.

Experience Does Not Close the Gap

What Helps, Partly

If neither self-assessment nor experience closes the gap, it makes sense to gather information that does not depend on the therapist's impression.

Routine progress feedback, also called routine outcome monitoring, means a client completes a brief, validated questionnaire on a regular basis, often every session.

The results are reviewed over time so that both people can see whether things are changing.

What Helps, Partly

The largest meta-analysis on this, by de Jong and colleagues (2021), pooled 58 studies and 21,699 patients.

• Feedback produced a small improvement in symptom reduction (d = 0.15).
• The improvement was slightly larger for clients who were not on track (d = 0.17).
• It also produced a small reduction in dropout (OR = 1.19).

These are small standardized effects, not percentages.

Importantly, the effect on deterioration was not significant: 5.4% of clients deteriorated without feedback and 4.6% with it (p = 0.07).

What Helps, Partly

A second meta-analysis, by Lambert and colleagues (2018), looked at 24 studies of two well-known feedback systems, the OQ System and PCOMS.

Two-thirds found that feedback-assisted therapy outperformed usual care by the same therapists, and the authors reported that feedback reduced deterioration.

Two cautions apply. This review covers only two systems, and its lead author developed the OQ System.

What Helps, Partly

Scores Are One Window

If a questionnaire is only a partial fix, what else belongs alongside it?

In my view, progress measures help ground a sense of progress in actual data rather than impression alone. But I think the client's own self-report, and functional accounts from people who see the client outside the therapy room (a partner, family, friends, or someone at school or work), are just as valuable.

Where we are unsure about a piece of information, it can be qualified rather than discarded: noted with its limits and weighed alongside the rest.

That is my clinical view, not a research finding. Research supports part of it, as the next slide shows.

Scores Are One Window

• In a meta-analysis of adult studies, Achenbach and colleagues (2005) found that self-reports and reports from people who know the person agreed only moderately. Mean correlations ranged from about .30 to .68, depending on the problem area and the instruments used.
• A meta-analysis of 341 studies of children and adolescents by De Los Reyes and colleagues (2015) found low-to-moderate agreement between informants such as the young person, parents and teachers (mean r = .28 overall). The authors argue that much of this disagreement reflects real differences in how a young person behaves at home, at school and elsewhere.

Moderate agreement is the point. Because these views do not simply repeat each other, each adds information. No single source (client, informant, therapist or questionnaire score) is the whole truth.

Scores Are One Window

There is a second reason to look beyond symptom scores, which is what most progress questionnaires track.

In a review of research on depression, McKnight and Kashdan (2009) found the relationship between symptoms and functioning to be weak and often bidirectional. Functional change often lagged behind symptom change.

A symptom score can therefore miss how daily life, work and relationships are actually going.

In my own practice, I combine several sources: a scale or scaling questions, a questionnaire such as the PHQ-9 or GAD-7, the client's own self-reports, and descriptions from people around the client. I only hear from people around a client with the client's informed consent, and the client decides who, if anyone, that is.

If You Are in Therapy

You do not have to rely on your therapist noticing everything. Your own account counts as real information.

You can ask how progress will be checked. For example:

• "How will we know if this is working?"
• "Do you use any questionnaires to track progress?"
• "What happens if the scores show I'm not improving?"

A therapist who does not use a formal questionnaire is not necessarily doing poor work. These questions are not a test. They make progress something you look at together.

If You Are in Therapy

For Clinicians

This slide is written for therapists, but anyone is welcome to read it.

The first step is the hardest: assume you share the bias. I include myself in that.

From there, you may wish to consider using a brief, validated progress measure at every session. Examples include the OQ-45, the ORS and SRS used in PCOMS, the CORE-10, and the PHQ-9 and GAD-7 for specific symptoms.

• Look at the trend with the client rather than on your own.
• Read it alongside the client's own report and, where appropriate, accounts from people who see the client outside sessions.
• When a client is flagged as "not on track", treat that as a prompt to talk, not a verdict on the client or on you.
• Over time, it may also help to track your own aggregate outcomes rather than relying on years in practice.

This is general information, not advice about any particular client or setting.

Limits of the Evidence

Each source has limits worth stating plainly.

• Hannan et al. (2005): one university clinic, with predictions gathered over only 3 weeks at different points in treatment.
• Østergård et al. (2024): trainee therapists only, at one clinic.
• Walfish et al. (2012): a self-report survey, compared with published rates rather than clinicians' own outcomes.
• Goldberg et al. (2016): naturalistic data from one setting.
• de Jong et al. (2021): mixed randomized and non-randomized studies, with small effects. It is unclear when and why feedback works.
• Lambert et al. (2018): only two feedback systems, one-third of its studies did not find feedback superior, and the lead author developed the OQ System.
• Achenbach et al. (2005): a thin evidence base, with qualifying correlations found in only 108 of about 51,000 articles screened (0.2%).
• De Los Reyes et al. (2015): children and adolescents only, so it applies to adults only by analogy.
• McKnight and Kashdan (2009): depression only, and the evidence is correlational.

Checking Progress Together

Taken as a whole, the evidence points to a human limit rather than a professional failing, and one that experience alone does not seem to correct.

A short questionnaire, looked at together over time, appears to help, modestly. In my view it works best as one window among several.

That shifts the question from "Is my therapist good enough?" to "How are we checking whether this is working?" That second question is one that clients and clinicians can answer together.

Module Complete

You've explored a common blind spot in therapy: what the research found, why it may happen, and how clients and therapists can check progress together.

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This module is part of the Psychotherapy Gaps series. For more modules in the series as they are added, return to the Western Psychotherapy course page.

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About this module. This module is education, not therapy. It is not counselling, assessment, diagnosis or treatment, and taking it does not create a therapist-client relationship. If you are struggling, please speak to a doctor, a registered mental health professional or another trusted support.