I described automatic negative thoughts (ANT) in my previous blog about PTSD. ANTs are common in all individuals but are more severe and problematic in many individuals with posttraumatic stress, anxiety, mood, and other psychiatric disorders. There are many different ways to try to change ANTs and I described the three steps we use in my clinics to address them in psychotherapy. A substantial amount of time in cognitive behavioral therapy and other types of cognitive therapy sessions is spent on addressing ANTs by identifying the thoughts, swapping them with more adaptive thoughts, and then connecting them to actual behavior change. The techniques of how to successfully address ANTs are well-known, but there is a gap in understanding of how rapidly ANTs can change.
If patients are going to make the commitments to psychotherapy, how rapidly should they expect this process to work? How many times should they expect to address ANTs? How soon will they see behavior change? How much time and commitment will this take? While much about psychotherapy is necessarily laissez-faire because humans are complicated and unique, it nevertheless seems reasonable to expect there to be answers to these questions about a psychotherapy technique that is so common.
This is another example of how our profession has done a poor job, in my opinion, of providing useful information to consumers about how psychotherapy works. For example, if you hire a contractor to work on your house, logical questions would include, how long will this take? What parts have to be replaced? How long is this fix expected to last?
For psychotherapy, similar questions would include, what ANTs do I need to address? How many times do I need to replace ANTs with more adaptive and positive thoughts? How long is this fix expected to last?
It is acknowledged that psychotherapists can never answer those questions as precisely as building contractors, of course, because psychotherapy is more multifaceted. Some situations are more complicated than others, some problems are more severe than others, and perhaps the biggest factor, motivation to change, can vary widely. But I try to view psychotherapy from a customer service perspective. In regards to questions that are reasonable to ask about, it seems to me there is too much of a gap in what consumers (i.e., patients) should demand and what psychotherapists can tell them in this area.
How Rapidly Can Thoughts Change?
We can get a rough estimate of how rapidly negative thoughts can be restructured by looking at the duration of treatment of patients in my clinics. I calculated the durations of treatments for all manner of psychotherapy treatments for anxiety, mood, and life situation problems. A limitation is that there was a wide variation in how much therapies were focused on ANTs. These durations do not include patients who needed primarily medication management.
Among adult patients, as measured by either clinician judgment or standardized outcome measures, 33% achieved improvement in less than 3 months, 43% achieved it within 3-12 months, and another 24% stayed in treatment longer than 12 months for continued work and maintenance. These calculations are only considering those who made the attempt. There were many patients who came for only one visit and decided they were not ready at this time or not ready to stay in therapy at this clinic.
Among seven- to 17-year-old patients in my child clinic, the time frame was a bit faster. Approximately 42% achieved satisfactory treatment endpoints in less than 3 months, which is higher than the 33% in adults. About 44% achieved success within 3-12 months; just about the same as adults. Only 14% stayed in treatment longer than 12 months for continued work and maintenance, which is lower than the 24% of adults.
The Missing Data on Outcomes and Why it Matters
Are these percentages at my clinics good outcomes, average outcomes, or poor outcomes? Are our therapists better or worse at helping patients compared to other therapists? I believe our therapists are better for certain types of problems, but it is difficult to conclude that based on any data for at least two reasons. (1) Outcomes depend on the severity of problems that walk in the door and that is likely to be different across different types of clinics. (2) Other clinics do not collect and report data on their outcomes.
In my non-comprehensive survey of other clinics in the world, I have looked for other clinics that publicly report any types of outcomes, and they are rare. I would even risk literary redundancy and say they are extremely rare.
The data that I reported above on how rapidly patients improved is not all that interesting by itself. It becomes much more interesting however when you start asking deeper questions about the data. Why do some patients improve faster than others? Is there a key predictive factor, or set of factors? Does speed depend on motivation, external life circumstances, the nature of psychiatric symptoms, or things therapists can do differently? Would augmentation with medication speed up the process in certain cases? None of these more interesting questions can be addressed until the more basic task of tracking outcomes exists as a foundation.
Being able to compare data on outcomes across clinics and therapists matters for a variety of reasons. The quality of psychotherapists is known to range from great to eccentric to incompetent, and patients have no good way to know ahead of time who is good. Specialization in psychotherapy is important. It is literally impossible for one therapist to be an expert on every type of problem, and patients have no good way to know who specializes in what. Technique is important. Many evidence-based therapies exist and it is well-documented that most therapists do not use them, and it is not easy for patients to know ahead of time what techniques therapists really know how to use. As I have written before, consumers have no way to rate the quality of therapists in general.
Data for comparison from other therapists on the speed of outcomes are largely missing, and it does not appear that this situation is going to change soon because therapists are not incentivized in the current business model to report their outcomes. It is unlikely to change until a game-changer arrives that can somehow demand that efficiency and quality of the psychotherapy industry must improve.