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Treatment Failures in Behavior Therapy

All clinicians experience treatment failures: The interventions are not successful, and the patient does not improve. Other times, some progress is made, but the patient continues to perform below the level of functioning he or she had prior to the onset of the problem. Therefore, it is important to try to understand the circumstances under which treatment is more likely to fail. Many of these parameters have been identified clinically and supported through research on predictors of treatment outcome for behavior therapy. There are a number of such predictors that elevate risk of poor treatment response, and various strategies are employed to enhance outcome in the face of such predictors. These can be divided into two main categories: patient characteristics and therapist characteristics.

Patient Characteristics

There are a number of patient characteristics that are related to how well a patient will respond to behavior therapy. These factors include motivation, expectation, severity of symptoms, insight, and comorbidity. Oftentimes, several factors interact within an individual patient, but for clarity's sake, each one is considered separately here.

Motivation

Motivation is a key factor in determining how well a patient will respond to behavior therapy. Motivation is defined by (a) how interested the patient is in making changes in his or her life and (b) how much of an investment the patient is willing to make to make a change. If a patient is brought in by a family member because others are bothered by certain behaviors but the patient does not view the same behaviors as problems worth changing, then the patient will be less likely to engage in treatment and therapy is more likely to fail. More frequently, a patient is interested in changing but may not be willing to endure the distress that it takes to make changes (e.g., not willing to tolerate being anxious during exposure therapy). Thus, a patient who is not both interested in changing and is unwilling to endure the stress of change will more likely fail the treatment.

In behavior therapy for the treatment of anxiety disorders, unwillingness to tolerate the anxiety that accompanies therapy is more frequently the issue. A patient who is suffering from obsessive-compulsive disorder usually does not want to continue to experience the distress of the symptoms, but is sometimes not willing to endure the short-term distress it would take to successfully complete exposure and response prevention. Some researchers have started to examine whether motivational interviewing, a treatment strategy developed to help resistant patients engage in treatments for substance abuse, can assist the patient in deciding to invest in the short-term distress to achieve the long-term gain.

Expectation

Expectancy is defined as how much the patient believes that the therapy will work or how credible the treatment seems to the patient. If a patient believes that he or she is an exception and that behavior therapy will never work for him or her, then the patient is less likely to invest time and energy into the treatment and therefore less likely to improve significantly. Furthermore, if the patient really does not expect that the treatment will help, then motivation to conduct exposures or engage in other behaviors that can cause distress will be low or nonexistent. Depending on the patient, this can lead to either avoidance (e.g., not doing homework, not fully engaging in treatment such as exposures during the session, etc.) or conflict with the therapist (arguments about the treatment rationale, etc.). There are a number of methods that behavior therapists use beyond motivational interviewing to increase patient expectancy. First, because it is founded in empiricism, behavior therapists are able to discuss success rates with their patients. Many behavioral treatments for anxiety disorders suggest that at least 75% of patients will have at least a 50% reduction in their symptoms. This information plus the persuasion of a coherent model of treatment, a good therapeutic alliance, and early change in treatment often help many patients acquire high expectancy of success when they engage in behavior therapy. When these things are not sufficient, the behavior therapist will often work with the patient to determine what factors contribute to low expectancy and attempt to remove the barriers by helping the patient to have positive experiences that are counter to his or her expectations.

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