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Jul 14, 2016

Client’s getting worse in counseling

In a recent blog post ( and the associated interview video, Scott Miller discusses some compelling research regarding negative outcomes in therapy. Based upon randomized clinical trials, it is estimated that 35% of clients in therapy do not improve at all in counseling and 15% see a negative outcome in treatment. How astounding to imagine that these numbers suggest that 15% of the average counselor’s clients get worse in treatment! Miller’s blog seeks to move away from shaming the therapists based upon the suggestion that these numbers are true of all of us. Thus the goal is to find ways to catch when clients are getting worse in treatment to intervene early on (thus session measures and outcomes measures are suggested to help improve tracking how the client is doing in treatment). Miller also mentions that perhaps this is a symptom of the field we work in. I wonder sometimes if the medical model of treatment that has constricted what we do in therapy and imposed at times higher caseloads as clinicians working in a variety of settings may play into outcomes.

But it is also curious that there is no mention of client specific variables in negative outcomes. Perhaps we aren’t helping make their life better but how do we know that the correlation of client entering treatment is the causation of their life getting worse? The old quotations from research methods courses in graduate school come back haunting me with ghosts of “correlation does not equal causation.”

While I really enjoy the conversation that Miller has been huge in helping to catalyze and think it is damn good for us to all take a more honest look at ourselves professionally, I do think it would be helpful to add to the discussion an analysis of client specific variables. For example some of the clients I work with enter treatment with severe handicaps or incur a TBI during treatment due to the “leisure activities” including the American pastime of slamming skulls into skulls vis-a-vis football. These factors may include medical ailments, environmental or family attributes, cultural considerations like experiences of prejudice, and so on.

Anyways, thanks for reading and do take a look at Miller’s blog. I think we all do this work better when we can take an honest look at our work. The numbers that 50% improve on average and 50% see no change or deteriorate (estimated at 35% no change and 15% get worse) are staggering and worth some serious and honest consideration. Hopefully these honest conversations will be a part of making us all better helpers.
Stephen Ratcliff is a Counselor in private practice in Albuquerque, NM. He specializes in helping Children and Adolescents with Addiction, Psychological Trauma, and Attachment Disorders. For more information or to contact Stephen, please visit

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