The Relapse Crisis: What the psychotherapy outcome research says about relapse rates.
- Jordanthecounselor
- 3 days ago
- 5 min read
I've been talking with my friend (and former coach) Alex Vaz, Ph.D., and the other day he casually let slip a bombshell.
"Remember that in most outcome trials of 12-18 sessions, 50% get better at the end, and from those, another 50% don't hold those gains at follow-up."
What?
Half of clients don't keep their gains after therapy?
I asked him to send me the research. He sent me a video of Jonathan Shedler and a chapter review of Bergin and Garfield's Handbook of Psychotherapy and Behavior Change, 7th ed (2021). Both pieces dive deep into psychotherapy outcome research, and the findings are unsettling.
Let's dive in.
Jonathan Shedler's Critique of Psychotherapy Outcome Research
Shedler's argument is basically that in the short-term manualized treatments that dominate modern psychotherapy outcome research—treatments clients are told are the gold standard—the relapse rate is 40-50 percent. This is because, in his view, these manualized treatments aren't really therapy.
Real therapy, he argues, is a process that takes years. Meaningful change begins around the 6-month mark and involves helping the person change their personality, which is ultimately the root cause of their distress.
Here's Shedler in his own words:
You know, depression is a great example. Half of the people approximately don't improve at all. Of the remaining half that does improve, most of them don't get well. They're improved, but they're not well. But those benefits dissipate quickly. People relapse. And when you do the arithmetic 50% don't get better, another, another 25 to 30 percent relapse.
And you look at the big picture, it's like, well, 75% of people who have so-called evidence-based treatment for depression—these brief manualized treatments—either don't improve at all or improve and relapse quickly.
It's beyond me how anybody can take research that shows that and then declare these to be scientifically proven evidence-based treatments.
What we've just proven scientifically is that these treatments are failing about 75 percent of depressed patients.
Shedler’s math breaks down like this: 50% of clients have no change from therapy. Of the 50% who do change, some of them only improve, not recover. But of those who do change, 50% of them will relapse.
Let’s do a little math. Say you have 100 clients with depression and 10% drop out. That means you have 90 clients. Half of those (45 people) won’t benefit from therapy. Of the remaining 45 people, some will improve and some will recover, but only about 23 will stay better.
100 to 90 to 45 to 23. That’s so shocking it can’t be true, right? I mean, that’s just this crazy Jonathan guy talking, right?
Right?
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What the Handbook Says About Psychotherapy Outcome Research
In Chapter 5 of the Handbook of Psychotherapy and Behavior Change, the authors review the research on how many clients relapse in short-term and long-term therapy. I invite you to get a copy and review the research yourself. However, I found this paragraph the most insightful:
Steinert et al. (2014) investigated the longer-term effectiveness of psychotherapy for depression and carried out two meta-analyses focusing on overall rates of relapse two years beyond treatment in a comparison with pharmacotherapy or treatment as usual over a similar time period.
From their review, they reported that upwards of 89% of people were recovered at the time of follow-up but that a lower percentage, between 35% and 60% of people, experienced a stable recovery during the follow-up period, meaning that they did not experience a further episode during the follow-up period (p. 172).
So between 35%-60% of people stayed recovered. Which means 65%-40% of people relapsed. If you average 65%+40% you end up with 52.5%
So Jonathan is wrong. It’s not 50%. It’s 52.5%.
The Implications of Psychotherapy Outcome Research: What It Means for Us
So what does this mean? It’s a strange and unsettling finding, to be sure. And it will most likely bring up a lot of feelings for most of us. I can only speak for myself.
I think this means we need to get better.
I know what you're thinking. You’re already trying really hard. You’re EMDR trained, trauma-informed, and Somatic Experiencing trained. You do reiki, listen to podcasts, and consult with colleagues. You do all the things.
But the research shows that just doing more things—learning more models, getting more certifications—doesn't automatically make us better. What if there was a way to do more with less? What if you could become more effective by training smarter, not harder?
The key is hidden in the psychotherapy outcome research itself: that 52.5% relapse rate is an average. It’s a range of 65%-40%. This means that some therapists have fewer relapses than others. Said another way, some therapists are better than others.
If you become a better therapist, your clients will have fewer relapses.
The single most powerful way to do this is to systematically review your own clinical work. It is the force multiplier for improving your skills. For professional athletes, this means watching game film. For us, it means watching our session tapes—what researchers call "process coding."
This is the foundational skill. By learning a specific process for breaking down your sessions, you stop guessing and start seeing exactly what works for each specific client.
If you want to learn more about the science of systematically reviewing your clinical work, here are three ways:
Listen to my podcast with Alyssa Di Bartolomeo. She’s a researcher who’s a specialist in reviewing clinical tapes.
Check out this blog about the 7 types of silences. This is one of the frameworks I use to review my own clinical tapes.
Come to our training on October 24th and October 31st. Space is limited, and we currently have 5 spots left.
I hope this serves you.
Best,
Jordan (the counselor)
Jordan Harris and Paul Peterson are co-founders of Private Practice Incubator, a consulting firm dedicated to:
Helping clinicians earn more money.
Helping clinicians help more clients.
If you'd like to learn more about launching your practice, visit us here.
Jordan Harris Jordan Harris, Ph.D., LMFT-S, LPC-S, received his Doctor of Philosophy in Marriage and Family Therapy from the University of Louisiana Monroe. He is a licensed professional counselor and a licensed marriage and family therapist in the state of Arkansas, USA. In his clinical work, he enjoys working with couples. He also runs a blog on deliberate practice for therapists and counselors at Jordanthecounselor.com
Paul Peterson Paul Peterson is a Licensed Professional Counselor (LPC) and Licensed Marriage and Family Therapist (LMFT) in the state of Arkansas. He has certification and/or training in EFT, hypnotherapy, and mindfulness as well as adult psychological development models. He's been in the mental health field since 2015 and in 2019 worked with a team of authors to publish a content analysis in the Journal of Marital and Family Therapy. The content analysis reviewed almost 1,000 research articles and tracked trends in publishing and clinical effectiveness research. He has also published a book on a Wholeness-oriented approach to contemporary Christian faith. He gives regular training on clinical skills, hypnotherapy, and business skills for solo practice therapists.
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