Why are some cases not on track? An investigation of common obstacles and solutions during feedback-informed psychological therapy.

OBJECTIVES

Using feedback helps to improve psychological treatment outcomes, particularly for patients whose symptom trajectory is not-on-track. However, little is known about why some cases are not-on-track and what strategies can help to improve their treatment response. This study aimed to examine common obstacles and solutions identified by feedback-using therapists.

METHOD: A cohort of therapists (N = 10) used a feedback algorithm that classified cases as on-track or not-on-track using session-by-session measures of depression (Patient Health Questionnaire-9) and anxiety (Generalized Anxiety Disorder-7). They followed a structured protocol to identify obstacles and potential solutions in not-on-track cases, and to document these using qualitative case notes. Case notes from 192 therapy sessions (across N = 44 cases) were analyzed using topic modeling, a machine learning approach to process qualitative data.

RESULTS

Common obstacles were: (a) impact of traumatic experiences, (b) indicators of resistance, (c) social/interpersonal problems, (d) stressful life events, and (e) therapy process problems. Common solutions included: (a) strengthening agreement on goals and tasks, (b) enhancing focality, (c) individualized case formulation, and (d) enhancing expectations and motivation for change.

CONCLUSIONS

Consistent with prior quantitative research, the topics identified in this qualitative study generally reflected problems related to motivation/resistance or interpersonal/relational problems. (PsycInfo Database Record (c) 2026 APA, all rights reserved).