Therapy is widely recognized as effective. Decades of research show that people who engage in psychotherapy generally fare better than those who do not. Yet every therapist knows a harder truth: not all therapy progresses as hoped. A study by Lambert, M. J. (2013) in Outcome in Psychotherapy: The Past and Important Advances shows that a meaningful percentage of clients fail to improve or even worsen during treatment, often without the therapist’s awareness. Recognizing early signs that therapy is not progressing has therefore become increasingly important in modern clinical practice.
Clients sometimes stall. Some disengage quietly. Others drop out altogether. Often, this happens without a clear rupture or dramatic moment. From the therapist’s perspective, sessions may feel “fine” — yet progress fails to materialize.
Most therapists rely on a mix of clinical training, experience, and intuition to assess how therapy is going. These skills matter. But research by Lambert and colleagues (2001) demonstrated that therapists correctly identify client deterioration less than a quarter of the time when relying on clinical judgment alone. The challenge is not a lack of care or competence. It is that progress in therapy is not always visible through conversation alone.
Clients may avoid expressing dissatisfaction, minimize ongoing distress, struggle to articulate when therapy feels unhelpful, or disengage internally long before they disengage behaviorally. Without a clear signal, therapy can continue in a well-intentioned but ineffective direction.
One of the strongest predictors of successful therapy is early change. Research consistently shows that when clients demonstrate improvement in the first few sessions, outcomes are significantly better. Conversely, when early change does not occur, the likelihood of dropout or deterioration increases. As noted by Lambert, Hansen, and Finch (2001), clients who fail to show early improvement are at substantially higher risk for poor outcomes.
Yet early lack of change often goes unnoticed. Sessions may feel collaborative. The relationship may feel warm. Goals may be discussed. But without tracking the client’s experience over time, subtle warning signs are easy to miss. This is not a failure of empathy — it is a limitation of relying solely on impression.
The therapeutic alliance is one of the most robust predictors of outcome across all therapy models. However, alliance is not something that forms once and remains stable. It fluctuates. As John Norcross (2011) has emphasized, the alliance must be continually monitored and repaired throughout the course of therapy.
A client may feel understood one week and unseen the next. They may agree with goals intellectually while feeling emotionally disconnected. Small misalignments can accumulate quietly. When alliance strain goes unspoken, therapists lose the opportunity to repair it early — when repair is most effective.
Clients rarely enter therapy intending to critique their therapist. Many worry about being perceived as difficult, hurting the therapist’s feelings, jeopardizing the relationship, or not knowing whether their experience “counts.” As a result, therapists may hear reassurance while clients feel uncertainty. Silence becomes mistaken for agreement.
This gap between what clients experience and what therapists perceive is one of the central challenges in psychotherapy.
Modern evidence-based practice increasingly emphasizes structured feedback — not to replace clinical judgment, but to inform it. Research on Feedback-Informed Treatment by Duncan and colleagues (2003) shows that routinely incorporating client feedback improves outcomes and reduces dropout, particularly for clients who are not progressing as expected.
Simple, session-by-session indicators of client experience and progress can surface patterns that conversation alone may not reveal, such as lack of early improvement, gradual deterioration, alliance strain, or a mismatch between therapist intent and client experience. When therapists have access to this information early, they gain the
opportunity to adapt collaboratively and transparently in alignment with the client’s goals.
The field of psychotherapy continues to evolve toward greater accountability, transparency, and client collaboration. This evolution does not diminish the role of the therapist; it strengthens it. By integrating the client’s voice more consistently into the therapeutic process, therapists can catch stalled progress sooner, address alliance issues earlier, reduce dropout, and improve outcomes across orientations and settings.
Ultimately, effective therapy is not about getting it right every time. It is about noticing when something is not working — and responding skillfully, together.
Early awareness of stalled progress creates space for conversation, realignment, and repair. Using simple tools that surface client experience over time can help therapists remain responsive and aligned with what clients are actually experiencing.
