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).