Using checklists for complex procedures such as general medicine, surgery, or psychological services may seem overly simplistic. However, proponents argue that checklists have value because of the complexity of these processes. Although the items in the checklist may seem basic, the risk that decision makers will make “dumb” mistakes increases when they are confronted with large amounts of complex information, much of which may be contradictory or ambiguous. Checklists can help health care professionals in difficult situations by reducing reliance on memory alone and, more importantly, by allowing them to step back, reflect on, and rethink their initial decisions (Ely et al., 2010).
For most patients, checklists would be unnecessary. Most patients do well in therapy, and 50% of patients terminate therapy in 10 sessions or fewer. Nonetheless, a few patients have more complicated problems, take more time to report therapeutic benefits, drop out of treatment unexpectedly, or otherwise fail in therapy. Checklists may be especially helpful with these difficult patients.
Knapp and Gavazzi (2012) proposed that treatment outcomes can be improved by using the “four-session rule.” According to this rule, if a patient is not making gains at the end of four sessions or does not have a good working relationship with the psychologist (in the absence of an obvious reason), the psychologist should reassess the treatment with this patient. The four-session rule does not require transferring the patient. Instead, the rule requires psychologists to reconsider the case, perhaps using the checklist provided at the end of this article.
Often, the reasons for a lack of improvement in psychotherapy may be obvious. For example, a patient enters therapy with a minor depression, but then gets worse because of a sudden and unanticipated layoff from work. The reason for the deterioration is clear and the psychologist has almost automatically talked to the patient about new modifications to treatment in light of the new life circumstances. However, the mere deterioration in the patient’s condition in this situation does not appear predictive of a treatment failure.
We consider the “four-session rule” as a useful heuristic because it helps control for over-optimism on the part of the psychologists. Evidence suggests that many psychologists are overly optimistic about their ability to help patients. For example, Stewart and Chambliss (2008) found that psychologists worked with patients for a median of 12 sessions before concluding that treatment was not working and considering alternative steps. Nonetheless, Lambert (2007) claims that his algorithm can predict risk for treatment failure by the fourth session with a high degree of accuracy. These two sources suggest that psychologists should adopt a lower threshold for considering a case at risk of failure.
We suggest using a checklist when treating a patient who falls into the “four-session rule.” After identifying an area of concern from the checklist, the psychologist can follow up in more detail, such as by answering some of the questions footnoted.
We know of no empirical studies to validate the use of the checklist for those patients at risk of treatment failure. Nonetheless, it does represent an effort of self-reflection that is needed in difficult cases. Readers may send any feedback or comments on this checklist to Drs. Sam Knapp or John Gavazzi.
Patient Collaboration (What does the patient say?)
YES ___ NO ___ 1 Does the patient think you have a good working relationship?
YES ___ NO ___ 2. Do you and your patient share the same treatment goals?
YES ___ NO ___ 3. Does the patient report any progress in therapy?
YES ___ NO ___ 4. Does the patient want to continue in treatment?  If so, does the
patient see a need to modify treatment?
Additional Reflections (What do you think about the patient?)
YES ___ NO ___ 5. Do you believe you have a positive working relationship with your patient? (Does he or she trust you enough to share sensitive information and collaborate?)
YES ___ NO ___ 6. Is your assessment of the patient sufficiently comprehensive? Do you need to obtain additional information?
YES ___ NO ___ 7. Do unresolved clinical issues of significant concern impede the course of treatment (such as Axis II issues, possible or minimization of substance abuse, or ethical concerns)?
YES ___ NO ___ 8. Does the patient need a medical examination?
YES ___ NO ___ 9. Have you documented appropriately?
Ely, J., Graber, M. L., & Croskerry, P. (2011). Checklists to reduce diagnostic errors. Academic Medicine, 86, 307-313.
Gawande, A. (2009). The checklist manifesto. NewYork: Holt.
Knapp, S., & Gavazzi, J. (2012). Ethical issues with difficult patients. In S. Knapp, M. C. Gottlieb, M. Handelsman, & L. VandeCreek, (Eds.), APA handbook of ethics in psychology. Washington, DC: American Psychological Association.
Lambert, M. (2007). Presidential address: What have we learned from a decade of research aimed at improving psychotherapy outcome in routine care? Psychotherapy Research, 17, 1-14.
Stewart, R., & Chambliss, D. (2008). Treatment failures in private practice: How do psychologists proceed? Professional Psychology: Research and Practice, 39, 176-181.
 Do you understand your patient’s goals and how he or she expects to achieve them? How do they correspond to your goals and preferred methods of treatment? If they differ, can you reach a compromise? Does the patient buy into treatment? Did you document the goals in your treatment notes? What did the patient say was particularly helpful or hindering about therapy? Have you incorporated your patient’s perceptions into your treatment plan?
 Do you agree on how to measure progress (self-report, reports of others, psychometric testing, non-reactive objective measures, etc.)? Does the patient need a medical examination?
 If yes, why?
 Can you identify what is happening in the relationship to prevent a therapeutic alliance? Does the patient identify an impasse? Do your feelings toward your patient compromise your ability to be helpful? If so, how can you change those feelings? Have you sought consultation on your relationship or feelings about the patient? If so, what did you learn?
 Have you reassessed the diagnosis or treatment methods using the BASIC ID, MOST CARE, or another system designed to review the presenting problem? Are you sensitive to cultural, gender-related status, sexual orientation, SES, or other factors? What input did you get from the patient, significant others of the patient, or consultants (this is especially important if there are life-endangering features)?