Journal of Consulting and Clinical Psychology Copyright 2006 by the American Psychological Association

2006, Vol. 74, No. 1, 160 –167 0022-006X/06/$12.00 DOI: 10.1037/0022-006X.74.1.160

Dose–Effect Relations and Responsive Regulation of Treatment Duration:

The Good Enough Level

Michael Barkham and Janice Connell William B. Stiles

University of Leeds Miami University

Jeremy N. V. Miles Frank Margison

University of York Manchester Mental Health and Social Care National Health
Service Trust and University of Manchester

Chris Evans John Mellor-Clark

Nottinghamshire Healthcare National Health Service Trust CORE Information Management Systems, Ltd.
and University of Leeds

This study examined rates of improvement in psychotherapy as a function of the number of sessions
attended. The clients (N ! 1,868; 73.1% female; 92.4% White; average age ! 40), who were seen for
a variety of problems in routine primary care mental health practices, attended 1 to 12 sessions, had
planned endings, and completed the Clinical Outcomes in Routine Evaluation—Outcome Measure
(CORE–OM) at the beginning and end of their treatment. The percentage of clients achieving reliable and
clinically significant improvement (RCSI) on the CORE–OM did not increase with number of sessions
attended. Among clients who began treatment above the CORE–OM clinical cutoff (n ! 1,472), the
RCSI rate ranged from 88% for clients who attended 1 session down to 62% for clients who attended 12
sessions (r ! ".91). Previously reported negatively accelerating aggregate curves may reflect progres-
sive ending of treatment by clients who had achieved a good enough level of improvement.

Keywords: dose– effect, good enough level, psychotherapy effectiveness, responsiveness

In their classic meta-analysis of dose– effect relations in psy-
chotherapy, Howard, Kopta, Krause, and Orlinsky (1986) charac-
terized the path of client improvement as a negatively accelerating
function of treatment length, in which 30% of clients made mea-
surable improvement after 2 sessions, 41% after 4 sessions, 53%
after 8 sessions, and 62% after 13 sessions. Subsequent research by
Kopta, Howard, Lowry, and Beutler (1994) elaborated this finding
by showing that the effective dose varied across different types of
Michael Barkham and Janice Connell, Psychological Therapies Re-
search Centre, University of Leeds, Leeds, United Kingdom; William B.
Stiles, Department of Psychology, Miami University; Jeremy N. V. Miles,
Department of Health Sciences, University of York, York, United King-
dom; Frank Margison, Manchester Mental Health and Social Care National
Health Service (NHS) Trust and Department of Psychiatry, University of
Manchester, Manchester, United Kingdom; Chris Evans, Rampton Hospi-
tal, Nottinghamshire Healthcare NHS Trust, Nottingham, United King-
dom; John Mellor-Clark, CORE Information Management Systems, Ltd.,
Rugby, United Kingdom, and Psychological Treatments Research Centre,
University of Leeds.
Michael Barkham and Janice Connell were supported by the NHS
Priorities and Needs Research & Development Levy.
Correspondence concerning this article should be addressed to Michael
Barkham, Psychological Therapies Research Centre, University of Leeds,
17 Blenheim Terrace, Leeds LS2 9JT, United Kingdom. E-mail:
m.barkham@leeds.ac.uk
symptoms. Fewer sessions were required for improvement in dis-
tress symptoms, and more sessions for characterological symp-
toms, but Kopta et al. described the negatively accelerated pattern
as common across problem types. From these classic reports has
sprung a lively and substantial research literature on dose– effect
relations in psychotherapy (e.g., Barkham et al., 1996, 2001;
Barkham, Rees, Stiles, Hardy, & Shapiro, 2002; Dekker et al.,
2005; Feaster, Newman, & Rice, 2003; Given, 2002; Gray, 2003;
Grissom, Lyons, & Lutz, 2002; Hansen & Lambert, 2003; Hansen,
Lambert, & Forman, 2002, 2003; Hoagwood, 2000; Howard,
Lueger, Maling, & Martinovich, 1993; Kadera, Lambert, & An-
drews, 1996; Kopta, 2003; Lueger et al., 2001; Lutz, Lowry,
Kopta, Einstein, & Howard, 2001; Lutz, Martinovich, Howard, &
Leon, 2002; Salzer, Bickman, & Lambert, 1999; Steenbarger,
1994; Warner et al., 2001).
The negatively accelerating pattern has usually been interpreted
as reflecting diminishing strength of each successive session. As
Kopta (2003) put it, “the effect of therapy is greater in earlier
sessions and increases more slowly at higher dosage levels” (p.
728). Reflecting concerns about administrative efficiency and fair
allocation of scarce resources, discussion has focused on the op-
timum number of sessions that clients should be offered. That is,
“How much is enough?” (Kopta, 2003, p. 728). For example,
Howard et al. (1986) suggested, “The present meta-analysis indi-
cates that by 26 sessions, about 75% of patients have shown some
improvement. . . . [I]n clinics that serve a large population with

160
 RESPONSIVE REGULATION OF DOSE
limited resources, 26 sessions might be used as a rational time
limit” (p. 163).
The usual interpretation in psychotherapy research has consid-
ered the aggregate curves as representing an average of individual
dose– effect curves that are also negatively accelerated, modeled as
log-linear functions of session number. There are, however, other
possibilities. Barkham et al. (1996) observed that session-by-
session plots of improvement in particular symptoms for up to 16
sessions tended to look more or less linear (e.g., see Figure 1 in
Barkham et al., 1996, p. 932) and noted that, in the dose– effect
studies by Howard et al. (1986) and Kopta et al. (1994), clients had
varying lengths of treatment, so that different aggregations of
clients were represented at each successive point. To encompass
these results, they suggested that problems might be assumed to
improve at a steady (i.e., linear) rate across sessions until it reaches
a good enough level (GEL), at which point the client and therapist
either redeploy therapeutic efforts to other problems or discontinue
therapy. The rate of improvement might vary depending on the
characteristics of the problem (e.g., acute distress vs. character-
ological issues), characteristics of the client (e.g., personal re-
sources, external stressors), or characteristics of the treatment (e.g.,
limitation to a greater or lesser number of sessions), and as a
consequence, different problems would take different numbers of
sessions to reach their GEL. Even though the response of particular
problems or symptoms might be linear, however, averaging across
multiple clients or multiple problems would yield a negatively
accelerated curve, as clients with more quickly responding prob-
lems dropped out of treatment (Barkham et al., 1996, pp.
933–934).
Our Figure 1, modeled on Barkham et al.’s (1996) Figure 2 (p.
934), illustrates this possibility. In our version of the figure, the
hypothetical GEL is set arbitrarily so that 70% of clients whose
changes have reached this level meet some external criterion for
improvement. Theoretically, this percentage represents the concor-
dance between the external criterion of improvement and the GEL,
understood as the level of improvement at which the client, in
Figure 1. Good enough level model. The endpoints of the dotted lines
represent the assumed constant percentage (70%) of clients meeting im-
provement criteria for groups who attended 1 to 12 sessions. The dotted
lines represent interpolated percentages at intermediate points. The solid
line represents the percentage of clients remaining in therapy at each
session who met the criteria, calculated as the average of the interpolated
percentages for clients remaining in treatment at each session.
161
negotiation with the therapist and considering all situational fac-
tors, decides that he or she has had enough treatment and stops
attending therapy. The endpoints of the dotted lines represent this
percentage as a constant for groups who attended 1–12 sessions.
The dotted lines represent interpolated percentages of each group
at intermediate points, modeled as linear functions. The solid line
represents the percentage of clients remaining in treatment who
have met criteria for improvement by that session, calculated as the
average of the interpolated percentages.1
Figure 1 thus illustrates the possibility that an aggregate nega-
tively accelerating dose– effect curve could reflect linear dose–
effect relations for each group of clients. The benefit of each
successive session to an individual client need not systematically
decline to produce this pattern. The quickly improving clients
differentially leave the pool as they reach their GEL, so that
aggregate estimates of the effectiveness of each successive session
are based on successively smaller groups of more slowly respond-
ing clients.
The GEL model suggests that, in routine practice, level of
improvement and treatment duration are mutually regulated so that
treatments tend to end when clients, on average, have improved to
a degree or level that is good enough. The GEL may be considered
as a manifestation of responsiveness, that is, of behavior being
influenced by emerging context (Stiles, Honos-Webb, & Surko,
1998). Responsiveness may involve adjusting the length of therapy
to reflect degree of improvement, adjusting the degree of focus and
effort of therapeutic work in response to the available time, ad-
justing expectations, or various combinations of such strategies.
Characteristics of the clients, therapists, and settings, including the
nature and severity of the problems, the personalities of the par-
ticipants, and available resources, combine to affect how quickly
clients improve and when treatment can be terminated. Most
obviously, clients and therapists may agree to end treatment when
goals have been reached or when an acceptable amount of progress
has been made. However, in addition, imposing time limits may
accelerate the process of therapy (Eckert, 1993; Reynolds et al.,
1996) and the rate of improvement. When clients were randomly
assigned to either 8 or 16 sessions of the same treatments, the
8-session groups averaged greater symptom reduction at the end of
1
More formally, the dotted lines indicate the expected percentage, pij, of
the clients ending treatment after j sessions who meet improvement criteria
by session i, modeled as pij ! (i/j)G, where G is the improvement rate
yielded by the average GEL (70% in Figure 1). The solid line, the
estimated percentage of clients remaining in treatment who have met
criteria by session i, can be represented as a weighted average of the
interpolated percentages,
! !
s s
Pi ! # njpij$/# nj$,
j!i j!i
where s is the number of sessions under consideration (i.e., s ! 12 in
Figure 1) and nj is the number of clients who eventually attended j sessions.
Assuming, for simplicity, that equal numbers of clients terminated at each
session, so that the weights are equal, this reduces to
!
12
Pi ! # pij$/#13 " i$.
j!i
162 BARKHAM ET AL.
treatment than the 16-session groups did at midtreatment
(Barkham et al., 1996).
For evaluating therapeutic change, Howard et al. (1986) ac-
cepted previous researchers’ definitions of improvement. Subse-
quent researchers, however, have tended to use the criteria for
reliable and clinically significant improvement (RCSI) proposed
and modified by Jacobson and colleagues (Jacobson, Follette, &
Revenstorf, 1984; Jacobson & Revenstorf, 1988; Jacobson &
Truax, 1991). These criteria have elicited discussion and contro-
versy (e.g., Bauer, Lambert, & Neilsen, 2004; Kendall, Marrs-
Garcia, Nath, & Sheldrick, 1999; Ogles, Lunnen, & Bonesteel,
2001; Tingey, Lambert, Burlingame, & Hansen, 1996a, 1996b;
Wampold & Jenson, 1986; Wise, 2004), but, for consistency with
previous work, we adopted them in this study. Achieving RCSI,
according to Jacobson and Truax, requires a client to meet two
criteria. First, pre–post improvement must be reliable in the sense
of being large enough not to be attributable to measurement error.
Second, it must be clinically significant, which is most often
understood as beginning treatment in the dysfunctional clinical
population and entering the nonclinical population during or after
treatment, assessed as moving from above to below a clinical
cutoff score on the investigators’ chosen criterion measure.
We examined the GEL model of dose– effect relations in a data
set gathered in routine primary care mental health settings in the
United Kingdom. In particular, we examined the RCSI rates of
psychotherapy clients at the end of their treatment as a function of
the number of sessions they attended. We reasoned that if clients
and therapists tend to end the therapy when the GEL is reached,
then the RCSI rate should be approximately constant across ses-
sions as illustrated in Figure 1. Insofar as the GEL model was
previously proposed only post hoc, in a discussion section
(Barkham et al., 1996), this is the first prospective application of
the model. Clinically, support for the GEL model would strengthen
the case for individualized rather than standardized decisions about
treatment length.
In estimating RCSI rates, some researchers have included clients
who began treatment below the clinical threshold on the criterion
measure. Such clients can never meet the second RCSI criterion;
that is, they cannot move from the clinical to the nonclinical
population because they were not in the clinical population to
begin with. Including such clients depresses the RCSI rate (see
Gray, 2003; Hansen et al., 2002, 2003). To permit comparison with
previous work, however, we calculated RCSI rates both ways in
this study, that is, both with and without clients who began
treatment below the clinical cutoff on our criterion measure, the
Clinical Outcomes in Routine Evaluation—Outcome Measure
(CORE–OM; Barkham et al., 1998, 2001; Barkham, Gilbert, Con-
nell, Marshall, & Twigg, 2005; Evans et al., 2000, 2002).
Method
Participants
We studied data from 1,868 clients who attended 1–12 sessions in
routine primary care mental health practices, had planned endings, and
completed the CORE–OM at the beginning and end of their treatment.
Endings were considered as planned if the therapist and client agreed to
ending therapy or a previously planned course of therapy was completed.
Data were collected at 33 sites in the National Health Service (NHS) of the
United Kingdom that provided primary care counseling or psychology
services and routinely used the CORE–OM to monitor clients at intake.
The data were anonymized at the sites; data collection complied with data
protection procedures for the use of routinely collected clinical data.
For 4,383 out of 6,610 clients who returned any CORE–OM forms at
these NHS sites during the 3-year data collection period (January 1999 –
November 2001), therapists recorded whether the ending to therapy was
planned (n ! 2,690) or unplanned (n ! 1,693). The remaining 2,227
included clients who had not ended their treatment by the closing date,
clients who did not attend their first scheduled session, and clients whose
therapists failed to complete the end-of-therapy form. Reliable pre- and
posttherapy CORE–OM forms (with less than three missing items; see
Evans et al., 2002) were completed by 2,494 of the clients. Posttreatment
forms were completed by 73% (n ! 1,956) of the 2,690 clients for whom
endings were recorded as planned, whereas they were completed by only
8% (n ! 136) of the 1,693 clients for whom endings were recorded as
unplanned. The number of sessions attended (range ! 1–30) was recorded
for 1,911 of the 1,956 clients with planned endings who competed reliable
pre- and posttherapy forms. Most of these 1,911 clients attended 12 or
fewer sessions, and we restricted our attention to this group (N ! 1,868).
Women accounted for 73.1% (n ! 1,365) of the 1,868 clients in our
study, and the age range was from 12 to 86 years with a mean of 40.0 years
(Mdn ! 39, SD ! 12.8). Ethnic origin was available for 96% (n ! 1,790)
of the sample, and of these 92.4% were White Europeans, 3.8% were
Asian, 2.0% were African–Caribbean, and 1.8% were mixed race.
The presenting problem was recorded for 98.0% of the clients by the
therapist, using the CORE Assessment form (Barkham et al., 2005; Mellor-
Clark & Barkham, 2006; Mellor-Clark, Barkham, Connell, & Evans,
1999). The majority of clients had anxiety (81.3%, n ! 1,519) and/or
depression (75.1%, n ! 1,403), and there was a wide range of additional
problems. The referral source was recorded for 94.6% (n ! 1,767) of the
clients, of whom 94.0% were from their general practitioner or primary
care practice. The therapeutic approach was recorded for 94.3% of the
sample (n ! 1,761), with the largest numbers having person-centered
(47.6%, n ! 839), integrative (42.6%, n ! 751), or cognitive– behavioral
therapy (22.3%, n ! 392), and with most (64.1%, n ! 1,129) indicating
more than one type of therapy. In 25 of the centers clients were routinely
offered 6 treatment sessions, though additional sessions could be negoti-
ated; in 7 additional centers, clients were routinely offered different fixed
numbers of sessions (from 2 to 10), though all such limits were adminis-
tered flexibly.
Outcome Measure
Previous articles have reported the CORE–OM’s rationale (Barkham et
al., 1998), development (Evans et al., 2000), psychometric properties
(Barkham et al., 2005; Evans et al., 2002), and clinical application
(Barkham et al., 2001; Evans, Connell, Barkham, Marshall, & Mellor-
Clark, 2003; Mellor-Clark, Connell, Barkham, & Cummins, 2001). Trans-
formation tables have been developed for converting CORE–OM scores
into Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Er-
baugh, 1961) scores and vice versa (Leach et al., in press). The CORE–OM
comprises 34 items addressing domains of subjective well-being, symp-
toms (anxiety, depression, physical problems, trauma), functioning (gen-
eral functioning, close relationships, social relationships), and risk (risk to
self, risk to others). Half the items focus on low-intensity problems (e.g.,
“I feel anxious/nervous”), and half focus on high-intensity problems (e.g.,
“I feel panic/terror”). Eight items are positively keyed. Items are scored on
a 5-point scale ranging from 0 (not at all) to 4 (all the time). CORE clinical
scores are computed as the mean of all completed items multiplied by 10
so that clinically meaningful differences are represented by whole num-
bers; thus, the clinical scores can range from 0 to 40 (Leach et al., in press).
Internal consistency reliability for the 34-item scale in clinical (n ! 713)
and nonclinical (n ! 1,009) samples was .94 and .94, respectively
(Barkham et al., 2001). Test–retest stability was .90 from a student sample
 RESPONSIVE REGULATION OF DOSE
(n ! 43) using a 1-week interval (Evans et al., 2002). The CORE–OM is
a copyleft measure, meaning that it is copyrighted but free for users to copy
providing no changes or financial gains are made.
Procedure
All centers in the study asked clients to complete the CORE–OM at
intake (i.e., before any intervention). In practice, the CORE–OM was
completed during screening or assessment by 73.8% of the clients and
immediately before the first therapy session by the remaining 26.2%.
Centers were instructed to give the posttherapy measure at the last session;
the timing and specific procedures for this were determined by what
worked best for each center administratively and were not recorded.
Therapists completed sections of the CORE Assessment form at intake and
at the end of therapy. Anonymized data were sent to the University of
Leeds for aggregation and analysis.
Results
The mean CORE clinical score was 17.9 (SD ! 6.5) at intake
and 8.4 (SD ! 6.1) at posttherapy (difference ! 9.5; 95% confi-
dence interval ! 9.1 to 9.7), yielding a pre–post effect size of 1.51.
RCSI
Following Jacobson and Truax (1991), we held that clients had
achieved RCSI if they entered treatment in a dysfunctional state
and left treatment in a nondysfunctional state, having changed to a
degree that was probably not due to measurement error. On the
basis of previous studies (Evans et al., 2002), we considered the
clinical cutoff on the CORE–OM, dividing the dysfunctional from
the normal populations, as 11.9 for men and 12.9 for women in
terms of CORE clinical scores. The reliable change index (a
pre–post difference that, when divided by the standard error of the
difference, is equal to 1.96; see Jacobson & Truax, 1991) for the
CORE–OM was 4.8 in this sample.
We classified clients’ outcomes into four categories: RCSI com-
prised clients whose pre–post scores met the criteria for both
reliable improvement (an improvement of 4.8 or more in the
CORE–OM clinical score) and also clinically significant improve-
ment (moving from above the clinical cutoff to below it); reliable
improvement only comprised clients who met the criterion of
reliable improvement but not clinically significant improvement;
no reliable change comprised those clients whose pre–post scores
did not meet criterion for reliable change; reliable deterioration
comprised those clients whose posttherapy scores were reliably
Table 1
Percentages of Clients With Planned Endings Meeting Criteria for Change
Change category
Reliable and clinically significant improvement
Reliable improvement
No reliable change
Reliable deterioration
Total
163
(more than 4.8 points) worse than their pretherapy CORE–OM
clinical score. Results are shown in Table 1.
Results were also summarized separately for clients who ini-
tially scored above and below the CORE–OM clinical cutoff (see
Table 1). Of the 1,868 clients, 1,472 (78.8%) were at or above the
cutoff and 396 (21.2%) were below the cutoff. When all clients
were considered, 56.5% met RCSI criteria, but when only those
clients initially scoring above the cutoff were considered, the
percentage of clients meeting the RCSI criteria rose to 71.7%.
Improvement Rates Session by Session
Table 2 shows the number of clients who achieved RCSI as a
function of the number of sessions they attended. It also describes
these clients both as a percentage of all clients who attended that
number of sessions (as some previous studies have done; see Gray,
2003; Hansen et al., 2002, 2003) and as a percentage of clients who
began treatment above the CORE–OM clinical cutoff. Of course,
the RCSI rate is lower when the below-cutoff clients are included
because, by definition, they could not achieve RCSI; we included
this analysis for comparability with previous studies.
The RCSI rates tended to stay roughly constant or decline across
number of sessions attended, depending on whether the rate was
calculated using all clients or only those who began treatment
above the cutoff. When all clients were considered, RCSI rates
tended to be similar across ending sessions (most rates were in the
50% to 60% range) and not significantly correlated with session
number (r ! ".46, p ! .135, n ! 12). Among clients who began
treatment above the cutoff, session number was strongly nega-
tively correlated with RCSI rates (r ! ".91, p % .0001, n ! 12).
That is, paradoxically, among clients who began above the cutoff,
those who attended fewer sessions tended to have higher RCSI
rates than did those who had more sessions. The magnitude of this
decline in rates across sessions was moderate, however, with a
range from 87.5% for those ending at Session 1 down to 61.7% for
those ending at Session 12. The relatively smaller (nonsignificant)
decline in RCSI rates in the full sample presumably reflected
differentially early termination by the clients who began below the
CORE–OM clinical cutoff, befitting their relatively lower initial
levels of distress.
Figure 2 depicts our results for clients who began above the
cutoff in terms of the GEL model. The endpoints of the dotted lines
represent observed percentages of clients meeting RCSI criteria
separately for groups who attended 1 to 12 sessions (shown in
Table 2). The dotted lines represent interpolated percentages, on
All clients with Above Below
planned endings clinical cutoff clinical cutoff
n % n % n %
1,056 56.5 1,056 71.7
345 18.5 171 11.6 174 43.9
442 23.7 229 15.6 213 53.8
25 1.3 16 1.1 9 2.3
1,868 100.0 1,472 100.0 396 100.0
164 BARKHAM ET AL.

Table 2
Rates of Reliable and Clinically Significant Improvement (RCSI) as a Function of Number of Sessions Attended, Based on All Clients
With Planned Endings and on Those Above Clinical Cutoff at Intake

Clients achieving RCSI

Clients above % clients above cutoff at intake predicted to
Sessions All clients cutoff at intake As % of all As % of clients above achieve RCSI after correcting for initial
attended (N) (n) n clients cutoff at intake severity

1 12 8 7 58.3 87.5 86.9

2 120 84 70 58.3 83.3 82.5
3 163 120 104 63.8 86.7 86.3
4 237 172 139 58.6 80.8 81.2
5 254 193 149 58.7 77.2 77.5
6 648 536 358 55.2 66.8 67.2
7 95 70 46 48.4 65.7 66.5
8 92 79 49 53.3 62.0 62.4
9 69 62 41 59.4 66.1 69.6
10 97 77 48 49.5 62.3 63.6
11 27 24 16 59.3 66.7 69.3
12 54 47 29 53.7 61.7 64.2
Total 1,868 1,472 1,056 56.5 71.7

the assumption of a linear progression in the percentage reaching
this standard. The solid line represents the estimated percentage of
the clients remaining in treatment at each session who met RCSI
criteria, calculated as the weighted average of the interpolated
percentages.2 That is, as before, points on the aggregate curve are
based on successively smaller groups of more slowly responding
clients.
The pattern depicted by the solid line in Figure 2 is not a tenet
of the GEL model. Instead, it is a demonstration of how aggregate
improvement rates may misleadingly appear negatively acceler-
ated even if the value of successive sessions to each individual
client tends to remain constant. The negative acceleration is a
by-product of a tendency for decisions to end treatment to be
responsive to clients’ differing rates of improvement.
Clients’ initial severity significantly predicted treatment length,
though the association was weak; pretreatment CORE–OM scores
were correlated with number of sessions attended among the
clients who were initially above the clinical cutoff (r ! .13, p %
.001, n ! 1,472) as well as in the full sample, where the range of
pretreatment CORE–OM scores was larger (r ! .15, p % .001, n !
1,868). This association is consistent with the GEL model in
suggesting that the more severely distressed clients tended respon-
sively to remain in treatment longer. Clients’ initial severity (pre-
treatment CORE–OM) was slightly negatively correlated with
their achievement of RCSI (dummy coded as 0 ! not achieved,
1 ! achieved) among clients who were initially above the cutoff
(r ! ".16, p % .001, n ! 1,472), suggesting that responsive
treatment was not entirely successful in overcoming the initial
differences. In the full sample, the correlation of initial severity
with achieving RCSI was, paradoxically, positive (r ! .33, p %
.001, n ! 1,868), reflecting the fact that none of the clients scoring
below the cutoff could achieve RCSI by definition. Finally, we
conducted a logistic regression in which the outcome variable was
RCSI and the predictors were number of sessions attended (coded
categorically) and intake CORE–OM scores. The rightmost col-

2
More formally, the dotted lines in Figure 2 represent the linearly
interpolated percentages, pij, at sessions i ! 1, 2, . . . j for clients who
terminated at session j. That is, pij ! (i/j)gj, where gj ! the observed RCSI
rate for clients who began treatment above the clinical cutoff and who had
j sessions (shown in Table 2). As in Figure 1, the solid line in Figure 2 was
Figure 2. Results plotted to compare with good enough level model. The
calculated as the weighted average of the interpolated percentages,
endpoints of the dotted lines represent observed percentages of groups of

! !
clients completing 1 to 12 sessions who began treatment above the clinical s s
cutoff on the CORE–OM and met reliable and clinically significant im- Pi ! # njpij$/# nj$,
provement (RCSI) criteria. The dotted lines represent interpolated percent- j!i j!i
ages at intermediate points for each group. The solid line represents the
estimated overall percentage of the clients remaining in who met RCSI where s is the number of sessions under consideration (i.e., s ! 12) and nj
criteria, calculated as the weighted average of the interpolated percentages is the number of clients who began above the clinical cutoff and who
for clients remaining in the pool at each session. attended exactly j sessions (see Table 2).
 RESPONSIVE REGULATION OF DOSE
umn in Table 2 reports, for each number of sessions, the predicted
RCSI rate for clients of average initial severity (i.e., as if there
were no relationship between initial severity and number of ses-
sions). This correction made little difference in the pattern of
results.
Discussion
Our finding that the percentage of clients showing improvement
stayed constant or declined as a function of the number of sessions
is consistent with—though it does not prove—the GEL model’s
suggestion that participants tend to end therapy when a satisfactory
level of gains have been achieved. It seems contrary to the sug-
gestion that the dose– effect curve for psychotherapy is a nega-
tively accelerating function of the number of sessions (Howard et
al., 1986; Kopta, 2003; Kopta et al., 1994). The GEL level implied
by our results was such that an average of 71.7% of the 1,442
clients who entered therapy above the clinical cutoff on the
CORE–OM, had a planned ending, and completed posttreatment
forms achieved RCSI. When this group was diluted with the 396
clients who entered below the cutoff (and hence could not move
from the clinical to the nonclinical populations), the RCSI rate fell
to 56.5%. We hasten to acknowledge that our results cannot be
generalized to the sizable number of clients in routine practice who
do not complete postsession forms, who leave treatment before
their planned ending, or who have treatments longer than 12
sessions.
Interpreting a dose– effect curve as applying to individual psy-
chotherapy clients (e.g., Kopta, 2003; Kopta et al., 1994) resem-
bles the concept’s use in medicine, where the dose response is the
physiological response observed when otherwise equal individuals
are given differing amounts of a compound. Too low a dose is
typically ineffective; in some middle range (sometimes called the
therapeutic window), effectiveness increases rapidly with dose;
and at some higher point, increasing the dose starts to be toxic. Of
course, individuals are not equal either in medical contexts or—as
our data show—in psychotherapy.
An alternative, population interpretation is offered by the dose–
effect methodology in agriculture, applied, for example, to the
effectiveness of insecticides. In that context, the sigmoid shape of
the dose– effect curve documents little effect from the poison at
very low doses, followed by a range of doses at which the effect
rapidly increases, until a point of diminishing effect is reached,
where only the very hardy or resistant insects remain alive. Ap-
plied to psychotherapy, this population interpretation does not
suggest that increasing doses lose potency—for example, that the
10th session tends to be less powerful than the 2nd— but instead
that the easy-to-treat clients have responded by the 10th session, so
only the hard-to-treat or resistant remain. This population inter-
pretation is actually consistent with the distribution of clients
ending treatment at each numbered session (columns 2 and 3 in
Table 2, or, if response is understood as achieving RCSI, then
column 4)—relatively few for whom low doses were sufficient or
for whom high doses were needed, with the most clients achieving
this desired effect with a midrange number of sessions.
The GEL model’s suggestion that treatment ends when accept-
able improvement is achieved could be construed as an individual
implication of the population interpretation. If different clients
require different numbers of sessions, individual clients must
165
achieve this acceptable effect at different times. The GEL is a way
of naming or characterizing what effect is acceptable. The model
does not specify how the decision to end treatment is made; it may
or may not involve the therapist and may not even be deliberate or
conscious.
The moderate but highly reliable decline in RCSI rates across
sessions among clients who began above the clinical cutoff (see
Table 2 and Figure 2) suggests a plausible elaboration of the
original GEL model: A client’s GEL factors in costs. As one
consequence, rather than being constant across all sessions, pro-
gressively lesser gains become acceptable (good enough) as treat-
ment takes longer. That is, clients and therapists may tend to be
satisfied with somewhat less as more time and effort are required.
This elaboration resolves the previously reported paradox that
spending more months in therapy predicts poorer outcomes (Rear-
don, Cukrowicz, Reeves, & Joiner, 2002). The GEL model sug-
gests that it would be fruitful to investigate the bases upon which
termination decisions are reached in routine practice.
One cost that might contribute to a declining GEL could be
formal and informal limits on number of sessions offered. The dip
in RCSI rates among clients in our study who attended seven or
more sessions (see Table 2 and Figure 2) may reflect the practice
of offering clients only six sessions at the majority of the NHS
sites. There was a prominent mode of 648 clients completing
exactly six sessions (see Table 2). Presumably, clients who re-
mained beyond six sessions were judged more seriously disturbed
and needful of additional treatment, and the jointly determined
GEL tended to be lower. The RCSI rate for six sessions was in line
with the general trend, consistent with suggestions that clients and
therapists may have adjusted their behaviors in sessions to allow
for time constraints (Eckert, 1993; Reynolds et al., 1996) or
availed themselves of flexibility to continue beyond the nominal
limits.
Our results suggest that previous reports of negatively acceler-
ated individual dose– effect curves for psychotherapy could have
reflected the effects of the more quickly improving clients’ selec-
tively leaving the sample. The solid lines in Figures 1 and 2
illustrate this possibility. Of course, our session-by-session de-
scriptions (see Table 2) also reflect grouped data. The support for
the GEL model is indirect and probabilistic. Even our data show
the importance of individual variation, as illustrated by the fact that
not every completed therapy met RCSI criteria. Different clients
may have different GELs, because of their personal characteristics,
therapists, mode of treatment, or circumstances, and not all GELs
result in meeting RCSI criteria. The very modest positive correla-
tion of initial severity with number of sessions attended is consis-
tent with this suggestion that symptom intensity is only one of
many factors that affect the GEL. Some clients may leave treat-
ment before they achieve all they wish, and in this sense, some
probabilistic level of frustration and disappointment is incorpo-
rated into (and lowers) their GEL. For many reasons, then, some
clients who ended treatment unilaterally (recorded as unplanned in
our data) may have had a GEL lower than that of their therapist.
There is evidence that the clients who complete posttreatment
measures tend to have improved more than clients who fail to
complete them (Stiles et al., 2003), and presumably this would also
be the case for clients with unplanned endings (a substantially
overlapping group). Probably, therefore, the overall estimated
GEL would have been lower if we could have included clients who
166 BARKHAM ET AL.
failed to complete the posttreatment CORE–OM or who ended
treatment prematurely. In the same vein, the average pre–post
treatment effect size of 1.51 standard deviation units might have
been lower if all clients had completed posttreatment measures.
Whether clients who fail to complete standard posttreatment mea-
sures would conform to the GEL model (i.e., with a lower
GEL)— or to alternative dose– effect models—is an important
question for future research but a difficult one. In routine practice
settings, persistent follow-up procedures could impose on the
privacy of the clients who chose to end contact. An alternative
strategy of recruiting clients for controlled trials may systemati-
cally eliminate precisely those clients who would have failed to
complete postsession measures.
From a scientific perspective, it may seem obvious and trivial
that RCSI rates increased (from 57% to 72%) when clients who
started below the clinical cutoff were excluded. We reported
results calculated both ways mainly to make this point, as a
corrective to previous studies in which the point has been over-
looked (see Gray, 2003; Hansen et al., 2002, 2003). From an
administrative perspective, it could be argued that services offered
to people starting below the cutoff absorb resources, so such cases
should be included in a center’s aggregate improvement rates. This
raises the question of whether they should have been offered
therapy in the first place. On the other hand, there may be impor-
tant reasons to treat such clients, for example, problems that are
not manifested as distress as measured by conventional self-report
forms. Relief from even subclinical levels of distress can have
substantial personal, social, and economic impacts (e.g., Judd,
Paulus, Well, & Rapaport, 1996). In this connection, we note that,
in our sample, 43.9% of clients who began below the clinical
cutoff did show reliable improvement (see Table 1).
A clinical implication of the GEL model is that participants have
and responsively use information about the amount of therapy that
clients need in deciding when to end therapy (cf. Stiles et al.,
1998). For some clients, treatments as short as two or three
sessions may yield clinically significant gains (cf. Barkham, Sha-
piro, Hardy, & Rees, 1999), and for others time limits may be an
effective means of accelerating progress (cf. Eckert, 1993). On the
other hand, our results suggest that there are large individual
differences in how quickly clients’ problems respond to treatment,
so that imposing standardized limits across clients may be inap-
propriate. These findings, therefore, have particular relevance in a
climate in which limited and finite resources tempt administrators
and policymakers to impose fixed durations of treatment.
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Received October 8, 2004
Revision received August 16, 2005
Accepted September 12, 2005 !