By Randy Walton, Ph.D.
Why measure therapy outcomes? There are a variety of answers to this question, but if you are a person seeking therapy or counseling the answer is “so you and your therapist know if the therapy is helping”. Tracking progress or outcomes in therapy helps you determine whether to continue spending your time, effort, and money on the process or to try something or someone different.
For decades the measurement of therapy outcomes has primarily been the focus of researchers, not therapists. These researchers have typically focused on identifying which therapy approaches are better than others at effectively treating particular problems. However, analysis of this research shows that no particular approach to therapy is consistently better than another, and no particular therapy approach is effective with everyone with a particular type of problem (1, 2). This conclusion is true for many activities, from particular teaching methods, to specific medications, to child-rearing methods, to economic policies; there is not one approach that works in all situations for all people.
However, one positive result of the therapy outcome research is the consistent finding that therapy works! The average person who participates in therapy is significantly better off than people with similar problems who do not engage in therapy (3, 4). This contrasts with popular opinions which found that 76% of potential consumers of therapy services identified low confidence in the outcome of therapy as the major reason for not seeking treatment, far more than other factors traditionally thought to deter people from seeing a therapist, e.g. stigma, 53%; length of treatment, 59%; lack of knowledge, 47% (5).
Consequently, the research evidence that therapy in general is effective is good to know if you are considering therapy – if there was no evidence that the activity helps, why bother? However, having outcome research that demonstrates the general effectiveness of therapy is only a start. It does not let you know whether therapy will help you specifically. This is where measuring therapy progress and outcomes while you are engaged in therapy can be helpful.
In recent years tracking progress for individuals in therapy has started to become more commonplace, but it is by no means a standard practice. Therapy has often been considered a mysterious, emotional, intuitive, and powerful process that is difficult to quantify. These conceptions of therapy can all be true, but they do not and should not preclude simple, useful efforts to measure or track your progress in therapy. You do not have to fully understand the process of therapy to determine if it is helping, any more than you have to understand the process of how a blood pressure medication works to determine if it is working for you. You simply find an appropriate way to measure the effectiveness of the treatment.
In therapy, measuring progress, effectiveness, or outcomes, and using the information to help guide or adjust treatment, has been shown to significantly improve therapy outcomes (6, 7). Measuring progress or effectiveness during the course of therapy allows a client and therapist to discuss what seems to be working, what doesn’t seem to be working, and any need for adjustments to the treatment (e.g., different approach, different focus, different therapist, or even an intervention other than therapy) if it is not helping. Measuring progress, effectiveness, and outcomes also helps determine when therapy is done, i.e., when a person has achieved what they wanted from therapy and the treatment can end.
Measuring the progress or effectiveness of therapy as it occurs also makes it less likely that people will waste time, money, and energy on something that is not helping. For example, research indicates that early improvement in therapy is predictive of a positive outcome (8, 9). If a person is not experiencing significant improvement within the first 4-6 sessions, research suggests that it is unlikely that significant improvement will be experienced later in treatment (unless there are significant changes in therapy approach/strategies). Consequently, tracking therapy progress and outcomes right from the start allows the client and the therapist to either continue an approach that is helping, or make changes to an approach that is not helping.
There are many ways in which progress or effectiveness of therapy can be measured. For many years the most common approach, which continues to be useful, was to have a written treatment plan which includes clear goals and objectives identified by the client. These goals and objectives are discussed throughout the course of therapy to determine progress and completion of treatment. More recently various outcome scales and checklists have been developed to track therapy progress, effectiveness, and outcomes in an even more quantitative and concrete manner. These measures range from brief (e.g., one to two minutes) rating scales completed by a client every session (such as those used in Colonial Behavioral Health Outpatient therapy services), to much more comprehensive and lengthy measures incorporating both client and therapist perspectives which can take 20 minutes or more to complete at various intervals throughout treatment.
Any approach to measuring therapy progress, effectiveness, and outcomes is not likely to be appropriate for all people in all situations. However, as a client or consumer of therapy services, it is reasonable and sensible to expect that the progress, effectiveness, and outcome of your therapy should be measured in one way or another, and discussed throughout the course of treatment. Just as with teaching methods, medications, child-rearing methods, and economic policies, general claims and testimonials about therapy or therapist effectiveness are a helpful start, but not sufficient. The proof of effectiveness is in the measured outcomes, e.g., student test scores, lowered blood pressure, or in the case of therapy, concrete measures of progress, effectiveness, and outcome.
Randy Walton, Ph.D., is a Licensed Clinical Psychologist who works full-time as Lead Clinician at Colonial Behavioral Health, and conducts a part-time private practice (http://www.williamsburgpsychologist.com/) in the Williamsburg, Virginia area. He has been in full-time clinical practice for over 25 years
References
1. Miller, S., Wampold, B. and Varhely, K. (2008). Direct comparisons of treatment modalities for youth disorders: A meta-analysis. Psychotherapy Research. 18 (1).
2. Imel, Z. Wampold, B., Miller, S., and Fleming, R. (2008) Distinctions without a difference: Direct comparisons of psychotherapies for alcohol use disorders. Psychology of Addictive Behaviors. 22 (4).
3. Asay, T.P., & Lambert, M.J. (1999). The empirical case for the common factors in therapy: Quantitative findings. In M.A. Hubble, B.L. Duncan, and S.D. Miller (eds.). The Heart and Soul of Change: What Works in Therapy. Washington, D.C.: APA Press, 33-56.
4. Wampold, B.E. (2001). The Great Psychotherapy Debate: Models, Methods, and Findings. Hillsdale, New Jersey: Lawrence Erlbaum.
5. American Psychological Association. (1998). Communicating the value of psychology to the public. Washington, D.C.: American Psychological Association.
6. Brown, J., Dreis, S., & Nace, D.K. (1999). What really makes a difference in psychotherapy outcome? Why does managed care want to know? In M.A. Hubble, B.L. Duncan, and S.D. Miller (eds.). The Heart and Soul of Change: What Works in Therapy (pp. 389-406). Washington, D.C.: APA Press.
7. Duncan, M., and Miller, S. (2000). The Heroic Client: Principles of Client-directed, Outcome-Informed Therapy. San Francisco, CA: Jossey-Bass.
8. Brown. J, Dreis, S., and Nace, D. (1999). What really makes a difference in psychotherapy outcome? Why does managed care want to know? In M. Hubble, B. Duncan, and S. Miller (eds.) The Heart and Soul of Change: What Works in Therapy. (pp. 389-406). Washington, D.C.: APA Press.
9. Howard, K., Moras, K., Brill, P., Martinovich, Z., and Lutz,W. (1996). Evaluation of psychotherapy: Efficacy, effectiveness, and patient progress. American Psychologist, 51.
Kaveh entered Loyola College on a premed track, but his father, a doctor in Iran, noticed his son’s interest in social sciences and encouraged him to explore a career in public health. Kaveh began his M.P.H. at Yale in 1987 when the AIDS epidemic was news around the world. After volunteering for AIDS Project New Haven, Kaveh teamed up with Jon Parker, a former drug user, who led many radical AIDS prevention efforts in New Haven – including distributing clean needle to drug users - at that time considered an act of civil disobedience. Parker later became a Yale School of Public Health graduate. “Parker connected with people at a human level. It was an unorthodox approach that was very different than what I was learning in school,” explains Kaveh.