What's New at CBH
Measuring Therapy Progress, Effectiveness and Outcomes
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.
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.
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.