EVALUATING THERAPY OUTCOMES
Outcome research refers to whether the client is experiencing change. More specifically, it examines whether the client is benefiting from therapy. Kenneth Howard is a pioneer in outcome research, particularly through his dosage model of psychotherapeutic effectiveness (Howard, Kopte, Krause & Orlinsky, 1986; Howard, Lueger, Maling, & Martinovich, 1993; Howard et al., 1996). His research exposed the relationship between the number of sessions and probability of client improvement (e.g., most change takes places earlier in treatment rather than later), and articulated three phases of treatment: (1) remoralization (giving clients hope when they feel demoralized); (2) remediation (bring relief of client’s symptoms); and (3) rehabilitation (unlearning maladaptive coping strategies). Howard’s research helped make the therapy process more transparent, which provided a window into client change and sparked other groundbreaking research in this area (Lebow, 2006).
Lambert et al. (2001) determined when client-focused feedback was provided to therapists, alerting them of potential treatment failure with at-risk clients, outcomes improved. The idea of client-focused feedback is consistent with Howard’s idea of measuring how clients are doing while we’re working with them in order to tailor our work to their needs. We can continue what’s working well and modify our approach when treatment is stagnant or potentially making things worse.
How does a therapist receive client-focused feedback? Standardized scales can be used to track client change. The data is immediately available to clinicians. Lambert and Shimokawa (2011) explain the basic rationale behind collecting client feedback:
If we get information about what seems to be working, and more importantly what is not working, our responsiveness to clients will improve. In many situations, performance and feedback are intertwined and obvious; in others, a certain degree of blinding occurs, such that the association is not so temporally connected and the effects of performance are harder to discern (such as in psychotherapy), making it much more difficult for the therapist to learn and improve. (p. 72)
Some therapists have an overly optimistic view of client progress, overlook negative changes, and are not particularly successful at predicting treatment outcome (Lambert & Shimokawa, 2011). These trends that mostly come from research with experienced therapists in private practice and advanced students may not be consistent for beginning master’s therapists, who tend to be overly self-critical and sometimes perseverate on negative changes. However, the research in this area is making an important point: Therapists often don’t really know how their clients are progressing; it’s often left to intuition. Data helps makes therapy progress more transparent.
Michael Lambert at Brigham Young University and his colleagues have done extensive research on tracking client outcomes in psychotherapy. They developed the OQ-A, a computer-based feedback system for monitoring and enhancing treatment effectiveness. The system helps therapists determine if their clients are staying on track toward positive treatment outcomes and helps them get their clients back on track if treatment is not progressing effectively. The implementation of the system is modified depending on the progress of the client. Part of the system is only used when clients are showing a lack of progress in therapy.
The Outcome Questionnaire–45 (OQ-45; Lambert et al., 2004) is a 45-item self-report measure for adult clients that can be given at the beginning of sessions and at termination. The system is set up to be computer-based in order to generate reports for the therapist, but you could use a hardcopy version to simplify. It measures three areas of client functioning: (1) symptoms of psychological disturbance; (2) interpersonal problems; and (3) social role functioning. Higher scores suggest greater levels of disturbance. While therapists can access similar information with other assessment instruments like the Beck Depression Inventory, the PHQ-9, the Family Assessment Device, and/or the Dyadic Adjustment Scale, the OQ-45 allows therapists to assess multiple areas with one questionnaire. Repeated administration allows therapists to track change over time. The results provide a “mental health vital sign,” including the ability to predict treatment failure based on pretreatment distress scores (Lambert & Shimokawa, 2011).
A child and youth version, the Youth Outcome Questionnaire (Y-OQ), is also available. The Y-OQ is a 64-item instrument completed by the parent or guardian as a measure of treatment progress for children and youth ages 4–17 (Burlingame, Wells, Lambert, & Cox, 2004). The 64 items include six separate subscales: interpersonal distress, somatic, interpersonal relationships, critical items, social problems, and behavioral dysfunction. The primary goal of the Y-OQ is to track changes in functioning.
After clients complete the OQ-45 or Y-OQ, they may be prompted to complete another questionnaire, the Assessment for Signal Cases (ASC; Lambert et al., 2007), if they are not making expected gains and are at risk for a poor outcome. The ASC is a 40-item measure that generates data about problems in the therapy when a client is not making progress or is worsening. The ASC measures therapy alliance, negative life events, social support outside of therapy, and motivation. The ASC directs a therapist’s attention to problematic areas to help make necessary treatment decisions. For example, a medication referral may be necessary if the client is working hard in therapy but getting worse. Or, the therapist might learn that she needs to use a more structured form of therapy (Rousmaniere, 2013).
Similar to Lambert and his colleagues, Scott Miller, Barry Duncan, and their colleagues have been advocating for therapist knowledge about progress in therapy. Rather than guessing that therapy is effective, they’ve been encouraging therapists to measure outcomes from session to session by using standardized outcomes measurement tools to learn what’s working and not working in therapy (Duncan, Miller, & Sparks, 2004). Their concerns about the time commitment in completing and analyzing the most frequently used instruments led them to create brief instruments that could be quickly completed, analyzed, and discussed with clients.
Miller, Duncan, Sorrell, and Brown’s (2005) Partners for Change Outcome Management System (PCOMS) includes two brief scales (four items each) that a client completes and reviews with the therapist during the session. The Session Rating Scale (SRS) was described in our earlier discussion about alliance. The Outcome Rating Scale (ORS; Miller, Duncan, Brown, Sparks, & Claud, 2003) is a four-item scale designed to assess areas of life functioning known to change as a result of therapeutic intervention. At the beginning of the session, a client is asked to quietly complete the ORS, which gives a snapshot of how the client is doing on a scale of 1–10 at that moment in time in three areas over the past week: individually, interpersonally (family), and socially (work, school, friendships). In addition, the client is asked to evaluate how he or she is doing overall (general well-being). The scale is scored immediately. Once a score is determined, the score can be easily placed on a graph to track progress from session to session. When the therapist and client are able to see which of the three areas receives the lowest scores, it can sometimes help determine areas that need immediate attention.
In comparison to Lambert’s Q-A computer-based system, the ORS doesn’t provide as much detailed information about a client’s functioning. However, the simplicity and brevity of the instrument and the ability to process the information in session with the client increases the likelihood that therapists will integrate client feedback into their work. The ORS, along with the SRS, are available in multiple languages at http://scottdmiller.com/performance-metrics.
CASE EXAMPLE
The following case illustrates how one therapist integrated the ORS into her work with a couple. Allen, a 69-year-old veteran, came to therapy with his wife, Frances, who was 63 and also a veteran. The couple was referred to therapy by Allen’s individual therapist because Allen complained his wife seemed unhappy in the marriage. He expressed confusion as to why she was unhappy, and indicated that he was content in the marriage. At the beginning of the second session, the therapist (Mandy) gave both partners the ORS to complete. The different levels of satisfaction with the marriage were clearly evident on the ORS. On the interpersonal scale, Allen scored a 9.5 while Frances scored a 2.5.
Mandy continued to have Allen and Frances take a couple of minutes at the beginning of each session to complete the ORS. She found this helpful in tracking how things were going in their individual lives and in their relationship. The ORS scores for both partners plotted over time (see Figure 18.1) reflected what happened over the course of therapy. As Frances began to express her dissatisfactions with the marriage and request changes in therapy, Allen would become upset. Not surprisingly, his scores on the interpersonal scale dipped as the initial work of therapy began. While Mandy encouraged Frances to articulate her concerns so that things could improve, she also tried to support Allen by acknowledging how difficult it must be to hear how unhappy his wife was with him. Mandy helped the couple negotiate some behavioral changes that Frances requested, which Allen was willing and capable of doing (e.g., more participation in household chores). As Allen made these changes, Frances’s scores on the interpersonal and overall scales improved dramatically. Allen’s scores on the interpersonal scale did not rebound initially, but his scores eventually returned to their initially high level once he grew accustomed to the new responsibilities and saw how much happier his wife was with the changes that had been made. Allen liked that Frances had become much less irritable with him.
Mandy also found the ORS scores helpful in monitoring how stressful events in Allen’s life were impacting him. On the initial ORS, Mandy noted that Allen scored a 1.5 on the social scale, which he attributed to stressors he was experiencing in his volunteer work where he had primary responsibility for an upcoming event. Successfully getting through this event and retiring from this volunteer position eventually led to improvement in his social scale scores. Stress in this and other areas led to many ups and downs in terms of Allen’s well-being scores. A health scare in the week prior to the eighth session resulted in Allen’s overall score dipping to a low of 1.5. Thankfully the health issue was resolved, and his scores rebounded. A portion of therapy was devoted to discussing these stressful events in his life, including one individual session when Frances was out of town. This helped Allen feel supported by the therapist. In addition, it was indirectly beneficial to Frances, who reported that his stress negatively impacted her because she would worry about him.
CLIENT-FOCUSED PROGRESS RESEARCH FOR FAMILY THERAPISTS
To this point, much of the client-focused feedback we’ve discussed has been mostly relevant for individual therapy. Although the measures described above can be applied to family therapy work as shown in the example above, William Pinsof and his colleagues specifically designed the Systemic Therapy Inventory of Change (STIC) to help therapists who work with couples and families (Breunlin, Pinsof, & Russell, 2011; Pinsof et al., 2009). The STIC is the first measurement system designed to track change in family and couple therapy and has five scales for assessing five areas in a family system: Individual Problems and Strengths, Family of Origin, Relationship with Partner, Family/Household, and Child Problems and Strengths (Pinsof et al., 2009). It generates self-report, web-based feedback about initial client concerns, tracks change from session to session, and provides information about the therapeutic alliance over the course of therapy.
The measurement system has three distinct instruments: (1) The Initial STIC, which is a lengthy instrument administered to clients before the beginning of therapy, including demographic information; (2) the Intersession STIC, which is a much briefer instrument given to clients before each session; and (3) the Short Form Integrative Psychotherapy Alliance Scales, which are administered along with the Intersession STIC. Friedlander (2009) describes the power of the STIC:
The beauty of the system is that it allows predictions to be tested about how change in one domain may be related to change in another. Does a decrease in couples’ conflict, for example, predict improved child behavior, even when only the partners take part in treatment? (p.130)
The STIC can test a multitude of other hypotheses: Does a reduction in depressive symptoms help reduce marital distress? Does a strong therapy alliance with an adolescent girl help facilitate change between the adolescent and her mother? Does therapy with a particular part of the family, or the use of a particular model of therapy (e.g., narrative therapy), have an impact on change in the family? STIC data are stored on a secure website and includes bar graphs with initial scores and change profiles on the scales over the course of therapy. Therapists can view the data prior to a session and also review the data with clients during a session.
There are valid concerns about using an instrument like the STIC, such as the time commitment for completion between sessions for therapists and clients. How can therapists and clients stay committed to the system over time? A bigger concern for independent practitioners is the financial cost associated with purchasing and maintaining the system. Eventually, the STIC, or data systems like the STIC, will be readily accessible and affordable. Currently, the Family Institute at Northwestern is offering the STIC at a nominal cost to all mental health training programs. For programs interested in a valid feedback mechanism, the STIC would be an invaluable training tool to give trainees immediate feedback on their progress with couples and families, which could be brought into clinical supervision for review and discussion.
CONCLUSION
In this chapter, we have reviewed a range of instruments that provide feedback to therapists to monitor a client or family’s response to therapy and satisfaction with the therapy relationship. Research has shown that this kind of feedback to therapists likely improves outcomes, particularly for clients at risk for therapy dropout (Lambert & Shimokawa, 2011). Although some of these tools are lengthy and costly (e.g., OQ; STIC), they provide a wealth of information at the beginning of treatment and enable a therapist to clearly track progress over time. Other tools (e.g., ORS, SRS) are quite brief and take only a few minutes to complete in session; these tools can be integrated into one’s work immediately.
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