The Fifty Minute Hour

Thoughts on therapy and life

Can you measure what therapists do?

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measure successWell, that’s a tricky question; just asking it can be enough to divide a room of therapists.  Added to which, there are many different types of therapy, psychoanalysis is maybe slightly out of favour, considered old fashioned and self indulgent, whilst Cognitive Behavioural Therapy (CBT) leads the developing field of new therapies promising effective short term results.  It appears foolhardy to attempt to classify results from different models using a single measure, yet without such a measure how can you compare modalities?

Looking within a single therapeutic style scarcely helps either – what we do in the therapy room regardless of orientation, cannot be done “by rote”, and each therapeutic relationship is different precisely because the therapist and client involved are unique individuals. Whilst there is general agreement that it is the relationship itself which is a large part of the healing (or not), this relationship is entirely subjective and difficult to measure.

Looked at like this, you can begin to see why some branches of the therapy professions are wholly opposed to measurement at all, believing that tick boxes and statistics cannot begin to covey the complexity of what we do, and what our clients experience. We point to the NHS and the accusations of patient care being sacrificed to paperwork, nurses at computers rather than the bedside and catastrophise that our profession will go that way  too if we are not vigilant against this culture of “measurement”.

But I’m not so sure…..don’t get me wrong, I’m not suggesting that therapist league tables are the way forward, but let’s think for a moment about the individual looking for a therapist to start working with. Any self respecting therapist will highlight their professional body and registration in their promotional material and this should definitely be the point at which to cull those who do not. But from this point on all you really have is perhaps a website, hopefully with a photo and a “gut feel” about how the therapist looks before you book an assessment. The assessment itself is crucial, if you don’t feel right with the person opposite you, then simply say “no thank you” and keep looking. If you are worried about the therapist’s experience then asking how many “client hours” they have (1,515 thanks for asking) is also a better indication of experience than years in the job.

Any one who doesn’t have access to this kind of information isn’t keeping any basic figures, which I find surprising. Because, in any profession the basis of getting better is surely by knowing how we are doing? Now obviously I know when a session has gone well or when it has gone badly, but I also want a more substantial record then my subjective experience. So, when I started my practice I started keeping basic records, which now tell me the following.

Results

To start with you probably won’t be surprised to hear that the majority of my clients are female with a 68% – 32% gender split in that favour, something I imagine is replicated by other therapists, particularly female ones. And if we are looking at the make up of my practice then I can tell you that my clients have ranged in age from 17 to 78, but that the average age is 37.

Clients often ask at the assessment session “how long will it take” and whilst I can’t ever answer that, I work on the basis that 6 sessions is generally a good point to asses how it is for you – and in fact 61% of my clients have 6 or more sessions. That’s not to say that therapy with me is endlessly ongoing, whilst I enjoy working with long term clients, 76% of clients see me for 12 or less sessions, what generally passes for “short term” work.

What are the reasons clients come to see me? Well, anxiety and relationship problems are currently the main difficulties, with depression not far behind. Again, I suspect this replicates most other therapist’s client breakdown as anxiety and depression account for the biggest amount of mental dis-ease nationally.

So, onto the nitty-gritty, how do I measure success? Well, there are two ways of doing this I think.

The first is a broad bush measure of ending type. Ideally, therapy ends when it feels right to, and in agreement with, both client and therapist. Part of the work, is leading towards the ending, and I categorise my endings as “Planned” when they as described above, and “Unplanned” when the client votes with their feet and stops turning up or sends an email explaining why they can’t carry on. Interestingly, the highest number of unplanned endings occur before the 6 session mark.  81% of clients, who have 6 or more sessions, go onto have a planned ending.

The other way is slightly more scientific; I use the CORE outcome measures also used in various NHS and private treatment centres. This is a simple list of 34 statements with differing levels of agreement for clients to choose from. I ask clients to complete one of these at the beginning, and again at the end of therapy. It doesn’t direct or affect the therapy, but provides an objective view of overall mood, symptoms, day to day functioning and risk level. A scoring system allows me to see if the difference in scores at the start and end of therapy represent a “reliable change” i.e. greater improvement than would be expected without any therapy.

My current figures are

No benefit from therapy 14%

Reliable change after therapy 86%

Not dissimilar from the Planned/Unplanned ending measure, perhaps the slightly higher score suggesting that some people derive benefit from therapy, but hate goodbyes?

I really do want to make the point that of course my own internal reaction to and experience of each client I work with, is a much stronger indication of how I feel I am as a therapist. But that’s not always easy to convey and if you’re thinking of therapy with me, I hope what I’ve written here gives a more objective indication.

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Author: Johanna Sartori BA MBACP Accred.

Finding my way through life, and travelling with those on the same journey

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