Friday, December 23, 2011

"Measuring" Progress in Therapy

I met with a client's parents today, and was slightly taken aback when the father pulled out a rather elaborate, multi-variable observation plan that he hoped to use to quantify his daughter's progress in treatment. Like many clients and their families, he feels frustrated that mental health care isn't more like other medical care - that we can't run tests and get a definitive diagnosis, nor can we then run more tests to demonstrate a measurable response to treatment. Insurance companies share the idea that a medical model should apply to mental health, and want concrete, observable, measurable treatment goals that demonstrate response to treatment (or lack thereof). However, this desire for black-and-white certainty runs counter to the organic, non-linear process of diagnosis and treatment in mental health treatment.

The challenge for providers is to find a meaningful way to recognize progress, without trying to impose a system of "measuring" or quantifying progress that oversimplifies or runs counter to the therapeutic process.

An example of oversimplifying would be considering complete abstinence the only meaningful measure of recovery from an addiction. In reality, relapse is an expected part of the recovery process for most people, and does not necessarily indicate an absence of progress, or a return to square 1, because the relapse may bring a new level of insight, allow underlying issues to be further integrated, and ultimately result in a new level of mastery over the addiction.

An example of measurement running counter to the therapeutic process would be asking someone to monitor/track their anxiety-related thoughts. To track anxiety thoughts, you have to think about having the thoughts. In other words, the process of self-monitoring actually increases the thoughts we want to decrease. Similarly, trying not to think about something also ends up triggering the thoughts you hope to avoid. In both cases, trying to quantify progress actually causes the symptom treatment is trying to reduce.

So, what is the alternative? How do we help ourselves, our clients, and insurance companies recognize real progress, or the lack thereof?

I think about it from two perspectives. First, I invite the client to imagine and describe their desired end result (e.g., the Miracle Question from Solution Focused Brief Treatment) - both because desired outcomes differ from person to person, and because getting specific about the end result offers insights into what changes need to happen, and what signs to look for to see progress occurring. That leads into the second perspective: looking - carefully and consistently - for incremental (minuscule, even) signs of change.

I look for tiny signs of change, for the better or for the worse, in any facet of functioning: cognitive (e.g., insight, thought process or content, concentration), emotional (e.g., type, intensity, range, appropriateness), social (e.g., isolation, communication), behavioral (e.g., frequency of adaptive and maladaptive behavior), occupational (e.g., academic, work, or volunteer role functioning). It takes careful listening and attention to detail to notice the little changes, little successes or experimentation with new responses...but I see the art of noticing and calling attention to these changes to be a vital aspect of my role as a therapist, because people often don't recognize small changes, but seeing progress, however small, can make or break one's motivation to keep going.

How do you think about/define progress in your work?

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