Introduction to the Series on Improving Effectiveness in Psychotherapy
This fall (2014) I gave a presentation on improving effectiveness in psychotherapy. Preparing for this presentation forced me to think, read, and examine research and theory on what has been shown to make therapy effective. In the series of upcoming blog entries I will highlight what I learned from preparing for, giving and reflecting on this presentation. While some of what I discovered was not surprising, other findings were more unsettling. Perhaps most unsettling is how we as therapists, advocates of change, are resistant to changing our own practice. Even when data clearly supports the use of specific interventions and strategies we are often likely to be resistant to adopt them, even in the face of compelling evidence that argues for their adoption. If it is any compensation, we are far from the only ones struggling with this dilemma. Physicians have been shown to be slow to adopt changes in practice (examples include the treatment of heart disease and breast cancer*) despite clear evidence supporting changes in practice/treatment strategies.
In this series of blog entries I will discuss what I have learned about improving effectiveness. I also hope to elucidate some strategies to help us all change our ways of practicing when the evidence clearly supports such change. As I have examined the issue of improving effectiveness I have increasingly come to believe that we not only need to attend to how we can improve our effectiveness as clinicians, but to how we can overcome resistance to change (or our tendency to do what we always have done). Scott Miller and his colleagues have focused on these issues and I want to stress that my thinking is influenced by their work and thinking about these issues.
* http://www.creators.com/health/david-lipschitz-lifelong-health/practice-is-slow-to-change-despite-clear-evidence.html and http://www.npr.org/blogs/health/2014/12/08/369346049/doctors-are-slow-to-adopt-changes-in-breast-cancer-treatment
Improving Effectiveness Series: What is Effectiveness:
Second Article in the Series Improving Effectiveness in Psychotherapy
Improving Effectiveness: What is Effectiveness?/improvingeffectivenessblog
The First Question: How do we define effectiveness?:
When I began to delve into the issue of effectiveness the first question that came to mind was: how do we define effectiveness? This is not an idle questions by any means. Any clinician with more than a little experience working with insurance companies (particularly managed care companies) knows that “medical necessity” and demonstrating “benefit” from treatment are frequent requirements (for purposes of obtaining insurance reimbursement). Moreover, the changing economics of health care clearly seem to indicate that therapists will need to be placing far more emphasis on ”demonstrate value” (1) in order to be reimbursed for providing therapy.
Effectiveness is easier to define in many other fields. A baseball pitcher is effective if he allows fewer runs. A medical intervention is effective if alleviates specific symptoms and resolves a specific problem, e.g., the criteria for a successful treatment for high blood pressure is a reduction in blood pressure. However, when it comes to psychotherapy the benefits can be far more difficult to quantify particularly for individuals who are apparently successful in most areas of their lives (i.e., where criteria such as employment status, no re-hospitalizations, and other concrete indicators are not appropriate). In fact, setting concrete criteria for children and teens may be easier: better grades, no detentions, no parent reported temper outbursts. This is also true for a few diagnoses such as substance abuse, e.g., days abstinent, or eating disorders, e.g., specific weight gain or loss. However, for many other problems outcome criteria is more ephemeral, e.g., decrease in depressed mood, greater sense of well being, lower level of anxiety, improved well being, improved communication and sense of emotional connection. Thus, mental health professionals are forced to rely on criteria that is often subjective (based on either their judgment or the judgment of the client). However, concerns about this subjectivity should be tempered by the development of many valid self-report scales for problems such as depression and anxiety.
The Second Question: Who determines effectiveness?:
The other preliminary question is perhaps even more complicated: who should define effectiveness? Years ago when I worked in a mental health center there was a psychiatrist who consistently asserted, “the customer is always right” when it came to determining appropriate care, treatment. The problem was that this was not always true (to most of us, and to him as well most likely). Patients diagnosed with a serious mental illness stopped taking their medications, deteriorated markedly (became psychotic, suicidal etc), and offered suffered much acute distress. Moreover, even when considering less troubled clients, many therapists can quickly cite examples of client choices, actions, beliefs, feelings and the like, they (and most others) considered highly problematic, e.g., deciding to continue an affair, refusing to stop drinking or using drugs or being unwilling to work on lessening a specific phobia or compulsive behavior. While these examples beg the question, why not let therapists be the arbitrators of effectiveness, there are many problems with this position. First, and perhaps foremost (particularly in private practice settings) is that the client is indeed the customer and if the client is not pleased, does not find the therapy effective, the client is likely to stop attending therapy. Second, because the benefits of therapy are often subjective the client’s experience of therapy, whether it is indeed helpful, is likely what matters. Third, there is an increasing volume of research (see the work of Scott Miller, Barry Duncan, John Norcross and Michael Lambert, to name a few) who clearly and consistently find that clients’ satisfaction with and perception of benefit are really the most effective measure to determine whether therapy is indeed helpful, i.e., effective. Clearly there are exceptions to this position. However, the preponderance of evidence strongly suggests that effectiveness is best assessed by asking clients whether they are feeling helped, benefiting from, therapy.
*Anton, Barry, Ph.D., The Collaborative Psychologist: An Inter-Professional mental Health Practice Model in an Era of Healthcare Reform. Illinois Psychologist Association, Annual Convention, November, 7, 2014.