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Psychotherapy: How do we know it’s working?

I have been lucky (or unlucky) enough to work with several very good psychotherapists and none has shown any apparent interest in evaluating the effect the therapy was having. This might reflect a value base that therapy isn’t about people changing, but being more themselves. Or it might be because no one has asked them how they know it is working.

 I come from a background of measuring change and developing tools such as the Outcome Startm,  so for me it seems an obvious question.  It is a question that is being asked more and more frequently.

 As I client I want to know whether my investment in time and money is worth it. As a therapist, I am curious about the journeys my clients travel along as they connect more deeply with themselves.  Therapists working as part of a service, with many clients need some form of measurement that can be summarised to show the nature of the impact the service is having, and where and with whom it is most effective. As a profession it is essential to show how useful we are to public health.

 What is it that you would be measuring?  If I reflect on my own experience in therapy, I entered therapy feeling lost, feeling distressed at the loss of a parent and a partner, and having difficulties with relationships.  Through these different episodes of therapy I have noticed changes in myself – a sense of direction, a greater ease in getting to know people, feeling more at ease with myself for more of the time.  Other people have commented on my being more relaxed and easier to get on with.  These are changes that matter to me.

 Measurement tools are developed by going through a process of finding out which changes are valued by clients and practitioners, and then summarising them in some form.  The most widely used tools take the form of questionnaires, such as PHQ9, GAD7, and CORE.

PHQ9 consists of nine questions which together build a picture of the clients level of depression: the higher the number at the end, the higher the depression.  It is used at the start and end of therapy (or at intervals during the course of the work).  GAD7 consists of seven questions focusing on anxiety.  These two questionnaires are used widely in the NHS.  CORE is a broader tool with 34 questions about how the client has been feeling over the previous week, covering subjective well-being, problems/symptoms, life functioning and risk/harm, to produce a picture of what they term the level of current psychological global distress (from 'healthy' to 'severe').

These three tools are all designed to create an ‘objective’ picture of where the client is at any particular time, and generate easily summarized numbers.  However PHQ9 and GAD7 both focus on symptoms, i.e. the show problems getting smaller rather than the emergence of different ways of thinking and being.

The Recovery Star takes a different approach.  This looks at the client’s life as a whole and sets out a journey of recovery, with a clear sense of what recovery looks like, so that you can see where you are, and what the next step might be.  It is based on your subjective experience of the issue, rather than an objective measure, i.e., it isn’t the severity of your depression that matters, but how you relate to it and manage with it.  The importance for me is that the Recovery Star charts a journey through awareness to an increasing sense of self, an increasing capacity to reflect and learn, and increasing independence and purpose.

However formal tools are not always necessary.  It is normal practice to agree some goals of therapy at the start.  One approach is to explore what achieving these might feel, look and sound like – what it would feel like, for example, to have a sense of purpose, how I might know that I was finding making relationships easier. These early thoughts can then be reviewed at a later date. One therapist I know says he always asks his clients how they will know they are ready to finish –  easier to ask than to answer!

Outcome measurement is easier when goals are very specific, which means that it is easier to measure the effects of focused short-term work.  In long-term work goals change and deepen as you travel a journey together, making a tool like the Recovery Star possibly more helpful.

There are dangers in trying to measure too much: long-term therapy has many ups and downs, long periods where nothing seems to happen, and times which are very painful.  In my experience these difficult, or plain boring times have usually been important stages on the way to growth and change.  The timing of reviews and expectation of change therefore is important – it needs to match the work.  If you are working over a long term period, such as two years, it might make sense to review after an initial phase of say three months and then revisit after a year or eighteen months, whilst noting client and therapist observations along the way.

Whether working short or long term I suggest that there is always scope for the client and therapist to reflect and note change together, whether positive or negative, and that this reflection in itself, is a constructive element of the work.







Wild Therapy by Nick Totton Book review

Nick Totton has written this book to make explicit the link between therapy and the environmental crisis  that we face.  He starts from the premise that we have domesticated ourselves, over centuries, and lost, for much of the time our connection to the wild, to the "other than human" and "more than human" that share this planet with us.  This not only leads to distress and ill health but also enables us to live in a way that is exacerbating the crisis and making it increasingly unavoidable.  He regards therapists as having a unique responsibility in helping people to reconnect with the "wild" and recognises that this is a challenge, as much of therapy has been regimented and regulated, to protect clients, and increasingly, to protect therapists from litigation.

This is an important and delightful book.  The author says from the start that he intends to enable the reader to forage, to meander along a path exploring interesting ideas and voices to right and left, and his pages are full of a wide range of voices from all over the world, inclduing fascinating tales from anthropologists describing the "wild mind" and its collapse in the face of "civilisation".  In the first part of the book he explores what wild and wilderness mean, and how our relationship to the wild has changed, and how we percieve the wild now.  Underlying this is a path exploring how humans have become separate from the wild, how we have strived to simplify complexity though domestication, and what we have lost in the process of separation.  

The later chapters look at the role of therapy and therapists in supporting the process of reconnecting, and the challenges this presents to an individual therapist - here he brings in his own experiences, as well as the voices of others and the author as a person starts to appear on the pages.

What can I do about climate change?

A gigantic iceberg looms ahead, clearly visble from the bridge.  With binoculars the crew and passengers can make out the different colours of ice, the intricate shapes, and more than anything else, its enormous size.  Even those without binoculars can see it - that is, if they are looking straight ahead.  The captain roars " full steam ahead!" 

" but sir, we will crash - its almost too late to avoid it already! We must change our course!" come the gasps around him and from passengers straining to climb through the barricaded entrances to the bridge.

"Nonsense" he says, "we will be fine - this is a very strong ship, we have always managed these things before.  Anyway we have a right of way through this passage - if we dont go this way someone else will and we will be left behind.  Icebergs arent a problem"

Panic starts to spread.  People rush for the lifeboats.  But there arent enough - no one ever thought the ship would need them.  The first class passengers decide that there are prpbably enough for them, as long as the second class and steerage passengers can be distracted and kept out of the way.  Before long fighting is widespread as people scrabble for their one chance of survival.

 A hackneyed metaphor maybe, but one that speaks to me.  Where are the lifeboats for the farmers seeing their livelihoods disappear in the mountains of chile, or in the drylands of the sahel and Sub Sahara?  Or island peoples such as the much quoted Maldives, literally disappearing beneath rising sea levels.  Even we here in the relatively safe UK are experiencing some very strange weather, with a wet and cold spring that has decimated bee populations (and subsequently fruit crops) and a summer with widespread and continuous flooding.  But are we taking it seriously?  It doesnt feel like it.  

I used to live in Oxford, and maybe that is one place where there is a huge amount of awareness and activity and mutual support for people trying to change their lives and live in planet friendly ways.  Now I live in a wealthy Yorkshire town, full of people (like myself) who have moved there because its so nice and has wonderful state schools for the kids.  Its a lovely place to live - but it is a haven of consumption, large cars and a feeling that the world is just fine here.  Its hard to remember that there is a world outside, to which we are connected, and that nothing very much is changing.

It's as if we are on that ship, its full steam ahead, and we have said yes, the icebergs there, but it wont really happen and if it does, we will be ok, and settled back down to enjoying a nice game of backgammon (or in my case playing the fiddle).  Maybe some people are saying - yes its there but there is nothing we can do about it so we may as well enjoy ourselves whilst we can.  Others know they will be ok, because they know they deserve place on that lifeboat - after all they have worked hard to be able to afford a first class ticket..... Others trust the captain, and his view that the ship is strong enough to meet and overcome any obstacle.

I feel I'm one of those people who are sitting anxiously, looking out, seeing what will happen, worrying about how the steerage passengers will cope, but not doing anything or knowing what to do.  I might have gone up to the bridge to try and say something and lend my voices to those asking the captain to change course, but I didnt feel very convincing and I didnt know what else to say, so I gave up.  And worried.

So how do I - and others gain a sense of power?  For me the biggest block to action is feeling that I dont have any power.  I know the answer is quite simply to get involved in something, join with others, and get something going.  And I have done that a bit over the last three years.  But it is easy to be dismayed by the high level failures, such as Copenhagen and most recently at Rio, and wonder what on earth can be done.

Round us the big issue is wind farms - and being in favour of these (generally) puts me in a small minority.  But I cant see the objectors being any keener on a fracking exploration, or open cast mining if that was to come our way.  Ill end for now on that note.

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