“We cannot be attached to outcome, says Zen Roshi Joan Halifax. Similarly, the Stoics point out that we do not have control of outcomes, but only the process.”

Here are two scenarios to think through the implications in real-world clinical practice:

Scenario #1

A therapist presented a case as “lack of progress” after three sessions. (Hats off to this therapist and to you the reader who have been systematically monitoring outcomes with every client). We looked at her outcome rating scale (ORS). “But the client is not progressing efficiently as the rest…” Granted, she should continue to keep an eye on the progress, but the truth of the matter, her concern was coming from a place of anxiety about one’s own performance, rather than the nature of a client’s growth and development. She was worried that her boss would notice the lack of speedy gains in her outcomes with this client.

Her engagement level with this client started low on the Session Rating Scale (SRS is used at the end of every session. See the ICCE FIT Manualsfor a useful guide), and was incrementally picking up. This is a GOOD sign. An increase in engagement across time is more predictive of good outcomes than high engagement levels throughout.[1]

Here’s my suggestion to her:

1. Use the measures to guide you, not paralyse you. What paralyses? Comparison. (that’s why facebook news feeds are a good way to trigger feelings depression).
2. Reflect on the following: What are the things that are within your control as the therapist? What are the things that you are doing that facilitated an improvement in the engagement level. Once identified, continue to do so;
3. Continue to monitor progress. Develop a rough algorithm for all of your clinical work, or a simple decision tree to decide when to
4. do something different,
5. seek further consult, etc.

For this particular therapist, we know from her outcome data that reliable improvement happens around the 4-6th session (consistent with the literature).

…

One of the ways feedback mechanism can backfire is to COMPARE with others. We must focus on the things that are influenceable and predictive of good outcomes, and be very clear on what we do not have control of.

In this instance, this therapist was doing a fine job heightening the engagement levels, though the outcomes were “not as efficient” as she had hoped for. We must not suffer fools in comparison. Instead, decision making must be paired with DATA + Clinical Knowledge, and not outsourced simply to an outcome measure alone.

Scenario #2

In another consult, the same therapist presented another case. This time, she shared one that she was happy with the progress after two sessions. There was indeed a big improvement on the outcome measure (i.e., ORS) just after the first session. However, the alliance ratings on the SRS has declined. “Did you get some feedback as to the drop in SRS?” I asked. The therapist replied, “Nope. We ran out of time.”

Here’s my suggestion to her:

1. Create a buffer: Leave a few mins at the end of the session. Devote the time and space to talk about the feedback. Even if there’s no significant verbal feedback, that’s fine. Communicate how important the client’s perspective is. (And then use those few minutes to breathe before your next session).

2. When there is a drop in the alliance ratings, ASK for more information (See this post). This is important. Your client is telling you something is amiss or not as on-track as before. You might not find out if you say, “I’d get the feedback in the next session” because

• Your client might say “oh it’s nothing” because they don’t remember the details, or
• They might not be there to tell you, because they’ve dropped out of treatment.

3. When there is an increase in the outcomes, figure out what your client is doing that helped them. Stay close to that which is working. Generalise and extrapolate.

“When you get involved in too much of the things you don’t have control it affects your focus on things that you have control of.” 

~ Legendary basketball coach John Wooden 

Here’s a contradiction to grapple with:

While I should not be attached to the outcome of an individual client, if my overall outcomes shows that I’m not effective, I should care. It is naive to repeat “we cannot become attached to the outcome” in light that we haven’t been helpful to the people we are supposed to help. This is why clarity on what are some key benchmarks[2] are so important.

I’m not saying we shouldn’t care about the outcomes. Actually, we must focus on the importance of client benefit. We must remember that good outcomes happen as a consequence of what we do in the process. Viktor Frankl reminds us, “Happiness cannot be pursued, but ensued.” [see related post on my other blog, Full Circles The Dark Side of Pursuing Happiness]

We must look at and work on making the conditions ripe for cultivating and nurturing our client’s growth, as we first facilitate to transform their suffering into true joy for Life. As Kahil Gibran says, the greatest joy is suffering unmasked.

World Renowned Photographer

Platon, a British photographer famed for taking pictures world leaders and pop icons, from Vladimir Putin to Collin Powell, has this to say about his photo taking process:

“At the beginning of a shoot, I’m not thinking ‘How can I get good photos?’

I’m thinking, ‘What can I learn about this person?’”[3]

The Take-Home Message:

Focus and measure the things that you can control, and are influenceable AND predictive of good outcomes.

Best,

Daryl

Footnotes:
[1] Owen, J., Miller, S. D., Seidel, J., & Chow, D. (2016). The working alliance in treatment of military adolescents. Journal of Consulting and Clinical Psychology, 84(3), 200-210. doi:10.1037/ccp0000035
[2] See Tak Minami and colleagues articles on Benchmarking in Psychotherapy. E.g., doi10.1007/s11135-006-9057-z

[3]From the documentary Abstract: The Art Of Design, Episode 7.