{"id":1504,"date":"2017-12-01T05:33:34","date_gmt":"2017-11-30T21:33:34","guid":{"rendered":"http:\/\/darylchow.com\/frontiers\/?p=1504"},"modified":"2019-05-03T18:49:56","modified_gmt":"2019-05-03T10:49:56","slug":"do-not-become-attached-to-the-outcome","status":"publish","type":"post","link":"https:\/\/darylchow.com\/frontiers\/do-not-become-attached-to-the-outcome\/","title":{"rendered":"Do Not Become Attached to The Outcome"},"content":{"rendered":"

\u201cWe cannot be attached to outcome, says Zen Roshi\u00a0Joan\u00a0Halifax<\/a>. Similarly, the Stoics point out that we do not have control of outcomes, but only the process.\u201d<\/p><\/blockquote>\n

Here are two scenarios to think through the implications in real-world clinical practice:<\/span>
\n<\/p>\n

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Scenario #1<\/span><\/h1>\n

A therapist presented a case as \u201clack of progress\u201d 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). \u201cBut the client is not progressing efficiently as the rest\u2026\u201d 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\u2019s own performance, rather than the nature of a client\u2019s growth and development. She was worried that her boss would notice the lack of speedy gains in her outcomes with this client.<\/span><\/p>\n

Her engagement level with this client started low on the Session Rating Scale (SRS is used at the end of every session. See the <\/span>ICCE FIT Manuals<\/span><\/a>for 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]<\/span><\/p>\n

Here\u2019s my suggestion to her: <\/span><\/p>\n

    \n
  1. Use the measures to guide you, not paralyse you. What paralyses? Comparison. (that\u2019s why facebook news feeds are a good way to trigger feelings depression).<\/span><\/li>\n
  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;<\/span><\/li>\n
  3. Continue to monitor progress. Develop a rough algorithm for all of your clinical work, or a simple decision tree to decide when to<\/span><\/li>\n
  4. do something different, <\/span><\/li>\n
  5. seek further consult, etc.<\/span><\/li>\n<\/ol>\n

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

    …<\/span><\/p>\n

    \n

    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.<\/strong><\/span><\/p>\n<\/blockquote>\n

    In this instance, this therapist was doing a fine job heightening the engagement levels, though the outcomes were \u201cnot as efficient\u201d 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.<\/span><\/p>\n

    \"\"<\/span><\/p>\n

    Scenario #2<\/span><\/h1>\n

    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. \u201cDid you get some feedback as to the drop in SRS?\u201d I asked. The therapist replied, \u201cNope. We ran out of time.\u201d<\/span><\/p>\n

    Here\u2019s my suggestion to her: <\/span><\/p>\n

      \n
    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\u2019s no significant verbal feedback, that\u2019s fine. Communicate how important the client\u2019s perspective is. (And then use those few minutes to breathe before your next session).<\/span><\/li>\n<\/ol>\n
        \n
      1. When there is a drop in the alliance ratings, ASK for more information (See this <\/span>post<\/span><\/a>). 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, \u201cI\u2019d get the feedback in the next session\u201d because<\/span><\/li>\n<\/ol>\n