What is Therapy Meets Numbers? Assuming that therapy and numbers don’t already meet …why would they want to? If they do meet … what could possibly happen? Here we try to answer all those questions and more …
I’ll come to the story of how we came to be later, but I’ll start with what we’re about. At its heart, TMN is about three things:
Making research accessible
Making routine measurement doable
Making therapy remarkable
Now, each of these three statements could be read to imply that there is a problem which it’s trying to solve, so I’ll come right out and say ‘Yes, I think there are problems, to some extent at least.’ Let me expand a little on each.
Making research accessible:
There is much research evidence for what works in therapy, including how we can enhance both client engagement and outcomes. Despite this wealth of evidence, however, much of therapy practice seems relatively untouched by it.
There are perhaps two key reasons for this disconnect. First, research barely figures in most foundation level therapy training. Unlike the discipline of psychology, where research and measurement is in the DNA of professional training, counsellors and psychotherapists are not routinely grounded in research methods.
Second, researchers tend to write with other researchers in mind, partly in order fulfil the requirements of peer reviewed publication processes. While those processes might deliver better quality research, however, their key messages are often shrouded in language which can seem incomprehensible to many therapists.
For research to influence practice, and vice versa,
there has to be a place where the two can meet in dialogue.
Making routine measurement doable:
There is also clear evidence that routinely measuring key aspects of client experience, such as their outcomes and the strength of the therapeutic alliance, can lead to better experiences of therapy and better outcomes for clients. Despite this evidence, however, many of us view measurement as an unwelcome intrusion into our practice, rather than a valuable opportunity to gain additional feedback from clients about their experience.
How many of us were ever properly trained in using routine outcome measurement? How many of us have had measurement imposed upon us, often in a clumsy and ill-prepared way? For many therapists, routine measurement seems a dark and complex art, whereas, in reality, its basics are remarkably straightforward.
Implementing and using routine measurement is a skill.
Like any skill, it needs to be learned.
But it is not, and neither should it be, complex. If I can do it, so can you.
Making therapy remarkable:
I know, and if you’re a therapist, you know, that therapy at its best can be a powerfully transformative experience. We also know that our seeming inability to help a client effect change can leave us feeling incompetent and powerless. Sometimes the therapy that we provide can feel remarkable, and sometimes it can feel anything but.
One key message from research is how poor we appear to be at predicting which clients are going to benefit from therapy, and which are not. It seems, also, that we routinely over-estimate how effective we are relative to our peers, and also relative to our clients’ actual outcomes.
Consistent, deliberate practice is the key to improvement.
The day you hear me say ‘I’m now good enough’, please put me out to therapist pasture.
Making the remarkable, unremarkable
I’ve spent a good part of the last twenty years involved in trying to work out how we can make more of our clients’ experiences of therapy remarkable. I’ve looked at research, I’ve implemented and used routine evaluation in my own practice and service settings, and I’ve helped many other practitioners and services in that process. I’ve seen and been part of what’s possible.
Therapist variables, including the quality of the therapeutic alliance, contribute between 5 – 9 times as much to client outcome as the therapeutic model we practice
It is who and how we are, and what we do, that makes the vastly bigger difference. Oftentimes, we make this difference uninformed by research and by routine evaluation. What additional difference could we make to our clients’ experience if our practice were informed by clear evidence from research, and client feedback from routine evaluation?
At TMN our aim to make research accessible and make routine measurement doable
We’ll do that by highlighting relevant research and putting it across in a way that makes sense. We’ll aim to demystify the dark arts of routine measurement with practical guidance, and we’ll share our own stories of success and failure, as well as the stories of other practitioners and services. If we do that right we hope we’ll be helping you, in some small way, to make therapy just a little more remarkable.
We want TMN to be a community, and we want you to feel it’s your community
It can be nothing without you. We’d love to hear your stories, and to have your feedback. Tell us what you like, what you don’t, and what do you want us to cover that we’re not. Don’t be a stranger, and be sure to sign up for our newsletter to keep up to date.
Thank you for your first blog Barry and Giles!
I’m really interested in your work-having worked in institutions as a therapist and latterly in service management for nearly 30 years I have been steeped in outcome measures and proving our worth to management. I’ve also trained other service managers in how to provide a comprehensive outcome measurement set for their services. However, I have now come back to the wonderful world of private practice and I suddenly find myself resistant to outcomes! Were they really all about management and not the clients I ask myself? I find myself shifting slightly uncomfortably in my seat! Surely in private practice clients speak with their feet?? But no of course they don’t always as attachment and transference gets in there.
So I await your next blogs with interest!
Tina – thank you so much for reading and responding! I confess to have struggled with the same resistance since being back in private practice. Surely, I have thought, I’ve reached a place where it’s OK to be ‘post-measure’? It seems fashionable to be post-something these days, even post-truth. Until I started to look at the hugely different attrition rates between my EAP and other clients, that is (more on that in a later blog). There’s something there to understand and I’ve committed to getting back with the programme 😉
The post reads clearly and makes a convincing case. A few things occurred to me while reading it:
I feel like it speaks more to therapists than service managers. Although many are people are both including me! As a service manager I’d be interested in something along the lines of you are already collecting a wealth of data and want help to make sense of it and use this information ethically to make decisions and improve quality…
I struggled with the heading ‘making the remarkable unremarkable’. For a while I misunderstood and then while I see the purpose it seemed to take away from acknowledging the remarkable bits of therapy. Which sometimes do happen in my experience without an obvious explanation. Perhaps it’s my standpoint – while I believe in routine evaluation to examine and improve practice there is also for me a less quantifiable aspect bound up in our narratives about the work and our supervision and this is important too. Perhaps this could be mentioned if you feel appropriate but also completely understand you may disagree with me on this.
Thanks Helen. I’m hoping that in time there will be something here for everyone, including service managers such as yourself who are doing such sterling work in collecting and using data. The ethical dimensions of using information…..what a great topic. We’ll come back to that.
Thanks also for your comment of the sense of the title detracting from the potentially remarkable aspects. I totally agree with you – and I think it’s the narrative that brings the numbers alive.
Am enjoying this blog and have more to say but the first thing that came into my head is this facebook post from Mick Cooper because it seems so connected.
21 April · Mick Cooper wrote on his facebook page:
If you’ve ever used an outcome measure as a therapy client (like the CORE-OM or PHQ-9), we’d love to know your experience of it. At Roehampton, we’re in the process of developing a tool that can help assess the helpfulness of different therapy measures, so that we can support the development of more client-friendly instruments.
Do, please, also consider forwarding this link to anyone who you think may be interested in completing the survey.
Thanks. …
See more
roehamptonpsych.az1.qualtrics.com
ROEHAMPTONPSYCH.AZ1.QUALTRICS.COM
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My thanks to you Rachel, and I love the connection you make with Mick’s initiative. I wasn’t aware of that, but it does look intriguing and I will check that out. Already starting to feel a sense of what richness a community can contribute here!
Hi Barry and Giles,
Really enjoyed reading the first blog. I would like to echo Tina’s comment. I think a lot of third sector and NHS mental health service will use outcome measures to meet management targets or the expectations of funders. Arguably these measures can be used with little heart or enthusiasm and therefore TMN could inject some fresh energy to transform services where measures are adhered to rather than valued. As Tina noted, in private practice there really is a different story, as I can’t think of any of my counselling colleagues that use regular measures with their private clients. It would be interesting to explore the barriers here. Barry – have you spoken to Roehampton about TMN as there are a number of researchers there that could be really interested in what you are doing and wish to get involved. Charlie Jackson who is part of the ETHOS study looking at humanistic counselling in secondary schools is conducting a piece of PhD research called AGENCY – a study of analysing goals in counselling where her work will have a key focus on measures. It may be an idea to get in contact with her through the official channels.
Thanks for the comment David. I agree that much of measurement seems to be more about being seen to be doing the right thing, than actually doing it. In forthcoming blogs we’ll be setting out some of the arguments for why we need to be doing more than paying lip service, and your and others’ thoughts on these issues really matter to us.
Not yet in touch with Roehampton, but it’s on the target list after this initial series. 🙂
Thank you Barry for your first TMN blog post which I read with all the responses too with such interest. I do agree that the tail can wag the dog in terms of service management rather than ensuring the client’s needs are met (although I hope we do that too). Having said that the way we use CORE here is empowering for the clients as they can see their change and development. Looking forward to the next post.
Hi Sarah and thanks – I agree with your comments about tails and dogs and am pleased that your approach is one that clients feel is empowering. If we can’t approach it in that way, then is using measures worse than just neutral – i.e. actually disempowering?
I am finding this very interesting – good to hear other people’s opinions.
I agree with Sarah’s comments above – I have spent a lot of time explaining the need for a progression measurement tool to our counsellors and want them to use it for the benefit of the client first – many find it hugely empowering. It is the skill of the therapist that makes it powerful and useful!
So true Verra, so true. Hands up all those who were trained in using measures in the early stages of their professional training?