Written By Dr Alistair Campbell
Is it good enough to just like your therapist – or that your therapist seems to like you? How can you know if your therapy is working for you?
These can be tough and challenging questions for both you and your therapist. For the therapist they go to the heart of our competency. Are we doing a good enough job? For you, they are questions about value. Are you getting what you need, for the money you pay? How would you know?
These are good questions. In fact, they are critical questions. Increasingly it is clear that getting feedback from you (clients) about how we (therapists) are doing, is key to promoting and motivating change. One of the things that I have always found is that I learn most from my clients. I especially learn when my clients tell me what I am doing that is not working for them. Without that type of feedback I really don’t know what it is I need to work on to improve my approach.
The Importance of Feedback
Giving and getting feedback, especially the “negative” type, is hard on the client and the therapist. Honestly, though, it is the best kind. I know I like to be told that I’m great or that I’m doing a good job. Yet these comments are usually general. Critical comments are often specific. Or, at least, it’s possible to explore them more until the specifics are uncovered. When a client tells me, “I didn’t feel heard when you spent so much time writing your notes,” this really gives me something to work on. How do I improve my note taking so that it doesn’t get in the way? I love the challenge!
There is no doubt that liking, and being liked by your therapist is a really important element in whether therapy works or not. Research that has been done since the 1970’s has shown that the quality of the “therapeutic” or “working” alliance is of more importance to clinical outcome than what the therapist does (their technique).
Essentially, if there is a good rapport between you and the therapist, if you feel that the therapist is working on goals that are right for your problem, and if the approach that the therapist is taking, no matter what it is, feels like a good fit – then it is more likely than not that you will achieve change in your identified problem. It is that simple.
What Do You Bring to Therapy?
Another very important part in this, however, is what you bring to the therapy room.
Are you committed to making changes? Do you have the support of friends, family and workplaces? Do you understand what is being asked of you? How do you see the hard experiences that you have had in your life? Have you had a mix of both positive and negative experiences in your life? Is the idea of doing something different, maybe changing your life radically and forever, exciting or scary? All these issues and more are as important, perhaps more so, than the next biggest factor of whether there is a good working alliance.
So how do you know whether all of these factors are coming together? How can you tell whether you’re progressing well? How do you spot when something is going wrong, or simply isn’t working? In research settings it is a matter of having clients fill in long standardised questionnaires, recording and minutely observing the interactions between clients and therapists, and measuring different aspects of outcome, like symptoms, wellbeing, and growth – again, on long standardised measures.
In real clinical practice most clinicians will avoid using these types of measurement like the plague, because these types of tools add hours and hours to the business of therapy. It simply isn’t feasible to do them in real time. It also isn’t at all necessary.
Evaluating Your Therapy
I learned very early on as a therapist that one of the simplest ways of evaluating these factors for positive outcome was just to ask you.
Asking a client “So, how do you think we’re going?” or “Was this a useful session? Are there any things that I could have done better?” does lead to answers. It may not be “scientifically” valid but I have found that it is practically valid. Most of the time you seem to want to help me to help you. Some of you certainly seem to feel that the questions are challenging but I have never found that clients feel that me asking the question reflects a lack of competence on my part. If anything, I have found that clients intuitively recognize the value in talking about the process of the work that we are doing.
As a beginning therapist you are often so anxious about not appearing “unprofessional” that it is hard to admit to yourself, let alone a client, that you might have done something wrong. But, in most trades, sports and professions the best way to get better is to make mistakes and, more crucially, know that you have made a mistake in order to practice a better approach. It’s no different in therapy. If we know what we are doing wrong then we can practice a habit, style, or technique until we do it differently – and probably better. Mistakes are invitation to change.
Measuring Therapy Outcomes
This is still not a common way of thinking about therapy. But it is changing. There are also now ultra-brief measures of therapeutic outcome and client-therapist relationship that are good enough to use to measure these things in real world clinical practice.
I will usually ask you to complete two quick measures; they often take less than a minute to complete. The outcome measure (Outcome Rating Scale, or ORS) gives me a quick and valid indicator of how well you feel things are going for you.
The relationship measure (Session Rating Scale or SRS) gives you the opportunity to rate how well the therapy itself has gone during the session. Both of these tools can then be used to talk about both therapy progress (are you getting better?) and therapy process (are we working well together?).
If you’re really lucky (just kidding- remind me if I forget!) I will even have a nice simple graph after a few sessions to show you how you say you are progressing through plotting your ORS scores on a chart. This becomes really valuable when you know that a lack of progress after six or so sessions is a trigger for me to have a really thorough discussion about how I might need to be working differently, or whether my approach is the right one for you.
I like to use your ratings on the SRS to have a talk at the end of the session about how you feel we’re working together. As this is nearly the most important predictor of therapy outcome, I think it’s really worthwhile to keep the topic near the top of the agenda.
So, if I don’t ask you to fill in at least these two forms – feel free to ask me about that – I might just be having a “senior moment”!
Dr Alistair Campbell is a Clinical Psychologist working with individuals, couples, and families. He is trained and experienced in a wide range of therapies including Narrative; Systemic; Solution Oriented; Narrative; Cognitive; Behavioral; and Hypnosis approaches.