Why do I measure my effectiveness?
If I ask you for simple feedback about how therapy is going and how you feel, I will be more effective in helping you get the change you want. Research strongly supports this (in the second graph, compare the first two benchmarks with the third and fourth columns). Also, by providing referrers (such as physicians) with data about my overall effectiveness, I can be accountable to them without compromising my clients’ privacy.

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Why don’t other therapists measure effectiveness?
Only 3% of independent psychotherapists collect any kind of effectiveness (“outcome”) data. Even fewer therapists systematically track the outcome of treatment in their practices with valid measures.
Why is this?

• New technology. Effective therapy doesn’t require any technology, but quickly identifying ineffective therapy does. A recently developed method of tracking effectiveness (which I use in my practice) is called the PCOMS, and it takes us only about 2 minutes to complete in the session. Clients usually find it very helpful to see their changes over time, and I can know much more quickly if there’s a problem in how the therapy is progressing for you. Despite a lot of clear research in this area, many therapists are unaware of it, and it is not yet taught in most training programs.
  
  
• Fear of being judged as ineffective. While most therapists are effective (significantly better than no treatment), there is a lot of variation between therapists in how effective they are. It is in a client or referrer’s interest to know this, but many therapists decline to find out where they fall on the “bell curve” of effectiveness.

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How does measuring effectiveness help you as a client?
Everyone is unique. Labeling you with diagnoses or scores on tests can’t fully capture how you feel or who you are. Yet, as long as a measurement of change is valid (actually measures what it claims to measure), and is used sensibly and with respect for your individuality, it can help us have a clearer sense of whether therapy is going in the right direction. In fact, some research shows that giving this kind of simple feedback to me (about how well the sessions are going, and how you are feeling in your life from session to session) can be enormously helpful in making therapy more effective.

The Outcome Rating Scale (“ORS”; Miller et al., 2003) is one of very few measures for clinical practice that is very brief, easy to use, validated with a “gold standard” (the OQ-45), and reflects your point-of-view about things. You, the client, are the most accurate judge of how things are going in your life and in therapy. The ORS is a “guardrail” to keep us on track and alert us to ineffective therapy and a lack of change.

It is a huge step in a new direction for psychotherapy to be accountable to clients and referrers (and without sacrificing our clients’ privacy or labeling them through unreliable and harmful diagnoses). More than a measure of “satisfaction” with therapy, the ORS is a measure of real change outside of therapy.

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Effectiveness Statistics for Jason A. Seidel, Psy.D. P.C.
Since I began measuring outcomes in my practice over four years ago, my clients have experienced significantly more change than they would in typical psychotherapy or with medication—including the type of treatment they would receive in a well-controlled clinical study.

• About 74% of my clients show a reliable clinical change by the end of therapy. Studies of therapy effectiveness show that most therapists help 20-70% of their clients achieve reliable change, with some therapists showing that their average client worsens in their care! Most medication studies show that about 50-65% of clients receive a clinical benefit.
  
  
• Researchers use a formula (called a case-mix adjustment) to establish the "average" amount of relief that clients are likely to experience from therapy, based on how distressed they feel when they start therapy. By definition (among all therapists), 50% of clients will feel more (and 50% will feel less) than this expected amount of change. In contrast, about 77% of my clients experience more than the expected amount of change by the end of therapy.
  
  
• My average client who started therapy as clinically distressed is better off at the end of therapy than about 98% of these clients at the start of therapy. Studies of therapy effectiveness show that the average therapist with clinically distressed clients has a percentage of 65-80%.
  
  
• My clients who have experienced a reliable positive change in well-being stay in therapy with me for an average of 12 sessions.
  
  
• The majority of these clients experience a reliable change within the first 4 sessions.
  
  
• Clients who do not experience reliable positive change stay in therapy with me for an average of 10 sessions. Contrast that with the common situation in which clients get “stuck” in therapy for many months or years, without any change, and without any indication they should fire their therapist. There are situations in which several years of therapy may be very helpful. However, it is good to have clear feedback early on about whether therapy is actually helping!
  
  
• Compared with the average cost, duration, effectiveness, and side effects of medications for clinically distressed clients, psychotherapy can be demonstrably cheaper, faster-acting, more effective in the long term, and with no troubling side effects!
  
  
• Please note that no one can predict the duration or outcome of any one person's therapy experience based on the statistics of a whole group, and simple outcome scores cannot possibly do justice to the richness and complexities of life. Yet data such as these can inform your decision about starting or continuing your course of treatment.
  

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A brief bibliography on psychotherapy effectiveness and outcome research
Asay, T.P., Lambert, M.J., Gregersen, A.T., & Goates, M.K. (2002). Using patient-focused research in evaluating treatment outcome in private practice. Journal of Clinical Psychology, 58(10), 1213-1225.
Barkham, M., Margison, F., Leach, C., Lucock, M., Mellor-Clark, J., Evans, C., Benson, L., Connell, J., & Audin, K. (2001). Service profiling and outcomes benchmarking using the CORE-OM: Toward practice-based evidence in the psychological therapies. Journal of Consulting and Clinical Psychology, 69(2), 184-196.
Brown, G.S., Lambert, M.J., Jones, E.R., & Minami, T. (2005). Identifying highly effective psychotherapists in a managed care environment. American Journal of Managed Care, 11(8), 513-520.
Duncan, B.L., Miller, S.D., & Sparks, J.A. (2004). The heroic client: A revolutionary way to improve effectiveness through client-directed, outcome-informed therapy. San Francisco: Jossey-Bass.
Gawande, A. (2004, December 6). The bell curve: What happens when patients find out how good their doctors really are? The New Yorker Online. Available through http://www.ihi.org
Hansen, N.B., Lambert, M.J., & Forman, E.M. (2002). The psychotherapy dose-response effect and its implications for treatment delivery services. Clinical Psychology: Science and Practice, 9(3), 329-343.
Harmon, S.C., Lambert, M.J., Smart, D.M., Hawkins, E., Nielsen, S.L., Slade, K., & Lutz, W. (2007). Enhancing outcome for potential treatment failures: Therapist-client feedback and clinical support tools. Psychotherapy Research, 17(4), 379-392.
Hawkins, E.J., Lambert, M.J., Vermeersch, D.A., Slade, K.L., & Tuttle, K.C. (2004). The therapeutic effects of providing patient progress information to therapists and patients. Psychotherapy Research, 14(3), 308-327.
Hubble, M.A, Duncan, B.L. & Miller, S.D. (1999). The heart and soul of change: What works in therapy. Washington, D.C.: American Psychological Association.
Lambert, M.J. (2004). Bergin and Garfield’s handbook of psychotherapy and behavior change, 5th Ed. New York: Wiley.
Miller, S.D., Duncan, B.L., Brown, J., Sparks, J.A., & Claud, D.A. (2003). The Outcome Rating Scale: A preliminary study of the reliability, validity, and feasibility of a brief visual analog measure. Journal of Brief Therapy, 2(2), 91-100.
Miller, S.D., Duncan, B.L., & Hubble, M.A. (2004). Beyond integration: The triumph of outcome over process in clinical practice. Psychotherapy in Australia, 10(2), 2-19.
Wampold, B.E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah, N.J.: Lawrence Erlbaum.

Also, see http://www.talkingcure.com for more information and resources.

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