How do you know if your therapy is going well?
There is a certain image of what being in therapy is like. The patient, passively suffering, laying on the couch talking about what ails them. The therapist, listening intently out of sight. For years, and years... and years... and...
Therapy, and how it works, can often be a mystifying experience for the patient. There are people who, unsure of what exactly is supposed to happen, may stay in treatment without fully questioning how this "talking cure" will help with their problem. At the same time, there are others who, without raising the question of how the treatment can help, may become frustrated and quickly leave psychotherapy. Part of this has to do with some psychotherapists having a history of not being fully transparent about how they work. It also has to do with clients not being given more information on how to tell if their therapy is on the right track. What I want to do here is tell you about 3 things you can use to figure out if you and your therapist are on the right track, and how to correct course if you're not. These 3 things are:
- Set your goals and monitor the outcome
- Provide your therapist feedback to improve the treatment
- Express your feelings about the therapist/therapy before deciding to bail
1. Set your goals and monitor the Outcome
Outcome monitoring is an important part of mental health treatment, and is fast becoming a new standard in patient-focused care. It is a series of tools we therapists use to answer the question--"Is this treatment, however constructed, delivered by this clinician, helpful to you at this point in time?" In other words, the question of whether your therapy is going in the right direction. We answer that question by doing one of two things (often at the same time):
- Identifying your goals at the beginning of treatment, and noticing how well we help you get closer to that goal over time.
- Using evidence-based outcome measures to rate the severity of your symptoms at the beginning of treatment, and then having you fill them out again over time to see if the treatment helps you feel better by reducing those symptoms.
For example, your goals might be to feel less anxious and improve your ability to communicate your needs effectively. If over time you notice you're feeling less anxious, and that you're getting better at expressing what you feel and have your needs met more often, we could interpret that as signs that we're on the right track with our treatment. Setting goals is fundamental to selecting a good treatment, as they set a bar against which we can measure its effectiveness.
A good framework for thinking about goal setting is the SMART system. Goals should be:
- Specific goals are better than really broad goals.
- Measurable in the sense that you can quantify that goal. e.g. Feel less depressed, or more comfortable approaching people at a party.
- Agreed upon, in that you and your therapist have a shared understanding of the problem. It's important to be on the same page!
- Realistic, achievable, and attainable goals are better than very distant goals you may not achieve right now. You may want the latter sometimes, but the former actually builds the bridge toward them.
- Time based, so that there is a reasonable time-frame within which changes can be expected.
Goals should also be tracked over time. Outcome measures work in a very similar way. If learning how to manage anxiety is a target goal, we might have you fill out an anxiety questionnaire like the GAD-7 at the beginning of treatment. This could give us a good sense of how much anxiety you're struggling with on a regular basis. If we have you fill it out again at least once every week or every month, we'll have real time data on whether what we're doing is working for you, and track those changes over time.
2. What if treatment isn't working? the role of feedback
Alternatively, if you notice you're feeling the same level of anxiety or more, or feel you're not making progress on your goals, or if our chosen measures suggest your symptoms are rising, these could be signs that the treatment is not working. Does this then spell the end for our work? Is it time to look for another therapist?
Not necessarily. CUE THE MUSICS!
Being able to monitor outcome and use that information as feedback, especially when we're not on the right track, gives us the opportunity to correct course, and make your treatment harder, better, faster, stronger, more therapeutic. The research backs this up pretty well. When patient and therapist are provided with feedback on how treatment is going, especially when things aren't going well, they are more able to talk about the problem and jointly figure out creative solutions. This helps the therapeutic relationship be more collaborative and more empowering to you. Ultimately, this makes it more likely you will have a better outcome and meet your goals.
3. what's left unspoken: the therapeutic relationship and voting with your feet
Research has shown again and again that the relationship between patient and therapist is not only a consistent predictor of outcome, but a major factor in deciding whether people stay in therapy and derive benefit, or drop out. And a major reason why people drop out of therapy is because there are things that are left unsaid by the patient. Thoughts, feelings, fears, and concerns the patient may have about the therapy, or even about the therapist themselves, may come up and often do come up over the course of therapy. Or, perhaps there is a tension or disconnect between patient and therapist--what we call "ruptures"--that isn't being talked about. Sometimes this has to do with not feeling heard by your therapist. Sometimes it has to do with cultural or racial differences that are rendered invisible, and become a source of missattunement with your therapist. Furthermore, it could be about fears, traumas, and anxieties about being hurt or rejected that become reactivated in the therapeutic relationship. Research shows that these ruptures, whether due to misunderstanding, trauma, or cultural differences, can happen in as high as 50 to 80% of all psychotherapy cases.
Which is to say anywhere from half to almost all psychotherapy.
And worse still, the therapist can have no clue there is a rupture to begin with.
I'm gonna let you sit with that for a minute.
Ok, let me say that again:
And so, you could vote with your feet and drop out of therapy. Either because you feel your needs aren't being met, you feel stuck, or it seems unfathomable that you could address this with your therapist. And we have no idea.
However, the research shows a very interesting trend. When you are able to bring up your thoughts and concerns to your therapist, and they become aware of the problem and are open to talk to you about it, this actually makes the therapy, and your therapeutic relationship, stronger. It's actually been shown that while therapies without such experience ruptures overall do well, therapies that experience a rupture, and patient and therapist are able to repair it, actually do a lot better. Scholars argue that this is because in part, as mentioned above, providing feedback to your therapist actually makes it more likely the therapy can get back on track. But it's also been argued that since part of the reason we come to therapy is due to problems in relationships, that being able to express our feelings with another person, especially one we feel conflict with, and having them respond in a different way than we might expect, helps us learn how to do relationships better.
Talking openly about problems, even problems in our relationship, and addressing them together is just good therapy.
do we have to write these things down?
That depends on you and your therapist. Some patients and therapists prefer to talk about these things verbally and keep them in mind throughout treatment. Others prefer to write these down, or to use paper versions of outcome questionnaires. Some clinicians even use a regular measure of the therapeutic relationship--called a working alliance inventory--to have you routinely rate how you feel the relationship is going. Even yet, there is an increasing number of web or phone based apps that you can use to track your progress, symptoms, or goals. I've spared many a tree using those! You have to use the right compass in order to figure out where you and your therapist are going and how to get to your destination. It's the best way to travel on this journey called change: