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How Do We Really Measure Success?

By Joan Normandy–Dolberg, LPC
Chair, AMHCA’s Public Awareness, Advocacy, and Marketing Committee

As a result of demands for accountability by insurance companies and public policymakers, mental health counselors face increased pressure to demonstrate that our work with clients is effective. But is it really possible to clearly define and objectively measure a counseling intervention, or identify a causal relationship between our counseling interventions and the client’s outcome? 

In order to make an objective assessment, we need to have a clear report of the client’s symptoms before we begin our work together. And we also need to know the client’s goals for treatment … how the client will measure success.

I created an easy-to complete 100-question inventory of symptoms that I use as part of an initial intake. The questions are organized by category (attention, depression, anxiety, stress or trauma, etc.) and provide a clear baseline of what a client was experiencing when he or she entered therapy. I also use this checklist to assess clients’ drinking and substance-use habits and history, providing them with the option to indicate that they would prefer to discuss these in person. Referring to this same inventory several times during the course of treatment allows me to have an objective method of reassessing the symptoms and discussing if we are achieving the goals of treatment.

But a clear report is not the same thing as a clear understanding. So many of the clues we read are subtle, and so much of the work we do is subjective. How do we really know if we have been successful? 

Insurance companies measure success in terms of cost-effectiveness of treatment … i.e. the fewer the sessions, the more “successful” we are. Research indicates that most clients experience some positive changes after only two sessions, and the median number of sessions a client sees a therapist is between five and six. By the eighth session, 22 percent to 50 percent of clients report improvements and that change continues for approximately the first 10 sessions. 

But how true is this for each of our clients? It would be nice to be able to see a client for 10 sessions and know that he or she is done with treatment, but we are often dealing with years of pain and suffering that manifest in symptoms that interfere with an individual’s ability to function and his or her quality of life. In my opinion, there is no real way to objectively measure the relief a person may feel when a skilled clinician empathically listens and acknowledges their pain.

What about the client we “talked off the roof” and continue to see weekly for five years, preventing hospitalization or suicide? What about the client we saw once or the ones we see monthly for years or the ones we referred to a different clinician? How can we measure their progress?

We all have had clients who stop coming after only a few sessions. We may tell ourselves that they are resistant, in denial, not able to trust, not ready for therapy or lacking the motivation or energy to change, but perhaps we need to look more deeply inside ourselves. Have we failed to create rapport? Do they sense that we find them boring, or dislike them? Do we lack the necessary skill and experience to deal with their particular problem? Have we failed to express genuine empathy, warmth, and understanding — not just of their symptoms but also for what lies underneath these manifestations?

In my humble opinion, the measure of success is not our ability to totally resolve a lifelong problem in 10 sessions, but rather to provide a place where a client feels welcome and cared about. Perhaps our job is simply to provide courage, strength, and hope to those in need.