Sharon Kopyc - Writing Measurable Outcomes in Psychotherapy

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Library of Congress Cataloging-in-Publication Data

Names: Kopyc, Sharon, author.

Title: Writing measurable outcomes in psychotherapy / Sharon Kopyc, LCSW.

Description: New York, NY : Oxford University Press, [2020] |

Includes bibliographical references and index.

Identifiers: LCCN 2019053058 (print) | LCCN 2019053059 (ebook) |

ISBN 9780190927684 (paperback) | ISBN 9780190927707 (epub)

Subjects: LCSH: PsychotherapyOutcome assessment. |

PsychotherapyPracticeEvaluation.

Classification: LCC RC480.75.K67 2020 (print) | LCC RC480.75 (ebook) |

DDC 616.89/14dc23

LC record available at https://lccn.loc.gov/2019053058

LC ebook record available at https://lccn.loc.gov/2019053059

This book is dedicated to the memory of my son, Jonathan Aaron Albert (19822003)

In 2013, I became very aware of the notion of measurable outcomes as an important part of clinical accountability. Unfortunately, my awakening was an abrupt and harsh experience when, in beginning my role as director of an outpatient clinic, an audit was conducted by our funder and the result was that a majority of the charts did not reflect any measurable outcomes based on the goals and objectives written in the treatment plans. It was a somber time for the agency, as thousands of dollars were returned to the funder for this deficit, and a provisional license was consequently given to the agency.

While I did not feel personally responsible as I had only been on the job for a month, it was clear what my work would be in the next year. What this meant was that I, as director, needed to rectify the problem by training therapists, already overburdened with large caseloads, how to write measurable outcomes. While it may seem to be a simple problem to learn how to write measurable outcomes, it became quite apparent that therapists had no training in writing objectives that were measurable. Treatment plan objectives typically looked like Client will increase self-esteem, Client will reduce anxiety, and Client will improve mood. These therapists, all well educated clinically, articulate both verbally and in writing, had very good analytical skills when it came to discussing cases and writing comprehensive narratives. The objectives they wrote were what they read about in texts and what they discussed in supervision, and they were typical of acceptable therapy goals for decades in this field we call psychotherapy.

What evolved over the next year was researching a process of writing measurable outcomes. Decades of clinical experience did not help when I undertook this task to write measurable outcomes, as I, too, had spent years writing goals, such as Client will increase self-esteem. What occurred to me was that, in order to write meaningful outcomes, we needed to carefully think about where clients were in thinking about their problem, because when that was identified, both the therapist and client would be able to write something that was meaningful and not just the attachment of a measurable action to the goal being written.

In this instance, my thinking focused on wanting to understand how to do that. At some point I came across a chart on Blooms taxonomy of six cognitive domains: remembering, understanding, applying, analyzing, evaluating, and creating. While Blooms taxonomy is an educational theory for learning, it seemed to be a good fit for what was needed in how to situate where clients are in thinking about their problems. The realization for me was that this is exactly what we do in therapyhelp clients situate or figure out where they are in thinking about their problems. Are they totally in the dark and need to remember or understand what the problem is, or are they unable to apply a strategy to deal with their problem? This realization became an inspiring and obvious way to teach therapists how to work with their clients to create a process for writing measurable outcomes.

One of the early first applications of using Blooms taxonomy and applying the cognitive domains in the assessment process and treatment plan occurred at that same clinic. A therapist and I looked at the common objective of improving self-esteem listed in a treatment plan of one of her clients who had vague complaints of not feeling good about herself. The client seemed resistant to following up on any ideas that the therapist suggested regarding positive self-talk or focusing on her strengths or engaging in ways to feel better. The therapists use of use of motivational interviewing and cognitive behavioral therapy approaches, for example, were met with resistance. The therapist then approached the client with the suggestion of working with her to rethink this issue of low self-esteem since she was not making any progress. The therapist spent a session asking the client to consider what this thing self-esteem would look like, and how it would act if it were to enter the clients life, rather than just talking about things she might do to feel better. The client was asked what and perhaps who might help with her self-esteem. This proved to be an interesting approach, and it took some time for the client to figure out what that actually meant to her. Using Blooms first cognitive domain, remembering/recalling, the therapist asked her to try to remember or identify what she thought self-esteem meant for her. The client reported that it was feeling good when interacting with people and having a sense that they liked her. This prompted a more in-depth discussion about the breakup with the clients ex-boyfriend. For the first time, she shared that her ex-boyfriend had often belittled her, something she previously had not spoken about, and she identified that after the breakup she spent a year isolating herself and came to believe she was a bore. She was asked to try to continue to work on remembering (cognitive domain 1) and be more specific about the kinds of things she did when interacting with others that were pleasurable. At first, she did not identify anything specific. That was a measurable outcome. Several weeks later, she identified that reconnecting with one particular friend who used to make her laugh was something that was always pleasurable and that started a new direction and focus for her. For the first time, she began to use various cognitive behavioral therapy (CBT) and dialectical behavioral therapy (DBT) strategies that she previously had shown no interest in doing, and soon she and the therapist together began to