As therapists, we have witnessed dramatic changes in the mental-health profession over the last 10 years — chiefly in the amount of control we have over our professional lives and activities (Berkman, Bassos, & Post, 1988; Cumming, 1986; Zimet, 1989). Once the complete and total “masters of our domain,” our power to make even the smallest of decisions regarding clinical practice seems to have dwindled to near nothing. Clinical decision making, in large part, has been usurped by giant healthcare corporations and our professional organizations. In place of the control we used to have are a host of activities that corporate types and policy wonks have implemented under the guise of improving effectiveness and efficiency.

Like most therapists, our team struggled mightily with the changing nature of clinical practice. Somewhere along the way, we decided that accommodation was the pathway most likely to lead to survival. So, when the call came for more efficient modes of mental healthcare delivery, we eagerly sought out training and worked to develop our own time-sensitive approaches to treatment (Berg and Miller, 1992; Duncan, Solovey, & Rusk, 1992). With an attitude of “Render under Caesar the things that are Caesar's,” we adopted the diagnostic language of psychiatry and learned how to write treatment plans. Sensitive to the changing trends in clinical practice, we learned, too, about psychotropic medications and worked collaboratively with professionals from different backgrounds in multi-disciplinary treatment teams. We even sponsored workshops in our own areas on what managed-care entities and our professional organizations were calling “best practices” — the idea that effectiveness and efficiency could be improved by applying the “right” treatment approach for a particular problem.

In truth, we had little problem with the idea that treatment should be as effective and efficient as possible (neither did any therapist we ever met in our more than 50 years in the field).

Reappraising our professional identity

Over time, however, it became increasingly clear that most of the changes we were making or being asked to make in our clinical work added little or, worse yet, were even at odds with these ends. We could not understand, for example, how completing lengthy treatment plans saved time or money or increased the effectiveness of treatment.

If anything, the growing number of phone calls and forms needed to obtain authorization for even a couple of sessions waste precious time. Moreover, few therapists found the negative, pathology-ridden language of the DSM (APA, 1994) particularly helpful in organizing or conducting their clinical work. Indeed, most often, the homage paid to diagnostic labels on managed-care forms only exacerbated long-held concerns about client confidentiality and access to treatment.
Finally, we found it more difficult to keep up with therapeutic approaches that flitted in and out of fashion with unparalleled rapidity. Even when we took the time to learn a new approach, our results were seldom as dramatic as those we witnessed on videotape at the ubiquitous continuing education workshops.

Of course, experiences like these led us to feel discouraged. We had truly believed that accommodation would enable us to thrive in the “brave new world” of managed care. In reality, however, our Darwinian efforts to evolve and adapt only made matters worse. Rather than being valued for our hard work, we nonmedical helping professionals had become what former APA president Nicholas Cummings predicted nearly 10 years earlier, ‘poorly paid and little respected employees of giant healthcare corporations.”

The discouragement we felt forced us to take a long hard look at the field of therapy and engage in an agonizing reappraisal of our professional identity. At first, we considered fleeing the field. Several close friends — talented therapists all — had already left for “greener pastures.” The truth was though that none of us actually wanted to leave. At the same time, we knew that continuing to accommodate was no longer an option. If we had learned only one thing from our experience up to that point, it was that continuing to go with the flow would only serve to erode any remaining worth and value of our work.

We were also aware that fighting (read: whining and complaining) would accomplish nothing. Managed-care entities and other third-party payers could simply shift their business to more “cooperative providers” (who, by the way, were in abundant supply). The question was, however, what options were available other than fighting, fleeing or going with the flow?

While struggling to answer this question, we eventually stumbled on the realization we possessed no reliable and valid means for showing our work was effective or efficient. Though originally intended as such, the various practices adopted and enforced by managed care had not proved helpful in this regard. Our own experience, in combination with reams of research, showed that therapists could use treatment plans, diagnostic labels and approved treatment models from now until doomsday and the overall effectiveness and efficiency of therapy would not improve in the least (Duncan and Miller, in press a, in press b; Johnson, 1995; Johnson & Shaha, 1995).

Daily, we could see the difference therapy made in the lives of our clients. We also knew that available research provided strong support for the overall effectiveness of treatment. Most studies find the average treated person is better off than 80 percent of those without the benefit of therapy (Asay & Lambert, 1999). And yet, divorced from formal, systematic feedback about the outcome of our work, the field had become a jumble of competing, complicated and often contradictory theories and practices. To outsiders, the therapy scene could only be viewed as “chaos.” Making matters worse, the overall effectiveness of psychological intervention had not improved a single percentage point over the last three decades despite the fact there was an explosion in the number of available treatment approaches (Hillman & Ventura, 1992; Garfield, 1982; Kazdin, 1986; Miller, Duncan, & Hubble, 1997).
The more we thought about this, the more convinced we became that this state of affairs was the crucial challenge facing our profession. The comet of managed care had struck “Planet Therapy” destroying life as we had once known it. We realized that if we were going to avoid the fate of the dinosaurs, if we wanted to be treated as respected and valued professionals, and if we wanted to insure the continuation of quality mental-health services for our clients, we had to lead into the next millennium. In particular, we would need to establish valid and reliable standards for assessing and improving both the effectiveness and efficiency of clinical work. To do otherwise would simply hasten the current transfer of control over our professional lives to accountants and actuaries, thus placing our independence as a group on the fast track to extinction.

Evaluating progress and effectiveness

We immediately set about forging this new pathway. A thorough review of the research literature uncovered a host of methods for evaluating the progress and overall effectiveness in treatment (Brown et al., 1999; Fischer & Corcoran, 1994a & 1994b, Froyd, Lambert, Froyd, 1996; Howard et al., 1996; Johnson & Shaha, 1996; Ogles, Lambert, & Masters, 1996). Much to our surprise, they were neither complicated nor expensive. They did not require a background in statistics or sophisticated research methodology to understand or implement them.

For the most part, they utilized simple paper and pencil rating scales that were either in the public domain or could be obtained for a nominal fee. More important, they all had the advantage of being standardized, psychometrically sound and accompanied by an abundance of normative data, which could be used for comparative purposes.

Within a short time, we had managed to piece together elements from several of these approaches and started tracking the outcome of all of our cases. Since then, we have been using the resulting data to inform our clinical work. Our particular approach assesses two types of outcome: (1) clinical; and (2) client satisfaction. Clinical-outcome measures, as the name implies, assess the impact or result of the service we offer our clients. Customer-satisfaction measures, on the other hand, assess the client's personal experience of how well they were served by us, including such factors as courtesy, timeliness, accessibility, professionalism, the strength of the therapeutic relationship and qualities of the treatment setting (Hill, 1989; Lebow, 1982; Pasco, 1984).

As surprising as it may be, using the outcome-assessment process has been mostly trouble free. With rare exception, our clients have been willing and interested participants. As one man we worked with put it, “We're evaluating you anyway!” We did learn early on that the measures we used had to be sensitive to our clients’ expectations for care. For example, we had to abandon a popular and well-respected outcome instrument when our clients expressed dissatisfaction with the 20 minutes that it took to complete. Further, we learned that the process had to be tailored to fit with the unique nature of the services we offered. As therapists working in an outpatient setting, for instance, we could not predict with any degree of certainty when our clients would stop coming for therapy. This meant that to have data on all our work with clients we had to find instruments that could be administered at every session.

Measuring clinical outcome

The clinical outcome measure we eventually chose is the Outcome Questionnaire 45 ([OQ-45]; Lambert & Burlingame, 1995). 1 We liked the measure for several reasons. First, the instrument is reliable, well validated and inexpensive — costing less than three cents per administration. Second, it can be administered and scored in less than five minutes. Third, and particularly important in the outpatient setting in which we work, the measure has the advantage of being applicable to a broad range of clients, presenting complaints. This saves us, of course, from having to master a different instrument for each problem or client population we encounter. To assess client satisfaction, we use the Session Rating Scale ([SRS]; Johnson, 1994). 2 As with the OQ-45, the SRS can be completed and scored in a matter of minutes. We also like the measure because it is sensitive to clients' perceptions of what matters most in successful treatment ([e.g., the creation of hope and expectancy, use of client resources, and a strong therapeutic alliance]; Lambert, 1992; Miller, Duncan, & Hubble, 1997).

Thus far, the evidence we have gathered has provided us with ample empirical proof that we are working efficiently and effectively. Indeed, the data indicate that our work has actually improved over time. This information came in rather handy when, some time into the project, our usual referrals were redirected to a group of practitioners that charged a lower per-session rate. We were quickly returned to the provider list and even given more referrals than before when we showed our data to the provider relations representative at the managed-care organization (Johnson & Shaha, 1995).

Clearly, data talks. For all that, in some instances what the data had to say was less reassuring. Specifically, the findings challenged the validity of a number of cherished beliefs and clinical traditions, forcing us to consider a radically different vision for the future of mental-health training and treatment. As just one example, consider the fairly common assumption that producing significant psychological change is a difficult, long-term process. In his massive and systematic review of the current research and thinking on change in psychotherapy, Michael J. Mahoney (1991), indicates that this belief is, one of the important points of convergence across contemporary schools of thought in psychotherapy. Our own research, however, found quite the opposite to be true. As a rule, the majority of our clients experienced significant improvement early in the treatment process or did not improve at all. In fact, clients' experience of meaningful change in the first few visits emerged as one of the best predictors of eventual treatment outcome.

When a review of the literature uncovered a large number of studies with findings similar to ours, we were left wondering how the field had ever come to view change as a difficult and long-term process. In most of these studies 60-65 percent of clients are found to experience significant symptomatic relief within one to seven sessions — figures which increase to 70-75 percent after six months and 85 percent at one year (Howard, Kopte, Krause, & Orlinksy, 1986; Howard et al., 1996; Smith, Glass, & Miller, 1980; Steenbarger, 1992, 1994; Talmon, Hoyt & Rosenbaum, 1988). And yet, research clearly shows that practicing therapists believe that achieving clinically meaningful change takes significantly longer — in most studies, between 400 and 800 percent longer — than it actually does (Garfield, 1994; Lowry & Ross, 1998). A host of aphorisms have even developed to support this view. For example, “some clients have to get worse before they get better,” and “long-lasting change comes from therapy that lasts long.”

The reason for this difference between clinical and empirical reality became apparent after we compared data gathered at the beginning stages of our outcome project with data collected at its completion. As already noted, we were working more efficiently and effectively at the end of the project. Contrary to what we expected to find, however, most of this improvement did not result from doing better clinical work in general. Instead, it came about from identifying a relatively small number of clients not making progress early in the treatment process and then doing something different with them. According to the research literature, similar clients account for only 10 percent of clients but a whopping 60 percent of total mental healthcare expenditures (Garfield, 1994). Before gathering outcome information at every session, we might have continued to meet and struggle with these clients for a long period of time with few positive results.

Dramatic results

A good example of how our work changed can be found in the case of Steven, a man in his thirties who presented for treatment with complaints of chronic depression, lethargy and low self-esteem. Steven reported having been in treatment numerous times before —on at least two occasions for a period lasting several years. While he believed that each of these experiences had been helpful, his continuing struggle with depression left him feeling that some “underlying issue” remained unresolved from his childhood. He expressed a strong desire to finally “get to the root” of the matter. We agreed and, over the next few sessions, worked with Steven exploring various experiences from his childhood and attempting to make connections to his current problems.

Steven expressed considerable satisfaction with the therapy, giving the work the highest marks possible on the SRS — our client satisfaction measure. His scores on the OQ-45 — our clinical outcome measure — told a different story, however. Though not obvious on the surface, Steven was not only not improving, he was slowly getting worse. The difference this time, however, was that we knew it. As a result, where in the past we might have continued with the same treatment for several more sessions, we were now able to explore different treatment options with Steven by his fourth visit. The results were dramatic. After a simple change in the treatment approach — from a dynamic to a more competency-based approach — Steven's scores on the OQ-45 reversed and began improving. We finished our work together by the eighth session. When recontacted a year later, Steve reported having maintained the changes without the need to revisit his childhood or seek further treatment.
Although opening a dialogue about the lack of progress most often stimulated positive therapeutic results, we were not always able to find a helpful alternative for such cases. On those occasions, we talked openly with the clients about the lack of results, taking the time to communicate our belief that our failure said nothing about them personally or their potential for change. Some clients terminated at that point, others asked for or accepted a referral to another clinician outside our group. In no such instance after starting our outcome project, did we continue to work with a client whose scores on the outcome measure showed little or no improvement by the sixth visit.

On reflection, our results should not be taken to mean that all therapy should be “brief therapy.” Quite the opposite. Carefully following the outcome of our cases was in large measure responsible for convincing us that the brief- versus long-term therapy debate obscured rather than clarified the important issues at hand. In terms of outcome, no optimal number of sessions emerged. Rather, only a number of sessions by which we could accurately predict whether or not a particular therapist, working with a certain client, using one treatment approach versus another was likely to be helpful or not. Regardless of the treatment model used, therapies in which little or no progress (or even a worsening of symptoms) occurred in the early sessions were not likely to be helpful in the long run and need to be changed or discontinued.

Neither should the results be viewed as an endorsement of one model or method of treatment over another — in the case of Steven, competency-based rather than dynamic treatment approaches. In fact, another challenging — if not disquieting — finding of our project was that who the individual therapist was mattered a great deal more in terms of outcome that what model or theoretical orientation the therapist practiced. Who the therapist was also mattered more than their licensure status, technical expertise, knowledge base, national reputation or years of experience. Simply put, some of us engendered change in our clients while others either did not or took significantly longer to do so.

Even when treatment was carefully monitored and everyone was using the same approach, large differences in effectiveness between therapists persisted. For example, in a study we participated in at the Brief Family Therapy Center where everyone was practicing solution-focused therapy, two therapists, who were students at the time, emerged as clearly more effective than the rest -—Mary Jo Robinson and Joann Sallman (de Jong & Hopwood, 1996; Hopwood, personal communication, 1998). Our review of videotapes of their sessions was of little help in accounting for the difference. Indeed, by all traditional standards, their work was crude and amateurish.

Here again, we found ample support for our finding in the general research literature. In general, studies indicate that the personal qualities of the individual therapist are two to three times more important in successful treatment than the model or theoretical orientation the therapist uses (Miller, Duncan, & Hubble, 1997; Luborsky et al., 1986). This is especially true of studies which have been conducted in the real world of clinical practice rather than in an artificial laboratory setting. In one representative study of more than 2,000 therapists and thousands of clients, for example, researchers Brown, Dreis and Nace (1999) found wide variations in outcome between clinicians that could not be accounted for by treatment approach (including medical treatment), type of training or certification, or years of experience.

Such research, along with our own results, made us aware of something we had known for a long time albeit only intuitively. There were clinicians we thought of as helpful, with whom we would entrust the care of our own family, and others that we did not. Most clinicians we knew and respected had similar intuitively-derived lists. Being able to document this empirically, however, changes matters entirely and has strong implications for mental-health treatment and training.

For example, some therapists however well intentioned or trained are simply not effective. Although research indicates that the number is low, it also shows that these clinicians' cases make up a disproportionate number of those with either poor or negative treatment outcomes. As heartless as it may sound, a system needs to be in place for removing these practitioners from direct service. Moreover, in order to prevent this problem in the future, we must change our current standards for admission, training and credentialing as therapists. In particular, from the current emphasis on the mastery of theory and techniques to the ability to achieve positive treatment outcomes.

Our professional organizations could help member clinicians gather and analyze outcome information and provide them with feedback about their day-to-day clinical work. This information, in turn, could be used to develop national norms for clinical practice. Norms which third-party payers and other funding agencies could use to determine appropriateness for psychological treatment based more on a prospective client's ability to benefit rather than empirically bankrupt practices such as psychiatric diagnosis, any treatment approach as a treatment of choice, or professional discipline. In the process, they would also help us establish a professional identity separate from our economically more successful half-siblings in the field of medicine — a group that we, as non-medically-oriented treatment professionals, have been subordinate to throughout our history.

Existing technology virtually insures that such a system is possible. Unfortunately, our professional organizations appear to be heading in the opposite direction. Rather than fostering the development of methods for the routine, systematic and empirical assessment of outcome, the American Psychological and Psychiatric Associations are currently competing with each other to generate lists of “approved” therapeutic modalities that will be used to dictate which treatment approaches their members employ. In a move that research clearly shows will neither improve outcomes or reduce costs, the American Psychological Association is spending a bundle trying to wrestle prescription privileges away from the field of medicine — a move which movers and shakers within the American Association of Marriage and Family are obviously considering given their recent collaboration with and generous support from a large pharmaceutical company (AAMFT, 1998; deLeon and Wiggins, 1996; Fisher and Greenberg, 1997; Greenberg, 1999; Hubble, Duncan and Miller, 1999; Klein, 1996; APA, 1992, Lorion, 1996).

Clearly, the people we work with would benefit from a field that credentialed practitioners on their ability to achieve results. They would also benefit from treatment innovations which, when introduced and used, had already been shown to result in better outcomes. Confidentiality would be virtually assured given that the availability of outcome data would make the transmission of sensitive personal information to third parties unnecessary. Moreover, because much of the data gathered would be based on clients' experiences and self-report, our consumers would be invited for the first time to become full and equal participants in the treatment process.

There were many other challenging findings from our project. Additionally, more provocative results are in store in the future as data from a much larger study that we are conducting at Nova Southeastern University become available. Suffice it to say, however, that our present results have provided us with a method for proving and improving the effectiveness and efficiency of our clinical work. We believe that becoming more outcome-informed is an alternative which fits with how most practicing therapists we know of prefer to think of themselves; that is, sensitive to client feedback and interested in results. We also believe that it is the best hope we have for insuring our survival and independence as nonmedical helping professionals. At the same time, we think that the “window of opportunity” we have to act proactively as a group is closing. We could be wrong, of course. One thing is certain, however, only the survivors will be around to tell the story.

1. The OQ-45 can be obtained from American Professional Credentialling, P.O. Box 346, Stevenson, MD, 21153-0346.

2. The SRS can be obtained from Lynn D. Johnson, PhD, Brief Therapy Center, 166 East 5900 South, Suite B-108, Salt Lake City, UT, 84107.

3. Institute for the Study of Therapeutic Change, Chicago, Illinois
Scott D. Miller, PhD., is a co-founder of the Institute for the Study of Therapeutic Change. He lives and works in Chicago, Illinois.

4. Barry L. Duncan, PsyD., is a Professor in the Department of Family Therapy at Nova Southeastern University in Ft. Lauderdale, Fla.

5. Lynn D. Johnson, PhD., is director of the Brief Therapy Center of Utah in Salt Lake City, Utah.
Mark Hubble, PhD, is a cofounder of the Institute for Therapeutic Change.

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