Therapeutic alliance questions (e.g., Did the client feel heard and understood by the therapist? or Did the client believe he or she was treated as competent to explore alternative thoughts, feelings, and behaviors, and to make decisions for him- or herself?)

Satisfaction questions (e.g., Did the client get what he or she wanted out of the therapy experience? or Based on the therapy experience, would the client be inclined to return to this therapist if counseling is needed in the future?)

Therapeutic alliance questions - I think it's important too add  :

I feel that therapist assist me (client) when I (client) speak about difficult and sensitive issues.

I feel that my therapist assist me  (client) in my striving for change.

So let me refine my question.  How would you define  yourself differently at the end of a successful therapy?   How have you changed?  What has changed?  

Do you (patient) like yourself again?

Good luck with your measure!

Psychoanalytic therapies in fact are partner-relationship therapies, the partners being I and Me: do I succeed in changing my attitude towards myself from being judgmental, demanding and condemning to being accepting, rewarding and validating?

In my opinion you need to define targets with patient and then at the end of the therapy, you can check the target list and find the achievements together

Making no apologies for the values implicit in derivation of outcomes, we would want to see a client on a path increasingly capable of deeper, richer, more meaningful  interaction with other people.  These "other" being those primarily those most immediate, capacities such as empathy, understanding, willingness to engage, etc.  Clearly, the client is aware of these targets from the onset.

Self-perception questions: As a result of therapy, do I see myself more positively? Do I accept myself more? Am I more satisfied with myself?

Others-perception questions: Do I see others more positively? Am I more open to them?

Relationships questions: Do I feel more confident about my relationships? Am I more open to initiate and maintain a relationship?

Productivity questions: Am I more confident at work? More motivated to face new challenges?

Best,

Stephen

As a result of therapy do I feel more hopeful about:

The Future, My self, my relationships, my ability to cope and manage they day to day,  long term goals, expectations I have for me and my world, the expectations the world has from me. 

I think Goal Attainment Scaling (Kiresuk & Sherman, 1968) has tremendous potential as an approach to measurement that is patient-centered, flexible, practical, and able to be aggregated.

The main question to be posed is: what are, you and the patient, hoping of this therapy?

It can be the disappearance of a sign, say a phobia or a global improvement of an illness, say depression or merely compassion.

It can be relatively easy to check objective result on a scale.

Besides, subjective result depends of bilatearal (trilateral ?) communication and, however, if curent fails to pass, machine fails to work.

Subjective satisfaction can be appreciated on a simple numeric or analogic scale.

Hi Jacques,

It is very useful to have evaluation of psychotherapeutic outcome. The first step towards final evaluation is introduction of such measures. My view is that discussion of expectations and outcome needs to be done in the first session. I usually start by asking a client to write down few goals she/he is prepared to work on,  than I would ask a client to break down the process into what I call "baby steps" through which the process will be monitored. That gives a chance to both, myself and client to keep close eye on the process and do corrections if and when necessary.  Finally, I ask a client to write down time span for each step desired.

The process of discussing expectations and goals gives me an idea how aware is the client of work that they need to do and how well they know themselves. I also ask the client to look at their previous record of changes and let me know if the steps and goals they wrote down are in line with his/her usual way of working towards goals or not. I sometimes find that part of the problem is the way some clients set up their goals and expectations. Not everyone is good at setting goals and measures and planning. So for me, the first step starts with understanding of how real or not, each client might be about their expectations. The funny part is that occasionally some clients' expectations or timing are so unreasonable that I take out magic wand ( I have play room and see kids and adults hence available toys) and wave it around - and say that what they desire will need one of these...  

Perhaps this article on psychotherapeutic outcome with focus on changes in behavior, increases in self-efficacy and improved coping would be of interest:

G. Krampen. Direct measurement of psychotherapeutic outcomes: Experimental construction and validation of a brief scale (2010). Psychological Test and Assessment Modeling, Volume 52, (1), 29-47.

 I find answering these two questions helpful:

1. Do I (client) feel more empowered after the therapy to deal with issue(s) which prompted me to engage in the therapy?

2. Do I (therapist) feel confident that I equipped this client with skills which will help them deal adequately with the identified issue(s)? 

Regards

Jacques

I am jealous I always wanted to develop the type of measure you are developing.

I am sure you are aware of the research by Connolly and Strupp (1996). They found that clients reported improved self-understanding, improved self-confidence, and greater self-definition in addition to improved symptoms/interpersonal distress. 

The thing that I really like about this article is that there are verbatim statements from clients about the changes that the clients made. I have always thought that these client statements would provide a good starting place for developing items to assess self-understanding, improved self-confidence, and greater self-definition.

I have found that an important aspect in therapy outcome is the client's increased ability to make use of problem solving strategies based on a realistic appraisal of their personal resources and amount of control that they can exert in various everyday life situations. Matching their personal efficacy with appropriate locus of control eventually leads to greater satisfaction and more effective functioning. 

Self-reported improvements in quality of life and/or improved functionality in every day activities.

I was pleasantly surprised how grateful patients were after I started regularly to do MADRS (using a structured protocol) for grading their depressive symptoms. Sometimes self-assessment can seem like a routine and not directly applicable to the patient. But in general, I agree with the previous statements of setting goals with a therapeutic relationship and adhering to those.

Though specific outcome measures are depend on the problem overall client would say " I feel better ". This is very subjective but really important. If the client accept him/herself as a worth human it is a good indicator, I will also look at their out appearance and their facial expressions and non verbal cues compared to the beginning. Their ability to resolve their problem would be another indicator. We have to make sure this ability is generalized. It is always better to have some baseline information about the personality and the behaviour of the person before he/she develop the problem. If necessary i would get help from a trustworthy key informant. As a therapist your satisfaction about the improvement   of the client also a good measure.

Good Luck

Kanthi

Dear Jacques,

Besides what you mentioned, I find it useful to ask my clients the following questions:

- looking back, was it worith the time and the money spent on psychotherapy?

- lookink back, what proportion of 100% possible change a therapy can offer did it occur to you because of the therapy?

- looking back, how much the therapist: gave his best, gave only half his best, didn't put much effort at all

- (transferrence) - I think my therapist: sympathized me, neither sympathized me, not antipathized me, antipathized me...

- etc.

(If you find this type of items interesting, write me at [email protected] and I will translate for you all the items I used in a personal research meant to boos up my psychotherapy practise.

Merci, Jacques!

What I hear from my patients is not that their symptoms or problems disappear but that their functioning has improved. That they can do more, listen more to their family, do things at home, go out for shopping, eventually start working again, et cetera. Most of them still have the same fears, nightmares, bad sleep, which appear in the symptom check lists, but when asked they say they feel better because they can do more.

My suggestion would be to include a general functioning list, although it stays important to listen to their own opinion about it.

I agree with the above, but also found that most patients also resolved general symptom such as anxiety and depression more than specific ones, especially if entrenched. In general, patients feel happier with themselves and get on with others better.

Client want to be able to link these functional improvements and symptom reductions with skills/toolsthey have been mastering.   Self efficacy with tools/skills are often a neglected outcome.  

I believe that the main item could be to measure the level or Insigth capacity. From the above, may depend success or failure of a therapy: interpersonal relations, theory of mind, anticipation, creativity, etc.

I think that one of the biggest things I can do for my clients is identify their informal supports. Being a social worker first I always include questions in the intake about who do they go to for support like family or friends.  I try to strengthen these supports so when therapy is not occurring the supports are identified and can be accessed for maintenance.  

I think as well as symptom reduction, patients also want to be able to function better in various domains such as developing friendships or at least increasing their social network, having intimate relationships, having satisfying work, and appropriate and satisfying recreational activities, etc. These things will of course be different for different people depending on what they value in life. Perhaps if we can assist people to not only reduce their psychiatric symptoms but also to pursue more of a life that is satisfying in these sorts of domains just mentioned then they are likely to obtain a greater overall level of life satisfaction and this may also protect them somewhat from relapse. The Values questionnaire that the Acceptance and Commitment Therapy (ACT) practitioners employ to guide therapy could well be useful here.  

John can you please send me the ACT questionnaire?  Thanks.  Hans and others, thanks for your feedback.  May researchers have tried to measure functioning but it's not really well done.  II would appreciate some thoughts about how to assess better functioning.

Denis, don't worry we'll send you a preliminary copy for feedback.  Thanks 

I think that an increased insight into symptoms and triggers for changes in mental health are an important indicator for assessing psychotherapeutic change.  I work in the field of adult learning disability and we assess people at the start and end of therapy in order to try to understand psychotherapeutic change.  This often seems to be reflected in the person experiencing greater engagement in interpersonal relationships and a more positive sense of themselves and their engagement in the wider community.

Functioning can be assessed by operationalizing the behaviours under study. Improvement can be detected by forming a hierarchy of behaviours in a particular domain and comparing the initial score with post therapy one. Alternatively, several behaviours can be mutually assessed by the therapist and client on a scale of one to ten and an increase in the score can indicate improvement. If the scale is administered post-therapy only, then a minimum criteria needs to be set to ensure that functioning is at an acceptable level.

improvement in overall functioning and greater capacity for pleasure and relatedness 

To assess client functioning, I'd consider some of these questions:

1. Problem-solving capacity questions: Am I more able to solve my own problems? Am I more confident in my ability to solve problems?

2. Adaptability questions: Am I able to adapt to new situations? Am I less flustered when confronted with unexpected situations? Am I more resourceful and creative in adapting to new circumstances?

3. Relationship questions: Am I more open and able to initiate and/or maintain relationships? Am I more content with myself and with my relationships? Am I more able to improve some of my interpersonal relationships?

Hi Jacques,

I wonder whether you are familiar with the work of Duncan and Miller in "Partners for Change Outcome Measures". They have 2 sets of questions to ask clients: one set is just at the beginning of the session - the Outcomes Rating Scales - which is a quite tool asking the client to position themselves in 4 (ambiguosly defined) 10 point scales: individually, interpersonally, socially and general.  At the end of the session they are asked to complete an equally 'simple' set of scales - Session Rating Scale - :  "felt understood and respected", "focus of the session" (where they abto to talk about what they wanted to talk), "a good fit with the style of the therapist" and 'overall sense of progress".

There is large amount of literature, starting with their original (?) book "the heroic agency''.

Hope this helps

Maria Nichterlein

Thanks Maria, we'll look into it

a greater sense of personal liberty

Absolutely including increased sense of freedom.  In our book, Psychodynamic Therapy: A Guide to Evidence-Based Practice, Rick Summers and I speak about freedom.  

I have also written a chapter with a colleague about therapists as "freedom workers".

Thanks for your feedback all.  

We have a draft of the measure and I will update you all on where we are with it

Post it on your page as a contribution

Although i went down the route of developing a sensitive distress measure (sPaCE) and both clinicians and clients found it useful - one other thing comes to mind - the sense from the client's point of view of a worthwhile authentic relationship. For some clients who have been very hurt feelings of trust, authenticity, genuineness and so on cannot be over emphasised. these feelings are hard to engender if the therapist is not trustworthy etcetera and prepared to connect with client feeling. I suspect that some of this is captured some of the time by relationship measures but clients have told me on various occasions about the need to protect the therapist who is well meaning and competent from the realisation that they are only getting half the story.

For some clients the extra mile needs to be walked, hard, but it may be the most valuable part of the journey for all concerned. For this subgroup outcome measures (including my own) may well prove rather useless.

Dear professor Barber,

I have a question for you. I am interested in methods that are trying to evaluate psychotherapy outcome but I am still very reluctant to accept all of them because of their way to distinguish placebo vs theraphy effect. I actually think that extraclinical ways of testing are not consistent for many reasons. Instead, an "intraclinical way" has to be preferred. I would like to discuss with you further this very important issue.

Kindest regards,

Maria

 I am sorry I didn't get notified of your comment, please email me directly. 

Jacques

A common measure that we use here is in terms of functioning: The Work and Social Adjustment Scale (Isaac Marks).

http://bjp.rcpsych.org/content/180/5/461.full This one doesn't appear below for some reason.

https://www.researchgate.net/profile/David_Mataix-Cols/publication/7722315_Reliability_and_validity_of_the_Work_and_Social_Adjustment_Scale_in_phobic_disorders/links/54ae3b360cf2213c5fe42948.pdf

https://www.researchgate.net/profile/Matteo_Cella/publication/51573471_Measuring_disability_in_patients_with_chronic_fatigue_syndrome_Reliability_and_validity_of_the_Work_and_Social_Adjustment_Scale/links/5474aa010cf245eb436ded18/Measuring-disability-in-patients-with-chronic-fatigue-syndrome-Reliability-and-validity-of-the-Work-and-Social-Adjustment-Scale.pdf

https://www.researchgate.net/profile/Kate_Tchanturia2/publication/224848756_Work_and_social_adjustment_in_patients_with_anorexia_nervosa/links/00b7d51f82c9823c96000000.pdf

It is a simple scale measuring impairment on 5 domains: work, family relationships, social relationships, leisure, home management.

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