Writing Measurable Outcomes in Psychotherapy [Illustrated] 0190927682, 9780190927684

Table of contents :
Cover
Half Title
Writing Measurable Outcomes in Psychotherapy
Copyright
Dedication
Contents
Introduction
1. About Psychotherapy and Outcomes
2. Bloom’s Taxonomy in Psychotherapy: The Cognitive Domain Rating Scale (CDRS)
3. Assessment: Gathering Information to Write Goals and Objectives
4. Goals and Objectives as They Relate to Outcomes
5. Examples of Writing Measurable Outcomes Using Language of Evidence-​Based Practices
6. Treatment Plans: Treatment Plans with Measurable Objectives/​Outcomes
7. Stumbling Blocks in Writing Measurable Outcomes
8. Questions and Review
Appendix
Index

Citation preview

Writing Measurable Outcomes in Psychotherapy

Writing Measurable Outcomes in Psychotherapy SHARON KOPYC, LCSW

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1 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © Oxford University Press 2020 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. 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: Psychotherapy—Outcome assessment. | Psychotherapy—Practice—Evaluation. Classification: LCC RC480.75.K67 2020 (print) | LCC RC480.75 (ebook) | DDC 616.89/14—dc23 LC record available at https://lccn.loc.gov/2019053058 LC ebook record available at https://lccn.loc.gov/2019053059 9 8 7 6 5 4 3 2 1 Printed by Marquis, Canada

This book is dedicated to the memory of my son, Jonathan Aaron Albert (1982–​2003)

CONTENTS

Introduction  1 1. About Psychotherapy and Outcomes  8 2. Bloom’s Taxonomy in Psychotherapy: The Cognitive Domain Rating Scale (CDRS)  28 3. Assessment: Gathering Information to Write Goals and Objectives  46 4. Goals and Objectives as They Relate to Outcomes  82 5. Examples of Writing Measurable Outcomes Using Language of Evidence-​Based Practices  103 6. Treatment Plans: Treatment Plans with Measurable Objectives/​Outcomes  124 7. Stumbling Blocks in Writing Measurable Outcomes  146 8. Questions and Review  162 Appendix  179 Index  189

Introduction

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

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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 Bloom’s taxonomy of six cognitive domains: remembering, understanding, applying, analyzing, evaluating, and creating. While Bloom’s 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 therapy—​help 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 Bloom’s 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 therapist’s use of use of motivational interviewing and cognitive behavioral therapy approaches, for example, were met with resistance. The therapist then approached the client

Introduction

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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 client’s 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 Bloom’s 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 client’s 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 create (cognitive domain 6) a number of action-​based measurable objectives that involved reaching out to her friend, in addition to identifying some activities and clubs she might join to meet new friends. In reviewing this process with the therapist, we concluded that in the beginning of this therapeutic relationship the therapist was too involved in the initial sessions trying to create things for the client to do to make her feel better, which was met with resistance. Change didn’t occur until the client was asked to participate in remembering (cognitive domain

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1) what she identified as being “self-​esteem” for her, which interestingly brought up memories of put-​downs by her ex-​boyfriend and elicited a response about self-​esteem, “interacting with people,” which then led to her reconnecting with someone who always made her feel good about herself. This example of the cognitive domain process may seem simplistic, and some might say that this could have been accomplished without using the process of “situating the client’s thinking” about remembering (cognitive domain 1). However, in this instance, it proved to be the place where this client was stuck with her problem of self-​esteem. She knew that was the problem, but directives to do things to alleviate her not feeling good about herself didn’t change until she was asked to take charge of what she remembered that made her feel good. This subtle difference in approach makes the point of how important it is for the therapist and client to “situate the client’s thinking about the problem” and not just create an arbitrary plan. In this case, starting with what the client remembered about self-​esteem led to discussions that empowered the client to finally make some progress. Other therapists in the clinic began using this model, and what was discovered was that, in some instances, therapy took on a positive direction and the client became more engaged in creating a dialogue that better identified what the client needed and wanted to work on or identified where the client was “situated in their thinking about the problem.” Some therapists discovered that the process provided a good way to illustrate more clearly what they and the client were working on already, it just described the issue better in measurable terms. Certainly, there were cases where the client made little or no change, but in all instances vague complaints were identified more clearly to create a measurable outcome. Some 5  years later, this book is the result of that experience. What started out as identifying a need to understand how to write measurable outcomes (level 2 cognitive domain, understanding) ended up in creating this text (level 6 cognitive domain, creating). As a result, the Cognitive Domain Rating Scale (CDRS) model for using Bloom’s taxonomy was developed as a way to situate clients’ thinking to write measurable objectives, done, of course, in the context of the psychotherapeutic process.

Introduction

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It is important to stress that much more has been learned along the way about psychotherapy and outcomes by taking on this task, as it reinforces how very important a strong psychotherapeutic relationship is for any outcome. Certainly, the importance of a therapeutic alliance is something that was stressed from graduate school and throughout my practice, but reviewing the overwhelming research about these elements and how it connects to outcomes is very relevant for this text and serves as a reminder even to veteran therapists. Writing measurable objectives is a skill, and it is a skill that is described in this text in the context of the psychotherapeutic process. It is a skill that involves applying Bloom’s taxonomy, which is integrated as an integral part of a treatment plan. In my opinion, the CDRS is one of the good practices involved in conducting psychotherapy, and as in any new skill building, rereading and practicing the skill take time. The case studies, dialogue, and treatment plans outlined in this text are designed to provide practical information to support the narrative description, the rationale, and the theoretical framework applied. The standardized tools and surveys in the Appendix were chosen to support the work in writing measurable outcomes, and, as discussed, some are very helpful in supporting and validating the CDRS process. It is important to point out that for many therapists it is not a difficult task to figure out how to write a measurable outcome, as one can certainly insert any number of action verbs to create some type of measurable outcome. The challenge and complexity involved are figuring out how to do it in a way that has legitimacy and is meaningful, which is what this process can accomplish. As the great leader Winston Churchill is quoted as saying, “Out of intense complexities intense simplicities emerge”; taking the complex task of writing meaningful measurable objectives out of the complex, sometimes morass, of issues that clients present is certainly what I believe the CDRS does for writing clear measurable objectives. And certainly, in thinking about the goal for all those who come to therapy, is it not to transform whatever is so complex and difficult into a simpler way of being and doing?

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Helping people make sense out of a complicated problem may have always been the goal of therapists, but providers and clients alike now expect evidence of outcomes, and more than just the employment of evidence-​ based practices but also evidence as determined by measurable outcomes. With limited resources, funders want evidence that clients are making observable changes. In addition, many of today’s sophisticated clients not only expect to know what kind of treatment they are receiving but also what they can expect as an outcome. This book is organized to provide the learner with all the information needed to write measurable goals, by beginning with a discussion of the important elements involved in psychotherapy as they relate to outcomes and continuing with a progression that runs the gamut from assessment to treatment planning. The use of real-​life composites of case examples, including evidence-​based practices, enables one to get a clear sense of the process, including the benefits of the CDRS, which I created as a shortcut reference to using Bloom’s taxonomy of six cognitive domains. As practitioners, we have an ethical responsibility to think first about connecting with our clients and helping them deal with their distress. If that is always the goal and focus, then the issue of developing the skill set offered in this text will not be a difficult task. The new skill set of writing measurable outcomes using the CDRS model will be added to what therapists already do and should make their job easier in clarifying and writing measurable outcomes. What has been taken into consideration in the development of this model is that it is effective, efficient, and in line with a person-​centered, shared decision-​making approach. It becomes a natural part of the assessment process as the therapist and client consider where the client is “situated in their thinking” or what cognitive domain is operating in the context of their problem, which paves the way for ease in writing measurable objectives. As I  review the chapters and the connections made about the psychotherapeutic process in the context of outcomes, it seems that this text is a good outline of what is necessary to conduct oneself in a useful way, from the moment a client contacts the therapist to the end point of treatment, while also accomplishing the goal of conveying how to write meaningful, measurable outcomes.

Introduction

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Though I can certainly say that writing this text was a solo effort, I am very grateful to those I’ve cited. These brilliant researchers and clinicians—​ confirmed and validated empirically and otherwise—​gave me the support to create the model I’ve put together for how to write measurable outcomes within the context of doing effective therapy. Additionally, it is important to mention that I would not be the therapist I am if it were not for the supervisors, colleagues, and clients whose paths I’ve crossed. I cannot help but think of my first clinical supervisor, the late Dr. Carl Mindell, an astute and compassionate psychiatrist, as the individual who influenced me most and put me on the path of my career as a therapist. His brilliance, patience, and ability to teach laid the foundation for the clinician I am today. I am most thankful for my colleagues, friends, and family, who have been extraordinarily supportive of my work and this venture. But, truth be told, this book would not have existed if it not were my husband, Alan Nadel, who insisted that I take on this task. His unrelenting belief in my ability and intelligence and his faith that I have something important to offer the field were given with much love and support, of which I am most appreciative.

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About Psychotherapy and Outcomes

The goal of this chapter is to introduce how elements of psychotherapy and outcomes are aligned. The objectives are as follows: 1. To provide an explanation of three critical elements in psychotherapy 2. To introduce Bloom’s taxonomy (Anderson & Krathwohl, 2002) as a way of “situating” or rating various cognitive domains 3. To provide a list of seven skills important to psychotherapy and writing outcomes 4. To provide a case study to illustrate how psychotherapy and writing outcomes are an interactive process This chapter provides the basic groundwork for understanding that outcomes are the end processes of the dynamic collaboration that occurs between the therapist and client, which is fundamentally the process we call psychotherapy. For both therapists and clients, psychotherapy is a very difficult process to capture. It is often an intense experience in which people look to the therapist as the authority for help to alleviate some type of distress. How that process works and how therapists should conduct themselves to advance that process has been the subject of many forms of research for decades.

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The beneficiaries of that research are therapists and clients: “Across a wide number of approaches, populations, and presenting complaints, in terms of client reported outcomes, the average treated person is found to be better off than 80% of those who do not receive treatment” (Wampold & Imel, 2015). It thus makes sense that we should be aware of some of the significant elements inherent in a successful therapeutic relationship to ensure better outcomes. First, there is overwhelming evidence that the “relationship,” that is, the relationship between the therapist and client, is of utmost importance: Numerous studies and meta-​analyses demonstrate that the alliance or relationship is the single most important common factor for predicting clinical outcomes in psychotherapy (Lambert & Barley 2001). Duncan et  al.’s (2003) review of over 1,000 studies demonstrated that the strength of the therapist–​client alliance is one of the best predictors of outcome, and the amount of change attributable to the alliance is over seven times that attributable to the specific method employed in therapy. (Orme & Orme, 2012) Second, clients should be regarded as experts in the therapist–​client dyad(Miller, Hubble, & Chow, 2018). Drawing from a comprehensive review of 40 years of outcome research, The Heart and Soul of Change: Delivering What Works in Therapy, edited by Duncan, Miller, Wampold, and Hubble (2010), identifies core factors responsible for therapeutic success, with strong support for client feedback being key to ensuring that the client maintain the role as expert in the therapeutic relationship. It is interesting to go back to 1994, when Steve deShazer, a brief therapist, studied Milton H. Erickson’s cases, a hypnosis pioneer. deShazer attempted to isolate what accounted for Erickson’s great success with his clients, and although stringent research protocols were not administered, it was determined by Erickson that most of the ideas for interventions came from the clients (Zeig, 1994). Additionally, clients now have access to treatment options and are apt to come to therapy with their own searches regarding treatment and expect to

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be a part of the shared decision-​making (Ben-​Sasson, 2011). These and other studies support the obvious—​that clients know best about themselves, their problems, and their issues. It is also important to consider the cultural issues that have impacted clients’ histories that may have significance in their psychotherapy. And, certainly, attending to the client’s cultural background is the most responsible way to conduct oneself as a culturally competent practitioner (Nicotera, 2018). The third, and a very important, aspect of ensuring meaningful and measurable outcomes is to obtain feedback from clients. In the area of psychotherapy, practitioners have much more confidence in their abilities to judge clients’ progress than is warranted by the data (Hannan et  al., 2005)  (Lambert et  al., 2003). Much as we might like to think of ourselves as highly perceptive, evidence demonstrates that most therapists cannot accurately determine how clients are responding to interventions (Lambert et al., 2002), except perhaps for changes in demeanor during sessions, without the aid of objective measures. (Orme & Orme, 2012) It seems clear that to achieve positive outcomes in psychotherapy these three elements must be present: a therapeutic alliance; a client-​centered approach, otherwise known as shared decision-​making; and, finally, feedback in the form of outcomes. To assess how well these aspects of treatment are playing out is important for outcomes. The research points out that feedback is obtained mostly through self-​report, along with additional data from standardized scales. According to Duncan, Miller, and Sparks (2004), “outcome management results in significant improvements in effectiveness of psychotherapy services” (p.  83). These same authors state that “outcome research indicates that the general trajectory of change in successful therapy is highly predictable, with most change occurring earlier than later in the treatment process” (p. 83). The value lies in the feedback that is given at the early stage of treatment, as it is reported that the critical time frame for engaging the client is in the first three sessions;

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dissatisfied clients are likely to drop out of therapy unless there is a change in the direction of treatment. As Lambert et al. (2001) state, “patient-​based research as typified by the use of markers that indicate progress (or lack of it) provides a perspective on change that cannot be derived from clinical intuition alone; the best way to predict final response to therapy is to measure current response to therapy” (p. 66). However, even given the stringent controls in these research settings, there are still limitations. As Lambert et al. (2001) point out in their conclusion on a study of psychotherapy and outcomes, “self-​report measures of improvement provides one view of the impact of therapy on patients” (p.  66). And, it must be remembered that standardized scales need to be used judiciously as the general constructs may not apply to any one particular client. Given these limitations, it seems reasonable, if not efficient, to consider a process that involves measuring outcomes based on an action on the part of the client. Action-​oriented outcomes are easily written using Bloom’s taxonomy, which involves assessing where the client is in thinking about their problem and then taking it a step further to determine what the client must do or how they should act on that problem for measurable change. While a more detailed explanation of Bloom’s taxonomy is found in Chapter 2, this process is introduced here. The cognitive theory of Bloom’s taxonomy is a way to “situate a client’s thinking” by “rating” their thinking on one or more increasingly complex cognitive domains: remembering, understanding, applying, analyzing, evaluating, and creating. This process is used to construct possibilities for creating meaningful, measurable outcomes by being able to discern cognitively how clients comprehend the problem. Using this rating scale affords a clear process for both the therapist and client to recognize what action to pursue toward change. However, before one can consider taking the steps toward learning how to write these measurable outcomes using Bloom’s taxonomy, we need first to reflect on psychotherapy and the elements just described, which is the essence or art of psychotherapy.

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Certainly, becoming a master therapist takes time, practice, and reflection. Knowing about the elements just outlined does not describe the dialogue or how to finesse creating that engagement, let alone what to do when you know therapy isn’t working. Even the best outcome rating scale may not be enough to figure out what to say and do about engaging a disengaged or dissatisfied client. In addition to learning processes about psychotherapy and writing objectives, looking at the work of master therapists can be illuminating. Viewing videos of Virginia Satir, Irving Yalom, Salvador Minuchin, Donald Michenbaum, Brene Brown, Janina Fisher, Marsha Linehan, Joan Borynshryko, and many other master therapists (see Psychotherapy and Counseling Videos, at https://​www.psychotherapy.net/​videos) can assist in learning the intricacies of conducting therapy:  Posing questions, responding to shifts in topic and affect, and attending to tone of voice, body language, and use of self can be critical in making that relationship work and how to redirect and deal with difficult clients or difficult topics. Also, reading the honest and humble dialogues of these and other master therapists can be very enlightening. Inside Therapy, edited by Ilana Rabinowitz (1998), is a series of essays by analysts who share personal observations of themselves and their clients. While in some ways these analytical reports seem dated, if not sexist, there is still much to be gained from reading these analysts’ descriptions about being in the therapy room with clients. This is particularly useful, as it is rare to encounter readings regarding issues of transference and countertransference since that phenomenon is hardly acknowledged in today’s “brief therapy” climate. In the Foreword in Inside Therapy, Irving Yalom discusses insightful, invaluable, and honest reflections from the perspective of the therapist and provides an authentic portrayal of what a client understands and experiences. Yalom was ahead of his time regarding the importance of a client-​centered approach and shared decision-​making, saying in the Foreword: “Creative therapy is shaped by both therapist and patient. In fact the process of creation of the therapy is an intrinsic part of the work, and therapists must facilitate the patient’s creative participation” (Rabinowitz, p. xv).

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More recently, Kottler (2017), in his book On Being a Therapist, provides a humble and candid discussion on what it means to be a “healer and helper,” including ideas of what skills can be learned to ensure success. Daryl Chow’s very interesting and timely book with a provocative title, The First Kiss, Undoing the Intake Model and Igniting the First Sessions in Psychotherapy (2018), provides a refreshing look at ways to engage with clients and also very specific ways to use outcomes to do that. He stresses the importance of when using the intake model of gathering information about who, what, when, where, and how that it not be done with the neutrality of a journalist gathering information but with empathetic curiosity. It is wise to look at his chapter on ways of questioning to elicit responses that do just that, to get the information while at the same time engaging the client. He resonates with the belief stressed throughout this text “that the goal may be to figure out the goal” (Chow, 2018, p. 61). Bergin and Gardifleld’s Handbook of Psychotherapy and Behavior Change (Lambert, 2013)  stands out as the handbook that all clinicians should have at their side. This all-​encompassing text begins with an historical overview of psychotherapy and goes on to extensively cover methodology, research, practice guidelines, and outcomes and reviews therapies for special groups. A totally different kind of view of practicing psychotherapy is offered by Lillian Rubin, psychotherapist, who does a masterful job of describing the process of “doing” therapy, in her book The Man with The Beautiful Voice (2003). While the text is almost two decades old, it is in essence undated, as she explains with eloquence and wit the art of therapy, both as a neophyte and as an experienced therapist describing cases from her practice. Her book is a rare opportunity for therapists to get a first-​hand sense of how to talk, engage, be human, and put the client in the role of expert and, perhaps even more importantly, how the reflection and humility in thinking about one’s “performance” as a therapist have a profound effect on how well it all goes. As beautifully as Rubin describes the therapeutic journey with her clients, it is unlikely that Rubin’s description of her cases would meet the standards for measuring outcomes. I say this hoping that the reader understands the absurdity of that statement, as it was not

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Rubin’s goal and intention to provide evidence for measuring outcomes. The reference here to her book, however, is very important in a discussion about psychotherapy AND measurable goals, because it is important that clinicians read how master therapists finesse the art of engagement, as clients are apt to continue in therapy only if that connection and relationship develop. And, obviously, measurable outcomes exist only if there is an ongoing therapeutic relationship to meet that end. Think about your own experience in therapy, or about others who have reported to you saying, “my therapist helped me with my self-​ confidence  .  .  .  my therapist helped me with my grief  .  .  .  helped me with my self-​esteem.” Those statements may be true, but how does one measure those claims? If the subjective experience of the client is that they were helped, why should it matter that those outcomes be measured? The demands that it matter have been driven in large part by funders, such as managed care entities that look at outcomes to assess quality of care and use outcomes as a way to justify cutting costs. But the importance of outcomes has also gained the attention of clinicians. Duncan and colleagues (2010) and Lambert and colleagues (2001) are clinicians whose recent research points to the importance and value of using outcome measurements and to the evidence showing that feedback is important to redirect treatment. Certainly, when clients are not satisfied, this feedback is crucial. These self-​report outcomes greatly assist in treatment, including helping with the process of writing measurable goals, but they are still subjective evaluations. Then there is the economic factor with managed care companies taking back money for treatment that is not identified as measurable. What this means for clinicians who work in clinics and those in private practice choosing to accept managed care payments is that therapists must learn the skill of writing treatment plans with goals and objectives and outcomes that can be measured. Another rationale is that clients are consumers who deserve having treatment with a specific objective that can be gauged in some way. No consumer should engage in and purchase any service without a clear sense of an expectation regarding the result!

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Finally, in an era where evidence-​based practice is expected to be the treatment choice by managed care companies, it is reasonable, if not mandated, that therapists use treatment approaches for which there is evidence of successful outcomes. Cognitive behavioral therapy (CBT) (Beck, 1979, 2011), eye movement desensitization reprocessing (EMDR) (Shapiro, 2018), dialectical behavioral therapy (DBT) (Pederson, 2012), and seeking safety (Najavits, 2002) are a few evidence-​based practices that have empirical evidence of positive outcomes. However, to effectively write measurable outcomes, regardless of the treatment modality, the therapist needs the following skill set: 1. Interviewing skills that create an empathetic, accepting, and understanding atmosphere where a client feels comfortable and trusting to talk openly and honestly about what brings them to therapy 2. Writing skills to present a coherent and comprehensive psychosocial assessment based on information obtained from the client and perhaps other supports, such as rating scales 3. Ability to interpret Bloom’s taxonomy of six cognitive domains (Anderson & Krathwohl, 2001) in order to situate where the client is in thinking about the problem or problems 4. Understanding of what constitutes goals versus objectives and what constitutes measurable outcomes 5. Ability to collaborate with clients in establishing goals and objectives 6. Ability to collaborate with clients to write measurable outcomes 7. Ability to maintain the therapeutic relationship, to advance treatment and re-​engage the client for future measurable outcomes to continue progress, and to re-​engage when outcomes are not realized These seven points describe the process of therapy, particularly as it relates to actually being able to determine measurable change. Each of these

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items is discussed in the chapters ahead, and a case study follows to illustrate this skill set.

CASE STUDY ILLUSTRATING THE SEVEN-​P OINT SKILL SET

The following case example illustrates how the seven-​point skill set was used in a short interview. It is important to pay close attention to how gathering information about the client’s behavior and history created an opportunity to write a measurable outcome within minutes. In this case, the diagnosis of schizophrenia was not considered as significant, and, in fact, paying more attention to the diagnosis rather than pursuing a line of who, what, when, where, and how questions concerning her current behavior and her past behavior (history) would have dramatically changed the direction of the interview and likely would have resulted in this woman not being accepted into the drug and alcohol program for rehab. That is not to say that diagnosis should be ignored. While a diagnosis may be a requirement of the agency or the insurance company, and perhaps even what the therapist or client feels it is crucial for treatment, it is not a requirement for measuring outcomes. The distinct advantage of not using a diagnosis to drive the treatment is that diagnoses may limit the possibilities for considering outcomes. On the other hand, it is also possible that a diagnosis can quickly identify and focus on problematic behaviors for making change. It is the astute therapist who determines how accurate or helpful diagnoses may help in the assessment process, including aspects of identifying where the client is situated in their thinking using Bloom’s taxonomy. In the case illustrated next, attending to the client and not the diagnosis paved the way for significant change from the first day she entered treatment in an inpatient drug and alcohol facility. Good interviewing skills, engagement, and writing a meaningful objective resulted in an important outcome within the first hour she arrived at the facility.

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REFERRAL INFORMATION ON LINDA

Linda, age 52, was referred to a drug and alcohol facility from an inpatient psychiatric facility. Her mood was stabilized, and the staff at the inpatient program felt that her substance abuse issues needed to be addressed in a long-​term drug and alcohol program. It was reported that Linda had a 30-​year history of drug and alcohol abuse, as well as a diagnosis of schizophrenia. She also had a history of several involuntary inpatient psychiatric hospitalizations. She admitted to hearing voices, and on this recent hospitalization, she was observed as being agitated, aggressive, and delusional as documented by inpatient staff. Other significant history sent from the hospital indicated that Linda had experienced trauma at an early age, as she had been sexually abused by relatives, both male and female, and physically abused by a partner for more than 10 years. Her most recent hospitalization report stated that police were out driving when they noticed her screaming and banging on a door one evening. They found her to be incoherent and summoned an ambulance to take her to a psychiatric unit. (At a later time in treatment at the drug and alcohol program, Linda related that the evening the police found her it was raining outside, and she was very upset because her daughter would not let her in the house because the daughter found evidence that Linda was using crack while staying at the daughter’s home.) While in the hospital, Linda was noted to be severely distressed, she rocked back and forth mumbling for hours at a time, and she was sedated with antipsychotic drugs. The referral information was reviewed by the lead therapist at the drug and alcohol facility. She reported to the director that it was her opinion that Linda not a good candidate for the drug and alcohol facility because of her diagnosis of schizophrenia, which was supported by her self-​report of hearing voices and being observed as delusional by hospital staff. The lead therapist felt that Linda’s mental health diagnosis should be the primary concern for treatment. While that was certainly a reasonable concern, the director questioned the diagnosis of schizophrenia because of Linda’s long history of drug and

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alcohol abuse. It was speculated that perhaps her voices might be the result of psychoses induced by drugs and/​or alcohol, and that her behavior at the rehab facility might be a residual effect of her using substances and of the trauma. Also, this most recent hospitalization was traumatic because she had been forced to the street on a rainy night. A decision was made by the director to interview Linda and to speak to the hospital staff about their concerns and impressions of the diagnosis and her current mental status. A telephone screening conducted by the director did not reveal any psychotic behavior. This was 3 weeks after admission to the rehab facility. Linda’s speech was appropriate and she did not present any delusional behavior. In fact, she was noted to be lucid, open to answering questions presented to her, and expressed an interest in the drug and alcohol facility. In that same telephone interview, Linda admitted to hearing voices when she was using crack and at times and when she experienced flashbacks about her sexual abuse and physical abuse. Staff at the inpatient psychiatric facility felt that Linda was stable enough to participate in a long-​term drug and alcohol facility given her response to detox treatment and medication as well as her engaging appropriately with staff and residents. By all accounts, there was reason for the director to think that Linda’s diagnosis may have been made hastily when she was hospitalized during episodes when she presented psychotic behaviors that were likely due to severe substance abuse. The case manager at the psychiatric unit supported this viewpoint. A decision was made to accept Linda into the drug and alcohol program, based on the telephone interview and after conferring with staff at the rehabilitation center. Linda met the profile of having a co-​occurring disorder, that is, crack/​cocaine dependence and post-​traumatic stress disorder (PTSD).

INITIAL INTERVIEW AT THE DRUG AND ALCOHOL FACILITY

Linda arrived at the drug and alcohol facility looking neat and clean. She presented as shy, but did greet residents and staff appropriately. As

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is customary, a therapist was assigned to conduct an intake to sign release forms, and to gather basic information. Within 20 minutes of this process, the lead therapist, who was conducting the intake, came to the director and stated that the client was psychotic. The therapist said Linda was mumbling about how “Jesus is going to protect her . . . that she will not be punished” in between the questions she was answering about basic information and signing release of information forms. The therapist said that Linda seemed to be dissociating. The director introduced herself to Linda and explained that she would be continuing the intake interview. The director initially reviewed a few questions from the intake form that Linda had answered appropriately. Linda made eye contact and her speech was appropriate, but she was noted to be rocking back and forth. The director asked Linda directly if she could explain what she was talking about when she said, “Jesus is going to protect me,” as she seemed distressed. Linda made eye contact and said, “It’s from the St. James Bible,” and explained that the passages she recites are her way of comforting herself in times of stress. When asked if coming to this facility was stressful (staff query to elicit information about causes of stress), she said that it was a stressful time, being involuntarily hospitalized, coming from rehab, and coming to yet another program. She was asked to describe other times when she was very upset and about hearing the voices, and she said yes, she heard voices when she used crack. She denied hearing any voices now, but said once more that the way she copes is to recite passages from the St. James Bible. A 25-​minute conversation continued, and Linda was asked about other times when she felt stressed or scared. She said that she had a job as a counselor at the Veterans Administration (VA) but that she had suffered a “breakdown.” She said that she “freaked out” when she was working as a counselor at the VA hospital. She reported that it was her first job and that when she started listening to the veterans’ stories about PTSD, it brought her back to her own trauma. None of that information was in the history, nor did Linda indicate in the telephone interview that she had experienced that type of distress at her job. Some time was spent discussing the incident at the VA, and when the director told her that it was understandable

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that she would “freak out” (supportive, engaging comment by staff) given her long history of trauma, Linda seemed to relax. Eventually a discussion about her reciting a passage from the Bible (information about how she copes) was brought up again, and Linda related that it kept her from “losing it totally” and made her feel “protected,” including times when she has flashbacks about her abuse. The director expressed to her that it was understandable that reading the Bible was a comfort for her, but then asked whether her “going off ” in this place to detach might be scary for some people and for others it may make them think she is crazy. She said she had never thought about that or that her rocking back and forth might look weird. Linda’s response was simply, “It’s just my way of praying.” It was suggested to Linda that perhaps when she felt distressed she let staff know (supportive, engaging comment from staff regarding how she can deal with stress) that she needed to go to “her place” to pray and that she be given some space to have time to do that. She said she could do that, and from the first day, she did inform staff when she needed to “pray” (information of how she will cope) and would use a quiet room to do that. But, it was also taken into consideration that Linda might not know when she was getting to that stressed-​out point, so she was asked if should could try to identify how she felt, and specifically if she could identify any particular bodily sensations when these feelings emerged. She said she would try to do that. Certainly, it is reasonable to consider that Linda was dissociating, but she presented a rational explanation regarding her distress and her way of coping. The session ended, but about 2 hours later, Linda approached a therapist, saying that she felt scared and her heart was racing and that she said she was starting to shake. The therapist spent some time helping her do deep breathing, and Linda asked to go to a quiet space to recite her Bible passages. Afterwards, the therapist asked Linda if she could recall how she was feeling and what the bodily sensations were that she remembered during that anxious moment. Linda was able to recall (cognitive domain 1—​remembering) that her heart was racing and she was shaking. With no prompts, Linda then said, “I think that when I start to shake and my

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heart races, I’m definitely scared and anxious, but sometimes I don’t even know why.” Given that interpretation, Linda had on her own “situated her thinking” at the next level, cognitive domain 2—​understanding. With this information, the therapist and Linda talked about how she might try to tune into her body and that when she began to feel her heart race or when she started shaking and perhaps if some other “weird” bodily feeling emerged, that was an indication of being anxious and scared and that she needed to ask for help. She expressed gratitude for this help, and this conversation began the journey for her to discuss in therapy her trauma that was the source of her bouts of anxiety. Fast-​forward to 6 months later: Linda “graduated’ from the drug and alcohol program and moved on to live in a long-​term halfway house. It should be noted that her antipsychotic medications were significantly reduced and several were eliminated all together. She was very responsive in group therapy and in individual therapy, particularly her participation in therapeutic drumming. She was usually calm, but on the occasions that she had angry outbursts, it was noted that her anger often involved incidents that were precipitated by other residents. In those instances she demonstrated an ability to use problem-​solving techniques. Her anxiety was noted to decrease as she became engaged in therapy discussing her past trauma, and eventually she moved throughout her treatment plans to higher-​level cognitive domains in treatment: applying—​cognitive domain 3, by using more coping skills, and analyzing—​cognitive domain 4, by analyzing situations better as she demonstrated an ability to discriminate situations more rationally when she recognized moments of being fearful or upset. She became the philosopher of the house, appropriately using Bible passages at times to convey words of wisdom and reflection. Overall, Linda was respectful of others, insightful, and cooperative and did not exhibit any behaviors consistent with a diagnosis of schizophrenia. Over a period of time she revealed that she was very musically talented and showed YouTube videos of herself that she had once recorded with some famous rappers.

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SUMMARY AND ANALYSIS

As a preview to a discussion about interviewing and assessment, this case illustrates that who, what, when, where, and how questions provide important information. In Linda’s case, the first question was what was she talking about that the therapist assumed was psychotic? Her explanation was “passages from the St. James Bible.” The second question was when did she feel stressed? She gave good answers: when she was at the VA listening to veterans talk about their PTSD, because it triggered her own trauma; when she had flashbacks from her abuse; and when she came to the new facility. All are reasonable explanations for feeling stressed. She reported that how she dealt with her stress is to pray. What was suggested to Linda was that when she became anxious she do something different, so as not to bring attention to herself that would reflect on her in a way that others might worry about her behavior. Additionally, she was asked to identify her feelings and bodily sensations (cognitive domain 1—​remembering/​ recalling) as a way for her to be aware when she became scared and afraid. Note that the director engaged the client in numerous ways: empathizing with the stress of coming to the drug and alcohol facility, accepting and empathizing that her experience at the VA would be upsetting, and, finally, accepting that her coping mechanism of reciting the Bible was acceptable, with adjustments that Linda become aware of when she was getting anxious and let others know when she wanted to recite her prayers. The engagement with Linda created an environment where she felt heard and accepted, and treatment began where she was at regarding her anxiety with first simply identifying bodily sensations when scared or fearful. This case illustrates how there are always opportunities for engagement, while at the same time opportunities to collect information needed to make an assessment. Very important here is that this information is a way to “situate the client’s thinking” and apply the appropriate cognitive domains. If the interview had not gone in that direction, it would have been easy just to assume that the client was, indeed, a disorganized schizophrenic.

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Engagement occurred and a trusting therapeutic alliance happened quickly. While there was not a formal outcome that was conducted regarding this session, the client, by agreeing to the objective of identifying bodily sensations when anxious, interpreted or understood that those sensations indicated she was anxious. She was then able to do something about it, implicitly indicating satisfaction with the session. Finally, this case demonstrates how to use Bloom’s taxonomy to “situate the client’s thinking” regarding their problem. It was assessed in Linda’s case that the first thing she needed to do was to identify (cognitive domain 1—​ remembering/​recalling) how her body was reacting when she was frightened or anxious. Having her apply (cognitive domain 3—​applying) a coping strategy as a first step might have failed without the connection that her body signals her anxiety. She was able to follow through with the simple task and it created a way for Linda, on her own, to interpret or understand (cognitive domain 2—​understanding/​interpreting) the connection between her bodily sensations and her anxiety. Not all clients will be able to make such a quick interpretation. But in her case it did, and then she was able to move on to the higher-​level cognitive domains of understanding and applying. In a treatment plan the objectives might look as follows: Objective #1 (remembering/​recalling—​cognitive domain 1): Linda identifies bodily sensations when she is fearful or scared. Objective #2 (understanding/​interpreting—​cognitive domain 2): Linda recognizes that she when she starts shaking and sweating she is anxious. Objective #3 (applying—​cognitive domain 3): Linda tells staff she is anxious and asks to go to a quiet place to recite her Bible passages. These objectives resulted in positive, measurable outcomes within a day and that continued throughout Linda’s stay, giving her a sense of control.

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SUMMARY: MEASURABLE GOALS—​B URDEN OR ASSET?

Like all the other competencies, writing measurable outcomes becomes another expertise required of therapists in the context of being ethical and professional in conducting oneself as a helping professional. For some, it may feel like an albatross around one’s neck, but therapists are reminded that while managed care companies may mandate documentation of outcomes, there are inherent benefits for the client and therapist. Participating in the process is likely to ensure that clients remain in treatment and that everyone is clear about what is occurring in treatment, rather than conveying some ephemeral notion that is the subjective written outcome or opinion of the therapist. The burden of proof is the outcome; it is a measure to gauge what is occurring, and it is the feedback, the result, and the behavioral consequence of treatment of the contract between the client and therapist. Like any new skill that needs to be learned, writing measurable outcomes using the model provided in this text is not a skill that will come automatically after reading about it. Therapists willing to critique themselves after sessions are likely to move more quickly into this mode. This means reviewing their interaction with the client, completing a comprehensive assessment based on the information gathered in the interview, determining where the client is “situated in their thinking” regarding the problem, then identifying the CDRS and proceeding with next steps to write the goals and objectives for the treatment plan. There are numerous ways for therapists to review progress to complete this new task using the CDRS. All aspects of the process can be done self-​ reflectively or through individual and group supervision. The use of video or audio tapes, watching or listening to process recordings in reviews, discussing countertransference issues, and regularly using the outcome rating scales (see Appendix for example) are all ways to obtain valuable feedback. The key is to be a reflective therapist. Writing meaningful and realistic goals and objectives using the CDRS model will eventually become a natural part of the process of therapy.

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The case of Linda is a good example of how important it is to develop the expertise in the role of the therapist to simultaneously do several tasks at once: gather information, engage the client, and validate their feelings. This requires that the therapist learn to develop the important skill of operating in several modes of thinking. This includes thinking about engaging with the client, thinking about the task of assessment, and thinking about analyzing the present situation to make necessary shifts. In this case, when an intervention seemed important to soothe the client, it became evident that it be used as a logical point to write an objective. It was done with ease by using the information the client offered regarding her distress and her coping strategy. The objective written was a socially acceptable way for Linda to calm herself in a way she was familiar with and proved successful. From the perspective of a managed care company, it was a measurable outcome, but it was also a thoughtful and effective treatment strategy. The client was able to change her behavior, just very slightly, but in a critical way that was agreed upon together by the therapist and Linda, hence the collaborative engagement. It was her first success in making a series of other small and not so small changes on her road to recovery. The significant point to take from this chapter is that measurable outcomes develop only when the therapist has facilitated a rich psychotherapeutic relationship and has all the necessary information to work collaboratively with the client. What is also important to keep in mind is that any therapist can write a measurable objective to create something to put in the chart, but it is the skillful, competent, and caring therapist who writes meaningful and measurable objectives. REFERENCES Anderson L.  W., & Krathwohl, D.  R. (2001). A taxonomy for learning, teaching and assessing: A revision of Bloom’s taxonomy of educational objectives. New York: Addison Wesley Longman. Beck, A.  (1979). Cognitive behavioral therapy and the emotional disorders. New  York: Penguin Books. Beck, J. (2011). Cognitive behavior therapy (2nd ed.). New York: Guilford Press.

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Ben-​Sasson, A.  (2011). Parents’ search for evidence-​based practice. A  personal story. Journal of Paediatrics and Child Health, 47, 415–​418. Chow, D. (2018). The first kiss: Undoing the intake model and igniting the first sessions in psychotherapy. Freemantle, Australia: Correlate Press. Duncan, B.  J., Miller, S.  D., & Sparks J.  A. (2004). The heroic client:  A revolutionary way to improve effectiveness through client-​directed outcome-​informed therapy. San Francisco: Jossey-​Bass. Duncan, B. L., Miller, S. D., Sparks, J. A., Claud, D. A., Reynolds, L. R., Brown, J., & Johnson L. D. (2003). The session rating scale: Preliminary psychometric properties of a “working” alliance measure. Journal of Brief Therapy, 3,  3–​12. Duncan, B. J., Miller, S. D., Wampold, B. E., & Hubble, M. A. (2010). The heart and soul of change (2nd ed.):  Delivering what works in therapy. Washington, DC:  American Psychological Association. Hannan, C., Lambert, M. J., Harmon, C., Nielsen, S. L., Smart, D. W., & Shimokawa, K. (2005). A lab test and algorithms for identifying clients at risk for treatment failure. Journal of Clinical Psychology: In Session, 61, 155–​163. Kottler, J. A. (2017). On being a therapist (5th ed.). New York: Oxford University Press. Lambert, M.  J. (2013). Bergin and Garfield’s handbook of psychotherapy and behavior change (6th ed.). Hoboken, NJ: John Wiley & Sons. Lambert, M. J., & Barley, D. E. (2001). Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy: Theory, Research, Practice, Training, 38(4), 357–​361. Lambert, M. J., Whipple, J. L., Bishop, J., Vermeersch, D. A., Gray, G. V., & Finch, A. E. (2002). Comparison of empirically-​ derived and rationally-​ derived methods for identifying patients at risk for treatment failure. Clinical Psychology and Psychotherapy, 9, 149–​164. Lambert, M. J., Whipple, J. L., Hawkins, E. J., Vermeersch, D. A., Nielsen, S. L., & Smart, D. W. (2003). Is it time for clinicians to routinely track patient outcomes? A meta-​ analysis. Clinical Psychology Scientific Practice, 10, 288–​301. Lambert, M.  J., Whipple, J.  L., Smart, D.  W., Vermeersch, D.  A., Nielsen, S.  L., & Hawkins, E.  J. (2001). The effects of providing therapists with feedback on patient progress during psychotherapy:  Are outcomes enhanced? Psychotherapy Research, 11(1),  49–​68. Miller, S. D., Hubble, M. A., & Chow, D. (2018). The question of expertise in psychotherapy. Journal of Expertise, 1(2). Retrieved from https://​www.journalofexpertise.org Najavits, L. M. (2002). Seeking safety: A treatment manual for PTSD and substance abuse. New York: Guilford Press. Nicotera, N. (2018). Essential interviewing skills for the helping professions. New York: Oxford University Press. Orme, J. G., & Orme, T. C. (2012). Outcome-​informed evidence-​based practice. New York: Pearson. Pederson, L.  (2012). The expanded dialectical behavior therapy skills training manual. Eau Claire, WI: Premier Publishing and Media. Rabinowitz, I. (Ed.). (1998). Inside therapy. New York: St. Martin’s Press. Rubin, L. B. (2003). The man with the beautiful voice. Boston: Beacon Press.

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Shapiro, F.  (2018). Eye movement desensitization reprocessing—​ EMDR (3rd ed.). New York: Guilford Press. Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2nd ed.). New York: Routledge Taylor & Francis. Zeig, J. K. (Ed.). (1994). Ericksonian methods: The essence of the story. New York: Routledge Taylor & Francis.

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Bloom’s Taxonomy in Psychotherapy The Cognitive Domain Rating Scale (CDRS)

The broad goal of this chapter is to introduce Bloom’s taxonomy as the basis for the Cognitive Domain Rating Scale (CDRS) used for writing measurable psychotherapeutic objectives and outcomes. The objectives here are as follows: 1. To provide historical background on the development of Bloom’s taxonomy 2. To explain each of Bloom’s taxonomy’s six cognitive domains from the perspective of educational and psychotherapeutic views 3. To introduce the concept of the CDRS in writing measurable objectives and outcomes, which involves “situating the client’s thinking” 4. To provide scenarios to illustrate use of the CDRS

HISTORY OF BLOOM’S TAXONOMY

Bloom’s taxonomy is a framework for classifying student learning outcomes. It was created in 1956 under the leadership of educational

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psychologist Dr. Benjamin Bloom to encourage higher forms of thinking in education, such as analyzing and evaluating concepts, processes, procedures, and principles. A  summary of the taxonomy is provided at: http://​www.nwlink.com/​~donclark/​hrd/​bloom.html#intro. A Taxonomy for Learning, Teaching and Assessing is “the revised framework of interrelationships of the cognitive process dimension: remember, understand, apply, analyze, evaluate and create” (Anderson & Krathwohl, 2001, p. 5). The cognitive psychologists, led by Lorin Anderson (a former student of Bloom), updated the taxonomy to reflect 21st-​century work. The authors used verbs to relabel the six categories and included “action words” to describe the cognitive processes by which learners encounter and work with knowledge. To summarize further, a taxonomy is an organizational hierarchy or classification, and Bloom’s taxonomy categorizes thinking skills. These thinking skills range from recalling information, the most basic skill, to evaluation, which involves more sophisticated analysis and judging. A description of these cognitive processes are discussed throughout this chapter, but first the logical question is posed: What does an educational theory and educational outcomes have to do with psychotherapy and psychotherapy outcomes? The answer to this question is that it has to do with thinking. The team that worked on the original and the revised taxonomy spent years researching cognition. If we define cognition as “mental action or process of acquiring knowledge and understanding through thought, experience, and the senses” (Oxford Dictionary) or the “conscious mental activities:  the activities of thinking, understanding, learning, and remembering” (Merriam-​Webster Dictionary) we can say in a very generic sense that cognition has to do with how people think, how they learn, and what they come to know and understand about themselves and the world around them. From an educational perspective, this taxonomy is about understanding how individuals think and learn. However, it seems very applicable when considering the problems posed

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by the client in psychotherapy. Isn’t what the therapist and the client do is spend time discussing the dilemmas that are present in a client’s life and think about the problem and think through what to do about the problem? The revised edition of Bloom’s taxonomy (Anderson & Krathwohl, 2001)  illustrates the interrelationships between the cognitive process dimension and a knowledge dimension. For our purposes here, the six cognitive processes are sufficient to illustrate the task of assessing cognitive processes. While the knowledge dimension certainly can be taken into consideration when creating objectives, the cognitive processes are at the heart of the model when writing objectives for measurable outcomes.

Note that the figure starts at the bottom of the ladder, with the simplest cognitive dimension of “Remembering.” From there, the climb up the ladder in each step requires “higher,” or more complex, levels of thinking.

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ADAPTING BLOOM’S TAXONOMY FROM AN EDUCATIONAL OUTCOME TO A PSYCHOTHERAPEUTIC OUTCOME

If we consider that the therapist’s attitude in working with clients is a person-​centered, shared decision-​making approach, it goes without saying that clients are actively engaged in treatment. Furthermore, it might be said that the therapist, in a sense, is a mentor as he or she helps to redefine, reframe, and educate clients about different ways to interpret their problems and their situation while facilitating clients in changing their behavior and/​or thinking about themselves. Duncan, Miller and Sparks (2004) are adamant about viewing the client as “expert,” asserting that realized outcomes occur when the “expert” client actively participates in treatment. Certainly, clients are the “experts” in their history, their cultural orientation, their experiences, and their desires and should be active agents in developing objectives for change. It might be added, however, that the therapist as a facilitator working with the client/​expert is in a position to enhance the client’s expert knowledge about their behavior and perhaps even the interpretation of the world around them. These are very abstract concepts and might be the goals for some clients, but the point is that the reality of therapy is it is about learning, and learning involves thinking. One of the goals of Bloom’s taxonomy is to offer teachers a way to assess student outcomes. Therapists will not test clients in the same manner with multiple-​choice tests and essays and grade them, but standardized psychological testing and surveys are ways to assess or obtain information about an individual. Again, this is another example of how the process of therapy is indeed about learning as it relates to acquiring more knowledge about an individual, whether it is to discern more specifics about their strengths and weaknesses or find out what personality characteristics they possess. The goal in using such tools is to assist in obtaining more information—​knowledge—​to help to point to directions for change.

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Given that, it is interesting to posit that, in a sense, clients are students, as they actively engage in meaningful learning about themselves. It is this thought that gives rise to considering how Bloom’s taxonomy is useful to help clients situate their thinking along the lines of the six cognitive domains as the therapist and the client consider how to work on the problem(s) at hand. While Bloom’s taxonomy has a long history of being used in an educational setting, the origins of this cognitive approach resonates with cognitive psychology, as noted by Bloom himself. Moreover, cognitive psychologists were instrumental in the development of the revised taxonomy. Certainly today, cognitive therapy is considered one of the major evidence-​based practices in psychotherapy with a theoretical framework that embraces wholeheartedly the notion that the client’s thinking is significant, as how one is thinking relates to the presenting problem and treatment approaches. It is helpful to first review each of the six cognitive processes in Bloom’s taxonomy to have a clear understanding of these categories of cognitive domains. From there, it will become clearer how applying those categories can create clarity for the therapist and client as they embark on the therapeutic process. As stated by the authors in the revised edition of A Taxonomy of Learning Teaching and Assessing (2001), “the value of the Taxonomy Table stems largely from its use as an analytic tool” (p. 254). The six cognitive processes in the revised Bloom’s taxonomy are key in developing objectives and outcomes. Use of the six cognitive processes helps identify knowledge that clients need to know about themselves and what they think regarding their problem. The client and therapist need to discern the who, what, when, where, and how issues or problems in order to make a change. The method takes the client out of the passive view of themselves as “patient.” In this model, the therapist and client work together to look at the facts and the feelings as they create a therapeutic alliance. In the therapy process, the client/​learner is on a path to learn more about themselves (knowledge) and how they think (cognitive processes), which results in the ability to engage in meaningful learning. This meaningful learning defines goals and objectives, resulting in measurable outcomes.

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THE SIX COGNITIVE PROCESSES

The six cognitive processes according to the revised Bloom’s taxonomy are as follows:

1. Remember 2. Understand 3. Apply 4. Analyze 5. Evaluate 6. Create

These six cognitive processes are referenced throughout the text for the purpose of “situating clients’ thinking.” Bloom’s cognitive domains in this context are referred to as the “Cognitive Domain Rating Scale” and are identified throughout as the CDRS. As Anderson and Krathwohl (2001) state, “The continuum underlying the cognitive process dimension is assumed to be cognitive complexity; that is, Understand is believed to be more cognitively complex than Remember, Apply is believed to be more cognitively complex than Understand, and so on” (p. 5). While it is true that the level of complexity increases throughout these six cognitive processes, and it might make sense from an educational point of view for students to learn from the simplest task to a more complex task, this is not necessarily how it might work when using these processes in psychotherapy. Examples of shifting throughout the processes are illustrated in the case scenarios provided in this chapter and are examined throughout the text. The critical consideration is to understand that thinking is fluid, and new information and new experiences are likely to create new objectives and result in outcomes that are met and other times are subject to change. The following cognitive processes are defined and then followed by a brief case scenario to provide a beginning understanding of how to transform and apply this educational model in the psychotherapeutic process and context.

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1. Remembering

“Remembering involves retrieving relevant knowledge from long-​ term memory. Remembering knowledge is essential for meaningful learning and problem-​solving as that knowledge is used in more complex tasks” (Anderson & Krathwohl, 2001, p. 66). Recognizing, recalling, and retrieving relevant knowledge from memory may create meaningful learning, as one is then able to integrate that memory into the “larger task of constructing new knowledge or solving new problems” (Anderson & Krathwohl, 2001, p. 66). A caveat here from this definition is that remembering and recalling may not necessarily be from long-​term memory but from memory at any time, perhaps even just seconds or minutes ago, that might be useful to enlighten the client about something that will be of aid to them as they become more aware of their senses, behaviors, and thinking. Scenario A common problem with individuals who are addicted to drugs or alcohol is that they often have little understanding of what triggers their drug use. A very common first objective in drug and alcohol settings is for clients to “name” triggers in order to remember or recall what triggers the urge to use drugs. The therapist may have to prompt or coach the client in recognizing what they may be thinking about or what they are doing just before they have urges. • Objective: Client will name (cognitive domain level 1—​ remember) triggers that elicit a feeling or response to want to abuse substances. In this example, it is possible that naming the triggers will help with the next step, to understand (the next cognitive level) why they use substances in certain situations. This objective may not prevent one from using, but

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it is a start as to name the people, places, and things and to remember and recall certain situations when one is more apt to use drugs or alcohol. It is an essential and measurable objective. Down the road, this knowledge may become part of a more complex task of taking action to control an addiction problem.

2. Understand

“Understanding is the ability to construct meaning from messages, oral, written and graphic communications. Understanding involves a number of cognitive processes that include interpreting, exemplifying, classifying, summarizing, inferring, comparing, and explaining” (Anderson & Krathwohl, 2001, p. 70). Understanding is about building connections between the new knowledge to be gained and prior knowledge. The incoming knowledge is integrated with existing schemas. Scenario Continuing with the scenario about remembering, let’s assume the client names triggers that create situations where they are apt to be vulnerable to abuse drugs. Recalling those triggers, in turn, creates a situation in which the client has new information. This new information provides a way to better understand (cognitive domain level 2—​understanding) that there are situations in which they are more apt to abuse substances. • Objective: Client agrees to avoid certain people and situations, knowing (level 2—​understanding) they are triggers to want to use substances. This example illustrates that the information obtained from the earlier objective with the task of naming (level 1—​remembering) triggers demonstrates thinking through the problem at a next step.

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3. Apply

“Apply involves using procedures to perform exercises or solve problems. Thus, Apply is closely linked with procedural knowledge. Procedural knowledge is generally knowing how to perform a procedure with “little thought” (Anderson & Krathwohl, 2001, p. 77). The apply category consists of two cognitive processes: executing—​when the task is an exercise (familiar)—​ and implementing—​when the task is a problem (unfamiliar) (Anderson & Krathwohl, 2001, p. 77). Note that in the case of the therapist–​client relationship, sometimes clients will execute the task easily, and other times implementing the task is difficult, because the act of implementing a task is unfamiliar. More often than not, clients are likely to have difficulty implementing a task, because if they could have executed the task, they might not have needed therapy! While there is no sound evidence that this is the juncture in the therapeutic process where clients get “stuck,” most seasoned therapists would agree that when clients do not follow through or implement tasks agreed upon in a treatment plan, this is the point when clients drop out of therapy. Scenario Panic attacks, otherwise known as panic disorder, is a common problem. A client suffering from panic disorder may know full well that their panic attacks are the result of trauma (level 2—​understand) and may even be able to articulate the reasons (level 4—​analyze) for their panic when they are not in a panic mode. The client might even be able to name (level 1—​remember/​recall) triggers. However, the key is to be able to apply the tasks learned and, in this instance, implement the strategies, such as deep breathing, visualizing a “safe place” or using a cognitive strategy such as “stop thought.” The challenge for both therapist and client is to work together to explore further (level 2—​understand) the barriers to applying the agreed-​ upon objectives if the client is repeatedly unable to follow through or implement the tasks.

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• Objective: 1. Client practices deep breathing exercises daily. 2. Client uses deep breathing exercise in the midst of a panic attack. In this example, let us assume that the outcome was the client was able to practice the breathing exercises but was not able to apply the breathing exercise when having a panic attack. In this instance, the therapist and client would need to discuss what prevents the client from using the breathing exercise when in a panic mode, and to think through what or who might help her. After several sessions, the client and therapist could agree that support from someone at that crisis moment is needed. The outcome, not realized, takes the therapist and client back to exploring another objective. • (Revised) Objective 2: Client will identify (level 1—​remember/​ recall) a list of supports to contact when having a panic attack to offer support and coach the client with deep breathing. This objective is measurable in that the client will either take action and call the identified supports or not take the action. Should the client choose not to call the supports, then, again, the therapist and client would need to think about the barriers to following through. Considering or identifying barriers might then be an objective.

4. Analyzing

Anderson and Krathwohl (2001) describe analyzing as involving “breaking material into its constituent parts and determining how the parts are related to one another and to an overall structure. Objectives classified as Analyze include learning to determine the relationship or important pieces of a message (differentiating), the ways in which the pieces of a message are organized (organizing), and the underlying purpose of the message (attributing). Although learning to Analyze may be viewed as an end

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in itself, it is probably more defensible to consider analysis as an extension of understanding or as a preclude to evaluating or creating” (p. 79). Scenario Anger management is likely to be a challenging presenting problem, particularly with a client mandated to treatment. This may require that the therapist and client spend time developing a trusting relationship that demands patience for analyzing the reasons for angry outbursts. Assuming that the client accepts (or eventually accepts) that they have a problem with anger, the therapist and client can then have a conversation analyzing memories related to childhood trauma as a way to attribute current overreactions in certain situations. Given that analysis, the therapist and client together then have an understanding (analysis defined as an extension of understanding as described earlier) of the client’s angry outbursts as having roots in childhood abuse. What may be helpful with this client is to take a step further in the analysis and help them think through how to differentiate, or discriminate, select, distinguish and focus on what is relevant and irrelevant information, or important from unimportant information, and then attend to the relevant or important information (Anderson & Krathwohl, 2001). The process described here requires a complex set of thinking skills. Assuming that the client and therapist agree that the client’s thinking is situated at this analytical level of thinking at this time, the following objectives may be written as follows: • Objectives: 1. At the first sign of feeling upset, the client internally asks the question: “Can I attribute my upset reaction (level 5—​analyzing) to this situation as an emotional or rational response?” 2. Client responds (applies—​level 4) with agreed-​upon appropriate retorts: “I am overreacting—​breathe. I am justified being upset, use I messages, for example, ‘I am angry because . . .’ ”

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In this example, the client analyzed the situation and then responded accordingly. Indeed, there is much information that is unknown in this scenario, but we can assume that the therapist and client spent time discussing behaviors that comprise upset feelings (which was likely a lower-​level earlier objective, such as identifying upset feelings; remember/​recall—​level 1). Additionally, we can imagine discussions about emotional versus rational ways to deal with upsetting conversations and perhaps role-​playing regarding the “agreed-​upon appropriate responses” situated in being able to think about applying a behavior, which is a measurable outcome.

5. Evaluate

Anderson and Krathwohl (2001) provide the following definition of the cognitive process of evaluation: “Evaluate is defined as making judgments based on criteria and standards. The criteria most often used are quality, effectiveness, efficiency, and consistency. The cognitive process of checking (judgments about the internal consistency) and critiquing (judgments based on external criteria) [is used]. Checking involves how well the plan is working. Critiquing involves the positive and negative features and is the core of critical thinking” (pp. 83–​84). Evaluation is a cognitive process that occurs throughout all of the other cognitive domains with varying degrees of clarity. If one is to create a measurable objective using any of the cognitive domains, evaluate is inherent in the process described. Scenario The treatment plan for anger management is likely to have an evaluative component to assess angry outbursts. That is relatively easy and may require a self-​report along with validation by another person, for example, a parent, spouse, or teacher, depending on the individuals involved. In this case, the evaluation may be quantitative (how many outbursts per day, per hour, for example), and the measurable outcome may involve a qualitative aspect—​for example, are different words used to express anger? Are there fewer times

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when swearing or yelling is noted? In either of these instances, someone must detect checking and critiquing, again either through self-​report or observation and perhaps even the use of a video recorder to record the interaction. • Objective: 1. Client identifies (level 1—​remembers/​recalls) physical feelings (heart racing, sweaty palms, talking fast) as indicators of emotional distress. 2. Client appraises (level 5—​evaluates) the situation of how to respond to what he views as criticism. Given that appraisal, the client chooses (level 3—​applies) rational language and behavior to deal with the circumstance (role-​plays from therapy sessions) while also attending (deep breathing) to identified signs of emotional distress (level 1—​remembering/​recalling). In this example, the evaluative component involves first identifying signs of emotional distress. Then the client evaluates or appraises what is occurring, before choosing how to respond to the criticism, thus applying an anger management strategy. Evaluating what to do requires that the client first be aware and understand that they are becoming emotionally distressed. This example further illustrates that “situating the client’s thinking” might involve more than one cognitive domain.

6. Create

According to Anderson and Krathwohl (2001), “Create involves putting elements together to form a coherent or functional whole. The connotation is that something new occurs as a result of reorganizing some elements or parts into a pattern or structure not present before and are generally coordinated with a previous learning experience. To create is likely to require aspects of earlier cognitive process categories, but not necessarily in . . . [sequential] order. . . . It is likely that elements from many sources result in a new product” (p. 84).

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In this domain, therapists and clients work together to create a treatment plan, to create a new approach to deal with the problem. In creating one assumes that “elements from many sources are put together into a novel structure or pattern relative to his or her own prior knowledge” (Anderson & Krathwohl, 2001, p. 85). Scenario Following are some objectives for a treatment plan with the presenting problem as anger management. The client has been in therapy for quite some time and is making progress. • Objective: 1. The client recalls the consequences of having an angry outburst (level 1—​remembering). This objective is likely to be in treatment plan #1 when the therapist and client agree that the client needs to recall the negative consequences for exhibiting angry outbursts.

2. The client distinguishes situations when unduly criticized and when he is misreading or overreacting to a situation that could result in a negative consequence (level 4—​analyzing).

This objective is likely to follow from treatment plan #1 when in subsequent sessions the therapist and client discuss more history revealing that the client experienced verbal abuse in his family of origin and is set up to overreact to many situations. This is an example of how the concept of insight may be helpful and written in behavioral terms. The client’s insight/​analysis of being yelled at during childhood resulted in being overly sensitive and misreading messages with a resultant misguided angry response.

3. The client practices meditation and yoga to calm an overactive neurosympathetic system (level 4—​applying).

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This objective may be recommended in treatment plan #1, but without the full buy-​in from the client, it is likely to fail. It is critical that the therapist and client agree that the client’s thinking is situated in applying, such as practicing an intervention to produce positive results. When the objective fails using cognitive domain level 3, apply, it may be that the therapist had more of an investment in the objective than the client did. The client may not be ready to apply anything without a better understanding of the problem. In this scenario, if the client cannot apply the intervention, it may be that the therapist needs to continue to help the client analyze his behavior, by offering an empathetic response regarding the abuse history before applying an intervention to make any behavioral changes. This is certainly the nuance of therapy, which illustrates how a “logical” format of pushing through the CDRS can be counterproductive without fully taking into consideration where the client is situated in their thinking. The client may feel resentment from past abuses and shame for their behavior, and may need more time in therapy to work through those feelings. Self-​soothing coping mechanisms might be a better intervention that could easily be developed as measurable outcomes.

4. The client decides what to do before responding with an angry outburst and than chooses an appropriate response (level 5—​evaluates, and level 3—​applies).

This objective is likely to appear in a later treatment plan, as it requires reflection and appraising the situation. Certainly, this objective would indicate that a number of steps had been accomplished in working on anger management issues, which indicates a shift in thinking about one’s anger and how to cope.

SUMMARY OF AND CONSIDERATIONS IN USE OF THE COGNITIVE DOMAIN RATING SCALE

Bloom’s taxonomy is used primarily in educational settings to measure learning outcomes, but it is an efficient approach to assessing cognition, or

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what is referenced as “situating client’s thinking” in the psychotherapy assessment process. Psychotherapy can be messy in the sense that rarely do clients resolve their problems in a straight trajectory, and new problems and situations in a client’s life often necessitate a change in assessment and the direction of treatment. Throughout the therapeutic relationship, the CDRS model directs the therapist and client to refer back to the six cognitive domain options—​remembering, understanding, applying, analyzing, evaluating, and creating. This may occur when the client is stuck or perhaps when there are significant changes in the client’s life that make it necessary to alter the direction of therapy. The CDRS model is also efficient in that it makes writing measurable objectives unambiguous, as the use of action verbs as a style of writing creates a way to make the outcome measurable or not. It occurs when the client accepts that they are at a particular place of thinking about the problem, rather than just focusing on the problem. Telling clients that they cannot even begin to solve their problem unless they are able to have an accurate sense about where they are in thinking about it takes pressure off from finding the “magic bullet,” the strategy that is going to “cure” them once and for all. It is helpful to tell clients that this is a discovery process to help lead to the cure, rather than being a cure in and of itself. It is a fair and reasonable expectation that both the client and the therapist are reminded that therapy is a process. Also, it is in some ways refreshing to not talk about how to get rid of the problem, but how to think about the problem. Using the CDRS in the context of an excellent therapeutic environment (assessment and therapeutic alliance) involves learning and remembering how to use a new skill set. The formula for the CDRS skill set of writing measurable objectives is completed in three simple steps: 1. Identify the cognitive domain. 2. Apply the measurable action verb. 3. Measure the outcome as either completed or not completed. It is fair to say that the therapist is certainly likely to influence the client’s thinking about their problem as questions and probes are forthcoming

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throughout the assessment process and throughout the entire therapeutic relationship. A challenge to this potential influence might be whether it is contaminating the notion and claim of “situating the client’s thinking.” The answer is that it does not much matter, and, indeed, the therapist’s comments, whether empathetic or gently confrontational, involving questions or inserting probes may encourage an insight or shift a certain way of thinking on the client’s part. The goal of therapy is change, and yes, the therapist is influential. What is important to remember is that, at some point, there need to be some agreed-​upon objectives to ensure that what is occurring in the therapeutic relationship is something that is clear to the client, as the client is the beneficiary of the process. Given this description, it is clear that both the client and the therapist are agents of change. The value of the CDRS model is that it zeros in on what is occurring at the particular moment the client comes to therapy. While the assessment involves information presented regarding one’s problem, taking into consideration current and past history of the who, what, when, where, and how, the focus on how to write an objective is dependent on where the client is currently thinking about the problem. In the Appendix there are two charts that are good sources of reference regarding cognitive domains and actions associated with each of the domains. The first chart, Revised Bloom’s Taxonomy Action Verbs, is simply a list of verbs. The second chart, Questions and Probes, proposes some questions that might be asked to elicit information to assist in confirming that particular domain. The verb list is not considered to be an exhaustive list, but it is a good, quick reference, particularly when beginning to use the CDRS. Therapists new to using the CDRS should be cautioned not to use the charts to force an objective but to use them as a reference only after thoughtful consideration of which cognitive domain the client is operating in. This is a process that can take several or more sessions to understand, although it might be apparent in the first session.

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REFERENCES Anderson, L.  W., & Krathwohl, D.  R. (2001). A taxonomy for learning, teaching, and. assessing (abridged ed.). Boston: Allyn and Bacon. Duncan, B.  J., Miller, S.  D., & Sparks J.  A. (2004). The heroic client:  A revolutionary way to improve effectiveness through client-​directed outcome-​informed therapy. San Francisco: Jossey-​Bass.

3

Assessment Gathering Information to Write Goals and Objectives

The goal of this chapter is to provide an assessment format that affords a way to obtain key information for writing measurable objectives. The objectives of the chapter are as follows: 1. To illustrate who, what, when, where, and how questioning 2. To illustrate a dialogue between the therapist and client to elicit probes and responses 3. To illustrate the Cognitive Domain Rating Scale (CDRS), which is based on Bloom’s taxonomy As all clinicians know, the beginning of any treatment involves an assessment process, which entails developing a therapeutic alliance to gather information about the presenting problem, as well as historical information. It is skill a set that includes being able to connect with an individual to develop the necessary trust to ask questions about deeply personal information. There are numerous texts about the assessment process; some notable ones include those by Cocoran and Walsh (2010), Evans, Hearn, Uhleman, and Ivey (2017), Franklin and Jordan (2015) Meichenbaum (2009), Nicotera (2018), Wiger (2012), and Shea (1998).

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Certainly, a rich, detailed understanding of a client’s complaint and the antecedents that led to that complaint must be obtained before any thought is put into developing any meaningful and measurable outcomes. Additionally, the clinician must maintain an empathetic response to their client’s story while at the same time posing focused questions to get information for measurable outcomes. Different professionals (social workers, psychologists, counselors, psychiatrists) have approaches to the assessment process that may be somewhat different. The language used in the assessment is apt to be different, and the decision to use specific assessment tools may vary, but the goal is still the same. However, a clinical assessment, sometimes called a biopsychosocial assessment, typically has all the elements to obtain the information to identify the problems and indicators of what the individual wants to change. In addition to the interview, there are a number of assessment tools or scales that augment the information obtained through the interview. The use of these various tools may provide useful information in assessing an individual’s intellectual, social, and psychological states. For example, the Beck Depression Inventory and the Beck Anxiety Inventory are widely used across professions to do a quick check on depression and anxiety. Tools such as these are brief and can be hand scored by the clinician and used during the interview to elicit further questioning or confirm what seems evident in the interview. An abbreviated list of common assessment tools and scales is provided in the Appendix. The assessment process is critical and, as noted by Duncan, Miller, and Sparks (2004), the first three sessions are significant as to whether the client returns to therapy. Therefore, the therapeutic alliance must be established at the outset and the client must be engaged to get the information to get to the heart of the problem. Wiger (2012) comments, “Vague assessment procedures contribute to vague treatment plans, which lead to unfocused treatment. Other factors, such as non-​measurable objectives and undefined treatment strategies also lead to treatment with uncertain outcomes” (p. 135).

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WHO, WHAT, WHEN, WHERE, AND HOW LINE OF QUESTIONING

The information obtained in the assessment provides the data for goals and objectives. This is done efficiently and simply by posing focused who, what, when, where, and how questions to collect current and historical information. This line of questioning allows for fine-​tuning pertinent issues about a problem and helps to delineate potential measurable outcomes. It is a structure that hones in on information, particularly when a client is “all over the place” or vague in their reporting. For example, asking someone a pointed question, “What is most bothersome at this time? or “Who is the most supportive person to your recovery?” can easily redirect an interview run amuck with conflicting information as the therapist reins in the story to guide the client toward a more narrow and focused way of sorting out the mélange of thoughts in their head. Unfocused interviews might be indicative of an anxious or resistant client, assuming that there are no reasons for concern about a cognitive deficit. As stated earlier, different professions are apt to have a writing style that reflects the language that is particular to their orientation. But the proposed line of questioning should elicit the information needed, whether the therapist is a trained social worker, psychologist, counselor, or psychiatrist. It is helpful to consider including direct quotes from clients in the assessment report as a way to obtain information. This requires discerning the who, what, when, where, and how from the content, which may not necessarily have the who, what, when, where, and how words in the sentence. For example: “The anniversary of my mother’s death always begins with an evening of binge drinking and from then on, I start drinking everyday.” This statement tells us important information about when this individual’s drinking begins and what happens after that (more drinking).

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“I’m ok if I  drive on side roads, but I  break out into a sweat and I have difficulty breathing if I think about getting on the highway to drive.” This quote tells you where the anxiety occurs and what happens to that individual. This could lead to a question about when this anxiety about highway driving first occurred and if the client had any idea how that might have come to be. In other instances one may have specific information by just reviewing what the therapist surmised and by reviewing the written assessment: “Judy began having anxiety after the birth of her first child.” This statement identifies when the anxiety started without directly quoting the client. “John came to therapy because he said he has a lot of anger issues, and upon further questioning he admitted that he mostly gets into angry interchanges with his teenage son. When asked about his teenage years with his father, John admitted that his father yelled a lot.” A quick review of these sentences provides a lot of information: The who involved with John is his son, as well as John’s father, because of the historical significance of this past relationship. How John expresses his frustration to his son is by yelling. Continuing with this model, it could lead to further questioning and point to consideration of a measurable outcome. It may simply begin with trying to help John identify what exactly frustrates him about his son. Another very effective strategy to obtain information from clients is to use one of the techniques of “externalizing,” taken from narrative therapy. Externalizing is a method in narrative therapy in which the therapist asks questions that help the client distance from his or her feeling state. The question posed to the client is such that the verb is changed to a noun.

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For example, the question might be prefaced with a simple “what if ” question: THERAPIST: What

if you didn’t have that “depression cloud” [depression is stated as a noun rather than a verb] over you? What would you do?

The client’s answer might be a direct link to a clear measurable outcome: CLIENT: I

would call a friend to ask if they wanted to go hiking or skiing, rather than just sit at home.

Another client answered with an entirely different response: CLIENT: I

can’t imagine ever not being depressed.

This reply might lead to asking when the client first remembers being depressed or what makes them feel most depressed. Detailed scenarios are illustrated later in the chapter to demonstrate the various ways of questioning and how to use the information obtained to create measurable outcomes. What is important to remember here is that assembling a coherent story is essential for both the client and the therapist in order for them to work together to create a path toward change. The therapist uses the assessment and later dialogues in therapy sessions to do a “close read” to look for clues and/​or obvious information regarding what the potential goals and objectives are. While it may seem artificial to think about structuring an assessment so that writing goals and objectives ensures measurable behaviors, this process actually promotes a thoughtful dialogue for opening up ways to elicit important information for the client and therapist. The therapist directs the questioning in a manner that enables the client to tell their story; particularly for those clients who may be overwhelmed, the methodical who,

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what, when, where, and how line of questioning provides a structure that validates the problem, or at least begins as a way to substantiate why they came in for help. And, the additional information from any measurements, for example, the Beck Depression Scale, can support or challenge the self-​ report of the client. This process is the same for any setting, whether it is inpatient or outpatient, as the goal for therapists and clients is to alleviate the problem situation after identifying the problem.

WRITING MEASURABLE OUTCOMES USING BLOOM’S TAXONOMY

Upon completion of the assessment, the next step in the process of writing measurable outcomes is to take in all the information from the who, what, when, where, and how responses to understand how the client is thinking about the problem. Using Bloom’s taxonomy, the therapist is able to assist the client in determining which cognitive domain the individual’s thinking process is situated in. This is a key part of the assessment process because if the therapist fails to identify where the client is cognitively, it may be difficult to engage the client in the process of identifying a successful outcome. Case in point: It is not uncommon for a therapist to suggest some behavioral techniques for clients to deal with their anxiety, for example, deep breathing, meditating, or journaling. However, there is a strong likelihood that the client will still be anxious if there is no recollection to identify the people, places, or things that are causing the stress or anxiety. In this example, use of recalling and identifying, the level 1 cognitive domain, and using that as a starting point may reduce anxiety before any psychotherapy techniques are assigned. While Bloom’s taxonomy of learning domains is an educational model, as discussed in Chapter 2, it is extraordinarily complimentary to identifying objectives for psychotherapeutic outcomes. As stated earlier, one cannot make change without having a full understanding of why

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something happened, and that has to be connected to when and how often it happened and perhaps who was involved. Analyzing this thinking can illuminate knowledge and information that are necessary for the therapist and client to identify objectives. The therapist, and perhaps the client, should discover that after a period of time they will become adept at identifying these various cognitive domains based on facts and may even develop shortcuts to identify the CDRS. How one tells their story provides information for doing this: If an individual is struggling with trying to understand why they are having a problem, the word understand situates the problem in level 2 cognitive domain—​understanding. If an individual says they are always failing to maintain a goal after being successful for a period of time, they might need to analyze the situation, which situates the problem in level 4 cognitive domain—​ analyzing. If an individual can’t remember what might have prompted them to behave in a certain way, for example, becoming angry, then they may need to recall or recognize things that occur before they get angry, which situates the problem in level 1 cognitive domain—​remembering. Keep in mind that as goals change, often the cognitive domain changes. As stated in the last scenario in Chapter 2, it is important to remember that cognitive domains don’t operate in a chronological format, from level 1 to level 2 and so on. Thinking is an active process and is something that the therapist encourages if not expects of the client when asking to report about their problem and their history or asking what they want to change. It is the therapist’s job to help the client identify where they are in that thinking process. By doing a close read and identifying just where the client is in their thinking about the problem or thinking about what they want to do or can’t do about the problem, the path to measurable outcomes for positive change is established.

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SCENARIOS

The following case scenarios are a composite of cases and illustrate several things discussed thus far:  how to interview and obtain information for an assessment, how to situate the client’s cognitive level or thinking, how to locate which level of cognitive domain is operating, using the CDRS model, and, finally, how to write a measurable outcome. The information in the scenarios includes the presenting problem, the assessment/​dialogue, and a section for goals and objectives. The use of dialogue illustrates how a therapist might proceed in conducting an assessment. While a therapist is unlikely to create a dialogue as part of their notes or assessment, it is always important to include quotes from clients, since a client’s report in their own words supports the analysis of the biopsychosocial assessment. Additionally, it is information that is necessary when identifying and supporting justification for identifying the CDRS, that is, where the client is “situated in their thinking” about the problem. Finally, in these scenarios, the dialogue is used to demonstrate how to create a who, what, when, where, and how line of questioning. In the dialogues these words will be highlighted in boldface.

SCENARIO 1

Client: Judy

Presenting Problem Judy is a 37-​year-​old women whose 41-​year-​old husband died of a heart attack 4 months ago. She called the outpatient mental health clinic for help in coping with her grief. She states that she has had difficulty sleeping and eating and spends most of her day crying. She took a month’s leave of absence from her work after her husband passed away, but after 2 weeks of being at work, she asked for a year’s leave, as she was unable to function in her job as an accountant. Judy is the mother of two young children, ages 7

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and 10, and she states that she is only able to deal with them with the aid of her mother. Her mother comes to her home every morning to get the children up and ready for school, and comes back in the evening to help with dinner and put the children to bed every night. Judy says that she wishes to return to some type of “normal life,” but she can’t imagine how she can ever go back to work or take care of her children on her own. Comments on Presenting Problem A review of Judy’s presenting problem points to a number of identifiable behaviors and potential goals and objectives that could be developed for attaining measurable outcomes. Any therapist might think that becoming more engaged with her children and getting back to work are obvious target outcomes. However, an assessment is the next step in obtaining information, to ascertain various who, what, when, where, and how questions in order to make clear determinations as to what goals and objectives should be dealt with first. Assessment/​Dialogue As might be expected, the conversation begins with the therapist conveying empathy and support to Judy. The therapist also validates Judy’s desire to return to a “normal life,” which is a goal that she identified to the social worker during the intake. Consider the following dialogue as a way of developing a therapeutic bond, but possibly also as ways to identify potential goals and objectives. THERAPIST: Judy,

it’s been so difficult for you to have any sense of a normal day since your husband died. As you said, getting up in the morning and going to work has been impossible for you, but you hope to find a way to get up and going and return to work. Am I right about that? JUDY: Yes, I have to find a way to get back to work. THERAPIST: That’s a great goal, but before you get back to work, what do you think you have to do, since getting up

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and getting yourself ready and your children ready for school must be overwhelming right now. JUDY: Yes, I can’t get out of bed in the morning. My mother has been staying here and getting the children up and out to school. THERAPIST: It’s wonderful to have your mother as a support. JUDY: Yes, but that’s my job, and I feel guilty that she is doing that. THERAPIST: Be kind to yourself, you’ve undergone the shock of abruptly losing your husband, and I  assume you are here because you hope to find the strength to move on. JUDY: Yes, I do have hope that I can move on, but I just don’t know what to do. THERAPIST: You mentioned that you don’t sleep, which may be one of the reasons you can’t get out of bed, in addition to not being able to face the day. JUDY: Yes, I am usually up until 5 a.m. and then fall asleep. I just don’t know how to fall asleep in the evening, but I  really need to get back to work. THERAPIST: Maybe the first thing we need to work on is finding a way for you to get back to a regular sleep routine before worrying about getting back to work. JUDY: But I have to get back to work! THERAPIST: Can we talk more about how your evening goes and then develop a plan for you to begin to get a good night’s sleep and then perhaps move on to talking about when you might go back to work? JUDY: I suppose you are right, I need to sleep to be able to function on the job. Stopping here for a moment, it is apparent that the therapist’s gathering of information about Judy’s loss, her anxiety about getting back to work, and issues with sleeping are grounded in an empathetic response. Judy seems less concerned about her sleep than about getting back to work,

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even though it seems logical that she needs to sleep if she is going to function at work. Let’s continue the conversation: tell me what life was like in the morning and in the evening when your husband was alive. Did you deal with the children by yourself or was your husband involved (who)? JUDY: My husband was wonderful. He got the children up every morning by going into their rooms and was playful, making them laugh (how). I would be downstairs making coffee and I could hear their gleeful screams as they ran into the bathroom to brush their teeth at my husband’s prompting. THERAPIST:  I imagine having that lovely memory is very hard right now. JUDY: Yes, it just makes me want to pull the covers over my head in the morning and not wake up. THERAPIST: So, it must be very difficult to think about how to start the day without him. JUDY: Yes, I have no sense of how to make it normal, how to create a morning routine with the kids, because that was his thing. I don’t know what to do and I am just avoiding it. THERAPIST: I can understand wanting to avoid the morning because it is so painful to have those memories of the morning routine. JUDY: Yes, but I also want to be there for my children. It’s important for me to get a grip. THERAPIST: Judy,

We know that Judy’s goal is to return to work. But it is clear that this long-​ term goal is a ways off. She has made it clear that she wants to be there with her children in the morning routine. So, the question is, should she focus on sleep first or the overwhelming memories? A continuing assessment/​dialogue helps to identify the first goal and objective:

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what do you think would help you sleep? JUDY: I think that I’d be a whole lot calmer and I could relax in the evening knowing that I’ll get up in the morning and get my kids off to school. THERAPIST:  Do you think you could have a conversation with your children about what they remember about the morning routine and what they would like to see happen with you now that their dad isn’t there? JUDY: Yes, I can talk to them about that, and I think it will help them, too. THERAPIST: Judy,

A summary of dialogue/​assessment thus far is as follows: • Judy doesn’t know what to do about not being able to fall asleep but says she thinks she will be calmer knowing that she will get up in the morning with her kids. • Judy doesn’t know how to face the morning, as she avoids the memory of her husband’s routine in waking the children, but agrees that talking to her children about the routine they had with their dad is a good idea. • Judy doesn’t know what to do about being flooded with thoughts of her husband. Note: When there are multiple issues and possibilities for several measurable outcomes, which is often the case, a summary with a bulleted list is helpful to maintain a clear focus before identifying goals. Identifying Goals and Objectives Using the CDRS A summary of these issues and problems points to the next step in identifying where Judy is in terms of her thinking, to determine a realistic and meaningful goal and objective. Situating the problem(s) in a cognitive domain will point to an action verb to identify a goal and objective. Using the CDRS process (based on Bloom’s taxonomy of remembering, understanding, applying, analyzing, evaluating, and creating) we see that Judy

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has an issue with remembering. It is interesting, as what she remembers causes her pain, and what she doesn’t remember makes her unable to function in the morning. This situates Judy’s thinking at the level 1 cognitive domain—​remembering. Judy’s recollection of the morning is a bunch of jumbled memories, things she remembers hearing—​for example, her children laughing and running to the bathroom to brush their teeth—​and not the specifics of what the children do to get ready in the morning. Judy likely has knowledge of the morning routine, but her loss creates a problem in her ability to think logically at this time. However, agreeing to speak with her children about what they remember about the morning routine is a clear measurable objective that involves them remembering together about the morning. Who, what, when, and how are all addressed in this problem set: Who involves Judy and her children, as well as the memory of her husband? What is the routine, when is the morning, and how are the behaviors, that is, the things the children do that occur during the morning routine? Given the information these questions prompt, and assuming that a continued dialogue with Judy about her desire to not feel so overwhelmed and be more engaged with her children in the morning could realistically result in goals and objectives to address those problems and concerns, the following goal and objectives are established: Goal (a broad statement with general intentions): Judy will feel less overwhelmed during the morning routine. Objective (a specific, measurable statement with tangible results): 1. Judy will have several conversations with her children to recall (action verb) together what the morning routine was like with their father. 2. Judy will name (action verb) one or two things to do with her children in the morning routine. These objectives exemplify CDRS level 1—​remembering.

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Comments on Remember Objective: CDRS Level 1 The objectives established here for Judy are measurable in that she is asked to simply have a conversation with her children to recall the morning routine. Further, she is asked to name a morning routine she could do with her children. From a therapeutic view, there are inherent benefits to these objectives. Judy will recall the memories rather than avoid them. The desired result is that she will no longer be flooded by a series of jumbled memories. Having a conversation with her children is a way for her to control the flooding and to work on reframing the pain and loss as cherished memories and as practical memories of how the morning routine goes. She is also asked to take a step toward engaging with her children in the morning routine and to take an active role in this routine instead of passively avoiding it. By opening the window to these conversations and images, Judy is encouraged to take a functional parenting role. Support for this is expected to occur during weekly therapy sessions where she will work on remembering the morning routine with the therapist, who might role-​play with her how to converse with her children. It is likely that self-​ soothing techniques, such as mediation, yoga, and exercise, and perhaps taking an antidepressant medication will help her be successful with this objective. It also is quite apparent that focusing on the sleep issue could easily be integrated as a second goal while also working on the first goal of Judy engaging with her children during the morning routine. Judy obviously understands that it is her grief that is impeding her sleep, so in terms of her thinking she may, with supportive counseling, recognize that she needs to apply behaviors to work on sleeping better. This situates Judy’s thinking in CDRS level 3—​applying. Let’s assume the therapist and Judy discuss this and agree to the following goal and objective: Goal (a broad statement with general intentions): Judy will get a restful night’s sleep. Objective (a specific, measurable statement with tangible results):

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Judy will schedule (action verb) a bedtime routine to get a minimum of 6 hours of sleep each night. Her strategies include taking a bath before bedtime and meditating for 10 minutes before getting into bed. Note: Sometimes the objective is a stand-​alone, specific measure, and other times it might be useful to include specific strategies, as with this particular objective. This objective and the strategies involved exemplify CDRS level 3—​apply. Comments on Apply Goal and Objective: CDRS Level 3 This objective is measurable, as Judy is scheduling (action verb) a bedtime routine to obtain her goal of getting a good night’s sleep. She is also very specific about what she will do, which also involves action verbs: take a bath, meditate. Whether Judy follows through or not with this objective and strategies is information that will point to the next objective. Should she require medication for sleep, it should be noted that it would be an acceptable measurable outcome, as complying or not complying is the measure. Taking sleep medication is a perfectly reasonable objective toward maintaining one’s physical and psychological equilibrium and could be included as a secondary objective.

Summary

This case scenario illustrates the complexity involved in determining the possibilities for identifying goals and objectives and further demonstrates how defining goals and objectives are often a fluid process. In Judy’s case, there are multiple benefits from her dealing with the issues of remembering and not remembering the morning routine. Just having a conversation with her children creates an opportunity to engage with them as a way to act and feel like a functional parent. It also creates a possibility for calming down and taking control of the flooding of memories. Finally, it paves the

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way to reinforcing the need for her to follow through with her objective to get a decent night’s sleep so she can be able to get up in the morning, rather than just doing a sleep routine for the sake of simply sleeping. Even if Judy proves to be unsuccessful at attaining her goals, the new objective might simply be that she take sleep medication.

SCENARIO 2

The next scenario has a straightforward, singular problem, as compared to the complicated issues of Judy struggling with sleep, caring for her children, not being able to function at work, and dealing with overwhelming grief. However, the next scenario exemplifies how taking a straightforward problem and beginning at the basic level of thinking in the level 2 cognitive domain of understanding and taking an active, measurable approach to identifying the problem can lead to deeper and complicated issues for treatment.

Client: Amanda

Presenting Problem Amanda is a 34-​year-​old divorcee who has come to the outpatient mental health and substance abuse program today because of her concerns about her drinking. She states, “I drink too much, and it makes me anxious about how I am viewed as functioning in my job.” Amanda reports that her father was an alcoholic, as was her grandfather. She observed her mother being verbally abused by her father throughout her childhood and adolescence. Amanda has no children and devotes her life to her career as a banker. Although she is successful, she worries that drinking to excess when out with clients might have a negative impact on her job. Other significant history includes a divorce a year ago after 10  years of marriage. Amanda has no interest in a romantic relationship at this time, because she is still reeling from her divorce a year ago. She says that her

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ex-​husband was verbally abusive to her and that on occasion there was shoving and pushing. Amanda says that she had a drug and alcohol assessment at another outpatient program and reports that she was told she was vulnerable to becoming an alcoholic. Amanda says that she didn’t go back after that assessment because she didn’t “connect” with the therapist from the other agency. She states that the therapist only seemed interested in talking about her father and her childhood and the abuse she endured with her ex-​husband. Comments on Presenting Problem While Amanda identified her drinking as the main problem, she also identified other issues in her life, that is, her recent divorce and her having grown up as a child of an alcoholic. It is always important for a therapist to consider starting where the client is, and while her childhood issues and her recent divorce may seem important for her to look at in regard to her drinking problem, it is important to carefully listen to what Amanda is seeking help for at this time. There is a better likelihood of more compliance and success with outcomes when the client identifies what they want to work on, which is confirmed in the ensuing dialogue and continued assessment with Amanda. Assessment/​Dialogue This dialogue begins with an open-​ended question asking Amanda what she wants help with today. Certainly, this is a good way to start a dialogue when beginning any assessment. Amanda identified at intake that she wants to work on her current issue with drinking, and asking again what she wants to work on will either confirm that or point to other issues that we know may be significant to her drinking problem—​for example, her history with her father and with her ex-​husband. Understanding what she wants to work on in the current time frame (problem drinking) or in a historical sense (issues with her father and ex-​husband) informs the therapist for posing the who, what, when, where, and how questions appropriately. Also, it is fair to think that what Amanda repeatedly states has a better chance for a successful outcome and ensures that the therapist will

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not mistakenly take charge and encourage or identify an objective that Amanda is not interested in working on. what can I help you with today? AMANDA: I need help with how to get my drinking under control. THERAPIST: What does “getting under control” mean? AMANDA: I don’t want to get trashed when I go out, either when I’m out drinking with clients or socially. THERAPIST: Can you tell me more about the drug and alcohol assessment that was conducted at the other program you attended? AMANDA: Well, I don’t drink every day, I don’t binge drink, but sometimes I just have too much to drink and get out of control. I guess they said I could become a “full-​blown alcoholic.” THERAPIST: Again, I’m not sure what “out of control” means. AMANDA: “Out of control” is when I am not aware of how many drinks I’ve had, and somewhere down the line I  get trashed and have a hard time speaking clearly. THERAPIST: When is that likely to happen? AMANDA: It’s hard to say, I somehow don’t really pay close enough attention to when it happens. THERAPIST: Other than when you are out, are there other times when you feel like drinking? AMANDA: I think so, but I can’t say for sure. THERAPIST: Would you be willing to keep a log of the times when you feel you want to drink and record what you are thinking about assuming you have an urge to drink? AMANDA: Sure. THERAPIST: Amanda,

Identifying Goals and Objectives Using the CDRS In reviewing this short dialogue, which constitutes a beginning assessment, Amanda and the therapist agree that she identify urges she has

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throughout the week and record what she is thinking and feeling about directly before or after her urges. (We assume that a dialogue occurred between Amanda and the therapist about her urges to drink.) Given the information that Amanda reports, this task is situated in the level 1 cognitive domain, remember, as she needs to recall why she gets out of control when she drinks and why she has urges to drink. The action verb identify fits well with the objective. The therapist might get a release from Amanda and obtain the drug and alcohol assessment that she had recently. As mentioned earlier, assessment tools can be helpful in obtaining facts and other pertinent information. While it might be significant that Amanda grew up as a child of an alcoholic, Amanda made it clear that she is mostly troubled about her current concerns and has agreed to begin working on identifying her drinking behavior. She has also agreed that having the information about her past history might be helpful for her and the therapist as they continue with the therapeutic process. Goal (a broad statement with general intentions): Amanda wants to stop her “out-​of-​control” drinking. Objective (a specific, measurable statement with tangible results): Amanda will identify what she is feeling and thinking as she gets an urge to drink (CDRS level 1—​remember). Comment on Remember Objective: CDRS Level 1 This measurable objective identifies what she is feeling and thinking when she has urges to drink. You might want to add logging how much she drinks, which is level 3, applying. It could be a probe to see if she would actually be able to do both—​identify urges and record what she drinks. Let’s assume that Amanda follows through with the objective and discovers that when she gets anxious she wants a drink. Further queries about her anxiety identify that when clients present as aggressive, particularly men, or when she

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thinks she said something wrong to lose a deal she is likely to pick up a drink. She recalls that she remembers ordering several glasses of wine during those interactions. All of this information is useful and was obtained by directing Amanda to create an objective based on her thinking about the problem through cognitive domain level 1—​remembering. Before she identified the urges, Amanda didn’t remember how many drinks she had. If the therapist had asked Amanda to just log how may drinks she had, the connection between her feeling anxious and having urges to drink as a result of her anxiety might not have been identified. Continued Assessment/​Dialogue Several sessions later, the therapist asks Amanda to discuss what it was like when her father was drinking. She says that he was a “classic alcoholic” who got nasty when he was drunk and would start picking on her mother. He would chastise her mother for not drinking. Amanda then imitated what she says her father said to her mother in his drunken state:  “You think you are so much better than anyone else because you don’t drink.” The therapeutic relationship is established at this point, and Amanda begins to engage in discussions about the trauma she endured as a child of an alcoholic and starts to talk about the effect it has had on her adult life. The dialogue begins with the therapist asking Amanda to recall some images and events that occurred that she finds scary. Given this information, there is a shift in the objectives: Amanda and the therapist agree that applying calming techniques when she feels anxious and fearful would help with urges to drink, as drinking is a way to avoid and numb herself from anxiety. The therapist then asks several pointed questions: THERAPIST: Amanda, do you remember the feeling you had when

you were a child and your father was drunk? AMANDA:  I felt scared and I  felt anxious. Sometimes he didn’t even have to say anything, I could just see it in his eyes that he was going to explode. THERAPIST: Is it anything like the anxious feeling you have when you are with clients and worry that you are not going to make

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a sale because you might have done something wrong—​ when in fact you really didn’t do anything wrong? AMANDA: Actually, it’s the same feeling! THERAPIST: Does this anxiety emerge when a client might challenge you. AMANDA: Yes! My heart races and I get sweaty. Identifying the feeling states as triggers to urges to drink was profoundly revealing to Amanda. She was able to make a connection that the urge to drink and numb herself occurred when she felt anxious and threatened. With the therapist’s help, she was able to connect this to earlier trauma. It was at this juncture that the therapy took on a significant change in direction, from Amanda wanting a “fix” to deal with her drinking “out of control” to her looking at how the trauma from being a child of an alcoholic needed to be addressed. Still, however, using the CDRS model allowed for identifying triggers and helping Amanda cope in the present while making the connection to the past. If you look through the dialogue of this initial assessment there are many indicators of who, what, when, and where which all help to identify potential outcomes. At the same time, note that in this conversation the therapist asks, “How did this make you feel?” referring to her father’s rages when he was drinking. The point here is that it is possible to maintain the therapeutic relationship and maintain an empathetic stance (which, as noted at the beginning of the chapter, is critical to connecting and getting information from a client) while also identifying information to determine a measurable outcome that is most relevant. The therapist is operating on two modes here: one of being an empathetic listener, and one who is also keying in on how to help with a specific problem with drinking by identifying the urges. Given Amanda’s discovery that she is anxious in specific situations that lead to urges to drink, the next goal and objective are established: Goal (a broad statement with general intentions): Amanda wants to feel less anxious.

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Objective (a specific, measurable statement with tangible results): Amanda will implement (action verb) a plan to use deep breathing as a calming technique when she feels her heart racing, her hands sweating, and any other physical symptom when she feels anxious. If needed, she will call one of her supports when she is feeling anxious, to get help and support to determine whether her anxiety is mostly imagined or real. This objective exemplifies CDRS level 3—​apply. Comments on Apply Objective: CDRS Level 3 Applying situates Amanda in the level 3 cognitive domain, and she is now actually doing something to calm herself, rather than grabbing a drink. It is also building on the thinking process as in CDRS level 1, where she was asked to identify urges, which was when she discovered that it was anxiety that prompted her to have to drink. Amanda is now able to think about her anxiety. Her anxiety prompts her to use calming techniques, and being calmer allows her to assess whether the anxiety is real or imagined. Looking at this measurable outcome in isolation seems disconnected from what she might be feeling, but keep in mind that during this 2-​week period Amanda met with her therapist and worked on dealing with the connections that trigger her anxiety. Discussions were about men who have been aggressive toward her, as well as work situations when she worried about failing and anxiety eroded her confidence. It is likely that the more sophisticated Amanda becomes in thinking about evaluating (CDRS level 5) her anxiety, the more she will naturally identify (CDRS level 1) triggers and apply (CDRS level 3) strategies to cope and avoid drinking. This is another example of how thinking shifts in various cognitive domains. Given this scenario, the therapist is encouraged to discuss with Amanda how this thinking process occurs to reinforce her using the process to gain control over her initial presenting problem: to control her drinking, and to be mindful of her anxiety and the effect on her behavior.

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Continued Assessment/​Dialogue The ultimate goal for Amanda is to move on to CDRS level 6, create, that is, to create an entirely different way of coping with stressful work situations, particularly with aggressive men. Manage, create, set up (all action verbs) promote a way to interact differently with people and change how she conducts and constructs her meetings. THERAPIST: Amanda,

have you ever thought it might be helpful to create a strategy for yourself to deal with these situations, so you might use some coping skills instead of picking up a drink to cope? AMANDA: No, I usually just get overwhelmed and start chugging when I am in a direct confrontation in a dinner meeting. In reflecting on my feeling embarrassed and worried about my drinking, that is what I did, just drink more. THERAPIST: How about we discuss some ways you might strategize in situations when you feel overwhelmed. Perhaps we could do a role-​play? You can probably imagine how this discussion continues with Amanda as she and the therapist develop an objective to create (level 6 cognitive domain) some coping skills. Goal (a broad statement with general intentions): Amanda wants to feel less intimidated by those in authority who challenge her. Objective (a specific, measurable statement with tangible results): 1. Amanda will apply specific coping skills when she feels overwhelmed in meetings. This objective exemplifies CDRS level 3—​apply.

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2. Amanda will redirect conversations that she interprets as aggressive and create a number of ways to respond to effectively take control: “Excuse me, but let me see if I can identify our difference in opinion”; “I beg your pardon, Mr. S., but I am not sure I understand your objections; could you restate that please”; “Perhaps we cannot come to an agreement at this time, I’ll send you an email if I can think of ways we might be able to come to more agreeable terms” This objective exemplifies CDRS level 6—​create Comments on Create Objective: CDRS Level 6 If Amanda is progressing to the point that she is working on strategies to deal with how she conducts herself in situations when she feels intimidated and overwhelmed, she is clearly in level 6 cognitive domain—​creating. In discussions in therapy sessions, Amanda reports that using the calming techniques (noted in the previous objective), focusing on changing her tone of voice, adjusting her body language, and making more assertive verbal responses all make her feel more in control. The next and final steps are to create strategies to deal with these situations differently.

Summary

As noted in this example, the various levels of thinking are illuminating and effective in helping Amanda make the behavioral changes necessary for her to be in control. You can see how a CDRS level 1 involving identifying a simple urge to use alcohol leads to a path to a more empowered, sophisticated level of thinking at CDRS level 6, creating, which enabled Amanda to take charge of her behavior. While the goal to improve “self-​esteem” was not identified, since the term itself is not measurable, Amanda would be quick to say that her self-​esteem improved, as noted by clear measurable outcomes (behavior change). In this example, the historical information

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about her father’s behavior was eventually introduced in a way that was relevant to her current situation, as she was able to remember the anxiety she experienced when her father became aggressive when he drank. A strong alliance was essential and accepting that Amanda was the expert in her treatment was initially important to work on given that she had not established a connection with her previous therapist. Using the CDRS to “situate her thinking” from the beginning of treatment and throughout, were important elements to the success of this case.

SCENARIO 3

Inpatient Outcomes

Measuring for outcomes for clients in an inpatient setting can be a challenge, because the testing ground for practicing many objectives are outside of the inpatient program. Objectives for aftercare are often done in regard to the future, for example, the client will participate in outpatient therapy, will find a job, and will take prescribed medications for depression. These are standard objectives where it is all but impossible to measure the outcomes. It is suggested here that the inpatient therapist go back to the presenting problem and review the who, what, when, where, and how items in order to think about ways to create meaningful objectives during inpatient treatment. Some objectives might be realized while the client is at the inpatient facility, which might impact the client’s discharge with a clear, defined outcome.

Client: Joe

Presenting Problem Joe is a 50-​year-​old musician who has abused alcohol and heroin for 25 years. He has been in outpatient therapy at least five times over the past

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10 years, and this is his sixth inpatient facility. He was twice hospitalized involuntarily for overdosing on heroin, and this is the fourth time he has voluntarily entered inpatient treatment. Joe has no history of suicidal or homicidal ideation. He has the support of his family, including his mother and four brothers and two sisters. Joe has never been married and currently does not have a significant relationship. He claims to have a large support system of friends. Joe claims to not be depressed or anxious. He says that he gets into a cycle of using drugs for fun, which leads to an obsession and this becomes his full-​time occupation. He says that he often gets into financial trouble to support his alcohol and drug habit. Comments on Presenting Problem Given Joe’s long history of drug abuse and inpatient rehabs and a vague reference that his use of drugs is primarily for “fun,” it may seem that taking a detailed history would be important to ascertain a better understanding of why he has a long history of abuse and whether there is any trauma associated with his abuse of drugs. However, given that he may be in the hospital for a short period of time, it may be more effective to use some standardized measurements to assist in this assessment. The Beck Depression Inventory, the Beck Anxiety Inventory, and other selected trauma assessment tools might provide the same information in a more efficient manner. Assessment/​Dialogue Because the therapist has information that Joe has had numerous inpatient hospitalizations and has been abusing drugs for years, it would make sense to ask him immediately what will help him today, since he didn’t get the help he needed in other inpatient hospitalizations to stay clean. It seems relevant to pose the who, what, when, where, and how line of questions in the context leading up to his hospitalizations and after discharge. you’ve been here several times, what do you think you want and need that we can give you that we haven’t given you in your other stays?

THERAPIST:  Joe,

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JOE: Whatever

magic you can do to get me to stop using drugs. THERAPIST: I wish I  had the magic potion, but sorry, you have work with us to figure that out. JOE: I know. I always do great when I am here in treatment, but when I leave, it all goes poof! THERAPIST:  Ok, let’s start with some basic questions, like what was the longest time you were clean after being inpatient, and what was the shortest time between inpatient stays and using again? JOE: Let me think about that. I think the longest time I was clean was 9 months, which was about 4 years ago, and the shortest was 10 days, which was a year ago. THERAPIST: Can you recall what was going on in your life during each of those times? JOE: When I was clean for 9 months I had regular work and I was living with my mother. I was helping her pay some bills, and I remember that I felt I had to stay straight because I needed to help her. THERAPIST: So you had a sense of responsibility to someone. JOE: Yes. THERAPIST: What about your shortest stay? JOE: When I  left treatment, I  didn’t have a job, I  stayed at my brother’s for a couple of weeks, but I didn’t feel like I could keep staying there and I  just met up with one of my street buddies and started using. THERAPIST:  Do you remember what your aftercare plan was supposed to be? JOE: Yeah, I was supposed to get a job and a place to live, but how do you do that if you have nothing and your don’t have any leads on a job? THERAPIST: So, the plan was unrealistic? JOE: Yes, I just told the therapist that I had all that stuff lined up because I wanted to get out of here.

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THERAPIST: Obviously,

you weren’t committed to doing what you needed to be stable.

JOE: No. THERAPIST: What

about today? Are you committed to treatment or are you committed to just getting out of here? JOE: I’m committed to treatment. I’m tired. I  want to finally be done with using. THERAPIST: Good, then let’s figure out together what you need to do, but let me ask you something that may seem a bit silly: If your “fun drug” left town, what would life be like? (example of an externalizing narrative therapy question) JOE: Then I’d probably have to deal with the reality of dealing with life—​work or no work, bills not being paid, being alone. The therapist chose to look at his pre-​and post-​hospitalization history and obtained a lot of information by simply asking what and when questions. What the therapist and Joe discovered was what he was doing when he left treatment at the longest and shortest periods of being clean. The therapist and Joe discussed in detail what he was feeling, thinking, and doing during those time periods as a way to discern what made the difference in maintaining sobriety for a period of time versus what did not work. Joe did give a clue that when he was inpatient he was not committed to treatment. Perhaps more significant was that when he did not have a job or a place to live, he relapsed. And when pushed to further explain his drug use, he identified that using drugs was fun because what drugs did for him was to ward off feeling depressed and anxious. In a further exploration of past history, Joe and the therapist discussed how little attached he was to anyone, despite coming from a big family. He said that his father was in the restaurant business, so at a very young age he was there helping in the family business along with his siblings. He said that it was fun, but he never felt a connection to them as they were always busy working and the friends who came to the restaurant weren’t really

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friends. They were always open for business on holidays and on weekends; the family connection was simply around working at the restaurant. This discussion resulted in the therapist finally asking Joe to discuss how he might feel if the “fun drug” left town, and his response was quite revelatory: Joe indicated that he would feel overwhelmed at not being able to pay bills, not having a job, being stressed in a job, and feeling alone. From there it further emerged how using alcohol and drugs helped him numb himself from his loneliness. He said that he had never thought about how alcohol and drugs had become his “best friends.” Identifying Goals and Objectives Using CDRS At this point the question is, at which cognitive domain is Joe in thinking about his problem of “being disconnected” or “not having any stability in his life?” The therapist and Joe agree that his thinking is situated in the level 6 cognitive domain, as he needs to create and build relationships for a healthy lifestyle. The therapist and Joe agree that he will participate in some family therapy sessions with two of his brothers who have been a source of support to him in the past. Joe admits that he did not always take them up on their offers for work or for him to stay with them in order to save money, because he felt “smothered.” Goal (a broad statement with general intentions): Joe will develop a committed relationship with several family members. Objective (a specific, measurable statement with tangible results): Joe will create specific ways to spend time with family members. 1. Meet for four family therapy sessions to identify supports that Joe’s family can offer in the way of jobs and living arrangement. 2. Identify three things to demonstrate a commitment to his family: attend dinner at least two nights a week, take on a chore

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that helps the family, and contribute to the family’s groceries once he obtains a job. 3. Make and keep weekly outpatient therapy appointments consistently for a period of 3 months This objective and ways to meet it exemplify CDRS level 6—​create. Comments on Create Objective: CDRS Level 6 These three clear, measurable outcomes will be significant in determining if this has an impact on Joe being able to stay clean. In an ideal world, the inpatient therapist would contact the outpatient therapist about these objectives. As stated in Chapter 1, measurable outcomes may not always result in a positive result and, in fact, the objective may fail. However, failures determine what to do next. Continuing Assessment/​Dialogue Joe ends up back in the same inpatient facility, relapsing again 7 months later. The therapist and Joe review the last treatment plan that involved creating supports. The client-​centered discussion reviewing the failed objectives from the last inpatient stay results in agreement that Joe needs to rethink and recall information (CDRS level 1)  to figure out what he was doing before he used, and when and how often the urges happened. Who was there or not there to support him? The dialogue goes as follows: what happened, and how are you today? JOE: I think I started feeling depressed and couldn’t handle that feeling and wanted to get high. THERAPIST: So, what do you make of that? JOE:  I think I  need to find ways to cope with my depression, I never thought about it that way before. THERAPIST: You mean this the first time you ever recognized that your depression is connected to your using drugs? THERAPIST: Joe,

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JOE: I

know that sounds dumb, but yes, I always go and find “Mr. Fun Drug” to make a fun time, to get rid of that awful feeling. THERAPIST: Maybe we need to work together to figure out ways you might identify the triggers so when you begin to feel depressed you can prevent yourself from hooking up with “Mr. Fun Drug.” JOE: Yes, that sounds like a good plan. The therapist and Joe discuss a goal and objective for undertaking how to engage Joe in recalling what happened that led to his most recent relapse. Goal (a broad statement with general intentions): Joe will not use drugs to cope with his feelings of depression. Objective (a specific, measurable statement with tangible results): Joe will recall moments of depression or other feelings that trigger his urge to use drugs (CDRS level 1—​recall).

Summary

Joe’s case illustrates how the process of working on goals and objectives continues even when an objective is not successful (although it was measurable). In Amanda’s case, her objectives involved more sophisticated levels of thinking, whereas Joe moved down to a more simple way of thinking involving level 1 cognitive domain, remember/​recall. What Joe was able to do with the therapist was to identify that he had suffered undiagnosed depression for years and that drugs were his way of coping. Identifying when he feels depressed may help him avoid using drugs to cope. During the previous hospitalization, the therapist and Joe were overzealous in thinking that Joe would be able to utilize a support system to keep him from using. While it may not always be the case that one needs to identify the cause of vulnerability, it makes sense to at least check

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in with clients to see if they have a sense about the cause of their problem. In Joe’s case, the “fun drug” explanation was not simply Joe having fun and then becoming obsessed with the good feeling, but rather his warding off depression. Certainly, there is no guarantee that Joe’s identifying his depressed feelings will lead to his avoidance of using of drugs, but it is a start in dealing more openly with his depression and the connection between his depression and drug use.

CHAPTER SUMMARY

Connecting to clients is key to any successful outcome, and key to connecting to clients is establishing the relationship necessary to develop trust and confidence. It is assumed that clinicians know this as they approach assessing a client’s presenting problem. As emphasized in this chapter, the importance of collecting information regarding the who, what, when, where, and how of something happening to someone has great significance for identifying measurable outcomes. Much like detectives, therapists must be patient, forthcoming, and persistent in getting all the facts, and getting the facts right. It is not uncommon for clients to be evasive, contradictory, and resistant in offering up information about their past and their problems. Clients who have experienced trauma often do not recall the who, what, when, where, and how of events accurately, and sometimes not at all, so this situation requires particular attention and patience when obtaining information from a trauma victim. As mentioned briefly, various assessment tools might be an asset to eliciting more information about a client’s state of anxiety or depression. Use of these tools can corroborate information or help to obtain information from a resistant client or add to the story for those who are not good reporters. Whatever the tools used—​interviewing, assessment tools, existing histories, information obtained from other sources—​all should help in coming up with a sound assessment to create a viable direction for treatment that can translated into some type of measurable outcome. Additionally, client feedback about sessions is important for ensuring that

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the client is engaged. Duncan and Miller’s Outcome Rating Scale (ORS) (see Appendix) is a way of ascertaining how well the client is engaged. Scott Miller (2018) asserts that studies suggest that when people are able to provide regular feedback that directly impacts the direction of treatment, treatment success rates increase by an average of 65%. A study conducted by Asay and Lambert (1999) suggested that 40% of the positive change occurring in treatment most likely results from the person’s strengths, resources, and relational supports, thus supporting the idea that common factors of therapy, not specific models, are what foster success. It is important to emphasize that the who, what when, where, and how questions be posed to obtain information about a person’s strengths, resources, and relational supports, for, as Miller points out, they are important factors in making positive change. As will be noted throughout the remaining chapters, the ORS and other similar scales are viewed as assets in the process of therapy and in identifying clear goals and objectives. As illustrated in the case scenarios in this chapter, situating which CDRS level a client is in is essential to understanding a client’s thinking process, which in turns makes it easy to create a meaningful measurable outcome. The starting point is typically the presenting problem, which tells the story. Interestingly, the therapist’s job involves being able to function on all of the cognitive domains. The therapist must be able to recall and understand what the client is reporting (levels 1 and 2), apply or interpret information and analyze the information (levels 3 and 4), and finally help the client to evaluate and create (levels 5 and 6)  new information, including helping them to identify measurable outcomes. This is quite a task, but it is the goal of the therapist to help the client transcend these various domains throughout the therapy process. This requires that the therapist operate continually on a meta-​level of cognition as they pay attention to what the client is saying, at the same time the therapist is attending to their own thoughts.

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While successful outcomes are always the desired result, it is a given that there are many poor outcomes. What writing measurable outcomes can do, however, is aid in reviewing the poor outcomes in a manner that might warrant going back to a simpler objective. As noted in the case of Joe, in the later scenario where he relapsed and went back to inpatient treatment, the therapist went to a very simple place in level 1, where Joe needed to recall what he was thinking just before he relapsed to get clues of why he could not use his supports. Retrospectively, in this case, it is fair to say that the client and/​or therapist were unrealistic about his ability to create, that is, CDRS level 6, creating. He was in a situation where he couldn’t maintain enough of a connection to seek out support and think about the consequences. It seems at this point in time Joe must pay attention to recalling or understanding his urge to use. The information revealed at the first contact between the therapist and Joe may have seemed appropriate for developing an outcome based on that sophisticated level of thinking, for example, creating connections to maintain sobriety, but it proved to be wrong. A reframing of that failed outcome is not so much a failure as it is more information. Viewed this way, clients can feel continued hope as their therapists offer them another chance at fine-​tuning a realistic objective. The term assessment connotes a rather definitive conclusion based on the information obtained by the therapist. However, here assessment is fluid, in the sense that it changes and it will change, whether the outcome is realized or not. It must also be stated that any assessment also involves a therapeutic relationship. Therapists are in a powerful position to facilitate change, and it cannot be emphasized enough that creating measurable outcomes is a responsibility that should not be taken lightly. Given the current climate in programs, whether outpatient or inpatient, there are instances where it may be tempting to create a simple, clear measurable outcome to ensure a good chart for a good audit. However, the ethical responsibility always lies with the therapist to encourage the client toward creating a meaningful goal and an objective that are challenging. As stated earlier, failure to meet an outcome must never be viewed as an opportunity that was botched, but as another opportunity to rethink what someone is

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realistically thinking. Therapy is a process that is never easy to pin down, which is why this method of assessment with cognitive domains helps make for a clearer path. Finally, it is important to remember that the client must be a part of the process. Educating the client as to where they are in their level of thinking helps them to obtain a better understanding and better control of their problem. If one can understand that one of the reasons they can’t change is because they don’t understand why they do what they do, this is a beginning. With this, the hope is to emphasize the benefit of the CDRS process: The client who doesn’t understand why they do what they do is at level 1 or 2 and needs to first remember and understand before they can move forward—​this is likely to result in more successful outcomes. Our goal as therapists, with goal defined as a broad statement that is hard to measure, is to help clients with the problem they present to us. However, we must remember that our objective as therapists, with objective defined as being specific, precise, and measurable, is to help the client identify specific behaviors they wish to change and to work collaboratively to identify specific objectives to make those outcomes happen.

REFERENCES Asay, J.  R., & Lambert, J.  J. (1999). The empirical case for the common factors in therapy: quantitative findings. In M. A. Hubble, B. L. Duncan, & S. D. Miller (Eds.), The heart and soul of change:  What works in therapy (pp.  33–​56). Washington, DC: American Psychological Association. Cocoran, J., & Walsh, J. (2010). Clinical assessment and diagnosis in social work practice (2nd ed.) New York: Oxford University Press. Duncan, B. L., Miller, S. D., & Sparks, J. A. (2004). The heroic client: A revolutionary way to improve effectiveness through client-​directed outcome-​informed therapy. San Francisco: Jossey-​Bass. Evans, E. R., Hearn, M. T., Uhleman, M. R., & Ivey, A. E. (2017). Essential interviewing: A programmed approach to effective communication. Boston: Cengage Learning. Michenbaum, D. (2009, May) Psycho-​cultural assessment and interventions: The need for a case conceptualization model. Presented at the 13th Annual Melissa Institute Conference:  Race, Ethnicity and Mental Health. Retrieved from https://​coping.us/​ images/​Psychsocial_​Assessment_​Interventions-​Meichenbaum.pdf

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Miller, S.  (2018). Client-​directed outcome-​informed therapy. Retrieved from https://​ www.goodtherapy.org/ ​ l earn- ​ a bout- ​ t herapy/​ t ypes/​ c lient-​ d irected-​ o utcome​informed-​therapy Nicotera, N.  (2018). Essential interviewing skills for the helping professions. New York: Oxford University Press. Shea, S. C. (1998). Psychiatric interviewing: The art of understanding. Philadelphia: W.B. Saunders Company. Wiger, D.  E. (2012). The psychotherapy documentation primer (3rd ed.). Hoboken, NJ: John Wiley & Sons.

4

Goals and Objectives as They Relate to Outcomes

The goal of this chapter is to provide an understanding of goals and objectives in the context of outcomes. The specific objectives of the chapter are as follows: 1. To provide background about the research regarding outcomes in the context of psychotherapy 2. To provide a definition of each term: goals, objectives, and outcomes 3. To provide a vignette illustrating how to write objectives using the Cognitive Domain Rating Scale (CDRS)

RESEARCH ON OUTCOMES

Research on outcomes in psychotherapy as early as the late 1960s and into the 1970s is described by Strupp and Hadley (1977): “the voluminous literature on outcome criteria for psychotherapy (Bergin & Garfield, 1971, Strupp & Bergin, 1969) demonstrate the absence of a consensus on what constitutes mental health, and consequently, how changes resulting from psychotherapy are to be evaluated” (p. 187). It seems that the researchers during this time period (1970s–​1980s) were more focused on measuring

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variables that they, the researchers, identified as significant, rather than looking at outcomes to measure the therapeutic alliance or to measure what the client identified in their life as significant changes resulting from psychotherapy. What is interesting is that even with this claim of “voluminous literature on outcomes,” it is likely that an anecdotal review of clinicians practicing psychotherapy prior to the early 1990s and perhaps even currently would show that measurable outcomes are just now getting the attention of clinicians. Clinicians practicing psychotherapy (either in private practice or in clinics) prior to the early 1990s were likely to provide comments that documentation in a chart was basically information about the reason for referral, a psychosocial assessment, and progress notes. Progress notes were typically a summary of the session that may or may not have had a clear goal and/​or objective(s). Clinics might have had some requirements for a treatment plan with a goal and objective, but measuring those goals and objectives, which is essentially the outcome, was not the norm. Life was simple: the therapist saw the patient, they told their story, a relationship developed, and some type of plan was formulated to help solve client issues for a time period that was usually not discussed but assumed to continue until the therapist felt that the client had resolved the issue. Jenna Jacob and Julian Edbrooke-​ Childs (2018) offer a historical perspective of goals and outcomes in their chapter in the book, Working with Goals in Psychotherapy and Counselling. Their analysis is mentioned here for those interested in the development of and progress in this area. Strupp and Hadley’s 1977 article in American Psychologist outlines a very complicated formula for assessing such outcomes. They pose the question of how therapists were to evaluate outcomes when clients entered therapy to deal with existential issues, such as “the meaning of life.” In another article, by Mintz, Luborsky, and Christoph (1979), the concern was who should be evaluating the outcomes—​the patient, therapist, clinical observers, or relevant others, such as relatives. In this same article, the authors question what should be measured—​behavior, personality, or affect? Strupp and Hadley (1977) state:

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More is involved in assessments of psychotherapy outcomes than changes in the person’s feeling state/​and or behavior. For example, it is one thing to observe that following therapy a previously anxious and shy male asks a girl for a date (overt behavior); one may also inquire whether he is now happier than he was previously (well-​being); and it is quite another matter to determine the extent to which an observed behavioral and affective disposition to deal differently with women or to determine the quality of the experience; for example, whether a rigid defense structure has been replaced with a more modulated approach in interpersonal relations. Empirical studies of therapy outcomes have rarely dealt with these topics. (p. 189) It is certainly true that “more [may be] involved in assessment of psychotherapy outcomes than changes in a person’s feeling state,” but it seems logical that what is most important is simply client satisfaction, both in regard to how they feel about their life and how they feel about the outcome of their therapy sessions. Duncan, Miller, and Sparks (2004) cite extensive research about the value of outcome feedback to evaluate just that, patient satisfaction. The Outcome Questionnaire 45.2 (OQ) (Lambert & Burlingame, 1996) is an oft-​cited outcome tool that measures important areas of functioning (symptoms, interpersonal problems, social role functioning, and quality of life). This tool preceded Duncan, Miller, and Sparks’ Outcome Rating Scale (ORS) (2004), and while noted to be of value in rating outcomes, practitioners report the OQ to be cumbersome as it takes as much as 15 minutes out of a therapy session to complete. Other outcome tools used to assess the client–​therapist relationship include Horvath’s (1992) Working Alliance Inventory (WAI) and Cooper’s (2015) Goals Form. The Session Rating Scale (SRS), developed by Lynn Johnson (Miller, Duncan, & Johnson, 2000), also assesses the therapeutic alliance to provide information about how the client felt about the session. And, while the scale developed by Adams and Grieder (2014) offers a comprehensive goal/​objective treatment planning process, like the OQ 4.52, it is time-​consuming to complete.

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It would make sense, given the person-​centered approach in psychotherapy, to adopt an outcome tool that provides feedback from the client rather than identifying a variable noted by a researcher to denote change. I think the ORS and the SRS are excellent feedback tools to obtain outcomes. The ORS is a Likert scale that scores four areas of a client’s life in the past week: individual, interpersonal, social, and a general overview. Negative rating scales are important to note, as this feedback helps the therapist and client point to areas to maintain focus or refocus treatment. The SRS, also a Likert scale, can be used to assess the therapy session and the therapeutic alliance, which is certainly critical for continuation of sessions. These outcome tools are recommended and can work effectively in tandem with the CDRS model proposed in this text. Together, the ORS and SRS provide a comprehensive overview: how the client is feeling in their life and how they feel about the therapy being offered. All of this information is most certainly significant for developing ongoing goals and objectives. We have addressed outcomes as the result of evaluating goals and objectives; Locke and Latham’s seminal work, “A Theory of Goal Setting and Task Performance” (1991), is worth noting in this regard. While their research focused on the workplace, their claims have relevance to clinical settings. They reinforce the need to set specific and difficult goals, and they outline other characteristics of successful goal setting. While their work clarifies the important elements in goal setting, it seems that using their definition of goals is more accurately a description of an objective, given the common definition that goals are broad with general intentions, and objectives are specific. Therefore, liberty is taken here to insert “objective” where they used “goal” in the subsequent list. Locke and Latham identified five points that are critical for successful objectives: 1. Clarity. Clear objectives are measurable and unambiguous. One ensures clarity of the objective by making it specific, measurable, and time-​bound. 2. Challenge. Ensure that an appropriate balance is set between a challenging objective and a realistic goal.

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3. Commitment. Objectives must be understood and agreed upon if they are to be effective. 4. Feedback. Feedback provides opportunities to clarify expectations, adjust objective difficulty, and gain recognition. 5. Task complexity. Don’t frustrate or inhibit people from accomplishing their objectives; make them attainable. As noted, while outcomes have been discussed in the literature for quite some time, the current view is that outcomes are an “integrated approach” to treatment, in that therapists consider an important aspect of evaluating the therapy process the view that the client is expert in collaborating on their own problem (Adams & Grieder, 2014). As mentioned throughout this text, the therapeutic process is often referred to as a “client-​centered” or “person-​centered” approach. Finally, outcomes are the result of whatever goals and objectives are identified, and as stressed in Chapter 1, the elements of good psychotherapeutic practice must be present if outcomes are to occur.

MANAGED CARE AND MEASURABLE OUTCOMES

Since a review of the research shows that there is evidence for at least some 40 years to support goal setting, why is it that measurable outcomes is the buzz word today and is expected in clinical settings? The evidence seems overwhelming that the scarcity of resources and a demand for quality service in the healthcare industry in the 1980s and 1990s resulted in managed care. And, given the managed care climate, therapists became not only accountable to their clients but also to other entities. According to McIntyre, Rogers, and Heier (2001), “the key constituents driving performance measurement (government payers, private sector regulators, business coalitions, health care providers) was the result of the rise in managed care, noting that in 1998 one out of four individuals were enrolled in some form of managed care, a 91% increase from 1993” (p. 7). In this same article, the authors state: “in addition to managed care

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companies needing to look at cost savings to remain competitive, they also needed to be competitive in terms of quality and its oversight activity is performance measurement” (p. 7). Given this statement, “performance measurement” is another way of saying “measurable outcomes,” with healthcare policy undergoing tremendous change over the past two decades, and some of those changes have involved an increasing emphasis on outcomes (Duncan, Miller, & Sparks, 2004). These authors quote Brown, Dreis, and Nace (1999), who argue, “In the emerging environment, the outcome of the service rather than the service itself is the product that providers have to market and sell. Those unable to systematically evaluate the outcome of treatment will have nothing to sell to purchasers of health care services” (p. 117). With the advent of managed care, there was development and research that attended to outcomes. Miller, Duncan, Brown, Sparks, and Gaud (2003) supports what was posited earlier about outcomes, stating that “a variety of approaches exist for evaluating the outcomes of psychotherapy, both clinician and client rated. They are valid and reliable, but the length of administration and cost often render them infeasible for many service providers and settings.” He adds, “many of the measures presently used to assess outcomes of therapy were not designed to measure change. On the contrary, most were specifically developed to assess stable personality traits or enduring patterns of problematic behavior” (p. 92). Patient care, particularly the quality of patient care, is often cited as the rationale for moving in the managed care direction. However, it was also at this time that changes were made in reimbursement for behavioral health because of increasing costs. Previously, most insurance plans would pay 80% of a clinician’s fee, minus a deductible. Managed care replaced those plans by controlling the number of sessions and establishing a set fee. Typically, a case manager reviews cases with the clinician, and it is the managed care employee who determines how many sessions are approved. (It should be noted that the fee ranges from $65 to $75 for master’s-​level social workers and perhaps more for PhD psychologists. For the majority of professionals who see clients for psychotherapy who collect insurance, their fee, as established by managed care, has not changed some 30+ years

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later. This is partly due to the surge of counselors and therapists who now compete for clients.) What does this have to do with goals and outcomes? It has to do with accountability. The purpose of this book is not to provide a detailed discussion of managed care from an historical, social, economic, or political perspective but to offer some background that the trend in managed care is traceable to the current demand and expectation that clinicians have charts with definitive measurable outcomes to justify reimbursement for clinical services. It is not that goals and objectives and outcomes were never discussed earlier, but that they were not considered in detail or with the expectation that outcomes be attached to funding, as is quickly becoming the mandate today. Ironically, one of the criticisms of managed care is that people don’t get the quality care they need, both medically and in regard to behavioral health. However, one of the positive things that managed care has done is to highlight the need for measurable outcomes. It is certainly in the best interest for all parties concerned that standards and accountability be met. What has happened is that practitioners are not yet trained in how to undertake this task. As noted by Stewart, Lareef, Hadley, and Mandell (2017), “P4P [pay for performance] in behavioral health is simple in concept but complex in execution. Behavioral health does not have definitive outcome measures, such as presence or absence of disease or mortality, with which to measure outcome” (p. 67).

DEFINING GOALS AND OBJECTIVES

We have determined that outcomes are the result of identified goals and objectives, and it is important to start with the basic understanding of what a goal is and what an objective is and how that translates to an outcome. It is helpful to begin this thinking by using simple examples from what we as individuals do every day. Goals and objectives are not just used for behavioral health clients, obviously! They are things that most

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everyone can relate to when prompted to think about what he or she does. “In life, objectives help us to focus our attention and our efforts; they indicate what we want to accomplish” (Anderson & Krathwohl, 2001, p. 3). For most individuals, every day begins with some type of goal and objective. For some, it goes without thinking consciously what that might entail, for others, there may be a specific goal and/​or objective in mind. Wanting to wake up to have time to get ready for work is a goal. And, for that outcome to be realized, one has to establish some type of objective. The mere act of setting one’s alarm to wake up at a certain time is usually how that is accomplished. Another goal might be, after getting to work on time, to have a plan or objective to accomplish specific tasks. The CEO might have a goal to organize his or her “to do” list, which might include an objective to complete specific tasks by the end of the day: writing an agenda for a staff meeting, conducting supervision with senior staff, sending the monthly budget to board members. Goals and objectives are ways in which we organize our lives, and they are part of the human condition, giving us some order to the meaning of things we do. While some might argue that one can have meaning in life without having any goal, in actuality one would be hard pressed to say that they did not have any goal in life. According to Emmons (2003), “without goals, life would lack structure and purpose” (p. 106). The following working definitions identify the differences between goals and objectives and their relationship to outcomes: Goals are broad statements with general intentions. Objectives are specific measurable statements with tangible results and involve incremental steps used to accomplish goals (Wiger, 2012). Outcomes are the result attained (or not) of intervention activities. Goals are great to have, but if one does not have a plan or type of action to accomplish that goal it remains an unfulfilled desire. For example, if one’s goal (broad statement with general intentions) is to eat healthy, then

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these might be actions or objectives (specific measurable statements with tangible results): 1. To purchase food from a list of healthy foods from two vegetarian cookbooks 2. To create healthy meals five out of seven nights per week The claim was made that everyone deals with goals, whether it is with intentions or not. However, writing goals and objectives in psychotherapy is a conscious intention that is determined by the therapist and the client. Psychotherapy outcomes measure progress or identify lack of progress or failure. Feedback outcome tools (see Appendix) assist in helping to make sure that the client and therapist are on the same page, and provide therapists with feedback to deal with “negative effects in psychotherapy” (Lambert, Whipple, et al., 2001; Strupp & Hadley, 1977). Bachelor (2013) notes, “Therapists should ensure that goals and therapeutic tasks are discussed together and mutually determined and remain vigilant for signs of tension in the relationship that could reflect a perceived lack of shared views, adjusting their responses accordingly” (p. 133). When writing goals and objectives for clients, the therapist and client need to work collaboratively to agree on the desired outcome. This process is illustrated throughout the book through case studies; the dialogue between the therapist and client is critical to obtaining information from the client about their presenting problem and their desire for a more positive outlook. In addition, use of the CDRS model ensures that thinking accurately about the problem results in meaningful outcomes, with accompanying outcome feedback tools (see Appendix).

CASE STUDY

A case study is presented here to illustrate how goals, objectives, and outcomes are realized. In the following example, note that the therapist begins with a list of broad goals based on a few sentences from the

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presenting problem and then identifies specific objectives to accomplish those goals. Included is a dialogue to illustrate how to consider conducting a session to meet the desired outcomes.

Brooke’s Presenting Problem

The following highlights information gleaned from the assessment: Brooke complains of depression and anxiety and expresses a desire to “figure out” how she can be happy and more at ease. She says that she has little interest in doing some of the things she used to do for fun and that she worries a lot. She says that she feels anxious about being successful in college. She admits to not taking her antidepressant medication that was prescribed by her primary care physician. Even with this little amount of information from the presenting problem, the following are possible goals. Goal (broad statements with general intentions):

• Brooke wants to feel less depressed. • Brooke wants to feel less anxious. • Brooke wants to have more fun in her life. • Brooke wants to worry less.

All of these statements are broad goals with general intentions that might be taken to be obvious. These “obvious” goals, however, tell us nothing about what Brooke will do to obtain those goals, though together they are a step in a positive direction in that Brooke wants to change. In just these few sentences, we have a lot of information about Brooke’s intentions—​to be happier, less depressed, and less anxious, and she wants to have fun and worry less often. At this moment, she appears to be motivated and is reaching out for help. To make these goals measurable requires a next step, which is to consider what Brooke needs to do to accomplish these goals. This process

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requires specific objectives. Here are the agreed-​upon objectives that the therapist and Brooke put together: Objectives (specific measurable statements with tangible results): 1. Brooke will take her antidepressant medication and log symptom reduction, defined as having more interest in and interactions with friends and family. 2. Brooke will use cognitive behavioral therapy (CBT) coping skills and log justifiable versus irrational worries. It is important to note that this very simplistic example may lack a lot of information about Brooke’s history and current situation. But it is possible that the outcomes could be realized even with this paucity of information. Assume, again, that there have been several sessions in which the therapist and Brooke have discussed these objectives. However, after several weeks, Brooke is still not feeling any different and admits that she didn’t follow through with any of the outlined objectives. During this period the therapist obtained feedback from two self-​report rating scales that Brooke completed at each session. This provided information regarding how she felt both individually and socially and how she felt about the therapy sessions. The therapist used the ORS (Miller & Duncan, 2000), “a brief, four-​item, self-​report instrument that takes less than a minute to complete and score. The client rates individual (or symptomatic) functioning, interpersonal relationships, and social role performance (work adjustment, quality of life) and an overall sent of well-​being” (p.  6). She also completed the SRS (Miller, Duncan, & Johnson, 2000), which “assesses four interacting elements, including the quality of the relational bond, as well as the degree of agreement between the client and therapist on the goals, methods, and overall approach of therapy” (p. 13). This information was useful for the therapist when Brooke reported no change in feeling better. On how she felt “interpersonally,” specifically in regard to her family, Brooke gave a low rating and reported she felt “stressed out” when she thought about and met with her parents. She

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reported that she felt “pressure.” Brooke’s rating of therapy sessions were in the mid-​range, and when asked about that she said, “I feel ok talking, but I’m not sure if it’s making me feel any better.” The therapist asked Brooke if it would be helpful to talk more about the pressure she feels, and she agreed. The specific objective was then changed to help Brooke identify (CDRS level 1—​remember/​recall) the nature of the pressure she was experiencing, and perhaps even what might have to change to make the pressure go away. In Chapter 3, on assessment, the point was made that it is critical to obtain important information regarding the who, what, when, where, and how details about the client’s presenting problem and that reassessing how the client is thinking about their problem is often necessary. Goals and objectives may change, and they may or may not be realized. Resistance may not be the problem; instead, the problem may simply be that the therapist and client need to spend more time figuring about where the client is in thinking about their problem. In Brooke’s case, the presenting problem that was initially identified was depression and anxiety, but in later sessions, it was uncovered that Brooke was feeling pressure. If the CDRS was to assist in establishing where Brooke was “situated in her thinking” about her depression, the first objective might have been for Brooke to identify (CDRS level 1—​remember/​recall) what thoughts and feelings come up when she feels depressed. It is possible that her thoughts about the pressure she’s feeling might have been a better starting point, rather than looking at medication as the cure and using CBT coping skills as a strategy, which assumed she could apply or “do” those tasks and carry out those objectives (CRS level 3—​apply). Given that outcome, medication and “stop thought” processes may have been blatantly inappropriate. The value of using the CDRS in goal and objective setting is to help the client be thoughtful about their problem and avoid misguided objectives. In just 1 week, Brooke returned to therapy and said she was able to identify thoughts about the pressure she was feeling. She identified it as pressure from her parents to complete college, and what she wanted to do was take a break. She was certain that she would return to college, but right now she wanted to travel and have time to think.

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In that session, the feedback tools (ORS and the SRS) were both much more positive. She expressed relief in being able to say that the pressure was causing her to feel trapped and depressed, and just being able to say out loud that she wanted to take a break from college provided relief. The new goal and objectives provided clarity. This was attained by using the CDRS model, and the feedback tools (ORS, SRS) turned out to be very helpful in changing the direction of therapy. It should also be noted that this result meets the first criteria for writing a measurable objective goal:  clarity (as proposed by Locke and Latham, 1991), which is an improvement on the first written objectives: Goal (broad statements with general intentions): • Brooke wants to consider an alternative to college next semester. Objective (specific statements with tangible results): • Brooke will create (CDRS level 6) a plan in the next 2 weeks outlining options for how to spend a semester off from college, including what she wants to do and how she will fund this time off. The objective and outcome were realized. Brooke met with her parents, who were accepting of her plan. Brooke then met with the therapist for two more sessions. Her mood improved significantly; she no longer felt depressed, anxious, or pressured and said she was very much looking forward to working and saving money so she could travel for a semester.

BEWARE OF LABELING RESISTANCE REGARDING UNMET OUTCOMES

When clients do not meet the desired outcome, therapists often claim that some type of resistance is taking place. However, this model challenges

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that claim because an assumption can be made that if an outcome is not realized, then perhaps it is an unrealistic objective. While resistance may be occurring by definition, the failure is not put on the client; the “thing” that was agreed on just didn’t work. One might argue that Brooke was being resistant and, if so, that may not have been such a bad thing after all. Mitchell (2003) claims that “the encountering of resistance is likely evidence that therapy is taking place. More specifically, getting to moderate levels of resistance is important to successful therapy, especially when followed by effective approaches and techniques.” The question in Brooke’s case, then, is why the resistance? The therapist might have blamed it on a passive-​aggressive personality disorder, or might have thought that she had some undisclosed trauma that was preventing her from being able to follow through, or that her depression needed to be dealt with from a psychopharmacological perspective before she could engage in making any change. Let us posit, instead of resistance, that the objective was unrealistic because it was the wrong objective. By accepting and being empathetic to Brooke’s not being able to follow through with the objectives and wondering if there wasn’t something else going on, the therapist and Brooke discovered the real reason for her being stuck: it was the pressure she was feeling to stay in college.

DIALOGUE WITH BROOKE

Following is the conversation that that took place with Brooke several weeks into therapy. Note the boldface what, how, and who sentences. These are informative, as they point to what Brooke was feeling and were important probes from the therapist as to how she might make some change and whom she felt pressure from. These types of probing questions are very helpful and critical in developing objectives. The reader is encouraged to go back and review how the who, what, when, where, and how queries can

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help define the clarity that Locke and Latham (1991) make reference to as being important for successful outcomes. THERAPIST: Brooke, you look dejected. Am I right to think you are

looking very sad? BROOKE: Yes, I am sad. I feel like a failure and I can’t please anyone. I keep “forgetting,” and I can’t get into using the “thinking good thoughts—​CBT” stuff because I  only think about feeling crappy. THERAPIST: How about we set aside not worrying about pleasing everyone, and who are those “everyone”? BROOKE: My parents, my teachers, you. THERAPIST:  Wow, that’s a lot of people to worry about! I  see in your rating scales that you indicate you are in the gutter with the “interpersonal–​ family, close relationships.” BROOKE: Yes, my parents want me to get this degree, my advisor says I should take more challenging courses, and I have to report to you that I can’t even remember to take my meds or do that simple CBT thing of “stop thought” about the negative thinking. THERAPIST:  You sound like you are feeling a lot of pressure to please everyone, is that right? BROOKE: Exactly! THERAPIST: What about you, you forgot you in this list of people. What would please you? And what can we do to make the sessions more in keeping with your needs, since your session ratings are rather lukewarm? BROOKE: What would make me happy is just to forget about school, not forever, but I just want a break. I don’t have the motivation now. I want to have some time to travel, to think, and not have the pressure of school. THERAPIST: So you feel pressure to stay in college because . . .?

Goals and Objectives as They Relate to Outcomes

BROOKE:  Because

my parents are academics, they feel strongly about higher education and I don’t want to disappoint them. THERAPIST: Let’s stay with what would please you. BROOKE: Like I  said, I  would be very pleased to just have a semester to travel and to have time to think about what I want to do. THERAPIST:  This doesn’t sound unreasonable, and twice you’ve said that same thing: you want to travel and have time to think. Have you given thought to how you might be able to pull that off? I mean, how would you support yourself? BROOKE: Well, yeah, I  would work for several months or more to save money, and research where I wanted to go and figure out what it would cost. THERAPIST: What about the part about your parents, are you worried this would not please them? BROOKE: Oh yes, I think about that all the time and it makes my head spin. I feel so much pressure to do what they want me to do. THERAPIST: Brooke, have you noticed that both you and I  have said several times in the last few minutes that you feel pressure. Am I right about that, is it pressure you feel? BROOKE: Yes, I feel tremendous pressure, and it’s always been that I feel I have to do what I am told to do. THERAPIST:  Again, you are telling me what would please you would be to take a semester off, that you would plan on a way to be able to do that, right? BROOKE:  Yes, and I  think I  would feel for the first time, ever, doing something I wanted to do and not feel pressure, as you say. THERAPIST: Ok, so I guess the problem you have is not so much that you are depressed, but that you are pressured?

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BROOKE: Exactly,

and it feels good just to be able to say that! THERAPIST: So, more than anything right now, is that you don’t want to feel pressured? (goal: general statement with broad intentions) BROOKE: Yes, I don’t want to feel pressured. THERAPIST: So, how might you make a plan to do what you want? (objective: an action with measurable outcomes) Do you think it would work, or is that just too much for you do think about right now? BROOKE: I actually have thought a lot about how I would plan it all out. I guess I need to stop whining and actually figure it out. From this dialogue we can imagine the rest, where Brooke comes back to therapy and formulates the plan that was described earlier. As stated in this example, the resistance was not “inside” the client but had to do with the therapist and Brooke being unable to accurately identify at the first shot what it was that she was feeling distressed about. However, the initial objectives were not necessarily unrealistic. Perhaps if she had taken the meds or done the CBT exercises she might have felt better. But it would not have addressed the heart of what she was actually experiencing. She moved quickly in therapy when she was able to identify the pressure she was feeling. With the help of the therapist’s empathetic responses in which there was no discussion about her not following through with her assigned tasks, Brooke responded to feeling validated and supported when the discussion pointed toward her feeling pressure. It is important to notice that toward the end of the dialogue the therapist put it out there for Brooke to decide whether it was ok now or “too much” for her to consider following through with this plan. Putting it that way placed Brooke in the position of making the decision and ensured that the therapist avoided placing pressure on Brooke to follow up with a plan, taking into consideration that CDRS level 7, create, might not be something she was ready to do. But Brooke reassured the therapist that she indeed wanted to create a plan.

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The question might be posed, what if Brooke didn’t follow through with the plan? Is she then considered a resistant client, and is it possible that clients never realize goals? The answer is yes and yes! There are resistant clients, but there are a number of strategies for working with clients to be more compliant, including using the model proposed in this text. As Mitchell (2003) so aptly states, “it is often the therapist’s failure to establish a mutually agreed-​on objective.” Often collaborating on agreed objectives and being empathetic will work with many individuals who seem impervious to change. Not all cases will be like Brooke, as there will be resistant clients. If it becomes clear that the client is indeed resistant, getting them or not getting them to agree on a goal and objective and getting outcome feedback will provide a clearer picture as to what can realistically be expected for the client. This is most often true for the mandated client who is ordered to treatment. Discussion of the resistant client is given more attention in Chapter 7.

WRITING MEASURABLE OUTCOMES

Outcomes are the result of the goals and objectives that are created, and measurable outcomes are actually crafted quite easily by using action verbs as a part of the objective. If a client’s treatment plan involves an objective to Identify triggers when wanting to drink Create a plan to find time to relax every day Apply three coping skills to reduce anger Withdraw from conversations involving gossip Pinpoint bodily sensations that indicate panic Distinguish real and imagined fears using CBT we can say that the objective results in a measurable outcome when stated with an with an action verb (noted in bold face). This outcome does not

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guarantee that the problem or issue will be resolved, but it is likely that it will create an environment in which the client will have better control, more information, and more success in beginning to understand what they are thinking about at that particular moment. Therapy is a process, and how long it takes to get to the place where the presenting problem is no longer a problem depends on the individual client and how well the client and therapist correctly identify the goal and objective. Again, in the case of Brooke, it was determined very early on that Brooke wasn’t depressed as much as she was feeling pressure, and when that goal, “not to feel pressure,” was clarified, Brooke moved quickly in the therapy process. SUMMARY

It is important to remember that defining objectives is not just creating some action verbs and plugging them into a sentence to create a measurable outcome. The thought involved in creating meaningful outcomes lies in the work and skill that the therapist brings to the relationship with the client. As emphasized throughout this text, it is a process that requires a skill set that was identified in Chapter 1, but it is also important to emphasize that it is likely that assessing and reassessing might take time to get to the “real” problem. It is important to accept that this process is not a trajectory that has a straight line. Goals are the opposite of the identified problem. For example, if your problem is that you are overweight, the goal is to lose weight. If a client has anger issues, then the goal is to manage angry feelings. Outcomes are realized only if there are specific objectives to change the behavior, so if the goal is to lose weight, then there must be specific objectives as to how to accomplish that. If a client has panic attacks, then the goal might be to reduce the panic attacks. The complexity lies in being able to identify the specifics or, in other words, the objective of how to get to that outcome. The therapist and client together write the measurable objectives that result in measurable outcomes. It might be wise to think about this type of

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writing as a craft, because crafting involves thoughtfulness, and it requires a great deal of thoughtfulness on the part of the therapist and client to craft objectives for meaningful outcomes. A word of caution here is to not put the cart before the horse. Instead, one should take as much time as needed to get to the heart of the problem and determine how the client is thinking about that problem or how their thinking may keep them stuck, as you consider together writing the outcome by using the simple but complex and powerful formula to produce a measurable outcome. But simple does not mean that the task of getting there is simple. As Steve Jobs, former CEO of Apple, said, “Simple can be harder than complex: You have to work hard to get your thinking clean to make it simple. But it’s worth it in the end because once you get there, you can move mountains.” This quote is consistent with Locke and Latham’s point number 5, “task complexity,” which is about making the goal challenging to motivate the client for real change. Again, to do this successfully, a client-​centered approach ensures that clients, as the “experts,” have an active part in deciding what they want to do, not the therapist or an evidence-​based practice driving the outcome. Finally, as stated throughout, the CDRS model provides the clarity to create measurable and meaningful outcomes.

REFERENCES Adams, N., & Grieder, D. M. (2014). Treatment planning for person-​centered care: Shared decision making for whole health (2nd ed.). London: Elsevier. Anderson, L.  W., & Krathwohl, D.  R. (2001). A taxonomy for learning, teaching and assessing: A revision of Bloom’s taxonomy of educational objectives. New York: Addison Wesley Longman. Bachelor, A. (2013). Clients’ and therapists’ views of the therapeutic alliance: Similarities, differences, and relationship to therapy outcomes. Clinical Psychology and Psychotherapy, 20, 118–​135. doi:10.1002/​cpp.792. Brown, J., Dreis, S., & Nace, D.  K. (1999) What really makes a difference in psychotherapy outcome? Why does managed care want to know? In M. A. Hubble, B. K. Duncan, & S. D. Miller (Eds.), The heart and soul of change: What works in therapy (pp. 389–​406). Washington, DC: American Psychological Association. Cooper, M.  (2015). Goals form. Available from [email protected], University of Roehampton.

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Duncan, B.  J., Miller, S.  D., & Sparks J.  A. (2004). The heroic client:  A revolutionary way to improve effectiveness through client-​directed outcome-​informed therapy. San Francisco: Jossey-​Bass. Emmons, R.  A. (2003). Working with goals in psychotherapy and counseling. New York: Oxford University Press. Horvath, A. O. (1992). Working Alliance Inventory (WAI). Retrieved from http://​wai. profhorvath.com/​ Jacob, J., & Edbrooke-​Childs, J. (2018). Measuring outcomes using goals. In M. Cooper & D. Law (Eds.), Working with goals in psychotherapy and counselling (pp. 111–​138). New York: Oxford University Press. Lambert, M. J., & Burlingame, Copyright 1996 OQ Measures LLC. All Rights Reserved. License Required for All Users. Locke, E., & Latham, G.  (1991). A  theory of goal setting & task performance. The Academy of Management Review, 16. 10.2307/​258875. McIntyre, D., Rogers, L., & Heier, E. J. (2001). Health Care Financing Review, 22(3), . Miller, S. D., & Duncan, B. L. (2000). Outcome Rating Scale (ORS). International Center for Clinical Excellence. Retrieved from https://​www.scottdmiller.com Miller, S.  D., & Duncan, B.  L., & Johnson, L.  (2000). Session Rating Scale (SRS v.3.0). International Center for Clinical Excellence. Retrieved from https://​www. scottdmiller.com Miller, S. D., Duncan, B. L., Brown, J., Sparks, J., & Gaud, D. (2003). The outcome rating scale: A preliminary study of the reliability, validity, and feasibility of a brief visual analog measure. Journal of Brief Therapy, 2, 91–​100. Mintz, J., Luborsky, L., & Christoph, P.  (1979). Measuring the outcomes of psychotherapy:  Findings of the Penn Psychotherapy Project. Journal of Consulting and Clinical Psychology, 47(2), 319–​334. Mitchell, C.  (2003). Resistance clients:  We’ve all had them, here’s how to help them. Psychotherapy.net. Retrieved from https://​www.psychotherapy.net/​article/​resistant​clients Stewart, R. E., Lareef, I., Hadley, T. R., & Mandell, D. S. (2017). Can we pay for performance in behavioral health care? Psychiatric Services, 68(2), 109–​111. Strupp, H. H., & Hadley, S. W. (1977). A tripartite model of mental health and therapeutic outcomes with special reference to negative effects in psychotherapy. American Psychologist, March, 187–​191. Wiger, D.  E. (2012). The psychotherapy documentation primer (3rd ed.). Hoboken, NJ: John Wiley & Sons.

5

Examples of Writing Measurable Outcomes Using Language of Evidence-​Based Practices

The goals of this chapter are to inform the reader of what comprises an evidence-​based practice (EBP) and how EBPs fit in with the therapeutic alliance, and to demonstrate how the method proposed in writing outcomes in a treatment plan is basically identical regardless of the kind of EBP one is employing. The objectives of the chapter are as follows: 1. To define EBP 2. To provide a history of EBPs 3. To clarify writing measurable outcomes using the language of the EBP 4. To illustrate through case examples how to write measurable outcomes in a treatment plan using the language and theory of any of the following: a. Cognitive behavioral therapy (CBT) b. Psychodynamic therapy c. Dialectical behavioral therapy (DBT) d. Mindfulness-​based therapy

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WHAT IS EVIDENCE-​B ASED PRACTICE?

Evidence-​based practice (EBP) has become the driver in the delivery of providing services to clients. EBP is known to many different kinds of practitioners, spanning the range of healthcare services from medicine to psychotherapy. EBP signifies that the process or method of service being delivered has been tried and tested by researchers and there is evidence of outcomes that a particular service or method is effective. Fraser, Richman, Galinsky, and Day (2009) define an evidence-​ based intervention as one “that has been evaluated using scientific methods with cumulative findings from several evaluations demonstrating effectiveness (p.  183). Catana Brown, in The Evidence-​Based Practitioner Applying Research to Meet Client Needs (2017), provides a comprehensive explanation of evidence practice: Questioning what we do every day as healthcare practitioners, and making clinical decisions grounded in science is what evidence-​based practice (EBP) is all about. However, the use of scientific evidence is limited; clinical decisions are made within the context of a clinician’s experience and an individual client’s situation. Any one profession will never have a suitable number of relevant studies with adequate reliability and validity to answer all practice questions. However, the process of science is a powerful self-​correcting resource. With the accumulation of research, clinicians can continually update their practice knowledge and make better clinical decisions so that clients are more likely to achieve positive results. (p. 2) There is increasing pressure on all stakeholders, such as clinicians, funders, and agencies, to accept that scientific methods, or as we now label EBP, support psychotherapeutic modalities. To name a few, dialectical behavior therapy (DBT), cognitive behavioral therapy (CBT), mindfulness-​based cognitive therapy (MBCT), and even psychodynamic therapy are deemed EBPs. This movement toward EBPs is described by Messer (2004) as a “culture war” with clinicians and researchers battling

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over what treatment approaches to use and when to use those approaches. Goodheart, Kazdin, and Sternberg (2006) assert that “practitioners begin serious consideration of how outcome assessments may fit best with their practices, values, and needs and of which of the available measures may fit best with the patient population with whom they work” (p. 31). Yet these same authors say that there are substantive and substantial disagreements for evaluating evidence within the EBP movement. While the EBPs mentioned here and others may provide evidence of effective outcomes, Brown (2017) states that it is crucial to understand that all EBPs are client-​ centered approaches, as “client choice and an appreciation for the client’s expertise in his or her life situation should always be considered in the treatment planning process” (p. 5).

HISTORY OF EVIDENCE-​B ASED PRACTICES

EBP is not a new concept. Researchers of evidence-​ based medicine advocated for improved patient outcomes. This involved looking at clinical practice and relevant research (Sox & Woolf, 1993; Woolf & Atkins, 2001). There is a history of evidence-​based outcomes being considered among psychologists before 1950. As noted in the 2006 report of the American Psychological Association (APA) Presidential Task Force on Evidence-​Based Practice, psychologists are given credit for the need for integrating a scientific/​research methodology to ensure improved patient outcomes, for as early as 1947 the idea that doctoral psychologists should be trained as both scientists and practitioners became the American Psychological Association (APA) policy (Shakow, Hilgard, Kelly, Luckey, Sanford, & Shaffer, 1947). Early practitioners such as Frederick Thorne articulated the methods by which psychological practitioners integrate science into their practice by “increasing the application of the experimental approach to the individual case into the clinician’s own experience (Thorne, 1947, p. 159).”

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David Sackett, a pioneer of evidence-​based medicine, and his colleagues further advanced EBP. As a physician, Sackett promoted “evidence based medicine [as] the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients” (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996, p.  71). EBP in psychology (psychotherapy) is consistent with the past 20  years (since the 1980s) of working evidence-​based medicine, which advocated for improved patient outcomes by informing clinical practice with relevant research (Sox & Woolf, 1993; Woolf & Atkins, 2001). EBP is consistent with the value that shared decision-​making, defined by Brown (2017) as “a collaborative process in which the clinician shares information from research and clinical experience, and the client shares information about personal values and experiences. Different options are presented, with the goal of arriving at an agreement regarding treatment. From a client-​centered practice perspective, the client is the ultimate decision maker, and the professional is a trusted advisor and facilitator” (p. 5). While there is definitely a push for EBPs, the information is contradictory about proven effectiveness of EBPs. According to Wampold and Imel, in their 2015 book The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work, and Wampold and colleagues (2017), the claim is that trials of hundreds of randomized controlled trials (RCTs) proved no particular EBP as superior over another. Nevertheless, it is important to address the issue of EBPs here, if just to demonstrate that it doesn’t matter which EBP one is using to apply the Cognitive Domain Rating Scale (CDRS) model for creating measurable outcomes. Also, it is an opportunity to stress once more that the important elements involved in the psychotherapeutic process—​the therapeutic alliance, a client-​centered approach, and feedback—​are all very critical to outcomes. As Goodheart (2004) notes, “Psychotherapy is first and foremost a human endeavor. It is messy. It is not solely a scientific endeavor, nor can it be reduced meaningfully to a technical mechanistic enterprise” (p. 41).

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SYNCING THE THERAPEUTIC ALLIANCE AND EVIDENCE-​ BASED PRACTICE PROMOTES WRITING OBJECTIVES LIKELY TO RESULT IN MEASURABLE OUTCOMES

To be successful in writing measurable outcomes, the therapeutic alliance needs to be in sync with whatever EBP is being used in treatment. Without the alliance there is less of a chance that the client is engaged enough to produce the information that must be shared in the therapeutic relationship. At the same time, the EBP, whether CBT, DBT, psychoanalytic, or mindfulness, functions as a means for the therapist and client to take action in some specific way. Then, given the language of the EBP being offered, the goal and objectives are written. There is sufficient justification for the importance of the alliance, as well as the more recent focus on the importance that therapists be trained in and practice EBPs.

The Case for the Therapeutic Alliance

The shared decision-​making/​client-​centered approach creates an atmosphere that is likely to create the strong therapeutic alliance that is essential to any successful outcome. The alliance begins at the assessment process when the client begins to tell their story, as was emphasized in Chapter 1. As Nicotera (2018) aptly states, “clinical interviewing skills are the foundation of clinical practice in any of the helping professionals, from clinical social work to nursing and doctoring to physical therapy and educational psychology. . . . The skilled interviewer simultaneously listens while deciphering what the client is saying and using the appropriate clinical interviewing skill to engage the client in telling his or her story with as much ease as feasible” (p. ix). Brown and Minami (2010), B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. (Eds.) state: “The strongest evidence regarding the psychical element points to the person providing the treatment, [which] is the therapist” (p. 280, italics added). Simply put, some therapists are more effective than

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others, further supporting that the therapist who is valued is obviously in a strong alliance with their client. Empirical evidence regarding the variability in outcomes among treatment providers dates back to the earliest days of the field (Luborsky, Crits-​Christoph, Alexander, Margolis, & Cohen, 1983; Rosenzweig, 1936). Donald Michenbaum, considered an expert in cognitive therapy, is quoted as saying at a workshop at the U.S. Journal Conference on Behavioral Health and Addictions conference in Clearwater, Florida, in 2017, “it doesn’t matter what you do—​CBT, DBT, EMDR, it’s the relationship, the connection between therapist and client that makes the difference.” It is important to remember and recall the importance of the alliance at a very critical time when EBPs are given much heft, as noted by the oft-​cited mandate by funders that clinicians deliver some type of EBP. But again, any outcome must involve a strong alliance, for without that, the client’s presence is limited. For a detailed discussion on this relationship and on the research done on self-​report outcomes, the reader is referred to Section II, “Delivering What Works: Practice-​Based Evidence,” in Duncan, Miller, Wampold, and Hubble’s edited book The Heart and Soul of Change (2010).

The Case for Evidence-​Based Practice

So why focus on or mention the value of EBPs when there is so much stress put on the therapeutic alliance? Brown (2017) notes: Ultimately, the most important reason to implement evidence-​based practice is that it improves the quality of the service you provide. An intervention decision that is justified by scientific evidence, grounded in clinical expertise, and valued by the client will, in the end, be more likely to result in positive outcomes than a decision based on habits or expediency. (p. 7) Perhaps not so obvious is the asset of a common language or reference for the therapist and client to discuss treatment with an EBP in place. As

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aspects of the EBP become a familiar and regular part of the discussion, objectives are more apt to be written with more ease as the therapist and client together discuss and work on treatment; the dialogue involves the language of the treatment being offered. This client-​centered approach, where the client is actively involved in the process, works as a secondary gain as a reinforcement of the all-​important alliance. Clients as consumers today are often well informed and expect that the therapist is able to provide a particular EBP, such as CBT or mindfulness-​ based therapy. As professionals, it is important for therapists to have a sound theoretical framework, just as any practitioner in any profession must have a set of standards and guidelines to responsibly offer their service or product. Finally, as noted by Orme and Orme (2012): “If you are using the best, state-​of-​the-​art empirically supported treatment model, do you really need to evaluate your practice in an ongoing, systematic manner? Yes.” They state four reasons for this. First, RCTs tell whether interventions are effective with the average client, but the practitioner needs to know if the intervention is effective with this client. As these same authors say, “Significant group effects do not guarantee positive effects for individuals. Second, “group data cannot account for individual circumstances, strengths, and resources. Third, “there is also reason for healthy skepticism about evidence-​based practice itself. What is evidence, and who decides what evidence is most valid?” (p. 40). Given the skepticism and confusion about the value and validity of EBPs, it is still wise to consider using an EBP that has some evidence of being helpful for a particular problem and with the client’s buy-​in. Case in point: DBT is the framework used in treatment with a client who has been diagnosed with borderline personality disorder (DBT is viewed as effective with this diagnosis).

Case Example

Presenting Problem This client admits to viewing “the world” and many situations as “black and white.” The client views situations and people as either all good or

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all bad at any given moment. The client experiences many emotional outbursts and reports many dysfunctional relationships. Assessment The client has a long history of trauma and abandonment at an early age. The client remembers and understands the reasons for their emotional dysregulation and has had previous therapy to deal with those memories but still has no idea of what to do about overreacting in many situations where overreaction is uncalled for. The therapist educates the client about DBT and the notion of the “wise mind,” which is basically a way to look at one’s view of a problem situation more rationally with “shades of gray” (Pederson, 2012). Cognitive Domain Rating Scale The client and therapist agree to work on a strategy to deal with the client’s black and white thinking. Insight about remembering and understanding that the client behaves that way because of early childhood experiences has not changed their behavior. Even understanding from a psychoeducational perspective about brain science that the part of the brain that handles emotions often gets “hijacked” and out of control is not enough to elicit change. The client’s thinking is situated in cognitive domain level 4, apply, as they need to apply ways to circumvent ways of this dysregulation. Goal: Reduce unnecessary emotional outbursts. Objective: Apply a “wise mind” strategy during (or even after) emotional outbursts. Outcome: Client reports a reduction in emotional outbursts and more positive satisfaction regarding interpersonal relationships.

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Summary At the assessment, it was determined that this client’s thinking was such that they could identify (CDRS level 1—​remember/​recall) and understand (CDRS level 2—​understand/​interpret) that they get unnecessarily upset about some situations, but it was no help in changing their emotional distress or how they behaved. Therefore, it was determined that CDRS level 3, apply, was where the client needed help to think through how to change. Use of DBT “wise mind” techniques were very successful in helping this client stop overreacting. The reduction in outbursts was a positive measurable outcome, along with the self-​report of the Outcome Rating Scale (ORS) over a 4-​week period, which indicated marked improvement in interpersonal satisfaction noted with peers and family and in the work situation. In this brief scenario, the therapist and client first agreed that the client participate with the therapist using the EBP, DBT. The language used in therapy sessions, for example, “wise mind” techniques and black and white thinking, helped the client discuss past situations (without shame or guilt) and think about strategies to reduce unnecessary emotional outbursts (goal). The objective of applying wise mind strategies included creating a plan to excuse oneself for a minute and then think about the situation as having some “shades of gray,” and asking more questions for clarification before making a “black” or negative assumption.

Support for the Need for the Therapeutic Alliance and Using an EBP

Sorting out where the emphasis should lie, that is, with the therapeutic alliance or with an EBP. can be confusing and conflicting. It is likely that using an effective theoretical framework may, indeed, enhance a stronger therapeutic alliance, as the client is more apt to “get better” using an EBP that resonates with their “recovery” as they understand and relate to the language of the EBP. For example, in CBT, a client may connect with the notion that thinking bad thoughts makes them feel bad, and using the CBT

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stop thought technique stops their “feeling bad” cycle. A client may find that a mindfulness approach involving their being more aware of their bodily sensations when getting angry and pausing to think before reacting results in a decrease in angry outbursts. It seems logical that if a particular EBP works for a client, they might then attribute that to the therapist’s expertise and in return feel a positive connection with the therapist, which, over time, reinforces a positive and stronger alliance. Sifting out all of the variables to determine how much is the alliance and how much is the particular EBP is something for researchers to consider. As clinicians, we must use all of the information and knowledge available and keep abreast of the latest research to ensure positive outcomes. At this juncture, being cognizant of both factors is what is central to the therapeutic process.

MEASURING OUTCOMES USING THE CDRS METHOD

The CDRS is a method for writing measurable outcomes. It is not a guarantee for a positive or successful outcome. As stated in previous chapters, if the outcome is not realized, then the task for the therapist and client is to go back to the drawing board, using the CDRS once more to figure out why it failed, again using the method of closely looking at what might have been going on with the client that they could not perform the action that was agreed on. While we consider that an assessment is done at the beginning of the therapy process, it is also wise to consider that all therapy sessions involve some type of review or reassessment of where the client is situated in their thinking. The review is a time to revisit the who, what, when, where, and how. Certainly it is a time to revisit carefully when the objective is not realized, but perhaps it is just as important to review the outcome when it is positive or realized so that behavior and action can be reinforced. Reviews are enhanced with tools such as the ORS and other psychotherapeutic scales to help to review and reassess the current status of the client’s situation or problem (see Appendix).

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Using the CDRS Model to Aid in Writing Measurable Outcomes for any Evidence-​Based Practice

Writing measurable outcomes using the CDRS is basically a generic process for any problem and can be applied to any particular treatment modality or EBP. What is likely to look different is the assessment, given that theoretical frameworks are different and what transpires during the assessment process may be different given different approaches. Also, objectives may be similar or different, based on either a similar or different assessment of the problem. However, the point emphasized here is regardless of the EBP, the process of writing measurable outcomes is the same. This point is best illustrated by comparing two EBPs side by side. Note that the assessments in the table comparing CBT and psychodynamic therapy are intentionally limited to a couple of sentences for this illustration. Important to note is the language differences between the EBPs. These examples have some aspects of a treatment plan, which will be discussed, as well as similarities between the two EBPs, including the language in assessing the cognitive domain. For a starting reference on these two EBPs look at Cognitive Behavior Therapy, Basics and Beyond, Second Edition by Judith Beck, (2011), and Psychodynamic Therapy, A  Guide to Evidence-​Based Practice by Richard F.  Summers and Jacques P.  Barber (2010). Deciding where the client is in their thinking and deciding which cognitive domain to work on is subjective. It is not so much about being right or wrong, but what is perceived as the problem, the goal, and the objective at a particular time, and certainly there will be differing assessments and goals. What is important is to see how the process is the same, even with different goals and objectives, and that the outcomes, though different, are ok, as long as the therapist and client agree on them. The outline presented here is designed to show the comparison and to highlight similarities and differences regarding the problem, assessment, CDRS, and, finally, the goal and objectives. In the comparison between CBT and psychodynamic therapy, note that the problem and goals are the same, yet the assessment, CDRS, and objectives are different.

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EBP: Cognitive-​Behavioral Therapy (CBT)

EBP: Psychodynamic Therapy

Problem:

Problem:

Client complains of feeling depressed.

Client complains of feeling depressed.

Assessment:

Assessment:

The therapist and client agree that the

The therapist and client agree that

client’s depression is fueled by frequent negative thought processes:  e.g., “I’m stupid,” “I’m a failure,” “I make bad decisions.” The therapist and client agree that the client’s thinking is situated in negative ruminations about why he is depressed, including who, what, when, and where instances, which exacerbate those negative thoughts (CBT language).

issues from childhood contribute to the client’s depressive symptoms related to low self-​esteem. The therapist and client agree that the client’s “thinking” is situated in childhood experiences that resulted in negative introjects (psychodynamic language) about his current self. There is agreement between the therapist and client that the who responsible for those feelings is the client’s father.

Cognitive Domain Rating Scale:

Cognitive Domain Rating Scale:

Remembering, Understanding,

Remembering, Understanding,

Applying, Analyzing, Evaluating,

Applying, Analyzing, Evaluating,

Creating

Creating

The cognitive domain that best suits

The cognitive domain that best

the negative thinking pattern (using

suits the negative thinking pattern

a CBT approach) is to apply a strategy

(using a psychodynamic approach)

to stop negative thinking.

is to understand and reinterpret the childhood experience.

Note: Apply involves using procedures

Note: Understanding is the ability to

to perform exercises or solve problems

construct meaning from messages (see

(see Chapter 3).

Chapter 3).

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Goal:

Goal:

To feel content with myself.

To feel content with myself.

Objective:

Objective:

1.  Use the “stop thought” (CBT technique)

1.  Recognize that childhood experiences

when negative ruminations present in

are the cause of current feelings of

thoughts.

self-​doubt and depression.

2.  Replace negative ruminations with positive self-​talk.

2.  Report corrective views of self in therapy sessions via the corrective client–​therapist interaction (transference).

As you can see in reviewing the two EBP comparisons, the cognitive domain ratings are different. As stated earlier, it is possible that two EBPs might have a similar assessment and perhaps similar objectives. Staying with the example of the differences, it is imperative to review the illustration once more to note that the process of using the CDRS is the same for both the CBT approach and the psychodynamic approach. The differences have to do with the difference in theoretical approaches to the problem and solution. In either case, measurable outcomes occur because of the use of measurable behaviors, despite the differences in assessment and objectives. Certainly, as emphasized throughout the text, a client-​centered approach is recommended no matter which EBP is employed and assumes the presence of a strong therapeutic alliance. Those factors, aligned with a solid assessment and a well thought-​out CDRS, are likely to result in written goals and objectives that the therapist and client are in sync with. This is likely to result in a positive outcome. Regardless, the outcome will be measurable using this process, until therapy is completed.

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While there are no outcomes listed in this graph, in each case positive outcomes were noted with the client’s reporting being “more content” as a result of completing the identified objectives. Despite being different EBPs and having different objectives, in each case their objectives determined an attained goal. An example of a complete treatment plan that includes all of these elements—​problem, assessment, CDRS, goal, and objectives/​ outcome—​is illustrated in Chapter 6. Following is a detailed explanation of the same and different aspects to this process of comparing the two EBPs. Problem We assume that the client identifies the same problem, as stated in the examples, “depression.” Assessment The assessment reads differently because the language of the EBP is written from the perspective of differing theoretical frameworks: • The CBT approach references negative thinking. • The psychodynamic approach references negative introjects. • Consider that a DBT approach might use language referencing black and white thinking as a way of assessing depression. Cognitive Domains The cognitive domains in the previous illustration are different because the assessment of the problem is taken from differing theoretical frameworks. Certainly, there is often overlap in theoretical approaches, but in this example, the assessment or the etiology of the problem is quite different. Regardless of a different assessment, the CDRS enables the therapist and client to agree on where the client is in thinking about their problem, which in turn allows for writing measurable goals and objectives. This process is NOT dependent on the framework.

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As noted in the table: • The CBT approach situated the client’s thinking in the domain that involves applying objectives using a stop thought CBT strategy and a positive thinking strategy, both involving measurable outcomes. In the assessment, using a CBT framework, remember (CDRS level 1) is determined to exacerbate the problem given the CBT framework. • The psychodynamic approach situated the client’s thinking in CDRS levels 1 and 2 and attributes writing an objective that involves recalling and understanding to the perspective that doing so will result in a positive transference, or a corrective experience, between the therapist and the client. Note that one might question which assessment is correct, since they are different. The point is that it does not much matter, because assuming that there is a strong therapeutic alliance, what the therapist and client agree to work on is what matters. In each instance, it is possible that each objective results in a measurable outcome. Given the success, the client experienced a change in behavior using the stop thought strategy and an increase in being more content—​the broad goal. Looking at the psychodynamic approach, the client’s recalling and understanding the childhood experience, with the help of the therapist, resulted in the client experiencing a more contented approach to life. The measurable goals with CBT are applying the CBT technique of stop thought given that thinking bad thoughts makes one feel bad. The measurable goal with a psychodynamic approach is recalling childhood experiences with the therapist to “correct” the memory, creating a better sense of well-​being because of the corrective experience. Basically, who is to say that either approach is superior to the other? What happened in these instances is that the therapist and client agreed on a particular framework (EBP) as a treatment modality. The “magic” of

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the therapeutic relationship is critical, but there is also credibility given the frameworks used. In each instance, the language of the framework and the basic approach to talking to the client (also using the language of the EBP) supported the client’s belief and trust that what was discussed in sessions was enough to have agreement on objectives. Goals The goal is the same for both treatment modalities, as the client is seeking therapy to feel less distressed, less depressed, and more content. Objectives The objectives are different for the reasons stated earlier regarding the different theoretical approaches. As you can see, the CDRS determines the objectives, which in turn create the measurable objectives using action verbs: • CBT is measuring instances of stopping negative thinking and instances of replacing it with positive thoughts by applying (measurable action verb). • The psychodynamic approach is measuring instances of recalling (measurable action verb) childhood experiences and sharing (measurable action verb) those feelings in the therapy session. In both cases, the outcome approaches can be assessed and applied with the specific objective being measured as the client either completes the agreed-​upon objective or not. The CDRS approach guarantees some type of measurable progress of a gain or not, which is not just a subjective rating by the therapist interpreting the outcome but a measured action or behavior change on the part of the client. In the following comparison between DBT and mindfulness, the problem and goals are the same, yet the assessment, CDRS, and objectives are different. For a starting reference on these two EBPs, see Pederson L.  (2012), The Expanded Dialectical Behavior Therapy Skills Training Manual for more about DBT and Kabat-​Zinn (2005), Coming To Our Senses Healing Ourselves And The World Through Mindfulness, as a reference for mindfulness.

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EBP: Dialectical Behavioral Therapy (DBT)

EBP: Mindfulness

Problem:

Problem:

Client has angry outbursts several times

Client has angry outbursts several

weekly that create problems with personal

times weekly that create problems with

and work relationships.

personal and work relationships.

Assessment:

Assessment:

The therapist and client agree that the

The therapist and client agree that

client’s thinking is situated in

the client’s thinking is situated as

misunderstanding messages, resulting in

incorrectly interpreting a message and

irrational extremes of reasoning in

often results in impulsive emotional

black and white terms (DBT language).

overreactions (mindfulness language).

Cognitive Domain Rating Scale: Remembering,

Cognitive Domain Rating Scale:

Understanding, Applying, Analyzing,

Remembering, Understanding, Applying,

Evaluating, Creating

Analyzing, Evaluating, Creating

The cognitive domain that best suits the

The cognitive domain that best suits

negative thinking pattern (using a DBT

the negative thinking pattern (using

approach) is to understand (cognitive

a mindfulness approach) is to analyze

domain 2) that there are often “gray areas”

(cognitive domain 3) the situation and

or options to consider other than responding

consider ways to be more self-​aware

to the extremes of black and white.

in order to correctly respond to the message conveyed.

Note: Understanding is the ability to construct

Note: Analyzing involves breaking

meaning from messages (see Chapter 3)

material into parts and determining how the parts are related to one another. It includes differentiating the ways in which the pieces of a message are organized and the underlying purpose of the message (see Chapter 3).

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Goal:

Goal:

To have fewer emotional outbursts.

To have fewer emotional outbursts.

Objective:

Objective:

To recognize or identify that the first reaction

To analyze the message, tone, and

to respond to a message with extreme

words, and observe facial expressions

negativity may be erroneous.

as a means to discriminate between

To choose* an option or options involving a

friendly, neutral, and hostile

state of “wise mind” thinking: a balance of

communication.

emotion and reason (DBT language). *Choose involves applying, situated in cognitive domain 5. This example illustrates how the increasing complexity of the cognitive domains as discussed in Chapter 5 compliments and builds on other domains.

Summary

Detailing the differences in DBT and mindfulness can be done in the same way as described in the comparison of the EBPs CBT and psychodynamic therapy. As noted in the comparison of DBT and mindfulness, the presenting problem is also noted to be the same, but the assessment and objectives differ, with the expectation that outcomes will differ as well. As was pointed out in the earlier EBP comparisons, the differences are accounted for given differing theoretical frameworks. In the case of DBT versus mindfulness, the DBT approach is more focused on ways of thinking about a problem or a situation, and mindfulness focuses more on bodily sensations and feeling states to cue one’s way of thinking.

CHAPTER SUMMARY

Writing measurable outcomes using the CDRS is applicable to any EBP. Creating a strong therapeutic alliance is equally if not more important

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than the particular application of an EBP, as EBPs cannot be considered a stand-​alone approach. The best EBP won’t work without the important elements that involve engagement and feedback in psychotherapy. That being said, using an EBP is more likely to result in positive outcomes than are other non-​EBPs, given the standards applied to EBPs and the resultant research outcomes. Additionally, therapists are being mandated by funders to use EBPs as Christon, McLeod and Jensen-​Doss state (2015), “We are currently in an era of evidence-​based practice (EBP) that places an emphasis on using scientific findings to inform clinical practice” (p. 36). Treatment is likely to be enhanced when a therapist is using an EBP with which they are familiar and that confidence and belief in the EBP is conveyed to the client. This brings up the important factor that the client should be educated about the EBP chosen to deal with their problems. There are ethical issues as well as practical issues related to engaging the client in treatment. Informing the client of the approach used to help them may be critical to the alliance and connection with the therapist. As stated throughout, the assessment process is important to gather important information about the presenting problem and how to proceed accordingly with treatment, and the particular EBP language the therapist uses won’t make a difference in the process using the CDRS. As illustrated in the case examples, there were decided differences in the CDRS, which had to do with the theoretical approaches. The reality is that all therapy is different and that even when two practitioners use the same EBP, it is likely that there will be a different CDRS and different objectives and outcomes. This is further supported by the recent findings of Wampold and Imel (2015), who claim that no one particular EBP is superior to another. What is most important is to have the therapist and client agreeing on the goal and objectives. Outcomes in this sense can be said to be individualized and particular to what is occurring between the therapist and the client at a particular moment. The value of using EBPs is that the therapist is using a treatment modality that has been researched and there is some evidence that some individuals benefit from that particular treatment modality, therefore ensuring a better possibility of a successful outcome, which certainly is an asset to the psychotherapeutic process.

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What should be remembered, however, is that if the outcome is not working, then perhaps a shift needs to be made, and that can take the form of re-​evaluating the CDRS and perhaps even the EBP. If we recall the case of Brooke in Chapter 4, she did not follow through with the CBT stop thought process because it didn’t work for her. In that instance, a reassessment determined that that problem wasn’t the EBP, but the wrong CDRS. However, it may be that a client might not be able to relate to a particular strategy in a EBP, which is why the therapist must be skilled in many areas as they continually evaluate and re-​evaluate outcomes. Although not the focus of this text, it might be interesting to think about changing different treatment modalities or EBPs, as it might shift thinking about a problem should a client get stuck in treatment or not make any further changes. In that way, the EBP might enhance or move forward the CDRS process and vice versa.

REFERENCES APA Presidential Task Force on Evidence-​Based Practice. (2006). Evidence-​based practice in psychology. American Psychologist, 61(4), 271–​285. Beck, J. (2011). Cognitive behavior therapy, basics and beyond, 2nd edition. (2011). The Guilford Press, NY: NY. Brown, C. (2017). The evidence-​based practitioner applying research to meet client needs. Philadelphia: F.A. Davis. Brown, G. S., & Minami, T. (2010). Outcomes management, reimbursement, and the future of psychotherapy. In B.  L. Duncan, S.  D. Miller, B.  E. Wampold, & M.  A. (Eds.), The heart and soul of change delivering what works (2nd ed., pp.  267–​297). Washington, DC: American Psychological Association. Christon, L. M., McLeod, B. D., & Jensen-​Doss, A. (2015). Evidence-​based assessment meets evidence-​based treatment: An approach to science-​informed case conceptualization. Cognitive and Behavioral Practice, 22,  36–​48. Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (2010). The heart and soul of change delivering what works in psychotherapy (2nd ed.). Washington, DC: American Psychological Association. Fraser, M.  W., Richman, J.  M., Galinsky M.  J., & Day, S.  H. (2009). Intervention research: Developing social programs. New York: Oxford University Press. Goodheart, C. D. (2004). Evidence-​based practice and the endeavor of psychotherapy. Independent Practitioner, 24,  6–​10.

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Goodheart, C.  D., Kazdin, A.  E., & Sternbert, R.  J. (2006). Evidence-​based psychotherapy: Where practice and research meet. Washington, DC: American Psychological Association. Luborsky, L., Crits-​Christoph, P., Alexander, L., Margolis, M., & Cohen, M. (1983). Two helping alliance methods for predicting outcomes in psychotherapy: A counting signs vs. global rating method. Journal of Nervous and Mental Disease, 171(8), 480–​491. Kabat-​Zinn, J.  (2005). Coming to our senses healing ourselves and the world through mindfulness. New York: Hyperion. Messer, S. B. (2004). Evidence-​based practice: Beyond empirically supported treatments. Professional Psychology, 35, 580–​588. Nicotera, N.  (2018). Essential interviewing skills for the helping professions. New York: Oxford University Press. Orme, J. G., & Orme, T. C. (2012). Outcome-​informed evidence-​based practice. Boston: Pearson. Pederson, L.  (2012). The expanded dialectical behavior therapy skills training manual. Eau Claire, WI: Premier Publishing and Media. Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psychotherapy. American Journal of Orthopsychiatry,6, 412–​415. Sackett, D., Rosenberg, W.  M. C., Gray, J.  A. M., Haynes, R.  B., & Richardson, W.  S. (1996). Evidence-​based medicine: What it is and what it isn’t. BMJ, 312,  71–​72. Sox, H.  C., Jr., & Woolf, S.  H. (1993). Evidence-​based practice guidelines from the U.S. Preventive Services Task Force. Journal of the American Medical Association, 169, 2678. Ernest R. Hilgard, E. Lowell Kelly, Bertha Luckey, R. Nevitt Sanford, Laurance F. Shaffer, David Shakow. (1947). Report of the Committee on Training in Clinical Psychology of the American Psychological Association Submitted at the Detroit meeting of the American Psychological Association, September 9–​13. Shakow, D., Hilgard, E. R., Kelly, E. L., Luckey, B., Sanford, R. N., & Shaffer, L. F. (1947). Recommended graduate training program in clinical psychology. American Psychologist, 2, 539–558. Summers, R. F., & Barber, P. (2010). Psychodynamic therapy, A guide to evidence-​based practice. The Guilford Press, NY: NY. Thorne, F. C. (1947). The clinical method in science. American Psychologist, 2, 159–​166. Wampold, B. E., Fluckiger, C., Del Re, A. C., Yulish, E. E., Frost, N. D., . . . Hilsenroth, M. (2017). In pursuit of truth: A critical examination of meta-​analyses of cognitive behavior therapy. Psychotherapy Research, 27, 14–​32. doi:1080/​10503307.2016.1249433 Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2nd ed.). New York: Routledge/​Taylor & Francis Group. Woolf., S.  H., & Atkins D.  A. (2001). The evolving role of prevention in health care: Contributions of the U.S. Preventive Service Task Force. American Journal of Preventive Medicine, 29(3, Suppl.), 13–​20.

6

Treatment Plans Treatment Plans with Measurable Objectives/​Outcomes

The goal of this chapter is to provide a template for a treatment plan that includes the Cognitive Domain Rating Scale (CDRS). The objectives of the chapter are as follows: 1. To explain the rationale for the use of the treatment plan 2. To use a case study to illustrate components of the treatment plan 3. To use evidence-​based practice (EBP) as the basis for the treatment approach

THE RATIONALE FOR TREATMENT PLANS

A treatment plan is a contract between the client and therapist. It should function as a way to get a snapshot of the client concerning who they are, what brings them to treatment, and what the therapist and client are doing together to alleviate the client’s problem or stressors. Historically, clients were not a part of the treatment planning process, but today most funders and state licensing agencies require that clients take part in the

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process and sign off on the treatment plan. Even in private practice where therapists may not do formal treatment plans, it seems wise ethically and for liability reasons that all therapists and clients engage in a treatment plan that requires a signature for agreed-​upon treatment. Most agencies require that clients sign a form, “Consent to Treatment,” so it only makes sense that the treatment be defined and that the therapist and client sign off on it. Therapists have an ethical responsibility to inform clients about what type of treatment is being conducted and that includes informing clients about changes. Therapists also need to let clients know when the CDRS process is being integrated as a new part of treatment. A  logical time to introduce this to existing clients is when a new treatment plan is being created. Providing clients with the cognitive domain chart (see Appendix) provides a visual that most clients can easily relate to. It is a new way to think about how to approach problem-​solving, and being prepared to give examples either in regard to the client’s situation or giving an example of a case can help convey this approach. The change toward clients partaking in treatment planning and having them sign off on the treatment plan is in keeping with the notion of a person-​centered approach. Including clients in shared decision-​making about their treatment is important in ensuring better outcomes, since it only makes sense that clients be fully involved in what they are doing and what the therapist is facilitating in this “thing” called “treatment.” Each person has their own values, priorities, and perspectives that should shape the kinds of help they receive. Acknowledging and respecting this is an aspect of a person-​centered approach, which is also a way to ensure a culturally competent approach. Person-​centered care is about the overall health of the individual, not just their mental health, as is the focus of this text. An excellent example of how person-​centered care should operate for all practitioners is noted by Adams and Grieder (2014): Consider a person diagnosed with diabetes, depression and alcoholism and feels ill and distressed but not sure about how best to seek help. One day the person has a hangover, and perceives his drinking as his greatest problem and says “I had better go get some

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substance abuse help.” On another day the person may feel so depressed that he can’t get out of bed and determines “I need to go get some mental health help.” On yet another day the same individual may be focused of their elevated blood sugar levels an decides “I had better get back to my primary care doctor.” But all of these issues are highly intertwined and cannot be reduced to three isolated and independent problems or health care responses; yet all too often that is exactly what happens. The road to health and wellness, and success in managing these problems, requires a holistic, integrated and individualized approach. (p. 359) The focus of this text in writing measurable outcomes is in the context of psychotherapy, but this example gives a very real picture of what it means to truly be involved in conducting a person-​centered approach. While that individual may have addiction and mental health needs that could conceivably be a part of a treatment plan in a mental health clinic, it is certainly reasonable that the individual’s diabetic condition also needs to be addressed. In fact, in that scenario, the CDRS might be that the individual needs to analyze (CDRS level 4—​analyze) how to prioritize which issues need to be taken care of first at any particular time. He may or may not need to go to the doctor to deal with his diabetes if he can better manage his eating habits; he may need to call his sponsor if he starts drinking again, and so forth. This approach assumes that all of these issues are part of an ongoing treatment plan. While some psychotherapists (psychiatrists, counselors, psychologists) may not see that as a part of their responsibility for treatment, since some professionals do not view their job as being involved with issues other than mental health issues, it nonetheless seems ethical to do so if one is using a person-​centered approach. It is obvious that in the example provided, each of the individual problems is most likely to affect the other problems. That is, if the client is depressed and not eating properly and abusing alcohol, this is likely to have a deleterious effect on his diabetic condition. Cases such as this are complex, but they can be managed better when they are included in a treatment plan involving the client where the expectation for certain behaviors is defined.

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Certainly, it is important that clinicians not operate outside their scope of licensure but refer clients for issues that are beyond their expertise. While there are various configurations of treatment plans, all typically have a place for goals and objectives (Jongsma & Peterson, 1999; Wiger, 2012). In the treatment plan illustrated in the forthcoming example, there is a clear distinction between goals (broad statements with general intentions) and objectives (specific measurable statements with tangible results). In this treatment plan, objectives are written in such a way as to provide tangible results or what we refer to as measurable outcomes. Whatever psychotherapy treatment modality one uses, there is a general method of treatment that implies a coherent and clinically expert process involving the presenting problem, assessment, identification of goals and objectives, and outcomes. This information is taken from the assessment. The treatment plan illustrated next was designed to include all the components involved from the beginning assessment to outcomes, but there also is a place to include the CDRS, results of standardized testing, as well as identification of an EBP being implemented. While this may seem a daunting task and even repetitive with regard to the expectation that there is already a written narrative assessment, you will see from the illustration that this format gives a clear picture of the client and what the client is doing in treatment. Certainly worth mentioning here is the way that the presenting problem box is configured. There is a place where the who, what, when, where, and how information can be inserted. This is an extremely helpful way to quickly and clearly identify the person(s) and problem(s) involved. Often therapists will write long narratives about the presenting problem and start including detailed historical information that is unnecessary. If one remembers Chapter 3, on goals and objectives, and the reference to Locke and Latham’s framework, the first consideration in writing objectives is clarity, and the first piece of information, the presenting problem, should be clearly and succinctly defined. Note that this short treatment plan has a lot of information that can be obtained with a quick, brief review. Not only is this something that funders will appreciate during an audit, but you, the therapist, will find

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that it will save you a lot of time when needing to review cases for updates on treatment plans, or as a supervisor when you need to review your supervisees’ charts to see what is happening with their caseload. Also note that it is only in the first treatment plan that a lot of this information has to be entered, as a brief summary of the outcome and the next goal/​objective are written in ensuing treatment plans. This particular treatment plan also has a space to include any standardized testing. This eliminates the need to go through a chart to find the standardized scores, whether it is a paper chart or an electronic chart. Having this score readily available can be very helpful when looking at the outcomes as there should be a correlation. It is also a quick way to look at changes when standardized testing is readministered. The following treatment plan is designed keeping in mind the busy practitioner, whether in a clinic or in private practice. It is also designed with the knowledge that the client may wish to have a copy to refer to for a clear sense of the expectation for treatment. Because the design takes into consideration succinctness and brevity, one can look at numerous treatment plans over a period of time and quickly see the outcomes. Two cases are illustrated here that include the following: • Presenting problem: The presenting problem should be a short description, often using the client’s words to succinctly reflect the problem that brings them to treatment. • Assessment of presenting problem: This short narrative gives some additional information about the client, for example, age and other details that may be significant. • Strengths/​obstacles: This section is commonly found in treatment plans and can be helpful feedback to clients. Reinforcing a client’s strengths can be incorporated into the objectives, and highlighting a client’s obstacles can also be helpful to bring awareness of barriers to treatment, including outcomes.

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• Standardized rating scales: Having this information upfront in the treatment plan is helpful in providing additional information about the client and their problem. Assuming that it is likely that a reassessment might occur to review changes, this is a quick way to review these changes. Seeing changes from one treatment plan to another provides important information regarding progress. • (CDRS) Cognitive Domain Rating Scale: The rating scale is an integral part of the treatment process and having the various cognitive domains listed helps in clarifying where the client is situated in their thinking. • Evidence-​based practice: EBPs are more often required by funders and need to be clearly identified in treatment plans. This may be particularly helpful when the outcome is not successful. A consideration, then, would be to look at both the CDRS and the EBP being used. • Goals, objectives, and outcomes: This part of the treatment plan is best used in a grid format as it gives a clear picture of what the client is expected to work on. The goal is the broader picture, while the objectives are the specific actions that are to take place. Having the outcome next to each goal gives a quick view as to what happened. Creating a treatment plan in this way makes it almost impossible to lose sight of what is occurring in treatment, as the grid provides a succinct way of indicating what is happening in treatment. Also, it should be a clear picture of a consistent path or plan. The case scenarios used in this chapter are built on those discussed in previous chapters; the identified problems and the assessments are illustrated along with a treatment plan. As stated earlier, these cases are composites of actual case studies.

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CASE SCENARIO: JUDY

TREATMENT PLAN Name of Client:     _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​ Signature:       _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Name of Therapist:  _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Signature:       _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​​ Treatment Plan: #         _​_​_​_​_​_​_​_​_​_​_​_​_​    Date _​_​_​_​_​_​_​_​_​_​_​ Outcome Review:  Initials _​_​_​_​_​_​_​_​_​   Date _​_​_​_​_​_​_​_​_​_​_​ Presenting Problem: Who, What, When, Where, How? Who: Judy and her young children are experiencing the loss of their husband and father. What: What most concerns Judy is not being able to function in routines at home with her children or at work. When: Judy’s husband died 4 months ago. How: Judy does not know how to get back to functioning in a routine with her children. Judy does not know how to deal with her problem of how to get to sleep or stay asleep.

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Strengths

Obstacles

Judy is articulate and is open to help

Judy is sleep deprived.

and direction. Judy has the support of her mother. Judy has financial resources to maintain her home and living status.

Judy’s grief is overwhelming any ability to cope with simple tasks, such as getting her children ready for school or functioning at her job.

Assessment of Presenting Problem • Summary of Dialogue/​Narrative • Identified Rating Scales • Cognitive Domain Assessment: Remember, Understand, Apply, Analyze, Evaluate, Create • Evidence-​Based Practice Summary Judy is a 37-​year-​old mother of two young children who is coping with the loss of her husband, who died suddenly of a heart attack 4 months ago. She and the therapist have discussed her long-​term goal of returning to work, and a short-​term goal of being able to function by getting up in the morning to get her children off to school and to also finding a way to get adequate sleep. Judy complains of having difficulty coping when thinking about the morning, as her husband had the task of getting the children off to school. She says that thinking about the morning routine causes her to be upset and she admits to avoiding the morning with her children. Rating Scales: Beck Depression Scale: 40 –​Severe depression Beck Hopelessness Scale: 9 –​Moderate hopelessness *Outcome Rating Scale: 12 *Session Rating Scale: 32 *See change chart for explanation.

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Cognitive Domain Assessment Remember, Understand, Apply, Analyze, Evaluate, Create The first cognitive domain, remember, is identified, as Judy finds it painful and difficult to recall the morning routine that involved her husband taking care of the children. Remembering anything that creates a memory of her husband no longer being a part of the family causes her to feel upset and unable to focus in a functional manner and causes her to feel overwhelming grief. Judy and the therapist agree that discussing the routine in the morning with her children to recollect and understand, the second cognitive domain, the children’s need to re-​establish the morning routine might help refocus her grief and empathize with her children’s grief. If Judy does have the conversations with her children and feels comfortable, she may want to consider getting up in the morning to help them with their morning routine, but only if she feels calm and relaxed about doing that. In this instance, the third cognitive domain, apply, would occur with her taking on that task. Evidence-​Based Practice(s) Cognitive behavioral therapy (CBT): Using thought stop technique when memories are overwhelming. Psychodynamic therapy: Engaging with her children around their feelings about the loss of their father as a way to extend empathic, nurturing responses; engage in grief work with therapy sessions and in a grief group.

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Goal: Broad statement with general intentions

Objectives: specific, measurable statement with tangible results

Outcome:

Judy will feel calm and

Judy will have several

Completed/​Not Completed

focused during the

conversations during the next Judy reported several

morning routine and

month with her children to

engage with her children. recall or remember together

conversations with her children* about their

what the morning routine

recollection of how their

was like with their father.

father woke them up in

This will help her understand the morning and what the and empathize the children’s

routine entailed.

need to re-​establish the

*Measurable goal

morning routine. Judy will wake her children

Completed/​Not Completed

and help with the morning

Judy reported that in the

routine if she feels calm and

past 2 weeks she got up

comfortable doing so.

several times to wake up the children* and helped them get dressed. *Measurable goal

Judy will use the thought

Completed/​Not Completed

stop CBT strategy when

Judy said that she used the

she begins to feel

thought stop CBT strategy

overwhelmed in the

every morning when she

morning to maintain

woke up and it helped her

her composure.

to focus on the children and not on her anxiety.

Judy will consider attending

Completed/​Not Completed

a grief group to focus.

Judy did not make any attempt to contact a grief group.

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TREATMENT PLAN Name of Client:     _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ Name of Therapist:  _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Treatment Plan:     _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​       Number      Date Outcome Review:   _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​    Date Treatment Plan Summary

Judy made significant progress in the past 30  days in that she had several conversations with her children about the morning routine and for a 2-​week period she got up several times to help them get dressed. Judy’s mood and affect were much brighter than when she met for the initial session, and she reports that she feels better physically and reports feeling less depressed. She indicates that while her sleep is improving, she still has sleepless nights. Judy admits that she is avoiding going to a grief group, as this “just makes it real,” meaning that being in a grief group signifies her husband’s death, stating that it is still hard for her to accept and believe that he is gone. A  discussion emerged when it was suggested that she go with a family member or friend, and she said she would think about doing that. Judy indicates that she has always been one to move slowly in undertaking any new activity, so she is comfortable waiting a while longer before considering attending a grief group. Judy asks that the goal of attending a grief group be put on hold at this time. There was some discussion about Judy not waking the children up every day, and she indicated that some mornings she is exhausted because she is still not sleeping well. In reviewing her sleep hygiene, Judy admits

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that she still needs to increase her sleep and to have a better routine, as she often will fall asleep watching TV while eating junk food

CDRS

Judy had conversations with her children and found the task of remembering the morning routine, CDRS level 1—​remember/​recall, as soothing both for her and the children. She related that her children responded in a positive way and that she now has a better understanding (CDRS level 2—​of their needs which helps her to re-​focus her anxiety and depression. She was able to get up and help her children in the morning, so the goal now is that she choose, CDRS level 3—​apply, to do the morning routine daily. Additionally, Judy will create, level 5—​ create, and apply—​level 4, behaviors in regard to sleep hygiene. The goals and objectives agreed on include the following: Goal: Broad statement with general intentions

Objectives: Specific, Outcome measurable statement with tangible results

Judy will continue with

Judy will get up and

the morning routine.

wake her children every school day to help them with the morning routine.

Judy will improve her

Judy will set a bedtime

sleep hygiene.

of 10:00 p.m. She will eat a healthy snack no later than 8:00 p.m. She will read short meditations before sleep.

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Summary of Treatment Plan 2

This format begins with a narrative summarizing what Judy did in the previous treatment plan. As is the case in all treatment plans, the narrative, as well as the goals/​objectives and outcome, should read in a logical format. Anyone reading treatment plans should have the ability to read it as a snapshot of what is occurring in therapy. In Judy’s case there is a clear progression of treatment in that she is engaged with her children in the morning routine. She did not follow through with the objective of attending a grief group. That was clearly identified in the grid, and a follow-​up identified that she does not wish to do that at this point. The CDRS continues as she is now choosing (the action) to get up daily to help her children every morning. Her thinking now is that she needs to work on getting a better night’s sleep and agrees that she needs to change some behaviors regarding that, so she will create and apply tasks regarding sleep. All of this is clearly and succinctly identified in the grid with goals, objectives, and outcomes. It is possible that when Judy is done with treatment, one could easily look at Treatment Plan 1 and then just glance at the goals, objectives, and outcomes grid in the following treatment plans to get a clear and quick view of what happened in this treatment process. Should anything change in Judy’s life situation, it can easily be integrated in the next treatment plan in the summary section, as well as in the goal and objectives section. Also, the CDRS can be changed to include any new changes.

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CASE SCENARIO: AMANDA

TREATMENT PLAN Name of Client:     _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Signature:       _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Name of Therapist:  _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Signature:         _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Treatment Plan: #   _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ 

Date ___​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​

Outcome Review:     Initials/​Date _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Presenting Problem: Who, What When, Where, How? Who: Amanda is struggling with a drinking problem. She indicates that her father was an alcoholic and her husband was abusive. When: Amanda finds that when she is in work situations and is out entertaining clients she often drinks too much when she becomes anxious. How: Amanda does not know how to get her drinking under control.

Strengths

Obstacles

Amanda is motivated to stop drinking.

Amanda is an adult child of an

Amanda is an intelligent and articulate

alcoholic father.

individual.

Amanda has a stressful job. Amanda is still dealing with the stress of a recent divorce.

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Assessment of Presenting Problem: • Summary of Dialogue/​Narrative • Identified Rating Scales • Cognitive Domain Assessment: Remember, Understand, Apply, Analyze, Evaluate, Create • Evidence-​Based Practice Summary: Amanda is a 34-​year-​old divorcee who is concerned about drinking to excess. She indicates that she left a previous therapist because that therapist felt she needed to focus more on her divorce and issues of being abused. Her trauma includes verbal abuse and “pushing and shoving” by her ex-​husband, and trauma she endured growing up with an alcoholic father where she witnessed her father verbally abusing her mother. Amanda has identified that instances of her “out-​of-​control” drinking occur frequently when she is at work-​related functions entertaining clients. She admits that she is embarrassed by her drinking, and recognizes that she does not pay attention to how much she is drinking, but remembers times when she was unable to speak clearly after consuming several drinks. Amanda does not seem to indicate that her drinking interferes with other areas of her life. She cannot identify other times when she has urges to drink, but thinks there may be other instances. Amanda has made it clear that she does not wish to spend sessions discussing issues regarding her relationship with her father or her ex-​husband, and that she only wants to focus on getting control over her drinking.

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Rating Scales: ASI (Addiction Rating Scale): 4 Beck Depression Inventory: 20 –​Borderline clinical depression Beck Anxiety Inventory: 36 –​Potential concerning levels of anxiety Outcome Rating Scale: Average score: 15 *Session Rating Scale: Average score: 30 *See change chart for explanation Cognitive Domain Assessment: Remember, Understand, Apply, Analyze, Evaluate, Create The first cognitive domain, remember, comes into play, as Amanda needs to identify when she has urges to drink, and specifically what she is feeling and thinking during those instances. This will be a challenge and requires a certain amount of self-​control and focus when she is in a situation where alcohol is involved. The second cognitive domain, understand, comes into play, as Amanda is motivated to understand why she gets out of control with her drinking. Evidence-​Based Practice: Cognitive behavioral therapy (CBT): Amanda and the therapist will use the technique “cognitive behavioral rehearsal” as a way to identify her thoughts and feelings when urges present themselves. Mindfulness: Amanda is asked to pay attention to her bodily sensations and rate her feeling states from calm to anxious several times throughout the day.

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Goal: Broad statement with general intentions

Objectives: Specific, measurable statement with tangible results

Outcome:

Amanda wants to control

Amanda will identify what

Completed/​Not Completed

her excessive drinking.

she is feeling and thinking

Amanda reported that she

as she gets an urge to drink.

feels anxious when she has urges to drink. She stated that in work situations she is worried that she will “screw up” the sale. Amanda stated that she had never paid any attention to how she was feeling when she had urges to drink, and that identifying this anxiety now helped her understand why she would grab a drink.

Amanda will track how

Completed/​Not Completed

many drinks she consumes

Amanda did not record the

over a 2-​week period.

number of drinks she had over a 2-​week period, but said she kept it to two glasses of wine at each meeting.

Amanda will maintain a

Completed/​Not Completed

journal to record her bodily

Amanda did this several

sensations several times

times throughout the week

throughout the day, from

and discovered that she is

calm to anxious.

often anxious, even when there is no urge to drink. She indicated that she notices that her heart races and she breaks out in a slight sweat at the least provocation.

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TREATMENT PLAN Name of Client:     _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_ Name of Therapist:  _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ Treatment Plan:    _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​ _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​   Number     Date Outcome Review:   _​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​_​    Date Treatment Plan Summary

Amanda made an important discovery in this first treatment plan by being able to identify that when she has urges to drink she feels anxious. She reported that identifying that she gets urges, particularly when she is anxious, helps her to better understand why she drinks to excess, especially in the work place. She identified that she becomes anxious when she worries about making a connection with her client. Amanda recognizes that there is likely a connection with her current behavior and her history of growing up with her alcoholic father but still wishes to focus on her current problem by dealing with her problem drinking and anxiety. Given that she is interested in working on ways to confront her anxiety, as she is now aware that when her heart races and she feels flushed she is likely to pick up a drink as a way to cope. She agrees to work on ways to calm herself during those moments as a way to decrease her physical symptoms and also to ultimately deal with drinking to excess. Evidence-​based practice: Cognitive behavioral therapy (CBT) and mindfulness

CDRS

The CDRS is changing to level 4, apply. Amanda will apply breathing and grounding techniques when she identifies that she is feeling and thinking

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about wanting to drink or when she has physical symptoms of her heart racing or feeling flushed, which she has identified as signs of being anxious. The goals and objectives agreed on include the following: Goal: Broad statement with

Objectives: specific, Outcome: measurable statement

general intentions

with tangible results

Amanda wants to be less Amanda will use deep

Completed/​Not

anxious, particularly

breathing as a calming

Completed

at times when she has

technique and will use

(notes about this will

urges to drink.

mindfulness grounding

appear at the next

techniques when she has

treatment plan review_​

mental or physical signs of anxiety. Amanda will practice breathing and grounding techniques three times daily (upon waking, during a break at work, and at bedtime) to instil these calming techniques.

SUMMARY

As noted in these treatment plans, the information is summarized in areas that create a clear narrative about the problem, the assessment, and the treatment goals and objectives. The grid format for the goals, objectives, and outcomes works well, as they are aligned. In each case the measurable objective using the CDRS and the outcome are easily identified. The treatment plan puts everything into clear focus. It would be expected that what was not completed might take on the same form or perhaps it may be changed, but this is where you should be

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able to see how the “story” and objectives continue. The next treatment plan is likely to summarize accomplishments, indicating any new information and then the same format with goals, objectives, and outcomes with either the same or a revised CDRS. Managed care companies often report that treatment plans are not done on time and therapists in clinics often complain that large caseloads make it difficult to keep up with timely treatment plans. It is speculated that part of the problem that therapists encounter in creating treatment plans is that they find it difficult to capture what actually happened in the past month in a coherent way to illustrate change. The model presented here is one that can capture the entire picture with a limited amount of effort. Keep in mind, however, that this can be done only when there is a thorough assessment, because no treatment plan can be done adequately without having a solid body of information from which to reflect back on to create a plan. Also, it is important that the therapist have a way to document through progress notes or other documentation what is occurring during the time in between treatment plans. What is not discussed here but should be noted is that therapists should have a check-​in with their clients at the beginning of each session to discuss how they are doing with the decided-​on objectives. While this may sound stilted, certainly there are ways to have that kind of discussion with clients that fit in with a dialogue that expresses interest, concern, and empathy while at the same time ensuring that they are in agreement with the treatment plan. Because the objectives written involve some type of action, the written format makes it easier to keep a check on measurable changes. This is also an opportunity to change direction should the treatment plan not be working. This is where the (Outcome Rating Scale (ORS) feedback helps in keeping tabs on progress. This all requires finessing how to gather information while still conducting treatment. There is no one perfect scenario for treatment, but paying attention to these components is likely to have good results with outcomes as discussed in Chapter 1, on psychotherapy and outcomes. Writing measurable outcomes is the end result of a systematic approach to treatment. It does not happen in a void.

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Looking at the goals, objectives, and outcomes grid, we can see what Judy and Amanda accomplished. Each of these treatment plans might have been expanded on, and one may question what is the “big deal” about Amanda, for example, “identifying what she is thinking and feeling when she has urges to drink.” Shouldn’t she just make a plan to stop drinking? Answering that question involves a discussion about clinical judgment, and in this case the clinical judgment that both Amanda and the therapist agreed on was that it was very important for her to pay attention to what she was feeling when she had urges to drink, as a way to identify bodily sensations to cue her before she gets “out of control”—​Amanda’s words. Measurable objectives should be thought about as a process, not the end result, and in this first treatment plan, it makes sense that going slowly to try to figure out what Amanda was thinking and feeling was likely to get better results in the long run than creating an objective to “cure” her “out-​of-​control” drinking at that time. This was also what Amanda identified as what she wanted to work on. In recalling this case from Chapter 3, on assessment, Amanda had left her previous therapist because that therapist wanted to focus on Amanda’s relationship with her alcoholic father and her abusive ex-​husband, as it seemed that the therapist speculated that her history was significant and attached to Amanda’s drinking. While there is some accuracy to that assessment and approach, attending to Amanda’s desire to figure out what is going on when she gets “out of control” with her drinking led to simply identifying anxiety, which later led to discussions about the connection with her past to her current drinking behavior. The takeaway from this case example is that the CDRS identified that Amanda needed to identify or remember/​recall (level 1) her feelings and thoughts at times she had urges to drink, and this simple objective unleashed memories that opened up the path for Amanda to discuss issues about her past. Never consider what appears to be a “simple” objective as irrelevant to treatment. Again, outcomes are likely to build on each other over time, and it is extremely important to always be attending to what the client is saying as a means to getting at where they are thinking, the place for rating the cognitive domain.

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If treatment plans follow this progression, with identifying and focusing on simple objectives that build on one another, then what should evolve is a clear, in-​focus picture of what is occurring in therapy. This also means that regressions and objectives that are not realized are revealed and can easily be understood by charting the re-​evaluation of the CDRS and creating new objectives based on that rating. For example, should Amanda regress and have an evening of binge drinking, it is no longer enough for her to identify what she is thinking and her feelings when she is drinking, as she was already able to identify anxiety. The next step would be to work with Amanda on creating a new CDRS, which might be that she needs to take action to apply, cognitive domain 4, and attend an AA meeting, accepting that she needs additional support to deal with “out-​of-​control” drinking. In some ways, the treatment plan is the most important part of the chart, because it is the record of what has occurred and is currently occurring in the treatment process. It is not so much a skill in writing as it is a skill of taking the data and placing it in the categories to reflect an accurate picture. The treatment plan is vital to many stakeholders who appreciate seeing a clear view of what is occurring in therapy: the funder who is paying the fee and conducting an audit, the supervisor reviewing numerous caseloads and therapists’ work, the therapist who must quickly view what was done in the last treatment plan to facilitate competent treatment, and, finally, the client who can see the progress they are making.

REFERENCES Adams, N., & Grieder D. M. (2014). Treatment planning for person-​centered care: Shared decision making for whole health (2nd ed.). London: Elsevier. Jongsma, A. E., Jr., & Peterson, L. M. (1999). The complete adult psychotherapy treatment planner (2nd ed.). New York: John Wiley & Sons. Wiger, D.  E. (2012). The psychotherapy documentation primer (3rd ed.). Hoboken, NJ: John Wiley & Sons.

7

Stumbling Blocks in Writing Measurable Outcomes

Expect that writing measurable outcomes may at times be a challenge. Consider the situation when therapy is not progressing despite using the procedures of a well-​grounded evidence-​based practice. You may have a client who is difficult and despite efforts in sessions, the problem or issue is still vague. These are the situations when the problem is difficult to write in measurable terms. This is the client who says, for instance, that they want to increase their self-​esteem but is unable to find a way to define exactly what that is. Then there are the many instances when clients simply don’t follow through with what they agreed to do. Discussed in this chapter are some examples of issues that may be a challenge in getting to the place of writing meaningful measurable outcomes. Obviously, they do not comprise an entire list of possible problems, but they are common problems encountered in therapy and can make it difficult to translate how to write objectives that reflect a measurable outcome. Some of these problems include: • Vagueness about problems or issues that are ephemeral or lack clarity as to where the client is situated in their thinking • Resistance on the part of the client who is difficult to engage and perhaps never quite agrees on an objective that is measurable

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• Chaos where the client is constantly in a crisis state, making it is difficult to adequately write an objective or assess a meaningful outcome • Trauma victims who are reluctant to discuss details and are unable to provide clarity as to what to work on • Atomistic, narrow objectives written by therapists who succumb to writing objectives only to fulfill a requirement for an agency policy or a funder rather than engaging with the client and creating meaningful outcomes • Ambiguous objectives related to writing that lacks clarity First, it is important to do a check on the following: 1. Is the client engaged in treatment and is there a strong therapeutic alliance? If you need to think about how to answer this question, it is possible that there is some type of alliance problem. There is better likelihood of knowing about alliance issues and commitment to therapy with regular use of some type of outcome rating scale (see Appendix). Regular feedback is useful, as it can provide indicators of being on the right path with the client. It is important to mention that high ratings do not necessarily indicate that the client is answering the questions on the scale accurately, as the client may be rating high to please the therapist. If that becomes apparent through use of the scales, then it is important that this issue be addressed with the client. Then it is possible to have better clarity in identifying goals and objectives. Any feedback is important, and the therapist must create a regular dialogue to make the client feel comfortable about saying what they are getting or not getting out of the therapy sessions. It is also difficult but wise to consider that perhaps you and this particular client are not able to make a connection. It is certainly reasonable to think that you may not be able to connect to a client despite your efforts, just as you understand that you don’t always connect with everyone you personally encounter. While it is rarely discussed, it might be wise to ask

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the client if they would like a referral to see to another therapist. This discussion might actually lead to a positive outcome with a client revealing a complaint or concern that might be resolved, or perhaps a disclosure of an issue that was hindering treatment. An outcome rating scale may be helpful in focusing on these types of issues. Daryl Chow is very open about how he had to take a look at his interviewing skills, as his way of posing questions did not always convey to clients an empathetic stance or a sense that he was truly interested in what they had to say. Through supervision, Chow was able to work on this problem, and he developed a different way of questioning clients that included posing questions that helped them to imagine possibilities for change and reframing queries that were more focused on the client and less on the problem. His book, The First Kiss (2018), and others that are referred to in Chapter 1 of this text are good resources for revisiting interviewing styles should clients be dropping out of therapy or if session ratings are not good. 2. Is there some problem that has not been clearly identified that might be revealed with the use of some assessment rating scales? The judicious use of assessment scales can greatly aid the therapeutic process, particularly in situations where the client is not forthcoming or where the self-​report that is given is contradictory. There are also situations where what the client says may not reflect the observation of what the therapist sees. For example, a client may claim not to be depressed, but self-​reports regarding his life and his affect and behavior in sessions seem to point otherwise. Use of validated scales can confirm, elucidate, and perhaps uncover issues that may have not been addressed in the assessment or in ensuing sessions. Reviewing these findings with the client may aid in furthering the process of setting goals and objectives that might not have happened in face-​to-​face sessions. Rating scales come in two forms: standardized rating scales based on a group to discern a particular normative result, and individualized scales,

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which are more personalized to particular issues. In either case, these scales should be used as a way to elicit additional information that can help with treatment planning. In all cases, these scales should be used only as an adjunct to the treatment process. All scales create probabilistic results. No scales can absolutely confirm personality, problems, or issues or point to a definitive method for treatment. They should be used as a way to triangulate with other kinds of data developed during assessment and treatment. For example, in some instances it may be helpful to have the client bring a family member or friend to a session who might be able to provide helpful contextual information as part of the clinician’s overall database. Also, confronting the client about dissonance is important but should be done in a way that does not make the client feel shamed. The videos of and books by master therapists referred to in Chapter  1 are helpful resources for phrasing such confrontations. Daryl Chow (2018) also addresses this issue very well. Minuchin (1974) states that one of the reasons why “patients move” is that they are challenged in their perception of their reality. 3. Is there reason to be concerned that the problem is related to a medical condition? It is important for the therapist to do a brief review of the client’s current medical condition, including finding out what type of medications the client is taking, as some problems that may present as psychological have a medical element that may affect mood and cognition. It may be appropriate to obtain a release to speak to the client’s physician if there is a question about their medication and its effect on the client’s psychological state. Asking such questions should be a standard part of history taking and also asked throughout therapy, particularly should the therapist note a change in behavior that is not otherwise understood as a change in one’s life situation. Discussed next are some common issues when therapy does not seem to be progressing.

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WHAT TO DO WITH CLIENTS WHOSE COMPLAINTS ARE VAGUE

Some clients present with vague complaints, such as:  “I’ve lost interest in everything,” “The state of the world is upsetting,” “I find everyone annoying,” “I can’t do anything right.” Even with further probing and asking the who, what, when, where, and how questions, certain clients are not good at giving information that points to anything in particular to help with the process of assessing the situation and figuring out where they are situated in their thinking about their dilemma. Whether the client is vague or oppositional to any consensus about a problem, it is fair to say that this is representative of a resistant client. Clients who present with equivocal presenting problems may have long-​standing issues with intimacy, fear of failure, or feelings of shame, or they may be passive-​aggressive and are unable to directly say or confront whatever is causing their ill-​defined statements about being bothered about various persons, places, or things. Therapy sessions may continue without any focus. Making an interpretation about any of these issues may help some individuals look at themselves and their situation more closely, but others may deny or dismiss that the therapist’s interpretation is not correct, and they may be right! Clifton Mitchell (2003, 2007)  has written extensively on the topic of resistant clients and offers some insight for the therapist and advice regarding resistance: Typically, as we become aware of the myriad possible solutions to a client’s problems, we become more certain that our knowledge can help them. As a result of such certainty, we begin talking more and more as an expert regarding the problem at hand. But here’s the catch:  The more expert you become, the more you give the client something definitive to resist against and the less psychological freedom clients have to explore possibilities on their own. Thus, being knowledgeable about obvious solutions may actually create resistance. A sure sign that you have become too much of an expert is

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getting “Yes, but . . .” answers. The way out of this situation is to reverse the paradox. The more obvious possible solutions become, the more naïve, inexperienced, and uncertain your displayed attitude of these solutions should be. The principle at work here is that your client cannot be resistant if here is nothing to resist. Mitchell also believes that a considerable amount of resistance comes from poor timing, for example, when the therapist offers explanations and perhaps suggestions for action in the form of an objective before the client is ready to accept them or when confronting the client too soon. Here, again, is where a good supervisor can assist the therapist in looking at what the therapist may be contributing to the problem. The question still remains as to how to create a measurable outcome with a client who resists being specific or committing to any type of objective. It may be wise to consider first taking Mitchell’s advice and become less of the expert and driving force in writing the objective and let the client take charge of the task. Letting the client take charge might involve the following: 1. Stay with the complaint that the client presents, no matter how vague. Accept that any attempt to get the client to focus on a problem that is solvable is not what they want or are capable of doing at this time. 2. Use the client’s exact language or terminology to reflect back to the client to validate their distress. As Mitchell says, it is important that “there is nothing to resist.” Using the client’s language is a way to “join” with them (Minuchin, 1974). 3. Ask the client to state what would be the opposite of the problem to create a broad goal. Kottler (1992) argues that the conflict the difficult client presents might be a constructive force for change and that the therapist use this as an opportunity to find ways to examine their abilities and deepen their compassion, rather than just view the client as being the problem. Roes (2002)

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makes a very important point about resistance, particularly as it relates to the client who has addictions: Resistance might actually be hopelessness. This is a very important consideration to bear in mind when viewing a client as resistant. That, coupled with Kottler’s point that the therapist needs to deepen a compassionate attitude toward the client, may be what is necessary to engage the client in a dialogue about goals and objectives. In association with any issue that may involve shame, this approach might make the difference in engaging someone who previously seemed unengaged. There must be engagement with the client in order for the therapist to get to the next step in the process of working with the client to help them situate their thinking, to discuss any sense of where they are in a CDRS. It might work to assume that the client’s thinking is situated in remembering or understanding since they are stymied by how to deal with the problem given that they can’t offer anything more specific or perhaps don’t want to, particularly if there is shame or guilt associated with the problem. Assuming this, then a dialogue that includes asking the client’s help to better remember can be a way to better understand what they experience, or what they feel, and how it impacts their day. This might be a way to create the needed engagement toward working together to write a measurable objective. Using a narrative approach mentioned in an earlier chapter, it might be helpful to take the verb that is causing them stress, for example, depression or feeling anxious, and change it to a noun and ask, “If that depression cloud left the room, what would your life be like?” or “If that anxiety bomb was removed from your space, who would be there for you or what would your body feel like?” Here are some other ideas of how objectives based on the vague complaint “I am bothered by the state of the world” might be written: Cognitive Domain Rating Scale: Remember/​Understand Objective: Client identifies thoughts throughout the day that are troublesome concerning the state of the world or anything else.

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Objective: Client names people who share similar views about the “state of the world.” Objective: Client recalls meaningful events both globally and personally. One might argue that the objective is being written just for the sake of writing an objective to meet a policy. It is fair to say that perhaps there is a requirement for that, but in this example, putting the client in the role of expert and using their exact language to define the problem may be just enough to appeal to the client’s desire to commit and work on an objective. The stated objectives probe what, how, and who questions, for instance:  “What thoughts  .  .  .,” “Who are the individuals he shares views with,” and “When were events meaningful?” It is likely that if the outcome of any of those objectives is realized, it could indirectly lead to information about more specific incidents in the client’s life concerning the who, what, when, where, and how, which could unleash a swell of information about this individual’s underlying distress. As Irving Yalom states in the foreword to Inside Therapy (Rabinowitz, 1998), “Creative therapy is shaped by both therapist and patient. In fact, the process of creation of the therapy is an intrinsic part of the work and therapists must facilitate the patient’s creative participation.” Yalom and the client just referred to remind us that there is nothing wooden or matter-​of-​fact about therapy, as there are always situations where the therapist cannot follow any cookbook procedure.

ARE CLIENTS WHO ARE ALWAYS IN CRISIS APPROPRIATE FOR TALK THERAPY?

Clients who are continually in crisis are defined as those whose lives are such that they are always dealing with a problem or problems that prevent them from having any kind of stability. Often these are individuals whose basic needs, whether it be financial, housing, or job stability, are

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not being met. Typically, these individuals regularly miss appointments. It may be that it is not realistic for them to be in therapy at this time, but to have support to deal with concrete services that will stabilize their circumstance. This situation brings to mind the therapist working in a clinic who is seeing clients mandated to therapy, but a closer look reveals that they may more realistically need a case manager. A realistic objective in such situations is to create obtainable objectives that may not address the individual’s anxiety and trauma, even though it may be a significant factor in why they are living in a constant state of crisis. This client may not be able to follow through with therapy to deal with their anxiety and trauma until their basic needs are met. Instead, they may be better served by having concrete objectives that they can easily complete. For example, Objective: “Client will go to the Social Security office to fill out disability forms.” Completing a simple, concrete task may make it possible for the client to be successful in just one thing, and that one thing may pave the way to an easier path for them down the road to deal with more complicated psychological issues. It may also be something as simple as agreeing on a goal to “take medication to alleviate anxiety” with the objective to “take medication daily as prescribed.” While this is not glamorous therapy, it is still therapy with a broad goal of engaging the client to stabilize their current life situation. It is important to remember that working on the therapeutic alliance always trumps the intended goal and objective and, as stated throughout, it is the way to work toward writing meaningful objectives that result in measurable outcomes.

THE CLIENT MAY BENEFIT FROM ALTERNATIVE APPROACHES TO TALK THERAPY

Increasingly there is evidence that alternative approaches to talk therapy can enhance and, in some instances, help clients move forward in dealing with their problems, particularly trauma. Yoga, meditation,

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working with the breath, physical exercise, and nutrition are all aspects of alternative therapies that yield positive results. For all clients, and certainly for those clients who are not making gains, it is wise for therapists to suggest these type of alternatives either as an adjunct to therapy or as a starting point for change should talk therapy not be working. In any event, these alternative therapies are easily incorporated into a treatment plan with clearly defined measurable outcomes. On the US Journal Training website talented master therapists and researchers present state-​of-​the-​art workshops at conferences located throughout the United States:  https://​w ww.usjt.com/​e vents/​w elcome-​t o-​u -​s -​ journal-​training/​event-​summary-​7fbdba52fea245d098a17b01eb1db702. aspx.

THE CLIENT HAS EXPERIENCED SIGNIFICANT TRAUMA AND RESISTS DISCUSSING TRAUMATIC EVENTS

First, it is important that, when the presenting problem is trauma, the therapist must have training in working with trauma. If the therapist does not have trauma training, it is usually smart to refer the client to a trained trauma therapist. In many instances when traumatic experience is involved, the client may not be able to verbally discuss issues or feelings; that is, they are unable to recall events or access feeling states in any coherent manner reflecting their story. Assuming one is going forward as a trained trauma therapist, it is possible to still create measurable outcomes, but it may be more about dealing with body work than with talk therapy. Ogden and Fisher state in their book Sensorimotor Psychotherapy: Interventions for Trauma and Attachment (2015), The body’s intelligence is largely an untapped resource in psychotherapy  .  .  .  the story told by the “somatic narrative”—​gesture, posture, prosody, facial expressions, eye gaze and movement—​is arguably more significant than the story told by words. (p. 13)

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In the case of Amanda, she was asked to pay attention to her bodily sensations, and this was a beginning for her, to be aware of her anxiety, which she was then able to connect to her childhood trauma observing her father during his drunken states. What is suggested here is that one needs to continually be skilled in order to nuance ways of providing effective treatment. Also, outcomes can be written about bodily sensations with trauma victims who might be challenged to discuss issues verbally. The reader is referred to texts on EMDR (eye movement desensitization reprocessing) and sensorimotor psychotherapy and to Bessel van der Kolk’s The Body Keeps the Score (2014) for further references regarding brain science approaches. It may be easier to document measurable objectives when the therapist and client are paying attention to body sensations and affective behavior. This is mentioned here to emphasize that measurable outcomes using the CDRS process can proceed with an outcome beyond the typical verbal, action-​oriented approach to therapy. In fact, when considering alternative approaches to therapy that involve mindfulness and body work, the CDRS process supports a way to create endless outcomes for measuring objectives for psychotherapy.

DO THE OBJECTIVES REFLECT A CLEAR PROGRESSION OF TREATMENT?

This question is likely to be posed by a supervisor, a funder during an audit, or perhaps even therapists reviewing their charts. A  chart should read like a story, with a beginning, middle, and an end; similarly, objectives should reflect a clear sense of the process, from the intake and presenting problem to assessment, goal and objective setting, and outcomes. When the objectives do not seem to match up to the notes, it may be a problem with the therapist’s writing skills, but it may also have to do with the therapist not having an adequate conceptual understanding of how to write objectives.

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The following questions might be posed to review each step in the process, to come to an understanding as to why the objective does not seem to tell the story of what is going on in therapy: Presenting Problem/​Intake: Is there a clear problem focus? Assessment: Does the assessment have sufficient data that elicit the who, what, when, where, and how questions as they related to the problem and relevant history? Cognitive Domain Rating: Is there sufficient justification to claim where the client is situated in their thinking about their problem based on the assessment process? Evidence-​Based Practice (EBP): Is the therapist sufficiently trained in the EBP that he or she is using in sessions? Was the EBP explained to the client and is there buy-​in on the client’s part? Goal: Does the client agree with the broad goal? Is the goal consistent with the written objectives? Objectives: Are the objectives consistent with the stated goal? Are the objectives written with a clear action verb that is measurable? Is there logic to the objectives that follow each outcome? Is there documentation for using an outcome rating scale to support the progression or change in therapy?

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SUMMARY

There will always be instances when it is difficult to write clear measurable outcomes. As stated earlier, therapy is messy. The manner in which the therapist and the client are able to understand the problems and issues and how they figure out what to do may take time. Objectives rarely proceed in a straight line and are more likely to move back and forth depending on the outcome. Also, objectives are subject to modification depending on any changes in the current situation in the client’s life and particularly if the client is showing no signs of progress or interest in the written objective. Narrowing in on key elements taken from what may be a vast amount of data collected during the assessment phase can be an overwhelming task. If an assessment is not clearly organized or clearly written or does not have substantive information—​who, what, when, where, and how—​there may be difficulty in being able to write succinct measurable objectives. It may be necessary to go back to review with the client, once again, what the presenting problem is and the story that brings them to therapy. It is not unusual that what clients report as the problem at intake changes later in therapy. This may be due to a number of factors, including the client’s unease at saying what is really the problem or perhaps not even having it be a conscious part of their thinking when they initially came to treatment. This is all a reminder that flexibility is important on the part of the therapist. Also, being accepting of and creative in working with the client, as Yalom points out, are important components in this unique client–​ therapist relationship. An environment where objectives need to be put in a chart in a time frame that is not necessarily in sync with what the therapist and client are working on puts pressure on the therapist. Certainly, the therapist should not force the client to engage in the task of composing objectives when they are unfocused or distressed. Individuals who are experiencing extreme grief or who are in crisis in the midst of trauma or are simply vague about their complaint may just need to have the support of a therapist who is a compassionate good listener. In those instances, it may be fair that the

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therapist and the client agree on an objective that involves understanding, using an action that recognizes the time needed to sort out what problems or issues the client wants to work on. This could be something as simple as the client taking action by journaling their thoughts. It is always important to remember that the client be reminded that the exercise of thinking about what it is that bothers them so much is in itself an objective. It could take the form of remembering, cognitive level 1, or understanding, cognitive level 2. As the therapist practices using the language and assessing the CDRS he or she will be in a better position to guide the client to an agreed-​upon objective even in the instances where it seems murky. There is certainly a difference between when the client is in the early stages of treatment and when the client has been in treatment for a while and things have stalled. If the therapist and the client have had difficulty from the beginning in identifying issues, it is likely related to an alliance or resistance issue. However, if they have had a good round of treatment outcomes and get stuck, one should consider that perhaps treatment might be over. Many therapists and clients have difficulty ending the treatment process, and if no new objective can be identified, perhaps it is time to recognize that all has been accomplished at this point or maybe it is time to just take a break. A word here about supervision is important. Typically, therapists provide a self-​report in supervisory sessions; it is not standard that some type of recorded or live view of sessions is a regular part of either graduate education or supervision for licensing. Some programs have students submit audio recordings of sessions, but it is not the norm. Therapy is confidential, it is private, and it is understandable that clients may not want to be observed or recorded. While that is another topic all together regarding treatment, it is mentioned here because documentation like this would most definitely be an asset to the therapy process and add to competency-​ based outcomes. But it should be mentioned that this type of review might be very uncomfortable to therapists, which is yet another topic that might be important for a discussion between the therapist and supervisor. Therapists need to have a sense of psychological safety in being able to

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be critiqued, and that can happen in a positive supervisory relationship. During the 1970s, when family therapy was a forerunner in treatment, the use of two-​way mirrors was popular and a team would observe a therapist treating a family. Another option might be to have a significant person involved in the individual’s life sit in on a session to offer a different perspective, which is a treatment strategy used in narrative therapy, where the “expert witness” attends a session or sessions (Freedman & Combs, 1996). These options might be helpful, particularly when the client is stuck or the problem is vague and ill-​defined. Finally, it is to be expected that despite best efforts and best practices, some clients will not follow through with treatment. A  big challenge is treating mandated clients when someone else has a vested interest in the client’s outcome. In those cases, a simple objective might be that the client identify that they have little or no interest in therapy and that they need to identify, CDRS remember/​recall—​level 1, reasons why they have little or no interest. This fits in the category of resistant clients. As Mitchell points out, if the therapist gives the client nothing to resist, then it is likely that the resistance will cease. In an actual case, a resistant client was asked to simply state why he didn’t want to be in treatment and what he needed to do in order to get out of treatment. He came up with a list of reasons why he was angry. This led to an objective of what to do about that anger, which led in turn to an objective and treatment plan involving writing a series of letters to individuals targeted as being responsible for his problem and pain. This was an adolescent who was abused by his parents and was placed in foster care. What sometimes appears as a dead end can end up becoming productive, with patience and creativity. Prochaska and DiClemente’s Stages of Change:  Pre-​ Contemplation, Contemplation, Preparation, Action, Maintenance and Relapse (Singer, 2009)  can assist in helping both the therapist and client identify where the client is at in terms of being able to take a step toward change. In this case, the adolescent was at the pre-​ contemplation state of change, as he did not see his behavior as a problem and did not see a need to change. Using the change model helps to identify what type of objective and approaches to take. In a pre-​contemplation

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state of change, the objective may be to just work with engaging the client to develop an alliance.

REFERENCES Chow, D. (2018). The first kiss: Undoing the intake model and igniting the first sessions in psychotherapy. Correlate Press. Freedman, J., & Combs, G. (1996). Narrative therapy: The social construction of preferred realities. New York: Haddon Craftsman. Kottler, J. A. (1992). Compassionate therapy: Working with difficult clients. San Francisco: Jossey-​Bass. Minuchin, S. (1974). Families and family therapy. Cambridge, MA: Harvard University Press. Mitchell, C.  (2003). Resistant clients:  We’ve all had them, here’s how to help them. Psychotherapy.net. Retrieved from https://​www.psychotherapy.net/​article/​resistant​clients Mitchell, C. (2007). Effective techniques for dealing with highly resistant clients (2nd ed.). Johnson City, TN: Clifton W. Mitchell Publishing. Ogden, P., & Fisher, J. (2015). Sensorimotor psychotherapy: interventions for trauma and attachment. New York: W.W. Norton. Rabinowitz, I. (Ed.). (1998). Inside therapy. New York: St. Martin’s Press. Roes, N.  A. (2002). Solutions for the “treatment resistant” addicted client:  Therapeutic techniques for dealing with challenging clients. New York: Routledge. Singer, J.  B. (Producer). (2009, October 10). Prochaska and DiClemente’s Stages of Change Model for Social Workers [Episode  53]. Social Work Podcast [Audio podcast]. Retrieved from https://​socialworkpodcast.blogspot.com/​2009/​10/​prochaska​and-​diclementes-​stages-​of.html van der Kolk, B. (2014). The body keeps the score. New York: Viking.

8

Questions and Review

This chapter is written as an epilogue, anticipating that the reader is apt to have questions or need clarification about the information presented. While it is safe to say that all uncertainties will not be addressed, it is an attempt to consider issues that some individuals might challenge or that need further explanation. This chapter is also meant as a way of filling in the gaps with ideas and thoughts that were not sufficient for an entire chapter but still worth mentioning. The review presented here will confirm what was understood and perhaps help the reader identify concepts that need to be revisited or a skill set that needs to be improved in a particular area. For example, the graduate student or therapist who needs to work on assessment can review that chapter by itself, and certainly it is expected that Chapter 2, on Bloom’s taxonomy, will be reviewed with regularity until one becomes more familiar with the six cognitive domains. The point has been made throughout that outcomes are not created in isolation, and that when it comes to psychotherapy, “the whole is greater than the sum of its parts,” as the entire psychotherapeutic process involves many working parts. And, as discussed in Chapter 7, there are times when it is necessary to review all those parts to figure out why therapy isn’t working, but in the end it all must come together.

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WHY USE THE CRDS MODEL?

The Cognitive Domain Rating Scale (CDRS) is an efficient model grounded in cognition that enables the therapist and client to get to the heart of what the client is thinking. In a real sense, it takes a lot of pressure off of having to “cure” the client of their problem right out of the gate. As stated throughout this text, the idea of “situating where clients are thinking” about their problem is very important, because without knowing that, it’s quite possible that the client and therapist may misjudge what the client can realistically do in treatment. For example, you cannot expect a client to apply a treatment strategy involving anger management if the person cannot clearly identify when and what it is that makes them angry. Additionally, the model is a way to create an objective that is written so that some type of action or behavior is identified as either having happened during the course of therapy or not. While the CDRS model relies on self-​report, which in some ways is not different from other self-​ reports, it does ensure information about some type of action. Depression, anxiety, fear, panic, loneliness, and anger can all be transformed into an action that clearly describes where the client is “situated in their thinking” as it is connected to behavior. Finally, the CDRS creates a way to write objectives that are measurable and, just as important, meaningful objectives, because knowing how the client is thinking about their problem ensures better outcomes.

Aren’t Measurable Outcomes Apt to Have Inaccurate Reporting?

Certainly inaccurate reporting of an outcome in the CDRS may occur, particularly when the client wishes to save face or to please the therapist by reporting information that inflates compliance. Regular check-​ins and reviews of treatment plans should reveal any cause for concern about “faking good,”

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for example, and certainly outcome rating scales will assist with attaining more accurate self-​reports when administered at each session. These scales are typically designed as Likert scales and can provide good feedback regarding client functioning and/​or client attitudes about therapy. A  user-​ friendly scale that is easy to complete and score should assist with affirming or questioning outcomes obtained from the CDRS. There should be some correlation between this feedback and the assessed or realized CDRS outcomes. If not, then the client and therapist need to review reasons for the discrepancy (see Appendix—​Outcome Rating Scales [ORS]). It is important to remember that a “realized” outcome does not necessarily mean that one will feel better. For example, identifying triggers, whether it is for anger or addictions, may not make one feel better, but it may be an important outcome for the direction of the therapy. Analyzing standardized testing results in the context of the CDRS outcome can also confirm or point to a discrepancy that needs addressing. However, it is important to keep in mind that the standardized test needs to be correlated with the identified objective. For example, if you are looking at an outcome to identify triggers for using drugs, comparing the results from a standardized test to assess anxiety may have no relevance to the objective and outcome designed using the CDRS. However, if dealing with anxiety is another objective, then obviously that test is relevant. But, to take a step further, if you, the therapist, suspect that the client uses drugs to deal with anxiety but does not report anxiety or denies it, then this might be a way to elicit information that is relevant to their drug use.

When to Integrate CDRS into Treatment with Existing Clients

When should one integrate CDRS into treatment with existing clients? What if your clients are doing just fine—​should you integrate CDRS? Before integrating CDRS into treatment it is important to have a clear grasp of the process. A way to ensure that you have a good understanding of the CDRS process is by reviewing the presenting problem and the assessment and looking at the who, what, when, where, and how questions.

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From there, consider in which cognitive domain you would place the client by reviewing the cognitive domain chart in Chapter 2. Then share that with the client, and together look at what action verb might be written for a measurable outcome. However, be aware that just inserting action verbs in creating objectives is likely to create objectives without any logical progression. Further conversations with clients help to identify and reveal where clients are truly situated in thinking about their problem or issues, and this may have changed since the assessment process took place. It is not a big learning curve to shift to using this process, and in fact it creates a path for more efficiency in writing objectives, and certainly more meaningful and measurable objectives. What might be discovered is that you will eventually find yourself using the client’s language in discussing issues, rather than using therapy vernacular. This helps treatment along as issues are better clarified regarding what is going on and what the client to is expected to do as a part of their treatment. There is a distinct move away from the therapist or the client using references like “low self-​esteem” or “flat affect” to more descriptive and concrete ways of describing feelings and behavior. Suggesting to clients that they might need to understand better who and what triggers their anger, for example, make for richer conversations. Clients are more apt to share more interactional reports and give a better sense about situations that involve others, including how they might use suggested treatment strategies. When to introduce the CDRS process might be at the point of the next treatment plan. Explain to clients that this process is designed as a way for you both to develop clarity about where they are in thinking about their problem, because that is crucial if they are to have a good understanding of what they need to do to make change. You might even use examples of cases from this text to explain how these individuals were helped by having a better sense not only of the problem that they brought to therapy, but also of where they were in thinking about that problem. Showing clients the cognitive domain chart might prompt them to give greater thought to their issues, and perhaps even why they are having difficulty moving forward in treatment. For example, helping someone

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to understand that they first need to identify and understand situations that cause them to feel anxiety makes more sense than asking them to do something to alleviate that anxiety when they don’t have a clue as to what triggers their anxiety. The question as to whether you should introduce the CDRS if clients are doing fine when there is no pressure for measurable outcomes raises a question about ethics. The impetus for this book came from the expectation that therapists need to learn a process to write measurable outcomes as required by funders. But it was also noted that perhaps some clients expect evidence of outcomes. The question is whether therapists should be accountable to outcomes. Should treatment be measured in some way, even if the client makes no such request? Another rationale for using the CDRS process is to gain focus when there is no movement in therapy. This could function as a probe when clients are stuck regarding how they are thinking in regard to their problem or issue. It may be just what is needed, to get a new angle, to get some new impetus toward moving along in treatment. This may or may not make a change, but it is a way for the therapist and client to look at a way to dislodge the obstacle when clients are making no progress.

Using Closed Cases as a Way to Practice with CDRS

Certainly, everyone learns new skills differently, and there is no one particular way to learn how to best insert this new skill in treatment. An exercise that might be of help is to go back to a closed case and look at the goals and objectives and try to rewrite the treatment plan with the CDRS. This method was used in workshops with therapists and proved to be very enlightening. First, it provides a context since there is already some type of formulation. Goals such as “improving self-​esteem” and “decreasing depression” are given an entirely different review. In these workshops, therapists went back to narrative assessments and found information that pointed to more clarity around problems of “low self-​esteem” and “depression.” In those instances when the therapists could not find any

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clarity in the narrative, they noted that it was hard to figure out how they might have written a measurable objective given the information they had. In those cases they created a list of various who, what, when, where, and how questions they might have asked as a way to think through clarifying where the clients were situated in their thinking. As stated earlier, when therapists dove into the new task of using the CDRS, they looked at the cognitive domain chart, but quickly conceded the need to improve their assessment approach in gathering who, what, when, where, and how questions. They also stated the importance of the person-​centered approach to engage clients in goal setting. The anecdotal review of how a group of therapists integrated CDRS is certainly not conclusive by any means. It is worth noting, however, that the use of this process over a 1-​year period with some 1,200 clients resulted in an audit the following year that resulted in the clinic obtaining permanent licensure again. Therapists stated that they were better able to monitor progress, had a better sense of how to deal with moments when clients were stuck or regressed, and felt less anxious about treatment planning. Treatment planning was a welcome review rather than a chore or something to be avoided because it was cumbersome. The CDRS provided a direct and efficient way to chart goals and objectives and to assess outcomes.

HOW TO EVALUATE OUTCOMES

The focus of this text is to write measurable objectives, but one might ask how do you evaluate the quality of the of written objectives? And who is the one to evaluate the quality of the objective? Following are some ideas of ways to evaluate outcomes that can be shared with the client, particularly in those cases where the client does not feel that they are making great gains: • Look at the small, cumulative outcomes. There should be some correlation between measurable outcomes and behavior. For example, if the client with “low self-​esteem” identified that they

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would feel better by socializing more and is having success in increasing interactions and taking part in more social activities, then it is likely that their mood will improve. They may not yet have a relationship that they want, but are moving in a positive direction rather than isolating. Their “self-​esteem” has improved by definition of their increased socialization, an objective that the client realized and an objective in which the vague term self-​esteem was defined in measurable terms. • Be aware that it takes time for positive results. For example, if one is dealing with an addiction problem and is successfully identifying triggers to using substances, it does not mean that this will not result in a relapse. It may be just a start of a long process. • It is important to remember that a “realized” outcome does not necessarily mean that one will “feel better.” For example, identifying triggers, whether it is anger or addictions or what causes anxiety, may not make one feel better, but it may be an important outcome for the direction of the therapy and for an improved lifestyle. • Have realistic expectations about what standardized tests can convey. Standardized tests are just that, standardizations for clients who may or may not fit the norms, so other individualized measures might need to be used. Using the CDRS model to measure outcomes in psychotherapy is best used in conjunction with other outcome measures to support the results. The CDRS model relies on self-​report regarding the outcome of the objectives, but the design of writing a specific action is assessed, rather than assessing an attitude on a rating scale, for example, the Likert scale. Still, Likert-​type scales can be helpful, and these user-​friendly outcome tools are important to support the outcomes established using the CDRS model. Additionally, standardized assessments might point to questioning an outcome.

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• Help the client prioritize what would be most significant to their well-​being when identifying goals, and discuss what they are looking for in terms of outcomes. It might be wise for the therapist to help the client be realistic as to what outcomes can be accomplished within any given time frame. A client may not just “get over” grief in a few sessions or perhaps in a number of sessions, so the goals and objectives and time frames need to be realistic. It is helpful to go back to Locke and Latham’s seven points about criteria for goals and objectives (1991). Clarity is always important, but also important is making sure the objective “is just right,” meaning that it needs to be challenging enough to be relevant to the client’s desires, but not so much that they find it unrealistic to attain.

HOMEWORK OR TASKS ASSIGNED OUTSIDE OF THERAPY

In addition to the alternative approaches to treatment mentioned in Chapter  7, assigning people to view YouTube videos, TED talks, bibliotherapy, and other uses of the Internet might be resources for psychoeducational objectives to learn more or experience something different in creating objectives related to the problem. Again, the discussion about the client’s desire for what kind of outcome they expect should be a part of the ongoing process. In recalling the example in the Introduction, of helping the client define what self-​esteem is for them, it is essential to connect with the client so that it is their definition of what will make them happy, and what and who might be a part of their life for them to no longer be depressed, and not just the therapist’s projection of what that looks like. The point is that the possibilities are infinite if the therapist–​client dyad is in sync and a clearly defined problem is identified. This united and creative force makes for endless possibilities for alternative approaches that can make a difference in the stated goal.

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REVIEW OF CHAPTERS TO IDENTIFY WHAT YOU KNOW AND WHAT NEEDS REVIEW

Integrating the CDRS is the heart of what this text is about, with the accompanying chapters designed to provide the context for psychotherapy. Writing outcomes is a part of the therapy process and is done well when taking into consideration the things involved in conducing therapy. That being said, this chapter continues with the “Cliff Notes” version of the book as a way to reinforce what has been learned. But this summary of the chapters is not meant to replace reading the book, because much would be lost in not reading the book. The objective is to identify the main points and concepts that should become a part of one’s working memory. It is a means of solidifying ideas and concepts for good practice, and it is a way to capture the points that are important in order to systematically apply this new way of writing measurable outcomes. The order in which the chapters are presented in this book is intentional. It begins with chapters that are generic to psychotherapy, because therapists need to be on solid ground with their clients if they are going to have any kind of outcomes. Then chapters add specifics regarding collection of information, and applying theory is the process to the end result: measurable outcomes. Using this chapter as a review of what has been read, readers might want to do a quick check to determine if they fully understand what they have read. Given that this is a short text, it would behoove some readers to consider a quick reread to “install” the concepts, as then the process will work easily. This is apt to happen when reading the case examples for a second time, because on a second read, the process will stand out on the page more than the client. It is highly recommended that readers reread the text as this will quickly move them in the direction of integrating the CDRS in one’s practice. Following are the salient points gleaned from each chapter. These should be accompanied by a self-​evaluation of either having fully grasped the concepts or seeing that a review of a chapter is needed to solidify the ideas.

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Chapter 1: Psychotherapy and Outcomes

Ensure that the three critical elements to psychotherapy—​the therapeutic alliance, a person-​centered approa, and regular feedback from clients about their therapy—​are present. Much has been said about the importance of a therapeutic alliance; its relationship to outcomes is that a strong alliance must be present if authentic treatment is going to take place. Authentic treatment means that clients are reporting accurately and honestly what is going on in their life and in regard to their treatment plan. While most therapists do not obtain regular feedback in the form of an outcome rating scale (see Appendix), it is something that should be introduced as a regular part of therapy, as it is an important means of ensuring accountability for all involved. As pointed out in this chapter, there is evidence that therapists are far too naïve in thinking that they have a clear sense about their “positive” perception about the therapeutic relationship. Authentic treatment means that a person-​centered approach is adopted. In this approach, the therapist views the client as the “expert” in their life, and all aspects of what is occurring with the client need to be taken into consideration. Such reasoning has strong implications for the belief that the client’s biopsychosocial aspects regarding their life are interrelated and affect how they will function and adapt to changes.

Chapter 2: Assessment

The skill in assessment lies in getting information about who, what, when, where, and how. The assessment process stands out as the critical time when the therapeutic relationship is building, and it is the time when the therapist needs to obtain valuable information about the client. The groundwork done in these first sessions can often make or break the relationship. As illustrated in the examples, the assessment can be done by asking these types of questions directly or obtained by reviewing notes where

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that information is implicitly stated. Clinicians can develop the assessment through a direct line of questioning or by having an open-​ended dialogue and going back and reviewing the interview. Conducting standardized testing might reveal answers to these questions and may be helpful in corroborating what the client reports. It is important to remember that the line of questioning using who, what, when, where, and how provides the information, making it possible to “situate the client’s thinking” in order to then make it easier to identify the cognitive domain that is operating, to write the measurable objective. If this is an area that needs strengthening, take a look at videos of master therapists (see Appendix). Observe your colleagues, record your sessions (with client’s permission), and critique yourself. Interviewing is a skill that can take quite some time to finesse, and observing other therapists can be very helpful. Share your recorded sessions with a supervisor or colleagues. While this requires that you have a sense of psychological safety in making yourself public, remember how vulnerable your client is when they walk through the door and unleash a personal narrative to you, a perfect stranger. A reminder is that assessment does not stop when the biopsychosocial assessment is written. Assessment is an ongoing process that must continually occur, either formally (using outcome rating scales, administering and readministering standardized testing) or during therapy sessions.

Chapter 3: Bloom’s Taxonomy

The six cognitive domains—​remember, understand, analyze, apply, evaluate, and create—​must be fully understood. For many, this taxonomy is a new framework, and it is critical to understand the connection to the notion of understanding how to “situate client’s thinking.” Each of these cognitive domains is associated with a number of action verbs that are key to understanding how to use these verbs in writing measurable objectives. It is imperative that one not just create a measurable outcome by inserting an action verb. Understanding of this concept occurs in conjunction with

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173

knowing how to conduct the assessment process, where the information is obtained to gather the who, what, where, when, and how in order to assess the cognitive domain. This taxonomy is rooted in cognitive psychology and has validity in educational environments where teachers use it to evaluate students. Using the CDRS is fluid; clients will not proceed in a straight line in these six cognitive domains. Clients’ thinking about and dealing with their issues is apt to progress with expected regressions as well as jumps to more sophisticated levels of viewing their problem, particularly as change occurs. This is the value of the CDRS process, because the line of questioning obtained in the assessment process and thereafter provides information for the therapist and client to determine where the client is currently situated in their thinking about the problem and, hence, how to best act on the problem. This process requires that the therapist have a very good grasp conceptually of the various cognitive domains. Expect that you will do a continual review of the cognitive domain charts located in Chapter 3.

Chapter 4: Goals and Objectives

Goals are broad statements with general intentions. Objectives are specific measurable statements with tangible results. Quite simply, it is easy to think of goals as being broad and objectives as being specific. In all cases it is best to work with clients at first identifying goals before developing any objectives. And as has been stated throughout, the assessment process is where information is obtained to develop goals and objectives. As put forth by Locke and Latham (1991), it is important that objectives have clarity, and this can be accomplished using the CDRS process. And it is very important to use a person-​centered approach that involves shared decision-​making so that the client is an active agent in the process of setting goals and objectives. Goals and objectives are a part of the treatment plan, and the task of getting there lies in the ability to use the skill set outlined in Chapter 2.

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Remind clients that not realizing a goal is not necessarily a failure, but information that indicates that re-​evaluation needs to take place. One of the problems with the idea of using the terms goals and objectives is that they set up an expectation that the client must be successful. It is probably important that the therapist broaden the concept of these terms in that even though there is an expectation that the client will put forth effort to meet the agreed-​upon objectives, they are also queries. Clients must never feel pressure but instead hope for change. This means that assurance must come from the therapist that, if the objective is not met, the therapist and client will both go back to the drawing board. Also important is that goals and objectives should have some type of logical progression and not just be a random set of things that the client is doing. If a chart appears to have a random set of objectives, even if they are positive outcomes, one might suspect that they have been added without a comprehensive sense about the problem and the treatment and are there just for the sake of getting something in the chart.

Chapter 5: Evidence-​Based Practices

Evidence-​based practices (EBPs) are the gold-​standard treatment modalities that have been researched and determined to produce positive results in therapy. These include cognitive behavior therapy (CBT), dialectical behavior therapy (DBT), mindfulness, and a host of other modalities cited throughout the text. However, as also stated throughout the text, the generic elements must be presented in the psychotherapeutic relationship, as there is no guarantee that any particular EBP will produce guaranteed results. In fact, a number of master therapists do not believe that it is the EBP that creates positive outcomes but the therapeutic alliance. That being said, EBPs should still be the preferred method for treatment. There is no conflict in using an EBP with the CDRS process. As illustrated in Chapter  5, the process is the same. The language is apt to be

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different because of the different ways that language and terminology are used in different EBPs. It is also possible that the CDRS might be different as the approaches might be different. This does not mean that the one approach is necessarily better than another, it is just a different way of assessing and evaluating the issues. Clients should be informed about what is involved in the EBP the therapist is using. This might help with engagement in the therapy process, and there is some thought that therapists have an ethical responsibility to educate their clients about the treatment modality that the therapist has chosen to help the client with their issues. Furthermore, clients might be more compliant in treatment when they are fully aware of the treatment strategy being used and participate in even subtle ways by using the language of the EBT. For example, a client using the CBT approach of “stop thought” might find that that terminology immediately triggers them to do just that—​stop thinking about the thing that is disturbing to them.

Chapter 6: Treatment Plans

Treatment plans outline the information about the client, their problem, strengths, goals, objectives, and approaches. It is likely that clinicians working in an agency or clinic will be required to have treatment plans. It is also likely that clinicians in private practice who take insurance are required to have treatment plans as well for accountability to funders. Ethically, it makes for good practice using a person-​centered approach that a treatment plan be put in place. Treatment plans provide a snapshot of all of the data about the client, including the CDRS. It is the contract between the therapist and the client. The grid format for goals, objectives, and outcomes gives a clear picture of the progression, thereby allowing for review of the client’s story without a dense narrative. Developing well-​ written, succinct treatment plans is accomplished when there is a well-​developed assessment that is written, since the

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information put in the treatment plan is culled from the assessment. While some therapists are good at writing long narrative assessments, is it yet another skill to put that information in a format where few words or sentences convey what is being conducted. The examples of treatment plans in this chapter illustrate how intense data can be succinctly inserted in just a couple of pages. The treatment plan is likely to be a very important part of the chart as it is where auditors will look for measurable outcomes. It is also a good place for the therapist and client to review progress. Treatment plans typically are conducted every 30 days, but should circumstances change in the client’s life, or if during sessions it is determined that the objectives are not meeting the client’s needs, then certainly a new treatment plan should be put in place.

Chapter 7: Stumbling Blocks

Psychotherapy is a complex process and sometimes treatment does not progress. This chapter provides a number of scenarios to speculate why treatment is not progressing, with some tips for ameliorating the situation. Probably at the top of the list is the resistant client who is not forthcoming with information and avoids giving information that is necessary to provide the clarity for identifying a goal and objective. When the client is not progressing, the therapist should do a number of things: discuss with the client their experience in the therapeutic process, including reviewing outcome measures; administer several standardized or individualized testing surveys to elicit other information; and consult with supervisors or colleagues. An important ethical consideration is that the therapist needs to make sure they have the skills to deal with the presenting problem. This includes when an issue emerges in which the therapist has little or no experience treating. In those cases, the therapist should always consider a referral to another therapist for treatment.

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A FINAL NOTE ABOUT BEING A GOOD PRACTICING THERAPIST

Being a helpful and competent therapist requires focus and ongoing commitment to one’s profession. Very recent discoveries about being a helpful therapist have been the work of Daryl Chow and Scott D.  Miller, who identified a “Taxonomy of Deliberate Practice Activities (TDPA)” (Miller, Hubble, & Chow, 2018). Looking at expertise and expert performance, the following are the four tenets of deliberate practice: individualized learning objectives, a coach, feedback, and repetition. It would be good for all therapists to take a look at these deliberate practices and heed the advice of Chow and Miller, who suggest that after ranking the top three activities, drill down to one area to work on. As therapists and researchers, they stress the importance of feedback, which is accomplished by regular review with the client. Certainly, reviewing outcomes with clients is also important, but making sure that the client is engaged is critical for truly accurate outcomes. Implementation of the CDRS is a way to enhance the process, as it is most important to understand where the client is in thinking about their problem and to stick with where they are at and not move the process along any faster. For those considering adopting the CDRS in their practice, perfecting the CDRS process would be an example of a deliberate practice to work on. It has been mentioned several times throughout this text that psychotherapy is messy, which is not to say that it is chaotic, but it has a messiness that can make the process interesting and hopeful, as there are always new options for change. It is our responsibility as therapists to always make sure we let clients know that there is hope for change and help reframe failures or letdowns, whether they are written objectives or something else in the client’s life as opportunities to do something different. And we must remember that if we ask clients to adapt, we as therapists must do the same. As the master therapist, Salvador Minuchin, states in Families and Family Therapy (1974), “joining a family requires of the therapist a capacity to adapt” (p. 125). Whether it is a family or individual, this directive

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to the therapist to join with them is key to engagement. And when engagement occurs, the possibilities for change, including potentials for measurable outcomes, are unlimited.

REFERENCES Locke, E., & Latham, G. (1991). A theory of goal setting & task performance. The Academy of Management Review, 16.102307/258875. Miller, S. D., Hubble, M. A., & Chow, D. (2018). The question of expertise in psychotherapy. Journal of Expertise, 1(2). Retrieved from https://​www.journalofexpertise.org Minuchin, S.  (1974). Families and family therapy. Cambridge, MA:  Harvard University Press.

APPENDIX

STANDARDIZED TESTS AND SURVEYS

The standardized tests listed in this Appendix comprise a small number of the widely available rating scales and tests that are available. They were chosen because they are easy to administer and are considered evidence based. The reality is that most therapists, either in private practice or in clinics, have no time or perhaps no inclination to administer time-consuming tests. Additionally, these tools represent a broad area of issues that clients typically present. Such ratings can enhance confidence in identifying problems and objectives and may correlate the Cognitive Domain Rating Scale (CDRS).

BLOOM’S TAXONOMY

The table of Bloom’s taxonomy of cognitive domains provides action verbs for each of the domains and suggests questions that can help with assessing domains.

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STANDARDIZED TESTS

Anxiety Beck Anxiety Inventory

https://beckinstitute.org/get-informed/ tools-and-resources/professionals/ patient-assessment-tools/

The Clinically Useful Anxiety Outcome Scale (CUXOS)

https://outcometracker.org/CUXOS. pdf

Generalized Anxiety Disorder Screener (GAD-7)

https://www.integration. samhsa.gov/clinical-practice/ gad708.19.08cartwright.pdf

Hamilton Rating Scale for Anxiety

https://dcf.psychiatry.ufl.edu/ files/2011/05/HAMILTONANXIETY.pdf

Fear Questionnaire (FQ)

https://outcometracker.org/library/ FQ.pdf

Penn State Worry Questionnaire (PSWQ)

https://outcometracker.org/library/ PSWQ.pdf

Social Phobia inventory (SPIN)

https://psychology-tools.com/test/spin

Depression Beck Depression Inventory

https://beckinstitute.org/get-informed/ tools-and-resources/professionals/ patient-assessment-tools/

The Clinically Useful Depression Outcome Scale (CUDOS)

https://outcometracker.org/library/ CUDOS.pdf

The Inventory of Depressive Symptoms and the Quick Inventory of Depressive Symptoms (IDS and QIDS)

http://www.ids-qids.org/

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181

Domestic Violence Danger Assessment

https://www.dangerassessment.org/

Danger, Lethality, and Risk Assessment

http://www.ncdsv.org/publications_danger.html

Eating Disorders Eating Disorder Diagnostic Scale (EDDS)

https://www.phenxtoolkit.org/toolkit_ content/PDF/PX120602.pdf

Sick, Control, One, Fat, Food Screening (SCOFF) Questionnaire

https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC1070794/

Mania Altman Self-Rating Mania Scale (ASRM)

http://www.cqaimh.org/pdf/tool_asrm. pdf

Bech-Rafelsen Mania Rating Scale (MRS)

https://www.opapc.com/uploads/ documents/MRS.pdf

Young Mania Rating Scale (YMRS)

https://dcf.psychiatry.ufl.edu/ files/2011/05/Young-ManiaRating-Scale-Measure-withbackground.pdf

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Mental Health Patient Health Questionnaire (PHQ)

https://www.phqscreeners.com/

Recovery Assessment Scale (RAS)

https://depts.washington.edu/ebpa/ sites/default/files/RAS%20-%20 double%20sided.pdf

Recovery Assessment Scale— Domains and Stages (RAS-DS) Manual

https://ses.library.usyd.edu.au/ bitstream/2123/15257/2/RAS-DS_ MANUAL_V2_2016.pdf

Suicidality Columbia-Suicide Severity Rating Scale (C-SSRS)

https://suicidepreventionlifeline.org/ wp-content/uploads/2016/09/SuicideRisk-Assessment-C-SSRS-LifelineVersion-2014.pdf

The Suicide Behaviors Questionnaire– Revised (SBQ-R)

https://www.integration.samhsa.gov/ images/res/SBQ.pdf

Trauma The Post-Traumatic Stress Disorder Checklist—Civilian Version (PCL-C)

https://www.mirecc.va.gov/docs/ visn6/3_ptsd_checklist_and_scoring. pdf

The Trauma History Questionnaire (THQ)

https://www.ptsd.va.gov/professional/ assessment/te-measures/thq.asp

The Trauma History Screen (THS)

https://www.ptsd.va.gov/professional/ assessment/te-measures/ths.asp

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Outcome Rating Scales Outcome Rating Scale (ORS)

https://scottdmiller.com/ wp-content/uploads/documents/ OutcomeRatingScale-JBTv2n2.pdf

Session Rating Scale (SRS)

https://scottdmiller.com/wp-content/ uploads/documents/SessionRatingScaleJBTv3n1.pdf

Working Alliance Inventory (WAI)

http://wai.profhorvath.com/

Goals Form

https://goalsintherapycom.files. wordpress.com/2018/03/goalsform-2015-12-15.pdf

Outcome Questionnaire 45.2 (OQ)

Quick Guide and Scoring: http:// www.projectechola.org/ wp-content/uploads/2014/01/ Outcome-Questionnaire-OQ45.2-Quick-Guide-2.pdf Questionnaire: https://booksite.elsevier. com/9780123745170/ Chapter%202/ Chapter_2_Worksheet_2.4.pdf

II. Understanding

ask associate cite classify compare contrast convert describe differentiate discover discuss distinguish estimate explain express extend generalize give examples

I. Remembering

define describe duplicate enumerate examine identify label list locate match memorize name observe omit quote read

act administer apply articulate calculate change chart choose collect complete compute construct determine develop discover dramatize

III. Applying

REVISED BLOOM’S TAXONOMY ACTION VERBS

advertise analyze appraise calculate categorize classify compare conclude connect contrast correlate criticize deduce devise diagram differentiate discriminate dissect distinguish divide

IV. Analyzing appraise argue assess choose compare conclude consider convince criticize critique debate decide defend discriminate distinguish editorialize estimate evaluate

V. Evaluating

adapt anticipate collaborate combine compile compose construct create design develop devise express facilitate formulate generalize hypothesize

VI. Creating

illustrate indicate infer interpret judge observe order paraphrase predict relate report represent research restate review rewrite select show summarize trace transform translate

employ establish examine experiment explain illustrate interpret judge manipulate modify operate practice predict prepare produce record relate report schedule simulate sketch solve teach transfer write

estimate evaluate experiment explain focus illustrate infer order organize plan prioritize select separate subdivide survey test

find errors grade judge justify measure order persuade predict rank rate recommend reframe score select summarize support test weigh

infer integrate intervene invent justify manage modify negotiate originate plan prepare produce propose rearrange reorganize report revise rewrite role-play simulate solve speculate structure test validate write

Adapted from Anderson, L. W., & Krathwohl, D. R. (2001). A taxonomy for learning, teaching, and assessing (abridged ed.). Boston, MA:  Allyn and Bacon.

recall recite recognize record repeat reproduce retell select state tabulate tell visualize

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QUESTIONS AND PROBES I. Remember (knowledge; shallow processing: drawing out factual answers, testing, recall, and recognition) Model Questions/Probes: Who? Where? Which one? What? How? What is the best one? Why? How much? When? What does It mean?

Verbs for Objectives: choose describe define identify label list locate match memorize name omit recite recognize select state

II. Understand (comprehension; translating, interpreting, and extrapolating) Model Questions/Probes: State in your own words. Which are the facts? What does this mean? Is this the same as . . . ? Give an example. Select the best definition. What would happen if . . .? State in one word. Explain what is happening. What part doesn’t fit? Explain what is meant. What expectations are there? What are they saying? This represents . . .  What seems to be . . .? Is it valid that . . .? What seems likely? Which statements support . . . ? What restrictions would you add?

Verbs for Objectives defend demonstrate distinguish explain express extend give example illustrate indicate interrelate interpret infer judge match paraphrase represent restate rewrite select show summarize tell translate

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III. Apply (knowing when to apply; why to apply; recognizing patterns of transfer to situations that are new or unfamiliar or have a new slant) Model Questions/Probes Predict what would happen if . . . Choose the best statements that apply. Judge the effects. What would result. Tell what would happen. Tell how, when, where, and why. Tell how much change there would be. Identify the results of . . .

Verbs for Objectives: apply choose dramatize explain generalize judge organize prepare produce select show sketch solve use

IV. Analyze (Breaking down into parts, forms) Model Questions/Probes: What is the function of . . .? What’s fact? Opinion? What assumptions . . . ? What statement is relevant? What motive is there? Related to, extraneous to, not applicable. What conclusions? Make a distinction . . . 

Verbs for Objectives: analyze categorize classify compare differentiate distinguish identify infer point out select subdivide survey

V. Evaluate (combining elements into a pattern not clearly there before) Model Questions/Probes What fallacies, consistencies, or inconsistencies appear? Which is more important, moral, better, logical, valid, or appropriate? Find the errors.

Verbs for Objectives: appraise judge criticize defend compare

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VI. Create (synthesis combining elements into a pattern not clearly there before)

Verbs for Objectives: choose combine compose construct create design develop do formulate hypothesize invent make make up originate organize plan produce role-play tell

INDEX

For the benefit of digital users, indexed terms that span two pages (e.g., 52–​53) may, on occasion, appear on only one of those pages. action verbs, 60, 68, 165, 184–​85 Adams, N., 84, 125 alternative therapeutic approaches, 154–​55 Altman Self-​Rating Mania Scale (ASRM), 181 analyzing domain action verbs, 184–​85 applications of, 21, 41 described,  37–​39 questions/​probes,  186 Anderson, L. W., 29, 33, 37–​38, 39, 40 anxiety, standardized tests, 180 applying domain action verbs, 184–​85 applications of, 21, 23, 40, 41–​42 black/​white thinking, 111 described,  36–​37 grief case study, 59–​60 questions/​probes,  186 substance abuse case study, 65–​66, 67, 68 assessment case studies generally, 53–​61 of client engagement, 147–​48 externalizing method, 49–​50 grief case study, 53–​61 importance of, 121 medical conditions, 149 overview, 46–​47,  171–​72

rating scales, in problem identification,  148–​49 substance abuse case study, 61–​70 substance abuse/​inpatient case study,  70–​77 of therapeutic alliance, 147–​48 who/​what/​when/​where/​how questions, 48–​51, 78, 158, 172–​73 attributing,  37–​38 Bachelor, A., 90 Bech-​Rafelsen Mania Rating Scale (MRS), 181 Beck Anxiety Inventory, 47, 71, 180 Beck Depression Inventory, 47, 71, 180 biopsychosocial assessment. See assessment Bloom’s taxonomy. See also CDRS model; specific domains action verbs, 184–​85 adaptation of, 31–​32 applications of, 2–​4, 11, 42–​43 cognitive domains, 29–​30, 32, 33–​42,  172–​73 history of, 28–​30 measurable outcomes, writing, 51–​52 process of, 11–​15 terminology,  29–​30 Brown, C., 104, 106, 108 Brown, G. S., 107–​8

190 I nd e x

case studies analyzing domain, 38–​39 anxiety/​depression,  90–​99 applying domain, 36–​37 assessment,  53–​77 black/​white thinking,  109–​11 create domain, 41–​42 evaluation domain, 39–​40 evidence-​based practice,  109–​11 goals/​objectives,  90–​99 grief,  53–​61 interviewing,  18–​21 referral information, 17–​18 remembering/​recalling domain,  34–​35 substance abuse, 61–​70 substance abuse/​inpatient,  70–​77 therapist skill set, 16–​23 treatment plans, 130–​42 understanding domain, 35 CDRS model. See also Bloom’s taxonomy applications of, 42–​44, 78–​80 benefits of, 5, 44, 93, 163–​67 black/​white thinking,  109–​11 closed cases as practice with, 166–​67 cognitive domains, 116–​18 (see also specific domains) development of, 4, 6 grief case study, 57–​60 integration of, 164–​66 measurable outcomes, writing, 52, 99–​101,  112–​18 outcome measures compatible with, 84–​85 process of, 113–​18 rationale,  163–​67 skill set, 43 substance abuse case study, 63–​65 substance abuse/​inpatient case study,  74–​75 treatment plans, 127, 129, 132, 135, 136, 139, 141–​42, 144–​45,  165–​66 Chow, D., 13, 148, 149, 177 Christoph, P., 83 client engagement, assessment of, 147–​48,  151–​52 clinical assessment. See assessment

Clinically Useful Anxiety Outcome Scale (CUXOS), 180 Clinically Useful Depression Outcome Scale (CUDOS), 180 cognition defined, 29–​30 cognitive behavioral therapy (CBT), 104–​7,  139 Cognitive Domain Rating Scale. See CDRS model Columbia-​Suicide Severity Rating Scale (C-​SSRS),  182 Cooper, M., 84 create domain action verbs, 184–​85 anxiety/​depression case study, 94, 98 applications of, 2–​3, 42 described,  40–​42 substance abuse case study, 68–​69 substance abuse/​inpatient case study,  74–​75 crisis state, chronic, 147, 153–​54 Danger, Lethality, and Risk Assessment, 181 Danger Assessment, 181 Day, S. H., 104 depression, standardized tests, 180 deShazer, S., 9–​10 dialectical behavior therapy (DBT), 104–​5, 111, 118, 120 differentiating, 37–​38, 41 domestic violence, standardized tests, 181 Duncan, B. J., 9–​10, 14, 47, 84 Duncan, B. L., 10–​11 Eating Disorder Diagnostic Scale (EDDS), 181 eating disorders, standardized tests, 181 Edbrooke-​Childs, J., 83 Erickson, M. H., 9–​10 evaluation domain action verbs, 184–​85 described,  39–​40 questions/​probes,  186 substance abuse case study, 67

I nd e x

evidence-​based practice benefits of, 108–​9, 120–​22 case studies, 109–​11 described, 104–​5,  174–​75 effectiveness of, 106 history of, 105–​6 language differences, 113 measurable outcomes, writing, 112–​18 support for, 111–​12 therapeutic alliance and, 107–​8 treatment plans, 129, 132, 139, 141 executing, 36 Fear Questionnaire (FQ), 180 feedback outcome tools, 90, 94. See also specific tools Fisher, J., 155 Fraser, M. W., 104 GAD-​7,  180 Galinsky M. J., 104 goals defined, 89 Goals Form, 84, 183 goals/​objectives atomistic/​narrow/​ambiguous,  147 case studies, 90–​99 defining, 88–​90, 100, 173–​74 evaluation of, 167–​69 managed care and, 86–​88 measurable outcomes, writing, 99–​101 outcomes research, 82–​86 resistance, labeling, 94–​95, 98–​99 specificity in, 91–​92 in treatment plans, 127, 129, 132, 139, 142, 143 treatment progression, 156–​57 what/​how/​who dialogue,  95–​99 Goodheart, C. D., 104–​5, 106 Grieder, D. M., 84, 125 Hadley, S. W., 82–​84 Hamilton Rating Scale for Anxiety, 180 Heier, E. J., 86–​87 homework, 169 Horvath, A. O., 84 Hubble, M. A., 9–​10

191

identifying. See remembering/​ recalling domain Imel, Z. E., 106, 121 implementing, 36, 67 insurance reimbursements, 87–​88 intake model, 13 Inventory of Depressive Symptoms, 180 Jacob, J., 83 Kazdin, A. E., 104–​5 Kottler, J. A., 13, 151–​52 Krathwohl, D. R., 33, 37–​38, 39, 40 Lambert, M. J., 11, 14 language, 113, 165 Latham, G., 85, 95–​96, 127, 169, 173 Locke, E., 85, 95–​96, 127, 169, 173 Luborsky, L., 83 managed care, measurable outcomes and, 86–​88,  143 mandated clients, 15, 38, 99, 154, 160–​61 mania, standardized tests, 181 McIntyre, D., 86–​87 measurable outcomes challenges in, 85, 176 clarity in, 85 commitment in, 86 defined, 89 diagnosis in writing, 16 evaluation of, 167–​69 feedback in, 86 inaccurate reporting, 163–​64 insurance reimbursement for, 14 managed care and, 86–​88 research historically, 82–​86 task complexity in, 86 in treatment plans, 23 writing, challenges in, 158–​61 writing generally, 1–​6 writing using Bloom’s taxonomy, 51–​52 writing using CDRS, 52, 99–​101, 112–​18 medical conditions assessment, 149 mental health, standardized tests, 182

192 I nd e x

Messer, S. B., 104–​5 Michenbaum, D., 108 Miller, S. D., 9–​11, 31, 47, 78, 84, 87, 177 Minami, T., 107–​8 mindfulness-​based cognitive therapy (MBCT), 104–​5, 118, 120, 139 Mintz, J., 83 Mitchell, C., 95, 99, 150–​51 Nicotera, N., 107 objectives defined, 89 organizing,  37–​38 Outcome Questionnaire 45.2 (OQ), 84, 183 Outcome Rating Scale (ORS), 84–​85, 94, 183 Patient Health Questionnaire (PHQ), 182 Penn State Worry Questionnaire (PSWQ), 180 Post-​Traumatic Stress Disorder Checklist—​Civilian Version (PCL-​C),  182 problem vagueness, 146, 150–​53, 158–​59 procedural knowledge, 36 psychodynamic therapy, 104–​7 psychotherapy/​outcomes case study, 16–​23 elements in, 8–​11, 171 evidence-​based approaches, 15 shared decision-​making in, 9–​11, 12, 14 skills/​core competencies, 11–​16,  177–​78 therapeutic relationship, 8–​11, 13–​14 questions/​probes, 44, 186 Quick Inventory of Depressive Symptoms, 180 Rabinowitz, I., 12 randomized controlled trials (RCTs), 106, 109 RAS-​DS Manual, 182 rating scales inaccurate reporting, 163–​64 outcome evaluation, 168, 183

in problem identification, 148–​49 trauma survivors, 182 in treatment plans, 127–​28, 129, 131, 139 Recovery Assessment Scale (RAS), 182 remembering/​recalling  domain action verbs, 184–​85 anxiety/​depression case study, 93 applications of, 20–​21, 22–​23, 40, 41, 51 black/​white thinking, 111 described, 2–​4, 33, 34–​35 grief case study, 51, 57–​58 mandated clients, 160–​61 problem vagueness, 152–​53, 158–​59 questions/​probes,  186 substance abuse case study, 63–​66,  69–​70 substance abuse/​inpatient case study, 75–​77 resistance dealing with, 146 labeling, 94–​95,  98–​99 timing as cause of, 151 Revised Bloom’s Taxonomy Action Verbs, 44 Richman, J. M., 104 Roes, N. A., 151–​52 Rogers, L., 86–​87 Rubin, L., 13–​14 Sackett, D., 106 SCOFF Questionnaire, 181 Session Rating Scale (SRS), 84–​85, 94, 183 situate the client’s thinking, 22–​23, 33, 42–​ 43, 57–​58, 93, 163, 172–​73 Social Phobia inventory (SPIN), 180 Sparks, J. A., 10–​11, 47, 84 stages of change, 160–​61 standardized rating scales. See rating scales standardized tests, 179 Sternbert, R. J., 104–​5 stop thought technique, 111–​12 Strupp, H. H., 82–​84 suicidality, standardized tests, 182 Suicide Behaviors Questionnaire–​Revised (SBQ-​R),  182 supervision, of therapists, 159–​60

I nd e x

taxonomy defined, 29 “Theory of Goal Setting and Task Performance, A” (Locke/​Latham), 85 therapeutic alliance assessment of, 147–​48 benefits of, 107–​8, 115, 120–​21 patient education in, 121 shared decision-​making in, 9–​11, 12, 14, 108–​9, 115, 117 support for, 111–​12 Trauma History Questionnaire (THQ), 182 Trauma History Screen (THS), 182 trauma survivors rating scales, 182 resistance to dialogue, 147, 155–​56 standardized tests, 182 treatment plans assessment of presenting problem, 128, 131, 138 case studies, 130–​42 CDRS model, 127, 129, 132, 135, 136, 139, 141–​42, 144–​45,  165–​66 client education, 124–​27 clinical judgment in, 144 evidence-​based practice, 129, 132, 139, 141

193

format, 127–​29, 130, 134, 136, 137, 141 goals/​objectives in, 127, 129, 132, 139, 142, 143 managed care companies and, 143 measurable outcomes in, 23 presenting problem format, 127, 128, 130, 137 rationale for, 124–​29, 145, 175–​76 standardized rating scales, 127–​28, 129, 131, 139 strengths/​obstacles, 128, 131, 137 understanding domain action verbs, 184–​85 applications of, 20–​21, 23 black/​white thinking, 111 described, 33, 35 questions/​probes,  186 Wampold, B. E., 9–​10, 106, 121 wise mind techniques, 110, 111 Working Alliance Inventory (WAI), 84, 183 Yalom, I., 12, 153 Young Mania Rating Scale (YMRS), 181