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Outcome-directed Counseling

1. What works in counseling?

Gay Men's Counseling uses an outcome-directed process based on research by Chicago's Institute for Therapeutic Change (http://www.talkingcure.com).

Researchers asked: "What works in therapy?" and identified four elements:

1. Extra-therapeutic: social and environmental influences in a client's life, unrelated to therapy, that contribute to symptom relief and problem resolution. Extra-therapeutic factors account for about 40% of client change.



2. Client-counselor relationship: the rapport or connection a client experiences with his therapist. Relationship—sometimes called therapeutic alliance—contributes about 30% to change.



3. Hope: a client's expectation that therapy will help. Hope influences change by about 15%.



4. Clinical methodology: the specific theory or technique a counselor uses. Methodology accounts for about 15% of change.

Researchers also noted that, while counseled individuals showed better outcomes than non-counseled peers, no therapeutic method seemed any better than any other. In other words, although therapy works, all methods—even those in sharp contradiction—are about equally effective. Meanwhile, methodology itself contributed only a modest 15% to clinical success.

These are surprising findings, especially in view of the counseling profession's strong and continued emphasis on methodology. Theories and methods come and go, but few professionals have questioned the primacy of methodology itself. As each new approach fails to live up to its promise, attention simply shifts to an even newer technique. These days, for example, it is the rare practitioner who aspires to train as a classical Freudian analyst, but almost every therapist lines up to learn about Thought Field Therapy or EMDR or Somatic Experiencing.

2. Tailoring strategies to clients

While not dismissing methodology, the outcome-directed counselor views it as secondary to extra-therapeutic factors and the client-counselor relationship.

Furthermore, since research finds all methods to be equally effective, therapeutic approaches are used pragmatically. Methods are chosen to complement and enhance a client's own understanding of his problem and the means by which, often without realizing it, he achieves symptom relief.

This is in marked contrast to traditional counseling, in which a standard theory is applied to everyone regardless of individual circumstances.

Traditional versus outcome-directed strategies

For example, if a client is anxious, a conventional approach would encourage relaxation and other stress-reduction techniques. According to research, this industry-standard method—aspects of cognitive-behavioral therapy (CBT)—would work as well as anything.

But what if CBT isn't suited to this particular client? He may view relaxation techniques as time-consuming and tedious. In fact, many clients do. So, while CBT makes good sense, it misses the mark with this client.

In contrast, an outcome-directed counselor tries to understand the problem of anxiety from the client's point of view. What is the client's description of his discomfort? What specifically is problematic about it?

For example, does anxiety always plague him or only sometimes? In what situations has the client managed to experience temporary relief? What specifically did he do to reduce his distress? In what situations can he function despite feeling stressed?

3. Encouraging what already works

Therapy focuses on the client's understanding of his problem, possible solutions and how change works. Of particular interest is symptom reduction. Together, client and counselor choose methods that mirror and enhance successful problem-solving strategies the client has already happened upon in the natural environment.

In this context, a method such as relaxation might be chosen if it fits. If an anxious client mentions that taking a walk sometimes helps when starting a stressful work project, for example, the counselor may label walking as a "relaxation technique" and encourage more.

Gradually, the counselor may also ask if the client is interested in practicing breathing techniques as he walks? Or, when walks aren't practical, the client could sit with his eyes closed and imagine walking around the block.

In this way, the counselor uses methods that fit with a client's pre-existing symptom-reduction strategies. Indeed, once a client-counselor dialogue really gets rolling, the client usually generates better strategies than the counselor. This is strongly encouraged, since active client participation is a major predictor of successful outcomes. By fitting methods to the client, counseling is tailored to an individual's unique circumstances instead of being applied regardless of context.

Tailoring interventions also enhances client-counselor relationship, another leading factor in successful outcomes. Instead of theorizing, the counselor focuses on helping the client deal with presenting problems. Research indicates that clients are more satisfied with such counselors. The element of hope, which influences outcomes by about 15%, is also enhanced by a therapeutic alliance that generates solutions the client finds easy to buy into.

4. Reaching goals sooner

Hope is reinforced when a client leaves after the first session with a clear direction. An outcome-directed counselor strongly encourages rapid improvement. This is supported by research, which indicates that clients with better outcomes experience gains earlier rather than later in therapy .

An emphasis on early improvement contrasts sharply with traditional approaches, where a rapid "flight to health" is viewed as a cover-up to avoid "deeper" issues. Even when a client complains about lack of progress, the traditional counselor may advise him to be patient, to wait for the work to "take root."

But whose perspective is important in therapy? Isn't counseling ultimately about encouraging a client to be confident in his own perceptions? What would we say about someone who bought a car that didn't work, yet week after week accepted the dealer's blandishments that eventually the engine would start? What would we say about the dealer?

Attributing success to the client's efforts

In successful therapy, the counselor encourages more of what works. Improvement, meanwhile, is attributed neither to the counselor's unique methods nor special skills, but to the client's own creativity and follow through. Since interventions are based on positive influences already in place in the client's life, improvement is credited to the client.

Outcome-directed counseling tends to proceed rapidly then terminate naturally, usually at the client's request. When a client experiences himself functioning better and feels confident about maintaining gains, there is little need to extend therapy. An outcome-directed counselor will encourage independence, but the decision to terminate is always the client's.

Since outcome-directed therapy emphasizes a client's dependence on himself rather than on the counselor, terminating clients usually feel more self-assured than patrons of traditional models. In many cases, clients feel ready to end therapy after about five to eight sessions.

5. Evaluating the counselor

Since successful outcomes are based on rapid client improvement and a positive client-counselor rapport, the outcome-directed counselor solicits formal feedback for both.

At each session, the client is asked to report his level of functioning during the previous week and to evaluate the counselor's work during the hour. If improvement seems slow, client and counselor strategize on how to kick-start it. If relationship needs improving, the client is encouraged to express clearly what seems missing.

If progress is stalled and/or the relationship doesn't click after four or five sessions, the counselor will suggest alternatives, including a referral to another therapist. In fact, feedback often has the result of getting therapy rapidly back on track.

The feedback process contrasts markedly with traditional counseling, where client and counselor almost always sense when therapy isn't working, but commonly avoid discussing it. Eventually, most dissatisfied clients vote with their feet, ending therapy without explanation. With feedback, the relationship can often be rescued and better strategies developed.

Not just another method

Outcome-directed counseling is a pragmatic rather than ideological approach to human interaction. It is best understood as process rather than method. It describes a special human relationship in which one of the parties aims to recover confidence in his ability to manage his life. Beyond that, the script must be rewritten by each new therapeutic alliance.

Source: What works in therapy? Institute for Therapeutic Change (http://www.talkingcure.com).

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