Have you ever heard the story of Niels Bohr who was asked to measure the length of a tower with a barometer by his physics teacher? He responded “Tie a long piece of string to the barometer, lower it from the roof of the tower to the ground. The length of the string plus the length of the barometer will equal the height of the building”. Of course, his teacher was not satisfied with the answer, but Niels Bohr was not wrong, he just liked thinking outside the box. Why? Because when you do that, you can find novel and practical ways to approach a problem that might be more effective in certain contexts.
At Practice Ground, we like thinking outside the box to find new solutions to problems therapists face in their everyday practice. We’ve applied this strategy, not to assess towers with a barometer, but to how we as therapists could measure problems and progress so that it is genuinely useful.
Assessing is a key aspect of our practice. We need to assess clients’ problems to choose our interventions, and we need to measure their progress to see if the interventions are working. Often, assessing is part of the intervention itself, as when we give tracking homework to our clients to help them become more aware of what they do and of the context of their actions.
What tools can we use to measure clients’ problems and progress? What is our barometer and how can we use it? For decades, most therapists have been using behavioral observations and clients’ reports to put them in categories of psychological disorders, and it has been useful to identity clusters of psychological problems. However, the rising evidence that treating transdiagnostic processes is important to good outcome, the controversy about DSM-5, and HIPAA requirement that the US transitions to ICD-10-CM in October 2014 have pushed us to return to our behavioral and psychological science roots to design tools to think about assessment that could better guide our decisions. Our own answer has been to move increasingly to find ways to measure transdiagnostic processes of change AND outcomes.
To take a page from Jackie Person’s great book, The Case Formulation Approach to Cognitive Behavioral Therapy: Make a problem list. Look across problems to identify the common processes that causally contribute across life problems. Target those causal factors and measure change. In other words, when a client comes in unhappy at work, struggling to find a romantic relationship, drinking too much, and trapped in a quagmire of self-judgment that leaves him anxious and depressed most days, ticking the boxes of diagnostic criteria doesn’t help much to determine the targets and interventions of therapy. It definitely is helpful to have strong skills in core competencies of helping clients get activated and approach what has been avoided (i.e., to know how to do behavioral activation and something like the unified protocol). But we think it is also important to think and to measure transdiagnostic processes like experiential avoidance (check out this great new study by Kashdan et al for example). This practical approach helps therapists and clients see what Les Greenberg describes the little “o’s”-the small changes that happen in session or between sessions-that cumulatively add-up to the Big O of a good therapy outcome. If you also share this sensibility, you might want to join in on the beta release of our new Online Progress Tracking (OPT) system. OPT makes it easy for clients to complete measures online so you can see problems and progress. Sign up for an invitation to the beta here.