I started my own practice in January last year. For the first time I was responsible for everything about my work. What sorts of clients I saw, how often I saw them, the interventions I used. While this is what I wanted, part of me wondered if I was ready for all this clinical responsibility.
As a result, I decided to try and measure my client outcomes more methodically . I’d already been convinced by a lot of the literature around the benefits of treatment outcome monitoring, and thought it would give a more objective answer to the “do I really know what I’m doing?” thoughts that sometimes keep me up at night. I chose the Core 10 because its brief, and unlike some measures has questions about functioning (I felt I have been able to cope when things go wrong, I felt I have someone to turn to for support when needed) as well as questions about mood.
For simplicity I only included adult clients doing individual therapy through Medicare (I also ran some group therapy during the year). I also excluded clients I had seen previously as I’d already used a different measure with them. I used Novopsych to administer the Core-10 before the first session, then again at sessions 6 and 10. That way it was linked to GP letters I sent. I made it clear to clients that completing the Core 10 was optional, and if a client didn’t complete if after multiple reminders I would forget about it. Outcome measurement purists would probably think this regimen is incredibly sloppy, but I knew if I made it more rigorous I probably wouldn’t stick to it.
Data Collection
The below pie chart has my dropout % and the % of clients who did the Core 10 more than once.
Of the clients that completed at least six sessions of therapy, around one third didn’t complete the Core 10. It’s possible the 1/3% non completion rate inflated my effect size but I don’t think so. The clients who didn’t complete the Core-10 verbally reported being just as satisfied with therapy. Not doing the Core 10 seemed to be mainly driven by forgetfulness on my or the clients part.
My Effect Size
Of the the clients who did complete the Core 10 more than twice, Novopsych calculated my effect size as 1.1. Put another way, the average client that completed therapy with me went from scoring in the “severe” range on the core 10 to the “mild range.”
This is a good effect size for therapy, and is on the higher side when compared to most studies of therapists effect sizes. More importantly it is a large and meaningful change, and makes me feel my work was worthwhile. Therapy might be expensive and time consuming, but for my clients it appeared it made a meaningful difference in their mental health.
What I want to Work On
As my effect size is on the high side, I think probably the biggest improvement I could make is trying to reduce my dropout rate. A 21% drop out rate is roughly in line with the literature, but it could also be better. Some of my clients who dropped out of therapy did so they moved away, or felt the therapy was done, or got busy with other things, but some on them dropped out because therapy wasn’t working. They were clients I didn’t engage with properly, or misunderstood, or where I tried somethingthat didn’t work. I want to try and make less of these mistakes this year. It will involve focusing more in initial sessions oon engaging clients and being alert to potential misunderstandings. I might write something more detailed in the future about how I plan to do this.
Final Thoughts
I’m glad I did routine outcome monitoring last year, and am going to do the same thing this year hopefully, with a little more rigour. Not only is it helpful in noticing overall trends, it was for individual clients. Sometimes you think therapy is going well for a client, but their mental health scores aren’t improving. I’ve found that usually that means something else is going on that isn’t being talked about in therapy, and this can be a prompt to explore that. More broadly, as health a health professional, it’s important to measure if what you’re doing is effective. Outcome monitoring is an easy way of doing that which doesn’t take much time.