The insights from therapy my clients find most useful generally occur spontaneously. They come from conversations where both of us were struggling with a question that we didn’t know the answer to. Looking back on these moments it’s often unclear who even came up with the insight. They said something, I said something back, and eventually what emerged was better than anything either of us could have thought of individually.

The benefits of these types of collaborative interactions aren’t confined to therapy. Jazz and Blues music is built off the idea that what spontaneously occurs when people interact is better than anything that could be written beforehand. Hollywood uses writers’ rooms because studios know collaboration can lead to better outcomes than individuals working alone. While our current culture values stories of individual genius, many of our best innovations, be they artistic or technological, came through collaboration.

Not all conversations are truly collaborative though. For starters, you need to be actually listening to the other person. If you’re too focused on what you’re doing you’ll just keep building in one direction and never add anything to what the other person is saying. You also need to be comfortable with uncertainty. Pressure to come up with an answer can make you jump on the first possible solution, potentially cutting off the richer idea that could have emerged if you’d allowed the interaction time to develop.

To make things harder, our society tends to value advice over collaboration. When we have a problem, we are told to consult an expert. In exchange for money they provide us with an answer that is better than anything we could come up on our own. If you hired a lawyer and they wanted to start brainstorming different legal strategies with you, you’d probably ask for your money back.

Despite knowing the benefits of collaborative interactions, psychologists feel this pressure as well. Most of us tend to market ourselves based on the knowledge we can provide our clients. It is simpler to tell someone that you can help them by teaching them something rather than trying to explain the benefits of insight-driven therapy. Giving them answers also feels satisfying. My easiest sessions are when clients are asking me for specific information. What I’m providing feels much more definite and tangible than trying to engage them in a collaborative conversation and hoping we can come up with something. However, the information I give in those moments is rarely what clients truly value from therapy.

A lot of the ways we are told to act in our professional lives also stifles collaboration. We are told to go into conversations with clear goals, to always remember our individual contributions lest we are passed over for promotion, to set agendas for meetings. While I understand the logic of this advice, I worry that the costs might be vague enough that they are overlooked. How can you even be aware of potential collaborative insights that were never even arrived at?

 More generally, a society that places a premium on expertise and agendas over collaboration is a society filled with people who struggle to collaborate effectively. In initial sessions my clients are often uncomfortable engaging in the sorts of conversations that can lead to insights. They don’t like speaking speculatively, will want to pre-plan agendas, will ask me to answer questions before they’ve even properly explored what the questions are. For these clients it is often a desire for accuracy that is holding them back. They feel that the serious nature of a therapeutic room requires them to only say things that they are sure are entirely accurate. They are like a musician so scared of playing the wrong notes that they repeat the same scales instead of truly improvising. It is only when they feel comfortable expressing things that they are unsure of, of responding in the moment to things I say, that we can start to build insights they find valuable.

I’ve written this piece to try and explain one of the main ways therapy is helpful, but also to encourage people to have more collaborative interactions in their daily lives. Collaboration shouldn’t be reserved to jazz bars, writers’ rooms and therapists’ offices. If you currently have a problem that has you stumped, try talking to other people about it.  Solutions will come from those conversations that you would have never thought of on your own. And the next time someone comes to you for advice, resist the urge to respond with the first thing you think of. Allow the problem to develop, kick it around, and hopefully something will emerge that is much better than your original solution.

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.