Saturday, February 5, 2011


I am a person who thrives on structure and routine.  I prefer for things to be straightforward and unambiguous.  I like for things to make sense.  I am task-oriented and I can't relax if I know there is work that needs to be done. 

When I started doing therapy I quickly concluded that I'd gone into the wrong profession.  Therapy is often about the process; I felt like I was doing a lot of talking but not really accomplishing anything.  It didn't seem like my patients were getting any "better;" I didn't even know what "better" would look like.  Therapy seemed like a never ending endeavor.  I had no idea how or when to terminate.  How was I supposed to know when a patient was "finished" with therapy?  Shouldn't the patient be the one to decide?  Because I was unsure about when to initiate termination I simply didn't do it.  Most of my patients just eventually stopped coming after a while.  (Maybe when they felt like they didn't need it anymore or maybe for any of a thousand other reasons).

Therapy, I decided, wasn't really a science; primarily it was an art.  This made sense to me; I'd never been good at art so why would I be good at therapy?

Oh how I struggled with this!  I considered going back to school to do research - real science.  I got accepted into a PhD program at Virginia Tech but I had a house and a mortgage; I couldn't afford to quit working to go to school full time.  I felt trapped.  I had no choice but to keep working in a profession I despised.

Two things happened that changed things.  First, I was introduced to "protocol" therapies.  Protocol therapies are very structured.  For each session there are certain topics that must be discussed and tasks that must be completed.  Patients are typically given "homework" assignments that they have to complete in between sessions.  These therapies are time limited; the number of sessions is built into the protocol.  Patients know from the very beginning how long the therapy is going to last.  Finally, the best thing about protocol therapies is that they are research based.  Each of these therapies have been the focus of well designed research studies and have been shown to be effective. 

In order to determine whether or not a treatment is effective a person has to measure outcomes of the treatment.  Protocol therapies lend themselves to research by design.  Each protocol therapy incorporates some means for measuring changes in patients' symptoms throughout the treatment process.

Protocol therapies appealed to me for all the reasons "other" therapy did not.  They were task-oriented.  If I covered everything that was on the agenda for a given session I felt like I'd accomplished something.  There was not a lot of ambiguity.  I knew what needed to be done during each session and I didn't deviate from it without a compelling reason.  The therapies were research based, so I felt confident that if I simply stuck with the protocol the patient would make progress.  Best of all, these treatments provided a means for measuring progress.  Each session, the patient completed an empirically validated scale designed to assess the presence and severity of their symptoms.  Oh the joy I felt as I watched my patients' scores fall each week!  This was the first time I'd ever felt certain that my efforts had helped someone heal.  This was why I'd wanted to become a therapist; I wanted to help people!  The reason, I realized, that I'd been so unhappy doing therapy was because I really didn't feel like I was helping anyone.  Now I knew that I was.   

So the first thing to convince me that maybe I hadn't made a mistake by becoming a therapist had to do with measuring outcomes.  This provided concrete evidence - both for me and the patient - that the patient was getting better.  The second thing that happened took me in the opposite direction. 

The second thing that happened involved a change in perspective.  I became interested in how the Buddhist practice of mindfulness -- paying attention in a particular way: on purpose, in the present moment, and non-judgmentally (Jon Kabat-Zinn) -- might be used in therapy to help patients learn to accept and tolerate their emotions.  The idea that it is not always possible or desirable to get rid of negative emotions was completely new to me.  Wasn't that my job -- to help people get rid of their negative emotions?  Not according to the principles of mindfulness.  In fact, Buddhist teachings suggest that refusing to acknowledge and accept negative emotions only creates more suffering.  Refusing to accept what is at any given moment creates anxiety.  We feel compelled to do something to change the way things are as quickly as possible.  If this doesn't happen we become increasingly anxious and upset. 

I was intrigued.  I bought books about mindfulness, went online to read articles and visit websites, and started trying to apply what I was learning in my own life.  I read a book about being a mindful therapist and learned that the best thing I could offer my patients in a therapy session was my own mindful presence.  This meant learning how to be with a patient without allowing myself to get distracted by concerns about whether he or she was getting better.  Mindful presence meant devoting my entire self -- and my undivided attention -- on that patient in that moment.  To worry about outcomes would take me out of the present moment.  I had to learn to just be with what is.

Over time I learned to stop putting so much pressure on myself to make people better.  That's not to say I completely stopped thinking about outcomes.  I just stopped obsessing about them.  Without the pressure, I actually started to enjoy the process of therapy.  I started thinking that maybe therapy wasn't such a bad choice for me after all.

The moral of my story is that, as with all things, there must be a balance.  Measuring outcomes is absolutely necessary for research and research helps us to identify treatments that are most helpful to patients.  Measuring outcomes helps to build confidence for both the patient and the therapist.  The patient sees concrete evidence that he or she is improving and is motivated to continue treatment.  The therapist sees that the patient is making progress and feels good about the work he or she is doing.

Focusing too much on outcomes, however, can be distracting.  Therapy is both a science and an art.  Above all things, though, it is a relationship.  If a therapist becomes too focused on where he/she and the patient are trying to go (the outcome of treatment) then he/she misses out on being with the patient where he/she is.  This takes away from the therapeutic relationship.  Without that, it is very unlikely that the patient will get any better.


  1. Great post. It's cool how you were led through a process of your own that brought you where you needed to be. I think you are very right about the balance of it all. I tend towards the art more than the research, myself. We need to know that people are getting the outcomes they want, we need to know that the relationship is good and we need to get some satisfaction out of it ourselves. I'd encourage you to look at the work of Scott Miller and Barry Duncan. They do a lot of work on alliance and outcome in therapy. You can find more info at

  2. This is exactly how I feel right now. I just began my first real job out of graduate school and I feel lost. Your explanation that therapy is an art and you've never been really good at art completely captures how I feel. I got into the profession to help people and I feel like I am stuck and going nowhere. I don't feel like I'm helping. I guess its comforting to know that it's normal.

  3. You have grown in your profession...


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