My Clinical Outcomes: How Good Am I?

Jordanthecounselor
2 days ago
5 min read

Why Share My Routine Outcome Monitoring System? The Dilemma of Average

How good of a therapist am I?

There’s a problem with me sharing my outcomes like this. It can make me look bad.

Most therapists assume they are highly effective—guesstimating they help 75–80 percent of clients. This is untrue. Research shows the average therapist helps only about 50 percent of their clients. Therefore, until proven otherwise, any therapist should assume their success rate is 50%.

So you can see the problem.

If I share my numbers and my data says I help 65% of clients, I am significantly better than average. But if others guesstimate their success rates at 75%-80%, I look like a bad therapist.

So why share my data? Because as someone who’s advocating for therapists to practice skills and engage in Routine Outcome Monitoring (ROM), it’s important for me to do the same.

As lethal shooter says, If you post your wins, you got to also post your failures.

Well, here’s my data.

Spreadsheet with columns labeled "Process" and "Outcomes," featuring color-coded rows in blue, yellow, and red. "Scholarship" appears twice.

My Routine Outcome Monitoring Approach

At the end of each week, I update an Excel sheet where I track three main counseling metrics: Process, Outcome, and Likelihood of Dropout.

Good Process

Good Process means I’m matching my interventions to the client’s current level of motivation and avoiding resistance. I generally assume there are four phases:

Level 4 - Resistance: This is where clients push against the therapist or the therapy, even through momentary disagreements. Good process here means reducing resistance by offering empathy and autonomy. Bad process is problem-solving or being directive.
Level 3 - Sustain: The client is giving reasons for not changing. Good process here is working with the client to find a goal they are motivated to change for themselves, not to push for a specific change.
Level 2 - Ambivalence: This is where clients give reasons for both changing and not changing. Most outpatient clients are here. Good process means reflecting their ambivalence and tentatively pushing toward change, monitoring their response closely. If they say "I don't know," back off. If their demeanor suggests "oh, let’s try that," move forward.
Level 1 - Action: Clients are ready and giving reasons for why they should change. This is the most rewarding phase. Good process here means being directive enough to provide the intervention, solution, or skill they are asking for. Poor process is being too open-ended or too person-centered.

Good Outcome

Good Outcome means the client has had a significant change in therapy. It’s pretty simple. I base this off of what clients self-report.

These Outcome and Process labels lead to a few different combinations.

Good Process (No Outcome Yet): 46% of clients. These clients are actively engaged, and I am meeting their needs, but they have not yet achieved significant change.
Good Process AND Good Outcome: 43% of clients. These clients are on track for change or have already changed.
Good Process, Poor Outcome: 7% of clients. This group is where my intervention matches the client's motivation, but they are still not getting better. I’ve learned you can’t help everyone because not everyone is in the action phase of change. For example, I have a client who is very distressed and avoids their inner world. Asking them to address the anxiety leads to pushback, so I’ve stopped pushing them to change and simply listen and reflect. This is Good Process because it matches their current motivation, but the client is actually getting worse, which is why I’ve coded them as Poor Outcome. I am basically waiting for things to get worse, which will lead them to ask for help, creating a window for deeper work.
Poor Process, Poor Outcome: This group consists of one client (3.6% of my caseload). I believe I made a clear mistake in the process, and the client is getting worse. I plan to correct this in our upcoming sessions.

Likelihood of Dropout

I code clients on dropout risk: Yellow (at risk) or Red (extreme risk). Since I record my sessions, I review tapes of my Red clients three mornings a week to devise strategies. (Light blue clients are scholarship recipients, irrelevant to outcomes).

Of my 30 clients, 8 are individuals. All Yellow or Red cases are couples. My sense is they are caught in a self-perpetuating cycle of defense and blame:

Person 1: “I’m really hurt.”

Person 2: “But what about me! I’m really hurt, and you hurt me!”

Person 1: “Why is it always about you! Can’t you see that I’m hurt?”

Person 2: “Stop being so angry with me! I’m hurting! Why are you so mean?”

...and round and round they go.

As I’ve been writing this article, I realized that likelihood of dropout is a really powerful metric that captures a lot of different factors.

In some ways likelihood of dropout captures the client’s severity as clients who are more distressed are more likely to drop out.
In some ways it captures the quality of the therapeutic alliance as poor alliance is related to dropout.
In some ways it captures the client’s expectations of therapy, because oftentimes clients expect therapy to be one thing and when it’s not that they drop out.
And in some ways it captures how stable their home lives are, as clients with less stable home lives tend to drop out at higher rates.

Now of course, the likelihood of dropout is not a metric you can passively monitor. You have to really think about it, but if you really think about it deeply it can give you a lot of insight into your clients.

The Deliberate Practice Process

I record all of my sessions. So three mornings a week, I review the tape of a red client and fill out my Process Coding Therapist Diary Form:

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The total process takes about 25–30 minutes: 15 minutes of watching and coding the tape, and 10 minutes to fill out the form, which includes reflecting on my psychological weaknesses (my "wrinkles")—such as my fear of a client—and devising strategies to work with these clients. I find both looking at my psychological wrinkles and devising strategies crucial because it’s often my own psychology which prevents me from seeing and using the skills I have effectively.

Final Caution on ROM: Why Clinician Opinion Isn't Enough

In order to become a better therapist, we must:

Routinely monitor client outcomes (ROM).
Watch tapes to identify weaknesses.
Practice specific skills to improve weaknesses.

I am showing you my personal process for these three steps.

However, most clinicians should not rely on their own opinion for process and outcome tracking. Research shows therapists often misperceive client progress, so if we want an accurate reading of our clients we should be using a standardized survey as part of Routine Outcome Monitoring.

I am only comfortable doing this because I have been specifically trained in how to read clients' motivation and analyze video recordings. I believe this training gives me a specialized skill set that most don’t have. That being said, I could be wrong, and this could be an arrogant trap of self-delusion.

Finally, I know this is a lot of work. Most therapist don’t have the time or energy to do all of this extra nonpaid work. It’s not for everyone. That’s okay. However, if we want to become master therapists, this is the way. My hope is that in the next 16 months, with advances in technology AI makes it easier for more therapists to engage in these three steps.

If that happens then we can have a class of supershrinks and master therapists who can help a lot of hurting people.

I think that’s beautiful.

Best,

Jordan (the counselor)

Jordan Harris Ph.D, LMFT-s, LPC-s, is a specialist in what makes a master therapist. He regularly offers trainings teaching this skills of master therapists. You can learn more about Dr. Harris's trainings here.