Defining Progress in Therapy

How do you know when therapy is achieving its stated aims? Measuring progress in therapy is challenging because of its inherently subjective and intensely personal nature. Also, generally speaking, metrics are a double-edged sword. On one hand, they allow you to visualize progress over time, which provides positive feedback and enables course correction when therapy is moving in an unproductive direction. On the other hand, there is a risk of fixating on metrics and losing sight of what they are supposed to represent, which (in the case of therapy) is the quality of one's lived experience. For example, consider the popular goal of "walking 10,000 steps a day". This is intended to be a lifestyle intervention that makes you feel good by improving your activity levels. But when people get obsessed with the metric itself and compulsively strive to hit 10,000 steps every single day, stress results whenever the goal cannot be achieved, leading to the opposite of the desired outcome.

With this caveat in mind, what makes for a good enough metric? It must be precise enough to define clearly, simple enough to measure conveniently, and useful enough to reflect outcomes that a client actually cares about. In this clinic, we focus on quality of life (QOL) as our North Star. Not only does QOL meet all three of the preceding criteria, but it is my belief that improving QOL is the true aim of any medical intervention or self-improvement effort, whether stated or unstated.

What is quality of life? This is a very complex question that evokes several related questions, including "what does it mean to live a satisfying life?" and "what is happiness?" There are many philosophical, psychological, and medical perspectives on this topic, all of which have something important to say. The simplest philosophical perspective is hedonism, which states that the aim of life is to increase pleasure because it is inherently good and avoid pain because it is inherently bad [Hedonism]. But while pleasure and pain are both important, this view is dissatisfying because it is easy to name examples of uncomfortable things that add significant value to life, such as exercise. In contrast, existential views posit that sense of purpose and meaning are the key to QOL, so discomfort in the pursuit of an overarching aim actually adds meaning to life [Man's Search for Meaning]. Medical perspectives tend to focus on illness and functional capability, defining QOL as the absence of physical and mental illness and the ability to perform meaningful activities, such as climbing the stairs or carrying one's groceries [SF-36; EQ-5D]. These relate conceptually to material views, which suggest that satisfaction of an individual's physical needs—things like a safe environment, access to transportation, sufficient financial means to afford biological necessities—is the most important requirement for QOL [WHOQOL]. Psychological perspectives such as Maslow's hierarchy of needs or Seligman's PERMA+ model state that, in addition to physical needs, one's emotional and intellectual needs must be met in order to maximize human potential and thereby, QOL. These include self-esteem, social connection and community, aesthetics, opportunities for education and skill development, and spirituality.

The QOL metric used in this clinic integrates these diverse perspectives with ideas from ACT therapy. ACT defines QOL in terms of how often a client is mindfully engaged with his or her freely chosen values through actions that are inherently motivating [Acceptance and Commitment Therapy]. In the ACT view, meaning, purpose, and (ultimately) life satisfaction arise naturally in proportion to how well one's day-to-day actions line up with one's values. Values can be thought of as an aspirational way of living that resonates on a personal level, for example a parent's desire to be undistracted when spending time with his children. In ACT, the greater the alignment between actions and values, the greater one's QOL. This definition of QOL stands in contrast to previously mentioned views that life satisfaction arises from having and achieving an overarching purpose, or from increasing pleasure and reducing pain. The aim of ACT is to help a client build increasingly effective action patterns that progressively increase the time one spends mindfully doing things that are inherently rewarding. This lines up with the best available evidence from happiness science, which shows that people are at their best when they are in a flow state. A flow state arises when people are focused on what they're doing in the present moment—as opposed to caught up in thoughts of past or future—and oriented more towards the process of doing the action rather than the outcome of the action.

To implement this practically, in the initial phase of therapy, clients construct a Valued Living Inventory (VLI), which identifies specific values in each of the key life domains—family, friendships, career, health, etc.—and rate the degree to which they are satisfied with the current level of action in each of these domains. This inventory is used to develop a Committed Action Plan, which defines a series of steps to help clients act on their values with increasing effectiveness over time. The VLI is also repeated at regular intervals over the course of therapy, and is the key metric used in this clinic to gauge progress.

As clients start to implement their Committed Action Plans, key skills (the 8 pillars of health) are taught to enhance effectiveness. The most important of these is how to be increasingly present, mindful, and engaged in day-to-day life (part of the Sustainable Resilience pillar). Clients are also taught the best available evidence from the science on human performance, which empowers them to decide how much or how little to incorporate this information into their existing value systems. There are two key questions to consider when making this decision. The first is, what is the client's current level of functional ability? Functional ability is the capacity, both in physical and mental terms, to do the things one cares about—it includes having sufficient time, space, energy, finances, physical fitness, etc. When one's existing functional ability is misaligned with one's stated values, implementing techniques from performance science may help to bridge the gap. For example, if a client prioritizes being physically active, but is lacking energy because they aren't getting enough sleep, we might collaboratively define action steps to address sleep specifically. The second key question is, how physically and mentally resilient is the client, i.e. can the client continue to do the things that matter for the long-term, even when circumstances are less than ideal? Increasing resilience is a critical focus of this therapy. After all, it's not much use to only be able to act on your values when circumstances are perfect. Many clients can benefit from incorporating principles from the science on resilience and longevity to help maintain function over time. For example, Psychological Richness is another of the eight pillars of health. It is a complex construct that involves spending time regularly engaged in creative pursuits; having fun and playing; feeding curiosity and exploring novelty; and encountering beauty and awe. Research has demonstrated that individuals with psychologically rich lives are more resilient. Clients may not enter therapy with richness as a value, but may decide that it's worth prioritizing because it increases the likelihood that they will be able to continue to act on their existing values for the long-term.

QOL, as defined above, is a far superior metric for therapy than conventional measures such as symptom score questionnaires. It is multidimensional and holistic, acknowledging the complexity and richness of human experience, while remaining succinct, focusing on eight high impact pillars. It is personalized to the individual client's value system. It incorporates subjective elements, such as one's perceived life satisfaction, as well as objective measures of one's functional ability and material circumstances. Finally, it is scientific, rooted in a growing body of research on the science of human flourishing.