Predicting the Course of Events

A constant emphasis we hear for any form of therapy is on achieving good outcomes. Is one approach better than the other? How do we, in the most efficient way, achieve the desired results?

In essence, what we aspire to do is predict the future course of events. It is worth taking a moment to savor what a difficult, yet crucial task that is. You must know two things to accomplish this

  • Where am I?

  • Where do I want to go?

Neither of these criteria is exactly easy in and of itself. Just figuring out where the client is presently requires a host of assessment challenges. And, while it is easy to think we all know where we want to go, that presents challenges as well. In essence, how will the client know they are better? But what criteria is this measured

Once those reference points are established, the therapist has to create a plan to get from where we are to the desired goal. As with any such task, there are many possibilities. If I wanted to get from Dayton, OH to Chicago, there are many possible choices.  At some point, one looks at the map and chooses a route. If you aren't exactly positive you are on the correct route, there is typically a sense of anxiety until you see a sign or familiar reference point that confirms you are on the right road.  The same can be said of the therapy journey as well. What signs along the way point to being on the road to improvement? 


This journey begins, at least at some level, at the end of the first session with a new client, when this person looks to me for further direction. Their question of "Now what?" is perfectly reasonable and appropriate. They want to know what to expect, how we plan to get there, and what signs along the way will point to progress. 

In response, my answer to this question is to lay out the most likely outcomes of our session. A typical answer might be something like the following:

  1. The improvement you now experience may last for several days and then symptoms may begin to return. I need to see you before they escalate to the original pain level. We don't want to lose all the improvement we have gained. 

  2. You feel better now, but symptoms may exacerbate in the next two days, only to abate significantly after the third day. We need to pay close attention to what happens then. 

  3. The improvement you notice now may be slightly better each day. If so, let's see how long we can "ride that wave". The if the symptoms increase and that lasts for more than two days, we need to work again. 

  4. It is unlikely, but it you notice nothing, symptoms are no better and no worse, I am completely off base and we need reevaluate the approach. 

I instruct the client to inform me right away if their experience is not one of the possible outcomes I have explained to them. This is vitally important; if the trajectory of treatment is a complete surprise to me, it means that my model of understanding of the problem is probably fundamentally incorrect. Yes, this would also be true if the client had a seemingly miraculous outcome. While they will certainly be thrilled with the results, I will not. All it means is that I got very lucky and the likelihood of repeating that outcome with the next client with similar symptoms is remote. In essence, if I understand the problem, (#1), I should also have a good idea where we are going (#2). If #2 is incorrect, refer back to #1!

This isn't an easy task- there are so many variables along the way. Like any journey, there are likely to be struggles and delays, but good travelers know to react to whatever comes their way. Good clinicians have the same skill set- every outcome is a clue as how to approach the problem. Fully engage your client in the process as well. It will give them a sense of agency in the process, something that is often lacking in their experience with the health care system.