En las siguientes tablas se presentan los principales resultados y balances del ejercicio de programación financiera

It is often proclaimed that in order to promote the most benefi cial client change therapists need to take the pulse of client satisfaction often and early (Miller, Duncan, Brown, Sorrell, & Chalk, 2006). However, one of the most challeng- ing methodological issues in measuring change is that in so many practical therapeutic contexts the therapist is very dependent on the client’s self-report, whether it be his or her responding to a questionnaire, reporting changes seen in everyday life, or keeping formal counts and self-observations. Because such self-reporting and self-rating is so notoriously unreliable, a new discipline developed in the 1970s called behavioral assessment, which was devoted to obtaining a much better understanding of how to develop practical, veridi- cal (true, accurate) measures of the clinical phenomena targeted for change in treatment. At one level it might be argued that who better than the client can tell you whether progress has been made? So self-reported satisfaction should perhaps be the only outcome of interest. Unfortunately there are systematic sources of error in self-ratings and other similar measures. It is revealing that when Tang and DeRubeis (1999) reported sudden gains in clients early in ther- apy, the measure was their self-reported strength of symptoms on the Beck Depression Inventory (BDI).

Subjective reports of change and self-report measures are not the same thing. By “subjective” we mean reports of feelings, moods, and inner satisfaction, states of being that can be known only to the individual and can ever be known only to the individual. Th ese are experiences that cannot be corroborated or validated by any other source. Concurrent overt manifestations such as facial expressions of emotion can be completely false and easily misjudged: there are tears of joy as well as sadness. However, if you ask the person what they had for breakfast, and they reply “sausage and eggs,” that is a self-report of an event that can be verifi ed, at least in principle, even if they ate alone, were not secretly observed or videoed, washed their dishes after they were fi nished, and had no missing eggs in their fridge—although if all of those conditions pertained absolute verifi ca- tion might require a stomach pump.

In other words, self-report is supposedly of a something that is real but usually private, and subjective report is the report of a feeling or experience that is its own reality. Self-report is frighteningly inaccurate (Smith, Jobe, & Mingay, 1991) and subjective report of client improvement is distorted by numerous interest- ing and quite well understood factors. I was once very pleased to see the progress being made by an adolescent client having major confl ict with his parents. I was encouraged when he told me all about his new part-time job at a fast food res- taurant and the special hat he wore and the net to keep his hair out of the food. But when he stole his mother’s check book and absconded with $5000 embezzled from her bank account, I found out from the fast food outlet they had never

heard of him. People have a desire to please and belong (conformity), they want to appear normal (social desirability), they have a need to justify their actions if they have spent money and resources on treatment programs (cognitive dis- sonance), and sometimes they see and feel what they think they should see and feel (expectancy eff ects).

Tr a j e c t o r i e s a n d D y n a m i c s

It is now clear that meaningful change does not occur in a simple linear or even a smooth curvilinear fashion, nor should we expect it to. As will be explained later, response interrelationships characterize individuals’ repertoires. Clients with an anxiety disorder probably have to feel a little less fearful before initi- ating changes in diffi cult approach behavior behaviors. If these are successful their confi dence will increase and their appraisal of their own effi cacy will be aff ected, resulting in less anxiety but greater risk for an aversive experience. In terms of measured symptoms they might experience sudden gains (Hofmann, Schulz, Meuret, Moscovitch, & Suvak, 2006). In psychotherapy, a client’s sub- jective sense of well-being usually occurs very early in treatment—within the fi rst few sessions (Hansen & Lambert, 2003). In fact, if that early eff ect is not experienced the likelihood of a successful overall outcome is greatly diminished: rapid (within the fi rst four sessions) reduction in binge eating strongly predicts feelings of self-control, eventual “remission” (not binge eating at all), and greater weight loss (Grilo, Masheb, & Wilson, 2006).

A seemingly opposite type of eff ect has also been reported as a “depression spike”: after a short period of rapid progress depressive symptoms suddenly increase, although eventually followed by a decrease (Hayes, Feldman, Beevers, Laurenceau, Cardaciotto, & Lewis-Smith, 2007). In writing narratives of their therapy experience, rapid responders expressed more hopefulness that the other clients. For those clients revealing a spike in depression symptoms, if these symptoms refl ect mood, it is not hard to imagine that as a client engages in deeper cognitive self-analysis it will exacerbate negative moods although ulti- mately it will facilitate change in a more positive directions.

Implications

In clinical work, change is usually not what you think it is—if you have thought about it at all. We have been somewhat misled by the confi nes of the experi- mental research literature into thinking of change as an alteration in a param- eter or the score on some measure. Clinically meaningful change requires that an individual, as a result of treatment, be diff erent, and that that diff erence is noticeable, desirable, and enduring. We have also been led to think that change means no longer showing symptoms—recovery. But that is not correct either.

Th erapy does not result in cures, although if someone has had an experience or a condition that has been disabling in some way, the impact of this disability can be dramatically reduced.

Psychometric measures, relying so heavily on ratings, self-report, and subjec- tive judgment, are much easier and more convenient to use in both practice and research than more veridical measures of actual change. Contemporary treat- ment research literature is overly dependent on the perception of others with a vested interest in the outcome, such as parents, teachers, or referring clinicians. Being able to gauge accurately how much something has changed remains very elusive. Ironically, in a few contexts subjective impression is the reality. If a cli- ent who was previously unhappy now says that he or she is much happier, what other index of change do we need to care about? If an angry teacher or a par- ent is confi dent that a child’s conduct has improved, there may be no real need for a more objective outcome. However, when these subjective judgments are overly infl uenced by factors such as wanting to please the therapist, or cognitive dissonance arising from the cost of treatment, or being too self-satisfi ed with unchanged behavioral patterns that may not be so readily tolerated by others (peers, partners, managers, friends), then subjective estimates of change have severe limitations.

When the target of treatment is the reduction of undesirable behaviors, clearly identifi ed as harmful to all concerned, such as criminal conduct, the importance of desisting is great, even though the individual’s overall change may be less than hoped for. When the negative behavior is more ambiguous, such as possibly serving a function for a person with very few or limited skills, ceasing the behav- ior entirely is not such a clear marker of desirable change. In such instances the acquisition of alternative, more appropriate life skills is the outcome that should be emphasized. If the focus is on individual behavior change, the resultant improvement in quality of life is an important outcome to document.

Change is not a simple linear process. Change can be spontaneous, dramatic, or minimal like an advancing glacier. With many behaviors, change in the con- sequences of the behavior for the person’s social context may be more important than radically altering the course of the behavior. Social criteria determine the level at which most behaviors will be considered acceptable and tolerated. Our exploration of how and why people change requires recognition that we need to be as clear and consistent as possible in defi ning what change is and the psycho- logical processes whereby a person’s life trajectory becomes meaningfully dif- ferent. It is complex because behavior is complex, interrelated, and intertwined with changing environmental systems. Th is will become more obvious when we examine motivation to change.

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