Some thoughts on outcome in response to a question posed

The question that has not been asked is: who gets to define the outcome?  If we are talking about managing a chronic illness any improvement represents a positive outcome and from a public health perspective, we're really looking at the three tiers of prevention: a. preventing it from happening in the first place, b. catching it early before it becomes a problem, and c. managing a chronic condition so that it doesn't get any worse.  I find Lambert's work most compelling in its potential application to practice and the parallel works of Scott Miller and Barry Duncan that actually operationalize Lambert's findings.  Basically Lambert found that only about 1% of clinical outcome has to do with the specific therapy that is applied, evidence based or not, and that the largest controllable contributor to outcome is the therapeutic alliance; the suggestion is, for example MET and MI work because of their facilitation of a therapeutic alliance.  While this is the case, there is nothing wrong with evidence based practices; the alchemy lay with what Miller termed "the client's theory of change" and the alignment of evidence based practices in a way that potentiates the change trajectory.  Outcome in the art and science of therapy is measured by engagement, for example the HEDIS measure, tracking improvement and decline, and applying timely interventions that are consistent with "the client's theory of change."