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Paradoxes and Innovations in Clinical Theory and Practice Sraw moments from which self-evaluations are elf-Esteem is considered by many to be constructed by the individual, so that the a central component of personality; how-chent learns to face Problems instead of ever, it is so interwoven in the personality, it habitually avoiding them. Consequently, it is has seldom been the focus of belleved that not onl y doei f °"ei f self-esteem psychotherapy...until now.improve, but other psychological symptoms may disappear as well. S^-^^ê lf-Esteem: Paradoxes and Innova-^^fc tions in Clinical Theory and Practice ^elf-Esteem: Paradoxes and tanovadescribes a therapeutic process which shifts tions in Chnical Theory and Practice the balance of focus, making issues related °Pens new do °rs m tne fleld of Psychotherto self-esteem more central. The process ^ Take the first ste P b V orderin S y°u r does not teach self-affirmation or positive copy toda y ! self-talk, but rather intervenes in the natural,

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The so-called age of accountability has been thrust upon psychotherapists by rising healthcare costs and the consequent growth of managed care. Accordingly, tracking psychotherapy outcomes is becoming a requirement for most practitioners. We suggest there is reason for optimism in accepting and employing treatment outcome measurement as an integral part of clinical practice. This article describes the construction and psychometric characteristics of two measures of treatment outcome. It then illustrates the potential applications of outcome assessment from two perspectives, managed care administrators and clinicians. The total cost of health care in the United States in 1991 was estimated to be $800 billion {Health Care Financial Administrative, 1992) and growing at a rate exceeding inflation by more than 4% (Survey of Current Business, 1992). A more alarming statistic is that mental health costs inThe authors wish to thank Richard Ferre, M.D., and Mark Latkowski, Ph.D. of Intermountain Health Care and Human Affairs International for their support and cooperation in the construction of the instruments.Correspondence regarding this article should be addressed to M.

The demand that providers of mental health services be accountable for the services they provide has highlighted the importance of identifying and tracking the relationship between service, cost, and outcome in the current context of managed behavioural health care. In order to meet this demand, it is imperative that clinicians, researchers, and administrators have reliable and valid measures with which to document and track treatment outcomes. In the arena of child and adolescent care, there is a gap between traditional diagnostic measures and measures specifically designed to track outcomes. This study reports the comprehensive development and testing of a new outcome measure, the Youth Outcome Questionnaire, designed cooperatively by clinicians, researchers, and managed care administrators in order to meet the needs of all three. Multiple clinical samples and normative groups were assessed and results suggest that the instrument meets recommended standards of reliability, validity, and sensitivity to change. The process of development and testing serve as an illustration of the types of issues which must be addressed by those charged with the responsibility for documenting treatment outcomes.