Feedback Informed Treatment
By Carys Cragg
I’ll never understand this 17-year-old boy, I worry. You’ve done a bad job with the ses- sion, my mind continues. As my new client* completes the feedback scale I’ve intro- duced into my sessions with him – witness- ing a lower mark he’s given me in the rela- tionship section of the tool – my thoughts begin to catastrophize…
Feedback on the therapeutic relationship effects client outcomes. The therapeutic relationship, or alliance as it is also called, is the number one predictor of positive out- comes for clients. This is what the research (and long term practitioner knowledge) tells us. What are we supposed to do with this information? How can we integrate brief yet effective tools into our diverse pantheoreti- cal counselling practices?
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It’s good news – I guess – while I read that bad news is good news, or so the pioneers of Feedback Informed Treatment (FIT) tell me. Put in other words, client feedback – “well, you kind of ignored something I said ½ way through the session” or “we didn’t get to speak about something I really wanted to talk about” or “when you raised your voice a little, I didn’t like it” – is helpful, however, is sometimes difficult to hear. I mean, how else can we integrate this highly subjective, individualized experience of the counselling service we provide our clients? Of course, we always individualize our approach to our clients – we tailor our techniques, our worldviews, our voice, and so on – depend- ing on who presents to us. There is no one- size-fits-all method, despite the proliferation of manuals and standardized practice. We do what the client needs in that moment, in that session, in that treatment plan. But what if there was another way to tailor our ap- proach, via our knowledge of the therapeutic relationship that has a direct and positive impact on client outcomes? Well, that’s what the creators of FIT, previously referred to
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as Client Directed Outcome Informed treat- ment, claim.
At the FIT training, I am instructed to use the Outcome Rating Scale (ORS) at the begin- ning of the session and the Session Rating Scale (SRS) at the end. Brief, accurate, and reliable predictors of client outcomes, these measures (found in the Performance Metrics section of
www.scottdmiller.com) are easily understood and incorporated into a range of behavioural health interventions and settings. With the ORS, given at the begin- ning of the session, like a mental health thermometer, I get an accurate, subjective experience of client distress and function- ing, tracked over time. Far from a checklist of objective symptoms of pathology, the ORS measures Individual, Interpersonal, Social, and Overall functioning in a (brief) holistic manner. Coupled with the SRS, which measures the Relationship, Goals & Topics, Approach or Method, and Overall experience of the client’s experience of the therapeutic relationship in that session, I have a great deal of information to assess both client outcomes and the therapeutic relationship I am constructing with my client, over time. With time, a direction of poor to good out- comes should mirror a poor to good thera- peutic relationship; when the therapeutic relationship isn’t improving, then something (approach, counsellor, or treatment) needs to change.
Consulting with a clinician regarding inte- grating FIT tools into her therapeutic work, she tells me a story about how a teenager she was counselling completed the ORS but was stuck on one of the sections. “Can I make two different marks – one for how I’m doing with my mom and one for how I’m doing with my dad?” her client inquires. The clinician inquires further as to what she means. “I’d give a high mark for my mom but I’m having a hard time with my dad,” she
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