Feedback-Informed Treatment: Empowering Clients to Use Their VoicesHow often does your therapist ask you how they’re doing? Or give you questionnaires to complete to see how you’re doing?

An approach called feedback-informed treatment or FIT does just that — uses a client’s feedback to inform their treatment. FIT “is all about empowering the client and increasing the client’s voice,” said Jason Seidel, PsyD, founder and director of The Colorado Center for Clinical Excellence in Denver. Seidel has been using FIT at his private practice since 2004.

Specifically, FIT “involves routinely and most importantly formally soliciting feedback from clients about the process of therapy, working relationship [with the therapist] and overall wellbeing,” he said.

The formal aspect of FIT is key because most therapists think they ask for feedback, but when they’re observed live or on video, they don’t do it nearly as much as they believe, Seidel said.

Receiving ongoing formal feedback from clients has clear-cut benefits. It’s been shown to boost the effectiveness of therapy, including enhancing clients’ wellbeing and decreasing dropout rates and no-shows. And it makes sense: Once the therapist knows precisely how the client is feeling, they’re better equipped to adjust treatment accordingly.

FIT’s History

The origins of FIT trace back to the 1980s and ’90s, when several researchers began tracking therapist effectiveness. However, these researchers mostly worked independently in university settings and administered lengthy instruments that contained upwards of 90 questions, according to Seidel. (As you can imagine, these measures weren’t exactly feasible in real-life settings.)

In the late ‘90s, a group of researchers, including Scott Miller and Barry Duncan, aimed to create several measures that were short enough for therapists to actually use during sessions and comprehensive enough to provide information on how a client was doing and how the therapist was doing in helping them.

Today, two of the most popular measures are the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS), which both feature four items. The ORS, which a client completes at the start of a session, asks about their wellbeing. The SRS, which is filled out at the end, asks about the therapist’s performance. For instance, one item asks if the client felt heard, understood and respected during the session. Another asks if they worked on or talked about what they wanted to.

Creating a “Culture of Feedback”

Administering the scales isn’t the only important part of FIT. Therapists have to be “hungry to see their failures and be interested in becoming better,” Seidel said. So therapists must create a “culture of feedback” and communicate this to their clients.

Clients need to truly believe that their therapists want honest feedback and to “feel safe that they won’t be retaliated against [for] negative feedback.” Therapists aren’t “just collecting the data, [they’re] collecting accurate data.”

What the Research Shows

Earlier work by pioneer researcher Michael Lambert and colleagues at university counseling centers found that giving therapists feedback on their clients’ wellbeing had a huge impact on their improvement. Feedback was especially critical for clients who weren’t getting better, since this group tends to leave therapy early (Lambert, Harmon, Slade, Whipple & Hawkins, 2005).

Recent research, which implemented the ORS and SRS, also showed significant improvements when feedback was given (e.g., Miller, Duncan, Brown, Sorrell, Chalk, 2006; Reese, Norsworthy & Rowlands, 2009). One large culturally and economically diverse study even found a boost in retention rates (Miller et. al, 2006). Another study found that clients in the feedback condition showed about twice as much improvement as clients who didn’t provide feedback and in fewer sessions (Reese et. al, 2009).

A 2009 randomized clinical trial of 205 Norwegian couples—“the largest randomized study of couples ever done,” Seidel said—had similar findings: Giving therapists feedback on their performance and the couples’ wellbeing almost doubled the effectiveness of therapy (Anker, Duncan & Sparks, 2009). Also, interestingly, at the six-month follow-up, couples in the feedback group had a significantly lower rate of divorce and separation than the no-feedback group.

Research conducted at mental health agencies has found that using feedback measures leads to fewer no-shows and dropouts. One reason, Seidel said, may be that it gives the therapist the opportunity to repair damage or small rifts that they might not know about otherwise. FIT also has been shown to shorten the course of treatment, he said.