FIT in Practice
Therapists are often amazed at how two simple and short scales change the therapy process, Seidel said. They receive a “whole other level of information,” which only helps their clients get better, and they don’t have to change the type of therapy they conduct.
Even using the feedback measures during the first session yields valuable results. Take Seidel’s initial session with a male client. (The details in both examples have been changed to protect client confidentiality.) Things seemed to be going great. They were making progress and Seidel felt like he had a good grasp of his client’s concerns. After the client completed the Session Rating Scale at the end of the session, Seidel noticed an eight, instead of a 10. When he asked what he could’ve done better, the client dropped a bombshell: For the last five years, he’d been having an affair, unbeknownst to his wife. The client was unsure about mentioning this to Seidel but completing the scale made him reconsider. Now, both therapist and client could address the affair in therapy, since it was a big source of distress.
Seidel also commonly sees clients whose wellbeing scales don’t match up with what they describe in session. Times like these also provide important opportunities for exploration. For instance, one client discussed struggling with work, feeling lonely and going through an overall difficult time. Surprisingly, his Outcome Rating Scale showed that he was doing quite well. Noticing the stark difference, Seidel inquired further. Turns out the client was just trying to fake positivity and put on a happy face—something he felt he should do.
The need to fake a good mood is common among clients. But, again, Seidel uses this as an opportunity to dig deeper. “We have a conversation about whether that’s what they want to do in therapy,” whether this serves them or if it’s important “to work on the space between.” (As Seidel said, faking a rosy face can actually exacerbate loneliness.)
What Clients Can Do
Unfortunately, while there’s a community of therapists who use FIT (Miller founded what is now a large international group called the International Center for Clinical Excellence), it hasn’t caught on with the majority of clinicians. The reason? Seidel said that it differs by therapy setting. In mental health agencies, the staff is already swamped with caseloads and paperwork. Not only do they feel like they have little breathing room but the “idea of being evaluated” can be threatening. (The “leadership [in these agencies] doesn’t understand how delicately and intricately to apply the training.”)
Finding a FIT therapist may not be easy.
It’s also not a concept regularly reviewed in psychology graduate programs. Plus, therapists worry about what they’ll find out and whether their clients will be comfortable. As Seidel said, “it’s easier not to deal with it” and to “do business as usual.”
So what can you do to be a smart consumer? You don’t have to hunt for clinicians involved in FIT. Rather, you can track your own progress and the therapist’s effectiveness by obtaining both measures or “com[ing] up with a homemade version,” Seidel said. (See here to download the two scales for free.) If you’re creating your own form, include questions like “Am I feeling heard? Does it feel like there’s something missing? How am I feeling in my daily life?”
Seidel suggested bringing the measures to your therapist (or a potential therapist) and saying something like: “Would you be open to getting some feedback from me? I’ve read and heard that this improves the quality of my experience.” If your therapist or a potential clinical says no, use this to help you figure out if you want to work with this person. “Be willing to fire your therapist if you aren’t getting what you need,” Seidel said.
Also remember that “If you’ve had bad therapy experiences, don’t give up,” Seidel said. “There are therapists out there who are passionate about doing good work and are doing good work.”
And, if you’re a clinician, remember that “like any kind of transformative growth, it’s scary as hell to do this at first [but] immensely rewarding” after you start. “Take the risk of just trying it, and see what happens in the very first sessions.”
Anker, M., Duncan, B., & Sparks, J. (2009). Using client feedback to improve couple therapy outcomes. Journal of Consulting and Clinical Psychology, 77, 693-704.
Lambert, M.J., Harmon C, Slade, K., Whipple, J.L., & Hawkins, E.J. (2005). Providing feedback to psychotherapists on their patients’ progress: Clinical results and practice suggestions. Journal of Clinical Psychology, 61, 165–174.
Miller, S. D., Duncan, B. L., Brown, J., Sorrell, R., & Chalk, B. (2006). Using outcome to inform and improve treatment outcomes. Journal of Brief Therapy, 5, 5–22.
Reese, R., Norsworthy, L., & Rowlands, S. (2009). Does a continuous feedback model improve psychotherapy outcome? Psychotherapy: Theory, Research and Practice, 46, 418-431.