How 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.
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.
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.