What is feedback informed treatment and why does it matter?
Use of the feedback informed treatment process helps facilitate a dialogue with clients regarding their experience in therapy. The therapist can then incorporate this feedback immediately into their work.
Feedback-informed treatment (FIT) is a practice that can be incorporated into the psychotherapy process that involves asking for client feedback on a session-by-session basis to evaluate, from the client point of view, the quality of each session, the quality of the therapeutic relationship between therapist and client, and the client’s sense of success or satisfaction in various areas of their life which can serve as measures of progress towards therapy goals.
FIT is recognized by the U.S. Substance Abuse and Mental Health Services Administration (SAMSHA)1 for having substantial evidence that it increases client satisfaction and improves therapy outcomes. With FIT, therapists gather input from clients using structured measures to identify what is and is not working well about the therapy process and then adjust to better meet client needs. The FIT process facilitates the development of what’s been called a “culture of feedback” from the outset of a client’s course of therapy. Research has shown that clients whose therapists use FIT on an ongoing basis are up to 2.5 times more likely to benefit from treatment.2
Specifically, the FIT process I utilize involves two brief measures that a client is requested to fill out each session – one at the beginning and one at the end.
The tools used for this feedback process are called the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). The Outcome Rating Scale, completed as the therapy session begins, makes the following inquiries:
Looking back over the last week, including today, help us understand how you have been feeling by rating how you have been doing in the following areas of your life:
Individually (your personal well-being)
interpersonally (with family and close relationships)
socially (in areas such as work, school, and friendships)
overall (your general sense of well-being).
The Session Rating Scale, completed as a session concludes, goes like this:
Please rate today’s session by placing a mark on the line nearest to the description that best fits your experience:
“I did not feel heard, understood, and respected” or “I felt heard, understood, and respected”
“We did not work on or talk about what I wanted to work on and talk about” or “We worked on and talked about what I wanted to work on and talk about”
“The therapist’s approach is not a good fit for me” or “The therapist’s approach is a good fit for me”
“There was something missing in the session today” or “Overall, today’s session was right for me”
One advantage of a therapist using formal scales to routinely measure the effectiveness of their work is that doing so enables them to identify key skill areas they can focus on for professional growth with all of their clients.
It’s been shown repeatedly that of all factors influencing therapy outcomes which a therapist can control, developing a trusting and comfortable relationship with clients accounts for the largest impact on positive results. The therapeutic relationship itself holds more importance overall than the specific methodology or interventions a therapist uses to help clients with their goals. Therapists who use FIT in the ways it’s intended have a commitment to ongoing improvement of their interactional skills with clients.
It’s all too easy for therapists to assume what they’ve customarily done to foster a connection with clients is adequate, rather than soliciting feedback and continuing to learn ways to improve in this area and strive to tailor their approach to each individual client. The FIT process helps therapists locate and address their own blind spots.
FIT also can serve to identify more rapidly when a particular client and therapist just aren’t a good match for each other. Sometimes as much as both parties earnestly want to engage together in the therapy process, they are not good counterparts to each other and it’s helpful to recognize that a client might be better served by a therapist with a different style, personality, or skill set. The sooner this is recognized and discussed, the sooner important decisions can be made about whether this is something that can be overcome in the current therapy or referral to an alternate therapist is in the client’s best interest.
You may sense here that filling out the ORS and SRS forms can take a bit of courage on the part of a client and you’d be right. Client’s may feel intimidated or uncomfortable with the thought of giving less-than-stellar marks to their therapist who they are hoping will respect them, who holds a position of authority, and who they may hold in high esteem. Often people are hesitant to be assertive with others and make their needs known. Client’s may be inclined to withhold information that indicates they’re not getting better or making good progress, as they don’t want their therapist to be disappointed or they don’t want to be seen as uncooperative, incapable, or “a hopeless case.” I like to address this hesitancy directly.
It’s my responsibility as the therapist to encourage honest and open responses because those are the most helpful and rewarding. It’s also my responsibility to be open to hearing feedback even when it isn’t altogether flattering or nudges me to act differently. In fact, this is the very core of the FIT process, as described above. From the outset I work to educate clients on the FIT process, including assuring them that the most benefit will come from their candidness.
You may be thinking “Doesn’t making a client fill out forms at every session use up valuable session time?” My answer is, it’s exactly because your time is valuable and our time together is limited that I use the ORS and SRS to propel our work forward and make sure we’re on the same page with your therapy goals. I want to keep tabs on whether what I’m doing feels helpful and right. In my experience over the years, I’ve come to trust that the tradeoff is well worth it. In reality we’re talking about roughly 5 minutes of session time that can have large payoff for client satisfaction and lead to productive paths for further conversation and focus. I have been incorporating FIT into my work with clients for several years and have a strong belief that it provides benefits both to me and my clients. Even if clients have been in therapy previously it’s likely they are unfamiliar with such a formalized version of conversation about their experience of the therapy and their progress, though I would hope to see an increasing number of therapists utilizing this powerful tool.
- The Substance Abuse and Mental Health Services Administration, or SAMHSA, is an agency of the federal government devoted to encouraging development of and identifying effective tools and practices in the field of behavioral health. SAMHSA leads public health efforts to advance the behavioral health of the nation and improve the lives of individuals living with mental and substance use disorders, and their families
- Brattland, et al, 2018 – The effects of routine outcome monitoring (ROM) on therapy outcomes in the course of an implementation process: A randomized clinical trial