Want to get more out of therapy? Data can help.
Most research shows that psychotherapy works. People who undergo some form of psychotherapy are better off than about 80% of those who go untreated. One way to make sure therapy is working the way it should is to measure it. Psychotherapy – unlike medicine – works via the ongoing interactions between therapist and client. Therapists all have a theory about how to best help a client. Alongside that is usually an idea about what led to the client’s current difficulties. These ideas heavily influence how the therapist understands the client, which affects the way he responds to the client.
The way a therapist responds to a client can determine the success or failure of a treatment. If the therapist is right, a client has ways of letting him know. These are signs that a therapist is on the right track:
- client show a reduction in symptoms
- client seems more engaged in the therapy
- client grows more vitalized
- client makes spontaneous insights or connections in session
Clients can also tell therapists when they are on the wrong track via:
- worsened symptoms
- lack of engagement in therapy
- client seeming depleted or flat
- repeating similar themes or content in session without much deeper understanding
Therapists process these feedback signals to help them know if they are on the right track. Of course, there is a lot going on in a session and sometimes this task is hard to do informally. A therapist has to respond to the client on a moment-to-moment basis while tracking these feedback signals.
Formally collecting and tracking client data helps a therapist to know if he’s on the right track and course-correct when he’s not. There are a lot of different measures that can be used for this purpose. I will focus on the Feedback-Informed-Treatment (FIT) system because it is what I use in my practice.
How Feedback-Informed Treatment works
FIT consists of two short 4-item questionnaires that clients complete before session and after session. The pre-session (Outcome Rating Scale – ORS) form asks clients how they would rate their wellbeing from 1 to 10 in the individual, social, interpersonal and overall dimensions of their lives. I ask clients to answer these questions relative to their reasons for coming to therapy. This ensures that clients are tracking progress specific to what we are addressing in therapy. As a result, declines or improvement in these ratings are more likely to be related to what’s happening in therapy.
The post-session form (Session Rating Scale – SRS) is also four questions long. Its purpose is to make sure a client felt like they got what they wanted to get from today’s session. The client is asked to rate whether we talked about the right topics, if the way I responded to them felt helpful, and if they find my overall approach a good fit for them.
Thanks to technology, encrypted hyperlinks to each form can be emailed to clients before each session. Their ratings are securely and anonymously tracked in a database so that I can observe changes over time. I regularly show clients line graphs of their completed forms so they can observe their own progress to date.
As I review each client’s entries, shifts in the SRS scores – whether up or down – can offer opportunities for discussion. If a client’s rating went up I might check in with what felt particularly helpful in the last session. Such information is very helpful to inform my hypotheses about how to best help them. Similarly, if the score goes down it is a great opportunity to check in on what didn’t feel quite right from the last session. Having open conversations about how clients believe the therapy is going can be therapeutic itself. Such conversations can show that the therapist is more concerned about helping the client than being right. Clients can find out that asking for what they want does not have to mean that the other person retaliates, gets defensive, or acts wounded.
Here’s an anonymous example of one client’s ratings:
You can see that there was more variability in the SRS (line with the squares) ratings at the beginning of therapy. By the fifth session we settled into a higher-scoring range. This client’s progress towards his/her goals generally improved but a difficult life event created a large dip in early July.
After using FIT for the past few years, I have found it particularly useful in these 3 ways:
1) Preventing early dropout: At the start of any therapy a client and therapist are trying to feel each other out. The therapist is trying his best to understand the client and communicate this. Sometimes, the client presents the therapist with information that takes a little longer to integrate into his understanding of the client. In such cases, the client may feel less helped by the therapy. I have found that addressing a client’s FIT ratings in the first ten sessions allows me to know more quickly what is helpful and not helpful to the client. As a result, clients can help me adjust the treatment to work best for them. Otherwise, I might not know that they were not getting what they were hoping to get from our work.
2) Giving ‘people-pleasers‘ a chance to be ‘displeasing’: For some clients, their main goal for therapy is to discover that it’s safe to disagree with others. They may have learned that relationships end if they insist on their perspective, feelings or needs. Gently inquiring about a small dip in SRS ratings can be anxiety-provoking but therapeutic for such individuals. They can learn that saying what they want me to do more of or less of does not threaten our relationship. On the contrary, such feedback can improve our experience of working together.
3) Identifying relapses in addiction recovery: When a client’s goal includes recovery from substance addiction, declines in ORS score can indicate a relapse. Addiction is a formidable opponent in therapy because it tries to convince its sufferers to keep it hidden. Someone who relapses in their attempts to recover from addiction can find it challenging to report this to a therapist. I have found that addressing declines in the ORS with such clients can lead to disclosure that a relapse occurred. I may not have known to inquire about this without the data. Discussing the relapse allows the client to disconfirm any ideas that he should feel ashamed about it and to work together to get their recovery back on track.
Wampold, B.E. (2010) The Great Psychotherapy Debate: Models, Methods, and Findings. Mahwah, N.J.: Lawrence Erlbaum Associates, Inc.
About the Author
Jay Reid is a Registered Professional Clinical Counselor at Well Clinic in San Francisco. According to Jay,
“I build safe, warm and trusting working relationships with my clients. This may sound simple, but it allows you to productively explore your feelings and thoughts. Together, we will understand your life’s story and figure out what’s preventing you from writing the next chapter in the way you truly want.”