In various research the claim has been that across treatment modalities one of the strongest predictors of a successful therapeutic outcome is the therapeutic alliance. Although some therapists develop a sense of what their alliance is with a client, it can be something challenging to speak about and measure during the therapeutic process.
Studies done have highlighted that getting real time feedback from clients in therapy is a growing culture. An article I read by Alexandra Bachelor titled, ‘Clients and Therapists Views of the Therapeutic Alliance: Similarities, Differences and Relationship to Therapy Outcome’, explored how clients and therapists view of the therapeutic alliance differs and overlap and how this relates to post-therapy outcome.
Overall, the study highlighted that therapists should be mindful of taking as a given that their views of the therapeutic relationship and work are shared by the client. Asking for feedback on this is important to the process and therapeutic outcome. Furthermore, engaging with the client’s perspective on problems and relevant work is valued. To achieve this, therapist may need to explicitly ask how am I being helpful? How is the process being helpful?
Based on this from the 11th-14th July 2017 the clinical team underwent the Feedback Informed Treatment (FIT) training, given by one of our partner organisations, DIGNITY. FIT is a web based program that captures clients voices and experiences of not only the therapy process but the therapist. It has a scoring process that is done before and after the session by the client. The Outcome Rating Scale (ORS), which is completed at the beginning of the session looks at the clients current wellbeing; The Session Rating Scale (SRS), which is completed at the end of the session looks at the client’s experience of the therapist approach. Asking the client if they felt heard, understood and respected in the therapeutic interaction; if they got to talk about what they wanted; if they felt the therapist approach was a good fit for them; or if they felt something was missing. This may seem daunting and it was experienced as daunting by therapist at the CSVR Trauma Clinic, at first. However, after much reflection and training, the purpose of such a tool was welcomed.
Jason Seidel, founder and director of The Colorado Centre for Clinical Excellence in Denver, explains it as a tool that use’s client feedback to inform treatment, stating that it “is all about empowering the client and increasing the client’s voice…routinely and most importantly formally soliciting feedback from clients about the process of therapy, working relationship (with the therapist) and overall wellbeing”.
Margarita Tartakovsky notes that it has been shown to “boost the effectiveness of therapy, including enhancing client’s wellbeing and decreasing dropout rates and no-shows”. Furthermore, allowing therapists to know how the client is feeling about their approach and thus, they are better equipped to adjust their approach to meet the client’s needs.
In the training it was emphasized that FIT encourages a culture of feedback from clients. As therapists we often ask clients, ‘how are you?’ ‘How does that make you feel?’ But rarely ask the client to reflect on us as therapist and how do they feel about us? (unless its relates to counter-transferential discussions). How do they feel about the way we are working? The approach that we are using? Does it fit for them? FIT creates a space for this. In my experience of using this feedback tool with clients it has been interesting to engage with clients on their experience and what about us as therapist work for them and what does not. Are we helpful? And are we helping them in the way they need?
Getting honest feedback from our clients may be challenging at times, especially taking into account the power dynamics in the therapeutic encounter and so getting clients buy-in, that, I actually wanted to be told, ‘this approach is not working for me’, ‘you missed the point today’ was hard. Personally, I had to ready myself to receive the feedback. No therapist wants to be told, ‘you’re not getting me’. As I think of a case in which this did happen, in hindsight, I think without the SRS score at the end of the session, I would have missed this and the client may not have returned or continued in therapy feeling frustrated. Addressing it in the session, led to me being aware that I may be perceiving something as carrying less weight, when it was clearly something of importance to the client. Furthermore, it made the client feel accepted and that I am keen to understand, all parts of them, not only the nice parts (exercising unconditional positive regard).
In my experience it has led to richer, genuine conversations which has enhanced the therapeutic relationship and made me reflect on my approach in the room and its impacts on individuals and their growth in therapy. Am I being helpful to the client and if not what can we do about this? For the client I noted it reduces the frustrations they may have in the therapeutic process and intensity of not being able to verbalise if the treatment works or not for that particular day. Opening up the conversation about the relationship itself, the way the interaction took place. This opportunity in itself empowers the client to take control and see themselves as part of their process and not coming to an expert whose prescribing to them how this medication needs to be taken.
Seidel states that, feedback measures such as FIT, gives the therapist the opportunity to repair damages in the therapeutic relationship sooner or making therapeutic adjustments sooner. I have also noted that it assists in developing a treatment plan and identify when therapy is just not working for a client and have an open and honest discussion about it, utilizing the tool as evidence of this.
In my original introduction to the tool I thought that FIT focused a lot on the therapist and questioning the ‘good enough-ness’ of the therapist, but in using it with clients I found that it’s really about helping the client and placing them at the center of treatment and wellbeing. Not that I don’t cringe when I see a client scoring me low on the SRS. But, understanding the rationale behind the process has opened me to exploring and having an open honest discussion with a client about our ‘fit’ together: as therapist and client (therapeutic alliance); does the therapeutic service offered meet their presenting problem?; and does the therapist approach work for them? (therapeutic effectiveness).
Therapist at the clinic, struggled with this idea of asking for direct feedback in sessions initially, holding in mind that most of us had been trained in traditional psychotherapy that somewhat goes against this method, and does not necessarily call for direct conversations about the therapeutic alliance and feedback from the client on the therapists approach, from day one of the interaction with the client. Is there a place for this (FIT) in the psychotherapy of today? Will it or is it being introduced at an academic level in the training of future therapist in South Africa? More importantly, I am interested in how this tool can be used in an African context. A context in which psychotherapy as a healing modality is still a very Western concept. Can it play a role in socializing clients into understanding ‘talk therapy’ and be aware from an early point in therapy if it’s something that meets their needs or not. If it’s the right ‘fit’ for them or not?
Written by: Sumaiya Mohamed
Alexandra Bachelor: Clients’ and Therapists’ Views of the Therapuetic Alliance: Similairities, Differences and Relationship to Therapy Outcome in Clinical Psychology and Psychotherapy Journal, Volume 20, Issue 2 (pg 118-135).
Margarita Tartakovsky: Feedback Informed Treatment: Empowering Clients to use their voices. Website address: psychcentral.com/lib/feedback-informed-treatment-empowering-clients-to-use-their-voices/