Feedback Informed Treatment (FIT)

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

Sources:

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/

Who is the keeper of the keeper?

 

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Written by Thembisile Masondo in collaboration with Sumaiya Mohamed 

On the 9th of June the Psychosocial Forum hosted the first Service Provider Dialogue Meeting/Indaba, and I was asked to write a reflection on the event. I explained that I found it hard to write on the subject because in all honesty I didn’t know what to say, I mean people were saying it was a wonderful event. For me this event was anxiety provoking between venue booking and preparation to finding a catering company and attending the task team meetings when I had little time to spare. At some point it became an issue of: these are professionals! Not that planning for nonprofessionals is less anxiety provoking, but the issue was, these are peers; and I wanted to make an impression. I honestly did not want to put on paper something I had not felt, because in the end I just wanted to forget and move on. It was not till I attended a seminar at Wits University that my reflection came. I can’t say what triggered this need to all of a sudden want to express my view.

Perhaps it was the subject of secrecy. The truth is this event and the process leading up to it did not unfold as I envisioned, in fact it surpassed my expectations and not in the way that one would expect. For me it was the team that I had that made this happen, it was such a humbling process, it was so beautiful and one could say stunning in the way it progressed, up until the last minute of when we bid goodbye to each after the event. I remember looking at the people gathered in that room and having this profound sense that the world is not doomed after all. I remember feeling a sense of accomplishment, not because we managed to put people in a room, but because I was not alone.  The comfort felt in organizing and doing the event with others, not alone, spoke to that unspoken truth: we as practitioners hold the need to break the silence: silence around our loneliness in hearing, holding the pain, darkness of the others experiences and the need to be strong and not seen as not able to do this.  That when we sit down together and reflect on our experiences in a non-judgmental; empathetic space, we realize that we are not alone in the experience of fearing the darkness.

The work we do isolates, it changes the way in which we see and feel the world. The work we do wounds, and breaks, it brings forth binaries like love and hate, light and darkness and good and evil. As practioners in this field we are constantly at war within and without, constantly questioning our sanity because we are privy to secrets and ethics binds us and dictate that we have to be keep these secrets. Ironically the people that come to unburden themselves do so under the promise that those secret shall be kept. Has anyone asked the secret holder the burden of holding, has anyone asked what the price is for holding? I love my work, at some point in my life I had to come to terms with my “specialness”, however there have been unspoken things about this job, no one ever tells you of the burden of being the secret holder, of being a mirror and compass.

I often wonder, if I stated our fear of the darkness, would it be seen as a weakness in my team, my work place, among my peers? If I expressed my burdens would I have supportive spaces offered to me, or would I have been banished into the darkness (on my own) to resolve my conflict, chew on it, digest it and let it go? Or will I be freeing my peers in this field of work; giving them the strength to finally say ‘whew! I thought I was alone!’

All this is hidden under big words such burn out, clinical supervision, vicarious trauma, secondary trauma…and there is the suggestion to get counselling. But have healers sat with each other and had real conversations about what this means to them? How about someone say: body, mind and soul you change; how about they tell you that you become part of the secret, that it also infiltrates your life and by the time you are conscience of it, it has manifested itself into something incomprehensible. I am tired, and yet I have this fire inside of me of that justice, which I cannot stop. After all what excuse do I make when I know evil exists in the world and I don’t do anything?

We are the tool; the listener; the person that holds the unbearable parts, and yet there is this presumption that I am unaffected, untouched by the pain, the trauma, the darkness. A colleague and I reflected on this, stating that it brings to mind the image of a person in a dark hole, as the therapist you aim to help this person, bring them out of the hole, out of the darkness. Yet, as therapist we fear being engulfed, overtaken, and consumed by our clients’ darkness.

A famous quote by Madeliene L Engle comes to mind, ‘you have to know the darkness before you can appreciate the light’. I think it speaks to our ability to believe that clients can overcome, are resilient, and are powerful……to be able to see their light through their darkest moments. And similarly, as healers we have to know our own and acknowledge our own darkness to know our light (our ability to function as a healer). I believe we enter into this field because we know of our light and aim to use it to lead others out of their darkness.  But  darkness consumes and we get lost in the dark, where do we go, where do we seek support and do we feel we will be held by the very structures that say, ‘I am here for you’? Who shares their light with us?

Chatting with a colleague about these struggles has helped me to feel liberated in my struggle. As I sat that feeling came, ‘it’s not only me’, and ‘I am not alone’. And we could have an open and real conversation that led to us both acknowledging the light in each other and in ourselves. This dialogue may have not opened up the conversation but those that showed up there were curious, to know is this the day when we get to open up and share the secret that is being held and that healers are people too. I believe that day is upon us  and are we as healers ready to face our own woundedness in the process of healing the other.

Linking psychosocial support with transitional justice processes

speakersSpeakers giving keynote addresses at the transitional justice workshop in Conakry, Guinea

On 8 May, the Centre for the Study of  Violence and Reconciliation (CSVR )’s Trauma Clinic co-facilitated a transitional justice workshop on atrocity prevention. This was done in partnership with the International Coalition for Sites of Consciousness (ICSC) in Conakry, Guinea.

This went towards our goal of ensuring that the importance of psychosocial support within transitional justice processes is understood by all actors, especially when these services are not prioritised or are scarce within a country context.

The workshop was unique in that it brought together NGOs, victim groups and journalists.  Furthermore, the workshop encouraged them to strategise around how they could work together to ensure that the human rights of people are restored and that transitional justice takes place within Guinea.  At the end of the workshop, media and transitional justice strategies were presented in plenary and suggestions for improvement were made by all. This ensured a clear development of  a vision which participants could use to guide efforts towards achieving transitional justice for all victims of violence from 1958 to 2009.

Country context

Guinea is a unique country in terms of its history with violence as outlined by ICSC representative, Ereshnee Naidu-Silverman in her trip report.

Since its independence in 1958, it is a country that has experienced ongoing cycles of violence characterized by massive human rights violations and ethnic and political tensions that were exacerbated by authoritarian rulers who failed to hold perpetrators accountable and allowed a culture of impunity to flourish. Due to the repeated cycles of violence and changing actors during different conflicts, there is no clear distinction between victims and perpetrators. The decades of impunity and the lack of vetting and institutional reform has resulted in previous structures remaining intact and perpetrators continuing to hold positions of power.

Many of the participants reported rape and other Sexual Gender Based Violence (SGBV)  violations as the most common trauma experiences of victims within the country.

Others highlighted the dissolving of the family bonds due to a relative being in prison for many years. This was particularly difficult for men who have lost their place of authority within the family as the wife had to take on that role while they were away. What was striking from the stories that the participants shared was the fact that this was the first time that they had told anyone about their trauma. Many participants stated that they shared in the group experiences which even their wives did not know about. Another powerful observation was the fact that many of the men who spoke experienced their trauma in Camp Barro, a concentration camp were thousands were tortured and murdered. The camp closed in 1984 and the men spoke as if the trauma was still very fresh for them – speaking to the power of unresolved trauma which extends across generations and decades. Another theme that was present from the stories of the participants was that of vicarious traumas and  how the experiences of others impact those who are trying to assist them. In particular, the women who are assisting the victims of female genital mutilation reported experiencing nightmares, low mood and a decrease in job motivation.

State of psychosocial resources

The participants reported that there are no psychosocial service providers based in Guinea.  The majority of services are provided by international Non-governmental Organisations (NGOs) and end when they leave the country.

In addition, these services revolved mainly around the outbreak of Ebola in the country and were not related specifically to treating psychological trauma.

An article by the International Medical Corps cited census data provided by Abaakouk (2015) and Psychology in Africa (2013) to highlight the dearth of mental health services in Guinea and the results are extremely concerning. Per 100000 people in the population, there are 4 psychiatrists; 1 child psychiatrist; 13 trained generalists; 11 psychologists; 0 psychiatric nurses; 12 nurses and 2 social workers (both of whom work for the ministry of social work). This is nowhere near enough to deal with the complexity of the population’s trauma as well as the number of people requiring assistance. As one participant stated, “I believe that everyone in Guinea is suffering from trauma.” If this is the case, something needs to be done to improve access to mental health services particularlly in the region.

Speaking to co-facilitators from Liberia and Tunisa, it would seem that the need for mental health services in Africa far outweighs their availability. The Guinean government has tried to engage the services of traditional leaders, traditional healers and faith-based leaders to assist. However, these relationships have not been smooth and much work needs to be done.

Ideas on the way forward

As CSVR, we believe there’s need to train lay counsellors who are able to incorporate traditional African healing models; ideologies and cosmologies are greatly needed on the continent.

This is far more sustainable than bringing in international professionals who have to leave after a time and who do not understand the languages and cultures of the country.

However, part of the training would also need to incorporate assistance to the potential lay counsellors to deal with their own trauma before assisting others as well as ongoing scheduled supervision and debriefing spaces.

This will all require investment and buy-in from governments and communities but could go a long way to assist healing and economic development in Africa. The continent has experienced and is experiencing a lot of pain, grief and loss. We as Africans need to do all we can to heal our mother and restore the dignity that was lost over generations.

Transcending the wounds of the past: A nation’s journey to healing

The team recently attended a research seminar at Freedom Park in Pretoria on March 31, 2017 which focused on the impact of transgenerational trauma in South Africa. The seminar highlighted work done by Prof. Pumla Gobodo-Madikizela; Prof. Sharlene Swartz; Dr Shanaaz Hoosain; and Prof Maurice Apprey.

These presentations reflected a need for us as individuals, families and communities to understand the traumas of the past, and the impact it has on the present, to begin transcending the wounds of the past and heal.

Transgenerational transmission of trauma refers to the way in which unresolved traumas of the past can be subliminally transmitted from one generation to another (Volkan, 1996). Taking into account the current state of affairs in the country-violence, corruption, a call for new leadership, this was a very relevant topic of discussion.
The seminar looked at the past history of apartheid in South Africa, a time in which violence was rife and many individuals endured cruel inhuman degrading treatment in various forms. The abolishment of apartheid and the event of the Truth and Reconciliation Commission (TRC), as a path to healing the past was meant to create a space of coming clean and forgiving as we forged the rainbow nation.

Have we as a nation healed?
Understanding the impact of trauma from a psychological perspective, trauma memories have a way of embedding themselves into our individual and collective psyche and if not processed, lay dormant within us and are often triggered, giving rise to the ghosts of the past. Trauma returns but with a different face. Over the past few years, South Africa has felt the presence of the ghost, as events such as Marikana, Fees must fall protests, SABC 8, Zuma must fall, has mimicked events of the past apartheid regime.

Post-apartheid research has concluded that the past has had an impact on the social fabric of South African society, and racially inspired injustices have traumatized us as a nation. This state of traumatization has passed on through generations and the wounded, unhealed have repeated the mistakes of the past. Noted in the following ways: the continuous struggle of racial division, inequality and poverty; the use of violence as an expression of power in families, communities and state level; the lack of empathy for the other; the othering that takes places between black nationals and black non nationals, black nationals and indian and coloured nationals.

We are the so-called rainbow nation but the socialization of apartheid continues in our homes and communities. We have not consciously reconfigured the past, we have not consciously dealt with our trauma, we were simply free, yet chained within ourselves to repeat what we taught, what was modelled to us.

When will we transcend the wounds and how is it possible?
It is a challenge to transcend the wounds of the past, when current circumstances have aggravated it. Re-traumatizing us. Prof Gobodo-Madikizela states that trauma in South Africa has three faces: Apartheid trauma, which involved experiences of forced removal, racism and violence; Struggle trauma, which looks at the experiences of ex combatants, who struggled for a place in post-aparthied South Africa, as they were iconized, yet faced challenges privately in the forms of Post Traumatic Stress Disorder, family relations neglect as parents were detained and children were exposed to apartheid violence; and lastly our current experience of trauma, which is betrayal trauma, referred to Prof. Gobodo-Madikizela as the experience of betrayal and abandonment by our leaders. Some of us may have directly experienced all three traumas and others not, but we are all victims of them, as they are a part of who we are, they have impacted on us indirectly. The history, as well as, the trauma (wounds) of the past has passed down, it is the source of our pain, rage and anger.

If we are bound to the ghosts of the past, is healing possible?
According to the speakers and their research, it’s not all doom and gloom. Healing can occur and it starts with acknowledging the traumas of the past. One would say, didn’t the TRC do this. Yes and no, it started the process but it was left incomplete. There is still gaps in the memory, as silences have left a void in history. Prof. Gobodo-Madikizela and Prof. Apprey argue that youth today are disconnected from the past, focusing on their current challenges, which are valid, but have a root in the past. If I don’t have the full picture, how do I proceed to make sense of the now and take action for the future?

Prof. Apprey put this eloquently as he stated that rushing through the pain of the trauma and not metabolizing the past places us at the risk of becoming repeat agents of the past. He further explores the psychology of our integration of our past experiences and how they subtly impact on us in the now. He states that at the bottom level lies our history, some of it remembered, some not; at the next level, is the history remembered which gives form to an individual’s mental representation of the world; and at the present everyday interactional level, the history that is remembered which forms the mental representation of the world dictates how we perceive others will treat or receive us in the world.

On this point he really touches on the ways in which South Africa’s historical trauma has subliminally transferred across generations. And it is something as South Africans we see every day, in our interaction with each other, perceptions of each other and receiving of each other.

He also states that restoration is possible, it starts with accepting the trauma history, breaking the silence and getting the whole picture and dissolving the internal resistance (fighting what we were taught, socialized to think about each other) to allow for possibilities to be re-socialised and work towards Uncle Kathy’s vision of a non-racial South Africa.

Written by Sumaiya Mohamed

Click here to read a comment by Thembisile Masondo.

First blog post

This blog was started by the clinicians that work within the CSVR Trauma Clinic. the purpose of the blog is to create a platform to raise awareness of mental health related issues that arise as a result of violence.

Violence is a predominant feature in South African and global history. The CSVR acknowledges this and the complexities in which violence takes form. The CSVR works towards understanding violence, heal its effects and build sustainable peace at community, national and regional levels. This is done through collaboration with and learning from lived and diverse experiences of communities affected by violence.

The Trauma Clinic is the intervention component of the CSVR, that provides mental health therapeutic services to individual, families and communities that are affected by violence.

Posts on this blog, are clinicians reflections of the impact that violence has on mental health of individuals, families and communities, and possibilities of healing.

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