How do you determine your level of effectiveness in your work with clients? In everyday practice, counselors typically rely on clinical judgment and their own assumptions about the therapeutic alliance and client progress. Few would argue against the importance of good clinical judgment, but there is persistent evidence that counselors’ views of the alliance and client outcomes are often at odds with the views of clients.
In regard to helping clients attain positive outcomes, research evidence and clinical wisdom converge strongly on the therapeutic alliance. However, while research and meta-analyses have repeatedly demonstrated the power of the alliance, an important nuance in those findings is that the client’s view of the alliance is consistently found to be a better predictor of counseling outcome than is the counselor’s view. Additionally, counselor views of the alliance frequently do not correlate well with the views of the client.
Because client perceptions of the alliance are a better predictor of outcome than the counselor perceptions are, a validated model for collecting continuous feedback from the client is needed. Furthermore, integrating client feedback into counseling services can help counselors check their assumptions, increase counseling’s effectiveness and privilege the client’s voice. This article is a review of a systematic, validated and practitioner-friendly method for monitoring the client’s view of the alliance and outcome known as feedback-informed treatment (FIT).
Formal client feedback
Collecting feedback from the client emphasizes counseling tenets related to understanding clients’ subjective experiences, cultivating a quality relationship, supporting clients’ abilities to choose their goals and how to meet them, and working in service of a positive outcome for clients. In counseling practice, counselors typically evaluate these important factors informally, but this is an area in which counselors — and clients — can benefit from formal feedback. Indeed, numerous studies have found that counselors, despite their confidence that they accurately appraise the strength of the alliance and client progress, are poor at gauging these elements when using clinical judgment alone.
In a representative study from 2009, researchers Morten Anker, Barry Duncan and Jacqueline Sparks conducted a randomized clinical trial of couples counseling in a naturalistic setting. Clients were randomly assigned to either a feedback group (in which the counselor would obtain session-by-session feedback from clients using a brief alliance measure and an outcome measure) or to a “treatment as usual” group. Pre-study surveys showed that all the counselors believed they were already acquiring outcome and alliance feedback from their clients without the use of a formal feedback process and that formal feedback would not improve their effectiveness. In contrast to those pre-study beliefs, findings revealed that 90 percent of the counselors improved their outcomes with clients after integrating formal client feedback using brief measures of alliance and outcome. This finding, coupled with findings from similar studies, illustrates the tendency for counselors to assume that their informal method of checking in with clients is as useful as a formal feedback process.
Because of cumulative research on the client’s view of alliance as a predictor of outcome, research on formal client feedback has burgeoned during the past decade, and the evidence is compelling. In 2010, outcome researcher Scott Miller conducted a review of existing research on integrating client alliance and outcome feedback into counseling services. At that time, 13 randomized trials with more than 12,000 ethnically and diagnostically diverse clients had found that simply incorporating client feedback improved counseling outcomes by as much as 65 percent, decreased client dropout rates by half and decreased deterioration (clients who got worse) by 33 percent. The act of consistently engaging with clients about their experience of the alliance and the degree to which the sessions were helpful had a profound influence on client outcome.
Barriers to formal feedback
The term formal in this case refers to using validated tools for eliciting client feedback about their perception of the alliance and outcome. We acknowledge that the notion of using a form to obtain client feedback can create resistance among counselors. The method might sound reductionistic to some clinicians, or they might regard it as having the potential to trivialize the alliance by assigning a number value to it.
Although these concerns are understandable, it is important to remember that client feedback tools are not for assessment in the traditional sense. Rather, they are primarily dialogue tools. The aim is to open dialogue and put clients in the driver’s seat to express their experience of the alliance and whether progress is being made. This in turn enables the counselor and client to work collaboratively to make adjustments and individualize the services being delivered.
When we present this information at conferences, there are sometimes counselors who indicate that they check in with their clients verbally or informally about the alliance and outcome. Counselor intentions to check in with clients are no doubt rooted in an aim to truly understand clients’ experiences. Some research has indicated, however, that counselors think they check in with clients far more frequently and consistently than they actually do. Indeed, our own experience of first beginning to use an alliance measure was that sometimes we would give the measure at the end of the session and sometimes we wouldn’t. The problem with counselors choosing whether or not to check in formally about the alliance is that it places the decision in the wrong hands.
FIT alliance and outcome tools
FIT involves incorporating the client’s perspective about the therapeutic alliance and outcome. Specifically, FIT includes the use of two ultra-brief, validated measures that are used to open and broaden conversation about the alliance and outcome.
The Session Rating Scale (SRS) is a four-item measure of the therapeutic alliance that the counselor administers at the end of each session. This takes only about one minute to do. The first three items of the SRS correspond directly with the domains of the alliance found in the dominant definition in the mental health field. The fourth item simply asks how the client felt about the session overall. The four items of the SRS are as follows:
1) Relationship (degree to which the client felt heard, understood and respected)
2) The goals and topics (degree to which the client was able to focus on what he or she wanted to in session)
3) The approach or method (how the client felt about the counselor’s approach)
4) Overall (degree to which the overall session felt right and on track for the client)
Each of the items is on a 10-point visual analog scale. Clients are asked to reflect on the session, complete the brief form and then discuss their feedback with the counselor.
The Outcome Rating Scale (ORS) is a brief four-item tool for measuring the client’s perspective of change or improvement (or lack of improvement) in relation to the initial score at intake. The counselor administers the ORS at the beginning of each session. This takes about one minute. The first three items are based on three domains of the much longer Outcome Questionnaire-45, while the last item refers to the client’s general sense of well-being. The four items of the ORS are as follows:
1) Individually (personal well-being)
2) Interpersonally (family, close relationships)
3) Socially (work, school, friendships)
4) Overall (general sense of well-being)
In 2012, the Substance Abuse and Mental Health Services Administration (SAMHSA) designated the systematic use of the SRS and ORS to monitor and improve alliance and outcome as an evidence-based program and practice. These measures have good reliability and validity for such brief measures and, unlike longer measures geared toward research, they are designed to be used in everyday practice.
Introducing formal feedback in counseling sessions
With most any intervention, process or method in counseling, simply going through the motions doesn’t translate into effective, competent practice. The same applies to the use of the ORS and SRS. These tools are intended to privilege the client’s voice and provide a reference point for the client’s experience. Intention, openness to feedback and clarity of purpose are required of counselors to truly engage clients collaboratively. With this in mind, sample scripts for introducing the measures are provided below. Keep in mind that the ORS is administered at the beginning of each session and the SRS at the end of each session.
Introducing the ORS
“A primary focus of mine in working with you is to make sure that you are getting what you want and need out of our sessions. So, it is really important that we are discussing and tracking how you are doing and whether things are improving in your life. I have a really brief form that I use every session just to get a snapshot of how things are going. This form allows us to get a sense of important areas of your life and how things are changing or not changing over time. It also helps me to figure out if I am being helpful or not, and that is really important for me to know. It will only take a minute or so to complete. On each of these four scales, just place a hash mark indicating how things have been for you over the past week, with lower scores to the left and higher scores to the right.”
The client then completes the ORS and, afterward, the counselor attends to and mentions any particular domain that is lower than the rest. The session then progresses in a traditional counseling format.
Introducing the SRS
“Before we wrap up today, I would like to ask you to fill out another really short form. This one deals directly with how our session was today. It is really important to me that you are getting what you want and need from coming here, and how well we work together directly relates to how well things go for you overall in counseling. I truly want to hear any feedback you have about our session, especially if it is feedback that you might think is not positive or about something that was lacking in our session. Sometimes it may be something big that I missed or that wasn’t right in our session, and I want to hear about that. However, it could also be something seemingly small that wasn’t quite right about our session today. It may seem so small that it’s not worth mentioning, but I’d like it if you would mention it. I also want to emphasize that you don’t have to be concerned about hurting my feelings and that I really welcome your feedback. Like with the other form, there are four different scales, with lower scores to the left and higher scores to the right. Just put a hash mark on each line indicating how the session was for you today. Thanks!”
After the client completes the SRS, the counselor inquires about and attends to scores in any domains that are lower. The counselor needs to maintain a stance that communicates not just openness to feedback but also that the counselor will attempt to incorporate the client’s feedback to guide treatment.
Creating a culture of feedback
On the surface, the use of these brief measures may seem simple. In fact, this is often the initial response of counselors when they begin using the SRS and ORS. However, it quickly becomes apparent that these tools can be used in a manner that makes them little more than a meaningless ritual at the beginning and end of sessions. To use these tools in a way that yields truly beneficial results for clients, counselors need to create a culture of feedback.
The first, and perhaps most challenging, step in this process is for counselors to become very clear about whether they really want client feedback and if they are prepared to handle feedback with openness and receptivity. In essence, the counselor’s goal with the SRS is to strive hard to encourage clients to share even small things that were not to their satisfaction about the session. Indeed, research findings on top-performing counselors (that is, counselors whose outcomes are significantly greater than those of the average counselor) indicate that they typically receive lower SRS scores in the early stages of treatment. These counselors are very adept at getting clients to share feedback about elements of the alliance that are weak. In fact, when counselors receive consistently high SRS scores from clients, it is often an indication that they have not adequately created a climate in which clients feel comfortable providing truthful feedback.
Creating a culture of feedback with clients essentially means that counselors are very receptive to feedback and will use this feedback to guide and adapt services. Soliciting feedback effectively requires that counselors clearly explain the ORS and the SRS as well as the purpose of these two tools. When counselors communicate openness to feedback (especially critical feedback) and responsiveness to client preferences, they are more likely to receive the feedback they need to individualize services.
There is strong evidence that integrating alliance and outcome feedback into counseling improves overall outcomes. FIT is pan-theoretical and can be used in conjunction with any treatment approach. Key considerations to start integrating client feedback into counseling services are as follows:
- Download the ORS and the SRS from the International Center for Clinical Excellence at centerforclinicalexcellence.com. This is free for individual practitioners.
- When downloading the performance metrics, read the information on how to score and introduce the measures.
- Practice administering the measures with a colleague. Use your own language, but hit the key points highlighted in the sample introductions in this article.
- Seek internal clarity on your openness to hearing and responding effectively to client feedback. Remember that a characteristic of top-performing counselors is that they often solicit negative alliance feedback (and receive it nondefensively) and are able to modify treatment according to that feedback.
- Read additional articles on this topic, a number of which can be accessed on Scott Miller’s website (scottdmiller.com).
- Work to create a culture of feedback with clients. Don’t use the ORS or the SRS with existing clients, but begin to use the measures in every session with new clients.
- Track client ORS scores on a graph for visual indication of the client’s outcome over time.
- If clients are not improving (by an increase of five points from the initial intake score) on the ORS by session four, have a conversation with the client about the alliance and what could be done to improve treatment.
- Seek supervision or consultation from someone who is familiar with FIT.
- Keep in mind that even the best counselors have clients on their caseloads who are not progressing or improving. Having a reference point for clients’ experiences of change allows you to individualize services and improve client outcomes.
As counselors, we have been trained to build and invest in an alliance with our clients. The therapeutic factor of the alliance itself has been found to be a better predictor of client outcomes than client diagnosis, the professional discipline of the clinician, years of clinician experience, the client’s previous treatment history and the specific treatment approach. Attending to the therapeutic alliance is critical for successful counseling, and given that counselors’ and clients’ views of the alliance are often at odds, a method for aligning those perspectives is needed. Integrating FIT practices is a way to create a consistent culture of feedback, privilege the client’s voice and individualize treatment needs for the people we serve.
Those interested in more information on this topic can refer to Sidney Shaw and Kirsten Murray’s article, “Monitoring alliance and outcome with client feedback measures,” published in the January 2014 issue of the Journal of Mental Health Counseling.
Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.
Sidney Shaw is a core faculty member in the clinical mental health counseling program at Walden University and a certified trainer for the International Center for Clinical Excellence. Contact him at firstname.lastname@example.org.
Kirsten Murray is an associate professor and chair of the Department of Counselor Education at the University of Montana. Contact her at email@example.com.
Letters to the editor: firstname.lastname@example.org