Collaborating with and becoming accountable to our clients FEEDBACK INFORMED TREATMENT

COUNSELLING WORKS In most studies of psychological treatments conducted over the last 30+ years the average treated person is better off than 80% of those without the benefit of service The average clinician achieves outcomes on a par with success rates obtained in randomized clinical trials( with or without co-morbidity)  Duncan B, Miller S, Wampold B, Hubble M (eds) (2009) Heart and Soul of change: delivering what works. Washington DC. APA press  Minami T, Wampold B, Serlin R, Hamilton E, Brown G, Kircher J (2008) Benchmarking for psychotherapy efficacy. Journal of Consulting and Clinical Psychology 75,

BUT NOT FOR EVERYONE On average counsellors achieve reliable clinical improvement with 50% of clients. Best therapists achieve around 70% 10 % deteriorate and 47% drop out before achieving RCI Clinicians not good at identifying these cases  Harmon, S.J., Lambert, M.J., Smart, D.M., Hawkins, E., Nielsen, S.L., Slade, K., Lutz, W., (2007) Enhancing outcome for potential treatment failures: Therapist-client feedback and clinical support tools. Psychotherapy Research, 17(4),  Lambert, M.J., Whipple, J., Hawkins, E., Vermeersch, D., Nielsen, S., & Smart, D. (2004). Is it time for clinicians routinely to track client outcome? A meta-analysis. Clinical Psychology, 10,

WE THINK WE ARE THE BEST In a survey in the USA half the clinicians polled considered that they achieved success with 80% of their clients 90% of clinicians thought that none of their clients ever deteriorated from seeing them  Walfish S, McAllister B, Lambert M.J _ Are all therapists from Lake Wobegon. An investigation of self assessment bias in mental health providers

EXPERIENCE AND TRAINING Counsellors tend to peak relatively early in their career and do not achieve better outcomes as they become more experienced Qualifications and training are not shown to make us more effective  Clement P (2008) Outcomes from 40 years of psychotherapy. American Journal of Psychotherapy 62(3)  Atkins D C and Christensen A (2001) Is professional training worth the bother? A review of the impact of psychotherapy training on client outcome. Australian Psychologist 36,

IS THERE A SUPERIOR THERAPY MODEL? Despite concerted efforts to prove otherwise no therapeutic model has been shown to be superior to the rest. All models work well with some people some of the time. Known as the Dodo verdict.  Rozenweig (1936)- Some Implicit common factors in diverse methods of psychotherapy. Journal of orthopsychiatry 6,  Wampold B E (1997) A meta-analysis of outcome studies comparing bona fide psychotherapies. “Empirically all must have prizes”. Psychological Bulletin 122 (3),

FACTORS AFFECTING OUTCOME Client and extratherapeutic factors. Includes clients resources, external support and ideas about change The Therapy Alliance  Wampold The great psychotherapy debate.

EARLY CHANGE In a study involving over 2000 therapists and clients Brown found that therapeutic encounters in which no improvement occurred by the third visit did not on average result in improvement over the entire course of treatment. Clients who worsened by the third visit were twice as likely to drop out as those reporting progress Variables such as diagnosis, severity and type of treatment not as important as knowing if the client believed they were making progress  Heart and Soul of Change p

THERAPEUTIC ALLIANCE Agreement on Goals Agreement on Tasks Relational Bond Congruent beliefs on how people change (Client’s theory of change)  Bordin E S. (1979)The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice, 16,  Gaston L (1990). The concept of the alliance and its role in psychotherapy: Theoretical and empirical considerations. Psychotherapy

FEEDBACK Counsellors need to monitor constantly the clients experience of : Change and improvement in the areas of their life that brought them to therapy. The strength of their alliance with the therapist.  Ankar, Duncan and Sparks- The effect of feedback on outcome in marital therapy. Journal of Consulting and Clinical Psychology 2009  Shimokawa K, Lambert M & Smart D (2010) – Enhancing treatment outcomes of patients at risk of treatment failure: meta-analytic and mega-analytic review of Psychotherapy quality assurance system- Journal of consulting and clinical psychology

FEEDBACK MEASURES  We need to have measures which are:  Reliable  Valid  Feasible

INTRODUCING THE MEASURES  Important that we are clear with the client why we are asking them to do this  If counselling is going to help it should start to help early  The client’s assessment of the therapy alliance is shown to be the more directly related to outcome than the therapist’s assessment

INTEGRATING THE MEASURES  Discuss each line and the overall score with the client  What is making them go up or down. What needs to happen to make them start to improve or continue to improve  Leave time at the end of the session to score and discuss the SRS especially if it is on the low side.

CHECKPOINT SESSION  If no progress shown on the ORS after 3 or 4 sessions it is time to discuss with the client what this means  Go over each line in the SRS  Brainstorm with the client what would be of more assistance. Different approach, different counsellor or continue as we are for now.

LAST CHANCE DISCUSSION  After 6 to 8 sessions and no improvement time to look seriously at alternatives  Important to be able to fail successfully and make a successful referral based on the client’s feedback  Clients who fail to make progress with one counsellor can frequently work successfully with another one.  By not letting go we could be standing in the client’s way to recovery.

RESPONDING TO THE SRS  A score above the cutoff generally tells you nothing  If the client scores below 36 or below 9 on any line we need to acknowledge this and invite a discussion  If the client scores above the cuttoff but clearly lower than in previous sessions we need to explore this with them

CULTURE OF FEEDBACK  Establish a culture of feedback  Take every opportunity to let clients know that you need and value their feedback.  Let your clients help you become a better therapist

Contact Bill Robinson Relationships Australia Mandurah Tel To download the measures go to For further support and ongoing discussion go to

TRACKING YOUR OUTCOMES  