Welcome to the July edition.
In SAVVY, STUMP THE SHRINK and SKILLS, a reader asks about my thoughts on Feedback Informed Treatment (FIT). It reminded me of how far behind we still are from the rest of healthcare’s Measurement-based Care practices. Check out Jim Walt’s entertaining and informative keynote presentation about golf and what it has to do with Feedback-Informed Treatment (FIT).
In SOUL, I share another joke-with-a-message from Funsteria about cutting off the end of the ham before baking it. How often do you do something because that’s the way it’s always been done?
David Mee-Lee, M.D.
DML Training and Consulting
SAVVY, STUMP THE SHRINK and SKILLS
Earlier this month, Delilah, a student at the Hazelden Betty Ford Graduate School of Addiction Studies, asked me my thoughts on several issues to do with Feedback Informed Treatment (FIT). Her questions have broader implications for the area of Measurement-based care of which FIT is a premier example and method. Here are her questions:
In the Hazelden class we are taking now, we are discussing Feedback Informed Treatment (FIT) surveys. Do you have anything you have written, or have an opinion on Session Rating Scale (SRS) and Outcome Rating Scale (ORS) surveys.
I think surveys are impersonal and generally can be ineffective.
When it comes to counseling and a good therapeutic alliance, isn't asking for feedback by the counselor of the client, better done when the timing is right and in person?
In a person centered approach, wouldn't asking for feedback on how the alliance is going be a natural thing to discuss and get live feedback?
A lot about the surveys seem like a mediocre way to collect feedback, from what is a very personal, often sensitive relationship.
I just wanted to check and see what you thought.
Thank you in advance.
Delilah
Delilah Mahl
Graduate School Student
Hazelden Betty Ford Graduate School of Addiction Studies
Email: DMahl@hazeldenbettyford.edu
Tip 1
Hear Scott Miller, Ph.D. briefly explain FIT and the FIT Alliance Stool. His work has for years changed my whole understanding of measurement and outcomes-driven care.
Go to scottdmiller.com, scroll down to Scott’s most informative FIT TIP 4 minute video. He introduces FIT, ORS and SRS and the FIT Alliance Stool - Improving Outcomes for “at risk” Clients: The FIT “Alliance Stool” April 11, 2023
The FIT Alliance Stool highlights:
The “What?” – Goals, Meaning or Purpose
The “How?” – Means or Methods
By “Whom?” – Client view of the bond and role of the helper
With “Whom?” – Client preferences, values, identity, culture/worldview
Tip 2
Focus on Treatment Outcomes Measured in Real-Time to Guide Treatment.
Delilah said: “When it comes to counseling and a good therapeutic alliance, isn't asking for feedback by the counselor of the client, better done when the timing is right and in person? In a person centered approach, wouldn't asking for feedback on how the alliance is going be a natural thing to discuss and get live feedback?”
You would think asking for feedback would be a natural thing to discuss; and yes, getting live feedback is the way to do it. The ORS and SRS are indeed done “live” but the timing is at every session in outpatient therapy and every week perhaps in residential settings.
If you provide counseling or therapy, how often has this happened to you?
- You thought you had a good session with a client, pointing out insightful self-defeating patterns with therapeutic brilliance, only to have them miss the next session or even drop out of treatment?
- The client sits passively in sessions and you feel like you are doing all the work to get them to talk.
- The client wants to see you, but they don’t seem to be making much progress or change in their life. You wonder if you have just created a dependent relationship where you are a paid friend?
Whatever real-time feedback mechanisms you use, the goal of such measurement-based care is to guide treatment in the here and now and hopefully avoid these common clinical dilemmas.
So getting live feedback is not left to when the timing is right, but rather a deliberate and routine process at every session. When you accumulate trend data on how the client is doing and the quality of the therapeutic alliance, you can be proactive about what to change in treatment to minimize dropout, increase engagement and improve outcomes.
With treatment of chronic illnesses, changes to the treatment plan are based on treatment outcomes and tracked by real-time measurement at every visit (e.g., blood pressure or blood sugar levels are monitored to determine the success of the current treatment regimen).
It should be no different with behavioral health treatment. How do you know if the client is engaged in a good therapeutic alliance and improving if you don’t actually measure and track the alliance and outcomes?
Tip 3
Practice without real-time feedback is like hitting golf balls and not tracking where they land.`
Ten years ago, in the August 2013 edition, I wrote about this TIP and the importance of real-time feedback to know if what you are doing with clients is effective or not. At the 2013 Annual Conference of the California Association of Marriage and Family Therapists (CAMFT), Jim Walt, a licensed Marriage and Family Therapist, gave a keynote presentation about golf and what it has to do with Feedback-Informed Treatment (FIT).
It is worth watching his entertaining and informative 15 minute presentation.
A few of his points:
- If your clinical practice is not focused with purpose, you may feel like you are doing good work, but without feedback, you don't really know if you are being effective.
- When you drive the golf ball, you need immediate feedback on how close you came to the 3 feet circle of the hole; or how far away you were from the 145 yard mark.
- Based on that real-time feedback, you can know whether you have to apply more force, a better angle or adjust your grip on the golf club to hit your mark.
- Hitting golf balls with no feedback is meaningless practice if the goal is to be effective and purposeful.
- Jim Walt talks about how we should relish getting feedback from the client on whether the session we just had hit the mark or not.
- Even better, candid feedback on how the session was not helpful provides the information the therapist needs to know how to adjust things for the next session.
Tip 4
Questionnaires and client surveys after the fact of treatment are inadequate to measure outcomes and effectiveness of your services.
Delilah said: “I think surveys are impersonal and generally can be ineffective. A lot about the surveys seem like a mediocre way to collect feedback, from what is a very personal, often sensitive relationship.”
I agree. I don’t know if treatment and service providers are still sending out surveys after a person “completes” treatment, asking them a variety of questions about the facilities, staff, food, programming and treatment experience.
If you really want to know how your services are experienced by your clients, the only effective way to have actionable data is real-time feedback and measurement-based care. Based on the immediate feedback – good, bad or indifferent – you now have a chance to collaborate on real-time changes to the treatment and service plan and enhance the therapeutic alliance and results.
SOUL
I have written before about my daily ritual to see what joke Funsteria has come up with to make me laugh. In March 2023, I shared a joke about the bear, wolf, fox and rabbit. If you missed it, take a look because it has a great lesson for your clients.
This month, I have another joke-with-a-message from Funsteria.
A young woman was preparing a ham dinner. After she cut off the end of the ham, she placed it in a pan for baking. Her friend asked her, “Why did you cut off the end of the ham”? And she replied ,”I really don’t know but my mother always did, so I thought you were supposed to.”
Later when talking to her mother she asked her why she cut off the end of the ham before baking it, and her mother replied,”I really don’t know, but that’s the way my mom always did it.”
A few weeks later while visiting her grandmother, the young woman asked, “Grandma, why is it that you cut off the end of a ham before you bake it?”
Her grandmother replied ,”Well dear, otherwise it would never fit into my baking pan.”
How often do you do something because that’s the way it’s always been done? When it comes to being more effective in our work with clients, it’s time to do something different. Actually ask clients, in real-time, at every session if what we are doing with them is a good fit for them; and if it is working for what they want?
If you don’t ask, you are likely doing the same thing because that’s the way it’s always been done.
Until Next Time
Thank-you for joining us this month. See you in late August.
David