Vivian Baruch

Estimated reading time: 8 minutes

My 48 minute interview by Juliet Austin & Clinton Power from the Mind Body Training Institute (MBTI). In it I discuss the science and art of Feedback Informed Treatment (FIT), which helps coaches, counsellors, psychologists, psychotherapists and social workers track the outcomes (results) and alliance (relationship) with our behavioural health clients.

What is Feedback Informed Treatment

JA: So, let’s begin. Just give us a definition. What is Feedback Informed Treatment? We’ll call it FIT for the purposes of this webinar, and how does it differ from other therapeutic models?

VB: OK, the first thing to know about FIT is that it’s not a model or a theory of therapy. That’s a really good thing to start off with. FIT is an empirically supported, transtheoretical approach for evaluating and improving the quality and effectiveness of behavioral health services. It’s a way to routinely get feedback from clients at the beginning and at the end of every session to see whether they’re getting the outcomes they’re looking for and to get their view on the alliance, the relationship between the client and us. FIT is different from a model or a theory. It’s asking for their evaluation of the service being provided.

CP: Thank you for that clarification. And is that different from saying “How are you going?” and “How was the session today?”

VB: Very different. Absolutely. Because when you say, “I’m going fine”, what fine might mean for you today might be different from tomorrow and also for the next client. So, we need to really understand what fine means in a lot more detail.

Why is gathering feedback essential for effective outcomes?

JA: Why is gathering feedback during therapy essential for effective outcomes?

VB: Okay, this is really important. If, for example, I want to lose weight after a holiday splurge, I have to measure my starting weight and I have to keep measuring my weight to see whether I’m on track or off track to getting the results that I want. And depending on what the measurements are showing me, I either keep doing what I’m doing, do more or do less. So, without measuring, we don’t know what’s happening in therapy.

There’s now a number of studies and meta-analyses that demonstrate the benefit of routinely monitoring and using the client outcome data and session feedback to inform what we’re doing. Do you want some stats or are stats too much?

JA: Stats.

The science underpinning FIT

VB: So, the first stat is that Routine Outcome Monitoring (ROM) improves client outcomes by 27%. It reduces deterioration rates by 50%. Routine measurements have found that about 5 to 10% of our clients can get worse in treatment, and without measuring we don’t know that.

JA: Just to clarify there Vivian, a deterioration rate is when a client enters therapy and then gets worse over time. Worse?

VB: Yep, deterioration rate is 5% to 10%. We have no way of knowing that if we’re not measuring. The other things that FIT does is increase client retention, so we can keep clients longer in treatment without them dropping out unexpectedly, with no warning or before any improvement has happened. And it also can shorten the length of stay. FIT is a way for actually working well with clients and them getting the outcomes that they want. You will see the results, they will see the results. And they say “Okay, great. We’re stable enough now. Thanks very much.” And they’ll leave therapy, having got what’s called a “clinically significant improvement” in their level of wellbeing and a reduction in their level of distress.

CP: Let’s talk about how it works practically in a session. Can you walk us through a therapist is using FIT, what does it look like at the beginning and the end of the session?

The Outcome Rating Scale (ORS)

VB: OK. In the first few minutes of every session, we use any one of the apps recommended by the International Center for Clinical Excellence (ICCE). These are empirically validated and reliable assessment tools. I’ve been using FIT for 21 years and the MyOutcomes app since 2010. And so, the first measure that we use is called the Outcome Rating Scale (ORS).

The ORS measures the client’s therapeutic progress while asking about their level of distress and functioning. It asks the client to rate themselves from 0 to 10 in four questions at the beginning of the session. 1. How they’ve been feeling within themselves in the last two weeks. 2. How they are in their close interpersonal relationships – with their family, their partner, the people they live with. 3. How they rate their social context, such as their work, their extended family, their friendships, their community. 4. How they rate themselves overall, in their general sense of wellbeing. The black dotted line on the graph below plots a client’s ORS progress over seven sessions.

What we’re looking for is the level of distress that they’re reporting. I ask the questions, and enter their numbers in the MyOutcomes app. Then I show them the graph so we can discuss it, asking questions like ”What do you mean by 8 out of 10 in your individual self? Say more about your rating of 6 out of 10 in your personal relationship? What do you mean by 3 out of 10 in your work and your social context?” This enables them to put words to the numbers (giving their qualitative explanation) for the quantitative numbers they rated. Really the numbers and measures are just the beginning of a conversation. Once we unpack their meanings, I’ll ask them “Given what we’ve talked about so far, what’s most important to address today?” And that’s what we focus on, they choose the focus for that therapy session.

The Session Rating Scale (SRS)

In the last few minutes of every session I ask four questions, again devised by the same smart researchers who have, over the last 25 years, refined the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS) so that they’re very simple and clear. The Session Rating Scale gets their quantitative view about the session, their experience of it. They’re not rating me, they’re rating their experience when asked the following questions: 1. “How much did you feel heard, understood and respected today?” 2. “Did we talk about what you were hoping to talk about?” 3. “How did the approach/method used today fit for you? Did it make sense?” 4. “How would you rate today’s session overall?” and “Was there anything at all missing?” The grey dotted line on the graph above plots a client’s SRS over seven sessions.

Their answers are plotted on the MyOutcomes app, and the FIT training teaches us that any rating under a total of 36 out of 40, (’cause there are four questions, rated 0-10), we must ask about it. I say something like “Tell me more about that”, “What didn’t make sense to you? Please, can you tell me when that happened?” or “Give me a specific example about when you didn’t feel heard or understood or respected”.

Because I mostly see couples, they’ll say something like “My partner didn’t do …”, or “They screwed up their nose”, or “They laughed.” They’re rating their real experience, giving real-time feedback, which is immediately incorporated into the next session. This enables therapists to adapt the work that we do based on the client’s experience of whether they’re improving, staying the same or getting worse, shown as green, yellow or red on their ORS graph done at the beginning of the session. We discuss their view of any improvement, or not, in their life outside of the therapy. And the Session Rating Scale (SRS) is their view of their experience of the therapy session and the working alliance with us.

It’s up to the therapist to be flexible

It’s on us to keep asking “How’s it going?”, “Is it working for you?”, “Is it not working?” “What needs to happen to make this work for you?” And the FIT training teaches us to accept and honour their feedback. This is called creating a culture of feedback so that you don’t take the feedback personally. This is about them giving voice to their experience. If someone doesn’t like a movie that we go to together, we don’t take it personally. We say, “Oh, what didn’t you like about it? I really liked the music, or I really loved the photography. What didn’t work for you? It’s the beginning of a conversation about the movie.

FIT teaches us to coach clients about how to give feedback regarding any little thing that didn’t work for them in that session, or could have been done differently…. The full trancript is shown next to the video above.

• This webinar was hosted by the Mind Body Training Institute: https://mindbodytraininginstitute.com/

• FIT training is available from the International Center for Clinical Excellence (ICCE)

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