Elternberatung und Jørgen Enstrøm Manager, Familiecentret Spiren, Holstebro Municipality Denmark Let the client guide you and improve your outcome trough Feedback Informed Treatment First I will ask you to spend a minute or two paying attention to our personal wellbeing. Look back on the week past and consider the following four questions. Imagine you put a mark on the line. At the left end is as bad as can be. A mark at the right end is as good as possible. So please consider and place your marks with your mind s pencil: Individually: How would you score your personal well being, in relation to yourself? Interpersonally: Your wellbeing in relation to family and close personal relationships Socially: In relations regarding work, school, friendships Overall: How do you experience your general sense of well-being? Thank you for engaging in this little exercise. In a moment I will get back to the scale, but let me introduce myself, and the topic I m here to talk about. Presentation Being educated as a psychologist and trained as a specialist of psychotherapy in the field of socially challenged children, youth and families, I have a strong experience of how useful therapy can be. It s a kind of work where you sometimes get close to the experience of actually saving people. To make a difference that really meant something in people s lives. But I also have numerous experiences with how useless a therapeutic meeting can be. How lost I can find myself, trying to help someone who came to me, with hopes that I could be the rescue from suffering. An overwhelming feeling of impotence. This is for me a defining dilemma in therapeutic work. For a long time I thought, that this was a condition of the job European Convention Educational Competencies require Parental Competencies" 25.-27.September 2013 in Potsdam
that I just had to contain. Frustrating to contain, when certain paradigms claim to produce results with evidence based certainty. How can that be, when my experience is, that nothing works without individual adjustment, and some cannot be helped anyway? But then I met the perspectives of Feedback Informed Treatment by Scott D. Miller, that showed me quite different and more meaningful approaches to this dilemma. Feedback Informed Treatment is based on numerous findings from scientific studies of therapy: 1. Therapy works Research in the effect of therapy shows that therapy works. We can make studies comparing different therapeutic styles and find varying effect sizes, but all studies show generally good effect of any intervention that is actually meant to be therapeutic. We have to remember though, that when we see research findings of effect of treatment, we always see a percentage that was helped. The rest did not. So we have to remember that, when we get excited about that new evidence based method: What will we offer those who don t get helped from it? 2. All therapists can help some With some of the clients a therapist meets, he will do what he prefers to do, given his personality and training. And it will be highly useful. Other cases will challenge him more. Effect does not come easy, and he may find that he will have to streach out of his professional comfort-zone to be of any help. But it may be possible. Others again, he may strive and try to adjust, and whatever he does it still does not help. A lot of professional helpers are brought up to see it as a personal and professional obligation, to be able to help everyone. Everyone who can be helped, that is. This implies a problem: When you fail to be helpful, how do you think about that? You are stuck with a choice between ideas such as these: - I am not good enough! - It s coming. We just didn t get there yet! - The client is a helpless case. If he can not be helped by me, it s because he is out of therapeutic reach! What do you choose?
Research has shown, that any average therapist will be able to help most clients he meets. But a substantial share probably about 1/3 he cannot help! Not because you are lacking a specific method or technique, or because the client is impossible to help. But because the alliance is the most important factor of any treatment, and that only works in some cases. When we look at the therapist s choices of perspective, in the unsuccessful case above, these research findings offers relief for the responsible therapist: Some meetings are just not meant to become helpful. The best you can do is to help the client move on to other, more helpful options of help. This happens to be very challenging to many helpers. Somehow, the concept that I can only help 2/3 is so disappointing, that it s more appealing to declare the sorry client untreatable. But if you re only covering up your own inability to be of help, this is a cardinal sin! 3. Positive outcomes shows early Some cases you treat will profit from a brief intervention. Some need longer durations of support. Consider carefully this research-result: A therapeutic intervention that ends up with positive results, will start showing results very early. As soon as 3 rd session. If you reach the 7 th session with no sign of positive effect, you re not likely to achieve any, no matter how long you go on. It can be a little hard to take in, if you, like I, have been working in a professional team of therapists, where we could spend a half year meeting the client weekly, expecting the positive alliance to emerge. Same research shows, that the time for the biggest change in therapeutic processes is the early period. You get better fast, or you don t get better at all. Longer therapeutic relations can be very useful, to support the consolidation of the achieved changes. But only based on an early experienced positive effect. 4. Engaging the client is key to effect In my years as a therapist, I have spent more time than I like to think of, discussing what a certain non-progressing client needed. We tend to follow the medical pattern: Analyse with the authority of the expert - what is the problem here? Then ordinate a treatment that is designed and tested to treat exactly that problem. But here the therapeutic job begins: How to get the client engaged? Let s take the impulsive and not so empathic mother of an outward reacting 8 year old son. We can all agree she needs to get more in balance with herself, contact her inner ambitions for her motherhood and suspend her own needs a bit, and develop more attentive relations to her son. And we ve got a program for that. Yet, she doesn t want to attend!
Research has revealed, that that having the client engaged in therapy is key to achieving effect. This can sound banal, but can be cruisal. It should guide myattention, when things doesn t go as I wish. Should I spend more time analysing what this client really needs? Or should I spend my attention figuring out what the client wants and how she wants it? The latter. Feedback Informed Treatment To take the consequences of all this, we need to identify which clients are making progress, and which are not. Unfortunately studies have shown, that surprisingly enough therapists are not very reliable in evaluating the progress of clients. We tend overlook non-progression or deteriorating, and come up with way too many explanations. So we need 1. Feasible and reliable ways of measuring change and effect 2. Feasible ways of evaluating the alliance 3. Ways of engaging clients Measuring change: the Outcome Rating Scale You have already experienced the FIT-measure of change, called Outcome Rating Scale. It is a general measure of wellbeing, so general, that it can seem naïve. But never the less. Imagine you come for treatment today, for whatever distress. At the outset, your therapist will tell you: We are here, because something in your life is not as you wish for. And you hope coming here will make things better for you, right? I will do all I can to help you, and you must do all you can to help me help you. We can expect, that you will experience change soon, if what we do together is beneficial. If we don t see things getting better soon, we have to see if we can change something, to make it more useful. OK? So to make sure we re on the right track, I use a very simple measure of your well-being. These are the parameters that are most likely to change, if what we do is useful. So every time we meet, I will ask you to consider these 4 questions, and register on these scales. Individually: How would you score your personal well being, in relation to yourself? Interpersonally: Your wellbeing in relation to family and close personal relationships Socially: In relations regarding work, school, friendships Overall: How do you experience your general sense of well-being
After having filled these four lines we can establish a quantitative score. The lines are 10 cm each, so measured from left to the mark on each line, we can calculate a sum-score between 0 and 40 cm. The score can be put in a diagram, so you can track the development. What I show here is registrations in a computer program, running conveniently on a tablet-pc for handy handling in the session. You expect to see people in treatment show some distress in the beginning. Otherwise there was no reason to be here. And you want to se things get better. Otherwise there is no reason to come back! You may ask: Is that valid? Can a tool as simple as that say anything relevant about effect of treatment? When we go through all sorts of trouble identifying detailed needs for development, we can not reduce the measurement of effect to 4 parameters as simple as that!?! First of all, whatever else is being addressed in treatment, we want it to affect these parameters, don t we? If the kid is being more quiet in school or the father s tempertantrums are less frequent, if the well-being-dimentions are not any better, or perhaps even going down, we don t trust the symptom-change to be lasting, do we? So whatever else we re addressing in treatment, we want people to be feeling better on dimensions such as these. Secondly, the fact that a measurement is complicated, does not guarantee validity, when we measure something as complex as human development. Several studies have shown, that this little measure is in fact as valid as many other much more complicated ways of measuring therapeutic effect. And last but definitely not least: This is feasible. You may desire all sorts of documentation, but what do you actually manage to gather, on a regular basis? This can be done. I should add two things, regarding the use of FIT with kids. - The ORS comes in a version designed for kids, - with kids, we often use the scores collaterally, so we ask someone to rate the ORS as they see the child s wellbeing. The parents of cause, the socialworker who sent the family to treatment, the teacher, an uncle or others, who know the child well. Monitoring the Alliance: the Session Rating Scale The second tool of Feedback Informed Treatment is both a measurement of the alliance, a tool for the therapist to finetune the relation, and a tool to stimulate the co-responsibility for and co-creation of the cooperative relation.
The so called Session Rating Scale is administered at the end of the session, and identifies 3 parameters that research has shown central to the client s experience of treatment: Relationship: Did I feel heard, understood and respected by the therapist? Goals and Topics: Did we work on and talk about what I wanted to talk about? Approach or Method: Is this therapist s approach a good fit for me? Again the fourth parameter is the overall evaluation, taking anything into account: Overall: Was todays session just right for me, or was something missing? So imagine again what it would be like, if your therapist would end each session something like this: That s it for today, then. But before you leave, I want to ask you to help me a bit, to help you better. Perhaps there are things I am unaware of, that could make the sessions more useful for you. There can be things that are obvious to you but I overlooked, that got in the way of our work today, or could have made our work more suitable for you. So please fill out this form, to help me understand anything that could make our work together better for you. You fill out the form, and we talk about it: Good to see there is a lot you liked and This parameter interests me, as it is a bit lower than the three others. Please tell me a bit more about why that is. Engaging the client Usually, publicly treated clients have some ordination assigned to them. They are in treatment, because someone figured out, that they need to change something. But that doesn t mean the client is interested in that. The only way to find out, is to ask. The job you are given may be, to develop the parental skills of your client. But if he is so caught up in worries of economics, of conflicts with his ex-wife or other issues, that he does not see the relevance of your agenda, chance of engaging him in his parental behaviour is minimal. So either you follow him to where his energy lies, and try to help him out in this. Or with some skills and luck, you are able to make him realise the value of focusing on the parental issues, in the middle of this always-unpredictable mess of a life he is experiencing. The point is: Work can only be done, where he is engaged. If he is not engaged in the parental issues, they will not develop. If you achieve an alliance based on what seems important to him, you become a person of significance. And with significance also a possibility of inspiring his engagement in directions such as the more honourful sides of his personal motives possibly even his forgotten ambitions of being a better father than his own father was.
Where I work now, the adult client s strongest motive can be the desire to get out of treatment. The mandated client will often have this as an overshadowing motive. If you just accept and acknowledge this, you have a good chance of contact. From there you can move on to: What will it take for the caseworker to accept, that you no longer have to see me? Usually he will show good insight and be able to point out needed changes of parental behaviours. And we surely can help him with that! Engaging the client is not new, what so ever. But we can easily forget, that engaging the client is more important than finding out what the client needs. The Session Rating Scale helps us keep contact with the clients motives at all times. The potentials of Feedback Informed Treatment Optimizing the relation Using Feedback Informed Treatment helps move the relation from an expert delivering something to a recipient, to a co-creative process. As the professional part of cause you are responsible for the relation and developing it, but getting the feedback so directly from the client, is extremely helpful. I was trained to consider the therapeutic relation a co-created construction, and to value the perspectives of the client. But how many times did I leave the therapeutic room with bad vibes, crawling to the support of colleagues or supervisors for them to help me find a better way - without asking the client? Now I see it as my overresponsibility for the relation that led me to avoid what would be most useful. Creating this atmosphere of feedback gives the client the hope and trust, that he can influence the relation, the room, and the process. Optimizing your time and resources The public resources are limited anywhere. It is crucial that we spend it wisely. Trying to help someone that you are never going to succeed helping, is waist of resources, if it can be predicted. The use of Outcome Rating Scale gives us strong indications, if we are starting out good, or have a lost case. It takes some of the heavy responsibility off the shoulders of the therapist, and puts the voice of the client in a stronger position. I carry in my catalogue of failures a number of cases, where I kept going on for months and perhaps years, without any real indication, that progress was being made. Given the above mentioned premise, that long term effect is well predicted by early change, the use of Outcome Rating Scale will soon let us know if what is happening is fruitful or not. If the ORS shows no progress, we can make it a shared focus of interest with the client that we need to do something else, for things to start getting better. It s my responsibility to have ideas - and access to more of them from colleagues - but the more the client can be co-
creative, the more chances of matching. Here the Session Rating comes in: What aspects of our cooperation need to be changed? If we try to change what we can think of, and still nothing helps, perhaps the client need to see someone else than me. Again we remember the above premise, that you can only help some. So for the therapist to accept, that this match is not meant to succeed is not so personal despite the fact, that it might very well relate to very personal aspects of the relation! I remember one client I honestly really didn t like. I thought: She really is an unfortunate girl, to be so difficult to like. Good for her she has got me to talk to, as I am a professional, and able to treat her decently despite her unfortunate relational appearance. So I kept up the relation, despite no obvious signs of development. Nothing to be proud of! I reveal this as a warning to everybody. It is so exciting to see, when we change therapists, how likability is so very varying from one therapist to another! A client that can provoke strong feelings of aversion in one therapist can evoke tender compassion in another. So accept I have to accept my human limitations, even as a professional helper, and let those go, who are better of without me! In a house of multiple therapists: Just let a colleague try. It just might do all the difference. Optimizing the effect To give an impression of the potentials of using Feedback informed Treatment I will quote a single of many clinical trials. In a Norwegian RCT-study from 2009, Anker and colleagues studied couples therapy on 461. Half of the couples had couples therapy from a team of therapists, the other had the same therapy from the same therapists, but with only the use of SRS and ORS added. The group of clients that were met with FIT, experienced outcomes three times the outcomes of the control group. Dropout-rate was half of the control, and divorce-rate in the two groups was 18.4% in the FIT-group as opposed to 34.2% in the control. Remember: With no difference in methods and approach. Since we implemented FIT in my organization, we treat 40% more families with the same staff, without any new method. Using FIT we make evidence of effect on a single-case level. We make sure we are making ourselves useful in every case, or we do something else fast. Thus we optimize the use of our public resources. FIT an Evidence Based Practice I hope I have made it clear, that using FIT sets no restrictions on the methods you use. You can do whatever you find relevant to do in co-creative processes with the client.
Therapy guided by the use of FIT is now acknowledged by the American organization SAMHSA as being evidence-based practice.