Feedback Informed Treatment–
Dr. Ryan Melton
Research Faculty/EASA Clinical Director
Portland State University
• The effect size of therapy is .80! (the average
treated individual is better off than 80% of
• Couples/Adolescents = .75-.80
• Family Psychotherapy = .58-.70
• This equates to the point that therapy is cost
effective when compared to psychological and
• Reference: (Minami, et al., 2008. Journal of
Consulting and Clinical Psychology).
• Make claims of effectiveness but only 3% of therapists count outcomes (Akins & Christensen,
• Despite all innovations (400 tx models) no improvement in 30 years!
• 47-50% of individuals drop out.
• Despite individuals feeling less stigmatized a lack of confidence in therapists exists.
• Continued emphasis on medical model despite better outcomes for most MH conditions.
• Ongoing claims of superiority amongst models without evidence.
– Model v. model= ES of .20
– Tx ingredients
– Individual demographics & dx (<1%)
– Therapist’s degree and demographics (0%)
– From The great psychotherapy debate by Wampold, B.E. (2001)
ARE ALL THERAPISTS FROM LAKE WOBEGON?
• COMPARED TO OTHER MENTAL HEALTH PROFESSIONALS WITHIN YOUR FIELD
(WITH SIMILAR CREDENTIALS), HOW WOULD YOU RATE YOUR OVERALL CLINICAL
SKILLS AND EFFECTIVENESS IN TERMS OF A PERCENTILE? (PLEASE ESTIMATE
FROM 0-100%. FOR EXAMPLE, 25% = BELOW AVERAGE, 50% = AVERAGE, 75% =
• WHAT PERCENTAGE (0-100%) OF YOUR CLIENTS GET BETTER (I.E., EXPERIENCE
SIGNIFICANT SYMPTOM REDUCTION/RELIEF) DURING TREATMENT? WHAT
PERCENTAGE STAY THE SAME? WHAT PERCENTAGE GET WORSE?
Walfish, S., McAllister, B., Lambert, M.J. (in press). Are all therapists from Lake
Wobegon? An investigation of self-assessment bias in mental health providers.
SURVEYED A REPRESENTATIVE SAMPLE PSYCHOLOGISTS, PSYCHIATRISTS, SOCIAL
WORKERS, MARRIAGE AND FAMILY THERAPISTS FROM ALL 50 US STATES:
• NO DIFFERENCES IN HOW CLINICIANS RATED THEIR OVERALL SKILL LEVEL AND
EFFECTIVENESS LEVELS BETWEEN DISCIPLINES.
•ON AVERAGE, CLINICIANS RATED THEMSELVES AT THE 80TH %TILE
•NONE RATED THEMSELVES BELOW AVERAGE;
•LESS THAN 4% CONSIDERED THEMSELVES AVERAGE;
•ONLY 8% RATED THEMSELVES LOWER THAN THE 75TH %TILE;
•25% RATED THEIR PERFORMANCE AT THE 90TH% OR HIGHER
• BELIEVED: 80%, 17%, 3%. ---- DATA: 50% (50-70% FOR SS), 10% DETERIORATION
• Walfish, S., McAllister, B., Lambert, M.J. (in press). Are all therapists from Lake Wobegon? An
investigation of self-assessment bias in mental health providers.
Feedback Informed Treatment
• “ FIT is a meta-theoretical approach. Where
traditionally counselors are guided by a particular
treatment model or theoretical orientation, FIT is
guided by outcome and alliance feedback provided by
clients. As such, FIT may be applied across
therapeutic modalities, disciplines, and service
• The client’s experience of the alliance and outcome are the
best predictors of retention and progress in treatment;
• Because of the low correlation between client and clinician
ratings of outcome and alliance, therapists must routinely
seek client feedback via valid and reliable measures of the
alliance and outcome;
• No one model, method, or clinician is sufficient for treating all
problems; (Same outcomes for last 30 years despite 400+
• Feedback is crucial to addressing the diverse problems and
people seeking behavioral health services.
• I REALLY WANT TO MAKE SURE OUR
WORK TOGETHER IS HELPFUL TO YOU
AND YOUR REASONS FOR COMING IN…..I
HAVE A SIMPLE FORM THAT I USE
• THIS ALLOWS US TO TRACK HOW YOU
THINK THINGS ARE CHANGING OR NOT
• IF THINGS AREN’T CHANGING OVER TIME
THE WAY YOU HOPE THEN THIS WILL HELP
US KNOW THAT AND ADJUST AS NEEDED
• IT JUST TAKES A FEW MINUTES TO
• Whether or not the sessions are going
the way you hope and if I am
providing what you want is really
important to me
• Want to make sure that you are
getting what you need;
• I really want any feedback you have,
especially negative feedback. I can
• Feedback is critical to success.
Outcome Rating Scale (ORS)
• 40 pt measure with 4 subscales
• Adult and child versions
• Higher scores=lower level of distress. Lower
scores=higher level of distress
• Clinical cutoffs: 25 (>18), 28 (13-18), 32 (<12)
• 5 pt change is considerable reliable change.
• Complete at start of session. It takes 1 min.
Session Rating Scale (SRS)
• 40 pt measure with 4 subscales
• Adult and child version
• Scores below 36 should be discussed with client
or any subscale below 9
• Lower scores early could mean anything-discuss.
Low scores later 4x likely to drop out.
• Done at end of session, takes 1 min.
• Can plot ORS & SRS on Excel.
• All materials free at www.scottdmiller.com
EMPLOYING MEASURES WITH CLIENTS:
• SETTING A NORM FOR DATA COLLECTION
• PROGRAM EVALUATION FOR DATA-BASED
DECISION MAKING (CCOs)
• EMPHASIS ON THE CLIENT PERSPECTIVE AND
POTENTIAL FOR CLIENT ADVOCACY
• ADDRESSING OWN SELF-EFFICACY & OPENNESS TO
• MEANINGFUL DATA BEYOND THE NUMBERS
• INFORMED CONSENT: WHAT EVALUATION TOOLS
WILL BE USED TO EVALUATE MY PERFORMANCE?
CLIENT FEEDBACK WITH TRAINEES: INFLUENCE ON
SUPERVISION & COUNSELOR SELF EFFICACY(REESE ET AL.,
28 TRAINEES ASSIGNED TO FEEDBACK OR NO FEEDBACK
• CLIENTS IN FEEDBACK GROUP EXPERIENCED TWICE AS MUCH
IMPROVEMENT IN OUTCOME
• SELF-EFFICACY SCORES INCREASED FOR BOTH GROUPS
• NO CORRELATION BETWEEN SELF-EFFICACY AND OUTCOME
FOR NO-FEEDBACK GROUP
• SELF-EFFICACY IN THE FEEDBACK GROUP WAS STRONGLY
CORRELATED WITH OUTCOME
Putting Feedback to work in practice: Three
1. Create a “Culture of feedback” by integrating
alliance and outcome feedback into practice.
2. Engage in deliberate practice.
3. Learn to “fail successfully.”
STEP 1: CREATE A CULTURE OF FEEDBACK
• WORK TOWARDS ADDRESSING BARRIERS TO
GETTING OPEN CLIENT FEEDBACK (E.G., ARE WE
OPEN TO FEEDBACK, WHAT DO WE COMMUNICATE
NON-VERBALLY, WHAT ARE OUR RESISTANCES,
• USE A SYSTEMATIC METHOD FOR ACQUIRING
FEEDBACK THAT IS RELIABLE, VALID AND FEASIBLE
• FOLLOW A STANDARD CASE PRESENTATION MODEL
STEP 2: ENGAGE IN DELIBERATE
• LISTENING & RESPONDING TO CLIENT FEEDBACK
• WORKING HARD AT OVERCOMING “AUTOMATICITY”
• PLANNING, STRATEGIZING, TRACKING, REVIEWING, AND
• VIEWING MISTAKES OR LOW RATINGS FROM CLIENTS AS AN
• INCLUDE THE CLIENT’S VOICE IN SUPERVISION VIA THEIR
FEEDBACK (USE THE GRAPH)
Step 3: Learning to Fail Successfully
• Know when the work is failing
• Things to change when
improvement is not occurring:
what, where, who????
• Gracefully get the client to
another place to accomplish their
CLIENT VIEW OF THE RELATIONSHIP
• What have you learned?
• Did we meet our goals today?
• Any feedback?