Monitoring Alliance and Outcome with Client Feedback Measures
1. Volume 36/Number 1/January 2014/Pages 43–57
Monitoring Alliance and Outcome with
Client Feedback Measures
Sidney L. Shaw
Kirsten W. Murray
The therapeutic alliance is foundational to counseling practice and has amassed strong empirical support as being essential for successful counseling. Counselors generally rely on their own
perspective when assessing the quality of the alliance, though the client’s perspective has been
found to be a better predictor of outcome. Formal methods for eliciting client feedback about
the alliance and counseling outcomes have been strongly supported in the literature, yet such
limitations as time constraints hinder counselor efforts to gather formal client feedback. Two
ultra-brief measures of alliance and outcome, the Session Rating Scale and the Outcome Rating
Scale, are feasible methods for counselors to secure client feedback. This article reviews the two
measures and makes a case for using empirical means to understand adult clients’ views of the
therapeutic alliance.
Sidney L. Shaw is affiliated with the University of Montana and Walden University, Kirsten W. Murray
with the University of Montana. Correspondence about this article should be addressed to Sidney L.
Shaw, College of Education and Human Sciences, Room 210, Department of Counselor Education and
Supervision, 32 Campus Drive, University of Montana, Missoula, MT 59812. Email: sidney.shaw@mso.
umt.edu.
Journal of Mental Health Counseling
43
Monitoring Alliance and Outcome
A quality therapeutic relationship is the foundation of successful counseling. While far from a new concept, the idea that the relationship is central
to human growth is increasingly relevant to the practice of counseling today
(Bohart, 2003; Wampold, 2001). A common definition of the therapeutic
alliance, on which we rely here, is that of Bordin (1979); it is an agreement
between counselor and client on goals, treatment tasks or methods, and the
relational bond. Meta-analytic research shows that alliance factors are major
contributors to successful client outcomes (Wampold, 2001). Additionally,
virtually all theoretical orientations acknowledge the importance of the alliance. However, an important nuance is that the client’s view of the alliance
is a better predictor of client outcome than the counselor’s view (Bachelor &
Horvath, 1999; Bedi, Davis, & Williams, 2005; Horvath & Bedi, 2002; Horvath
& Symonds, 1991; Wampold, 2001). Further, counselor views of essential relationship factors often do not correlate well with client views (Tyron, Blackwell,
& Hammel, 2007). While steadfast counselor intentions to develop a therapeutic relationship are essential, the true litmus test of an effective alliance is how
the client perceives it.
In everyday practice, counselors generally rely on their own conjectures
about the therapeutic relationship, although these notions are often at odds
2. with client views (Hannan et al., 2005; Stewart & Chambless, 2007). Because
the client’s perception of the therapeutic alliance is a strong predictor of outcome, and a better predictor than the counselor’s perceptions, we recommend
a formal model for collecting continuous feedback from the client. Further,
formally assessing the counseling relationship becomes critical when honoring
the therapeutic alliance and potentiating its powerful effects. Collecting feedback from clients directly privileges their voice, attends to the client-counselor
relationship, and establishes a framework for constructing individualized, client-directed counseling.
This article reviews evidence supporting the need for formally collecting
alliance and outcome feedback from clients. The Outcome Rating Scale
(ORS; Miller, Duncan, Brown, Sparks, & Claud, 2003) and Session Rating
Scale (SRS; Duncan et al., 2003) are reviewed as evidence-based methods for
formally monitoring alliance and outcome. These measures are introduced
as part of the Partners for Change Outcome Management System (PCOMS;
Duncan, 2012). We make the case for formal client feedback as an ethical
obligation and present considerations for employing alliance and outcome
feedback processes.
Predicting Counseling Success
A large body of research, including exhaustive meta-analyses, has found
the therapeutic relationship to be a strong, if not the best, predictor of successful counseling (Conners, Carroll, DiClemente, Longabaugh, & Donovon,
1997; Orlinsky, Rønnestad, & Willutzki, 2004; Wampold, 2001). Studies continue to support the notion that the partnership between counselor and client is
one of the best indicators of successful counseling outcomes in a variety of contexts (Horvath & Symonds, 1991; Martin, Garske, & Davis, 2000). Further, the
client’s rating of the alliance is generally a better predictor of a good counseling
outcome than the counselor’s view (Bedi et al., 2005; Horvath & Bedi, 2002).
Given the established potency of the counseling relationship as a determinant
of outcome, monitoring the alliance from the client’s perspective is crucial to
counseling success.
The Client’s Perspective
Research consistently demonstrates the powerful effect of the client’s
perception of a positive therapeutic relationship. Citing over 100 studies that
elicit the client’s perspective, Norcross (2010) concluded that the relationship
is central to therapeutic success. The shift from the counselor’s perspective of
the therapeutic relationship to formally understanding the client’s perspective
is strongly supported by research indicating that clients show significantly more
therapeutic gain when their feedback is sought (Duncan, Miller, Wampold, &
Hubble, 2010; Lambert, 2010).
Though apparently simple on the surface, the process of reliably and consistently obtaining the client’s perspective of relationship factors is subtle and more
powerful than is immediately evident. Formal client feedback measures were
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3. Monitoring Alliance and Outcome
examined in a study where 48 counselors (26 trainees and 22 licensed staff) in
a “real-world” clinical setting were asked to predict their clients’ outcomes using
their “clinical judgment” (Hannan et al., 2005). Client outcomes were then
assessed using Outcome Questionnaire-45 (OQ-45), a reliable assessment for
determining the client’s perspective on improvement or outcome (Miller et al.,
2003). It was found that counselors’ perceptions of counseling outcome aligned
poorly with those of clients. The study found that 40 clients showed significant
decline or deterioration during counseling, and in only one case did counselors
correctly identify a client as deteriorating. In other words, the counselors in the
study did not identify the 39 out of 40 clients who were getting worse during
counseling. These findings underscore the importance of counselors seeking to
understand client perspectives to use formal processes as well as clinical judgment and general impressions (Hannan et al., 2005).
Greenberg, Watson, Elliot, & Bohart (2001) presented another finding
that emphasized both the correlation of therapeutic relationship and outcome
in counseling and the discrepancies between counselor and client perceptions. Their meta-analysis of 47 studies comprising 3,026 clients examined the
impact of counselor empathy, a central relationship factor, on outcome. They
found that empathy was indeed a good predictor of outcome with a moderate
effect size of .32. Further, the theoretical orientation of the counselor was not
predictive of outcome. Perhaps most important, the ratings of empathy varied
significantly depending on the evaluator (client, observer, or counselor). Client
ratings of empathy (mean uncorrected r = .25) were found to be the best predictor of outcome, followed by observer ratings (.23), and counselor ratings
(.18)—the least predictive of the three (Greenberg et al., 2001).
The Client’s View of Empathy
Not surprisingly, the question of whether a counselor is being empathic
can only be answered by the client. Empathy, a central component of therapeutic relationships, is classically defined by Carl Rogers (1957) as “the
therapist’s sensitive ability and willingness to understand clients’ thoughts,
feelings, and struggles from their point of view” (p. 98). Numerous studies have
underscored the importance of the client’s view of empathy and the relationship. For instance, client-perceived empathy has repeatedly been found to be
a better predictor of outcome than counselor-rated empathy (Barrett-Lennard,
1981; Bohart, Elliott, Greenberg, & Watson, 2002; Gurman, 1977; Orlinsky,
Grawe, & Parks, 1994); and meta-analytic research consistently finds that the
client’s view of relationship factors is more predictive of a successful counseling
outcome than the counselor’s view (Bachelor & Horvath, 1999; Horvath &
Bedi, 2002; Horvath & Symonds, 1991; Wampold, 2001). It is thus evident that
understanding the therapeutic relationship requires feedback from the client.
The essence of empathy, in the practical sense, is the counselor’s efforts to be
empathic, but more important from both an empirical and clinical standpoint
is the client’s sense of experiencing empathy. Though counselors can make
efforts to respond in ways they think are empathic, whether they are being
experienced as empathic requires continuous client feedback.
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4. The Case for Formal Client Feedback
Collecting feedback from the client emphasizes counseling tenets related
to understanding clients’ subjective experiences, cultivating a quality relationship, responding with empathy, and supporting clients’ abilities to choose their
goals and how to meet them (Cain, 2001; Raskin, Rogers, & Witty, 2008).
Research on formal client feedback has burgeoned in recent years, and use of
formal feedback measures has been found to consistently improve client outcomes (Duncan et al., 2010; Lambert, 2010). For instance, a randomized clinical trial that covered 110 community mental health clients and 28 counselor
trainees found that client feedback about the alliance and outcome increased
client outcome in comparison to the no-feedback group (Reese et al., 2009).
This study found that the mean effect size for counselor trainees utilizing client
feedback was .92, but trainees in the no-feedback condition had a mean effect
size of .23 (Reese et al., 2009).
A randomized clinical trial of couple counseling randomly assigned clients to a feedback group (i.e., the counselor would obtain session-by-session
feedback from clients using an alliance measure and an outcome measure) or
treatment as usual group (Anker, Duncan, & Sparks, 2009). Pre-study surveys
of the counselors showed that they all believed they had already acquired outcome and alliance feedback from their clients without the use of a formal feedback process and that formal feedback would not enhance their effectiveness.
Yet nine out of the 10 counselors improved their client outcomes when they
sought formal client feedback using the ORS and the SRS (Anker et al., 2009).
This finding illustrates not only the benefits of feedback but also the tendency
for counselors to assume that an informal method of checking-in with clients
is adequate.
In addition to randomized clinical trials, evidence supporting the use
of client-driven formal feedback has also emerged from quasi-experimental
research in clinical settings. Miller, Duncan, Sorrell, and Brown (2005) examined counseling outcomes when 6,424 culturally and economically diverse
clients provided feedback to counselors using the ORS and SRS. Researchers
obtained baseline measures of client outcomes over a six-month period during
which counselors were not exposed to formal client feedback. Following the
baseline period, counselors gathered session-by-session feedback from clients
about their view of the therapeutic alliance and outcome of counseling using
ORS and SRS client report measures at every session. The ORS and SRS
opened dialogue between clients and counselors about the client’s experience
of therapeutic change and the alliance; simply providing counselors with session-by-session feedback about the client’s view of the alliance and outcome
doubled the effect size from the baseline phase. The act of consistently engaging with clients about their experience of the relationship and the degree to
which the sessions were helpful had a profound influence on client outcome.
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5. Monitoring Alliance and Outcome
Improving Alliance and Outcome
The practice of integrating client feedback requires counselors to step
out of their own subjective view and check their perceptions with those of the
client. The process of formally collecting feedback from the client has been
shown to improve both alliance and outcome (Duncan et al., 2010). Seeking
formal feedback from clients about the therapeutic relationship becomes
central if counselor attempts to build an alliance are to be successful. Further,
when clients have visual markers of their positive counseling outcomes (based
on the feedback they give), early progress becomes concrete and is easily recognized. This recognition of progress supports even more positive outcomes,
encouraging clients to continue to make gains.
The importance of consistently monitoring client outcomes is highlighted
by numerous studies finding that early client improvement predicts a good outcome at the end of counseling and that the majority of change occurs early in
treatment (Baldwin, Berkeljon, Atkins, Olsen, & Nielsen, 2009; Brown, Dreis,
& Nace, 1999; Howard, Kopta, Krause, & Orlinsky, 1986). Without collecting
feedback from clients, counselors are left to make assumptions about client
trajectories of change. The beneficial effect of alliance and outcome feedback
is clearly linked to removing guesswork and obtaining clarity about predictors
of positive client outcomes. However, the question remains: if seeking formal
client feedback is central to a strong alliance and positive outcomes, why is it
not common practice?
Barriers to Collecting Feedback
Unfortunately, using alliance and outcome measures can trigger resistance in counselors, perhaps partly because many measures are too time-consuming for use in everyday practice (Miller, Duncan, & Hubble, 2004). Some
common alliance measures range from 12 to 19 items and measures like the
Outcome Questionnaire consist of 30 to 45 items (Duncan et al., 2003). Such
lengthy measures work well for research purposes, but in clinical settings their
demands on time and energy interfere with their consistent use. In a study
of formal feedback using more lengthy measures, 75% of counselors stopped
gathering client feedback because the measures were cumbersome and lengthy
(Miller et al., 2004).
In addition to time demands as barriers, some counselors may be opposed
for philosophical reasons. For instance, the idea of formally assessing something as personal as the therapeutic relationship may seem to contradict the
value of holism rather than reductionism (Raskin et al., 2008). Further, rating
an alliance numerically runs the risk of mechanically diluting empathy to
a number on a page. Lastly, such formal assessments have the potential to
promote a directive stance and endorse a counselor’s power. In light of these
philosophical concerns, we will explore a more nuanced understanding of
the process for collecting formal client feedback while continuing to support
the case of utilizing focused, time-sensitive formal client feedback tools to
empower clients and improve counseling outcomes.
47
6. Obtaining Formal Client Feedback
Used in counseling settings, alliance and outcome measures are intended
to improve services by exposing counselors to client feedback that will allow
them to individualize and tailor their services (Smith, Fischer, Nordquist,
Mosley, & Leadbetter, 1997). These measures also help counselors ensure that
the flow of the session does not influence whether or not they check in with the
client about the relationship, and a norm is developed for collecting feedback.
In particular, when counselors commit to using brief alliance and outcome
measures, the formal process serves as a safeguard to push counselors to routinely engage clients about their perspective rather than relying on their own
suppositions about the client’s experience. Just as counselors have rituals for
scheduling appointments and taking session notes, they can also incorporate
brief measures into sessions to encourage client feedback and dialogue about
the alliance and outcome.
In addition to tailoring and individualizing services, thoughtful presentation of formal client feedback methods in itself delivers a message to clients
that the counselor intends to form collaborative, empowering relationships
with them and that their perspective is consistently valued as a guiding force in
counseling. These routine inquiries support frequent and consistent means for
understanding alliance and outcome in a way that honors the client’s voice and
creates a context for the counselor to accept influences to improve and tailor
services. Finally, a number of studies have found that formal client feedback
reduces drop-out rates and improves counseling outcomes (Duncan et al.,
2010; Hatcher & Barends, 1996; Miller et al., 2005). Given these benefits and
the intrinsic therapeutic value of honoring client feedback, attending to client
views of the counseling alliance and outcomes is essential to support and privilege the client’s experience. We recommend adopting a norm of consistently
requesting formal client feedback, and using such formal measurement tools
for collecting that feedback as the SRS and the ORS.
The SRS and the ORS
The SRS (Duncan et al., 2003) and ORS (Miller et al., 2003) were developed to fulfill a need for ultra-brief tools to regularly gather client feedback
in counseling settings. Their systematic, session-by-session use falls under
the evidence-based treatment program of the Partners for Change Outcome
Management System (PCOMS). PCOMS is a client feedback system that was
established as an evidence-based practice in January 2013 by the Substance
Abuse and Mental Health Services Administration (SAMHSA) National
Registry of Evidence-based Programs and Practices (NREPP). The PCOMS
can be used with or integrated into any counseling theory or method (Duncan,
2012). The PCOMS clinical process involves tracking client reports of alliance
and outcome and modifying treatment in response. Collecting formal feedback
from clients about the alliance and outcome is intended to improve client
outcomes and identify clients who may not be improving with expected trajectories of change (Duncan, 2012).
48
7. Monitoring Alliance and Outcome
The brevity and simple administration of the SRS and ORS, each of
which has four items rated on a visual analog scale, make them highly suitable to clinical practice. They demonstrate strong internal consistency and
good concurrent validity with lengthier measures of alliance and outcome
(Campbell & Hemsley, 2009). The two scales can be easily administered every
session, taking just two minutes to administer and score. In addition, ultra-brief
analog scales such as the SRS and ORS generally have more face validity than
longer measures, which can be remote from the client’s experience (Duncan
et al., 2003; Miller et al., 2003). The client is instructed to simply place a hash
mark on the analog lines, indicating via the SRS their experiences of alliance
and via the ORS their level of distress in four domains of their lives (Duncan
et al., 2003; Miller et al., 2003). Since each analog line on the SRS and ORS
is 10 cm long, the SRS and the ORS both have a maximum score of 40. The
counselor measures client responses at every session, using a metric ruler to
score them (Duncan et al., 2003; Miller et al., 2003). This gives counselors
the client’s perspective of alliance and outcome at every session and also the
patterns across sessions. As a result, counselors can track client progress over
time but also address alliance or outcome issues in the moment as they arise.
The four scales of the SRS (Appendix A) measure the client’s view of
the therapeutic alliance for a particular session in terms of the therapeutic
relationship (degree to which the client felt heard, understood, and respected);
the goals and topics (degree to which the client felt that the session focused
on the goals he or she wanted); the approach or method (degree to which
the counselor’s approach in the session was a good fit); and overall (degree to
which the session was “right” for the client). The client completes the SRS
near the end of each session. The counselor reviews the responses and opens
discussion with the client about them. This immediate feedback thus gives
counselors the opportunity to address alliance problems in the moment. The
SRS typically takes about one minute to administer and score and is available
in 25 languages. A child version is recommended for use with children aged
6 to 12 (Miller et al., 2004). Used appropriately, the SRS facilitates open dialogue about the client’s experience of the session and the alliance. The SRS
has demonstrated strong internal consistency (α = .88), test-retest reliability of
.64, and validity coefficient correlations with the Working Alliance Inventory
that range from .37 to .63 (Campbell & Hemsley, 2009).
The four scales of the ORS (Appendix B) measure the client’s view of
change relative to the initial complaint from the first session and across all
sessions. The four scales measure views individually (personal well-being);
interpersonally (family, close relationships); socially (work, school, friendships);
and overall (general sense of well-being). The individual, interpersonal, and
social scales are adapted from the three domains of functioning assessed by
the OQ-45.2 (Miller et al., 2003). Unlike the SRS, the ORS is designed to be
administered at the beginning of each session to find out how the client has
been doing since the last session. When the ORS is completed, the counselor
scores and discusses the responses with the client. As with the SRS, the ORS
takes about one minute to administer and score, is available in 25 languages
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8. and in a child version, and provides counselors with real-time feedback about
the client’s view of progress or lack thereof (Miller et al., 2004). The ORS has
demonstrated strong internal consistency (α = .87 - .96) and a respectable correlation coefficient (r = .59) with the much lengthier, well-validated OQ-45.2
(Campbell & Hemsley, 2009). The ORS correlation with the OQ-45.2 provides evidence of its construct validity (Reese, Norsworthy, & Rowlands, 2009).
Counselors use of the SRS and ORS is quite high in comparison to their
longer counterparts. For instance, when use of the ORS and OQ-45 were compared over a 12-month period at a community family service agency, the ORS
had an 89% compliance rate and the OQ-45 a 25% compliance rate (Miller
et al., 2003). Similarly, the SRS had a 96% compliance rate and the 12-item
Working Alliance Inventory a 29% compliance rate (Duncan et al., 2003).
These compliance rates, along with their validity and reliability, make the SRS
and ORS well-suited to counseling practice. The practicality of the SRS and
ORS thus makes them a feasible option for counselors wishing to honor the
client’s voice and improve client outcomes via client feedback. Integration of
the SRS and ORS into daily practice also communicates to clients the importance of their voice in dialog about two factors of critical importance to clients
and counselors, the alliance and the outcome.
Using the Measures: A Brief Illustration
The SRS and ORS are practical because they are brief, valid, and promote dialogue with clients about important aspects of treatment. Because their
utility hinges on competent, client-directed integration, the following script is
provided as guidance:
Counselor: I have a couple of short forms that I ask clients to complete, one near the beginning of each session and one near the end.
These forms help us keep track of how things are improving or not
improving in your life and also how our sessions are going. Does that
sound okay?
Client: Sure.
Counselor [giving the client the ORS]: This one focuses on important areas of your life that could improve. I’ll keep track of these over
time so we can see how things are changing or not changing. Since
this is our first meeting, today’s score will rate how things have been
going up until now. Just put a mark on each of these lines showing
how things are going in these four areas of your life, lower scores to
the left and higher scores to the right. Make sense?
Client: Sounds good to me. [Client completes the ORS.]
The counselor then scores the ORS using a metric ruler and can use the ORS
score to open the session by simply acknowledging areas the client scored as
particularly high or low. Opening these dialogues may sound something like,
“I noticed you scored this section lower than the others. Can you tell me more
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9. Monitoring Alliance and Outcome
about what is most troublesome here?” or “This area continues to be highly rated
for you. Tell me more about what is going well here.” As the session unfolds it is
important to connect client presenting problems to scores on the ORS.
Near the end of each session the counselor engages the client about the
alliance via the SRS:
Counselor: I’d like to ask you to fill out one more brief form before
we end our session today. This one is to help us understand how our
sessions might be adjusted to improve our work together. I really
want any feedback you have. You should know that I’m not looking
for a perfect score. I know that life isn’t perfect and neither am I.
This will help me adjust things here to make sure you get the most
from our time together, so I’d appreciate any feedback you can give
about today’s session. If something wasn’t quite right for you I won’t
take it personally and I can handle the feedback. Like the first form,
this one has four scales. Make a mark on each line showing how you
felt about today’s session. Again, mark lower scores toward the left
and higher scores toward the right. Also, like the first form, we will
spend a little time talking about your ratings. Any questions?
Client: No. Seems pretty clear. (Client completes the SRS.)
Counselor: Thanks for taking time to think about each of these
scales before marking down a score [counselor acknowledges the
client’s thoughtfulness and care in completing the form]. How you
feel about our sessions is really important to me. [Counselor quickly
scores the SRS.] I notice that you scored the “goals and topics” scale
a bit lower than the others. Can you tell me a little more about what
wasn’t quite right there?
Client: Well, you listened really well and I felt understood by you.
I felt like I had so much to talk about with problems at my job that
I just didn’t get around to discussing my boyfriend. We’re arguing a
lot.
Counselor: Thanks so much for telling me that and I’m glad you felt
understood and listened to today. I want to make sure that we are
focusing on topics that are really important to discuss, so I’ll make a
note about your relationship with your boyfriend.
Client: Great. It’s not a real big deal but our arguing is putting a
strain on us and me.
Counselor: Sure, and that strain can impact so much of what’s going
on for you. I’m glad you feel comfortable bringing this up and that
you can tell me where we should focus.
As indicated in these examples, the ORS and SRS are tools for dialog as
well as for tracking progress over time. After several sessions, counselors can
51
10. construct a simple line graph of client ORS scores and also use this to guide
dialog with clients. Having a visual representation of client ORS scores over
time is useful so that counselors and clients can work together to tailor treatment to maximize outcomes. In addition, as indicated in the example, the SRS
can give clients an opportunity to voice areas of concern about a session. In this
case, the counselor gained understanding of what was not discussed in the session that the client may have simply forgotten to mention, did not have enough
time to talk about, or was possibly avoiding. Ultimately, the SRS and ORS help
counselors and clients collaboratively track alliance and outcome while also
opening dialogue about concerns that might otherwise remain unexpressed.
Limitations and Concerns
Although it is clear that the potential for therapeutic success can be fostered with formalized client feedback models like the SRS and ORS, there are
also possible limitations. As is true with the art and science of assessment, the
power of the instrument rests in how it is used. If not protected against, three
risks may surface when incorporating formal client feedback: a mechanistic
counseling process, a propagation of power over the client, and a reductionist
understanding of the therapeutic alliance.
Central to counseling is being present in the moment and establishing a
rich and meaningful connection with the client. The basis for this relationship
is belief in a client’s potential to grow with the necessary conditions. With this
tenet in mind, it is necessary for a counselor to establish a therapeutic environment, and then adjust to client preferences and needs. However, perfunctory
use of feedback measures can dilute the richness of dialogue and client-directedness that stems from thoughtful integration of formal client feedback. The
ORS and SRS are not meant to be rushed bookends to a session but to be clinical tools for sparking deeper discussions of the alliance, monitoring change,
and individualizing treatment. If circumstances are hurried, the quantitative
indicators may lose their utility because the counselor is using them mechanically. Done well, however, integration of formal client feedback not only honors
the ethical mandate to monitor counselor effectiveness (American Counseling
Association, 2005; American Mental Health Counselors Association, 2010) but
also helps to elevate the client’s voice in relation to the direction and effectiveness of the counseling experience.
Formal feedback must be integrated into the counseling process with
grace and transparency, allowing clients to recognize their freedom in a session
and the counselor to maintain a nonhierarchical role. Done with sensitivity
and intent to honor the client’s voice, formal feedback is formative as well as
summative: The scores on the page push counselors to engage in client-driven
dialogue in order to individualize counseling (and challenge counselor
assumptions).
Fostering client empowerment, which is at the root of counseling, can
be cultivated with thoughtful integration of formal client feedback. However,
a contradiction emerges in the double bind of privileging the client’s voice
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11. Monitoring Alliance and Outcome
while also directing the client to quantify the counseling experience in a counselor-determined format. For example, if participation in the feedback process
results in forcing scales upon clients and heavily influencing their responses,
the client’s voice is lost, and so is the I-thou relationship. To best protect against
this power-broking stance, the counselor must ensure there is clear informed
consent when asking the client to participate in the formal feedback process
and communicate and behave in a way that privileges the client’s perspective.
When clients perceive that the counselor embraces the formal feedback process with humility and openness, they become the primary guides in tailoring
services to best meet their needs.
A final critique of the formal client feedback process surfaces when the
view of the therapeutic alliance is reductionist. For example, when referencing
the SRS, it could be argued that the scale limits client response by grounding their reactions in a few specific questions and analog ratings. The risk of
reducing the therapeutic relationship to four questions is especially high when
a counselor embraces the quantitative data as the endpoint. Rather, we recommend embracing the scale as a gateway for client feedback and using the scales
and results to open dialogue. Ultimately, it is vital that a process orientation
be embraced when discovering the nuances of the therapeutic relationship. A
solid therapeutic relationship is not something arrived at in accordance with
four quantifiable domains but is rather something the counselor becomes part
of by constantly evaluating, learning, and responding.
Conclusion
The therapeutic relationship is at the crux of successful counseling
(Norcross, 2010; Wampold, 2001). Although the counseling relationship is the
most potent therapeutic factor, it has been found that counselors are not as
accurate as they believe at understanding client perspectives of empathy and
the relationship (Greenberg et al., 2001; Orlinsky et al., 1994). Failure to seek
client feedback leads to a breakdown in understanding the client’s subjective
experience and promoting client empowerment. Because the client perspective is central to a strong alliance, client feedback must be sought routinely.
Yet counselors often assume that they do check in with clients about their
subjective experience and that formal feedback from clients will not improve
outcomes (Anker et al., 2009).
The SRS and ORS invite client feedback consistently, encouraging counselors to actively understand the client’s perspective, and empowering clients
to tailor their counseling experience. However, any formal feedback process is
only as useful as the way it is presented and used; counselors are cautioned to
avoid mechanistic, reductionist, and power-propagating stances. To privilege
the client’s voice, research clearly reveals that a formal means of collecting client feedback is necessary so that counselors can step beyond assumptions about
alliance and outcome, begin to honor the client’s perspective, and maximize
client benefit.
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12. References
American Counseling Association. (2005). ACA code of ethics. Alexandria, VA: Author.
American Mental Health Counselors Association. (2010). American Mental Health Counselors
Association code of ethics. Retrieved from http://www.amhca.org/assets/content/AMHCA_Code_
of_Ethics_2010_update_1-20-13_COVER.pdf
Anker, M. G., Duncan, B. L., & Sparks, J. A. (2009). Using client feedback to improve couple
therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of Consulting and
Clinical Psychology, 77, 693–704. doi:10.1037/a0016062
Bachelor, A., & Horvath, A. (1999). The therapeutic relationship. In M. A. Hubble, B. L. Duncan,
& S. D. Miller (Eds.), The heart and soul of change: What works in therapy (pp. 133–178).
Washington, DC: American Psychological Association.
Baldwin, S. A., Berkeljon, A., Atkins, D. C., Olsen, J. A., & Nielsen, S. L. (2009). Rates of change
in naturalistic psychotherapy: Contrasting dose–effect and good-enough level models of change.
Journal of Consulting and Clinical Psychology, 77, 203–211. doi:http://dx.doi.org/10.1037/
a0015235
Barrett-Lennard, G. T. (1981). The empathy cycle: Refinement of a nuclear concept. Journal of
Counseling Psychology, 28, 91–100. doi:10.1037/0022-0167.28.2.91
Bedi, R. P., Davis, M. D., & Williams, M. (2005). Critical incidents in the formation of the
therapeutic alliance from the client’s perspective. Psychotherapy: Theory, research, practice,
training, 42, 311–323. doi:10.1037/0033-3204.42.3.311
Bohart, A. C. (2003). Person-centered psychotherapy. In A. S. Gurman & S. B. Messer (Eds.),
Essential psychotherapies: Theory and practice (2nd ed., pp. 107–148). New York, NY: Guilford
Press.
Bohart, A. C., Elliott, R., Greenberg, L. S., & Watson, J. C. (2002). Empathy. In J. Norcross (Ed.),
Psychotherapy relationships that work (pp. 89–108). New York, NY: Oxford University Press.
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance.
Psychotherapy: Theory, Research & Practice, 16, 252–260. doi:10.1037/h0085885
Brown, J., Dreis, S., & Nace, D. (1999). What really makes a difference in psychotherapy outcomes?
Why does managed care want to know? In M. Hubble, B. Duncan, & S. Miller (Eds.), The heart
and soul of change (pp. 389–406). Washington, DC: American Psychological Association.
Cain, D. J. (2001). Defining characteristics, history, and evolution of humanistic psychotherapies.
In D. J. Cain & J. Seeman (Eds.), Humanistic psychotherapies: Handbook of research and practice
(pp. 3–54). Washington, DC: American Psychological Association.
Campbell, A., & Hemsley, S. (2009). Outcome Rating Scale and Session Rating Scale in
psychological practice: Clinical utility of ultra-brief measures. Clinical Psychologist, 13, 1–9.
doi:10.1080/1328420080267639
Connors, G. J., Carroll, K. M., DiClemente, C. C., Longabaugh, R., & Donovan, D. M. (1997).
The therapeutic alliance and its relationship to alcoholism treatment participation and outcome.
Journal of Consulting and Clinical Psychology, 65, 588–598. doi:10.1037/0022-006X.65.4.588
Duncan, B. L. (2012). The Partners for Change Outcome Management System (PCOMS): The
heart and soul of change project. Canadian Psychology/Psychologie Canadienne, 53, 93–104.
doi:10.1037/a0027762
Duncan, B. L., Miller, S. D., Sparks, J. A., Claud, D. A., Reynolds, L. R., & Brown, J. (2003).
The Session Rating Scale: Preliminary psychometric properties of a working alliance measure.
Journal of Brief Therapy, 3, 3–12.
Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (2010). The heart and soul of
change: Delivering what works in therapy (2nd ed.). Washington, DC: American Psychological
Association.
Greenberg, L. S., Watson, J. C., Elliot, R., & Bohart, A. C. (2001). Empathy. Psychotherapy: Theory,
research, practice, training, 38, 380–384. doi:10.1037/0033-3204.38.4.380
Gurman, A. S. (1977). The patient’s perception of the therapeutic relationship. In A. S. Gurman
& A. M. Razin (Eds.), Effective psychotherapy: A handbook of research (pp. 503–543). New York,
NY: Pergamon Press.
Hannan, C., Lambert, M. J., Harmon, C., Nielsen, S. L., Smart, D. W., Shimokawa, K., & Sutton,
S. W. (2005). A lab test and algorithms for identifying clients at risk for treatment failure. Journal
of Clinical Psychology, 61, 155–163. doi:10.1002/jclp.20108
54
13. Monitoring Alliance and Outcome
Hatcher, R. L., & Barends, A. W. (1996). Patients’ view of the alliance in psychotherapy: Exploratory
factor analysis of three alliance measures. Journal of Consulting and Clinical Psychology, 64,
1326–1336. doi:10.1037/0022-006X.64.6.1326
Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross (Ed.), Psychotherapy
relationships that work (pp. 37–69). New York, NY: Oxford University Press.
Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in
psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38, 139–149. doi:10.1037/00220167.38.2.139
Howard, K. I., Kopta, S. M., Krause, M. S., & Orlinsky, D. E. (1986). The dose–effect relationship
in psychotherapy. American Psychologist, 41, 159–164. doi:http://dx.doi.org/10.1037/0003066X.41.2.159
Lambert, M. J. (2010). Yes, it is time for clinicians to routinely monitor treatment outcome. In
B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of
change: Delivering what works in therapy (2nd ed., pp. 239–266).Washington, DC: American
Psychological Association.
Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome
and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68,
438–450. doi:10.1037/0022-006X.68.3.438
Miller, S. D., Duncan, B. L., Brown, J., Sparks, J. A., & Claud, D.A. (2003). The Outcome Rating
Scale: A preliminary study of the reliability, validity, and feasibility of a brief visual analog
measure. Journal of Brief Therapy, 2, 91–100.
Miller, S. D., Duncan, B. L., & Hubble, M.A. (2004). Beyond integration: The triumph of outcome
over process in clinical practice. Psychotherapy in Australia, 10, 2–19.
Miller, S. D., Duncan, B. L., Sorrell, R., & Brown, G. S. (2005). The Partners for Change Outcome
Management System. Journal of Clinical Psychology, 61, 199–208. doi:10.1002/jclp.20111
Norcross, J. C. (2010). The therapeutic relationship. In B. L. Duncan, S. D. Miller, B. E.Wampold,
& M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy (2nd ed.,
pp. 113–141).Washington, DC: American Psychological Association.
Orlinsky, D. E., Grawe, K., & Parks, B. K. (1994). Process and outcome in psychotherapy—Noch
einmal. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy and behavior change
(4th ed., pp. 270–378). New York, NY: Wiley.
Orlinsky, D. E., Rønnestad, M. H., & Willutzki, U. (2004). Fifty years of process-outcome research:
Continuity and change. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy
and behavior change (5th ed., pp. 307–390). New York, NY: Wiley.
Raskin, N. J., Rogers, C. R., & Witty, M. C. (2008). Client-centered therapy. In R. J. Corsini &
D. Wedding (Eds.), Current Psychotherapies (8th ed., pp. 141–186). Belmont, CA: Thomson
Brooks/Cole.
Reese, R. J., Norsworthy, L. A., & Rowlands, S. R. (2009). Does a continuous feedback system
improve psychotherapy outcome? Psychotherapy: Theory, research, practice, training, 46, 418–
431. doi:10.1037/a0017901
Reese, R. J., Usher, E. L., Bowman, D. C., Norsworthy, L. A., Halstead, J. L., Rowlands, S. R.,
Chisholm, R. R. (2009). Using client feedback in psychotherapy training: An analysis of its
influence on supervision and counselor self-efficacy. Training and Education in Professional
Psychology, 3, 157–168. doi:10.1037/a0015673
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change.
Journal of Consulting Psychology, 21, 95–103. doi:10.1037/h0045357
Smith, G. R., Fischer, E. P., Nordquist, C. R., Mosley, C. L., & Ledbetter, N. S. (1997).
Implementing outcomes management systems in mental health settings. Psychiatric Services, 48,
364–368. Retrieved from http://search.proquest.com/docview/619384106?accountid=14593
Stewart, R. E., & Chambless, D. L. (2007). Does psychotherapy research inform treatment decisions
in private practice? Journal of Clinical Psychology, 63, 267–281. doi:10.1002/jclp.20347
Tyron, G. S., Blackwell, S. C., & Hammel, E. F. (2007). A meta-analytic examination of clienttherapist perspectives of the working alliance. Psychotherapy Research, 17, 629–642.
Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and findings. Mahwah,
NJ: Erlbaum.
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