Overview
This blog post explores the use
of ongoing structured client feedback in adherence to the responsivity
principle of effective correctional treatment. After an introduction to the
concept of Feedback-Informed Treatment (FIT), it describes the work of two ATSA
members who are using FIT in very different settings.
Background
Information
In
an important study of what works in group treatment of people who have sexually
abused, Beech and Fordham (1997) stressed the importance of attending to
therapeutic processes and cohesion in group treatment and found that therapists
typically rated themselves as being more helpful and concerned than their
clients did. Indeed, client perceptions are more influential in treatment
progress than therapists’ beliefs about their own skills (Orlinsky, Grawe, &
Park, 1994). Despite what professionals want to believe, we are not the
best judges of the therapeutic alliances.
At a time when our field
argues whether treatment for people who have sexually abused works, many (e.g.,
Prescott & Levenson, 2009) have wondered whether our field is actually
asking the right questions. Perhaps the most important question is what
professionals can do to create programs for clients who may be at risk for
refusing treatment or dropping out to “get it” and make meaningful change (Marques, Wiederanders, Day, Nelson, & van Ommeren, 2005).
What
is clear, however, is that findings of the past decade have cast
confrontational approaches into a much less favorable light (Marshall, 2005; Parhar, Wormith, Derkzen, & Beauregard, 2008). In fact, in an influential article
regarding addictive behavior, William White and William Miller (2007) stated:
There are
now numerous evidence-based alternatives to confrontational counseling, and
clinical studies show that more effective substance abuse counselors are those
who practice with an empathic, supportive style. It is time to accept that the
harsh confrontational practices of the past are generally ineffective,
potentially harmful, and professionally inappropriate.
An emerging body of research in
the behavioral health field indicates that incorporating formal feedback
regarding progress and engagement into treatment services builds responsivity
while simultaneously improving outcome and retention (Prescott
& Miller, 2014, 2015). Feedback-Informed Treatment (FIT) has been
successfully integrated into both mental health and substance abuse services,
serving both voluntary and mandated clients, in agencies and systems of care
around the world (Bertolino & Miller, 2012). Multiple randomized clinical trials document
that adding FIT to existing treatment services as much as double the
effectiveness of the care provided, and reduces attrition and deterioration
rates by 50% and 33%, respectively (Miller, Hubble, Chow & Seidel (2013).
FIT involves administering two
scales over the course of treatment; one measuring the quality of the
therapeutic relationship (the Session Rating Scale [SRS]), and the other
assessing progress or outcome (the Outcome Rating Scale [ORS]). Over 1,100 studies have made clear the importance
of the therapeutic relationship to treatment outcome (Duncan, Miller, Wampold,
& Hubble, 2010). Indeed, in an era that emphasizes evidence-based practice,
the therapeutic relationship is the most evidence-based concept in
psychotherapy research (Bargmann & Miller, 2011). Understanding changes in
the relationship can help ensure that clients are meaningfully engaged in
change efforts, assist treatment providers in adjusting their strategies to
meet each client’s needs (thereby adhering to the responsivity principle), and
act as an early warning system for treatment deterioration and failure. At the
same time, research has demonstrated that changes in a person’s individual,
relational, and social functioning are strong predictors of successful therapeutic
work (Bargmann & Miller, 2011; Miller, Duncan, & Hubble, 2004).
As research to date shows, access
to real time feedback regarding progress and engagement provides clinicians
with an opportunity to adjust services in a way that enhances individual client
responsivity and achievement of treatment goals
(e.g., decreased reoffending). The same body of evidence documents that
FIT promotes professional development, resulting in measureable improvements in
individual provider responsivity and effectiveness (Miller, Hubble, Chow, &
Seidel, 2013). In 2013, FIT was deemed
an evidence-based practice by the Substance Abuse and Mental Health Service
Administration (SAMHSA) and listed on the National
Registry of Evidence Based Practices and Programs.
Of
course, evidence-based practices in the field of treating sexual aggression
involves adherence to the principles of risk, need, and responsivity. FIT is
best thought of as improving adherence to the responsivity principle. As the
two vignettes below illustrate, programs adhering to the risk and need
principles can further build responsivity by using FIT. The big question is
whether the treatment provider and his or her agency is ready for the challenge
of listening to their clients’ feedback and open to the professional
self-development that follows. Changing one’s practice to meet the needs of
clients is not easy. Indeed, maintaining a stance of eager anticipation about
what one can learn from their client is vital to collecting the most helpful
feedback.
FIT in a Sexual Offender Civil Commitment Setting (Valerie Gonsalves)
At the beginning of each session, I have the patient complete the
ORS. If there’s a particular area that rates low, we can direct attention to
that area. If there are inconsistencies between unit report and patient report, it can open up the discussion about those
areas. For example, if someone received three or four sanctions in a week, but
reports that they are doing well overall, raising this discrepancy can provide
a nonjudgmental manner of addressing the sanctions. Similarly with the SRS, I
administer this instrument at the end of each setting. For patients who may be
hesitant to provide feedback or may experience distrust about the nature of the
relationship, the SRS can serve as a launching point for conversations about
alliance. I typically expand my discussion of alliance to include variables
that have been found to be specifically relevant to mandated therapeutic relationships,
such as trust, caring and fairness, and toughness (Skeem Louden, Polaschek,
& Camp 2007).
Notably, in a civil commitment the mandated nature of the
therapeutic relationship can serve as a barrier to accurate reporting. Patients
may be frightened of experiencing negative consequences, either legally or
within the institution, if they provide the clinician with an honest assessment
of their current functioning or suggest an area for therapist improvement. As
such, these patients typically demonstrate consistently high ratings on the ORS
and the SRS. When this occurs, it can serve as a launching point for a
discussing about meaningful treatment engagement or that the therapist may have
to engage the patient in a discussion about methods of collecting this
information in way that allows the patient to feel safe about being
transparent. More often than not, my experience in a civil commitment setting
demonstrates that patients will utilize these instruments in a manner that
mimics that of community use.
FIT in a Private Practice Setting (Jim Reynolds)
The importance of a positive
therapeutic alliance has been consistently described in the literature and is
well known by treatment providers.
However, no agency or organization where I have worked has actively
measured the therapeutic alliance, much less incorporated aspects of the
therapeutic alliance in the treatment planning/delivery processes. Consultation
with colleagues suggests that this remains the general state of affairs within
our field.
Implementing FIT into a solo,
community-based practice is probably much easier than in agencies or large
criminal-justice systems. I did not need
to ask anyone's permission. I simply
received training and implemented it without any difficulties. I was able to easily adjust the policies and
procedures which guide the treatment I provide clients, incorporating important
principles from FIT into the therapy I provide. For example, my clients are
provided complete and unfettered access to their treatment records - within the boundaries of relevant ethical
principles and practices. There is no paper work for them to complete. No board
or committee needs to be consulted. A
client only has to ask and they can see their case file.
FIT helps me to individualize
treatment based on building client capacities and managing risks. I can structure treatment according to the priorities, goals, preferences, and progress of the individual client as those elements relate to
the reason(s) for being in treatment. These goals are not imposed on the
client, either by me or by a supervising entity such as probation or parole.
Client feedback on the ORS and SRS is taken seriously, and used to
monitor/modify the course and length of treatment in real time.
Collaborating
with clients and being transparent in my interactions with them helps to create
a positive “culture of feedback” in which client input and feedback are
integrated into the therapeutic process. The ORS and SRS are valid, reliable,
and “user friendly” outcome measures of alliance that I use to guide services throughout the therapy process. Using the ORS and SRS allows me to
objectively monitor and chart each individual client's progress, to determine
which clients are making progress and which are at risk for a negative or no
change outcome.
Information from the ORS and SRS helps
me identify problems/concerns in the therapeutic relationship that may
compromise the effectiveness of treatment. Identifying and repairing problematic alliances can improve clients'
motivation for treatment as well as their level of active engagement in
therapy. I am able to use the information
from the scales to adjust the level and type of care that I provide each
client, in both individual and group therapies, in order to be responsive to
each client's perceived needs and treatment goals.
Overall, integrating FIT into a
private practice can be easily accomplished.
Doing so has allowed me to easily collect client outcome data in real
time that I can then use to help guide the treatment process. I use that
information to guide the focus of therapy, as well as the frequency with which
I meet clients. I am able to objectively identify clients who have achieved an
optimum level of functioning and appropriately titrate treatment. I can also identify
clients who are not benefiting from treatment and, if adjustments to treatment
are unsuccessful, make appropriate referrals to another provider.
Conclusion
At first, implementing FIT can be
challenging for people working in criminal-justice settings. It involves
creating a culture of feedback and being willing to listen to unflattering
feedback in order to strengthen the alliance and improve outcomes. However, those who monitor their alliances
and outcomes commonly report improved treatment progress, earlier detection of
treatment problems and dropout, reduced client-driven complaints and grievances,
and a seemingly endless resource for deep professional development and
knowledge.
David S. Prescott,
Valerie Gonsalves,
Jim Reynolds,
Scott D. Miller
References
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