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Making Sense of Client Feedback

January 4, 2021 By scottdm Leave a Comment

Kitchen NightmaresI have a guilty confession to make.  I really like Kitchen Nightmares.  Even though the show finished its run six L O N G years ago, I still watch it in re-runs.  The concept was simple.  Send one of the world’s best known chefs to save a failing restaurant.

Each week a new disaster establishment was featured.  A fair number were dives — dirty, disorganized messes with all the charm and quality of a gas station lavatory.  It wasn’t hard to figure out why these spots were in trouble.  Others, by contrast, were beautiful, high-end eateries whose difficulties were not immediately obvious.

Of course, I have no idea how much of what we viewers saw was real versus contrived.  Regardless, the answers owners gave whenever Ramsey asked for their assessment of the restaurant never failed to surprise and amuse.   I don’t recall a single episode where the owners readily acknowledged having any problems, other than the lack of customers!  In fact, most often they defended themselves, typically rating their fare “above average,” — a 7 or higher on a scale from 1 to 10.

Contrast the attitude of these restaurateurs with pop music icon Billy Joel.  When journalist Steve Croft asked him why he Billy Joelthought he’d been so successful, Joel at first balked, eventually answering, “Well, I have a theory, and it may sound a little like false humility, but … I actually just feel that I’m competent.”  Whether or not you are a fan of Joel’s sound, you have to admit the statement is remarkable.   He is one of the most successful music artists in modern history, inducted into the Rock and Roll Hall of Fame, winning a Grammy Legend Award, earning four number one albums on the Billboard 200, and consistently filling stadiums of adoring fans despite not having released a new album since 1993!  And yet, unlike those featured on Kitchen Nightmares, he sees himself as merely competent, adding “when .. you live in an age where there’s a lot of incompetence, it makes you appear extraordinary.”

Is humility associated with success?  Well, turns out, it is a quality possessed by highly effective effective therapists.  Studies not only confirm “professional self-doubt” is a strong predictor of both alliance and outcome in psychotherapy but actually a prerequisite for acquiring therapeutic expertise (1, 2).  To be clear, I’m not talking about debilitating diffidence or, as is popular in some therapeutic circles, knowingly adopting a “not-knowing” stance.  As researchers Hook, Watkins, Davis, and Owen describe, its about feedback — specifically, “valuing input from the other (or client) … and [a] willingness to engage in self-scrutiny.”

Low humility, research shows, is associated with compromised openness (3).  Sound familiar?  It is the most common reaction of owners featured on Kitchen Nightmares.  Season 5 contained two back-to-back episodes featuring Galleria 33, an Italian restaurant in Boston, Massachusetts.  As is typical, the show starts out with management expressing bewilderment about their failing business.  According to them, they’ve tried everything — redecorating, changing the menu, lowering prices.  Nothing has worked.  To the viewer, the problem is instantly obvious: they don’t take kindly to feedback.  When one customer complains their meal is “a little cold,” one of the owners becomes enraged.  She first argues with Ramsey, who agrees with the customer’s assessment, and then storms over to the table to confront the diner.  Under the guise of “just being curious and trying to understand,” she berates and humiliates them.  It’s positively cringeworthy.  After numerous similar complaints from other customers — and repeated, uncharacteristically calm, corrective feedback from Ramsey — the owner experiences a moment of uncertainty.  Looking directly into the camera she asks, “Am I in denial?”  The thought is quickly dismissed.  The real problem, she and the co-owner decide, is … (wait for it) …

Ramsey and their customers!   Is anyone surprised the restaurant didn’t survive?

closed for businessSuch dramatic examples aside, few therapists would dispute the importance of feedback in psychotherapy.  How do I know?  I’ve meet thousands over the last two decades as I traveled the world teaching about feedback-informed treatment (FIT).  Research on implementation indicates a far bigger challenge is making sense of the feedback one receives (4, 5, 6)  Yes, we can (and should) speak with the client — research shows therapists do that about 60% of the time when they receive negative feedback.  However, like an unhappy diner in an episode of Kitchen Nightmares, they may not know exactly what to do to fix the problem.  That’s where outside support and consultation can be critical.  Distressingly, research shows, even when clients are deteriorating, therapists consult with others (e.g., supervisors, colleagues, expert coaches) only 7% of time.

Since late summer, my colleagues and I at the International Center for Clinical Excellence have offered a series of intimate, virtual gatherings of mental health professionals.  Known as the FIT Cafe, the small group (10 max) gets together once a week to finesse their FIT-related skills and process client feedback.  It’s a combination of support, sharing, tips, strategizing, and individual consultation.  As frequent participant, psychologist Claire Wilde observes, “it has provided critical support for using the ORS and SRS to improve my therapeutic effectiveness with tricky cases, while also learning ways to use collected data to target areas for professional growth.”FIT Winter Cafe 2021

The next series is fast approaching, a combination of veterans and newbies from the US, Canada, Europe, Scandinavia, and Australia.  Learn more or register by clicking here or on the icon to the right.

Not ready for such an “up close and personal” experience?  Please join the ICCE online discussion forum.  It’s free.  You can connect with knowledgeable and considerate colleagues working to implement FIT and deliberate practice in their clinical practice in diverse settings around the world.

OK, that’s it for now.  Until next time,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence

 

Filed Under: deliberate practice, excellence, Feedback, Feedback Informed Treatment - FIT, FIT, Therapeutic Relationship

Umpires and Psychotherapists

December 9, 2020 By scottdm Leave a Comment

umpireCriticizing umpires is as much a part of watching baseball as eating hotdogs and wearing team jerseys on game day.  The insults are legion, whole websites are dedicated to cataloging them:

“Open your eyes!”

“Wake up, you are missing a great game!”

“Your glasses fogged up?”

“Have you tried eating more carrots?”

“I’ve seen potatoes with better eyes!”

“Hey Ump, how many fingers am I holding up?

Are you “seeing” a common theme here?

And interestingly, the evidence indicates fans have reason to question the judgement and visual acuity of most umpires.  A truly massive study of nearly 4 million pitches examined the accuracy of their calls over 11 regular seasons.  I didn’t know this, but it turns out, all major league stadiums are equipped with fancy cameras which track every ball thrown from mound to home plate.  Using this data, researchers found “botched calls and high error rates are rampant.”   How many you ask?  A staggering 34,246 incorrect calls in the 2018 season alone!  It gets worse.  When the pressure was on — a player at bat, for example, with two strikes — umpire errors skyrocket, occurring nearly one-third of the time.  Surely, the “umps” improve with time an experience?  Nope.  In terms of accuracy, youth and inexperienced win out every time!therapists and horses

Now, let me ask, are your “ears burning” yet?

Turns out, umpires and psychotherapists share some common traits.  So, for example, despite widespread belief to the contrary, clinicians are not  particularly good at detecting deterioration in clients.  How bad are we?  In one study, therapists correctly identified clients who worsen in their care a mere two-and-a-half percent of the time (1)!  Like umpires, “we call ’em as we see ’em.”  We just don’t see them.  And if you believe we improve with experience, think again.  The largest study in the history of research on the subject — 170 practitioners treating 6500 clients over a 5 year period — reveals that what is true of umpires applies equally to clinicians.  Simply put, on average, our outcomes decline the longer we are in the field.

If you are beginning to feel discouraged, hold on a minute.  While the data clearly show umpires make mistakes, the same evidence documents most of their calls are correct.  Similarly, therapists working in real world settings help the majority of their clients achieve meaningful change — between 64 and 74% in our database of thousands of clinicians and several million completed treatment episodes.

Still, you wouldn’t be too far “off base” were you to conclude, “room for improvement exists.”

Truth is, umpires and therapists are calling “balls and strikes” much the same way they did when Babe Ruth and Alfred Alder were key players.  Solutions do exist.  As you might guess, they are organized around using feedback to augment and improve individual judgement ability.  So far, major league baseball (and its umpires) has resisted.  In psychotherapy, evidence shows clients of therapists who formally and routinely solicit feedback regarding the quality of the therapeutic relationship and progress over time are twice as likely to experience improvement in treatment.

The measures are free for practitioners to use and available in 25+ languages.  If you don’t have them, click here to register.   You’ll likely need some support in understanding how to use them effectively.  Please join the conversation with thousands of colleagues from around the world in the ICCE Discussion Forum.  If you find yourself wanting to learn more, click on the icon below my name for information about our next upcoming intensive — online, by the way!

What more is there to say, except: BATTER UP!

Until next time, wishes for a safe and healthy Holiday season,

Scott

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
ICCE FIT Intensive Online Scott D Miller

Filed Under: Feedback Informed Treatment - FIT

Augmenting the Two-Dimensional Sensory Input of Online Psychotherapy

November 30, 2020 By scottdm Leave a Comment

ORS and SRS utilization pandemicTake a look at the graphic to the left.  It shows the use of the Outcome and Session Rating Scales (ORS & SRS) from the beginning of this year to the present by users of one of the three , authorized FIT software programs.

What do you see?

A couple of things stand out for me.  First, a steady rise in administrations of the tools beginning in late January and continuing to the third week of March when use significantly dropped.  You can literally “see” the pandemic coming.  In the weeks and months that followed, use of the measures steadily recovered and is, as of today, up nearly 30% over its record high in the weeks before virus mitigation efforts brought the world to a standstill.

The cause of the rise in online use of the ORS and SRS is no mystery.  The number of therapists seeing clients virtually has, virtually, exploded.  In this “brave new world” of clinical practice, its clear clinicians are looking for concrete, evidence-based ways to augment the two-dimensional sensory input (sight and sound) characteristic of video conferencing.

In a previous blog, I summarized the research on the effectiveness of online behavioral health services.  The data are clear: it works.  More, a brand new meta-analysis, released just this week, adds to the body of evidence documenting that being physically present is not essential for successful outcomes.

The ORS and SRS are particularly well suited for online service delivery.   Indeed, the original validation studies of the two scales were actually ORS SRSconducted in a teletherapy setting.  It was the era before high-speed broadband and Zoom.  Therapists spoke with their clients by landline, administering the measures orally using a standardized script.  Since those early days, scores of studies have documented the impact of routinely soliciting formal client feedback on both outcome and retention in behavioral health services.  In one recent study, clients of therapists using the ORS and SRS were 2.5 times more likely to experience a successful outcome.  Using standardized measures as part of service delivery is now considered a “standard of care” by Joint Commission and SAMHSA.  Next year, the State of California follows suit, allowing psychologists to use the tools to earn required continuing education credits (see top of page 4, under “Practice Outome Monitoring [POM]”).

If you don’t have copies, you can get them for free here.   Looking for detailed instructions and “how to” videos on integrating the ORS and SRS into online services, click here — all free.  The six-volume set of feedback-informed treatment manuals is the most comprehensive source for using the tools to inform and improve mental health service delivery (if you don’t have a set, you can get the entire set for 80% off the full price through Friday December 4th.  At checkout, simply type in the code: FITMANUALS).

OK, that’s it for now.  Thanking you for your continuing friendship and interest, and wishing you, your family, and colleagues safety and health during these challenging times.

Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
Feedback Infomed Treatment FIT Intensive 2021FIT Supervision Intensive 2021

 

 

 

 

P.S.: Registration for the two FIT Intensives is open — both online! As always, space is limited to 40 participants to ensure quality and connection.  Click here for more information or to register.

Filed Under: Feedback Informed Treatment - FIT

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