At first, we simply hand scored the measures.

Next came an Excel® spreadsheet. It not only automated administration and scoring, but plotted progress from session to session on a graph. Purple represented the client’s actual score. The blue, green, and red lines showed the 50th, 75th and 25 percentile, respectively, for clients with the same start score in the entire normative sample.

Its hard to recall just how revolutionary such technology was at the time. No more paper forms, a single program for keeping track of all clients, the ability to calculate one’s overall effectiveness and, most importantly, a way for determining when an individual client was “at risk” for a negative or null outcome from treatment.

Over time, both science and technology have evolved considerably. Now, three powerful, web-based systems are available that enable clinicians, agencies, and healthcare systems to track client progress in real time, administer the scales both in person and remotely, and provide an array of sophisticated clinician, program and agency metrics.

Of course, the systems still make it possible to identify “at risk” clients. They do so, however, in a far more accurate way. No more guesswork or comparison of individual clients to percentile rankings or sample averages. As explained in this week’s “FIT TIP,” the “signal light” colors on the graphs are predictive, telling you when your specific client is on or off track toward to positive result.

“How?” you might ask.

Well, listen for yourself. True of all FIT TIPS, this one is just a few minutes in length.

I’ve never been enthusiastic about categories, whether aligning myself with a particular therapeutic approach or assigning a diagnostic label to a client. Any order achieved seemed to come at the expense of freedom and possibility.

Lately, however, I’ve found myself feeling an affinity for a particular classification scheme. Maybe its my age. In July, I turn 65. On that birthday, I will have worked as a psychologist for longer than I had been alive when I entered the profession! And according to psychoanalyst Erik Erikson — a person whose work I’ve not thought about since my undergraduate days — that puts me at the doorstep of the eighth, and last stage of psychosocial development: integrity versus despair.

I’d forgotten Erikson coined the term, “identity crisis.” It was central to his theory of personal growth. The nature of the dilemma one faced was different at each stage. Successful resolution led to the development of character strengths a person could use to manage life and circumstance; failure, to an unhealthy sense of self and reduced capacity for fulfillment.

From the time I first heard them, Erickson’s “stages” had struck me as similar to a horoscope. You know, statements that feel personalized and specific but in fact are so vague and general they apply to everyone. That said, with fewer years of my professional life ahead of me than behind, that last stage had started speaking to me. More and more, I found myself thinking about where we were as a field, if we had made any progress and could feel proud of our work?

The challenges were stark, and frankly overwhelming. To name a few:

*An unprecedented rise in the number of people suffering from mental and emotional problems;
*No improvement in the outcome of psychotherapy over the last 50 years;
*No evidence that traditional training models or clinical experience (e.g., diagnostic specific treatments, ongoing supervision, licensing, mandated continuing education) contributes to clinician effectiveness despite widespread belief and regulation to the contrary.

Erikson maintained that each person must learn how to hold both extremes of each specific life-stage challenge in tension with one another, not rejecting one end of the tension or the other.  How, I wondered, could anyone not give into despair in light of the facts noted above?

That’s when I reached out to my longtime, colleague, mentor and friend, Dr. Bruce Wampold. Together, we confront the the present and future state of psychotherapy research and practice. Should we feel discouraged or hopeful? Listen for yourself.

It’s a question that comes up at some point in most trainings on feedback-informed treatment (FIT):

“Can I use FIT with all my clients?”

Having encountered it many times, I now have a pretty good sense of the asker’s concerns. Given our training as mental health professionals, we think in terms of diagnosis, treatment approach and service delivery setting.

Thus, while the overall question is the same, the particulars vary:

“Does FIT work (with people in recovery for drug and alcohol problems, those with bipolar illness or schizophrenia, in crisis settings, group or family therapy, long term, inpatient or residential care)?

Occasionally, someone will report having read a study indicating FIT either did not work or made matters worse when used with certain types of clients (1) or in particular settings (2).

While I have posted detailed responses to specific studies published over the last couple of years (3), the near limitless number of ways questions of efficacy can be parsed ultimately renders such an approach clinically and pragmatically useless. Think of the panoply of potential parameters one would need to test. The latest edition of the Diagnostic and Statistical Manual of Mental Disorders alone contains 297 diagnoses. Meanwhile, more than a decade ago, Scientific American identified 500 different types of psychotherapy. If history is a reliable guide, the number of approaches has most certainly increased by now. Add to that an ever evolving number of settings in which treatment takes place — most recently online — and the timeline for answering even the most basic questions quickly stretches to infinity.

So, returning to the question, “how best to decide whether to use FIT with ‘this or that’ client, treatment approach, or service setting?”

That’s the subject of my latest FIT TIP: Does FIT work with all Clients?

As promised, every 10 days or so, I’ve released a brief video providing practical guidance for optimzing your use of feedback in treatment. To date, these have addressed:

How to solicit clinically useful feedback

How to use client feedback to improve effectiveness

Identifying the best electronic FIT outcome system for you

What to do when your client is not making progress

Should you start FIT with established clients