“We should not try to design a better world,” says Owen Barder, senior fellow at the Center for Global Development, “We should make better feedback loops.”
Feedback has become a bit of a buzzword in mental health. Therapists are being asked to use formal measures of progress and the quality of the relationship and use the resulting information to improve effectiveness.
As it turns out, not all feedback is created alike. The key to success is obtaining information that gives rise to increased consciousness—the type that causes one to pause, reflect, rethink. In a word, negative feedback.
Nearly a decade ago, we noticed a curious relationship between effectiveness and the therapeutic alliance. Relationships that started off poorly but improved were nearly 50% more effective than those rated good throughout.
And now, more evidence from a brand-new, real-world study of therapy with adolescents (Owen, Miller, Seidel, & Chow, 2016). Therapists asked for and received feedback via the Outcome and Session Rating scales at each and every visit. Once again, relationships that improved over the course of treatment were significantly more effective.
Importantly, obtaining lower scores at the outset of therapy provides clinicians with an opportunity to discuss and address problems early in the working relationship. But, how best to solicit such information?
The evidence documents that using a formal measure is essential, but not enough. The most effective clinicians work hard at creating an environment that not invites, but actively utilizes feedback. Additionally, they are particularly skilled at asking questions that go beyond platitudes and generalities, in the process transforming client experience into specific steps for improving treatment.
As statistician and engineer Edward Deming once observed, “If you do not know how to ask the right question, you discover nothing.”
Little useful information is generated when clients are asked, “How did you feel about the session today?” “Did you feel like I (listened to/understood) you?” or “What can I do better?”
The best questions are:
- Specific rather than general;
- Descriptive rather than evaluative;
- Concerned with quantities rather than qualities; and are
- Task rather than person-oriented.
Over the years, we’ve come to understand that learning to ask the “right” question takes both time and practice. It’s not part of most training programs, and it only comes naturally to a few. As a result, many therapists who start using formal measures to solicit feedback about progress and the therapeutic relationship, give up, frustrated in their efforts to solicit helpful feedback.
Learning to develop better “feedback loops,” as Barder recommends, is the focus for the upcoming FIT Implementation, Training of Trainers, and Professional Development Intensives scheduled for August in Chicago, Illinois (USA). Our March courses sold out months in advance so reserve your spot now by clicking the icons to the right.
Until then, get started with these free articles.
Best wishes,
Scott
Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence
The Barder quote applies to any change effort — psychotherapy being just one of them.
The nicest and best-sounding ideas for productive change in social, organizational, or relationship arrangements and practices may be so enchant those seeking change that they override the observed responses (feedback) from those involved — even from the promoters of the nice ideas. Pressing onward despite contrary responses and without learning from those responses is likely to replicate the system’s problems — or even exacerbate them. Think of all the revolutions, on large and small scales, which reproduced many of the problems and even oppressions their planners intended to solve.
Dr. Miller’s blog with the Barder quote arrived when I was already considering how best to tell the Los Angeles County Supervisors that their ideas for using a consultant to advise them on a hazard in the way they were describing the tasks they were considering hiring a consultant for regarding the County’s Probation Department. They were talking about asking the consultant to advise them about what major structural changes to implement.
That seemed to be cart before the horse; their efforts and spending would stand a better chance of actually solving priority problems if the consultant’s first task was to seek, receive, and analyze input from all concerned parties (including of course probation supervisees, and not just county staffers).
There is a helpful byproduct — or perhaps it is a main product — of seeking and using feedback: the empowerment of the client/person giving the feedback. They are being told, and shown, that their needs and views count. Therapy clients may have had experiences which they concluded showed them that their well-being and needs did not count, were not to be considered. A therapy too determined to help the client in the way the therapist knows is best may actually repeat some of that unfortunate experience.
Contemplating a shift to “feedback informed” in therapy and other realms brought up my own anxiety about not having a map. However, the truth is that the map is there; it is being supplied in every moment if we can leave off our preconceptions and read what is being presented.