The data are clear: working feedback-informed improves both retention and effectiveness (1). Studies further show FIT achieves these effects, in part, by improving responsiveness to the individual client — particularly those at risk for a negative or null outcome or dropout from treatment (2, 3).
Such positive results notwithstanding, what happens when an outcome measure misleads — when the tool used returns results that are incongruent with the client’s experience?
Consider two recent studies (4). In both, researchers found clients largely agreed when an outcome measure — in this instance, the Outcome Questionnaire 45 — indicated they had improved, but disagreed when it suggested they had worsened. The size of the disconnect was ginormous: 91% saw themselves as benefitting significantly! In such instances, concluding treatment wasn’t helping and opting to terminate or refer, would be the antithesis of responsiveness — which leads me to what I like to call, “my most misunderstood “FIT Tip.”
Early in FIT trainings, therapists learn three ways they can adjust services in the absense of client progress: “Change the ‘what.’ Change the ‘where.’ Change the ‘who.'” Evidence-based guidelines are also provided for when such modifications should be introduced:
- Little or no progress or deterioration by the third visit? Revisit the goals of treatment, paying particular attention to differences between the services being offered and the client’s stated reason for seeking help.
- Little or no progress or deterioration by the fifth to seventh visit? Consider adding/augmenting services, providers, or participants.
- No improvement or deterioration by the tenth to twelfth? Consider changing the provider, location, or type of services.
Of the three, the third is the most misunderstood. On more than one occasion, for example, I’ve heard therapists say, “According to Scott Miller, if a client isn’t improving by the 10th or 12th visit, treatment should be ended.”
Just to be clear, I have never made such a suggestion. Nor do I believe it. The entire point of FIT is to increase the likelihood of my clients getting what they hope for from their interaction with me. As such, the feedback from standardized measurement tools like the Outcome and Session Rating Scales should be considered starting rather than stopping points, opportunities to lean in and explore, not defer or refer.
I had a chance recently to interview the author of one of the aforementioned studies, Dr. Eric Ghelfi. Not only does he describe the studies in intriguing detail, he offers specific guidance for using the results to enhance responsiveness to the individual client, especially when there’s a disconnect between the tool and the client’s report. The “tips” he offers, I’m certain, will make a difference in your use of FIT.
OK, that’s it for now! Until next time,
Scott D. Miller, Ph.D.
Director, International Center for Clinical Excellence