Not long ago, my friend and colleague Dr. Rick Kamins was on vacation in Hawaii. He was walking along the streets of a small village, enjoying the warm weather and tropical breezes, when the sign on a storefront caught his eye. Healing Arts Alliance, it read. The proprietor? None other than, “Scott Miller, Master of Oriental Medicine.”
“With all the talking you do about the alliance,” Rick emailed me later, “I wondered, could it be the same guy?!”
I responded, “Ha, the story of my life. You go to Hawaii and all I get is this photo!”
Seriously though, I do spend a fair bit of time when I’m out and about talking about the therapeutic alliance. As reviewed in the revised edition of The Heart and Soul of Change there are over 1100 studies documenting the importance of the alliance in successful psychotherapy. Simply put, it is the most evidence-based concept in the treatment literature.
At the same time, whenever I’m presenting, I go to great lengths to point out that I’m not teaching an “alliance-based approach” to treatment. Indeed–and this can be confusing–I’m not teaching any treatment approach whatsoever. Why would I? The research literature is clear: all approaches work equally well. So, when it comes to method, I recommend that clinicians choose the one that fits their core values and preferences. Critically, however, the approach must also fit and work for the person in care–and this is where research on the alliance and feedback can inform and improve retention and outcome.
Back in 1994, my long time mentor Dr. Lynn Johnson encouraged me to begin using a simple scale he’d developed. It was called…(drum roll here)…”The Session Rating Scale!” The brief, 10-item measure was specifically designed to obtain feedback on a session by session basis regarding the quality of the therapeutic alliance. “Regular use of [such] scales,” he argued in his book Psychotherapy in the Age of Accountability, “enables patients to be the judge of the…relationship. The approach is…egalitarian and respectful, supporting and empowering the client” (Johnson, 1995, p. 44). If you look at the current version of the SRS, you will see Lynn is listed on the copyright line–as Paul Harvey would say, “And now you know…the rest of the story.” Soon, I’ll tell you how the measure went from a 10-item, Likert scale to a 4-item visual analog scale.
Anyway, some 17 years later, research has now firmly validated Lynn’s idea: formally seeking feedback improves both retention and outcome in behavioral health. How does it work? Unfortunately science, as Malcoln Gladwell astutely observes, “all too often produces progress in advance of understanding.” That said, recent evidence indicates that routinely monitoring outcome and alliance establishes and serves to maintain a higher level of baseline performance. In other words, regularly seeking feedback helps clinicians attend to core therapeutic principles and processes easily lost in the complex give-and-take of the treatment hour.
Such findings are echoed in the research literature on expertise which shows that superior performers across a variety of domains (physics, computer programming, medicine, etc.) spend more time than average performers reviewing basic core principles and practice.
At an intensive training in Antwerp, Belgium
The implications for improving practice are clear: before reaching for the stars, we should attend to the ground we stand on. It’s so simple, some might think it stupid. How can a four item scale given at the end of a session improve anything? And yet, in medicine, construction, and flight training, there is a growing reliance on such “checklists” to insure that proven steps to success are not overlooked. Atul Gawande reviews this practice in his new and highly readable book, The Checklist Manifesto: How to Get Things Right
The only question that remains is, I suppose, with all the workshops and training on “advanced methods and specialized techniques,” will practitioners interested in bringing up baseline?