Using Client Feedback in Therapy
In Using Client Feedback in Therapy, Barry L. Duncan illustrates his client-directed, outcome-informed approach to psychotherapy, which enlists the use of client feedback to ensure a positive treatment outcome. In this process, the client's voice is a highly integrated part of how the service is delivered, with feedback about therapeutic benefit and the quality of the alliance both shaping how therapy unfolds and demonstrating its effectiveness.
In this session, Dr. Duncan works with a woman in her 40s who is struggling to make sense of the end of her marriage. While the client has successfully moved on from the termination of her relationship, she is still nagged by a lack of understanding of how it happened and what responsibility she carried as a partner.
What is CDOI?
Client directed, outcome informed (CDOI) clinical services is an empirically-based approach to human problems grounded in 50 years of research about what works in mental health and substance abuse services, and how to deliver it on the front lines. CDOI contains no fixed techniques or causal theories regarding the concerns that bring people to treatment.
Any interaction can be client-directed and outcome-informed when the consumer's voice is privileged, social justice is embraced, recovery is expected, and helpers purposefully form partnerships to:
- enhance the factors across theories that account for success — the so-called common or healing factors of change (Duncan et al., 2010);
- use client's ideas and preferences (theories) to guide choice of technique and model (Duncan et al., 2004); and
- inform the work with reliable and valid measures of the consumer's experience of the alliance and outcome, or PCOMS (Duncan, 2010).
What is PCOMS?
PCOMS stands for Partners for Change Outcome Management System.
Devoted to empirically-derived clinical practices, PCOMS incorporates the most robust predictors of therapeutic success into an outcome management system that partners with clients while honoring the daily pressures of front-line clinicians. PCOMS uses two brief scales, the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS), to measure the client's perspective of benefit and the alliance, respectively.
Unlike other methods of measuring outcome, this system truly gives clients the voice they deserve and assigns consumers key roles in determining how services are both delivered and funded. It is the only system that includes a transparent discussion of the results with clients and the only system to include routine measurement of the therapeutic alliance.
PCOMS was launched after 7 years of development, research, and publications in peer reviewed journals to establish the psychometric validation of its instruments. Since that time, PCOMS has been shown in 3 randomized clinical trials, all conducted by those affiliated with the Heart and Soul of Change Project, to significantly improve effectiveness in real clinical settings.
There is a growing worldwide movement, both private and governmental, to involve consumers in mental health and substance abuse care and improve the outcome or value of rendered services. PCOMS proactively partners with consumers to improve the value of the care they receive and is the only system that by design includes clients in all aspects of outcome management.
The use of evidence-based treatments (EBT) does not guarantee success. In recognition of the inability of any model to predict success for the individual client, the APA Task Force on evidence-based practice (EBP) suggested that "ongoing monitoring of patient progress and adjustment of treatment as needed are essential." PCOMS provides a method to combine EBP with "practice-based evidence" to ensure success at the individual client level.
Although psychosocial intervention is successful for many clients, a portion of clients do not benefit. In addition, drop-out rates average 47%. Making matters worse is the fact that clinicians often fail to identify people at risk for dropping out or unsuccessful outcome. PCOMS provides an early warning system to identify failing clients based on the best known predictors of outcome and retention.
Two factors are predictive of retention, progress, and the eventual success of treatment: The consumer's rating of the alliance with the provider of services and the consumer's rating of early progress in response to the provider, level, and type of treatment offered. PCOMS monitors these two predictive variables with reliable, valid, and feasible outcome and alliance measures.
Providing clinicians with ongoing consumer feedback regarding the alliance and progress in treatment dramatically increases success rates as well as the cost-effectiveness (reduces cancellations, no shows, length of stay, etc.) of provided services.
Four studies have demonstrated the benefits of client feedback with the ORS and SRS.
Miller, Duncan, Brown, Sorrell, and Chalk (2006; Journal of Brief Therapy) explored the impact of feedback in a large culturally diverse sample utilizing a telephonic employee assistance program (EAP). Although the study's quasi-experimental design qualifies the results, the use of outcome feedback doubled overall effectiveness and significantly increased retention setting the stage for more sophisticated investigation.
Three recent randomized clinical trials (RCT) used the ORS and SRS to investigate the effects of feedback versus treatment as usual (TAU).
First, in an independent investigation, Reese, Norsworthy, and Rowlands (2009; Psychotherapy) found that individuals who attended therapy at a university counseling center and a graduate training clinic demonstrated significant treatment gains for feedback when compared to TAU.
Second, a recent study in Norway (Anker, Duncan, & Sparks, 2009; Journal of Consulting and Clinical Psychology), the largest (N = 410) RCT of couple therapy ever done, found that feedback clients reached clinically significant change nearly four times more than non-feedback couples. The feedback condition maintained its advantage at 6-month follow-up and achieved a 46% lower separation/divorce rate. Feedback improved the outcomes of nine of 10 therapists in this study.
Finally Reese, Toland, Slone, and Norsworthy (2010; Psychotherapy) replicated the Norway study with couples.
The Norway Feedback Study led to the national adoption of CDOI in family counseling agencies in Norway. The States of Arizona and Colorado have adopted CDOI as an evidence-based practice.
Barry L. Duncan, PsyD, is a therapist, trainer, and researcher with more than 17,000 hours of clinical experience. He is director of the Heart and Soul of Change Project, a practice-driven training and research initiative that focuses on what works in therapy and, more importantly, how to deliver it on the front lines via client-based outcome feedback.
Dr. Duncan has over 100 publications as well as 15 books to his credit, including The Heroic Client, Brief Intervention for School Problems, and the second edition of The Heart and Soul of Change.
He is the codeveloper of the Outcome Rating Scale (ORS), Session Rating Scale (SRS), Child ORS, and Child SRS, which are measures designed to give clients the voice they deserve, as well as to provide clients, clinicians, administrators, and payers with feedback about the client's response to services, thus enabling more effective care tailored to client preferences.
Because of his self-help books, he has appeared on The Oprah Winfrey Show, The View, and several other national TV programs. His latest self-help book, What's Right With You, demonstrates how to rally natural resources and resiliencies to overcome life challenges.
Dr. Duncan conducts seminars internationally in hopes of inciting insurrection against practices that diminish clients and encouraging therapists to establish their own identity.
- Duncan, B. L. (2010). On becoming a better therapist. Washington, DC: American Psychological Association.
- Duncan, B. L., Hubble, M. A., & Miller, S. D. (1997). Psychotherapy with "impossible" cases: The efficient treatment of therapy veterans. New York, NY: W. W. Norton & Company.
- Duncan, B., Miller, S. D., Hubble, M., & Wampold, B. E. (Eds.). (2010). The heart and soul of change: Delivering what works (2nd ed.). Washington, DC: American Psychological Association.
- Duncan, B. L., Miller, Scott D., & Sparks, J. A. (2004). The heroic client: A revolutionary way to improve effectiveness through client-directed, outcome-informed therapy. San Francisco, CA: Jossey-Bass.
- Duncan, B. L., Solovey, A. D., & Rusk, G. S. (1992). Changing the rules: A client-directed approach to therapy. New York, NY: The Guilford Press.
- Miller, S. D., Hubble, M. A., & Duncan, B. L. (1996). Handbook of solution-focused brief therapy. San Francisco, CA: Jossey-Bass.
- Murphy, J. J., & Duncan, B. L. (2010). Brief intervention for school problems, second edition: Outcome-informed strategies. New York, NY: The Guilford Press.
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