Friday, May 27, 2011
Using Motivational Interviewing with Feedback Informed Treatment (FIT)
In February 2011, I went through Scott Miller's Advanced Training in the use of Feedback Informed Treatment. If you are not familiar with Scott's work, he wrote many articles and books when he was doing Family Therapy, in the development of Solution-Focused Therapy. His book, The Heroic Client, describes his departure from the use of any one "model" or "technique" to focus on what actually works from the viewpoint of the client, rather than the practitioner's opinion on how well the client has done with them.
I have begun using his Outcome Rating Scale, in which the client is asked about the level of distress re: their presenting problem using a Likert scale of 0 to 10, with 0 being "very bad" and 10 representing "very good". This data is then entered into a database to follow how the client is assessing their problem per session.
At the end of the session, the clients are asked to fill out the SRS, Session Rating Scale, whereupon they rate the practitioner, their satisfaction with the session including the content of the session, whether or not they experienced being heard and understood, whether the practitioner missed anything and can/should include logistical matters such as being on time, chewing gum, etc.
My first client did not want to fill out the questions at all, and when I asked the second session, she still did not want to. I started getting worried that this might become a problem, so I began telling my clients while on the phone making the appointment that I would be using these tools. I explained that I could not become a better practitioner without their brutally honest feedback, and that their progress on their "problem" would guide both of us as to whether what I was doing or whether I was a good fit for the client. One client told me (on the phone) that she saw a therapist for 7 years almost weekly, and felt she made very little progress. She was reluctant to terminate with her (though she liked her) because she (the client) thought that it was something she rather than the therapist had done wrong. It was only through a good friend urging her to try someone else that she did.
I have found that the approach of getting honest feedback from the client is easier than I would have thought. By explaining it as an issue of them being an "educated consumer" as well as assisting me in becoming a better therapist was very helpful. One client said "I feel like I am grading you!" "You are!", I responded. I encouraged them to be very honest, as I was interested in what would bring a number up. I have found that I get some 7's out of 10 in some sessions, and I ask them "What would bring it up to an 8?" I get very specific feedback: I don't want writing assignments, I would need help accessing and using a computer for a website you recommended, I don't like to read, etc.
All of this data is then put into a database, which then allows me to plot if they are getting "better" (according to them) as well as their experience of me as being helpful. If by session 6, their level of distress has gotten worse rather than better, we have already discussed on the phone and first session that it is time to discuss other options. Using me to be "their paid best friend" is not effective therapy, if they are feeling worse instead of better. It could be finding out what would be more useful to them (we always cover that) will also reveal that they need a practitioner with a different skill base than my own. Perhaps a healthcare practitioner would be the person to see or perhaps going to a Buddhist temple might be the answer! People solve their dilemmas with different pathways and they do not all involved psychotherapy.
This August, I am going through Scott's Training of Trainers, and I am looking forward to learning more about how to interpret the data of Evidenced Based Practices more accurately, as well as hone my skills in FIT. I can use any tool in my toolbox, anything I feel competent in, whether it is MI, hypnotherapy, Cognitive Behavior Therapy, helping them develop a resume, couple/family therapy, anything I feel competent in. If they needed help with Anxiety, I would find a good referral for them as I don't have enough background for in vivo work, which is the CBT method I like best.
I have not had my feelings hurt by getting scores of less than 10. I thank my clients when they give me a 6 or 7, as they can then share what they need and want. This approach increases the sense of collaboration that I love about Motivational Interviewing. I am a MITI 3.1 coder and coding trainer, and I am always thinking about how the client would have rated the practitioner in the session. Here I am, rating them and why is not the "expert", the client, rating them? It is an acquired skill to present the desire for honesty about me, and yet so far, I think they have been quite honest. I tell them most clients (most people) overrate everything on surveys such as this, whether in a restaurant or online. What good does it do any provider to get no feedback from their "customer"?
I am digging it!
Jacque
I have begun using his Outcome Rating Scale, in which the client is asked about the level of distress re: their presenting problem using a Likert scale of 0 to 10, with 0 being "very bad" and 10 representing "very good". This data is then entered into a database to follow how the client is assessing their problem per session.
At the end of the session, the clients are asked to fill out the SRS, Session Rating Scale, whereupon they rate the practitioner, their satisfaction with the session including the content of the session, whether or not they experienced being heard and understood, whether the practitioner missed anything and can/should include logistical matters such as being on time, chewing gum, etc.
My first client did not want to fill out the questions at all, and when I asked the second session, she still did not want to. I started getting worried that this might become a problem, so I began telling my clients while on the phone making the appointment that I would be using these tools. I explained that I could not become a better practitioner without their brutally honest feedback, and that their progress on their "problem" would guide both of us as to whether what I was doing or whether I was a good fit for the client. One client told me (on the phone) that she saw a therapist for 7 years almost weekly, and felt she made very little progress. She was reluctant to terminate with her (though she liked her) because she (the client) thought that it was something she rather than the therapist had done wrong. It was only through a good friend urging her to try someone else that she did.
I have found that the approach of getting honest feedback from the client is easier than I would have thought. By explaining it as an issue of them being an "educated consumer" as well as assisting me in becoming a better therapist was very helpful. One client said "I feel like I am grading you!" "You are!", I responded. I encouraged them to be very honest, as I was interested in what would bring a number up. I have found that I get some 7's out of 10 in some sessions, and I ask them "What would bring it up to an 8?" I get very specific feedback: I don't want writing assignments, I would need help accessing and using a computer for a website you recommended, I don't like to read, etc.
All of this data is then put into a database, which then allows me to plot if they are getting "better" (according to them) as well as their experience of me as being helpful. If by session 6, their level of distress has gotten worse rather than better, we have already discussed on the phone and first session that it is time to discuss other options. Using me to be "their paid best friend" is not effective therapy, if they are feeling worse instead of better. It could be finding out what would be more useful to them (we always cover that) will also reveal that they need a practitioner with a different skill base than my own. Perhaps a healthcare practitioner would be the person to see or perhaps going to a Buddhist temple might be the answer! People solve their dilemmas with different pathways and they do not all involved psychotherapy.
This August, I am going through Scott's Training of Trainers, and I am looking forward to learning more about how to interpret the data of Evidenced Based Practices more accurately, as well as hone my skills in FIT. I can use any tool in my toolbox, anything I feel competent in, whether it is MI, hypnotherapy, Cognitive Behavior Therapy, helping them develop a resume, couple/family therapy, anything I feel competent in. If they needed help with Anxiety, I would find a good referral for them as I don't have enough background for in vivo work, which is the CBT method I like best.
I have not had my feelings hurt by getting scores of less than 10. I thank my clients when they give me a 6 or 7, as they can then share what they need and want. This approach increases the sense of collaboration that I love about Motivational Interviewing. I am a MITI 3.1 coder and coding trainer, and I am always thinking about how the client would have rated the practitioner in the session. Here I am, rating them and why is not the "expert", the client, rating them? It is an acquired skill to present the desire for honesty about me, and yet so far, I think they have been quite honest. I tell them most clients (most people) overrate everything on surveys such as this, whether in a restaurant or online. What good does it do any provider to get no feedback from their "customer"?
I am digging it!
Jacque
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