Therapist perspectives on the use of feedback on process and outcome: Patient-focused research in practice.

Abstract

The aim of this qualitative study is to explicate how therapists describe and evaluate the use of two measures, the Session Rating Scale (SRS) and the Outcome Rating Scale (ORS), in order to monitor therapeutic work. Results confirm the feasibility of these scales as conversational tools although some difficulties and disturbances were identified in relation to both. The therapist perspective identified six conversational types. Two of these confirm use of the measures as tools for supplying feedback on process and outcome. In addition, four conversational types were identified that represented a surplus value for the therapist. The SRS and ORS and all of the conversational types they generated were seen as central components in creating and upholding collaboration between the families and their therapists. Keywords: therapist perspectives, feedback, family therapy, patient-focused research Investigating the effect of supplying feedback to therapists is the agenda of patient-focused research. Howard, Moras, Brill, Martinovich, and Lutz (1996) proposed the systematic monitoring of patient responses to treatment during the course of therapy with this information available to the therapist. This required regular measurement of process and outcome (Johnson & Shaha, 1996). Lambert and Brown (1996) made the case for monitoring practice through the continuous use of standardized scales throughout the therapeutic work (Kadera, Lambert, & Andrews, 1996). A first step in this process was to operationalize clinically significant change (Jacobson, Follette, & Revenstorf, 1984). The next step in developing a monitoring system was to create expected recovery curves. Using the OQ45 (Lambert, Lunnen, Umphress, Hansen, & Burlingham, 1994) as measurement, two variables - initial level of distress and early response to treatment - were found to account for the majority of the variance (Brown & Lambert, 1998) and were used in computing expected recovery curves in relation to the initial score or severity. A sufficiently large deviation from the expected score and curve represented either clinically significant change or treatment deterioration (Jacobson et al., 1984). This was graphically expressed by curves in which the direction of this deviation, either above or below the expected recovery curve, expressed these two positions.1 The final step was to use this information to monitor the treatment and as feedback for therapists (Harmon, Hawkins, Lambert, Slade, & Whipple, 2005; Harmon et al., 2007; Hawkins, Lambert, Vermeersch, Slade, and Tuttle, 2004; Lambert et al., 2001; Lambert et al., 2002; Shimokawa, Lambert, & Smart, 2010; Whipple et al., 2003). The results pointed clearly toward the use of feedback as a systematic way of improving outcome where no gains or detrimental results were reported. Barry Duncan, Mark Hubble, Scott Miller, and Jacqueline Sparks have elaborated possible clinical consequences of this research (Duncan & Miller, 2000a, 2000b; Hubble, Duncan, & Miller, 1999; Miller, Duncan, & Hubble, 2004), and Anker, Duncan, and Sparks (2009), and Miller, Duncan, Sorrell, and Brown (2005) have shared in the development of this research. Duncan et al, (2003) and Miller, Duncan, Brown, Sparks, and Claud (2003) investigated the feasibility, reliability, and validity of two tools for providing feedback: the Session Rating Scale (SRS) and the Outcome Rating Scale (ORS). Their psychometric properties were found to support the conclusion that these tools yield measurements that fulfill the aim of supplying reliable and valid conclusions concerning the therapeutic alliance (SRS) and the outcome of psychotherapy (ORS). As they were designed specifically as clinical tools, a reduction in their psychometric properties compared with the accepted research tools against which tiiey were measured was viewed as a necessary trade-off (Duncan et al., 2003; Miller et al., 2003). Although the utility of these scales as research tools is not the focus of this article, the standard of their psychometric properties was still seen as important and valuable within the clinical context. …