The SRS, appreciation, and a call for therapist stories

I have thinking a lot about SRS scores and am very encouraged by what I have been seeing. I believe therapists are getting better and better at soliciting lower scores and feeling more comfortable with alliance feedback from clients. I believe we will see a downward trend of initial SRS scores in the overall data base as time goes on. Keep in mind that the SRS is the first real clinical use of an alliance measure, so as more and more therapists see the benefits, and more and more clients become part of the culture of feedback, the more the SRS will be used to generate alliance discussions. In the Norway study, based on all administrations of the SRS (2294), there was a mean of 34.8. Said another way, 51.8% scored 36 and higher, while 67.67% scored 34 and higher. The mean first session SRS was 33.4 And the SRS scores increased, on average, session by session. We are analyzing the data now and I'll keep you informed of our progress.

While I am talking about the alliance, I wanted to say a few words about "appreciation" because I think it is a very important concept and therapist action. It is essentially an expression of positive regard, another incredible idea that gets too little attention. This therapist quality is characterized as warm acceptance of the client’s experience without conditions. It is understood as a prizing, an affirmation, and a deep nonpossessive caring. Early research (e.g., Truax & Carkhuff, 1967; Orlinsky & Howard, 1978) was very supportive of the association between positive regard and outcome, with about two-thirds of the studies in the positive direction. Recent reviews, however, found that only 49% (27 of 55) of all associations were significant (Farber & Lane, 2002). When outcome and therapist positive regard were both rated by clients, however, the percentage of positive findings jumped to 88% (Farber & Lane, 2002). Let’s face it, that Carl Rogers guy was on to something.

Appreciation of clients is therefore a critical relational skill: appreciation of people in general, of their struggles, and of their humanity and innate goodness. I appreciate people and it shows, and I think it helps. In the new Heart and Soul, Norcross (2010, p. xx) concludes:

Clinically, the research results indicate that, first, the provision of positive regard or validation is strongly indicated in practice. Second, similar to empathy and the alliance, it is the client’s perspective of the therapist’s positive regard that has the strongest association with outcome. At the risk of redundancy, supportive therapists will privilege their client’s experience. Third, therapists cannot be merely content with feeling good about their clients, but should ensure that their positive feelings are communicated to them. This does not require a stream of compliments or an outpouring of love. Rather, it speaks to the need for therapists to communicate a caring, respectful attitude, affirming a client’s basic sense of worth (Duncan & Moynihan, 1994; Farber & Lane, 2002).

And finally, I have a project for any of you who fancy an opportunity to write about your therapy experiences. I started a new book that focuses a bit on therapist’s experiences and am looking for 2-3 page (double spaced) therapist stories about the use of feedback and how it has improved your work or developed you as a therapist. This could be about a particular client and how he or she specifically taught you to do good work in ways that you wouldn't have otherwise done, or how feedback over many clients has had a cumulative effect on your outcomes and perceptions about being a therapist. I am looking for evocative stories infused with your personal reflections that will both resonate with therapists and encourage them to take the risk to systematically solicit client feedback. Please change details about clients significantly to ensure confidentiality.

I will select several for inclusion, and the ones not selected will have another shot when Jackie and I do the next edition of Heroic Clients, Heroic Agencies. Thanks very much for your consideration. The deadline is June 15, so get crackin’.

Best,
Barry

The Norway Couple Feedback Study

After a year of contemplating and debating the best possible design and methodology for an RCT in a naturalistic setting, 2 years of intensive data collection, and a year and a half of data analysis, writing, and rewriting, the Norway Couple Feedback Study (Anker, Duncan, & Sparks, in press) has received final acceptance from what I consider to be one of the top (if not the top) psychotherapy research journals on the planet, the Journal of Consulting and Clinical Psychology. Hoorah! I want to publicly thank and congratulate my colleagues and very good friends, Morten Anker and Jackie Sparks not only for their dedicated efforts on the largest RCT ever done with couples, the first feedback study to address couples, and the first RCT published using the ORS and the SRS, but also for their spirit of collaboration and teamwork—that often not experienced stuff that really makes each person bring out their best and propel such a project to fruition.

While we cannot disseminate the article, I can now let you know more about the results.
As most of you know, the study tested the effects of feedback in couples therapy compared with couples receiving treatment as usual (TAU) in a naturalistic setting (n=410). Consistent with our hypothesis, the feedback condition emerged as significantly superior to TAU. A moderate to large ES (0.50) was found for the feedback condition. The predicted score adjusted for severity of an average client in the feedback group was 4.89 points higher than an average client in the TAU group. The difference was, in effect, the difference required for reliable change. Said another way, the average post score for persons in the feedback condition (26.35) was nearly 5 points greater than the average post score for those in the TAU group (21.69). The difference between the groups, in other words, nearly constituted both a reliable change and transcended the clinical cut off. The proportion of clients responding to treatment in the TAU group was 41.7% (both in couple, 22.6%) and in the feedback group was 64.6% (both in couple, 50.5%). The strong effect of feedback seems particularly noteworthy given the relative simplicity of the intervention and in light of the comparison group being an active treatment.

In addition, the significant superiority of feedback over TAU was maintained at follow up. Moreover, the TAU group had a 34.2% separation/divorce rate v. 18.4% rate for the feedback condition. In the feedback group, 40.8% (both in couple) scored 25 or above and 5 or more points in change compared with 10.8% of non-feedback couples, a difference of nearly four times. Six month follow-up revealed that feedback maintained nearly a three-fold advantage in proportion of clinically significant change (35.7% v. 12.5%).

Another finding really blew us away—about therapist effects and feedback. The effect of feedback varied significantly across therapists, and was not due to outliers (extreme scores). The correlation between the variability in the effectiveness of a therapist with no feedback and variability in the effect of feedback was unusually high, r = -.99. Although the small number of therapists significantly limits any conclusions that can be drawn, it does suggest that the less effective therapists (those who had the worst outcomes without feedback) benefited more from feedback that the most effective therapists. Feedback, therefore, seems to act as a “leveler” among therapists, raising the effectiveness of lower or average therapists to that of their more successful colleagues. In fact, check this out: the therapist with the WORST results without feedback became the therapist with the BEST results with feedback! These preliminary findings based on but ten therapists warrant further investigation and replication. Nine of ten therapists benefited from the effects of feedback.

With this study in the bank, Jackie is writing a grant for replication with kids and families, and with Barry W. in Louisville, we are hoping to replicate in an inpatient setting.

Bottom Line: Add feedback to your work and watch your effectiveness soar!

Barry