Feedback Informed Treatment: What does it mean?

A feedback-informed treatment functions as more than just an assessment tool in therapy; it supports psychotherapeutic outcomes

Therapists generally use various tools to assess their clients, including standardized tests, individual narratives, and other assessment methods. A feedback-informed approach is also a tool for therapists to get real-time information about treatment progress. A feedback-informed treatment (FIT) functions as more than just an assessment tool in therapy; it supports psychotherapeutic outcomes. As its name implies, the FIT involves collecting real-life feedback from individuals on a continuous basis. This approach is based on receiving regular, structured feedback from clients throughout the therapy process and integrating this feedback into the treatment. This method was developed to enhance the effectiveness of the therapeutic process and improve therapy outcomes (Lambert & Shimokawa, 2011). The core practice of FIT is that the client assesses the therapeutic relationship (including alliance, trust, and goal congruence) and the progress made in therapy and informs the therapist in each session. This assessment is typically conducted using short, standardized measurement tools. In this therapy sketch, we will explain how the feedback-informed approach works and how it is integrated into therapy sessions.

Feedback-Informed Approach (FIT)

One of the most fundamental questions in the mental health field is “How can we increase the effectiveness of therapy?”. In this context, studies conducted since the 1990s and findings revealed that the relationship established with the client and the client's experience of the process are more determinant in the success of the therapy process than the theoretical approaches used (Lambert, 1992). These findings highlighted the need for systematic feedback from individuals who receive therapy to enhance the effectiveness of the therapy process. As a result of this need, the FIT emerged over time.

FIT was developed by psychologist Scott D. Miller and his colleagues, Barry Duncan and Mark Hubble. They demonstrated that the therapeutic relationship and individuals' expectations play a significant role in the therapy process, as well as non-client factors (such as life circumstances, support systems, and therapy modality). These findings supported the idea that therapeutic interventions should be client-centered and dynamic, a common factor in psychotherapy. To further explain the FIT, we need to address the common factors of therapy, which also directly explain the rationale for the FIT.

Common Factors

The common factors approach suggests that factors common to all therapeutic approaches, rather than specific techniques, are the most determinative factors in predicting the success of different types of therapy (Lambert & Ogles, 2004). Here are the common factors argued in the literature:

• Readiness to Change: According to Prochaska’s transtheoretical model, therapy is more effective when it is conducted at a stage when individuals are ready to change. This is related to the therapist's ability to recognize the individual's intrinsic motivation and develop an appropriate approach rather than the therapist's technical skills.

• The Therapeutic Alliance: Prochaska states that a healthy therapeutic alliance is a facilitating factor for change. This is centered on common factors such as empathy, trust, and collaboration.

• Timing of Appropriate Intervention: Also, the transtheoretical model discusses that applying direct action techniques when the client is still in the “preparation” stage would be ineffective. Therefore, the intervention needs to be flexible and adaptive to the client's stage of change. This corresponds to the “flexibility and personalization” aspect of the common factors.

• Hope and Expectancy: In therapy, the client's hope and expectation of improvement are potent factors in change. This supports the “placebo/expectancy” effect in Lambert's common factors model.

• Awareness and Insight: Prochaska emphasizes that change involves both behavioral and cognitive processes. Increasing the client's understanding and reinterpreting the problems in their life is a way of change that is common to different theories.

How does FIT support the common factors in therapy?

FIT is one of the systematic approaches developed to strengthen common factors in therapy. Here is an explanation for each factor:

Readiness to Change and FIT

When individuals begin therapy, they may be at different stages of change. Prochaska defines these stages as precontemplation, contemplation, action, and maintenance. FIT supports this process, allowing for regular feedback to monitor the client's progress.

For example, Jenny may not want to be in therapy because they say they “don’t have a problem”. They might not be aware of the problem or do not believe that change is necessary, which is known as precontemplation. Individuals often come to therapy under external pressure (family, school, work, etc.). In this situation, FIT encourages the therapist to use motivational approaches rather than focusing directly on the solution at this stage.

Over time, Jenny might say, “I think something is wrong, but I don't know where to start”. This stage is called contemplation, where individuals have begun to realize that change is necessary; however, they're still unsure about where to begin. The FIT helps therapists identify these inner conflicts and develop an action plan tailored to each individual’s needs.

The action phase is where individuals begin to modify their behaviors in response to their needs. For example, over time during therapy, Jenny might have started going out with friends and communicated more openly. Through the FIT approach, the therapist makes Jenny's steps visible, emphasizes the importance of small changes, and supports the process with positive feedback.

After a while, Jenny began to use her new communication skills regularly and reported feeling more at ease in social situations. This marks the maintenance phase of change. FIT monitors whether progress continues during this period, allowing Jenny to recognize early on the risks of relapse. Together, the therapist and Jenny assess how to make these gains permanent and what to do in the event of a relapse.

The Therapeutic Alliance and FIT

The therapeutic alliance is one of the strongest common factors of the therapy process. The strength of this alliance directly affects the individual's participation in the process and capacity for change. FIT helps therapists to assess the strength of this relationship and take necessary actions to support if the therapeutic alliance is not formed strongly.

For example, when Jenny first started therapy, they were reluctant to attend sessions, saying that they had “nothing wrong with them,” so their relationship with the therapist remained superficial. However, the FIT enables the therapist to receive regular feedback on Jenny's experience of the session. In this way, Jenny gradually began to feel safer and open up more to the therapist. As the therapeutic alliance strengthened, Jenny's involvement in the process increased, and their motivation to change improved. The FIT approach not only allowed for the assessment of this relationship but also enabled its restructuring in real time.

Timing of Appropriate Intervention and FIT

Not only what is done but also when it is done is of critical importance for the effectiveness of therapy. Interventions that do not consider the individual’s readiness for change may hinder the process or lead to the individual's withdrawal. FIT provides an important structure to adjust the timing of interventions according to each individual's feedback.

For example, Jenny was not open to change when they first started therapy. If the therapist had wanted to talk about her deep relational issues at this time, Jenny's responses might have been superficial, withdrawn, or they might have wanted to discontinue therapy. Through FIT, the therapist can recognize when interventions or topics to be addressed are moving into an area that Jenny is not ready for. Based on this feedback, the therapist can slow down the pace of the intervention. For instance, the therapist focused on Jenny's coping with stress in her daily life rather than focusing on deep relational issues directly.

Hope, Expectancy, and FIT

Another common factor is hope and expectancy; the individuals need to have hope for healing and an expectation that the therapy will be effective. These two elements increase commitment to the therapy process and motivation to change. FIT aims to keep this hope alive by making visible the small changes the client experiences.

For example, when Jenny first started therapy, she did not believe that change was necessary and had no expectations from the therapy process. But over time, the therapist can track how Jenny feels in each session with the FIT. This measurement allowed Jenny to recognize small but meaningful changes.

Awareness, Insight, and FIT

In the therapeutic process, awareness means that the individual is able to observe their feelings, thoughts, and behaviors more consciously. Over time, this awareness transforms into insight, enabling the individuals to understand the origins of their difficulties and their inner world more deeply. FIT supports this process by enabling the individuals to regularly evaluate their own experiences in therapy.

For example, FIT contributed to the development of insight by enabling Jenny to look at their own life from the outside. The therapist used this data to create a space where Jenny could talk more openly about her emotional processes.

How to use FIT in therapy sessions?

We mentioned the benefits of using FIT in sessions and how it contributes to the therapy process. To do that, there are a couple of assessments that can be used during the sessions.

1. Outcome Rating Scale: The most commonly used tool for this purpose is the Outcome Rating Scale, a short 4-item scale that allows the client to assess individual, interpersonal, social, and general well-being. At the beginning of each session, individuals are asked to evaluate how they have felt in general during the previous week.(Miller et al., 2003).

2. Session Rating Scale: Another scale is the Session Rating Scale. This scale gathers the client's opinion through four brief questions about the relationship with the therapist, session content, goal alignment, and overall experience. Satisfaction (Duncan et al., 2003). At the end of the session, clients are asked to evaluate the session and their relationship with the therapist.

After applying the scales, the next step is to evaluate the scores gathered from each individual. The therapist reassesses the appropriateness of the therapy goals by monitoring the progress, restructures the methods or interventions according to the client, and considers alternative clinical interventions.

Take aways

• Feedback-informed therapy is an evidence-based method built in the 1990s to support therapeutic outcomes.

• Therapists used assessments before and after sessions to assess both individuals’ well-being and session content, goal alignment, and overall experience.

• By doing that, they aim to assess the readiness for change, strengthen the therapeutic alliance, determine the timing of appropriate intervention, and improve other common factors of therapy.

References

• American Psychological Association (APA). (2006). Evidence-based practice in psychology. APA Presidential Task Force on Evidence-Based Practice.

• Duncan, B. L., Miller, S. D., Sparks, J. A., Claud, D. A., Reynolds, L. R., Brown, J., & Johnson, L. D. (2003). The Session Rating Scale: Preliminary psychometric properties of a “working” alliance measure. Journal of Brief Therapy, 3(1), 3–12.

• Lambert, M. J., & Ogles, B. M. (2004). The efficacy and effectiveness of psychotherapy. In M. J. Lambert (Ed.), Bergin and Garfield's Handbook of Psychotherapy and Behavior Change (5th ed., pp. 139–193). Wiley.

• Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48(1), 72–79. https://doi.org/10.1037/a0022238

• Miller, S. D., Duncan, B. L., & Hubble, M. A. (2004). The Heart and Soul of Change: Delivering What Works in Therapy. American Psychological Association.

• Miller, S. D., Duncan, B. L., Brown, J., Sparks, J. A., & Claud, D. A. (2003). The Outcome Rating Scale: A preliminary study of the reliability, validity, and feasibility of a brief visual analog measure. Journal of Brief Therapy, 2(2), 91–100.

• Prochaska, J. O., & DiClemente, C. C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research & Practice, 19(3), 276–288. https://doi.org/10.1037/h0088437

• Prochaska, J. O., & Norcross, J. C. (2010). Systems of psychotherapy: A transtheoretical analysis (7th ed.). Belmont, CA: Brooks/Cole.