This document provides an introduction to Feedback Informed Treatment (FIT), which is a meta-theoretical approach to therapy guided by outcome and alliance feedback from clients rather than a single treatment model. The document discusses several key points about FIT: 1) Client ratings of the therapeutic alliance and outcomes are the best predictors of retention and progress in therapy. 2) Therapists should routinely seek formal client feedback through measures to evaluate the alliance and outcomes, as client and therapist ratings often do not align. 3) No single treatment model or clinician works for all clients, so feedback is crucial for addressing diverse client needs. The document then reviews the Outcome Rating Scale (ORS) and Session Rating Scale

1. Feedback Informed Treatment–
an introduction
Dr. Ryan Melton
Research Faculty/EASA Clinical Director
Portland State University
rymelton@pdx.edu

3. Therapists Rock!
• The effect size of therapy is .80! (the average
treated individual is better off than 80% of
untreated individuals)
• Couples/Adolescents = .75-.80
• Family Psychotherapy = .58-.70
• This equates to the point that therapy is cost
effective when compared to psychological and
medical interventions
• Reference: (Minami, et al., 2008. Journal of
Consulting and Clinical Psychology).

4. Therapists Suck!
• Make claims of effectiveness but only 3% of therapists count outcomes (Akins & Christensen,
2001).
• Despite all innovations (400 tx models) no improvement in 30 years!
• 47-50% of individuals drop out.
• Despite individuals feeling less stigmatized a lack of confidence in therapists exists.
• Continued emphasis on medical model despite better outcomes for most MH conditions.
• Ongoing claims of superiority amongst models without evidence.
– Model v. model= ES of .20
– Disorders
– Tx ingredients
– Individual demographics & dx (<1%)
– Therapist’s degree and demographics (0%)
– From The great psychotherapy debate by Wampold, B.E. (2001)

5. ARE ALL THERAPISTS FROM LAKE WOBEGON?
• COMPARED TO OTHER MENTAL HEALTH PROFESSIONALS WITHIN YOUR FIELD
(WITH SIMILAR CREDENTIALS), HOW WOULD YOU RATE YOUR OVERALL CLINICAL
SKILLS AND EFFECTIVENESS IN TERMS OF A PERCENTILE? (PLEASE ESTIMATE
FROM 0-100%. FOR EXAMPLE, 25% = BELOW AVERAGE, 50% = AVERAGE, 75% =
ABOVE AVERAGE).
• WHAT PERCENTAGE (0-100%) OF YOUR CLIENTS GET BETTER (I.E., EXPERIENCE
SIGNIFICANT SYMPTOM REDUCTION/RELIEF) DURING TREATMENT? WHAT
PERCENTAGE STAY THE SAME? WHAT PERCENTAGE GET WORSE?
Walfish, S., McAllister, B., Lambert, M.J. (in press). Are all therapists from Lake
Wobegon? An investigation of self-assessment bias in mental health providers.

6. LAKE WOBEGON
SURVEYED A REPRESENTATIVE SAMPLE PSYCHOLOGISTS, PSYCHIATRISTS, SOCIAL
WORKERS, MARRIAGE AND FAMILY THERAPISTS FROM ALL 50 US STATES:
• NO DIFFERENCES IN HOW CLINICIANS RATED THEIR OVERALL SKILL LEVEL AND
EFFECTIVENESS LEVELS BETWEEN DISCIPLINES.
•ON AVERAGE, CLINICIANS RATED THEMSELVES AT THE 80TH %TILE
•NONE RATED THEMSELVES BELOW AVERAGE;
•LESS THAN 4% CONSIDERED THEMSELVES AVERAGE;
•ONLY 8% RATED THEMSELVES LOWER THAN THE 75TH %TILE;
•25% RATED THEIR PERFORMANCE AT THE 90TH% OR HIGHER
• BELIEVED: 80%, 17%, 3%. ---- DATA: 50% (50-70% FOR SS), 10% DETERIORATION
• Walfish, S., McAllister, B., Lambert, M.J. (in press). Are all therapists from Lake Wobegon? An
investigation of self-assessment bias in mental health providers.

7. Feedback Informed Treatment
• “ FIT is a meta-theoretical approach. Where
traditionally counselors are guided by a particular
treatment model or theoretical orientation, FIT is
guided by outcome and alliance feedback provided by
clients. As such, FIT may be applied across
therapeutic modalities, disciplines, and service
settings.”

8. FIT
• The client’s experience of the alliance and outcome are the
best predictors of retention and progress in treatment;
• Because of the low correlation between client and clinician
ratings of outcome and alliance, therapists must routinely
seek client feedback via valid and reliable measures of the
alliance and outcome;
• No one model, method, or clinician is sufficient for treating all
problems; (Same outcomes for last 30 years despite 400+
models)
• Feedback is crucial to addressing the diverse problems and
people seeking behavioral health services.

9. Implementation
ORS
SRS
• I REALLY WANT TO MAKE SURE OUR
WORK TOGETHER IS HELPFUL TO YOU
AND YOUR REASONS FOR COMING IN…..I
HAVE A SIMPLE FORM THAT I USE
• THIS ALLOWS US TO TRACK HOW YOU
THINK THINGS ARE CHANGING OR NOT
CHANGING.
• IF THINGS AREN’T CHANGING OVER TIME
THE WAY YOU HOPE THEN THIS WILL HELP
US KNOW THAT AND ADJUST AS NEEDED
• IT JUST TAKES A FEW MINUTES TO
COMPLETE. THANKS!
• Whether or not the sessions are going
the way you hope and if I am
providing what you want is really
important to me
• Want to make sure that you are
getting what you need;
• I really want any feedback you have,
especially negative feedback. I can
take it.
• Feedback is critical to success.

10. ORS/SRS
www.scottdmiller.com

11. Outcome Rating Scale (ORS)
• 40 pt measure with 4 subscales
• Adult and child versions
• Higher scores=lower level of distress. Lower
scores=higher level of distress
• Clinical cutoffs: 25 (>18), 28 (13-18), 32 (<12)
• 5 pt change is considerable reliable change.
• Complete at start of session. It takes 1 min.

12. Session Rating Scale (SRS)
• 40 pt measure with 4 subscales
• Adult and child version
• Scores below 36 should be discussed with client
or any subscale below 9
• Lower scores early could mean anything-discuss.
Low scores later 4x likely to drop out.
• Done at end of session, takes 1 min.
• Can plot ORS & SRS on Excel.
• All materials free at www.scottdmiller.com

13. EMPLOYING MEASURES WITH CLIENTS:
BENEFITS
• SETTING A NORM FOR DATA COLLECTION
• PROGRAM EVALUATION FOR DATA-BASED
DECISION MAKING (CCOs)
• EMPHASIS ON THE CLIENT PERSPECTIVE AND
POTENTIAL FOR CLIENT ADVOCACY

15. PREPARING FEEDBACK
• MINDSET
• ADDRESSING OWN SELF-EFFICACY & OPENNESS TO
FEEDBACK
• MEANINGFUL DATA BEYOND THE NUMBERS
(FORMATIVE)
• INFORMED CONSENT: WHAT EVALUATION TOOLS
WILL BE USED TO EVALUATE MY PERFORMANCE?

16. CLIENT FEEDBACK WITH TRAINEES: INFLUENCE ON
SUPERVISION & COUNSELOR SELF EFFICACY(REESE ET AL.,
2009)
28 TRAINEES ASSIGNED TO FEEDBACK OR NO FEEDBACK
FINDINGS:
• CLIENTS IN FEEDBACK GROUP EXPERIENCED TWICE AS MUCH
IMPROVEMENT IN OUTCOME
• SELF-EFFICACY SCORES INCREASED FOR BOTH GROUPS
• NO CORRELATION BETWEEN SELF-EFFICACY AND OUTCOME
FOR NO-FEEDBACK GROUP
• SELF-EFFICACY IN THE FEEDBACK GROUP WAS STRONGLY
CORRELATED WITH OUTCOME

17. Putting Feedback to work in practice: Three
Steps
1. Create a “Culture of feedback” by integrating
alliance and outcome feedback into practice.
2. Engage in deliberate practice.
3. Learn to “fail successfully.”

18. STEP 1: CREATE A CULTURE OF FEEDBACK
• WORK TOWARDS ADDRESSING BARRIERS TO
GETTING OPEN CLIENT FEEDBACK (E.G., ARE WE
OPEN TO FEEDBACK, WHAT DO WE COMMUNICATE
NON-VERBALLY, WHAT ARE OUR RESISTANCES,
SYSTEMIC BARRIERS)
• USE A SYSTEMATIC METHOD FOR ACQUIRING
FEEDBACK THAT IS RELIABLE, VALID AND FEASIBLE
• FOLLOW A STANDARD CASE PRESENTATION MODEL

19. STEP 2: ENGAGE IN DELIBERATE
PRACTICE
• LISTENING & RESPONDING TO CLIENT FEEDBACK
• WORKING HARD AT OVERCOMING “AUTOMATICITY”
• PLANNING, STRATEGIZING, TRACKING, REVIEWING, AND
ADJUSTING
• VIEWING MISTAKES OR LOW RATINGS FROM CLIENTS AS AN
OPPORTUNITY
• INCLUDE THE CLIENT’S VOICE IN SUPERVISION VIA THEIR
FEEDBACK (USE THE GRAPH)

20. Step 3: Learning to Fail Successfully
• Know when the work is failing
• Things to change when
improvement is not occurring:
what, where, who????
• Gracefully get the client to
another place to accomplish their
goals.

21. CLIENT PREFRENCES
GOALS/MEANING/PURPOSE INTERVENTION
CLIENT VIEW OF THE RELATIONSHIP

22. Wrapping Up
• What have you learned?
• Did we meet our goals today?
• Any feedback?

23. Questions?