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The Norway feedback project: a clear and sensible way to make psychotherapy more helpful

I wrote a few days ago about Barry Duncan's interesting book "On becoming a better therapist".  Duncan cited three major influences that had helped to form the book.  The first was his involvement as an editor of the recently published, multi-authored "The heart and soul of change: delivering what works in therapy" - for further details about this more academic publication, see my blog post "The heart and soul of change."   The second major influence has been findings from the fascinating Norway Feedback Project.  As I've already written, the main research paper here is "Using client feedback to improve couple therapy outcomes: a randomized clinical trial in a naturalistic setting".  Also interesting are the follow-up papers "The alliance in couple therapy: Partner influence, early change, and alliance patterns in a naturalistic sample" and "Footprints of couple therapy: Client reflections at follow up using a mixed method design in routine care."  Free full text copies of all three of these articles are available from Duncan's website.  I think this is really important and exciting work. The main paper's abstract reads "Despite the overall efficacy of psychotherapy, dropouts are substantial, many clients do not benefit, therapists vary in effectiveness, and there may be a crisis of confidence among consumers. A research paradigm called patient-focused research - a method of enhancing outcome via continuous progress feedback - holds promise to address these problems. Although feedback has been demonstrated to improve individual psychotherapy outcomes, no studies have examined couple therapy. The current study investigated the effects of providing treatment progress and alliance information to both clients and therapists during couple therapy. Outpatients (N = 410) at a community family counseling clinic were randomly assigned to 1 of 2 groups: treatment as usual (TAU) or feedback. Couples in the feedback condition demonstrated significantly greater improvement than those in the TAU condition at posttreatment, achieved nearly 4 times the rate of clinically significant change, and maintained a significant advantage on the primary measure at 6-month follow-up while attaining a significantly lower rate of separation or divorce. Mounting evidence of feedback effects with different measures and populations suggests that the time for routine tracking of client progress has arrived."

At follow-up "The ES (Effect Size) for individuals from couples who received feedback versus those who did not was d =0.44.  More specifically, at 6-month follow-up, the proportion of clients responding to treatment as measured by the ORS (Outcome Rating Scale) in the TAU (Treatment As Usual) group was 39.1% (both in couple, 18.8%) and in the feedback group was 66.7% (both in couple, 47.6%) ... the effects of feedback at follow-up were also assessed by examining the marital status of couples ... a significantly greater proportion of couples were intact (i.e., not divorced or separated) in the feedback condition (81.59%) than in the TAU condition (65.75%)".  These are startling differences.  If one was assessing whether one form of psychotherapy was more effective than another, then a 0.44 effect size would be a pretty impressive difference.  Remember too that these results have now been replicated for couple therapy with Reese et al's "Effect of client feedback on couple psychotherapy outcomes" also showing very encouraging benefits - "couples in a client feedback condition demonstrated statistically significantly more improvement compared with couples receiving treatment as usual and that improvement occurred more rapidly.  Also, 4 times as many couples in the feedback condition reported clinically significant change by the end of treatment."  And, as I've noted before, similar gains from instituting a simple, quick feedback system have been noted for individual psychotherapy - see "Using formal client feedback to improve retention and outcomes" and "Does a continuous feedback system improve psychotherapy outcome?" (all articles are freely viewable in full text on Duncan's website).     

It's worth noting that this method of eliciting session-by-session client feedback on both the effects of therapy & the working alliance is not just about having a better mapping system for how therapy is going.  The feedback is available in real time and very much becomes part of the therapy process.  The Norway project involved ten therapists and the main research paper reports "A simple attitude survey developed for this study was administered to determine therapists' views about attaining client feedback via assessment instruments.  None of the therapists were experienced in assessing client progress, and all believed that their usual methods of acquiring feedback (asking clients and evaluating by impression) would be as effective."  So experienced therapists didn't realise how powerfully this kind of process can impact on their therapy.  I'm the same.  I'm a very experienced therapist and I've routinely tracked outcome (using standard questionnaires), elicited session by session feedback and kept charts showing progress that both the client and myself can observe and discuss.  It's very likely that I already use a much more extensive feedback system than most other therapists - however I'm finding that dipping my toe into these additional methods (the Outcome Rating & Session Rating Scales) is leading to some fascinating and helpful conversations with clients and some surprising and productive changes in therapeutic focus and alliance.


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