Feedback Informed Treatment: Clinical and Cost Implications

Abstract

Psychotherapy research has been dominated by the question, “does this treatment work?” However, in the quest to determine specific treatment effectiveness, the issue of cost has been largely ignored. Given the current economic climate of limited resources, agencies and providers are being asked to do more with less and document that what they are doing is working. Feedback Informed Treatment is a meta-level platform to treatment delivery in which outcomes are monitored on a session-by-session basis to track progress so treatment can modified if the current approach is not working. More specifically, FIT takes into account the two factors consistently shown to be related to be predictive of outcome: 1) strength of the alliance (from the client’s perspective) and 2) early change in the therapeutic process. This report briefly provides a rationale for the use of FIT as well how it might be applied in practice.

Feedback Informed Treatment: Clinical and Cost Implications

Historically, psychotherapy research in the US and throughout the world has been driven by the question, “Does this treatment work?” Depending on the nature of the intervention under study, the population being treated, and the conditions under which the treatment is delivered, this question has been refined, modified, narrowed, or broadened.

Interestingly, the near myopic focus on outcome in clinical research trials ignores long-standing concerns about the economic profile of health care in the U.S., including that related to mental health. Concerns about these costs might be alleviated if the amount of expenditure was positively (and strongly) related to quality; however, this is not the case. Health care quality in the U.S. is not measurably better than many other industrialized countries that spend far less on these costs [1].

Evolving from these conclusions are what may, at first glance, appear to be two competing agendas: quality enhancement and cost containment. However, these aims might be better conceptualized as complimenting each other [2]. More specifically, perhaps the key question is not how much is spent on health care, but rather how it is spent. Thus, a “new” question has emerged in health care research: “How much does this treatment cost to deliver and is it really worth it?” Moreover, at a micro level, it is also important to not only identify those clients making progress, but also those which are not improving and draining therapist and agency resources. Thus, the challenge for clinicians is to identify these no progress, long-term, resource-draining cases and modify treatment accordingly to more efficiently allocate resources and better meet client needs. In fact, it’s estimated that a relatively small percentage of clients exceed average session numbers and do not report progress, yet occupy a significant portion of the therapists’ caseloads. Over time, these long-term, nonimproving cases create frustration for clients, burnout in therapists, and an excessive use of agency resources compared to the costs associated with treating most clients. Given the current economic landscape of limited (and often declining) resources, therapists are tasked with more regularly monitoring progress to better meet client needs and also identify those clients that may not be benefitting from treatment and draining resources.

The ultimate goal for providers and payors is to provide interventions that are both effective and efficient; that is, to provide the most positive benefit for the least cost to the most people. Feedback Informed Treatment (FIT) is an evidenced-based delivery mechanism which includes methods of measuring, integrating, and analyzing client progress to better inform clinical decisions and treatment planning on a session-by-session basis. While FIT has been applied in individual contexts with clients presenting with an array of issues or concerns, it has not been widely implemented in practice in the US. The purpose of this brief report is to provide a description of FIT and how it might be used at a meta-level of abstraction [3] to conceptualize and enhance current treatment delivery models.

Feedback Informed Treatment (FIT)

FIT is a Continuous Quality Improvement (CQI) strategy in which therapists routinely monitor both process and outcome and use the data to inform clinical practice. From this vantage, clients are perceived as partners in the change process and are asked to provide feedback as a way to ensure they are making progress toward goals (i.e., effectiveness). Measuring two factors identified as being predictive of positive outcomes (i.e., strength of the therapeutic alliance and early change), clients are asked to complete measures of progress on a session-by-session basis. Prior to the start of the session, clients are asked to complete the Outcome Rating Scale [4]. Which is a brief assessment of progress since the last session on four domains: 1) individual (e.g., personal well-being), 2) interpersonal (e.g., family, intimate relationships), 3) social (e.g., work, school, friends), and 4) overall distress. The Session Rating Scale [5] is a brief measure of the therapeutic alliance focused on the following relationship components: 1) goals and topics, 2) approach or method, and overall. The SRS is administered to the client toward the end of each session. Given that one of the best predictors of successful outcome is the client’s perception of the relationship by the end of the second session, SRS data allow the therapist to identify alliance ruptures early on, and modify treatment to better meet client needs which may have implications for retention. As noted by [6]. FIT is “meant to make use of outcome and alliance feedback from clients to inform practice, regardless of the therapist’s preferred way of practicing, and to engage therapists in an ongoing process of improving their effectiveness.

The focus on soliciting and responding to client feedback allows the therapist to identify sooner those clients who are not making progress (through use of the ORS) as well as if there has been a rupture in the alliance (by use of SRS); thus, treatment planning can be revised as needed to better meet client goals and objectives and provide more cost-effective and cost-beneficial services. To be clear, the decision to incorporate FIT does not mean that therapists must change their approach; rather, they are simply being asked to ask for and incorporate client feedback as a way to continuously monitor progress.

In order to successfully incorporate FIT into practice, the clinician (or agency) must develop a culture of feedback in which therapists routinely solicit client feedback about the services provided and express a sincere desire to use the feedback to modify services as needed [7]. As such, the therapist must be transparent about the purpose of the measures, the importance of the client’s voice in directing the process, and his or her genuine willingness to use the feedback to inform the treatment process. To be clear, the incorporation of client feedback on alliance and outcome in shaping the treatment planning is critical in this process.

Given the current climate of decreased and shrinking resources, coupled with the demand for therapist accountability, FIT represents an opportunity to become more deliberate in tailoring interventions to specific client needs and monitoring outcome while also staying with a preferred therapeutic framework. The idea of actively involving client feedback in the therapy process may be scary for some therapists as they may feel that any negative feedback is condemnation on their clinical skills and abilities. Others clinicians may privilege their voice over those of the clients and feel that clients are unable to best determine their course of treatment. No matter the rationale for reluctance or refusal to engage in a feedback oriented approach, the reality is that client’s perception of alliance (not therapist) is a strong and consistent predictor of outcome and clients not making progress rarely spontaneously report that things are not working, but schedule a follow-up appointment and then drop-out. Despite preferred theoretical orientation, the machinery of FIT provides a platform for monitoring these areas on a regular basis to identify problems as they arise. Creating a culture of feedback may require a paradigm shift from that of near exclusive focus on adherence and competence in delivering interventions to increased emphasis on relationship building skills and feedback solicitation.

References

1. Reinhardt UE, Hussey PS, Anderson GF. US Health Care Spending in an International Context. Health Affairs. 2004; 23: 10-25.
2. McGlynn EA, There is no perfect health system. Health Affairs. 2004; 23: 100-102.
3. Seidel J, Miller SD. Manual 4 documenting change: A primer on measurement, analysis, and reporting. Chicago. 2012.
4. Miller SD, Duncan BL. Outcome rating scale. Chicago. 2000.
5. Miller SD, Duncan BL, Johnson L. Session rating scale: Preliminary Psychometric Properties of a “Working” Alliance Measure. Chicago. 2002.
6. Tilsen J, McNamee S. Feedback informed treatment: Evidence-based practice meets social construction. Family Process. 2015; 54: 124-137.
7. Bargmann S, Robinson W. Manual 2: Feedback informed clinical work: The basics. Chicago. 2012.