The Best Way to Improve Trauma Outcomes… Get Client Feedback

Family Trauma Step-by-Step Tools with Dr. Scott Sells: Episode #2- Improving Trauma Outcomes By Getting Client Feedback

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So today’s topic or technique is called How Client’s Feedback Will Dramatically Improve Our Trauma Outcomes, and this is going to be through the FST ethnographic interview. Because one of the problems that we have sometimes is we think the session went great, the client did not. And their perception is so importantly because if they don’t think the treatment is going well they will terminate prematurely. So how can we avoid this? How can we improve retention?

So I’m going to show you these five questions that we did in our research that you can use in your practice.

I’d like to begin with a story. It goes way back to when I was a young PhD student at Florida State.  At the teaching clinic, we would do one way mirror supervision where a team of us would watch our colleagues do family therapy with couples or families.  What I noticed was sometimes the counselor would come out of the session saying, “I nailed it.” And I could just tell watching the session that it didn’t go well. So I was always wondering, what impact will that have if the client and the therapist aren’t on the same sheet of music?

So let me show you what can happen. When I looked at the research on this very issue, let me show you the dangers of this and then how we solve this problem and how you can solve this problem in your own practice.  I like the caption of today’s webinar because all these family members have thoughts and ideas that they often don’t share with us because either they think, “I don’t want to be rude. I don’t want to hurt the therapist’s feelings or the person I’m working with.” But if we don’t get at what they’re thinking, this could hurt their outcomes and ours as well.

The research is showing that if we think that variables such as diagnosis, severity, type of therapy are the most important things that determine successful outcomes, the research is showing that it’s not.  It’s now as important as the client’s perspective of whether they think it’s working.

In other words, we might think our type of therapy is the bomb, but the client doesn’t think it is and they’ll drop out by the third session on average.  The worse part is we don’t even know why so we’ll keep repeating the same thing over and over again. The research study really showed this with a large sample size of over 6,000 clients.  It found that if we could get access to their formal feedback in real time, like how they think it’s going, that this is going to improve outcomes on retention.  And they’re going to be happier in treatment and they’ll do better.

Going back to my story here, am I okay with really wanting to answer this question to find real time feedback? Where do I go? In one of my research classes, there was a thing called ethnography and I liked it.  It was an anthropologist that would go to the actual people they worked with, either dead or alive, to find out from his point of view what worked and what didn’t work.  I wrote a study with some colleagues where I wanted to see what would happen if I talked to the clients after a session was over separately in another room.  Then I asked the same questions of the therapist to I find out a difference in how they saw treatment.

Well we were successful in this and here’s what we found. There was five ethnographic questions that we found that would optimize the client’s feedback. So at the end of the session we would instruct the therapist and, me as the researcher, I would go in there and I would first interview the client and I would say, “I want to know the overall session improvement or lack there of. I want to know how helpful the therapist was or not. And I want to know most importantly how we can make these future sessions more productive.”

Well it was like lightning in a bottle. Here are the questions I asked. So I remember the first client from that research study like it was yesterday. I interviewed a therapist first and here is the questions I asked and I asked the same questions to the client. “So overall,” I can’t remember her name, “Sandra, how helpful was the session today that you think as a therapist?” “Oh, it was great.” I said, “Well, what was the most helpful?” “Why I used a model called solution focused so I was able to do scaling with them and I was able to ask them on a scale of one to five how things are going in there. And they came in because the husband had an affair with the wife and I think they’re doing much better according to my treatment model.”

“What was least helpful, Sandra?” She goes, “Nothing. I think we’re on our way in fact we’re graduating and I might do one more followup, but I think they’re good to go.” I said, “Is there anything that you did that was most helpful?” “Yeah, I kept it focused. I had a clear beginning, middle and end. I asked strengths based questions.” “And was there anything least helpful?” And she said, “No, there wasn’t. I think I did well. I mean maybe what was least helpful is that I could have asked for more clarity, but I’m not sure.” “Well, what do you think would happen in future sessions to make it more productive?” And she said, “They already told me when I use the scaling that they were at a four or five so I don’t think anything.”

So I go into another room and the couple’s waiting for me. And I said, “Overall what was most helpful?” The husband and wife said, “That we feel that she’s compassionate, she cares about us.” But then when I got to least helpful it was like all heck broke loose. The mom starts tearing up. I mean the wife starts tearing up and says, “You know, we’ve been here five, six times and our counselor never asked me what my pain was.  How that’s hurt me? She never wanted to see me individually to hear just my pain. And I merely moved to what she calls, “Solutions like if things were better and you guys were closer what would it look like?  If the affair and the violation had healed what would that look like? All forward. But I had to heal from the past.”

And then they said something I’ll never forget. “We’re not coming back again. We just don’t want to hurt our therapist’s feelings.” So when I gave that feedback back to the therapist she was shocked. She was like, “Oh my gosh how many other clients have I had who I thought everything was going well that they didn’t?”

So here’s what we found out. If we could take five to 10 minutes at the end of a meeting and ask if we could ask these questions, they would tell us.

One thing we did find is we had to use a disclaimer. We had to say the first time we asked these questions something like this, “You won’t hurt my feelings. I want to know honestly what you think actually will help me because then I will know how to make our meetings more productive in the future.  So please be honest and candid. I have thick skin. You won’t hurt my feelings.” If you did not say that disclaimer oftentimes the clients would not give you an honest answer because they just didn’t want to hurt your feelings.

In summary, you guys just learned the ethnographic interview. That is it and I just wanted to summarize today.  Of course what we did is, number one, obviously perception is nine tenths of the law. So when you think that your clients are doing great they may not be. So using these five questions is absolutely critical and if you don’t think it will work just try it.

And number two, the questions are there to elicit a very clear response. As we close today I just want to thank you for coming today.  Until next time I want to thank you guys for all you do to work with our traumatized families. It’s really fun to do this with you and thank you for coming on.