Client Feedback Improves Trauma Outcomes: The FST Ethnographic Technique

Why Feedback from Clients Matter

Feedback comes in different forms, positive and negative, however, no matter what, it should always be constructive. Sure, it’s mostly subjective, but whenever I ask for feedback, I am “amazed” by how often people use absolute terms and words during sessions I’ve been a part of. They are eye opening and extremely effective. One of the biggest core values we share as human beings is to feel needed, acknowledged and heard. Feedback is something we all need, whether we’re intrinsically or extrinsically motivated because it shows us what we’re already doing correctly and where we need to develop to get better and more successful helping others.

When was the last time you remember your client offering or that you asked for feedback? If you can’t recall practicing this interaction, what held you back? Do you feel you lack the right tools to formally assess your client’s perception of sessions or maybe you don’t see the benefits of receiving feedback?

Research shows significant improvements in outcomes when therapists have access to real-time client feedback on a session-by-session basis. It’s been well documented that if clients see no improvement by the third visit, they are twice as likely to drop out of therapy than those who reported making progress. When a client prematurely terminates or is showing little or no improvement, if you aren’t asking for feedback, you are likely not sure why they left. To be certain, if mistakes are made on your end, chances are, they’re being repeated again and again.

The FST Ethnographic Interview

The Family Trauma Institute understands the value of seeking real time feedback from clients. That’s why we developed the FST Ethnographic Technique based on the FST Family Systems Trauma Model. An ethnography qualitative method allows researchers to directly interact with people through open observations and asking questions to discover what something is and how it works. The FST Ethnographic Technique is a set of helpful questions allowing both clients and therapists to formally assess what works and doesn’t work within a particular therapy session.

We conducted a four month ethnographic research study in which we performed post-session interviews with clients and therapists. Through that research, we discovered five ethnographic questions listed below that therapists can use to optimize client feedback in the areas of: (a) overall session improvement or lack thereof; (b) the therapist’s level of helpfulness; and (c) how to make future sessions more productive.  This step-by-step procedure is outlined in Treating the Traumatized Child: A Step-by-Step Family Systems Approach.

The FST Ethnographic Questions

  1. Overall, what was most helpful in today’s session?
  2. Overall, what was least helpful in today’s session?
  3. What did I do or say as your therapist that was most helpful?
  4. What did I do or say as your therapist that was least helpful?
  5. What would need to happen in future sessions to make them more productive or of value to you or your family?

These five questions allow the trauma therapist to easily and effectively gain a holistic view of treatment from your clients. Not only can older children and their family members tell you overall what was helpful or not in the session, but also what you did or said that was or wasn’t helpful. And the best part? Clients are better able to communicate what you can do or say in future sessions to make treatment more productive in the future. Utilizing these questions allows treatment to become collaborative between you and families by making real time adjustments to improve outcomes as you go. Everyone wins, and that’s a good thing. Right?

Give Families the Green Light to Provide Critical Feedback

During our four month study, the only challenge we uncovered was an initial hesitancy on the part of the family to give any critical feedback unless we explicitly gave them permission before the first question is asked. The reasons most consistently given were that the families did not want to “hurt their therapist’s feelings,” “cause them any distress,” or they believed “their ego cannot handle criticism.” As a result, we developed this introductory statement that can be used:

Before we end our session today, I want to get your opinion about your experience during our meeting today. I want to ask you just a few simple questions, but before I ask these questions, I want to give a disclaimer. I want you to be as honest and candid as you want to be. I promise you that whatever you say, good or bad, you will not hurt my feelings. In fact, if there are areas to improve in or we are not going in a direction you want, that is good information because I then will have the opportunity to correct the problem and get us back on track as quickly as possible.

Without this disclaimer, we found that clients were afraid to give criticism. However, once we shared it, clients often felt safer and more willing to give honest feedback.

Trauma Family Therapy Scares Me to Death!

During a recent FST workshop, several of the trainees from the same agency and I went to lunch. I asked them how they felt training was going so far?  I was surprised when Carl, a therapist, said:

Dr. Sells, the training is literally mind blowing for us. We have never experienced family trauma therapy quite like this. We are all trained in individual trauma work with children, adults, or couples, but not family therapy. We love the step-by-step and know deep in our hearts that we must engage and treat the entire traumatized family, not just the child. But I have to be honest. And I think I am speaking for our entire group…Family Therapy Scares Us to Death. And this fact keeps us up a night! Even with your book, we don’t know if we have what it takes–, and your book that has an easy to use script and manual with it. We do all our trauma therapy behind closed doors. There is no direct supervision. So, how are we supposed to know if we are making progress or making mistakes?

This is one of the most frequently asked questions I get during FST trainings and workshops. It is a really common fear and problem. Many counselors specialize in individual treatment but often lack intensive step-by-step training in family systems therapy. It’s one of the reasons I founded FST.

My response to Carl was simple and came with a challenge to the entire group.

“What if I told you that the FST Model has a simple but powerful tool to elicit a family’s feedback in real time allowing you both to gain confidence at the same time? They’ll be like your co-therapist, giving you concrete suggestions of what’s working, what’s not and how to improve as you move forward. As a result, you learn higher level family therapy directly from your clients, taking out a lot of the guesswork. Would you and your team be interested?”

I got an enthusiastic ‘yes!’ So I asked the therapists to use the FST Ethnographic Technique on their next five clients along with the FST Model. The results were extremely promising. They all had more confidence and developed an even deeper rapport with their patients. And, their feedback was excellent.

Here’s a sample:

  • “It [the FST Ethnographic Technique] gave me confidence because the family over and over again told be what was working and what was not. As a result, I suddenly knew where to go with the FST Model”
  • “It helped trauma treatment become one of collaboration between me and the family. They were not just a patient anymore. We were now a team!”
  • “I can now adjust my treatment methods and delivery in real time, and not after treatment is over”
  • “It is like having one-way mirror supervision but with my client’s empowered to now give me that direct feedback instead of just guesswork.”

Try the Technique Yourself

FST therapists often report that their overall confidence in the FST Model exponentially increases with use. And with increased confidence there can be better delivery effectiveness and outcomes.

Why not try out this FST Ethnographic Technique with your own clients?  And as always, we love feedback here at FST, so please leave us your comments in Leave a Reply Box.

About the author

Scott P. Sells, Ph.D., MSW, LCSW, LMFT, is the author of three books, Treating the Tough Adolescent: A Family-Based, Step-by-Step Guide (1998), Parenting Your Out-of-Control Teenager: 7 Steps to Reestablish Authority and Reclaim Love (2001), and Treating the Traumatized Child: A Step-by-Step Family Systems Approach (2017). He can be contacted at or through LinkedIn and Facebook.

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