On the minds of many therapists are these two questions:

How can I increase client commitment to therapy? How can I make sure they don’t drop out of treatment?

At this year’s Therapist Leadership Conference, Bob Bertolino shared some interesting research related to how and why our clients get better. But first, here are some findings that can cause us to pause.

The average therapy client is 80% better off than the untreated (non-client). That is great news! But, look at this:

Since 1977, Bob reports that our therapeutic outcomes have not improved. In fact, the average client dropout rate – those who terminate prematurely – is 45-50%. This could be for a number of reasons, for example, there seems to be a lack of consumer confidence in therapy; they wonder if it really works. Furthermore, we as a profession haven’t taken strong stance in measuring/tracking outcomes.

Where should we be spending our times to improve client retention and outcomes?

Bertolino reports the common facts that influence positive treatment outcomes are as follows:

• 87% of client treatment success is due to the client. The means individual factors such as: his or her strengths, and the resources that the client has to tap into. Also, factors such as persistence and faith, and a sense of membership in a community are important predictors.  How the client uses these resources is a factor as well – as is the client’s personal level of motivation, and resiliency.
• 6-9% of positive outcomes come from the “therapist effect.”  This is the ability for a clinician to go in and connect with a particular client with methods that generate hope. The clinician sees herself (or himself) as an active ingredient to create change with this particular client.
• 5-7% is due to relationship alliance between therapist and client. This surprised me – I was taught this was the single biggest factor and today it is reported to account for only 5 – 7% of successful outcomes. Yes, positive outcomes start with  the therapist’s ability to create the alliance. Clinicians who are good at creating and maintaining therapeutic alliance are flexible and good at making adjustments as needed. Beyond that, most of the potential for outcome relates to the client and the above-mentioned client factors.
• 1-2% of outcome success is related to a specific therapy model and techniques. Bertolino suggests that before we take more classes in theoretical models, we find out how positive our clients see our/their outcomes.

The questions remain: What do we do to help people not leave treatment prematurely and how do we help them reach positive outcomes? In other words, how do we know that are clients are benefiting from our work? Many therapists will say, “I just know I am effective.” In studies, almost all therapists identified themselves as above average or exceptional. Statistically, we can’t all be above or way-above average as compared to our peers. So let’s figure out how to measure our success.

Research is pointing to the idea of clinicians using a “feedback measure” (which can be as simple as a checklist or a rating scale) given to routinely to the client. These type of feedback measures, can help reduce client dropout rate and improved outcomes by as much as 50-65%.

On the feedback measure, the client reports to the therapist how they are doing and how the therapeutic relationship is perceived by the client. You can see if the client’s functioning is going down or up. You can keep track week to week and look for changes that can pave the way for important clinical discussions.

Two such measures are offered by Scott D. Miller. He offers the “Session Rating Scale 3.0 (SRS)” designed to assess key dimensions of effective therapeutic relationships. He also offers the “The Outcome Rating Scale (ORS)” designed to assess areas of life functioning known to change as a result of therapeutic intervention. These feedback measures aren’t complicated – just four questions each.

These are generously offered at no-charge by Dr. Miller and can be downloaded here.

When we put the client at forefront (since 87% if the success is related to the client) and use feedback measures, it provides a plethora of information. We can notice a client’s score is less than last time and ask, “What does the drop mean? What can you do to help yourself this week?”  These measures allow us to connect deeper and be very helpful to the client.

In addition, a feedback measure done regularly can help identify a client with one foot out the door. During or at the end of a session, you can pause and ask, “I’d like to pause here and ask how it is going – are we talking about what you want to talk about?”

If there has been a therapeutic break, we can really hear the client and respectfully tell them we are sorry we missed it and address it with the client. Maybe with simply being asked and heard, enough repair has been done for the client not to leave treatment.

If you are wanting to improve your outcomes and effectiveness, you might want to consider a feedback measurement. There are many measurement scales out there. As I said, two of them are at http://www.scottdmiller.com/?q=node/6 These are very important too as many of you are building private-paying practices. Those clients reaching deep into their own pockets to pay for therapy sometimes tend to spread out their sessions or not come regularly. By using “feedback measures” this might change. (Let me know your results if you start doing this. I’d love to hear how they work for you.)

I can’t wait to hear your thoughts, comments and experiences in the comments box below.

As I close this article, I really want to thank Bob Bertolino for making all this easy to understand. If you’d like to connect with him, please do so at this website.

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