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Clinician's Digest

By Garry Cooper

A Therapeutic Game Changer?

Researchers like Michael Lambert and the late Ken Howard have proven that therapists who receive structured feedback from or about clients after each session have fewer premature terminations and stronger therapy alliances—factors that generally lead to more successful therapy outcomes. To assist this process, clinician–researchers such as Lambert, Scott Miller, and Barry Duncan have developed short questionnaires for clients to complete, providing quick snapshots of the therapeutic progress at every session. But the brevity of these questionnaires may also be a limitation.

Such forms focus on one or two dimensions of therapy—the alliance and/or how clients assess their own progress—mere snippets of one client’s subjective experience. Longer forms could give therapists much more information about what’s really happening in therapy. However, since few therapists take the time to use even the short forms already available, preferring to rely on their own instincts, perceptions, and emotionally charged clinical moments, it seems a stretch to suppose they’d welcome longer questionnaires.

What if there were a multidimensional feedback system that took clients just five to seven minutes to fill out, covered more of the complexities of therapy, had a systemic perspective, fed the information to therapists in user-friendly graphs on the Internet that required just a couple of minutes to examine, and revealed information not always apparent in sessions? Family therapist and researcher William Pinsof, president of The Family Institute at Northwestern University in Evanston, Illinois, thinks he’s found just that, which he calls a real game-changer for therapy. He and colleagues have developed the Systemic Therapy Inventory of Change (STIC), which is filled out by clients online, allowing clinicians to quickly and efficiently tap into a mother lode of information about a session, the client, and the client’s family. It’s especially useful for couples and family therapists, who can see at a glance what’s happening with each client and what’s going on among family members from the different perspective of each individual. “STIC tells you about the therapist–client alliance, but also gives a complex picture of where the trouble is and where the strengths are,” says Pinsof. “Other feedback measures mostly just give you an idea of how clients feel and how they think the therapist is doing.”

Let’s say a depressed wife has a joyous breakthrough in therapy, but in going over the data before the next session, the therapist sees that the husband’s self-ratings of satisfaction with the therapist took a nosedive in the same session. Or, curiously, their ratings of how close they feel toward each other, which had been approaching congruence during the last few sessions, suddenly diverged after her breakthrough: the wife feels closer, but the husband now feels more distant. When there’s some kind of anomalous spike on the graphs such as this, Pinsof will often just show the information to clients and ask what they think explains it, which helps create a process of collaborative hypothesizing with clients.

Family Institute therapists have already begun using STIC. The Institute has bought 20 iPads and mounted them in therapists’ waiting areas. Institute clinicians go to the STIC website (access isn’t available to the public), and look at their clients’ graphs before their sessions. “It gives you so much data, it’s like having MRIs of clients’ brains,” says Doug Breunlin, the Director of the Institute’s Marriage and Family Therapy Program at Northwestern.

With a large new grant, Pinsof is rolling out a multisite, multicountry research program to further test STIC with more than 400 therapists and more than 4,000 cases. He says that the resulting database will add another useful dimension to STIC by allowing therapists to see how other therapists around the world intervened in cases with similar dynamics.

For therapists who are used to navigating by their own observations and intuitions, the prospect of using STIC may seem at first like being asked to wear a straightjacket while swimming in a deep ocean of information. They may feel they’re being compelled to ignore clinical hunches while they “read” multiple graphs and factor in dozens of variables before making a move. But therapists can use their intuitions to home in on which graphs to examine. Instead of constricting therapy, Pinsof says, “STIC gives therapists more clinically relevant information than they’ve ever had access to before.” Speaking as both a therapist and a researcher, he adds, “I think it offers a glimpse of what the more science-based therapy practice of the future will be like.”

Therapy Skill and Clinical Research

Even a clinical model with solid empirical support for its effectiveness is only as good as the therapist practicing it. You can train therapists to follow treatment manuals and protocols more or less accurately, but how well they deliver the treatment is often what makes the difference between success, mediocrity, and even failure. Therapy researchers describe the degree of precision with which practitioners follow the prescribed steps of a model as “adherence,” and refer to the skill with which therapists practice the model as “fidelity.” Not surprisingly, the correct intervention delivered awkwardly, incompletely, or at the wrong moment can score as high adherence and poor fidelity.

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