Helping clients talk about their psychotherapy with their therapist

Another great post from the heroicagencies listserve by Dr. Barry Duncan:

Let me first deal with the precipitous drop in ORS score.  The first order of business is getting the client’s explanation of what has happened. Is the drop related to the reason for service—a deterioration—or is it the pothole phenomenon or where some recent event or perhaps even the events of the day are holding sway over the client’s rating? If it is a deterioration, then this is a red flag for sure, and signals the necessity to have a heart to heart about what needs to happen different to quickly turn things around.  

But a pothole effect warrants different action. The pothole metaphor goes like this: The client hit a pot hole on the way to the session and got a flat tire. It was raining cats and dogs, and the client’s nice clothes were soaked and soiled. Then the client was in such a hurry that radar caught them, and so on.  You get the idea. The pothole effect is where the events of the day overly influence the client’s response on the ORS rather than how the week has gone in general as related to the reasons for therapy. If the client reports it is a pothole, then ask him or her to redo the ORS looking at the week in general, and related to the reasons that served as the impetus for therapy. If the event or events are important to the client and seem to trump the original reasons for therapy, then of course, go with it. Just reconnect the issues at hand to the open spaces on the ORS. Just be cautious and alert to the problem of turning everyday life events, the ups and downs of being a human being, into therapy issues—don’t stir the cauldron.

Sometimes client scores, even when connected to the client’s experience of the problems to be worked on in therapy, go up and down over time. These graphs depict a zigzag pattern. It’s okay, it’s not so unusual. Do your best to keep the measure as the accurate representation of the client’s described experience and reasons for therapy. Of primary interest is whether there is an upward or downward trend in the pattern, which leads back to the basic question that the ORS addresses:  Are things getting better or not? If the zigzag progression of the ORS plots depicts an overall change from the intake score, then you are on the right track. Conversely, if the fluctuations reflect no change at its lowest point, then the implementation of the strategies of when things are not changing are warranted.

So if it is not a pothole, your client still has an upward progression (from 11 to 15) but still warrants caution

Now the SRS: I believe the drop in the SRS scores in session three tell the tale.  Not only is it a very low score but it is a significant drop from the previous two sessions. Something is amiss.  First some general comments:

If a client scores less than a total of 36, or less than 9cms on any dimension on the SRS, there is a potential problem that should be discussed. There are really only two choices. Either the SRS is good or it’s not. And your actions are equally simple: Either you thank the client for the feedback, and invite them to share any future concerns—letting them know it’s the best favor they could do for you; or you thank the client for the feedback, and explore why their ratings are a bit lower so that you can try to fit what they are asking for. A high rating is a good thing but difficult to interpret. A lower rating is cause for celebration.

Traditionally, clients have given their evaluation of the alliance with their feet—they walk out and don’t come back. Clients, however, will let us know on the SRS long before they will confront us directly or bolt. That is what the SRS offers us. People will mark the scales a little lower when they might never say anything. But it still takes more than a bit of work to create the conditions that allow clients to be candid with us. Indeed, the disparity in power between therapist and client, combined with any socioeconomic, ethnic, or racial differences, can make it difficult for our clients to tell us we’re on the wrong track. When was the last time you told your physician, “Listen, you’re making a big mistake with me”?

It’s okay for the client to go slow with the SRS. Remain open and keep encouraging the client to let you know if there’s anything else you can do. Don’t be expecting specific feedback or grand revelations, although they do happen from time to time. Usually the feedback is somewhat vague and general. Remember it is hard, for nearly all of us, to give interpersonal feedback, especially critical, so any feedback is a godsend and is communicating something. Just try to get at what it is. Is there anything else I could have done differently, something I should have done more of or less of, some question or topic I should have asked but I didn’t?

It sounds like with your client that you did indeed thank and explore. But when the score is that low and a drop from before, it might take a bit more time and effort to shed some light on what is going on. For me, I just try to hang in there a bit longer, commiserate with how hard it is to talk about the relationship, and transparently share my concerns about drop out or null outcome. It’s a lot like hanging out with client’s distress. When we learn to embrace, understand, and appreciate it instead of thinking we have to change it, a lot more connection occurs. But I first start with appreciating the feedback:

Therapist: Thanks so much for your feedback. I really appreciate your help here and you are doing me a huge favor to let me know that things could be better because you are giving me an opportunity to do something different for next time.  A lot of times people will mark the SRS a bit lower long before they will say anything about what needs to happen differently. Any thoughts about what that could be?

Client: “Well, it was actually a really good conversation, maybe I didn’t fill the measure out right, I think it just looks lower, but really it felt the same as session 1 and 2”.

Therapist: Okay. Well a couple of things concern me here, and please bear with me because I know this is hard to talk about this stuff. In fact, people don’t usually talk about the relationship at all so this is a lot of new ground. First is the drop in score, when SRS scores drop like that, clients are generally at a big risk for not coming back, especially combined with your drop in ORS score. So if you have any ideas about what I can do to prevent that, I would greatly appreciate it. The last think I want is that you would leave here without benefiting, without getting what you wanted from this process. Do you think it might help if we went through the SRS items one by one? Would you be willing to give it a try?

So essentially, my only thought is that you stay with it longer, allowing silence and uncomfortableness to linger, showing your appreciation for the difficulty of the conversation and for any feedback you might get. Given her drop in ORS score, you might consider calling her.



Barry Duncan, Psy.D.
Institute for the Study of Therapeutic Change;;
954.721.2981; 561.239.3640

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