“We should not try to design a better world,” says Owen Barder, senior fellow at the Center for Global Development, “We should make better feedback loops.”

Feedback has become a bit of a buzzword in mental health.  Therapists are being asked to use formal measures of progress and the quality of the relationship and use the resulting information to improve effectiveness.

As it turns out, not all feedback is created alike.  The key to success is obtaining information that gives rise to increased consciousness—the type that causes one to pause, reflect, rethink.  In a word, negative feedback.

Nearly a decade ago, we noticed a curious relationship between effectiveness and the therapeutic alliance.  Relationships that started off poorly but improved were nearly 50% more effective than those rated good throughout.

Additional evidence comes from a real-world study of therapy with adolescents (Owen, Miller, Seidel, & Chow, 2016).  Therapists asked for and received feedback via the Outcome and Session Rating scales at each and every visit.  Once again, relationships that improved over the course of treatment were significantly more effective.

Importantly, obtaining lower scores at the outset of therapy provides clinicians with an opportunity to discuss and address problems early in the working relationship.  But, how best to solicit such information?

The evidence documents that using a formal measure is essential, but not enough.  The most effective clinicians work hard at creating an environment that not invites, but actively utilizes feedback.  Additionally, they are particularly skilled at asking questions that go beyond platitudes and generalities, in the process transforming client experience into specific steps for improving treatment.

As statistician and engineer Edward Deming once observed, “If you do not know how to ask the right question, you discover nothing.”

Little useful information is generated when clients are asked, “How did you feel about the session today?” “Did you feel like I (listened to/understood) you?” or “What can I do better?”

The best questions are:

• Specific rather than general;
• Descriptive rather than evaluative;
• Concerned with quantities rather than qualities; and are
• Task rather than person-oriented.

Over the years, we’ve come to understand that learning to ask the “right” question takes both time and practice.  It’s not part of most training programs, and it only comes naturally to a few.  As a result, many therapists who start using formal measures to solicit feedback about progress and the therapeutic relationship, give up, frustrated in their efforts to solicit helpful feedback.

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