When I’m good, I’m very good, but when I’m bad I’m better: A new mantra for psychotherapists - summary of an article by Duncan and Miller (2008)

When I’m good, I’m very good, but when I’m bad I’m better: A new mantra for psychotherapists
Duncan and Miller (2008)


The majority of clients experience change in the first six visits. Early change predicts engagement in therapy and ongoing benefit.  

The outcome rating scale (ORS)

The ORS assesses three dimensions: 1) personal or symptomatic distress 2) interpersonal well-being 3) social role.

Changes in these dimensions are considered widely to be valid indicators of successful outcome.

The ORS translates the three areas and an overall rating into a visual analog format of four 10-cm lines. The score is the summation of the marks made by the client to the nearest millimetre on each of the four lines

It can bring the risk of negative outcome front.

The session rating scale (SRS)

Client’s ratings of the alliance are far more predictive of improvement than the type of intervention or the therapist’s rating of the alliance.

The session rating scale (SRS) measures to encourage routine conversations with clients about the alliance. It contains four items: 1) A relationship scale rates the meeting. ‘I did not feel heard, understood and respected’ to ‘I felt heard, understood and respected’ 2) Goals and topics ‘We did not work or talk about what I wanted to work on or talk about’ to ‘We worked on or talked about what I wanted to work on or talk about’ 3) Apporach or method scale ‘The approach is not a good fit for me’ to ‘The approach is a good fit for me’ 4) How the client perceives the encounter in total ‘There was something missing in the session today’ to ‘Overall, today’s session was right for me’

The SIS translates what is known about the alliance into four visual analogue scales, with instructions to place a mark on a line with negative responses depicted to the left and positive responses indicated on the right.

The SRS allows alliance feedback in real time so that problems may be addressed.

An alliance problem that occurs frequently emerges when the client’s goals do not fit our own sensibilities about what they need.

Sometimes it takes a bit more work to create the conditions that allow clients to be forthright with us, to develop a culture of feedback. The SRS helps us take clients and their engagement more seriously.

Step one: introducing the ORS in the first session

The ORS is administered prior to each meeting and the SRS toward the end. In the first meeting, the culture of feedback is continually reinforced.

Step two: incorporating the ORS in the first session

The ORS pinpoints where the client is and allows a comparison for later sessions. Incorporating the ORS entails bringing the client’s initial and subsequent results into the conversation for discussion, clarification and problem solving. You need to mention the client scores as it relates to the clinical cutoff (under 25).

Clients usually mark the scale the lowest that represents the reason they are seeking therapy, and often connect that reason to the mark they’ve made without prompting from the therapist.

The ORS makes no sense unless it is connected to the described experience of the client’s life. At some point in the meeting, the therapist needs only to pick up on the client’s comments and connect them to the ORS.

Step three: Introducing the SRS

The SRS is best presented in a relaxed way. The SRS is given at the end of the meeting, but leaving enough time to discuss the client’s responses.

Step four: incorporating the SRS

You can do a quick visual check on the SRS and integrate it into the conversation. You should address any hint of a problem.

Always thank the client for the feedback and continue to encourage their open feedback. Your appreciation of any negative feedback is a powerful alliance builder. The SRS allows the opportunity to fix any alliance problems that are developing and shows that you do more than give lip service  to honouring the client’s perspectives.

Step five: check for change in subsequent sessions

Each subsequent meeting compares the current ORS with the previous one and looks for any changes. The scores are used to engage the client in a discussion about progress, and what should be done differently if there isn’t any. The idea is to involve the client in monitoring progress and the decision about what to do next.

The discussion prompted by the ORS is repeated in all meetings, but later ones gain increasing significance.

If change has not occurred by the checkpoint conversation, the therapist responds by going through the SRS item by item. Alliance problems are a significant contributor to a lack of progress. It can indicate that the therapist needs to try something different.

The importance of referrals

There is rarely justification for continuing work with clients who have not achieved change in a period typical for the majority of clients by a particular practitioner.

When no change occurs, some clients terminate and others ask for a referral to another therapist or treatment setting.

Therapist cannot be effective with everyone, and other relational fits may work out better for the client.

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