In Therapy

A user's guide to psychotherapy

How To Give Feedback to Your Therapist

Improving therapy through feedback

Does this look like the hot seat?
NOTE: Tuesday, September 25th is the first annual National Psychotherapy Day [website, facebook]. Among the many ways to participate, it's suggested that clients give feedback to their therapists that week. Here is one of many ways to do this.

You are your therapist’s boss.

The odd power dynamics of therapy can cloud this over, but that’s the ultimate truth: you pay your therapist’s salary and you determine whether or not he or she has a job (for that hour, at least). One of the tasks of an employer is the performance evaluation. It’s your “state of the union” discussion, and you can have it any time.

Why feedback? Let’s say you went to a personal trainer and had a workout so gentle you felt no benefit. Or it was so difficult and painful it took you a week to recover. Or the bizarre exercises left you dumbfounded. Would you say anything to the trainer? If you were an ongoing client, wouldn’t you want them to know, so you’d get the best treatment? And don’t you think they’d want to hear your feedback, as opposed to doing the wrong thing day in and day out? Same thing for therapy.

I think client feedback is necessary to correct a flaw in our system. Therapists are supervised and evaluated when they’re in school and collecting hours for licensure. Beyond that, they’re on their own. Sure, they can seek out a consultation group or engage in specialized training, but they’re ethically allowed to fly solo for the rest of their career. If they learned a bad habit early on, they may repeat it for years if they never receive constructive feedback. Feedback allows us to tap into the best resource of all: clients who have a front row seat each week to the therapist's skills and abilities.

But we don't do this very often. Therapists don’t solicit feedback because they weren't taught how, they're afraid it will take away from the client’s time, or they’re concerned about what they’ll hear. We can learn how in this article, and if you think it's a waste of session time, consider how much time you may be wasting if you're using flawed theories or techniques. And if you're that concerned about what you'll hear, you probably need to hear it. 

Clients don’t offer feedback because therapists don’t ask for it, they don't know what to evaluate, and they worry that any critique will result in defensiveness or a backlash against the client’s efforts. Clients ultimately come to therapy to resolve their issues, not to improve their therapist. But the feedback may help clients reach their goals faster, and even the process of giving feedback can be enlightening.

I believe the feedback loop is essential to tailor the work to the client's personality and issues, but don't just take my word for it. Research has shown that client feedback improves the therapist’s ability to help their clients. Not a paltry amount, either, more like three to four times better treatment outcomes. Let's get down to business.

There are some heavily researched and validated programs for therapists to measure client feedback, and many revolve around the work of feedback guru Scott D. Miller and the International Center for Clinical Excellence. For free, a therapist can obtain a complete feedback protocol for immediate use in their practice. If you're a feedback believer, I highly recommend this simple, yet powerful system.

For a less structured approach that therapists and clients can use together, I propose a feedback discussion based on four simple questions:

  • How is the client?
  • How is the therapist?
  • How is the relationship?
  • What’s next?

You may be concerned about how to bring up a discussion like this. I'd recommend bringing it up at the beginning of the session to allow enough time. It doesn't need to be too formal or serious, a simple “I’ve been thinking about our work together, and I’d like to talk about it” would be a reasonable opener. Saying “It’s the week of National Psychotherapy Day, and one recommendation is giving constructive feedback” is another worthwhile option. By the way, feedback doesn’t need to be restricted to a yearly or bi-annual event, you could do whenever you’d like.

This feedback discussion is really just engaging in a here-and-now talk: "how am I feeling here with you now?" But for those who like a bit more structure, I've included some conversation starters below. Clients may want to think about these questions before the session, and possibly print this out to bring as an outline:

How is the client?

You may want to start with a general overview of your progress since you entered therapy. Compared to where you were before you started meeting, how do you feel? What have you gained from this process? What are you now doing to take care of yourself? What do you say when you talk to yourself? How do you feel about your relationships? Have you noticed differences in your thoughts, feelings, or behaviors?

Consider the main issue that brought you to therapy. How well do you understand it? Have you learned how to change or accept it? How much power do you feel over it? What has changed?

How is the therapist?

This can be a little awkward, but it’s for a good cause. How well does the therapist listen? How well are details like appointment times and finances handled? How is her memory? Are her observations and recommendations easy to understand? Does she spend time to explain? Does she maintain healthy boundaries? Does she seem to care? What has been her most helpful contribution to your work? If you could change anything about her approach, what would it be? 

How is the relationship?

Now we’re on to the most intense portion: talking about the relationship. How do you feel when you come to therapy? Do you feel safe talking about your issues? Do you ever feel like you held back some important issue because you were afraid of the response? How do you deal with disagreements and conflicts in therapy? Is your work too shallow, too intense, or just right? These issues are important to know and vocalize.

What’s next?

Now that you've discussed all this, what changes will you make? What will you both do to address these concerns? Will you plan to talk about this again? When?

And that’s feedback. It's commenting on the work and taking practical steps to improve the level of care. This is what it means to be an empowered client, having a voice in therapy and actively improving the outcome. As a bonus, the therapist is learning their strengths and weaknesses and hopefully growing as a result. 

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Want to participate in National Psychotherapy Day? Come learn more at the website and the rowdy facebook page.

Did I sell you on the importance of feedback? If you want to practice, you’re welcome to give me feedback in the comments section or on my facebook page. 

Ryan Howes, Ph.D., is a clinical psychologist, writer, musician and professor at Fuller Graduate School of Psychology in Pasadena, California.

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