Feedback-informed treatment

1. Introduction

Version followed: Feedback-Informed Treatment (FIT) as defined by Scott D. Miller and the International Center for Clinical Excellence (ICCE): ICCE core competencies and FRIFM (2009–2012), the ICCE/CYP-IAPT CAMHS guide (Low, Miller & Squire, 2012) and Miller et al. (2006), using the Outcome Rating Scale (ORS) and Session Rating Scale (SRS). Where Barry Duncan's Partners for Change Outcome Management System (PCOMS; Duncan & Reese, 2015; Sparks & Duncan, 2018) differs, the difference is named.

FIT is not a therapy model. It is a pantheoretical practice framework laid over whatever therapy you already do: at every session the client rates their wellbeing (ORS, start of session) and the alliance (SRS, end of session), the scores are discussed openly, and the clinician changes the work when the data show the client is not improving or the alliance is off track. At the clinician level, aggregated outcome data set a baseline and guide deliberate practice. [source: ICCE Core Competencies; FRIFM; Wikipedia FIT page]

How change happens (the model's claim): outcome depends mostly on factors common across therapies, on the client-rated alliance and on early change; clinicians are poor at spotting by judgement which clients are deteriorating or about to drop out; so formal, routine client feedback catches non-responders and alliance problems early enough to adjust, and clinicians improve only by measuring their results and practising deliberately against them. [source: ICCE Core Competencies, Competency 1; Miller blog on deliberate practice]

Origins: the ORS was developed by Miller and Duncan (2000) as a brief alternative to the OQ-45; the SRS was adapted from Johnson's (1995) longer scale and built on Bordin's alliance concept plus the client's theory of change [source: Miller et al., 2006]. Miller leads the ICCE and uses the term FIT; Duncan's Heart and Soul of Change Project uses the same measures under the name PCOMS [source: Duncan & Reese, 2015; Sparks & Duncan, 2018]. How and when the two lines diverged organisationally is [uncertain]. Measures are free for individual clinicians via the ICCE/Miller website and licensed for organisations; this guide describes them but does not reproduce items [source: Shaw & Murray, Counseling Today; Miller store pages in search results].

2. Framework

FIT has no fixed number of sessions or phases of therapy; it is a recurring per-session routine plus decision points keyed to the client's progress. Length of service is meant to be set individually from ORS data. [source: FRIFM Realm 2]

Per-session format (every session, every client):

• Start: ORS (or CORS for ages 6–12), rating the past week; score it in front of the client, plot it, discuss it (about 1 minute to complete). [source: CAMHS guide; Shaw & Murray]
• Middle: your usual therapy, steered by what the ORS conversation showed. [source: Shaw & Murray]
• End: SRS (or CSRS) in the last ~5 minutes, leaving time to discuss it before the client leaves. Administration, scoring and discussion of both measures together should take roughly 3–5 minutes. [source: Sparks & Duncan, 2018; CAMHS guide]

Key numbers (version noted):

• ORS/SRS: four 10 cm visual-analogue lines each, total 0–40. [source: CAMHS guide; Duncan & Reese, 2015]
• ORS clinical cutoff: adults 18+ = 25; ages 13–17 (self or carer report) = 28; CORS child self-report (6–12) = 32; CORS carer report = 28. Sparks & Duncan (2018) list CORS as 28 without separating self vs carer report [uncertain on child self-report figure]. [source: CAMHS guide; Sparks & Duncan, 2018]
• SRS/CSRS/Group SRS cutoff: 36 (all ages). [source: CAMHS guide; Duncan & Reese, 2015]
• Reliable change on the ORS: 5 points in ICCE sources (Miller et al., 2006; CAMHS guide); 6 points in Sparks & Duncan (2018, PCOMS) [uncertain: the sources differ; this guide follows 5 (ICCE)]. Reliable change that also crosses the cutoff = clinically significant change. [source: CAMHS guide]

Stages and decision points:

The rationale for the timing: most clients who benefit show it within roughly 3–6 sessions, and duration of therapy without positive change predicts a poor outcome. [source: Duncan & Reese, 2015; ICCE Core Competencies]

3. Guiding principles

• The client's voice is central. Practical meaning: the client's ratings, not your impression, define whether therapy is working. [source: Duncan & Reese, 2015; ICCE Core Competencies]
• The client is the final authority on what a score means. Practical meaning: offer norms as reference points, then ask whether that fits; never tell the client what their mark “really” means. [source: Sparks & Duncan, 2018]
• Measure every session, with every client. Practical meaning: do not rely on informal check-ins; clinicians overestimate how often they check in. [source: Shaw & Murray; FRIFM Realm 1]
• Transparency. Practical meaning: share and discuss scores right after collection, and tell clients up front what happens if therapy is not helping. [source: ICCE Core Competencies, Competency 2; FRIFM Realm 5; Duncan & Reese, 2015]
• Build a culture of feedback. Practical meaning: make it safe and expected to say what is not working, so ruptures are caught and repaired and dropout is prevented. [source: ICCE Core Competencies, Competency 2]
• Collecting is not enough; act on it. Practical meaning: when scores show no improvement, change something in the work; measurement without follow-through becomes an empty ritual. [source: Miller, MedCentral interview 2023; Shaw & Murray]
• The numbers never dictate action. Practical meaning: scores open a collaborative conversation; decisions are made with the client. [source: Sparks & Duncan, 2018]
• Negative feedback is the most valuable feedback. Practical meaning: thank the client for low scores and treat them as information about what to adjust, not as criticism. [source: CAMHS guide; Duncan & Reese, 2015]
• Clinicians cannot reliably judge risk of failure by intuition. Practical meaning: let the data flag at-risk cases rather than waiting until you notice. [source: ICCE Core Competencies, Competency 1]
• Early change matters. Practical meaning: treat the first 3–6 sessions as the window to detect non-response and adjust. [source: Duncan & Reese, 2015; ICCE Core Competencies]
• Alliance has four parts: preferences, goals, methods, bond. Practical meaning: when the SRS dips, check which part is off and adjust it; ask about preferences for focus, type, length, intensity, location and provider. [source: ICCE Core Competencies, Competencies 1–2]
• Pantheoretical. Practical meaning: FIT does not tell you which therapy to use; it tells you whether what you are doing is working for this client. [source: Wikipedia FIT page; ICCE Core Competencies]
• Feasibility over length. Practical meaning: use ultra-brief measures you will actually use; a measure is too long when clinicians won't use it. [source: ICCE Core Competencies; Sparks & Duncan, 2018]
• Combine feedback with other information. Practical meaning: integrate ORS/SRS with client preferences, your observation, collateral reports and other measures. [source: ICCE Core Competencies, Competency 2]
• No clinician serves all clients. Practical meaning: referral or transfer when the work is not helping is good practice, not failure. [source: Duncan & Reese, 2015]
• Credit the client for change. Practical meaning: when scores rise, ask what the client did differently. [source: CAMHS guide; Duncan & Reese, 2015]
• Continuity of care. Practical meaning: standing appointments and continuity with one clinician were part of implementation; have a policy for non-progressing clients that preserves continuity. [source: Miller et al., 2006; FRIFM Realm 2]
• Continuous professional improvement. Practical meaning: know your own baseline effectiveness and use deliberate practice, not more years of experience, to improve it. [source: ICCE Core Competencies, Competency 4; Miller deliberate-practice posts]

4. Intervention inventory

FIT's "interventions" are the routines for gathering, discussing and acting on feedback, plus clinician-level improvement procedures. All example language is labelled. Short quoted phrases come from Duncan & Reese (2015, PCOMS) unless noted; they are not Miller's wording. [source for section: CAMHS guide; Duncan & Reese, 2015; Sparks & Duncan, 2018; Miller et al., 2006; ICCE Core Competencies; FRIFM; Shaw & Murray]

4.1 Clinician preparation and rehearsal

• Purpose / when: before using the measures with any client; poor introductions turn FIT into a form-filling ritual.
• Steps: (1) Obtain the ORS/SRS (free individual licence from the ICCE/Miller site; organisational licence for agencies). (2) Read the administration guidance and decide how you will score (ruler on paper, or approved software). (3) Write your own introductions covering the key points (why, how long, what you will do with the answers). (4) Role-play the introductions and a low-SRS conversation with a colleague. (5) Check your own openness to critical feedback. (6) Arrange supervision or consultation from someone who knows FIT. (7) Start with new clients only; do not retro-fit existing clients. [source: Shaw & Murray]
• Example language: see 4.2 and 4.6.
• Watch for: feeling defensive in role-play; wanting to skip the SRS when short of time. Working: you can introduce both measures in under a minute each without reading a script.

4.2 Introducing the ORS (first session)

• Purpose / when: first contact, before discussing the problem in depth; establishes that the client's view of progress steers the work.
• Steps: (1) Explain in everyday language, without jargon, that the form tracks how the client is doing so you can both see whether therapy is helping. (2) Say it takes about a minute and will be repeated each session. (3) Read the instructions aloud; the client rates the past week. (4) Invite questions. (5) In family work, ask every family member present to complete one on themselves. (6) Hand it over and ask permission. [source: CAMHS guide; Shaw & Murray; Duncan & Reese, 2015]
• Example language (illustrative): "Each time we meet I'll ask you to fill in this short form about how the last week has gone. It helps us both see whether what we're doing is actually helping, and if it isn't, we'll know early and can change course. Would that be OK?" Duncan & Reese frame it as "an anchor point so we can track your progress" and ask "Would you mind doing it for me?" [source: Duncan & Reese, 2015, p. 393]
• Watch for: reluctance or confusion (see section 5). Working: the client completes it with little prompting and later refers to it themselves.

4.3 Administering, scoring and graphing the ORS

• Purpose / when: start of every session.
• Steps: (1) Client marks each of the four lines (individually, interpersonally, socially, overall) for the past week. (2) Measure each mark with a ruler in front of the client to the nearest millimetre (e.g. 3.5 cm = 3.5). (3) Write each item score in the margin and add them (0–40). (4) Plot the total on a session-by-session graph, with the clinical cutoff drawn in; software can do this and show the expected treatment response (ETR) for clients with the same intake score. (5) Telephone or oral version: ask the client for a 1–10 rating per area; if they give two numbers, ask which to record; if they give different numbers for parts of an area, average them. [source: CAMHS guide; Duncan & Reese, 2015; Miller et al., 2006]
• Example language (illustrative): "Let me measure these with you so we both see the numbers."
• Watch for: scoring out of sight of the client (loses transparency); forgetting the graph. Working: the graph becomes a shared reference point in later sessions.

4.4 Connecting ORS scores to the client's story (setting the focus)

• Purpose / when: first session immediately after scoring; and whenever a single item moves.
• Steps: (1) Give the total and the cutoff, explained as a reference point: scores below the line are typical of people who are struggling and seeking help, above it of people managing well. (2) Note which line is lowest; clients usually mark lowest the area that brought them in. (3) Ask what led them to put each mark where they did, and link their answers to the reason for referral. (4) Check the interpretation with the client; they have the final say. (5) Ask what would need to happen for a mark to move a little to the right, both in life and in therapy, to define goals and what success would look like. (6) In family or multi-rater work, ask each person about their marks and explore differences. [source: CAMHS guide; Duncan & Reese, 2015; Sparks & Duncan, 2018]
• Example language: "You scored about the average intake score of persons who enter therapy" and "move your mark just one cm to the right" [source: Duncan & Reese, 2015, p. 393]. Illustrative: "Your lowest mark is on relationships. Is that where the main struggle is right now? What would be different if that mark moved a centimetre to the right?"
• Watch for: the client disagreeing with the norm-based interpretation (follow their meaning). Working: the client can say in their own words what the low mark represents and what would show improvement.

4.5 Intake ORS above the clinical cutoff

• Purpose / when: about a quarter of clients score at or above the cutoff at intake; these clients, on average, show little improvement or may worsen in therapy. [source: Miller et al., 2006]
• Steps: (1) Ask what brought them in given that their ratings look like people who are managing. (2) Check whether the concern is narrow (one domain), about someone else, or externally imposed (mandated/referrer concern; see 4.15). (3) Agree a specific, limited focus and how you will know it is achieved. (4) Consider briefer contact or monitoring for deterioration. Steps 2–4 are [synthesis]; the sources document the pattern but give no specific protocol [uncertain].
• Example language (illustrative): "Your marks look like those of people who are generally coping. Help me understand what made now the time to come in."
• Watch for: decline on the ORS over sessions; a client who came at someone else's insistence.

4.6 Introducing the SRS

• Purpose / when: end of the first session and every session after, in the last ~5 minutes.
• Steps: (1) Explain that you want to know how the session went for them so you can keep doing what helps and change what does not. (2) Explicitly ask for critical feedback, including small things, and reassure them they will not hurt your feelings. (3) Explain the four lines: feeling heard and understood; working on what they wanted to work on; whether your approach fits them; overall. (4) Ask for a mark on each line. (5) Score in front of them. (6) Tell them you will actually use what they say. [source: Shaw & Murray; CAMHS guide; Miller et al., 2006; Duncan & Reese, 2015]
• Example language: "It's kind of like taking the temperature of our session today" and "If something is amiss, you would be doing me the best favor" [source: Duncan & Reese, 2015, p. 394]. Illustrative: "Even something that seems too small to mention is useful to me."
• Watch for: rushing it as the client stands up; leave time to talk about it.

4.7 Discussing SRS scores

• Purpose / when: immediately after scoring, every session; aims to detect and repair alliance ruptures before they affect outcome.
• Steps: (1) Total at or above 36: thank them, ask what was most helpful, and still ask whether anything could be done differently. (2) Any single item below 9: ask about that specific line, even if the total is high. (3) Any drop from the previous session, even of one point: mention it and ask about it. (4) Total below 36: adopt a grateful stance, acknowledge the session may have gone less well, ask what you could do differently next time, whether there was something you should have asked, clarify the lower marks, and check whether they expect the next session to be better. (5) Change something visibly next session and refer back to the feedback. [source: CAMHS guide; Duncan & Reese, 2015; Shaw & Murray]
• Example language: "Looks like it could have gone better for you today" and "What could I have done differently?" [source: Duncan & Reese, 2015, p. 394]. Illustrative: "Your mark on 'approach' is a bit lower than the others. What would have fitted you better?"
• Watch for: consistently perfect scores (may mean the client does not feel safe to be honest; see section 5). Working: clients begin to volunteer criticisms and SRS scores often move upward after a repair.

4.8 Session-by-session progress review

• Purpose / when: start of every session from session 2.
• Steps: (1) Compare today's ORS with the previous and intake scores on the graph. (2) Ask whether things are better or not, and what accounts for any change. (3) Classify change against reliable change (ICCE: 5 points; PCOMS: 6) and the cutoff. (4) Where software is used, compare with the ETR; ICCE implementation used warning bands (e.g. 25th and 10th percentiles of expected scores) to flag clients at risk of dropout or null/negative outcome. (5) Use the answer to decide the session's focus. [source: Duncan & Reese, 2015; Miller et al., 2006; Sparks & Duncan, 2018]
• Example language: "Are things better or not?" [source: Duncan & Reese, 2015, p. 394]. Illustrative: "Your score has gone up four points since we started. What's been different?"
• Watch for: improvement in one domain masking decline in another; check items, not just totals [synthesis].

4.9 Crediting the client for change

• Purpose / when: whenever the ORS rises.
• Steps: (1) Point out the rise. (2) Ask what they did differently, what they learned about themselves. (3) With carers, ask what they and others have been doing that helps. (4) Link these to plans for maintaining gains. [source: CAMHS guide; Duncan & Reese, 2015]
• Example language (illustrative): "That's a real shift. What did you do this week that made the difference?"
• Watch for: client attributing all change to luck or to you; keep returning to their part.

4.10 Checkpoint conversation (no change)

• Purpose / when: no reliable improvement by around session 3 (ICCE CAMHS guide) or sessions 3–6 (PCOMS).
• Steps: (1) Name the lack of change openly using the graph. (2) Ask how the client makes sense of it. (3) Review the SRS for alliance problems. (4) Check whether goals still fit and whether they target symptoms or functioning. (5) Ask whether the approach should change. (6) Discuss with your supervisor. (7) In child/family work, consider widening to other family members or the school, or meeting carers. (8) Agree specific changes and when you will review again. [source: CAMHS guide; Duncan & Reese, 2015]
• Example language: "Okay, so things haven't changed since the last time we talked" and "How do you make sense of that?" [source: Duncan & Reese, 2015, p. 394].
• Watch for: reassuring the client that change "takes time" without changing anything; that is the pattern FIT is designed to interrupt [synthesis].

4.11 Adding services and the last-chance discussion

• Purpose / when: still no change around sessions 5–6 (consider adding services or a referral to another agency) and sessions 8–10 (ICCE CAMHS) or 6–9 (PCOMS), when urgency is higher.
• Steps: (1) Revisit the graph together. (2) Shift from whether to change to what to change: different clinician, different approach, different format, a higher level of care, or additional services. (3) Agree with the client when you would both say the current arrangement is not working. (4) If transferring, make an active referral that preserves continuity. (5) Document the decision. [source: CAMHS guide; Duncan & Reese, 2015; ICCE Core Competencies Competency 2; FRIFM Realm 2]
• Example language: "When will we know when to say 'when'?" [source: Duncan & Reese, 2015, p. 394]. Illustrative: "We've given this a fair try and the numbers aren't moving. I'd rather help you find something that works than keep going with something that doesn't."
• Watch for: the client feeling rejected; frame transfer as their right to effective care. Supervisor framing in PCOMS: "No clinician serves all clients." [source: Duncan & Reese, 2015, p. 395]

4.12 Consolidation and ending

• Purpose / when: ORS shows reliable change that crosses the cutoff, or scores plateau at the client's likely maximum benefit.
• Steps: (1) Show the trajectory. (2) Review goals against the original low marks. (3) Ask what the client has been doing that produced the change (4.9). (4) Shift to planning continued recovery outside therapy. (5) Agree ending, spacing out, or stepping down, guided by ORS data rather than a fixed session limit. [source: CAMHS guide; Duncan & Reese, 2015; Sparks & Duncan, 2018; FRIFM Realm 2]
• Example language (illustrative): "You're now above the line where most people are managing. Shall we talk about what you'll keep doing, and whether to space our meetings out?"
• Watch for: ending prematurely when only one domain has improved [synthesis].

4.13 Eliciting and tracking client preferences

• Purpose / when: from the first session, and whenever the SRS "approach" or "goals" line dips.
• Steps: (1) Ask directly about preferred focus, type of help, length, intensity (frequency), location and provider. (2) Use SRS feedback to monitor and clarify those preferences over time. (3) Adjust the service plan accordingly. [source: ICCE Core Competencies, Competency 2; FRIFM Realm 1]
• Example language (illustrative): "Some people want practical strategies, others want space to talk things through. What suits you?"
• Watch for: stated preferences that change after a few sessions; the SRS is the check.

4.14 Multi-informant use with families and carers

• Purpose / when: child and adolescent or family work, where the source of distress is often unclear.
• Steps: (1) The young person rates themselves. (2) Carers rate the young person (and may also rate themselves). (3) Other distressed family members rate themselves and may be invited to rate others. (4) Teachers or other closely involved professionals can rate the young person. (5) Everyone present completes an SRS/CSRS, because the alliance with each member matters. (6) Show all forms and graphs to everyone. (7) Use differences in scores to open non-blaming conversations about what each person sees and what has changed. (8) Where there is conflict, empathise with both sides, reframe goals as shared family goals, and check that the approach fits. (9) Meet parents separately if differences need fuller exploration. (10) In PCOMS software, only caregivers' and the identified young person's scores are entered; others use paper so all perspectives are still discussed. [source: CAMHS guide; Sparks & Duncan, 2018]
• Example language (illustrative): "Dad, your mark for how Sam is doing is quite a bit lower than Sam's own. Sam, what do you think Dad is seeing? Dad, what do you see that worries you?"
• Watch for: discrepancies used to blame; keep the tone curious. Working: SRS ratings after a discrepancy conversation stay at or above the cutoff (Sparks & Duncan use them as the check).

4.15 Couples

• Purpose / when: conjoint couple work.
• Steps: (1) Each partner completes their own ORS at the start and SRS at the end of every session. (2) Show both forms and progress graphs to both. (3) Treat differences between partners' scores as a topic to explore; they can reveal needs and lead to mutual goals. (4) Respond to either partner's low SRS. [source: Sparks & Duncan, 2018]
• Example language (illustrative): "Your scores are moving in different directions this week. Can we look at that together?"
• Watch for: an alliance that is strong with one partner and weak with the other (split alliance) [synthesis].

4.16 Children (CORS, CSRS and young-child versions)

• Purpose / when: ages 6–12 (CORS/CSRS); under 6 (YCORS/YCSRS).
• Steps: (1) Use the CORS (domains: me, family, school, everything) and CSRS (listening, how important, what we did, overall), which have smiley and frowny faces at the ends. (2) The child rates themselves; the carer rates the child on the CORS. (3) Score and discuss as with adults, in child-friendly words. (4) For children 5 and under, the young-child versions use faces or drawings and have no established psychometric properties; use them as conversation aids only. (5) Ages 13+ use the adult ORS/SRS (cutoff 28 for 13–17). [source: Sparks & Duncan, 2018; CAMHS guide]
• Example language (illustrative): "Put a mark on this line to show how things are at school. Closer to the sad face if it's hard, closer to the happy face if it's good."
• Watch for: the CAMHS guide contains an apparent typographical inconsistency about which form ages 13+ use; follow the appendix (SRS for 13+) [uncertain].

4.17 Mandated or involuntary clients

• Purpose / when: client did not choose to attend (court, school, child protection, employer).
• Steps: (1) Ask the client to complete the ORS on themselves. (2) Also ask them to complete it as they think the referrer or a concerned person would rate them. (3) Use the gap between the two to discuss what would need to change for the referrer to be satisfied, and what the client wants for themselves. [source: CAMHS guide]
• Example language (illustrative): "Now fill it in the way your probation officer would, if they were rating you. ... What would they need to see for their marks to move?"
• Watch for: high self-ratings with low referrer-perspective ratings; this is the working material, not dishonesty [synthesis].

4.18 Group sessions (Group SRS)

• Purpose / when: group therapy.
• Steps: (1) Each member completes an ORS at the start (as in individual work). (2) At the end, use the Group SRS (ages 13+) or Child Group SRS (6–12); cutoff 36. (3) Follow up low scores, privately if needed. [source: CAMHS guide] Group-specific discussion procedures are not described; Prescott et al. (2017) include a group chapter using different instruments (OQ-45 and Group Questionnaire) that is not drawn on here [uncertain].
• Example language (illustrative): "A few of you marked the group lower today. I'd like to hear about that, here or afterwards."
• Watch for: members unwilling to criticise in front of peers; offer a private channel [synthesis].

4.19 Responding to an alert (signal) from outcome software

• Purpose / when: software flags an ORS trajectory below expected (e.g. yellow at the 25th percentile, red at the 10th) or an SRS below expected.
• Steps: In the ICCE EAP implementation, therapists had three response options: (1) talk with the client about problems in the alliance; (2) change the type or amount of treatment; (3) seek consultation or supervision. For a yellow SRS signal, check in about the client's experience, express concern about the relationship, and explore what to change before the session ends. [source: Miller et al., 2006]
• Example language (illustrative): "Your rating today tells me I may have missed something. Before you go, can we look at what would make this more useful?"
• Watch for: treating the alert as a verdict; it signals risk, not certainty.

4.20 Feedback-informed supervision and consultation

• Purpose / when: any case flagged by low or unchanged ORS, low SRS, or reaching a checkpoint without change.
• Steps: (1) Bring the graph, not just the narrative. (2) Prioritise flagged cases. (3) Options: consult a colleague, team review, supervisor sitting in, or referral to another clinician. (4) Use aggregate caseload data in supervision to review the clinician's overall effectiveness and set an improvement plan. [source: Duncan & Reese, 2015; FRIFM Realm 1; ICCE Core Competencies Competency 2]
• Example language (supervisor, illustrative): "Let's look at the clients who aren't improving first. What do their SRS scores tell us?"
• Watch for: supervision drifting back to case narrative only.

4.21 Measuring and benchmarking your own effectiveness

• Purpose / when: ongoing, once you have enough completed cases.
• Steps: (1) Keep complete, organised ORS/SRS records for every client. (2) Report transparently: which data were included or excluded, missing data, client demographics and setting, the measures' psychometrics, and the formulas used. (3) Calculate overall effectiveness: reliable change rates, effect size, or percentage reaching targets. (4) Compare with the best available norms or benchmarks for similar clients. (5) Identify areas below benchmark: retention, alliance or outcome. [source: ICCE Core Competencies, Competencies 3–4]
• Example language: not applicable.
• Watch for: cherry-picking cases; intake scores above the cutoff deflate effect sizes, so report them separately [source: Miller et al., 2006].

4.22 Deliberate practice

• Purpose / when: after establishing your baseline (4.21), to improve effectiveness rather than competence in a model.
• Steps: (1) Establish a baseline of performance. (2) Using the Taxonomy of Deliberate Practice Activities (TDPA, free from Miller's site with the ORS/SRS packet), assess your work and identify the aspects of your performance most likely to affect effectiveness. (3) Set small, individualised learning objectives. (4) Design practice activities targeting them. (5) Get corrective feedback from a coach or supervisor (a coach version of the TDPA exists). (6) Monitor progress and successively refine the plan. (7) Beyond benchmarks, set new outcome, retention or specialty targets and repeat. Ordinary clinical work, generic workshops and mastery of a specific model do not count as deliberate practice in Miller's account. [source: Miller, "Three common misunderstandings"; Miller, "Naive, purposeful and deliberate practice"; ICCE Core Competencies Competency 4] Detailed exercises are in Miller, Hubble & Chow (2020) Better Results and the Field Guide to Better Results, not drawn on here [uncertain].
• Example language: not applicable.
• Watch for: practising what you already do well; Miller stresses activities that make you question automatic habits.

4.23 Organisational implementation (FRIFM)

• Purpose / when: services adopting FIT.
• Steps: Use the Feedback Readiness Index and Fidelity Measure to rate the service across six realms (rated N/A to 5), for example: clinicians administer and score ORS/SRS every unit of service and plot scores; supervision uses aggregated outcome data; admission, transfer and discharge policies use expected-treatment-response data; there is a policy for non-progressing clients that preserves continuity; clients are told the process and timeframe for dealing with ineffective treatment. Use it to start staff discussion, plan, and re-evaluate implementation over time. Do not reproduce its items. [source: FRIFM]
• Watch for: billing, IT or funding barriers that make feedback hard to act on [source: ICCE Core Competencies Competency 2].

5. Handling problems

Items tagged [source] come from the FIT/PCOMS materials; items tagged [synthesis] are this guide's own suggestions and are not attributed to Miller, Duncan or the ICCE.

• No change on the ORS (stuck client). Follow the checkpoint sequence: discuss at around session 3, add or change services at 5–6, last-chance discussion at 8–10 (ICCE CAMHS) or 6–9 (PCOMS); review the SRS, goals and fit of approach; take it to supervision; widen to family or school in youth work; refer if needed (4.10–4.11). [source: CAMHS guide; Duncan & Reese, 2015] Before the checkpoint, make one concrete change you can name (focus, method, frequency, who attends) so the next scores test something [synthesis].
• ORS getting worse. Raise it the same session; check for an alliance problem and for new life events; consult. [source: CAMHS guide] Treat a sharp drop as a prompt for a standard risk assessment; the ORS is not a suicide or risk screen and does not replace one [synthesis].
• Alliance rupture (low SRS, falling SRS, an item below 9). Thank the client, ask what to do differently, clarify the low line, change something next session and refer back to it; if a rupture cannot be repaired, consider referral to a colleague. [source: CAMHS guide; Duncan & Reese, 2015]
• SRS always at or near maximum. This may mean the client does not feel safe to give honest feedback. [source: Shaw & Murray] Respond by asking about any single item below 9 or any one-point drop [source: CAMHS guide]; ask for one thing that could be even slightly better; ask about the session in behavioural terms ("what was least useful?") [synthesis]. Miller's materials note top performers tend to receive lower early SRS scores, i.e. more honest feedback [source: Shaw & Murray, summarising ICCE work].
• Client reluctant to complete the forms. Re-explain the purpose in plain language (it is for them, to check therapy is working); offer the oral version (rate each area 1–10) [source: Miller et al., 2006; CAMHS guide]. If they still decline, respect it, record it, and ask the four questions conversationally [synthesis].
• Non-adherence: missing SRS or skipped measures. Clients who did not complete the SRS showed lower retention and less change in Miller et al. (2006), so treat a missing SRS as a warning sign, not neutral. [source: Miller et al., 2006] Build the SRS into the last 5 minutes so it is never squeezed out [source: Sparks & Duncan, 2018]. For clinician non-adherence, use FRIFM ratings and supervision review [source: FRIFM].
• The measures become a ritual. Without openness and follow-through, scores become meaningless. [source: Shaw & Murray] Check: did any score change what you did this month? If not, revisit 4.7–4.11 [synthesis].
• Therapist defensiveness or anxiety about low scores. Practise non-defensive responses in role-play before using the measures; adopt a grateful stance [source: Shaw & Murray; CAMHS guide]. Use supervision to normalise that not all clients benefit [source: Duncan & Reese, 2015].
• Client in acute distress or overwhelm. Keep administration brief (about a minute); acknowledge the score and move straight to what the client needs; do not let forms delay crisis response [synthesis].
• Intake ORS above cutoff. See 4.5: these clients often show little change or worsen; clarify focus and watch for decline [source: Miller et al., 2006; procedure is synthesis].
• Mandated clients scoring themselves as fine. Add a referrer-perspective ORS and work with the gap (4.17). [source: CAMHS guide]
• Family members disagree. Use differences for non-blaming exploration, reframe as shared goals, meet parents separately if needed (4.14). [source: CAMHS guide; Sparks & Duncan, 2018]
• Literacy, language, visual or motor difficulties. Use the oral/telephone version [source: Miller et al., 2006]; use child-friendly versions for younger clients [source: Sparks & Duncan, 2018]. Validated translations exist in several languages (e.g. a Spanish psychometric study) [uncertain]. Check cultural fit of the four domains with the client [synthesis].
• Dropout risk. Low early SRS and ORS below the expected trajectory flag risk of dropout; respond in-session rather than waiting [source: Miller et al., 2006; ICCE Core Competencies].
• Scores used against clinicians (performance management) or clients (eligibility). Use data to prioritise supervision and learning, report transparently, and separate intake-above-cutoff clients in aggregate figures [source: ICCE Core Competencies; Miller et al., 2006]. Agree local policy that individual scores are not used punitively [synthesis].
• Software unavailable. Paper forms, a ruler and a hand-drawn graph with the cutoff line are sufficient; ETR comparison is then approximate [source: CAMHS guide; ETR point is synthesis].
• Ending disagreements (client wants to stop while scores are low, or to continue after a plateau). Discuss the graph; the numbers do not dictate action, so the client's choice stands, with an open door and, where relevant, alternatives offered [source: Sparks & Duncan, 2018; open-door detail is synthesis].

Sources

Sources:

• ICCE Manuals on FIT: Feedback Readiness Index and Fidelity Measure (FRIFM) and Instructions
• ICCE Manuals on FIT: Core Competencies for ICCE Clinicians
• Low, Miller & Squire: The ORS & SRS: Feedback Informed Treatment in CAMHS (CYP-IAPT, 2012)
• Miller, Duncan, Brown, Sorrell & Chalk (2006): Using formal client feedback to improve retention and outcome
• Duncan & Reese (2015): The Partners for Change Outcome Management System (PCOMS): Revisiting the client's frame of reference
• Sparks & Duncan (2018): PCOMS: A both/and system for collaborative practice
• Shaw & Murray: Incorporating feedback-informed treatment into counseling practice (Counseling Today)
• Miller: Three common misunderstandings about deliberate practice for therapists
• Miller: Naive, purposeful and deliberate practice: only one improves outcomes
• McGee & Miller (2023): Feedback-informed treatment as a clinical skill (MedCentral)
• Feedback informed treatment (Wikipedia)
• Table of contents: Prescott, Maeschalck & Miller (eds.), Feedback-Informed Treatment in Clinical Practice

Further reading (not drawn on):

• Miller, S. D., & Duncan, B. L. (2000/2004). The Outcome and Session Rating Scales: Administration and Scoring Manual. ICCE/ISTC.
• Bertolino, B., & Miller, S. D. (Eds.) (2012). ICCE Manuals on Feedback-Informed Treatment (Manuals 1–6). ICCE.
• Prescott, D. S., Maeschalck, C. L., & Miller, S. D. (Eds.) (2017). Feedback-Informed Treatment in Clinical Practice: Reaching for Excellence. APA.
• Miller, S. D., Hubble, M. A., & Chow, D. (2020). Better Results: Using Deliberate Practice to Improve Therapeutic Effectiveness. APA.
• Miller, S. D., & Hubble, M. A. (2011). The road to mastery. Psychotherapy Networker.