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Creating a Successful Private Practice
What makes for a successful private practice as a Marriage and Family Therapist? Success in business is more than the cash in a bank account. This is about impacting lives. Our work has a ripple effect. As marriage and family therapists we know that by the shifts and transformation of the person on the couch or in the therapy room, that transformation becomes multiplied through the lives that the client touches. One change can upend an entire system whether that be familial relationships or beyond. That shift also transcends generations. You see it when people get sober, embrace their identities, heal traumas, and stop abuse cycles.
As marriage and family therapists we are most successful when we facilitate those transformative outcomes for our clients. But we don’t do this on our own efforts alone. Improving clinical outcomes is a co-creative process for both the clinician and the client.
Defining Positive Clinical Outcomes
For the purposes of this article, it’s important to establish the definition of a positive clinical outcome in therapeutic practice. Good outcomes are about your client’s experience. There needs to be an observed and felt transformational value of therapy by the client and that the client is able to verbalize or express the positive changes in their life. Yes, you could go with a score on the SRS or ORS but ultimately what matters most is the client's experience and reflection.
Clinical Outcomes Research
Clinical outcomes require the feedback from our clients. Miller & Duncan* found that "providing therapists with real-time feedback improved outcomes nearly 65%. No downside exists to determining your baseline effectiveness. One either is proven effective or becomes more effective in the process."
Scott Miller who has been studying what puts some therapists consistently getting the top 25% of outcomes across all kinds of different settings and with different types of clients found the following: “Super shrinks, our research shows, are exquisitely attuned to the vicissitudes of client engagement. In what amounts to a quantum difference between themselves and average therapists, they’re much more likely to ask for and receive negative feedback about the quality of the work and their contribution to the alliance."
"We have now confirmed this finding in numerous independent samples of practitioners working in diverse settings with a wide range of presenting problems. The best clinicians, those falling in the top 25 percent of treatment outcomes, consistently achieve lower scores on standardized alliance measures at the outset of therapy—perhaps because they’re more persistent or are more believable when assuring clients that they want honest answers—enabling them to address potential problems in the working relationship. Median therapists, by contrast, commonly receive negative feedback later in treatment, at a time when clients have already disengaged and are at heightened risk for dropping out.”
Based on decades of research about what makes some therapists great and get consistently better outcomes Scott Millers teaches the following
“(1) determining your baseline of effectiveness, (2) engaging in deliberate practice, and (3) getting feedback—depends on and is informed by the others, working in tandem to create a “cycle of excellence.”
Not to oversimplify, but just by being intentional and asking your clients how they are doing in therapy and making it truly SAFE for them to respond honestly, your outcomes overall will improve even if initially that feedback is negative.
Clinical Outcomes Conversations
You can find a script to use in our training that covers this in detail on The Outcome Driven Practice, where we list questions to ask your clients. Our clients report that these are often some of the most transformational conversations they have with their clients, deepening the therapeutic relationship and also improving future outcomes.
You would use a session for inquiry and shared dialogue. Asking questions such as
- Share what you remember about how life was immediately before you started therapy.
- What was the last straw when you decided to reach out to find a therapist?
- Do you remember what it felt like to call a therapist?
- Do you remember what in particular you were expecting and hoping for when you found me and came into your first session?
- What do you recall feeling during and immediately after that first session?
- Who do you have for support right now?
- What are your biggest world-related concerns right now?
- Is there something you wish we could change about your therapy?
- Has there been a time when you’ve tried to tell me something and I missed it or you didn’t feel fully heard?
It is important that in your initial consult and in your first session you stress that you will be checking in on outcomes on a regular basis, after each session but in depth quarterly or every 6 months depending on your treatment pacing. Set the tone from the beginning of the relationship that you are open to feedback, positive, negative, and neutral and that you will be asking for it, even persistently because outcomes matter to you and are important for the client.
Negative Feedback
Sometimes the feedback is negative. Negative feedback is a good sign! It is a sign that there is enough trust to share. Often, there also won't be as much negative as you think it will and we find most therapists have a more negative view of their work than their clients do. These conversations can help you see yourself more clearly, including the positives and where you can really improve vs where you think you need to improve.
The ability to have this conversation and receive any kind of feedback is a tool to help the client pattern how to have conversations where feedback may be negative, giving them a safe space to practice navigating the emotions and tension that might arise.
Creating a Feedback Loop
While the responses are documented as part of the clinical note, you want to take the feedback and make adjustments accordingly. You can use the feedback to improve clinical intervention - there may be a different methodology, a referral to another provider for adjunctive services, or a change in frequency or length of session, for example. You can also use the feedback to get clarity on how you best do your work and with whom. You may discover that you prefer working with a niche, providing a different approach or level of service. You will learn not only about the client but about yourself as well so that you can speak more clearly to future clients in your informed consent and marketing. This is how the feedback creates a loop of excellence. Outcomes inform improvements that improve future outcomes.
As you take the feedback and implement changes it will impact your joy, making you more burnout resistant as you now KNOW you are doing good work and have language for that when you question yourself. You will increase your commitment to refer people out that aren’t progressing and that drain your energy and it allows you to focus your energy, time, and investments into what really works for you and your clients.
Co-Creation with Clients
We cannot build our practices without our clients. By integrating clinical outcomes conversations, we co-create a better practice and improved transformation for our clients. To learn more about having these conversations, access the free training here.
*Miller, S.D., Duncan, B.L., Brown, J., Sorrell, R., & Chalk, M.B. (2006). Using Formal Client Feedback to Improve Retention and Outcome: Making Ongoing, Real-time Assessment Feasible.
Miller, Scott & Hubble, M. & Duncan, Barry. (2008). Supershrinks: What's the secret of their success?. Psychotherapy in Australia. 14. 14-22.