Achieving Better Outcomes and Improving Client Satisfaction

By Nathan Cobb, Ph.D. in MFT, R.Psych, RMFT

This is a method we use to help improve client satisfaction and achieve better outcomes. Essentially, we invite our clients to complete at least one, if not more, symptom tracking and satisfaction surveys during the course of services. These surveys provide your therapist with feedback about what is helping or not helping. They also serve as a means of tracking progress over time.

We know some people find it tedious to fill out satisfaction or feedback surveys. You may wonder what the benefit is to you. Before I describe the process, let me start with a story that will set the stage for why I believe this program of feedback is so important.

The Story

Starting in the summer of 1999, I conducted an in-depth study of couples in chronic conflict (my dissertation). I was interested in developing a theory of how couples experience positive, therapeutic change based on the viewpoint of couples in marital therapy.

I held 49 interviews over a one-year period with 5 couples who were receiving marriage counselling at the Comprehensive Clinic at Brigham Young University. These interviews focused on positive change moments and turning points that occurred in each session and between sessions. I asked each couple how they explained these changes moments or what they believed allowed these moments to happen. These were detailed interviews with lots of follow-up questions.

Each couple had a different therapist. The therapists were not present for any of the research interviews. (Each therapist was interviewed at the same time as the therapist's couple by a friend of mine and fellow student who was conducting a parallel study. We collaborated on the two studies together). The interviews took place directly after each session.

Each interview was recorded, transcribed and added to an ever-growing pool of transcripts—almost 900 pages of text in the end. I spent many hours pouring over the transcripts, looking for concepts, themes, repeated patterns and the relationships between concepts. I used what I learned from each interview to guide the upcoming interviews.

In this back-and-forth way, I was able to put together some concrete ideas about how change happens for couples participating in marital therapy. One of the exciting things about the results was that this theory was not tied to one specific way of doing therapy, as each therapist had an entirely different approach.


The reason I'm telling you this is because of an interesting side-finding that came from this study, not directly connected to the main purpose of the project. This finding was about the role of the research method on the course of change.

It was clear that the majority of positive changes were taking place because of the effective work that the couples were doing in marriage counselling. However, all of the couples indicated that their involvement in the research interviews played a role in their overall change process.

I specifically chose not to tell the therapists what I was learning because I didn't want them to be influenced by the findings. I also made it clear to the couples that my intention was not to do "therapy" with them. However, the research method itself—detailed interviews with couples about how and why changes were happening from their perspective—still ended up being therapeutic for the couples. In other words, the research method was also part of the therapy.

Couples spoke of four specific characteristics of the research process that were influential in encouraging change. Specifically, the research process (the in-depth interviews):

  1. Provided spouses with more opportunity to step back and reflect about their experience,

  2. Helped spouses to continue making sense of and solidifying changes that had already begun in the therapy session,

  3. Helped the couples to “detach” from their issues and discuss what was happening in their relationship with less emotional volatility or intensity, and

  4. Created an expectancy for particular questions that focused their attention on change. The couples knew they were going to be questioned about change, so they started paying more attention to change. They started thinking more about why changes were happening, and what they were each doing differently when changes happened. They began to look for evidence of progress that may have otherwise gone unnoticed.

Client-Directed, Outcome-Oriented Feedback

Since then, I have been interested in finding ways to duplicate this process in therapy. For example, I regularly inquire about change moments with my clients. I explore what is making a difference, and how clients account for those differences.

Unfortunately some things are hard to duplicate. The couples in my study, for example, told me that there was something very helpful about the opportunity to reflect on change in a systematic way apart from the therapy session.

You can probably imagine some of the significant problems with using this research method in private practice. Having someone else come in for a twenty-minute follow-up interview after every session with every client, for example, is not practical for most practitioners.

I wondered if using ongoing questionnaires in some way might be useful. I also wondered what would happen if the therapist was given the feedback. Would that affect how therapy was conducted? Would positive changes happen more often or more quickly? Would client satisfaction and active participation in therapy improve?

These thoughts led me to client-directed, outcome-oriented research about the positive influence of repeatedly measuring progress over the course of therapy. That is, when clients provide regular feedback about their experience of counselling and how much progress they feel they are making, they tend to stay in counselling longer and to achieve better outcomes.

This probably does not sound like a surprising finding to most readers. The amazing thing is how little this has actually happened, historically, in most private practices.

Symptom Tracking and Client Satisfaction Surveys

So that brings us back to the feedback surveys we currently use at Cobb & Associates Inc.The information clients provide in these surveys helps everyone involved.

Clients benefit from some of the characteristics of the "research-as-therapy" process that I described earlier, namely the opportunity to stand back and reflect on their experience. Both the client(s) and the therapist benefit by using the information to guide the sessions and make needed adjustments.

I can't emphasize enough how helpful this can be. I know from experience that if a client completes even just one feedback survey midway through counselling and the therapist uses that information it can mean the difference between that client staying on track and resolving the issues versus ending services pre-maturely.

Even in close relationships it can be hard to gauge what the other person is thinking or feeling. Research has shown, for example, that there can be a large gap between how well the client feels a session went and how well the therapist feels a session went. This finding holds true across therapist experience level. Using a consistent feedback system provides a way to close the gap.

We find that it works best if clients complete a survey periodically every 3-4 sessions. Your responses can be as brief or as detailed as you wish. Generally, the forms should take no more than two to five minutes to complete. They can be completed in the office, at home, or online.

If you would like to participate, you can access the client satisfaction survey forms here.

I hope you find these surveys helpful. If you have any questions or concerns please do not hesitate to contact us.

Top | Home