When it comes to a systems approach, such as a solution-focused approach (Chapter 22), people often ask about measurable effects. That’s an understandable question, so let’s delve into this.

Measuring effects
With a stable process, you can work well with a protocol. It lends itself perfectly to effect measurements. If you know what goes in and what comes out, you know something about the quality of the protocol. You then measure the effect of the intervention. A production process in a factory can be an example of this.

In stable conditions, measuring effects (with pre- and post-measurement) provides a good picture of the quality of an intervention

The quality of feedback
In a dynamic process, input, intervention and output can always change due to external factors (downward control). If this happens, feedback is needed to keep track of these changes. This way you can process the effects of the changing factors. If you want to comprehend the quality of the intervention a pre- and post-measurement will not suffice, because the results are not only caused by the intervention, but also by many other factors, like by the quality of the feedback. The greater the dynamics and variation in unpredictable factors, the more important it is to receive good feedback. For example, consider car navigation or a psychotherapy treatment.

When there are many unpredictable factors, the success of the overall process is not only determined by the quality of the intervention, but also by the quality of the feedback.

There are many forms of feedback. The workings of thermostats, pacemakers and navigation systems rely on feedback, but it also plays an essential role in cybernetics, endocrinology, sociology, robotics and artificial intelligence.
When a process has a high degree of uncertainty, feedback seems obvious. However, it is not yet common practice. Often protocols, guidelines and standards are still implemented without generating good feedback.

Feedback is the information you get back from the environment, it says something about downward control

‘Best practice’
Psychotherapy, a field characterized by irregularity, makes extensive use of treatment protocols based on scientific research. But feedback is rarely used. Evidence-based practice (treatment based on scientific evidence) or best practice (generally accepted as better than alternatives) are considered to be the approach for the best outcome.

Suppose you are the cycling coach of a young and talented cyclist and you have to prepare him for the upcoming world championship. You are a staunch believer in a scientific approach. You decide to use the best practice approach and collect all data from the last world champion. You choose the same training schedule, the same nutrition, the same bike and the same competition tactics. That should generate the best result. But what if your cyclist has different physical features? What happens when the race is held on a different course? And will your approach be effective if his teammates and the competition are different?

Integrating feedback
Feedback should be integrated in methods that are used in fields that involve capricious factors, such as psychotherapy. Miller and Duncan [1] have done much to incorporate feedback in psychotherapy, developing instruments and scaling questions that patients can answer to indicate on a scale from 0 to 10 how they are doing and to what extent their therapy is effective. By asking how things are going at every therapy session, you can measure progress, stalled progress, or decline. The great thing about scaling questions is that they make complex things simple. For example, a scaling question could be about ‘a new and better life’. In doing so it gathers feedback about the whole, not the parts. They ask about the music, not the components of the radio. They inquire about the cake, not the eggs, flour or butter. We can of course measure different things with scaling questions. They can also be used, for example, to ask feedback about the practitioner’s role. In their article Supershrinks. What’s the secret of their success [2] Miller, Hubble and Duncan describe that much of the success of the most effective therapists is based on their solicitation for feedback. And besides measuring the effects of a therapy, generating feedback also turns clients into co-experts and establishes a more equal relationship between the therapist and his/her client. They are recognized as experts of their own lives.

Dutch health insurance companies have a responsibility to efficiently use the resources that are being deployed to treat their policyholders. In the Netherlands it is currently customary to request outcome measurements, called routine outcome monitoring (ROM), for treatments in mental healthcare. Unfortunately, these are mainly used for benchmarking: comparing a treatment protocol with other protocols, or comparing a mental healthcare institution with other mental healthcare institutions. The aim is to arrive at a best practice. The systematic use of feedback to adjust the ongoing treatment processes is still only done sporadically. It is not (yet) requested by health insurance companies. You may wonder, however, which practice is more useful in psychotherapy, a field that is known for its unpredictability: the best protocol (Figure 1), or the best feedback system (Figure 2).

Avoid cycling the wrong race with the wrong bicycle.

Using the best practice protocol in a unique and dynamic process contradicts itself. Continuous feedback and flexibility, constantly reacting and adapting, gives better results according to Miller, Hubble and Duncan.

The best approach
Solution-focused practitioners choose the attitude of ‘not knowing’. They ask their clients/patients solution-focused questions about their goal, their competencies, their resources, who or what may be useful to move forward, what next signs of progress will be, or next steps to achieve their goal. It is their job to invite their clients/patients to be curious about their own answers and to provide as much positive reinforcement as possible for everything that works in the client’s life (Chapter 22). There are good reasons for adopting such a ‘not knowing’ attitude, considering what we wrote about observer and reality (Chapter 15).

Two paradigms, two languages
As long as we predominantly communicate in analytical terms, we will be inclined to use the analytic approach. Klasien Horstman, professor of healthcare philosophy puts it this way (about preventive healthcare measures):

“Let’s start by acknowledging that we don’t know exactly how to do it all. And stop with the concept of an ‘intervention’, that word means ‘hostile takeover’ and it often is. They (the preventive healthcare measures) all have to be effective quickly, magic bullets, while everyone knows that context, also a complicated word, matters. Many professional practices break down because of illusions of manufacturability, …. “ [3]

Terms such as research, intervention, effect measurement, protocol, indicator, …. they inherently direct us towards analytical thinking. This makes it more difficult to think differently. How do we design the best individual progress? What is working for this person, at this moment, in this context? When there is a high degree of complexity and dynamics, adjustment can be more useful than calculation. And we could also do both.