The practice of using a version of the Session Rating Scale (SRS) to measure alliance has been popularized by the meta-analytical work of researchers such as John Norcross and Bruce Wampold who have shown alliance to be one of the most robust predictors of treatment outcomes (Evidence-based therapy relationships: Research conclusions and clinical practices. Psychotherapy, 2011).
The SRS is a clinical tool created as a balanced trade-off between the reliability and validity of longer research measures, and the feasibility of using a self-report measure to regularly monitor its quality. Offering the SRS is a way to encourage clients to identify alliance problems and serves to elicit signs of client disagreements about the therapeutic process so that the clinician may change to better fit client expectations.
The SRS simply translates what is known about the alliance into four visual analog scales, with instructions to place a mark on a line with negative responses depicted on the left and positive responses indicated on the right. The SRS allows alliance feedback in real time so that problems may be addressed. The SRS is scored by adding the total of the client's marks on the four 10-cm lines. The total score falls into three categories:
SRS score between 0–34 reflects a poor alliance,
SRS Score between 35–38 reflects a fair alliance,
SRS Score between 39–40 reflects a good alliance.
The SRS is best presented in a relaxed way that is integrated seamlessly into your typical way of working. Providing feedback to clinicians on the clients' experience of the alliance and progress has been shown to result in significant improvements in both client retention and outcome. Additionally, research has found that clients of therapists who opted out of completing the SRS were twice as likely to drop out and three times more likely to have a negative outcome. The SRS is given at the end of the meeting, leaving enough time to discuss the client's responses.
"Let's take a minute and have you fill out the form that asks for your opinion about our work together. It's like taking the temperature of our relationship today. Are we too hot or too cold? Do I need to adjust the thermostat? This information helps me stay on track. The ultimate purpose of using these forms is to make every possible effort to make our work together beneficial. Is that okay with you?"
To give you an idea of how the SRS can be used to monitor alliance, the ICCE has created this video demonstrating how oral administration of the Session Rating Scale can be incorporated into a Telehealth session.
Looking for more information about the psychometric properties of the SRS?
Campbell A., & Hemsley S., (2009). Outcome Rating Scale and Session Rating Scale in psychological practice: Clinical utility of ultra-brief measures. Clinical Psychologist, 12, 1–9.
Duncan B. L., Miller S. D., Sparks J., Claud D., Reynolds L., Brown J., Johnson L., (2003). The Session Rating Scale: Preliminary psychometric properties of a “working” alliance measure. Journal of Brief Therapy, 3 (1), 3–12.
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