Draft:Measurement-Based Care in Mental Health Services

In the context of mental and behavioral health, Measurement-Based Care (MBC), also known as routine outcome monitoring (ROM) or feedback informed treatment (FIT), involves assessing patient progress and therapy processes through the course of treatment. The goal of MBC is to improve the quality of mental health services.

Typically, MBC involves the following steps:

The patient completes various measures (see below) periodically (e.g., before or after each session, or once per week, whether there is a session or not). The data from the measures is presented graphically to the therapist, and in some instances, to the patient. Often the MBC system provides messages to the therapist, using various algorithms, regarding whether the patient is on track for success or is at risk for failure. It is recommended that the therapist discusses the information with the patient and, in collaboration with the patient, adjust therapy as necessary.

The measures used in MBC assess various aspects of patient function and therapy processes, including one or more of the following:

Symptoms (usually symptoms of depression and anxiety, but also disorder specific symptoms in specialty care). Psychological well-being and quality of life Functioning, particularly with interpersonal relationships and in work or school. Loneliness Therapy process, such as the alliance, confidence in the therapist, and confidence in the treatment.

Research evidence, including meta-analytic evidence, strongly supports the conclusion that MBC improves the outcomes of psychotherapy. The result is most particularly evident for cases which are not on track for success (viz., cases at risk for not succeeding). Various organization, including the American Psychological Association are considering professional practice guidelines for MBC. California offers continuing education credits for therapists who use MBC.

There are two systems that are most frequently used and for which there is the strongest evidence are (a) The OQ-Analyst, which is based on the Outcome Questionnaire, and (b) Partners for Change Outcome Management System, based on the Outcome Rating Scale (ORS) and the Session Rating Scale (SRS). Both systems involve commercial enterprises, although pen and paper versions of the ORS and SRS are in the public domain for use without a system. Recently, the comprehensive Electronic Medical Records system offered by CarePaths, Inc. includes MBC system assessing symptoms, well-being, loneliness, and confidence in the therapy and in the treatment.

There are several issues involved in MBC. First, and foremost, most therapists and most agencies do not use MBC. Even agencies that routinely employ MBC, therapist do not use the information sufficiently in their practice. Furthermore, it appears that therapists who use MBC do not improve their outcomes over time, suggesting that therapists do not learn how to become a more effective therapist, despite the fact that MBC is helpful with an individual patient.

References

Boswell, J. F., Kraus, D. R., Miller, S. D., & Lambert, M. J. (2015). Implementing routine outcome monitoring in clinical practice: Benefits, challenges, and solutions. Psychotherapy Research, 25(1), 6-19. https://doi.org/10.1080/10503307.2013.817696

Boswell, J. F., Hepner, K. A., Lysell, K., Rothrock, N. E., Bott, N., Childs, A. W., Douglas, S., Owings-Fonner, N., Wright, C. V., Stephens, K. A., Bard, D. E., Aajmain, S., & Bobbitt, B. L. (2023). The Need for a Measurement-Based Care Professional Practice Guideline. Psychotherapy, 60(1), 1-16. https://doi.org/10.1037/pst0000439

Goldberg, S. B., Rousmaniere, T., Miller, S. D., Whipple, J., Nielsen, S. L., Hoyt, W. T., & Wampold, B. E. (2016). Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. Journal of Counseling Psychology, 63(1), 1-11.

Goldberg, S. B., Babins-Wagner, R., Rousmaniere, T., Berzins, S., Hoyt, W. T., Whipple, J. L., Miller, S. D., & Wampold, B. E. (2016). Creating a climate for therapist improvement: A case study of an agency focused on outcomes and deliberate practice. Psychotherapy, 53(3), 367-375.

Lambert, M. J. (2015). Progress Feedback and the OQ-System: The Past and the Future. Psychotherapy, 52(4), 381-390. https://doi.org/10.1037/pst0000027

Lambert, M. J., Whipple, J. L., & Kleinstäuber, M. (2018). Collecting and delivering progress feedback: A meta-analysis of routine outcome monitoring. Psychotherapy, 55(4), 520-537. https://doi.org/http://dx.doi.org/10.1037/pst0000167

Miller, S. D., Duncan, B. L., & Hubble, M. A. (2005). Outcome-Informed Clinical Work. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration (2nd ed.). (pp. 84-102). Oxford University Press.

Miller, S. D., Duncan, B. L., Sorrell, R., & Brown, G. S. (2005). The Partners for Change Outcome Management System. Journal of Clinical Psychology, 61(2), 199-208. https://doi.org/10.1002/jclp.20111

Wampold, B. E. (2015). Routine Outcome Monitoring: Coming of Age-With the Usual Developmental Challenges. Psychotherapy, 52(4), 458-462. https://doi.org/10.1037/pst0000037