Routine Outcome Monitoring History and Research

 

 

The routine of monitoring outcomes emerged in the 1990s as a response to a set of challenges and pressures, both internal and external to the field of psychotherapy.

Under scrutiny, mental health care systems were put under tremendous pressure to demonstrate the effectiveness of their services in improving patients. Thus, national health services and public and private institutions providing psychosocial care, which need to be accountable for the effectiveness and efficiency of their results, found themselves faced with the need to present objective data. [1]

 

In 1996, patient-focused research emerged, a research paradigm developed by Howard et al. [2] These researchers suggested that the session-to-session application of clinical progress monitoring measures could inform therapists on how best to help their clients and consequently get better therapy outcomes. [3] Since then, several measures of outcome monitoring - or "feedback systems" - have been developed and studied, such as the OQ-45 [4], the CORE-OM [5] or the PCOMS [6], among others. Of the available systems, the OQ-45 and the PCOMS currently have a strong empirical basis to support their effectiveness, having demonstrated that their use significantly decreases the number of clients who deteriorate in psychotherapy. [7, 8]

  

  

Apart from the already mentioned external pressures, some challenges revealed by research are added to the need for outcome monitoring:

  • 30 to 50% of patients end psychotherapy without therapeutic benefits; [9, 10]
  • 5 to 10% of adult patients worsen after psychological interventions; [10]
  • In the case of children and adolescents, between 14 and 24% end psychotherapy in a more negative state than when it started; [11]
  • There is considerable outcome variability among different psychotherapists, regardless of their intervention model; [12, 13]
  • Contrary to what seems to be a rooted belief, the generality of therapists is ineffective in recognizing clients in clinical deterioration and in assessing the state of the therapeutic relationship; [14, 15]
  • 1 in 5 patients prematurely quit psychotherapy; [16]
  • The enormous investment in investigating and implementing empirically validated treatments has not had the expected return, since research developed over the past few decades has not demonstrated the advantages of establishing manualized interventions for specific psychological disorders. [17, 18, 19]

 

 

Several studies have been demonstrating the effectiveness of feedback systems in identifying patients who are not benefiting from psychotherapy. These systems act as a complementary source of information to the clinical evaluation of the psychotherapist and have accumulated evidence of their effectiveness especially for clients at risk of clinical deterioration. [ex: 20, 21, 22]

 

The meta-analysis by Shimokawa, Lambert and Smart analyzed the results of studies comparing "feedback" and "non-feedback" interventions. [1]

With a total sample of 6151 clients, this study reported that clients at risk of deterioration would be on average 70% better in the "feedback" condition. At the end of the intervention, 9% of clients with "feedback" status had deteriorated, with 38% achieving significant clinical improvements. These values contrast with the "non-feedback" condition, where 20% of clients deteriorated and 22% achieved significant improvements. 

 

A more recent example is the study by Probst and colleagues, where the experimental group (“with feedback system”) and control group had the same percentage of patients to deteriorate (17.1%), and the experimental group had less 65% worsening of this deterioration, compared with the control group. The researchers concluded that the preventive value of feedback systems was evident. [23] Although these systems appear to be especially useful for brief therapies, recent studies suggest that they may also have a positive impact on long-term therapies. [22]

 

 

Despite the accumulated research proving the effectiveness of outcome monitoring, some studies suggest that the effects of feedback systems are not consistent among therapists. Slowly, we started to empirically realize that feedback systems, by themselves, do not guarantee results. [24, 7] Congruent with the central importance of the therapist's effects on clinical outcomes, recent research has begun to demonstrate that the impact of feedback systems is significantly influenced by therapist effects (De Jong, 2012, Simon et al., 2012 ). [25, 26] A recent study, for example, found that differences in the attitude of the therapist and the client towards the use of feedback systems explained 5.4% (therapist attitude) and 5.7% (client attitude) of outcome variability. [27]

 

Feedback systems are presented as a possible way to objectively assess therapist effectiveness. Despite the existing studies on the personal and professional characteristics of psychotherapists, there is still a gap in research regarding the systematic study of extremely effective therapists. [28] In many of the studies focused on the so-called "expert" therapists [ex: 29], the criterion of choice is often based on the prestige of the therapist, rather than on an empirical certainty of consistently better outcomes than those of his colleagues. Although some influential therapists are considered "experts", this assumption is often unsubstantiated - that is, without proof by rigorous outcome monitoring. [30, 31] Without this, it becomes impossible to assess the quality of the professional's performance, thus identifying who the "top therapists" are. Feedback systems are therefore fundamental in order to identify the so-called "supershrinks" -  so that later they can be studied. [32]

 

As such, outcome monitoring in psychotherapy should be complemented with the therapist's Deliberate Practice. Deliberate practice assumes the monitoring of results over time in order to establish which areas of work the therapist should improve with the help of a coach. By monitoring their clinical outcomes, therapists can tailor their training to their personal needs, ensuring that their performance will improve objectively over time. For more information, visit our page on Deliberate Practice: http://clinica.ispa.pt/pagina/pratica-deliberada

 

The routine of monitoring outcomes emerged in the 1990s as a response to a set of challenges and pressures, both internal and external to the field of psychotherapy.Under scrutiny, mental health care systems were put under tremendous pressure to demonstrate the effectiveness of their services in improving patients. Thus, national health services and public and private institutions providing psychosocial care, which need to be accountable for the effectiveness and efficiency of their results, found themselves faced with the need to present objective data. 

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