What are Outcome Monitoring and Feedback Systems?


The main goal of outcome monitoring is to improve the final outcomes of psychotherapies by collecting information about the progression of psychological interventions and providing this information to the therapist so that the intervention is adapted to the needs of the patient.
The routine of monitoring outcomes with feedback systems combines clinical practice and empirical research. Outcome monitoring is also called patient-focused research or practice-based evidence. It is a response to the movements of empirically validated treatments, which have insisted on the need for only interventions based on empirical evidence to be considered as scientifically valid. Conversely, outcome monitoring is based on the assumption that evidence stems from the psychotherapeutic process itself, in which the patient's variables, the psychotherapist's person and his/her ability for responsiveness largely supplant the intervention's manipulation. [0]

Routine outcome monitoring is performed through feedback systems that, in addition to an objective reading of psychotherapy outcomes, perform a reading about relevant factors of the therapeutic process that can influence the trajectory of the psychological intervention, such as the quality of the therapeutic alliance. The use of these feedback systems complements the therapist's clinical reading and has been shown to significantly improve final clinical outcomes and decrease the number of dropouts. [12]


Several feedback systems have been developed over the last few years. The two most empirically supported systems are the Outcome Questionnaire System (OQ System) [3] and The Partners for Change Outcome Management System (PCOMS) [4],both of which have been recognized by the Substance Abuse and Mental Health Administration's National Registry of Evidence-based Programs and Practices. The ISPA Clinic and the Academy of Psychotherapists have partnerships with the organizations that hold the rights of these two feedback systems and have been pioneers in the introduction of routine outcome monitoring in psychotherapy in Portugal.



Feedback systems have accumulated evidence of their effectiveness, especially for clients at risk of clinical deterioration. To date, more than a dozen randomized controlled trials (RCTs) and several meta-analyses have evaluated the impact of feedback systems on psychotherapy.



Figure 1. Impact of routine monitoring in psychotherapy (Lambert & Shimokawa, 2011)[2]

These studies suggest that feedback systems can, at best: double the number of clients who achieve significant improvements; lower the rate of dropout in therapy; reduce the risk of clinical deterioration by one third; and reduce the duration of the intervention by two thirds. [5]


In the largest meta-analysis to date on the use of feedback systems, Shimokawa, Lambert and Smart (2010) have analyzed the results of studies comparing "feedback” and "non-feedback" (“treatment-as-usual”) interventions. In a total sample of 6151 clients, this meta-analysis reported that clients at risk of deterioration would be on average 70% better in the "feedback" condition. [6, 2]


The use of feedback systems is also important because therapists often have a skewed assessment of their own clinical performance and the state of the therapeutic alliance. [789] In addition, most psychotherapists have great difficulty in identifying the existence of clinical deterioration in their clients. [10] All of these issues can be significantly reduced with the use of outcome monitoring systems. [12]


Thus, routine outcome monitoring systems respond to a set of challenges identified by research:

  • They provide a reliable estimate of the therapist's clinical effectiveness. [12]
  • They allow the assessment of the state of the therapeutic alliance and the identification of clients in clinical deterioration. [12, 14]
  • They are based on client self-reporting, which is the best predictor of clinical outcomes. [13, 14, 15, 16]
  • They encourage the involvement and active participation of the client in his own therapeutic process, an essential variable for therapeutic success. [17, 16]
  • They allow us to receive continuous feedback on the performance of the clinician, an activity that is intrinsically linked to the development of superior performance, or expertise, in any area of work, including psychotherapeutic practice. [18, 19]

For additional information, see our page on outcome monitoring history and research .



The fundamental principle is the collection of information, based on the patient's self-report, on how the patient feels and how the psychotherapeutic process is taking place. The collection is performed with instruments and self-reporting scales, which assess aspects of the psychological functioning of the person, as well as dimensions related to the psychotherapeutic process. The data collected is given back to psychotherapists, which provides direct feedback on the patient. The data presented has different configurations. The outcome of the ongoing psychotherapy can be compared to normative data, giving a reference whether the process is progressing favorably or not. In this sense, the progress of psychotherapy is evaluated, along with an expected treatment curve.



Learn more about relevant research and how to start establishing routine outcome monitoring:





[0] Lutz, W., De Jong, K., & Rubel, J. (2015). Patient-focused and feedback research in psychotherapy: Where are we and where do we want to go?. Psychotherapy Research, 25(6), 625-632.

[1] 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.

[2] Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48(1), 72.

[3] Lambert, M. J. (2015). Progress feedback and the OQ-system: The past and the future. Psychotherapy, 52(4), 381.

[4] Duncan, B. L., & Reese, R. J. (2015). The Partners for Change Outcome Management System (PCOMS) revisiting the client’s frame of reference. Psychotherapy, 52(4), 391.

[5] Miller, S. D., Hubble, M. A., Chow, D., & Seidel, J. (2015). Beyond measures and monitoring: Realizing the potential of feedback-informed treatment. Psychotherapy, 52(4), 449.

[6] Shimokawa, K., Lambert, M. J., & Smart, D. W. (2010). Enhancing treatment outcome of patients at risk of treatment failure: meta-analytic and mega-analytic review of a psychotherapy quality assurance system. Journal of Consulting and Clinical Psychology, 78(3), 298.

[7] Walfish, S., McAlister, B., O'donnell, P., & Lambert, M. J. (2012). An investigation of self-assessment bias in mental health providers. Psychological Reports, 110(2), 639-644.

[8] Tryon, G. S., Blackwell, S. C., & Hammel, E. F. (2007). A meta-analytic examination of client-therapist perspectives of the working alliance. Psychotherapy Research, 17(6), 629-642.

[9] Hartmann, A., Joos, A., Orlinsky, D. E., & Zeeck, A. (2015). Accuracy of therapist perceptions of patients' alliance: Exploring the divergence. Psychotherapy Research, 25(4), 408-419.

[10] Hatfield, D., McCullough, L., Frantz, S. H., & Krieger, K. (2010). Do we know when our clients get worse? An investigation of therapists' ability to detect negative client change. Clinical Psychology & Psychotherapy, 17(1), 25-32.

[11] Duncan, B.L. (2015). The person of the therapist: One therapist’s journey to relationship. In Schneider, K.J., Pierson, J.F., & Bugental, J.F.T. (Eds.) The Handbook of Humanistic Psychology: Theory, research, and practice (pág. 457-472). Thousand Oaks, CE: Sage.

[12] Lambert, M. J. (2010). “Yes, it is time for clinicians to monitor treatment outcome.” In B. L. Duncan, S. C., Miller, B. E. Wampold, & M. A. Hubble (Eds.), Heart and soul of change: Delivering what works in therapy (2ª ed., pág. 239 –266). Washington, DC: American Psychological Association.

[13] Bohart, A. C., Elliott, R., Greenberg, L. S., & Watson, J. C. (2002). Empathy. In J. Norcross (Ed.), Psychotherapy relationships that work (p. 89– 108). New York: Oxford University Press.

[14] Busseri, M. A., & Tyler, J. D. (2004). Client–therapist agreement on target problems, working alliance, and counseling outcome. Psychotherapy Research, 14(1), 77-88.

[15] Elliott, R., Bohart, A. C., Watson, J. C., & Greenberg, L. S. (2011). Empathy. Psychotherapy, 48(1), 43.

[16] Bohart, A. C. (2000). The client is the most important common factor: Clients' self-healing capacities and psychotherapy. Journal of Psychotherapy Integration, 10(2), 127.

[17] Levitt, H. M., Pomerville, A., & Surace, F. I. (2016). A qualitative meta-analysis examining clients’ experiences of psychotherapy: A new agenda. Psychological bulletin, 142(8), 801.

[18] Miller, S. D., Hubble, M. A., Chow, D. L., & Seidel, J. A. (2013). The outcome of psychotherapy: yesterday, today, and tomorrow. Psychotherapy, 50(1), 88-97.

[19] Goodyear, R. K., Wampold, B. E., Tracey, T. J., & Lichtenberg, J. W. (2017). Psychotherapy expertise should mean superior outcomes and demonstrable improvement over time. The Counseling Psychologist, 45(1), 54-65.

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