April 25, 2023 07:58 AM
An article just published in the journal, Psychotherapy by Boswell et al advocated for measurement based care (MBC) to be recognized as a Professional Practice Guideline (PPG) for psychotherapy services. And no wonder, given the mountain of evidence that has amassed (mainly by two teams, Lambert and colleagues at Brigham Young University and Duncan/Reese and colleagues at Better Outcomes Now). So in addition to all the accrediting bodies (the Joint Commission, the Council on Accreditation (COA), and the Commission on Accreditation of Rehabilitation Facilities (CARF) now requiring client-generated outcome monitoring, soon MBC will be an expected practice across settings. Afterall, MBC does improve outcomes and reduce dropouts, according to the latest meta-analysis of 58 randomized clinical trials (de Jong et al., 2021). Unfortunately, therapists remain enamored of the all the fads and fashions in the therapeutic boutique of techniques, although none have demonstrated that they are better than anything else. By the way, of the 58 included trials in the de Jong et al. meta-analysis, the Outcome Questionnaire system accounted for 38% of the available evidence and the Partners for Change Outcome Management System (PCOMS) accounted for 36% while the rest of the included approaches were only used in one or two studies.
Measurement Based Care Defined
Boswell et al. (2023) defined MBC:
MBC is a clinical process consisting of three essential elements which include as follows: (a) routinely collecting patient-generated data throughout the course of treatment; (b) sharing timely feedback with the patient about these data (e.g., patient-reported outcome measure scores) and observed or predicted trends over time to engage patients in their treatment; and (c) acting on these data in the context of the provider’s clinical judgment and the patient’s experiences (i.e., shared decision-making regarding treatment. (p. 3)
Consistent with calls to deliver person-centered, transparent, and collaborative care that empowers patients to be active participants in shaping their treatment, MBC allows for treatment to be tailored to the individual patient according to their specific needs. It also provides a structure that facilitates exchange of information and supports shared decision-making about treatment goals and course of care, best practice implications included providing a clear rationale for MBC, discussing results frequently, actively engaging patients in discussions of MBC data, and using graphs to visualize progress (p. 6-7).
Does this sound familiar?
The Evolution of Feedback
The Boswell et al. (2023) article illustrates how far the field has come regarding transparent, collaborative, and clinical processes as integral parts to MBC. Consider the difference with the 2015 Psychotherapy special issue on “Progress Monitoring and Feedback,” regarding the evolution of thinking as well as the differential attention of the included approaches to the clinical processes involved. Although instructions to the authors requested discussion of clinical application, except for PCOMS (Duncan & Reese, 2015), little detail is provided about any accompanying collaborative clinical process. A crude indication of the differences among the approaches can be gleaned from counting the lines of text devoted to clinical process: Outcome Questionnaire System (Lambert, 2015) -30 lines; PCOMS (Duncan & Reese, 2015)-170 lines; Clinical Outcomes in Routine Evaluation (CORE; Barkham et al., 2015)-0; A Collaborative Outcome Resource Network (ACORN; Brown et al., 2015)-24 lines; the Treatment Outcome Package (TOP; Boswell et al., 2015)-39 lines; and the Behavioral Health Measure-20 (BHM-20; Kopta et al., 2015)-22 lines.
The field seems to have embraced (finally) the transparent, collaborative PCOMS clinical process. Early excerpts speak to the original intent of the PCOMS measures.
PCOMS is transparent in all aspects and intended to promote collaboration with clients in all decisions that affect their care. PCOMS is integrated into the ongoing psychotherapy process, creating space for discussion of not only progress but also the alliance (Duncan & Sparks, 2002, p. 83), the original PCOMS manual).
All scoring and interpretation of the measures are done together with clients. This not only represents a radical departure from traditional assessment but also gives clients a new way to look at and comment on their experience of both progress and the fit of therapy. Assessment, rather than an expert-driven evaluation of the client, becomes a pivotal part of the relationship and change itself (Duncan et al., 2004, p. 98, The Heroic Client).
From the Duncan and Reese (2015) article in the Psychotherapy special issue:
PCOMS provides a methodology to partner with clients to identify those who aren’t responding and address the lack of progress in a proactive way that keeps clients engaged while new directions are collaboratively sought…. PCOMS is distinguished by its routine involvement of clients; client scores on the progress and alliance instruments are openly shared and discussed at each administration. Client views of progress serve as a basis for beginning conversations, and their assessments of the alliance mark an endpoint to the same. With this transparency, the measures provide a mutually understood reference point for reasons for seeking service, progress, and engagement. (p.347)
The recent attention to the clinical processes is promising and its delay is understandable. All but one of the approaches arose from rigorous measure construction and psychometric research to prevent treatment failure. In contrast, PCOMS emerged from everyday clinical practice and a desire to privilege the client in the therapy process.
What’s In a Name
A variety of terms have described the use of measures to inform treatment decisions. These terms include patient-focused research, systematic client feedback, progress monitoring, patient feedback, progress feedback, routine outcome monitoring, feedback-informed treatment, patient-reported outcome measures, and from the medical/psychiatric literature, measurement-based care. While recent articles have adopted “measurement based care” (Boswell et al., 2023), a term that obscures where the research comes from, we oppose using medical terms and further medicalizing psychotherapy (Duncan et al., 2004; Duncan & Reese, 2012, 2015; Duncan et al., 2017). Importantly, MBC seems a sterile misnomer for a largely clinical process occurring in a collaborative relationship between therapist and client. Similarly, the term, “routine outcome monitoring” doesn’t fit. It suggests neither clinical process nor client feedback and is therefore another inaccurate description of the relational components involved in collaborating with clients to measure outcomes and change directions in therapy. Consequently, we will stick with the term we have employed, “systematic client feedback” (Duncan & Reese, 2015), which places clients in the middle of the feedback process, where they belong.
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 CareProfessional Practice Guideline. Psychotherapy, 60 (1), 1-16. http://dx.doi.org/10.1037/pst0000439
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