Results in the Real World: Serving the Impoverished

RealA 2018 meta-analysis by feedback pioneer, Michael Lambert unequivocally demonstrates that PCOMS significantly improves outcomes. Lambert et al. (2018) concluded:

 In sum, aggregated findings from the nine studies indicate that the PCOMS rests on a growing empirical base that boosts confidence in its use as an ROM system. Practitioners can expect that PCOMS feedback will enhance client outcomes with an average effect size of .40...it is recommended that psychotherapists use either the OQ-System or the PCOMS with adults across treatment modalities and clinical settings . . . (pp. 532,534).

That is a powerful effect! Keep in mind that the effect size of psychotherapy is generally reported to be .80. This means that PCOMS has the potential to raise your effect size up to 1.20! This translates to many more clients benefitting from your services. Of course, this is why the Joint Commission, COA, and CARF all now require client generated outcome measurement.

But I am often asked, “Barry, what about results in the real world, not just randomized clinical trials (RCT)?” That is a valid question. The real world of providing behavioral health services is quite different than a controlled study—no careful selection of clients, no randomization, and no special attention to the providers. In everyday practice settings, therapists see whoever walks in the door without any additional assistance other than the agency’s usual practice.

But there is a way to address results in the real world and it’s called “Benchmarking.” Benchmarking permits comparison of treatments delivered in non-controlled settings against a reliably determined effect size in clinical trials or meta-analyses of clinical trials. Given that we are committed to public behavioral health (PBH) and the provision of services to the chronically underserved and disenfranchised, we were keen to investigate the effects PCOMS in the public arena. The result: the largest benchmarking investigation ever conducted in public behavioral health, the Southwest Behavioral & Health Services study.

Reese, Duncan, Bohanske, Owen, and Minami (2014) evaluated the effectiveness of a large PBH agency, serving only clients at or below the federal poverty level, that had implemented PCOMS as a quality improvement strategy. We investigated the outcomes of 5,168 ethnically diverse individuals seeking treatment for a broad range of diagnoses. A subset of clients with a primary diagnosis of a depressive disorder was compared to treatment efficacy benchmarks derived from clinical trials of major depression. Given that the PBH agency had also implemented an outcome management system, the total sample was also compared to benchmarks derived from clinical trials of PCOMS.

PCOMS achieved outcomes comparable to RCTs of both depression and feedback. This study demonstrated that contrary to earlier research findings of dismal outcomes in public behavioral health, services to the poor and disenfranchised can be successful when systematic client feedback is implemented, data collected, and clients at risk identified and proactively addressed.

Routine collection of client feedback, providing individualized, responsive services, and involving consumers in decisions about their care holds promise to not only inform us about the effectiveness of PBH care but also a viable strategy to ensure quality to those who are often not considered in discussions of psychotherapy--the poor and disenfranchised.