The good news is that psychotherapy is effective with many clients. The bad news is that not everyone benefits. Behavioral health organizations need to accept the fact that some clients do not improve under their care. Identifying these clients early on and providing alternative strategies is not only the right thing to do clinically, but also what ethical practice demands. To put it bluntly, continuing a treatment that does not benefit the client is unethical.
Studies show that treatment failure in everyday public behavioral health settings is more pervasive than expected. One study involving 6,000 individuals receiving an average of four therapy sessions in a community-based setting found that only approximately 35 percent of clients improved. In addition, about 8 percent experienced worse symptoms or functioning.
Other studies report that 85 to 100 percent of individuals who get worse during treatment can be identified using measurement-based approaches – a much better strategy than relying only on clinical judgment. In fact, clinical judgment in one study predicted deterioration accurately only one out of 40 times, while a routine monitoring approach identified 37 out of 40 clients who got worse.
Finally, if your organization is on the fence about the decision to implement, measuring outcomes is now required by all three accrediting bodies, the Joint Commission, the Council on Accreditation (COA), and the Commission on Accreditation of Rehabilitation Facilities (CARF). Don’t wait for your site visit to get started.
With So Many Choices, How Do I Choose?
Routine outcome monitoring or measurement-based care has finally come of age. It is required by all three accrediting bodies and will soon be a Professional Practice Guideline of the American Psychological Association. This is a good thing. But given its rise in popularity and increase in status, every Tom, Dick, and Mary has entered their hat in the ring including big companies with substantial money to invest in slick websites and marketing.
But how do you discern marketing fluff from substance? How do you separate the perfunctory flicking of forms at clients to meet a requirement from an evidence-based practice that has demonstrated improved outcomes?
All accreditation bodies call for “standardized” measures to inform treatment decisions. This is, of course, a good thing because in times past agencies often made up their own measures of outcome that were not “standardized.” This meant that the measures were not reliable or valid and couldn’t be used to truly evaluate effectiveness nor compare one program to another. Standardized measures have been psychometrically validated and have established norms for distinguishing clinical vs. nonclinical populations.
Because a measure is standardized, however, does not mean it is evidence-based.
Evidence-Based or Baloney Based?
New companies purporting to provide evidence-based web solutions to administer and score outcome measures are appearing at the pace of the book-of-the-month club main selection. Hoping to cash in on the new requirements, these new, very well-funded companies, with bulging staffs and slick websites, claim to provide a measurement-based care solution firmly grounded in “evidence.” Unfortunately, this is marketing hype, not reality. To be evidence-based means that any given approach has demonstrated improved outcomes in at least two published randomized clinical trials (RCT) in peer-reviewed journals.
For example, consider one example of corporate slickness, Mirah. While it's 400 (that’s right, 400) measures have likely demonstrated reliability and validity, its claims to improve effectiveness and efficiency are total marketing blather--it has zero RCTs to support such claims. All the evidence used to make the case for measurement-based care solutions come from the Outcome Questionnaire 45 System (OQ) and the Partners for Change Outcome Management System (PCOMS). Measurement-based care does have the oft-cited evidence base, but not the systems touting it!
The ten randomized clinical trials of PCOMS span across cross-cultural sites (U.S., Europe, and China), client populations, therapeutic models, and modalities of service. Learn more about the science behind PCOMS.
Feasibility and Measuring Mental Health Outcomes
Although there are various methods to measure behavioral health outcomes, an easy, quick, and practical way to do so is by using the web application of PCOMS, Better Outcomes Now (BON). Using a tablet, phone, or computer, clients can report improvement or lack-there-of at the beginning of each therapy session and their experience of the encounter at the end of the meeting. BON identifies clients who aren’t responding, allowing providers to address the lack of progress in a proactive way that keeps clients engaged while working together to collaboratively seek new directions.
PCOMS and BON provide the most feasible measurement-based care solution. PCOMS uses two standardized four-item scales to collaboratively monitor both the outcome and the alliance, taking only five minutes to administer, score, and discuss. With over twenty years of implementation experience, I know that clinicians won’t waste valuable time with lengthy measures or lists of measures to select the one most applicable to the client in their office now.
That’s why Mirah’s 400 measures to choose from is a joke.
Chose the only system. that is both evidence-based (truly) and feasible (truly) for the grind of everyday clinical practice.