Making Therapy Better

Measurement-Based Care (MBC) – The theory, practice, and research

As MBC is becoming an evidence-based practice, widely used, it is important to examine the theory, practice, and research related to MBC. Below are some of the key references for those wanting to take a “deep dive” into the literature.
The major conclusions, as I see them, are as follows:
  • Does it work? Compared to treatment as usual (no MBC), MBC improves outcomes and reduces length of treatment.
  • For which patients? It appears that the primary effect of MBC is for patients who are at risk for poor outcomes (often called “not on track” cases).
  • How does MBC work? Interestingly—and importantly—we really don’t know what therapists do with the feedback they receive. We know that MBC generally does not make therapists more effective over time. That is, therapists using MBC do not become more effective therapists. But clearly, in the right conditions, using MBC improves the quality of care.
  • Will an agency or system of care installing an MBC system achieve better outcomes? The evidence is clear that the implementation of MBC is absolutely critical to success. How the agency uses MBC, the climate of the agency relative to MBC, and the training and effort to use MBC usefully are critical factors.
  • Does it matter which MBC system is used? There are several MBC systems, using different measures, different procedures, and different displays. There is no evidence that one system is better than another—it is more important how the systems are used by the agency and by the therapist.
  • What should be measured? Again, there is little evidence about measures, but there seems to be agreement that different domains should be measured, including (a) symptoms and distress, (b) general functioning (e.g., well-being, quality of life, loneliness), and (c) therapeutic processes (importantly relationship with the therapist and confidence in the treatment).
  • Does MBC provide prescriptive actions that are needed in therapy? MBC provides important information to the therapist. This information needs to be interpreted in the context of the therapy, requiring clinical expertise and judgment.
  • Does MBC promote collaboration? There is general agreement that MBC information should be available to both the therapist and the patient. This information should be discussed during the course of therapy, creating a climate of shared-decision making. Of course, therapist expertise is vital, but there should be a context where the successes and challenges of treatment are discussed openly and honestly.
  • Should MBC be adopted universally? In many systems of care, MBC is mandated. Practice guidelines are forthcoming that will suggest that MBC be used as a standard of care. Given the evidence for MBC, it seems to be in the patient’s best interest to use MBC.
  • What are the challenges? Therapists’ workload is challenging and patients do not want any extra burden as well. MBC systems must be designed to minimize the burden on the therapist and the patient. The utility of MBC needs to be clear to therapists and patients and the usefulness of MBC should be readily apparent to everyone involved in providing therapy.

References

Bickman, L., Lyon, A. R., & Wolpert, M. (2016). Achieving precision mental health through effective assessment, monitoring, and feedback processes. Administration and Policy in Mental Health and Mental Health Services Research, 43(3), 271–276. https://doi.org/10.1007/s10488-016-0718-5
Boswell, JF. (2020). Monitoring processes and outcomes in routine clinical practice: A promising approach to plugging the holes of the practice-based evidence. Psychotherapy Research, 30, 829-842. doi: 10.1080/10503307.2019.1686192
Boswell, J. F., Hepner, K. A., Lysell, K., Rothrock, N., Bott, N., Childs, A. W., Douglas, S., Owings-Fonner, N., Wright, C. V., Stephens, K. A., Bard, D. E., Aajmain, S., & Bottitt, B. L. (2022). The need for a measurement-based care professional practice guideline. Psychotherapy.
Boswell, J.F., Kraus, D.R., Miller, S., & Lambert, M.J. (2015). Implementing routine outcome assessment in clinical practice: Benefits, challenges, and solutions. Psychotherapy Research, 25, 6-19. http://dx.doi.org/10.1080/10503307.2013.817696
Brattland, H., Koksvik, J. M., Burkeland, O., Gråwe, R. W., Klöckner, C., Linaker, O. M., Ryum, T., Wampold, B., Lara-Cabrera, M. L., & Iversen, V. C. (2018). The effects of routine outcome monitoring (ROM) on therapy outcomes in the course of an implementation process: A randomized clinical trial. Journal of Counseling Psychology, 65(5), 641-652. https://doi.org/10.1037/cou0000286
Connors, E. H., Douglas, S., Jensen-Doss, A., Landes, S. J., Lewis, C. C., McLeod, B. D., Stanick, C., & Lyon, A. R. (2021). What gets measured gets done: How mental health agencies can leverage measurement-based care for better patient care, clinician supports, and organizational goals. Administration and Policy in Mental Health, 48(2), 250–265. https://doi.org/10.1007/s10488-020-01063-w
de Jong, K., Conijn, J. M., Gallagher, R. A. V., Reshetnikova, A. S., Heij, M., & Lutz, M. C. (2021). Using progress feedback to improve outcomes and reduce drop-out, treatment duration, and deterioration: A multilevel meta-analysis. Clinical Psychology Review, 85. https://doi.org/10.1016/j.cpr.2021.102002
Goldberg, S. B., Babins-Wagner, R., Rousmaniere, T., Berzins, S., Hoyt, W. T., Whipple, J. L., Miller, S. D., & Wampold, B. E. (2016). Creating a climate for therapist improvement: A case study of an agency focused on outcomes and deliberate practice. Psychotherapy, 53(3), 367-375. https://doi.org/http://dx.doi.org/10.1037/pst0000060
Goldberg, S. B., Rousmaniere, T., Miller, S. D., Whipple, J., Nielsen, S. L., Hoyt, W. T., & Wampold, B. E. (2016). Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. Journal of Counseling Psychology, 63(1), 1-11. https://doi.org/10.1037/cou0000131
Harmon, S. C., Lambert, M. J., Smart, D. M., Hawkins, E., Nielsen, S. L., Slade, K., & Lutz, W. (2007). Enhancing outcome for potential treatment failures: Therapist-client feedback and clinical support tools. Psychotherapy Research, 17(4), 379–392. https://doi.org/10.1080/10503300600702331
Jensen-Doss, A., Haimes, E., Smith, A. M., Lyon, A. R., Lewis, C. C., Stanick, C. F., & Hawley, K. M. (2018). Monitoring treatment progress and providing feedback is viewed favorably but rarely used in practice. Administration and Policy in Mental Health, 45(1), 48–61. https://doi.org/10.1007/s10488-016-0763-0
Lambert, M. J. (2010). Prevention of treatment failure: The use of measuring, monitoring, and feedback in clinical practice. American Psychological Association.
Lambert, M. J., Whipple, J. L., & Kleinstäuber, M. (2018). Collecting and delivering progress feedback: A meta-analysis of routine outcome monitoring. Psychotherapy, 55(4), 520–537. https://doi.org/10.1037/pst0000167
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. https://doi.org/10.1037/a0031097
Miller, S.D., Hubble, M.A., Chow, D., & Seidel, J. (2015). Beyond measures and monitoring: Realizing the potential of feedback-informed treatment. Psychotherapy, 52, 449-457. http://dx.doi.org/10.1037/pst0000031
Muir, H., Coyne, A., Morrison, N., Boswell, J.F., & Constantino, M.J. (2019). Ethical implications of routine outcome monitoring for patients, psychotherapists, and mental health care systems. .Psychotherapy, 56(4), 459-469. https://doi.org/10.1037/pst0000246
Sapyta, J., Riemer, M., & Bickman, L. (2005). Feedback to clinicians: Theory, research, and practice. Journal of Clinical Psychology, 61(2), 145–153. ihttp://dx.doi.org.proxy.library.vanderbilt.edu/10.1002/jclp.20107
Scott, K., & Lewis, C. C. (2015). Using measurement-based care to enhance any treatment. Cognitive and Behavioral Practice, 22(1), 49–59. https://doi.org/10.1016/j.cbpra.2014.01.010