The Evolution of Measurement Based Care and Collaboration
Measurement based care (MBC), also know as routine outcome monitoring, feedback informed treatment and a host of other terms, is the systematic and collaborative collection of client feedback to engage consumers in therapy and improve outcomes. The field has come a long way since the original conceptualizations of “patient focused research” by pioneers Michael Lambert and Kenneth Howard. In 2001, the year of the first feedback randomized clinical trial (RCT), in a special section of the Journal of Consulting and Clinical Psychology, Lambert described patient focused research:
…endeavors to improve psychotherapeutic outcome by monitoring patient progress and using this information to guide ongoing treatment…patient-focused research attempts to answer the question, Is this particular treatment working for this patient? (pp. 147-148).
Thus, if an at-risk client can be reliably identified before dropping out or deteriorating (a process more reliable than clinician judgment), then therapists will have an opportunity to evaluate the reasons for the lack of progress and modify treatment accordingly.
You’ve Come a Long Way, Baby
Fast forward to a 2023 special section of the journal, Psychotherapy. Boswell et al. (2023) propose MBC as a Professional Practice Guideline, based in not only empirical support but also MBC’s “fundamental provision of feedback and empowering patient engagement…” (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… (pp. 6-7).
Illustrating the evolution of thought regarding feedback, compare the recent trend to the 2015 Psychotherapy special issue on “Progress Monitoring and Feedback.” Although instructions to the authors requested discussion of clinical application, only one approach, the Partners for Change Outcome Management System (PCOMS) provided detail about accompanying collaborative processes, illustrated by the devoted lines of text: Outcome Questionnaire 45.2 (OQ) -30 lines of text; PCOMS -170 lines; Clinical Outcomes in Routine Evaluation -0; A Collaborative Outcome Resource Network -24 lines; the Treatment Outcome Package -39 lines; and the Behavioral Health Measure-20 -22 lines. The included approaches conceptualized feedback as mainly a normative or actuarial endeavor while PCOMS included communicative and collaborative components.
Always a Part of PCOMS
Transparent, collaborative, clinical processes have been a part of PCOMS since the beginning:
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).
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).
From the Duncan and Reese (2015) article in the special Psychotherapy issue:
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… 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 understandable. All but one approach arose from psychometric research and a desire to prevent treatment failure. In contrast, PCOMS emerged from everyday clinical practice and an aspiration to privilege the client in the psychotherapy process. Another way of saying it, clinicians have a very different view of therapy than researchers.
The Partners for Change Outcome Management System
Concerns regarding the feasibility of the 45-item OQ for every session use and a desire to operationalize client privilege and the common factors provided the impetus for the Outcome Rating Scale (ORS) and later, the Session Rating Scale V.3 (SRS). Based on two years of private practice experience as well as supervision of graduate students in a multicultural community clinic, Duncan created the clinical process of using the ORS and SRS and detailed it in the first PCOMS manual (now in its fourth edition), and refined in later publications including the first PCOMS RCT.
With PCOMS, science caught up with the clinical process rather than vice versa. Over time, psychometric studies were published, Duncan, Reese, and colleagues completed eight RCTs documenting improved outcomes and reduced dropouts, and three benchmarking studies demonstrating effectiveness in public behavioral health. PCOMS, while starting as a purely clinical, collaborative process evolved to be both a normative and collaborative system. The feedback field, in general, started as a purely normative/actuarial process and has evolved to be both normative and collaborative.
Researchers Can Be a Little Slow
We are glad the field finally came around to our way of doing things! One last word on research. Researchers, in large part, don’t do the work. I have an abiding respect for research and for the folks who do it. I know firsthand that it is indeed a herculean task to conduct research and publish it, especially in top-tier journals. Research should inform practice and be consumed by clinicians—and translated by clinicians. This has been a core goal of mine since I attempted the translation of common factors research in my first book, Changing the Rules in 1992 and first article in Psychotherapy in 1994. And many publications since. So, I’m not saying that there isn’t much to learn from researchers. But research needs to pass the through a final clinical filter—when you get two or people in the room in an endeavor to make a meaningful difference in someone’s life, does the research resonate with the work itself and the people doing it.
PCOMS resonated from the very start.