The Outcome Rating Scale: A Horse of a Different Color
The Outcome Rating Scale (ORS), the measure of the Partners for Change Outcome Management System (PCOMS), is quite different than other outcome instruments. The ORS provides a functional and quality of life assessment that casts a wider net in both screening and treating client problems. It represents a departure from expert-driven formulations that attempt to classify client distress and problems of living from a theoretical or symptom vantage point.
Instead, clients are empowered to highlight their views of distress/well-being, refocusing therapy toward individualized problem construction and solution building and away from options based on diagnosis, symptomology, or normative functioning, the main culprits of ethnocentric and cultural biases. Unlike other validated outcome instruments, the ORS is not a list of symptoms or problems checked by clients on a Likert scale; it is not forced-choice or symptom-oriented.
Rather it is an instrument that is individualized with each client to represent his or her idiosyncratic experience and reasons for service. Both our clinical and research experiences suggest that improvements in functioning and quality of life as measured by the ORS are often more relevant to client treatment goals than symptom improvement. Its brevity encourages a real-time scoring and discussion of client goals, as well as immediate feedback on treatment progress.
Adding the Flesh and Blood of Client Experience
Technically, the Outcome Rating Scale is called a visual analog scale. It consists of four 10-cm lines, corresponding to four domains of human experience (Individual, Interpersonal, Social, Overall). Clients place a mark on each line to represent their functioning, well-being, or distress in each domain or a touch or click on an electronic device.
A centimeter ruler is used to measure the distance to the nearest millimeter from the left end of the scale to the client’s mark on each line, or it is automatically scored by our web system, Better Outcomes Now. Scores range from 0 to 40, with lower scores signaling higher distress and very low scores alerting therapists to the possibility of harm to self or others.
The major domains of life depicted on the ORS offer only a framework of life, a skeleton of human experience to which clients add the flesh and blood of their lived experience via the therapeutic conversation. For example, the interpersonal scale could represent a conflict with a partner or concerns about an ailing father; the social scale could involve recently being laid off a job, racial inequality, or stress in college. In relating their stories, clients color in the even more specific details of their unique life situations.
From its beginnings, PCOMS was designed to be transparent in all aspects and to promote collaboration with clients in all decisions that affect their care. Inquiring about and honoring clients’ perspectives of whether therapy is benefiting is central to the work. Conversations generated by client scores on the ORS are openings for therapists to inquire about clients’ reasons for service, views on precipitating and contextual factors, the impact of the problem in clients’ lives, and thoughts about general directions for problem resolution.
Reaching a Shared Understanding
Clients usually score the scale the lowest that represents the reason for service. The therapist deliberately connects the client’s discussion of the reason for service to how they filled out the ORS, to a specific mark on a specific domain or scale. This helps the client and therapist to collaboratively define a starting point—a shared understanding of the problem, the client’s preferred focus of therapy, and what success will look like.
It also helps both client and therapist to know whether services are of benefit. Following the first session, the client and therapist can compare the most recent score with those from previous sessions and raise the critical question: “Are things better or not?” When ORS scores are not increasing—things are not better—the therapist engages the client in a collaborative conversation to chart a different therapeutic course
Better Outcomes Now provides a more nuanced identification of clients at risk via comparing the client’s progress to the expected treatment response (ETR). The progression of the conversation with clients who are not benefiting goes from talking about whether something different should be done to identifying what can be done differently.
The Outcome Rating Scale and Better Outcomes Now make lack of change impossible to ignore, igniting both therapist and client into action. The process of noting change or no change necessitated by the ORS is a continuous, evolving dialogue between therapist and client that promotes the evolution of new meaning and ongoing possibilities for change.
The ORS also helps with psychotherapy quality assurance and discharge planning. When a client reaches a plateau or maximum benefit from service, the ORS stimulates a conversation about the next steps including increasing the time between sessions, termination, and continued change after therapy.
Acquiring This Evidence-Based Outcome Management System
The ORS provides vital information to the therapeutic process, indicating when action is needed to prevent a negative outcome and informing discussions about stepping down or terminating services. To add this tool to your practice today, visit the PCOMS Measures page of this website or request a free trial of Better Outcomes Now.