Measurement-based care is giving psychologists and their patients a better picture of treatment progress

Routinely collecting feedback from patients during psychotherapy and using the data to guide treatment decisions can improve outcomes, reduce costs, and lower the chance that a patient’s symptoms will worsen—yet the vast majority of psychologists are not taking advantage of this technique.

The practice, known as measurement-based care, gives patients and practitioners an opportunity to review progress over time, and if symptoms aren’t improving, explore why and adjust the approach.

“We need to understand who is progressing and who is not because the literature shows that relying on our own personal assessments of patients is not accurate enough,” said Kari Stephens, PhD, an associate professor of family medicine at the University of Washington and chair of APA’s Advisory Committee for Measurement-Based Care and the MBHR (Mental and Behavioral Health Registry).

Michael Lambert, PhD, a psychology professor at Brigham Young University who has researched outcome measurement for decades, has found in surveys that therapists believed 85% of their patients improved, but research suggests that the actual rates of improvement are between 40% and 60%. Lambert also discovered that, on average, providers believed that about 3% of their patients had deteriorated, yet studies have shown that 5% to 10% of adults and 15% to 25% of adolescents worsen while in therapy (Prevention of Treatment Failure: The Use of Measuring, Monitoring, and Feedback in Clinical Practice, APA, 2010).

Measurement-based care can help mental health providers see into potential blind spots, especially when patients are not progressing. A recent meta-analysis of more than 21,000 patients showed that this practice helped to reduce symptoms across all case types—and the effect was even stronger among patients who were not improving or “not on track” (de Jong, K., et al., Clinical Psychology Review, Vol. 85, 2021opens in new window).

With mounting evidence that outcome measurement benefits psychologists and patients, APA is forming a workgroup this summer that will develop a professional practice guideline to help psychologists in private practice, hospital systems, and other large organizations implement this system of gathering and using feedback from patients (Boswell, J. F., et al., Psychotherapy, online first publication, 2022opens in new window). State licensing boards are also supporting the technique. Effective January 1, 2023, California’s Board of Psychology began allowing practitioners to earn up to 9 hours of continuing education credits when using measurement-based care with nine patients.

“Measurement-based care is designed not to replace clinical judgment but rather to augment it,” said Kimberly Hepner, PhD, a clinical psychologist and senior behavioral scientist at the RAND Corporation. “It will help us listen to our patients, and collaborating with engaged, empowered patients who understand their symptoms will make us better as a field.”

Evidence shows that progress monitoring is beneficial, but advocates for measurement-based care acknowledge that instigating changes to established routines can be difficult. To understand how to make the transition smoother, Hepner studied clinicians who used measurement-based care with their patients at the Veterans Health Administration.

Depending on the needs of each patient, the clinicians asked patients to complete assessment tools for posttraumatic stress disorder (PTSD), generalized anxiety disorder, depression, or substance use. The clinicians could decide how to collect the data (electronically or paper and pencil) and whether patients completed the assessments before or after each session.

The findings suggested that explaining the rationale for the new practice only at the outset of treatment was not enough (Psychotherapy Research, Vol. 31, No. 2, 2021opens in new window). “When people are first coming to treatment, there is a lot going on, so they may not remember why they are doing the assessment each time they return,” Hepner said. “We found that repeating the rationale to patients during multiple visits was helpful.” When describing the reason for collecting feedback, clinicians can share that having a standard method of measuring symptoms allows them to look at changes over time and learn from the information, said Hepner. Then explain that this information could lead to modifications in treatment if needed.

In the study, showing graphs to visualize the data over time also increased the chances of buy-in from patients, she said. In addition, clinicians who connected symptom changes to what had been discussed in therapy and new skills the patient was learning helped people engage in treatment.

Amber W. Childs, PhD, an assistant professor of psychiatry at the Yale School of Medicine, recently implemented measurement-based care across ambulatory psychiatry and behavioral health services within the Yale New Haven Health System. She used the Collect, Share, Act framework to help clinicians adopt the new practice (Barber, J., & Resnick, S. G., Psychological Services, online first publication, 2022opens in new window). The “collect” step is partnering with the patient by introducing the rationale for measurement-based care, selecting which measures to use, and administering and scoring the measures. “Share” is discussing the results with the patient and working collaboratively to reflect on whether the scores match the patient’s experience. “Act” is reviewing the data trajectory, working with the patient to brainstorm next steps, and deciding on a plan of action.

Childs also shares with providers that this new model has the potential to help ensure equitable care for marginalized patients. “Data show that racial and ethnic minority patients drop out of therapy at higher rates than White counterparts because there can be disconnects in the therapeutic alliance, and the measurement-based care process provides a structured opportunity for the provider and the patient to get on the same page,” Childs said.

In one analysis of 27 studies on child and adolescent therapy dropout, researchers found that non-White patients were at higher risk of terminating treatment, and Black patients were at particularly high risk (de Haan, A. M., Transcultural Psychiatry, Vol. 55, No. 1, 2018opens in new window). “It is difficult to attribute treatment dropout to any single factor, but researchers have hypothesized that reasons may include parent or patient disagreements with the provider about the diagnosis, concerns about confidentiality, and likelihood of accessing alternatives outside the medical system,” said Childs. The trends are similar among adult non-White patients, with studies showing that Black and Latinx adult patients are less likely than White adult patients to have favorable perceptions of the mental health care services they received, even after adjusting for demographic and health status variables (Robst, J. M., & Cai, A., Health Economics eJournal, 2015opens in new window). To decrease the risk of dropout, clinicians can use measurement-based assessments to collaborate with patients about treatment objectives and potential changes in treatment.

Susan Douglas, PhD, an associate professor of the practice of human development in the Department of Leadership, Policy, and Organizations at Vanderbilt University, has seen how measurement-based care benefits pediatric patients. “When you are working with children and adolescents, there are multiple stakeholders who may have different perspectives on how the child is doing,” said Douglas. Getting feedback from both the youth and their caregivers can give a more robust picture of treatment progress, and the data can help parents understand why treatment is necessary, she said.

In one case, a 12-year-old boy was referred to treatment because he refused to attend school. The boy had lived with both parents until his mother moved away to live with a boyfriend. The boy was playing video games for up to 10 hours a day to cope with her absence. The clinician asked the boy and his father to fill out the Symptoms and Functioning Severity Scale, which gave the boy the opportunity to report if he was feeling unhappy, unable to get along with others, having trouble sleeping, or was having other issues. The feedback showed that the father rated the boy’s symptoms much less severely than the boy rated his own feelings. The therapist turned her computer around to show them the differences in graphical form (Jensen-Doss, A., et al., Evidence-Based Practice in Child and Adolescent Mental Health, Vol. 5, No. 3, 2020opens in new window). “The father looked at his son and said, ‘I had no idea,’” said Douglas, and the boy began to cry. “The feedback became a vehicle for the son to share his voice.”

The shift toward value-based care in the health care industry is another incentive for psychologists to consider practicing measurement-based care, said Elizabeth McKune, EdD, vice president and chief operations officer at Peace Hospital in Louisville, Kentucky. Value-based care programs reward providers with incentive payments for the quality of care they give to patients, not the number of patients seen. “There is increasing interest in large health care organizations to quantify progress because payment contracts are based on outcomes,” she said.

McKune previously worked at an organization that launched a pilot project to explore whether effective behavioral health care helped patients engage in other types of health care that could lead to higher reimbursements. Patients with severe mental illness began providing regular feedback about their mental health symptoms as well as preventive care behaviors such as getting a physical, tests for diabetes, dental visits, and blood pressure checks. “The new feedback process helped us provide better behavioral health management, which resulted in improved performance on measures tied to payment contracts, such as reduced emergency room visits,” McKune said. They launched a similar measurement-based care pilot for pediatric patients in foster care, and this led to increased behavioral health services, better day-to-day functioning of the participants, fewer emergency room visits, and overall cost savings.

Although many providers rely solely on their personal clinical judgment or patient preferences and feedback to guide treatment, some organizations are using outcome-monitoring systems that also provide suggestions for clinical care based on data from patients and from research on what practices might work best. Bruce Chorpita, PhD, a professor of psychology and psychiatry at the University of California, Los Angeles, helped develop approaches like this that were first adopted in Hawaii’s public mental health system in 2002. “A good measurement-based care system needs an evidence-based benchmark or zone of what progress is expected for youth and families, and when someone is not in this zone, it needs to provide evidence-based ideas for what to try next,” said Chorpita.

In Hawaii, Chorpita helped custom build the tool into the existing health information system, and this approach to feedback has significantly improved mental health outcomes for youth served by the state. Now the software tool is used in 39 states in more than 300 health care organizations.

Although larger health systems are increasingly open to outcome-measurement practices, adoption of a patient feedback system is less common among psychologists in private practice. Jacqueline Persons, PhD, director of the Oakland Cognitive Behavior Therapy Center in California and a clinical professor in the department of psychology at the University of California, Berkeley, was trained to monitor patient outcomes during graduate school—a rare practice 4 decades ago—and she has continued measuring outcomes ever since. “It’s easy to avoid asking for feedback based on fears of feeling inadequate if patients are not improving,” she said. “But if we can view it as an opportunity to learn, we can use the feedback to improve our skills.”

Persons uses an online tool called PsychSurveys, which includes a library of assessment tools that can be customized. She asks patients to complete the measures she has assigned to them before the session, and the tool produces a graph showing scores over time. “This tool has been particularly important when patients are doing sessions online rather than coming into the office,” she said. “In online sessions, I am getting less information from their body language and other cues.”

She remembers one young adult woman diagnosed with ADHD and depression who was struggling to stay organized. Her grades in school were dropping, and Persons had focused on helping her build organization skills. The feedback showed that the young woman’s depression symptoms were not improving, and the data were instrumental in prompting a discussion about why she was still experiencing symptoms. Persons learned that the woman had not been taking her ADHD medication because she felt ambivalent taking the drug, and she was not taking her antidepressants because her physician had not refilled the prescription. Persons worked with the woman to solve these problems, and after the patient resumed her medications, her symptoms improved.

Regular patient feedback has the potential to also improve outcomes for psychologists in training, said Tony Rousmaniere, PhD, executive director of Sentio Counseling Center in Los Angeles, a low-fee online counseling service. “Currently in the field we measure training effectiveness by how many students pass exams, graduate, or get a job,” he said. “All of those things are important for a career, but they are not necessarily associated with good patient outcomes.”

At the center, supervisors teach trainees how to explain to patients the reason for seeking patient feedback, and supervisors can view a dashboard showing patient data. “If patient symptoms are not improving, this is not the trainee’s fault,” he said. “The data help us be accountable as supervisors and identify gaps in training.” Recently, the outcome data revealed that patients with suicidal ideation were not progressing as expected, so the supervisors enhanced the training on how to help patients who are experiencing suicidality and self-harm.

Rousmaniere is collecting data to investigate whether outcome monitoring among trainees is making a difference, and preliminary results suggest symptoms are improving more quickly and fewer patients are deteriorating. He also plans to study whether teaching students to use measurement-based care increases the chances that they will use the tool once they are licensed practitioners.

Although asking patients to complete assessments before each visit may initially seem like a hassle, the feedback feels particularly valuable at Sentio because the organization serves patients with lower incomes, said Rousmaniere. “This population doesn’t always receive cutting-edge treatments because they are often in clinics with fewer resources,” he said. “It is especially important to make sure this population is receiving quality care, and patient feedback is a way of holding the field accountable.”