Improving therapy outcomes with measurement-based care

Across myriad psychological studies, measurement-based care (MBC)—the use of validated instruments to inform psychotherapy treatment—is associated with improved therapy outcomes. “When clinicians receive systematic feedback, they are more likely to detect when a case is drifting off course and adjust treatment accordingly,” said Matteo Bugatti, PhD, an assistant professor of psychological sciences at Oregon State University, where he studies the use of technology in psychotherapy. Further, MBC allows psychologists to identify what is working and intentionally reinforce it while increasing patient motivation and engagement.

Despite the growing evidence base supporting MBC, implementation rates by mental health professionals remain low (Jensen-Doss, A., et al., Administration and Policy in Mental Health and Mental Health Services Research, Vol. 52, 2024opens in new window). While psychologists are trained to use assessments to diagnose and treat patients, using data in a long-term, guided way may be less familiar. Logistical, implementation, and financial concerns—not necessarily disagreement with the concept—are common barriers.

Clinicians may be concerned that MBC takes up too much valuable therapy time and that patients will not like filling out measures (see January/February 2025 Monitor). Some worry about being penalized by managers or insurance companies if measures reflect lack of patient progress, said Jessica Jackson, PhD, a clinical psychologist and founder of Therapy Is for Everyone Psychological and Consultation Services. It can also be difficult to choose the right MBC approach and, if needed, a technological tool to support it.

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Implementing MBC may require an initial adjustment, Bugatti said, but ultimately it should simplify and support psychological care, not complicate it. While clinical impressions alone can be reliable, this objective data can add a layer of evidence, allowing psychologists to uphold their ethical imperative of beneficence, or providing care that helps patients.

“It gives us a quantitative indicator that can enhance the information we’re getting from observations and self-report,” said Jessica Barber, PhD, an assistant clinical professor at the Yale University School of Medicine, cofounder of the Yale Measurement Based Care Collaborative, and associate director for the Measurement Based Care in Mental Health Initiative with the Veterans Health Administration Office of Mental Health. “With MBC, we have a systematic process that becomes our fail-safe so we don’t overlook something important.”

For clinicians who want to better track and apply data to support therapeutic outcomes, MBC is one option. Here are some best practices for incorporating MBC into your practice, including how to choose assessments that best support patient care, how to integrate those assessments into your current workflow, and whether you should switch from paper and pencil to a dedicated MBC software.

The first step of implementing MBC is determining what you want to measure. “It’s very important to find something useful and relevant for each patient, so go through your entire caseload and ask yourself what specific measure will help your decision-making for each patient,” said Dan Cheron, PhD, a clinical psychologist and founder of Center for Behavioral Health Solutions in Wellesley, Massachusetts.

To start, reflect on your current patient base, specialty, and therapeutic approach. “It matters a lot what you’re aiming to do in therapy because you’re trying to measure its specific effect,” said Kim de Jong, PhD, an associate professor of clinical psychology at Leiden University in the Netherlands.

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Symptom measures—such as the General Anxiety Disorder-7 and Patient Health Questionnaire-9 for anxiety and depression—can be useful, especially if you use symptom-based modalities like cognitive behavioral therapy. Clinicians who employ insight-based methods such as psychodynamic therapy may prefer a quality-of-life measurement, such as the Recovering Quality of Life Measureopens in new window. Assessments that measure the therapeutic alliance, such as the Working Alliance Inventory, can help fine-tune the clinician-patient relationship to promote growth over time.

Patient demographics should also be a consideration. For example, therapists working with children and adolescents may want to use a simple, behavior-based approach. The Youth Top Problems Assessmentopens in new window—which identifies and ranks the three most challenging issues at a given time—can help narrow down an area of focus with behavioral issues. “It gets back to someone’s true, primary concerns and allows me to help them build the skills most likely to help,” said Rachel Kim, PhD, a clinical psychologist and founder of Magnolia Psychological Consulting in Natick, Massachusetts.

The key to sustainable use of MBC is starting small, said Bugatti. You could begin with one brief, validated measure. Explain to patients what it is and why you are using it, which can promote engagement. Then, administer it consistently. After gaining experience with a handful of patients, slowly progress through your caseload. “Clinicians can set up their own MBC SMART [specific, measurable, achievable, relevant, time-bound] goals or experiments as they try MBC, see what they like and don’t like, and then make adjustments over time,” said Barber.

After landing on measures, determine how to implement them. Some clinicians collect the data in real time with patients or ask them to complete an assessment before an appointment. There are pros and cons to each approach: While asynchronous collection can save therapy time, patients may not always remember to complete measures—and therapists may not remember to circle back to the data in session. For an asynchronous approach, de Jong typically tells patients not to complete assessments more than a day before the session, because proximity yields more up-to-date results and provides a reflective moment to prompt talking points for therapy.

Clinicians who conduct assessments in session should determine how to incorporate them into the existing therapy flow. A patient-centered approach can be effective but also requires flexibility. “I like to do mine as part of my check-in so we can decide together if we want to do what I’ve planned or spend more time on something specific from the check-in,” said Kim. It can help to ask the patient to complete the assessment at the end of the session and then come up with next steps for future sessions.

Assessment frequency may vary from patient to patient. Ruben Martinez, PhD, an assistant professor of psychiatry and human behavior at Brown University and chair of APA’s Measurement-Based Care Committee, recommends collecting data when you first meet with someone, and then again every one or two sessions. “Choose the most important measures early on, preferably after the initial assessment and diagnostic impression, to simplify things for you and the patient,” he said. Because early sessions are often predictive of long-term growth, de Jong said, it is especially important to prioritize frequent assessments in someone’s first several sessions.

Data are only beneficial when implemented in clinical care. “Reviewing scores in session, asking patients what they notice, and integrating that information into clinical decision-making is where the impact happens,” said Bugatti.

When patients are not improving, take time to consider causes and potential solutions, whether that is increasing therapy frequency, using a different treatment modality, referring to a psychiatrist for medication, or potentially revisiting your initial diagnosis. “For example, in exposure therapy, we expect to see improvements within three or four sessions,” said Martinez. “When people aren’t improving, the type of exposure, intensity, or diagnostic impression could be wrong.”

Collaborative decision-making can be an important step to support growth. Barber recommends working with patients to make sure you understand ratings. If worrying was prevalent in a patient’s assessment, be sure you are on the same page about the specifics—do not assume the worries are the same as last session. It is also important to discuss potential barriers to improvement, whether those may be aspects of your treatment, the therapeutic relationship, or the patient’s personal life outside therapy. When needed, come up with a plan to change course.

When patient data reflect consistent improvement, talking about their upward trajectory—with a visualization tool like a chart or graph when possible—and pointing out the strategies that have helped can build confidence while improving self-efficacy and motivation. “Often clients say, ‘I got better because you helped me,’ and I tell them, ‘But you applied what we worked on in your daily life, so you did the bulk of the work,’” said Barber.

Data that reflect ongoing improvement may also change the focus of therapy or session frequency. “If someone’s data have been consistent, I may bring that up and ask if they want to shift what we’re working on. Alternatively, they may be ready to meet less frequently, or maybe they’re ready to end therapy,” said Barber. Showing the patient their graph can give them confidence that they have been using therapy skills in their lives. MBC data make it very easy to remind patients what types of symptoms or changes to watch for that might signal the need to revisit therapy in the future.

More broadly, consider how data trends can help you grow as a therapist. For example, maybe young male patients do not improve as much as other patients under your care. “Maybe you’ll realize you’re not as comfortable with certain patients and refocus your practice, or that you need to develop a new skill,” said de Jong.

MBC does not require technology and can be done with paper and pencil. The next progression is inputting patient data, whether completed online or on paper, into a spreadsheet that allows you to both organize and visualize patient-reported data.

Clinicians seeking more workflow automation can consider investing in a technological tool. Stand-alone MBC software, such as Greenspace, Mirah, and NeuroFlow, is one option. Many electronic health records (EHRs) also have add-on assessment capabilities you can purchase. While EHR-based tools do not often include a wide breadth of assessments—Barber said this may be because of legal or copyright issues—they can streamline workflow. “When documentation, billing, and assessment live in separate systems, administrative burden increases,” said Bugatti. “Integration reduces friction and makes consistent implementation far more likely.”

If you do not have an EHR or want to switch to one with measurement tools, think through processes that would simplify workflow and patient outcomes. Systems that automatically administer measures via text or email before sessions, Bugatti said, can significantly improve adherence. He recommends an MBC system that allows assessment across multiple domains, including symptom severity, functioning, working alliance, and patient-defined goals.

It is also useful if the system helps you interpret the data with automated graphing, clear visual displays, and clinical support tools that make it easier to detect patterns. “Some tools have algorithms to calculate expected improvement trajectories and tell you if someone’s not progressing as expected,” said Barber, though these technological mediations are not required.

While MBC can improve therapy outcomes, patient-reported measures are not always an exact representation of a person’s well-being or a psychologist’s effectiveness. For example, Jackson said, patients may not always accurately report their symptoms on a given measure; it can be difficult to remember how you felt last week or a couple weeks ago.

Further, mental health is influenced by many outside factors, which a psychologist cannot control. A patient with depression may not show signs of improvement in measurements if their environment is not changing—for example, if they have ongoing financial stress, job dissatisfaction, or chronic health challenges. “Therapy could help provide coping skills, but if you take a measure, depression symptoms may not improve because the person feels stuck,” said Jackson.

MBC for patients with certain complicated diagnoses, such as treatment-resistant depression, may reveal lack of progress in therapy. In these cases, patients may require medication adjustments before showing signs of improvement. These nuances do not make measurement useless; they simply provide a broader context for what the patient needs. “By measuring symptoms, at least you know what has an influence,” said de Jong. “You can ask your patient, ‘Can we determine why your score isn’t improving and what we can do to help you moving forward?’”

If MBC still feels burdensome a few months after implementation, your workflow may need tweaking. Consider whether clinical documentation and MBC can be better integrated, whether administrative tasks can be automated, or if assessments can be streamlined—for example, by putting a tablet in the waiting room so patients can easily fill out measures before a session.

It is also important to ensure your selected measures align with how you conceptualize change. MBC originated in medical settings, so many studied models focus heavily on symptom-based measures. While tracking symptoms is important, it may not always capture the most helpful markers of change with every patient, such as shifts in avoidance, relational patterns, alliance, or functional improvement. “If the data you collect maps directly onto the decisions you’re making in sessions, MBC will feel more clinically meaningful,” said Bugatti.

To learn more about how to implement MBC, consider attending a related training or taking a continuing-education course. The Yale Measurement Based Care Collaborative, for example, offers free videos, resources, and research. There are also consultants and coaches, many of whom are psychologists themselves, who can help you implement MBC effectively in clinical practice. While the process comes with a learning curve, keep the end goal in mind: “No matter how good our judgment is, we’ll always have gaps in our awareness and operate with assumptions,” said Martinez. “Using MBC is a great way to hold ourselves accountable and ensure we’re helping clients be active decision-makers in their treatment path and progress.”