Discussing measurement-based care with patients: An analysis of clinician-patient dyads

Patients' and Therapists' Experiences of Standardized Group Cognitive Behavioral Therapy: Needs for a Personalized Approach

Personalizing psychotherapy can be challenging within standardized group Cognitive Behavioral Therapy (CBT), in which sessions are structured according to a protocol and must accommodate the needs and preferences of multiple patients. In the current study, we aimed to examine patients' and therapists' experiences of standardized group CBT and identify their perceptions of different patient needs. Furthermore, we explored how these needs can inform possible content of add-on interventions for patients who are not improving as expected during group CBT.We conducted 21 individual in-depth interviews with patients with depression and their therapists about their experiences during group CBT with Routine Outcome Monitoring (ROM) and feedback. Interviews were analyzed by using a hermeneutic-phenomenological thematic analysis. Five themes, representing different patient needs, were identified: (1) Individual attention, (2) Psychological exploration, (3) A focus on the patient's life outside of therapy, (4) Extended assessment, and (5) Agreement on therapeutic tasks.The study supports that "one size does not fit all" when it comes to psychotherapy. Patients have varying needs when they are not making progress in therapy, and these needs, when unmet, can negatively impact the overall experience of group CBT. By acknowledging the unique needs of each patient and providing additional individual sessions as necessary, we can move towards a more personalized approach that maximizes the benefits of group psychotherapy.

Dose-Response Effects of MittEcho, a Measurement Feedback System, in an Indicated Mental Health Intervention for Children in Municipal and School Services in Norway

Including routine client feedback can increase the effectiveness of mental health interventions for children, especially when implemented as intended. Rate of implementation, or dose, of such feedback interventions has been shown to moderate results in some studies. Variation in implementation and use of client feedback may also contribute to the mixed results observed within the feedback literature. This study evaluates dose-response associations of client feedback using a novel Measurement Feedback System (MFS) within an indicated group intervention. The primary aim was to determine whether the rate of MFS implementation predicts symptom reduction in anxiety and depression among school-aged children. The secondary aim was to assess whether the rate of MFS implementation influences children's satisfaction with the group intervention or their dropout rates. Data were collected via a randomized factorial study (clinicaltrials.gov NCT04263558) across 58 primary schools in Norway. Children aged 8 to 12 years (N = 701) participated in a group-based, transdiagnostic intervention targeting elevated symptoms of anxiety or depression. Half of the child groups also received the feedback intervention using the MittEcho MFS. Group leaders (N = 83), recruited locally, facilitated the interventions. The MFS dose was measured using the Implementation Index, which combines the use of MFS by both children and providers (group leaders) into a single dose variable. Results showed no significant additional effect of dose of MFS on change in depression or anxiety scores, on user satisfaction with the intervention or on intervention dropout. The discussion addresses potential reasons for these non-significant findings and implications for MFS implementation in preventive, group-based interventions in school settings.

Using Progress Feedback to Enhance Treatment Outcomes: A Narrative Review

We face increasing demand for greater access to effective routine mental health services, including telehealth. However, treatment outcomes in routine clinical practice are only about half the size of those reported in controlled trials. Progress feedback, defined as the ongoing monitoring of patients' treatment response with standardized measures, is an evidence-based practice that continues to be under-utilized in routine care. The aim of the current review is to provide a summary of the current evidence base for the use of progress feedback, its mechanisms of action and considerations for successful implementation. We reviewed ten available meta-analyses, which report small to medium overall effect sizes. The results suggest that adding feedback to a wide range of psychological and psychiatric interventions (ranging from primary care to hospitalization and crisis care) tends to enhance the effectiveness of these interventions. The strongest evidence is for patients with common mental health problems compared to those with very severe disorders. Effect sizes for not-on-track cases, a subgroup of cases that are not progressing well, are found to be somewhat stronger, especially when clinical support tools are added to the feedback. Systematic reviews and recent studies suggest potential mechanisms of action for progress feedback include focusing the clinician's attention, altering clinician expectations, providing new information, and enhancing patient-centered communication. Promising approaches to strengthen progress feedback interventions include advanced systems with signaling technology, clinical problem-solving tools, and a broader spectrum of outcome and progress measures. An overview of methodological and implementation challenges is provided, as well as suggestions for addressing these issues in future studies. We conclude that while feedback has modest effects, it is a small and affordable intervention that can potentially improve outcomes in psychological interventions. Further research into mechanisms of action and effective implementation strategies is needed.

Routine Outcome Monitoring and Clinical Feedback in Psychotherapy: Recent Advances and Future Directions

In the past decade, there has been an increase in research related to the routine collection and active use of standardized patient data in psychotherapy. Research has increasingly focused on personalization of care to patients, clinical skills and interventions that modulate treatment outcomes, and implementation strategies, all of which appear to enhance the beneficial effects of ROM and feedback. In this article, we summarize trends and recent advances in the research on this topic and identify several essential directions for the field in the short to medium term. We anticipate a broadening of research from the focus on average effects to greater specificity around what kinds of feedback, provided at what time, to which individuals, in what settings, are most beneficial. We also propose that the field needs to focus on issues of health equity, ensuring that ROM can be a vehicle for increased wellbeing for those who need it most. The complexity of mental healthcare systems means that there may be multiple viable measurement solutions with varying costs and benefits to diverse stakeholders in different treatment contexts, and research is needed to identify the most influential components in each of these contexts.

The Connections Matter: Bi-Directional Learning in Program Evaluation and Practice-Oriented Research

Intended for researchers and clinical leaders, this article suggests that embedded program evaluation is a good fit with the desired features of practice-oriented research. The systematic nature of evaluation that is built into the operational workflow of a practice setting may increase the diversity of methods available to explore processes and outcomes of interest. We propose a novel conceptual framework that uses a human-centered systems lens to foster such embedded evaluation in clinical routine. This approach emphasizes the evaluator-practitioner partnership to build confidence in the bi-directional learning of practice-based evidence with evidence-based practice. The iterative cycles inherent to design thinking are aimed at developing better evaluation questions. The attention to structure and context inherent to systems thinking is intended to support meaningful perspectives in the naturally complex world of health care. Importantly, the combined human-centered systems lens can create greater awareness of the influence of individual and systemic biases that exist in any endeavor or institution that involves people. Recommended tools and strategies include systems mapping, program theory development, and visual facilitation using a logic model to represent the complexity of mental health treatment for communication, shared understanding, and connection to the broader evidence base. To illustrate elements of the proposed conceptual framework, two case examples are drawn from routine outcome monitoring (ROM) and progress feedback. We conclude with questions for future collaboration and research that may strengthen the partnership of evaluators and practitioners as a community of learners in service of local and system-level improvement.

Measurement-Based Care in Youth: An Opportunity for Better Clinical Outcomes?

Measurement-based care (MBC) is a procedure in which systematic and routine assessments are performed. Through this practice, clinicians can verify the progress of the symptomatology of the patient and adapt the appointments and the intervention to the current symptoms. Studies have reflected on the importance and the benefits of this type of procedure in the adult population, and have shown positive results. However, there is a lack of evidence concerning the remaining populations. Regarding youth, for instance, few articles have evaluated the benefits of using this procedure in clinical practice. However, research focused on this topic has revealed positive results, especially when clinicians were loyal to the MBC procedures. Still, further research is needed. This letter aims to share the methodology used by our multidisciplinary team, composed of psychologists and psychiatrists, in a clinical context at the Hospital Cruz Vermelha, Lisboa, applied to the adult population; the objective is to share and discuss some alterations that could be made to our evaluation protocol to enable the same to be used with the youth population. We believe that implementing MBC for youth is crucial for several reasons, including enhanced treatment efficacy, more personalized treatment, a reduced reliance on subjectivity, and empowerment not only of patients but also families.

Motives of Therapists for Using Routine Outcome Monitoring (ROM) and How it is Used by Them in Clinical Practice: Two Qualitative Studies

Despite its demonstrated value, many mental health institutions struggle to implement progress feedback effectively. There is also insufficient information about how therapists utilize progress feedback. To gain more insight, two qualitative studies were conducted. The first study compared the attitudes and motives of therapists who used and those who did not use progress feedback. The second study examined how psychologists incorporated progress feedback into their practice. In total, 23 therapists were interviewed, and the data were analyzed using thematic analysis. The first study found that almost all the therapists had a positive attitude about progress feedback. Those who did not use it indicated reasons such as a heavy workload and patient-related factors, and they also lacked sufficient information about the potential benefits of progress feedback. The second study revealed four major ways in which the therapists utilized feedback, namely: supporting actions to discuss progress feedback, discussing progress feedback with patients, modifications in the ongoing treatment, and peer consultation. However, discussions during peer consultations about using progress feedback for patients who were not benefitting from treatment and how the treatment might be adjusted accordingly were often lacking. In conclusion, it is crucial that training and education be provided to therapists on how to use progress feedback effectively. Having regular discussions about progress feedback during peer consultations could also facilitate its integration into clinical practice.

Psychotherapists' Experience with In-Session Use of Routine Outcome Monitoring: A Qualitative Meta-analysis

Routine outcome monitoring (ROM) has become an increasingly utilized tool in therapeutic practice that has the potential to improve therapy outcomes. This study aimed to synthesize the findings of existing qualitative studies investigating how clinicians use ROM in their work with clients. A systematic search of qualitative studies on clinicians' experience with the use of ROM in mental health services was conducted via PsycInfo, PsycArticles, Medline, Web of Science, and Scopus databases. Qualitative meta-analysis was used to synthesize the finding of the primary studies. Forty-seven studies met the inclusion criteria. The analysis resulted in 21 meta-categories organized into six clusters, namely (1) obtaining clinically relevant information, (2) adapting treatment, (3) facilitating communication, (4) enhancing the therapeutic relationship, (5) facilitating change in clients, and (6) personalized usage of ROM. The meta-analysis revealed that clinicians utilized ROM in diverse ways, including both informational and communicational functions. From the clinicians' perspective, ROM was an element that, on the one hand, introduced additional structure and standardization in treatment and, on the other hand, allowed for greater flexibility and tailoring of treatment.

Therapists' and patients' experiences of using patients' self-reported data in ongoing psychotherapy processes-A systematic review and meta-analysis of qualitative studies

OBJECTIVE

Using patient-generated quantitative data in psychotherapy (feedback) appears to enhance treatment outcome, but there is variability in its effect. Different ways and reasons to implement routine outcome measurement might explain such variability. The goal of this review is to address the insufficient knowledge on how these data are used by therapists and patients.

METHODS

The present study is a systematic review and meta-analysis of qualitative reports of therapists' and patients' experiences using patient-generated quantitative data during ongoing psychotherapy.

RESULTS

Four main categories of use were identified: (1) uses of patients' self-reported data as nomothetic/objective markers for assessment, process monitoring, and treatment planning; (2) intrapersonal uses that enhance self-awareness, initiate reflection, and influence patients' mood or responses; (3) uses that prompt interactional processes by facilitating communication, supporting exploration, creating ownership in patients, changing treatment focus, enhancing therapeutic alliance, or disturbing the psychotherapy process; and (4) patients responding for specific purposes due to uncertainty and interpersonal motives, or strategic responding to achieve a desired result.

CONCLUSION

These results demonstrate that patient-reported data, when used in active psychotherapy, is very clearly not just an objective measurement of client functioning: the inclusion of patient-data has the potential to influence psychotherapy in numerous ways.

Case report: A dual case study of how clinical feedback can be a communication aide and influence therapeutic work

Background

While routine outcome monitoring and clinical feedback may improve outcomes after psychotherapy, results from efficiency studies have been mixed. Moreover, how clinical feedback is implemented influences how it works for patients and clinicians, and working mechanisms are hitherto not thoroughly explored. Researchers have argued that inviting and using feedback from patients is best conceived of as a clinical skill. In this paper, we use case study methodology to explore and describe feedback's functions within three clinical skill themes: actualizing alliance work, concretizing change and stagnation and verbalizing the non-verbal.

Case presentation

Sonja is a young adult patient with a trauma background. She has a history of serious suicide attempts and distrust in relationships. She attended psychotherapy for eight months. Harald is a middle-aged man with a stable family. Traumatic events in his past has made him conceal own needs and developing depression. He attended psychotherapy for 19 months. Case material include the patient's clinical feedback over a range of life areas, medical health notes and the therapist's process notes.

Conclusion

Clinical feedback can be a positive supplement to the therapeutic work and process. The importance of making this as a joint tool between the client and the therapist is significant.

Effects and experiences of idiographic patient-reported outcome measures for feedback in psychotherapy: A systematic review and secondary analysis of the empirical literature

Objective: There is a growing interest in idiographic patient-reported outcome measures (I-PROMs) for routine outcome monitoring (ROM) and clinical feedback (CF) in psychotherapy, but to our knowledge, no systematic reviews of the empirical literature. Method: We conducted a systematic literature search for empirical papers investigating effects and experiences of I-PROMs for ROM/CF and found a total of 13 papers. There was only one experimental controlled effectiveness study. Results: We formulated a narrative summary of the data set as a whole. We conducted a secondary analysis of nine papers containing qualitative data on stakeholder experiences with I-PROMs and found three superordinate themes and eight subthemes, summarized as "I-PROMs can facilitate self-reflection for patients, assist in identifying and tracking therapeutic topics, and make patients more committed to therapy by giving them a greater sense of responsibility and empowerment. Formulating goals and problems can be difficult, and lack of progress can be demotivating. Time in therapy is precious and must be spent wisely. Effective use of I-PROMs is facilitated by flexibility and therapists' use of clinical skills." Conclusion: We discuss the limitations of the study and provide recommendations for future research and clinical practice.

Taking a Magnifying Glass to Measurement-Based Care Consultation Sessions: with What Issues Do Mental Health Clinicians Struggle?

PURPOSE

Ongoing consultation following initial training is one of the most commonly deployed implementation strategies to facilitate uptake of evidence-based practices, such as measurement-based care (MBC). Group consultation provides an interactive experience with an expert and colleagues to get feedback on actual issues faced, yet there is little research that unpacks the questions raised in consultation and what types of issues are important to address.

METHODS

The current study characterized the questions and concerns raised by community mental health clinicians (N = 38 across six clinics) during group consultation sessions completed as part of an MBC implementation trial. We conducted a qualitative content analysis of consultation forms completed by clinicians before each MBC consultation session.

RESULTS

Clinicians sought MBC consultation for clients across a range of ages and levels of depression severity. Qualitative results revealed five main questions and concerns in consultation sessions: (1) how to administer the PHQ-9, (2) how to review PHQ-9 scores, (3) how to respond to PHQ-9 score, (4) the types of clients for whom MBC would be appropriate, and (5) how MBC could impact a clinician's usual care.

CONCLUSION

Findings highlight the need for ongoing consultation and limitations of workshop training alone. Practical recommendations for addressing the common questions and concerns identified are presented to support MBC use.

Routine Outcome Monitoring (ROM) and Feedback: Research Review and Recommendations

OBJECTIVE

To provide a research review of the components and outcomes of routine outcome monitoring (ROM) and recommendations for research and therapeutic practice.

METHOD

A narrative review of the three phases of ROM - data collection, feeding back data, and adapting therapy - and an overview of patient outcomes from 11 meta-analytic studies.

RESULTS

Patients support ROM when its purpose is clear and integrated within therapy. Greater frequency of data collection is more important for shorter-term therapies, and use of graphs, greater specificity of feedback, and alerts are helpful. Overall effects on patient outcomes are statistically significant (g ≈ 0.15) and increase when clinical support tools (CSTs) are used for not-on-track cases (g ≈ 0.36-0.53). Effects are additive to standard effects of psychological therapies. Organizational, personnel, and resource issues remain the greatest obstacles to the successful adoption of ROM.

CONCLUSION

ROM offers a low-cost method for enhancing patient outcomes, on average resulting in an ≈ 8% advantage (success rate difference; SRD) over standard care. CSTs are particularly effective for not-on-track patients (SRD between ≈ 20% and 29%), but ROM does not work for all patients and successful implementation is a major challenge, along with securing appropriate cultural adaptations.

The Implementation of Measurement-Based Care in the Context of Telemedicine: Qualitative Study

BACKGROUND

The Measurement Based Care in Mental Health Initiative launched by the Department of Veterans Affairs in 2016 is an example of an evidence-based practice that uses patient-reported outcome measures (PROMs) to improve patient outcomes. The acceptance of measurement-based care (MBC) among Veterans Affairs providers is relatively high. However, there are barriers to MBC for telehealth providers. Health information technologies might afford opportunities to address some of the barriers related to the uptake of MBC.

OBJECTIVE

This paper reports on an implementation effort to integrate MBC into mental health care telehealth practice using eHealth solutions.

METHODS

Qualitative data were generated from 22 semistructured interviews with psychiatrists (n=4), psychologists (n=3), social workers (n=3), nurses (n=6), a pharmacist (n=1), and administrative staff (n=5) who provide telemental health care through a community-based outpatient clinic in the rural Midwestern United States. The interviews were conducted during the pilot phase of an implementation initiative to increase the adoption of MBC by revising clinic workflows to integrate the use of eHealth technologies. Data were analyzed using thematic analysis.

RESULTS

Time burden and workflow issues were the most common barrier to provider adoption of MBC; sharing and reviewing pencil-and-paper measures and results in the same room was no longer possible in novel telehealth workflows necessitated by the COVID-19 pandemic. Providers voiced concerns about how long it would take to collect, adequately score, interpret, share, and document the PROMs during the telehealth visit. Concerns about time might also correspond to a gap in providers' familiarity with these assessments, greater comfort in assessing symptoms through clinical interviews, and being accustomed to using the assessments as screening tools more so than longitudinal outcome measures. Capacities associated with eHealth technologies may address workflow concerns and promote providers' understanding and use of the measures as tracking tools.

CONCLUSIONS

The need to use limited appointment time well was a top priority for telemental health providers. eHealth technologies provided operative supports that protect time in appointments by shifting when and how PROMs are collected. Bolstering providers' familiarity with how to use PROMs in the course of treatment may impact providers' buy-in by encouraging them to reconsider how sharing and acting on PROMs could be time well spent.

Characterizing measurement-based care implementation using therapist report

The effectiveness of measurement-based care (MBC), an evidence-based practice that uses regularly collected assessment data to guide clinical decision-making, is impacted by whether and how therapists use information from MBC tools in treatment. Improved characterization of how therapists use MBC in treatment sessions with youth is needed to guide implementation and understand variability in MBC effectiveness. To meet this need, this study examined therapists' sharing and discussion of MBC in treatment sessions. Thirty therapists were randomly assigned to the MBC condition as part of a comparative effectiveness trail of treatments for adolescent anxiety and depression. A qualitative content analysis was conducted on therapists' written explanations of changes made to the session based on the MBC data. Therapists reported sharing data with youth and caregivers in an average of 34.6% and 27.4% of sessions, respectively. Therapists reported incorporating MBC data in an average of 21.1% of sessions. When data were used, therapists predominately focused changes on short-term (e.g., current symptoms, treatment skill) rather than long-term (e.g., symptom progress, treatment goals) decision-making. Therapists inconsistently used MBC data, highlighting the need for improved training in and monitoring of how therapists use MBC in session to guide collaborative treatment decision-making with youth and caregivers.

Understanding routine outcome monitoring and clinical feedback in context: Introduction to the special section

The practice of routine outcome monitoring and providing clinical feedback has been widely studied within psychotherapy. Nevertheless, there are many outstanding questions regarding this practice. Is it an evidence-based adjunct to ongoing psychotherapies, or an ineffective complication of treatment? If it is effective, through what mechanism(s) does it act? Is it effective with all patient populations, treatment types, and service delivery mechanisms, or does its impact vary across context? What choices in the implementation process affect the utility of patient-reported data feedback on psychotherapy outcomes? The studies in this special section explore these questions using a wide variety of methods and significantly expand the reach of studies on feedback. Together, these studies represent a snapshot of a maturing field of study: Initial discoveries are developed into more robust theories and applied in a wider range of contexts, while the limits of that theory are tested. They also signal directions for future clinical and research work that may improve patient care in psychosocial interventions into the future.

How therapists and patients need to develop a clinical feedback system after 18 months of use in a practice-research network: a qualitative study

BACKGROUND

A personalized computer-adaptive system for clinical feedback and routine outcome monitoring in mental health, Norse Feedback aims to bridge the needs for standardized and idiographic measures in ordinary practice.

METHODS

Item response theory analyses of completed treatment processes (n = 800) informed a qualitative study comprising individual in-depth interviews and focus groups with patients (n = 9) and clinicians (n = 10). The research question was: How do clinicians and patients contribute to developing a clinical feedback system in a continuous process aimed at refining its clinical usefulness?

RESULTS

We conducted thematic analyses and found five themes: 1. Added clinical needs, 2. Needs for re-organizing the clinician report, 3.Needs for differentiation of clinical content, 4. User-interface needs, and 5. Item level suggestions.

CONCLUSION

In this article, we detail resulting needs for continuous adaptation to practice, and discuss implications of the concrete experiences with the Norse action research program for the larger field of ROM/CFS implementation.

Understanding Health Talk in Behavioral Health Encounters: A Qualitative Analysis

Although physical and behavioral health conditions commonly cooccur, best practices making behavioral health treatment responsive to clients' health needs are limited. Particularly little is known about how physical health is addressed by clinicians within routine therapeutic treatment. This study describes the frequency and type of health talk occurring within integrated behavioral health sessions, and explores how this talk functions within ongoing therapeutic work. Participants in this study included 51 dyads of clinical social workers (n = 13) and clients (n = 51) receiving therapy within an integrated community health and behavioral health center. Therapy sessions were recorded and transcribed verbatim. Content analysis determined the frequency and content of health talk in sessions. Thematic analysis was used to understand the function of health talk within these visits. Health talk occurred in 92% (n = 47) of sessions. Clients initiated the majority of discussions. Talk about sleep (40%, n = 19), diet/exercise (35%, n = 16), and chronic health conditions (28%, n = 13) were most common. Health talk either complimented or conflicted with therapeutic work, depending on the topic discussed and when it occurred during session. Health talk changed the scope of therapeutic work by integrating care coordination into routine practice. Health talk was pervasive and was frequently initiated by clients, signaling its relevance to clients' recovery. Providers leveraged heath talk to complement their therapeutic work, but these strategies were not universally applied. Care coordination activities were a part of routine therapy. Practice and policy changes that support a more interdisciplinary approach to clinical work are needed.