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Abstract

While highly effective, psychotherapy outcome studies suggest 5–14% of clients worsen while in treatment and that therapists are unable to identify a substantial portion of such cases. Methods to systematically collect feedback from psychotherapy clients are discussed and two systems for monitoring treatment response, feeding back this information, and assisting in problem-solving with such cases are described. Within these systems, obtaining client ratings of their relationship appear to be highly important. We summarize meta-analyses of the effects of these feedback systems (The combined weighted random effect size for the Partners for Change Outcome Management System was r = .23, 95% CI [.15, .31], p < .001, k = 3, n = 558; the effect size for the Feedback condition of the Outcome Questionnaire (OQ) system among not-on-track patients was r = .25, 95% CI [.15, .34], p < .001, k = 4, n = 454; the effect size for the Patient/Therapist Feedback condition of the OQ system among not-on-track patients was r = .25, 95% CI [.15, .34], p < .001, k = 3, n = 495; the effect size for the Clinical Support Tools feedback condition among not-on-track patients was r = .33, 95% CI [.25, .40], p < .001, k = 3, n = 535). The number of psychotherapy patients who deteriorate can be cut in half by use of these systems. We conclude with a series of practice implications, including that clinicians seriously consider making formal methods of collecting client feedback a routine part of their daily practice.
... While psychotherapy has proven effective, research suggests that 5%-14% of clients deteriorate while in treatment and that therapists cannot effectively identify such cases (Lambert, 2013). Client feedback has been demonstrated to reduce deterioration and consequently improve therapy outcomes (Lambert & Shimokawa, 2011). Boswell et al. (2015) have highlighted the importance of implementing routine outcome monitoring in clinical practice to identify negative events and clients at risk of deterioration as well as to act in service of positively reverting the change process. ...
... Through the information collected with the FIS-C, clinicians will be able to adjust their interventions based on client feedback. As discussed, monitoring clinical progress and using client feedback to tailor psychotherapy interventions to clients has been shown to have a positive impact on therapy outcomes, potentially reducing undesirable therapy effects (Lambert & Shimokawa, 2011). The process of developing and validating the FIS-C scale in this study revealed that the instrument has appropriate psychometric properties, making it a new possible option for clinical use. ...
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Objective: Psychotherapy studies have revealed that therapist characteristics are responsible for 5% to 9% of outcome variance. The therapist-facilitative interpersonal skills (FIS) have been shown to predict both alliance and outcomes, indicating that higher FIS therapists are more effective than lower FIS therapists. The current study focused on the development and validation of the FIS-client version (FIS-C) instrument, aimed at collecting the clients' perspectives on relevant therapist characteristics. Method: The clinical outcomes in routine evaluation-outcome measures, the session rating scale, and the FIS questionnaire-client version were filled out by psychotherapy clients. Exploratory, confirmatory factor, and test-retest analysis were conducted. Results: Results indicate robust psychometric characteristics, in terms of validity (factorial, convergent, discriminant, and nomological), reliability, and sensitivity. Conclusion: The validation of the FIS-C represents an important contribution to clinical research and practice, namely to the field of client feedback and therapist expertise.
... Utilizing the data collected during treatment to give feedback to therapists has been shown to significantly contribute to the improvement of psychotherapy. This additional and continuous information may prevent treatment failure, which is poorly identified by average clinicians who tend to overestimate their therapeutic performance (Lambert and Shimokawa, 2011). ...
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Introduction Routine Outcome Monitoring (ROM) has emerged as a strong candidate to improve psychotherapy processes and outcome. However, its use and implementation are greatly understudied in Latin-America. Therefore, the aim of the present pilot study conducted in Argentina was to implement a ROM and feedback system grounded on a psychometrically sound instrument to measure session by session outcome in psychotherapy. Methods The sample consisted of 40 patients and 13 therapists. At baseline, the patients completed the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7, and they also completed the Hopkins Symptom Checklist-11 before each of the first five sessions. To estimate patient change during the first sessions, we conducted a quantitative analysis using Hierarchical Linear Models. Furthermore, we conducted a qualitative analysis using Consensual Qualitative Research to analyze therapist perception regarding the ROM and feedback system. Results Results showed a significant reduction in patients’ symptomatic severity during the first five sessions. Additionally, baseline depression significantly predicted the estimated severity at the end of the fifth session. Feedback was given to the therapists after the first four sessions based on these analyses. With regard to the perception of the feedback system, clinicians underlined its usefulness and user-friendly nature. They also mentioned that there was a match between the information provided and their clinical judgment. Furthermore, they provided suggestions to enhance the system that was incorporated in a new and improved version. Discussion Limitations and clinical implications are discussed.
... Client feedback helps the clinicians know about a treatment's effectiveness, therapy relationships and adverse outcomes. It alerts them to change the course of treatment and institute risk mitigation strategies [75]. However, in an early bereavement phase, feedback provided by the emotional family members might not always genuinely represent the quality of palliative care services [76]. ...
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Background Although a significant proportion of children with cancer need palliative care, few are referred or referred late, with oncologists and haematologists gatekeeping the referral process. We aimed to explore the facilitators and barriers to palliative care referral. Methods Twenty-two paediatric oncologists and haematologists were purposively recruited and interviewed. Data were analysed using reflexive thematic analysis. Findings were interpreted using the critical realist paradigm. Results Four themes were generated. 1) Oncologists expressed concern about the competency of palliative care teams. Palliative care often symbolised therapeutic failure and abandonment, which hindered referral. Trustworthy palliative care providers had clinical competence, benevolence, and knowledge of oncology and paediatrics. 2) Making a palliative care referral was associated with stigma, navigating illness-related factors, negative family attitudes and limited resources, impeding palliative care referral. 3) There were benefits to palliative care referral, including symptom management and psychosocial support for patients. However, some could see interactions with the palliative care team as interference hindering future referrals. 4) Suggested strategies for developing an integrated palliative care model include evident collaboration between oncology and palliative care, early referral, rebranding palliative care as symptom control and an accessible, knowledgeable, and proactive palliative care team. Conclusion Presuppositions about palliative care, the task of making a referral, and its cost-benefits influenced referral behaviour. Early association with an efficient rebranded palliative care team might enhance integration.
... Verlaufsmessungen in Rahmen von entwickelten Instrumenten hilfreich sein kann (de Jong et al., 2021) und solche klinische Unterstützungstools das Therapieoutcome signifikant erhöhen, indem bspw. Verschlechterungsraten bei prädizierten Therapiemisserfolgen durch die Verwendung von Warnsignalen an Therapeut_innen und die Unterstützung durch Problemlösestrategien reduziert werden (Delgadillo et al., 2017Harmon et al., 2005;Lambert et al., 2001Lambert & Harmon, 2018;Lambert & Shimokawa, 2011;Shimokawa et al., 2010;Simon et al., 2012). Allein das regelmäßige Monitoring einhergehend mit der Entdeckung von Schwankungen in der Symptombelastung der Patient_innen kann zu einem besseren Therapieergebnis führen . ...
Article
In recent decades, randomized-controlled trials (RCTs) have established a broad evidence base of psychotherapy with moderate-to-large effects for various mental disorders. In addition to determining the efficacy of psychotherapy, studies examining its effectiveness under everyday conditions historically paved the way for developing a practice-oriented research paradigm. This paper argues that, within this paradigm, practice-based studies are a valuable complement to RCTs as they can address existing problems in psychotherapy research. In current practice-oriented research, new approaches from personalized medicine and methods from computational psychiatry provide important clues for optimizing effects in psychotherapy. In the context of personalization, for example, clinical multivariable prediction models are being developed that enable evidence-based outcome monitoring through feedback loops to practitioners in the short term and strengthen the German practice-research network in the long term. In conclusion, the paper derives and discusses future directions for practice-oriented research in terms of the “precision mental health care” paradigm.
... Some ROM software, for example, includes "alarms" that alert therapists when patients may be at risk for deterioration or indicate when a change in treatment might be warranted due to nonresponse (based on dose-response analyses of 10,000 patients, Lambert, Hansen, & Finch, 2001). These alarms have been shown to enhance treatment outcomes (for a summary of meta-analyses of the effects of these feedback systems, see Lambert & Shimokawa, 2011). ...
Article
The use of routine outcome monitoring (ROM) has been shown to improve treatment outcomes, reduce symptom deterioration and treatment dropout, and is especially relevant for training clinics. However, the use of ROM in a psychodynamic training clinic has remained relatively unexplored. We aimed to instigate an open dialogue about the use and usefulness of ROM within the context of contemporary psychodynamic clinical practice. As a graduate trainee and professor in a psychodynamic training program, we reflect on the seemingly irreconcilable differences between psychoanalytic thinking and ROM, the anxiety around being evaluated as a trainee, whom ROM is for, the pragmatic challenges when trying new tools and technology (especially when not chosen yourself), and the limitations of standardized self-report measures, such as the OQ. Overall, these complexities suggest that although ROM is likely worthwhile for patients, therapists, supervisors, and researchers, it will only come to its fruition if we integrate it into the tri-legged stool of evidence-based practice . We will need to engage in a genuine discussion about the use of ROM and consider the possibility that ROM might even improve our psychodynamic practices. Integrating ROM into psychodynamic didactic courses and supervision in graduate training could be a good starting point.
... Over the last two decades, the incorporation of routine outcome monitoring (ROM) as part of clinical practice has been one of the most outstanding developments (Lambert & Shimokawa, 2011;Lutz, de Jong et al., 2021). While the literature supports the effectiveness of ROM as a resource for a vast array of setting, clinical conditions, and treatment modalities, there are some indications of shortcomings in its applicability (Boswell et al., 2015). ...
Article
This work presents a case study in which Cognitive-Integrative psychotherapy was used to treat a patient with obsessive-compulsive disorder with the implementation of routine outcome monitoring (ROM) at Aiglé Foundation in Argentina. The patient, a 34-year-old female with a university degree reports having obsessive ideas about dirt or pollution, causing harm to others, and religious and superstitious topics on a daily basis. The therapeutic process carried out during the first 17 psychotherapy sessions is described: construction of the therapeutic alliance, psychoeducation, and main interventions. The purpose of the article is to describe a case in which the measures' results did not show clinically relevant improvement even though the clinical indicators assessed by the therapist and the patient's subjective evaluation were positive. The article , shows the application of ROM during the supervision process, proposes interpretations of these results, and discusses decision-making processes in the light of this discrepancy.
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Purpose: This study used a linear mixed model and descriptive analysis of quantitative, archival data to evaluate improvement among clients receiving graduate trainee-delivered individual psychotherapy ( N = 421), and for those in dialectical behavior therapy ( n = 52). Method: The OQ 45.2 was administered to clients on a session-by-session basis. This analysis gave attention to an overall course of recovery and to meaningful interaction effects: to those variables serving as potential moderators. We gave attention to both attrition and deterioration, based on Lambert’s earlier observation of this elevated risk among trainees. Results: Analysis showed evidence of client improvement (change over time), broadly. Distinct trajectories emerged early in treatment for participants who went on to improve versus those who deteriorated. Discussion: Clinical and training implications are discussed, including the importance of giving attention to these unique and potentially distinct trajectories early in a clinical relationship.
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Patient-focused research attempts to provide information that answers the question: Is this treatment benefiting this patient? Although several systems have been developed to monitor and provide feedback about a patient's response to psychotherapy, few if any have been tested empirically. The current study divided 609 patients into four groups (two experimental and two control) to determine if feedback regarding patient progress, when provided to a therapist, affected patient outcome and number of sessions attended. Results showed that feedback increased the duration of treatment and improved outcome relative to patients in the control condition who were predicted to be treatment failures. Twice as many patients in the feedback group achieved clinically significant or reliable change and one-third as many were classified as deteriorated by the time treatment ended. For those patients who were predicted to have a positive response to treatment, feedback to therapists resulted in a reduction in the number of treatment sessions without reducing positive outcomes.
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Industry-wide, there is a trend toward making outcome evaluation a routine part of therapeutic services. Although various multidimensional assessments of outcome are valid and reliable, their methodological complexity, length of administration, and cost often render them infeasible for many service providers and settings. The present article describes the development and validation of an ultra-brief outcome measure, the Outcome Rating Scale (ORS). The instrument’s psychometric properties are examined and reported for both clinical and nonclinical samples. Based on experience with the instrument at the various sites in the study, the feasibility of the scale is considered. Results indicate that the ORS represents a balanced trade-off between the reliability and validity of the longer measures, and the feasibility of this brief scale. Results and implications for clinical practice and future research are discussed.
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Patient-focused research systems have been developed to monitor and inform therapists of patients' treatment progress in psychotherapy as a method of enhancing outcome. The current study examined the effects of providing treatment progress information to only therapists and to both patients and therapists during the course of psychotherapy. Outpatients (N = 201) at a hospital-based psychotherapy clinic were randomly assigned to 1 of 3 treatment groups: treatment as usual, therapist feedback, and patient–therapist feedback. Patients in the 2 feedback conditions demonstrated significantly greater improvement at termination than those in the treatment-as-usual condition, with no average increase in sessions attended. These findings suggest that providing feedback to patients and therapists may be a viable approach to enhancing patient outcomes.
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Client-focused research systems have been developed to monitor and provide feedback information about clients' progress in psychotherapy as a method of enhancing outcome for those who are predicted to be treatment failures. In the current study, the authors examined whether feedback regarding client progress and the use of clinical support tools (CSTs) affected client outcome and number of sessions attended. Results showed that clients in the feedback plus CST group stayed in therapy longer and had superior outcomes. Nearly twice as many clients in the feedback plus CST group achieved clinically significant or reliable change, and fewer were classified as deteriorated by the time treatment ended. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Sensitivity to change of the Outcome Questionnaire (OQ; M. J. Lambert et al., 1996) items, subscales, and total score was evaluated for clients receiving personal counseling in university counseling center settings. OQ data collected for 248 university students who did not receive treatment and 5,553 students who received treatment from 527 therapists employed in 40 university counseling centers nationwide were included in the analyses. Comparisons between the treated and untreated groups indicated that the OQ total score, all of the subscales, and 34 of the 45 items met 2 preset criteria for change sensitivity, providing support for the OQ as an appropriate index of outcome in counseling center clients. The 11 OQ items that failed to demonstrate change sensitivity were aimed at assessing aspects of interpersonal functioning, related to specific physical symptoms, or were susceptible to floor effects. The possibility of using change sensitivity results in revising the OQ for optimal use in counseling center settings is addressed, and general implications for outcome test development are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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Several systems have been developed to monitor and feedback information about a client's responses to psychotherapy as a method of enhancing client outcome. The current study divided 1020 clients into four groups (two experimental and two control) to determine if feedback regarding client progress, when provided to a therapist, affected client outcome and number of sessions attended. Results showed that feedback increased the duration of treatment and improved outcome for clients identified as potential treatment failures thereby replicating an earlier study using nearly identical methodology. Nearly twice as many clients in the feedback group achieved clinically significant or reliable change and fewer were classified as deteriorated by the time treatment ended. For those clients who were predicted to have a positive response to treatment, feedback to therapists resulted in an equal number of treatment sessions and equivalent outcomes compared to the no feedback controls. The results are discussed in terms of quality management in routine clinical practice and the need to base treatment decisions on clients' response to treatment rather than arbitrary session limits. Suggestions for additional research aimed at enhancing the effects of feedback on client outcome are made. Copyright © 2002 John Wiley & Sons, Ltd.
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An emerging practice-based research strategy attempts to monitor ongoing patient treatment response for the purpose of improving psychotherapy outcomes. This body of research uses information about patient improvement and declines to prompt psychotherapists about the possible need to modify their treatment approach, step up or step down the intensity of interventions, attend to relationship ruptures, or even make referrals to other providers. Within this research paradigm, all systems use statistical methods that attempt to predict the final outcome of psychotherapy. In this study, the dependence and homogeneity of session-by-session responses to psychotherapy were explored with data from 3 clinical settings (N=608). The results suggest that dependence (i.e., early change predicts later change) and nonhomogeneity (i.e., decelerating improvement courses) cannot be taken for granted. An outcome-monitoring strategy is recommended that takes these findings into account. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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