Culture matters: Chinese mental health professionals' fear of losing face in routine outcome monitoring.

OBJECTIVE: The culturally salient fear of losing face might influence Chinese therapists' attitudes toward and use of routine outcome monitoring (ROM). We tested a model wherein self-face concern is associated with ROM use by way of attitudes toward ROM, and whether this process is weakened when therapists report high counseling self-efficacy and perspective-taking. METHOD: A national sample of Chinese mental health professionals (N = 371) completed questionnaires on their fear of losing face, attitudes toward ROM, ROM use, counseling self-efficacy, and perspective-taking. RESULTS: Regression-based analyses showed that fear of losing face was linked to greater negative attitudes toward ROM and lower ROM use. Greater negative attitudes mediated the relationship between fear of losing face and ROM use. However, neither counseling self-efficacy nor perspective-taking mitigated the relationship between self-face concern and ROM use; instead, they exacerbated this relationship through different paths. In the mediated pathway, counseling self-efficacy in coping with clients with difficult problems interacted with self-face concern to predict negative attitudes toward ROM. Perspective-taking served as a moderator that exacerbated the direct relationship between self-face concern and ROM use. CONCLUSIONS: Findings suggest the importance of considering culturally salient factors in implementing ROM in China and other non-Western contexts.

Health-related quality of life and the physician-patient alliance: a preliminary investigation of ultra-brief, real-time measures for primary care.

PURPOSE: Many psychometrically sound measures exist but feasibility makes real-time use difficult. This study validates two ultra-brief, patient-rated instruments, the Wellness Rating Scale (WRS) and the Provider Alliance Scale (PAS). METHODS: The WRS and the EuroQol visual analogue scale (EQ VAS) were completed by patients in a primary care practice (n = 97) and a non-clinical sample of graduate students (n = 122). The WRS and the Patient-Completed Health Outcome Measures Information System-Global 10 (PROMIS) were completed by patients in a primary care setting (n = 305). The WRS and PROMIS were also administered to graduate students (n = 158). The PAS and the Patient Physician Working Alliance were administered to a primary care sample of 40 and a retrospective sample of students (n = 228). RESULTS: The WRS generated reliable scores, with coefficient alphas ranging from .83 to .91. Bivariate correlations between the WRS and the EQ VAS (r = .55-.75) and PROMIS (r = .64-73) indicate moderate-to-strong concurrent validity. The larger coefficients were with patient samples. Construct validity was evidenced by higher levels of distress for chronic conditions as well as for clinical samples. The PAS achieved an alpha of .94 for the primary care sample and .87 for the retrospective sample and bivariate correlations (r = .61-.72) indicate moderate-to-strong evidence of concurrent validity. CONCLUSIONS: The WRS and PAS demonstrate sufficient reliability and validity to move to the next phase of research: a randomized clinical trial comparing the use of real-time feedback from the two measures to treatment as usual targeting outcomes of chronic disease patients.

Client feedback in China: A randomized clinical trial in a college counseling center.

Although client feedback has been demonstrated to improve psychotherapy outcomes in over a dozen randomized clinical trials, no studies to date have investigated the feedback effect outside of the United States or Europe. This study examined the impact of a client feedback intervention, the Partners for Change Outcome Management System, in a college counseling center in Wuhan, China (N = 186). Using a randomized design within routine care, treatment as usual (TAU; n = 85) was compared with a feedback condition (n = 101) in which therapists had access to client-generated outcome and alliance information at each session. Clients in the feedback condition demonstrated significantly greater improvement than those in the TAU condition at posttreatment. Not-on-track (n = 60) clients also demonstrated significantly more improvement at 6 times the rate of reliable change compared with the TAU condition. Survival analysis revealed that 66.7% of the clients in the feedback condition achieved reliable and clinically significant change after a median of 4 sessions whereas 57.0% of the clients in the TAU condition achieved reliable and clinically significant change after a median of 6 sessions. Alliance scores improved significantly more across treatment and were higher at posttreatment in the feedback condition. Although preliminary, this study suggests that the positive effects of improved outcomes and increased efficiency associated with systematic client feedback can also occur in a college counseling setting in China. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

The Partners for Change Outcome Management System: A Both/And System for Collaborative Practice.

Systematic client feedback (SCF) is increasingly employed in mental health services worldwide. While research supports its efficacy over treatment as usual, clinicians, especially those who highly value relational practices, may be concerned that routine data collection detracts from clinical process. This article describes one SCF system, the Partners for Change Outcome Management System (PCOMS), along a normative (standardized measurement) to communicative (conversational) continuum, highlighting PCOMS' origins in everyday clinical practice. The authors contend that PCOMS represents "both/and," providing a valid signal of client progress while facilitating communicative process particularly prized by family therapists steeped in relational traditions. The article discusses application of PCOMS in systemic practice and describes how it actualizes time-honored family therapy approaches. The importance of giving voice to individualized client experience is emphasized.

The evolution of feedback: Toward a multicultural orientation.

There have been great strides in psychology regarding diversity, equity, inclusion, and multicultural competence, but a need remains to translate these values into actionable practices in psychotherapy. While the case has been made that measurement-based care is an evidence-based intervention that improves outcomes and reduces dropouts (de Jong et al., 2021) and recently that it provides a transparent collaborative process to engage clients in treatment (Boswell et al., 2023), it has not been widely considered as a methodology for multicultural competence. We trace the evolution of what was once called "patient-focused research" (Lambert, 2001) and identify a significant change in recent writings to include important clinical and collaborative processes, a transition from a strictly normative or nomothetic understanding of the value of feedback to an appreciation of its communicative or idiographic processes. We propose that systematic client feedback promotes a "multicultural orientation" (Owen, 2013) at the individual therapist-client level and that client responses to outcome and process measures can foster cultural humility and create cultural opportunities (Hook et al., 2017) to address marginalization and other sociocultural factors relevant to treatment. Using one system to illustrate what is possible for all feedback approaches, we present client examples that demonstrate an integration of a multicultural orientation. We suggest that systematic client feedback can provide a structure to address diversity, marginalization, and privilege in psychotherapy. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

When meta-analysis continues to mislead: A reply to Østergård and Hougaard (2020).

Reply to comments on an article by Duncan and Sparks (see record 2018-10637-001). Østergård and Hougaard (2020) reiterate the flawed conclusions of their meta-analysis of the Partners for Change Outcome Management System (PCOMS) and obfuscate the main point of our critique (Duncan & Sparks, 2020). Despite the lauded statistics and selection criteria, the inclusion of six significantly confounded investigations resulted in a misleading overattribution of meaning to studies of questionable methodology that warranted exclusion. Further, their hypothesis that social desirability leads to inflated effect sizes on the Outcome Rating Scale (ORS) is insufficient. It is not supported by studies finding comparable results to the ORS on independent outcome measures or investigations reporting that change on measures of life functioning, like the ORS, precedes that depicted on symptom scales. While more research is needed, the totality of credible research supports the efficacy of PCOMS. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Measurement-based care in integrated health care: A randomized clinical trial.

Introduction: Many suggest that the next step for integrated care is widespread implementation of measurement-based care (MBC). Although the measures most associated with MBC are standardized, no randomized clinical trial has demonstrated their use to improve psychotherapeutic outcomes with embedded behavioral health providers in integrated care. Two evidence-based MBC systems have been studied in a variety of behavioral health environments, but neither system has been investigated in integrated health care. Addressing this gap in the literature, the present study evaluated the use of MBC, specifically the Partners for Change Outcome Management System, in three integrated care sites. Method: Using a randomized design within routine care, treatment as usual (TAU; n = 133) was compared using the Outcome Rating Scale (ORS) and Patient Health Questionnaire-9 (PHQ-9) with a feedback condition (n = 147) in which behavioral health providers had access to patient-generated outcome (ORS only) and alliance information at each session. Results: Patients in the feedback condition demonstrated significantly more improvement than those in the TAU condition posttreatment on the ORS. Patients in the feedback condition also achieved significantly more clinically significant change as measured by both the ORS and PHQ-9. Feedback condition patients also attended significantly more sessions and dropped out significantly less that TAU patients. Discussion: Although our findings need to be replicated, this study offers evidence that the improved outcomes and reduced dropouts associated with MBC in traditional behavioral health centers also occur in integrated care settings. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

When meta-analysis misleads: A critical case study of a meta-analysis of client feedback.

Consumers of psychotherapy outcome literature consider meta-analysis the gold standard for assessing the efficacy of interventions across disparate studies. Many assume that findings are valid, especially when published in journals with research credentials. Uncritical acceptance, however, can result in real-world consequences, including whether interventions attain evidence-based status or become marginalized or are considered for implementation in public service arenas. This article examines one meta-analysis, "The Effect of Using the Partners for Change Outcome Management System as Feedback Tool in Psychotherapy-A Systematic Review and Meta-Analysis" (Østergård, Randa, & Hougaard, 2018). The findings are at odds with both the empirical record of routine outcome management as well as professional taskforce recommendations and thus provide an ideal exemplar of the risks of uncritically accepting the conclusions of a meta-analysis. Using guidelines from the Cochrane Handbook for Systematic Reviews of Interventions (Higgins & Green, 2011) and a qualitative case study methodology, this article examines Østergård et al.'s (2018) study selection, quality of evidence, and appropriateness of interpretation, emphasizing the link between flawed method and the ultimate validity of its conclusions. The method illustrated in this case study can be used to assess the legitimacy of meta-analytic findings to inform practice, funding, and policy decisions as well as how rhetoric minimizes flaws and bolsters believability. Our analysis revealed that half of the selected studies of the meta-analysis contained significant limitations, including inadequate dose of treatment and/or adherence problems, thereby calling into question its conclusions. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Psychotherapy for depressed youth in poverty: Benchmarking outcomes in a public behavioral health setting.

Research demonstrating the effectiveness of treatment with youth from low socioeconomic backgrounds is limited. To address this limitation, we evaluated pre-post psychotherapy treatment outcomes with youth presenting with depression-related diagnoses (N = 469) at a public behavioral health agency after they implemented a systematic client feedback approach as a quality improvement strategy. Clients were ethnically diverse youth at or under the poverty line. Treatment outcome was measured with the Outcome Rating Scale (Miller, Duncan, Brown, Sparks, & Claud, 2003) and the Child Outcome Rating Scale (Duncan, Sparks, Miller, Bohanske, & Claud, 2006). Benchmark methodology was used to compare effect size estimates to those achieved in randomized clinical trials. Average treatment effect sizes for the public behavioral health depression samples of children and adolescents (d = 1.39 and d = 1.69, respectively) were clinically superior to a waitlist benchmark drawn from clinical trials of youth depression, and clinically equivalent to a treatment benchmark drawn from youth depression clinical trials. Findings demonstrate that mental health services for depressed youth in poverty across an agency can be effective, and systematic client feedback may be a useful strategy to improve treatment outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Patient feedback as a quality improvement strategy in an acute care, inpatient unit: An investigation of outcome and readmission rates.

High psychiatric readmission rates continue while evidence suggests that care is not perceived by patients as "patient centered." Research has focused on aftercare strategies with little attention to the inpatient treatment itself as an intervention to reduce readmission rates. Quality improvement strategies based on patient-centered care may offer an alternative. We evaluated outcomes and readmission rates using a benchmarking methodology with a naturalistic data set from an inpatient psychiatric facility (N = 2,247) that used a quality-improvement strategy called systematic patient feedback. Benchmarks were constructed using randomized clinical trials (RCTs) from inpatient treatment for depression, RCTs from patient feedback in outpatient settings, and national data on psychiatric hospital readmission rates. A systematic patient feedback system, the Partners for Change Outcome Management System (PCOMS), was used. Overall pre-post effect sizes were d = 1.33 and d = 1.38 for patients diagnosed with a mood disorder. These effect sizes were statistically equivalent to RCT benchmarks for feedback and depression. Readmission rates were 6.1% (30 days), 9.5% (60 days), and 16.4% (180 days), all lower than national benchmarks. We also found that patients who achieved clinically significant treatment outcomes were less likely to be readmitted. We tentatively suggest that a focus on real-time patient outcomes as well as care that is "patient centered" may provide a path toward lower readmission rates in addition to other evidence-based strategies after discharge. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Casting a wider net in behavioral health screening in primary care: a preliminary study of the Outcome Rating Scale.

Introduction The integration of behavioral health services into primary care has led to enhanced use of brief screening measures to identify mental health problems. Although useful, such instruments are largely symptom based and diagnosis specific. This narrow focus can potentially limit the identification of broader social or relational distress in patients that affect medical outcomes, as well as present feasibility challenges using a multi-measure approach in identifying mental health comorbidities. METHOD: This exploratory study of adult primary care patients compared an ultra-brief, and widely used measure of global distress across life functioning, the Outcome Rating Scale (ORS), with the Patient Health Questionnaire (PHQ-9 and PHQ-2). RESULTS: Correlations between the ORS and the PHQ-9 and PHQ-2 indicated agreement between the measures in classifying patients, and the ORS identified significantly more patients in the clinical range. Discussion Although results are preliminary, the ORS may cast a wider net in identifying patients with significant distress in primary care.

The Partners for Change Outcome Management System (PCOMS) revisiting the client's frame of reference.

Despite overall psychotherapy efficacy (Lambert, 2013), many clients do not benefit (Reese, Duncan, Bohanske, Owen, & Minami, 2014), dropouts are a problem (Swift & Greenberg, 2012), and therapists vary significantly in success rates (Baldwin & Imel, 2013), are poor judges of negative outcomes (Chapman et al., 2012), and grossly overestimate their effectiveness (Walfish, McAlister, O'Donnell, & Lambert, 2012). Systematic client feedback offers 1 solution (Duncan, 2014). Several feedback systems have emerged (Castonguay, Barkham, Lutz, & McAleavey, 2013), but only 2 have randomized clinical trial support and are included in the Substance Abuse and Mental Health Administration's National Registry of Evidence-Based Programs and Practices: The Outcome Questionnaire-45.2 System (Lambert, 2010) and the Partners for Change Outcome Management System (PCOMS; Duncan, 2012). This article presents the current status of PCOMS, the psychometrics of the PCOMS measures, its empirical support, and its clinical and training applications. Future directions and implications of PCOMS research, training, and practice are detailed. Finally, we propose that systematic feedback offers a way, via large-scale data collection, to reprioritize what matters to psychotherapy outcome, reclaim our empirically validated core values and identity, and change the conversation from a medical model dominated discourse to a more scientific, relational perspective.

The ethics and science of medicating children.

Prescriptions for psychiatric drugs to children and adolescents have skyrocketed in the past 10 years. This article presents evidence that the superior effectiveness of stimulants and antidepressants is largely a presumption based on an empirical house of cards, driven by an industry that has no conscience about the implications of its ever growing, and disturbingly younger, list of consumers. Recognizing that most mental health professionals do not have the time, and sometimes feel ill-equipped to explore the controversy regarding pharmacological treatment of children, this article discusses the four fatal flaws of drug studies to enable critical examination of research addressing the drugging of children. The four flaws are illustrated by the Emslie studies of Prozac and children, which offer not only a strident example of marketing masquerading as science, but also, given the recent FDA approval of Prozac for children, a brutal reminder of the danger inherent in not knowing how to distinguish science from science fiction. The authors argue that an ethical path requires the challenge of the automatic medical response to medicate children, with an accompanying demand for untainted science and balanced information to inform critical decisions by child caretakers.

Benchmarking outcomes in a public behavioral health setting: feedback as a quality improvement strategy.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of a large public behavioral health (PBH) agency serving only clients at or below the federal poverty level that had implemented continuous outcome feedback as a quality improvement strategy. METHOD: The authors investigated the post treatment outcomes of 5,168 individuals seeking treatment for a broad range of diagnoses who completed at least 2 psychotherapy sessions. The Outcome Rating Scale (ORS; Duncan, 2011; Miller & Duncan, 2004) was used to measure outcomes. Clients had a mean age of 36.7 years and were predominantly female (60.7%) and White (67.8%), with 17.7% being Hispanic, 9.3% being African American, and 2.8% being Native American. Forty-six percent were diagnosed with depression, mood, and anxiety disorders; 18.8% were diagnosed with substance abuse disorders; and 14.4% were diagnosed with bipolar disorder and schizophrenia. A subset of clients with a primary diagnosis of a depressive disorder was compared to treatment efficacy benchmarks derived from clinical trials of major depression. Given that the PBH agency had also implemented an outcome management system, the total sample was also compared to benchmarks derived from clinical trials of continuous outcome feedback. RESULTS: Treatment effect sizes of psychotherapy delivered at the PBH agency were comparable to effect size estimates of clinical trials of depression and feedback. Observed effect sizes were smaller, however, when compared to feedback benchmarks that used the ORS. CONCLUSIONS: Services to the poor and disabled can be effective, and continuous outcome feedback may be a viable means both to improve outcomes and to narrow the gap between research and practice.

Outside the Black Box: Re-assessing Pediatric Antidepressant Prescription.

OBJECTIVE: The purpose of this review is to assess whether evidence supports a favorable risk/benefit profile for pediatric antidepressant use and reconsideration of the black box. METHOD: The review examines studies post-black box purporting to show declines in pediatric antidepressant use and rising youth suicide, summarizes evidence for efficacy and safety of pediatric antidepressants, and discusses irregularities in recent meta-analyses of fluoxetine for youth. RESULTS: Pediatric antidepressant prescription did not significantly decline post-black box and youth suicide has risen only in recent years. Recent meta-analyses fail to undermine evidence that antidepressants are associated with increased risk of suicidality in youth. CONCLUSIONS: First line prescription of antidepressants for youth is not advisable. The black box and international warnings on pediatric use of antidepressants are warranted. Wider availability of psychosocial options for depressed youth is recommended.

OBJECTIF: Cette revue a pour but d'évaluer si les données probantes soutiennent un profil risques-avantages favorable à l'utilisation d'antidépresseurs pédiatriques, et de réexaminer la boîte noire. MÉTHODE: La revue examine les études postérieures à la boîte noire censées démontrer l'utilisation décroissante d'antidépresseurs pédiatriques et la montée du suicide chez les adolescents, résume les données probantes sur l'efficacité et l'innocuité des antidépresseurs pédiatriques, et présente les irrégularités des récentes méta-analyses de la fluoxétine pour adolescents. RÉSULTATS: La prescription d'antidépresseurs pédiatriques n'a pas connu de baisse significative postérieurement à la boîte noire, et le suicide chez les adolescents n'a augmenté que dans les dernières années. Les méta-analyses récentes n'infirment pas les données probantes de l'association des antidépresseurs à un risque accru de suicidabilité chez les adolescents. CONCLUSIONS: La prescription en première intention d'antidépresseurs à des adolescents n'est pas à conseiller. La boîte noire et les mises en garde internationales sur l'utilisation pédiatrique d'antidépresseurs sont justifiées. Une offre plus variée d'options psychosociales pour les adolescents déprimés est recommandée.

The alliance in couple therapy: Partner influence, early change, and alliance patterns in a naturalistic sample.

OBJECTIVE: The purpose of this study was to explore the relationship between the alliance and outcome in couple therapy and examine whether the alliance predicted outcomes over and above early change. The authors also investigated partner influence and gender and sought to identify couple alliance patterns that predicted couple outcomes. METHOD: The authors examined the alliances and outcomes at posttreatment and follow-up of 250 couples seeking treatment for marital distress in a naturalistic setting. The Session Rating Scale was used to measure the alliance; the Outcome Rating Scale and Locke Wallace Marital Adjustment Scale were used to measure outcomes. Couples were White, Euro-Scandinavian, and heterosexual, with a mean age of 38.5 years and average number of years together of 11.8. On a subsample (n = 118) that included couples with 4 or more sessions, the authors investigated the relationship between the alliance and outcome controlling for early change, and patterns of alliance development were delineated. RESULTS: In the full sample, first-session alliances were not predictive of outcomes, but last-session alliances were predictive for both individuals and their partners. In the subsample, third-session alliances predicted outcome significantly above early change (d = 0.25) that exceeded the reliable change index. Couple alliances that started over the mean and increased were associated with significantly more couples achieving reliable or clinically significant change. Gender influences were mixed. CONCLUSIONS: Given the current findings suggesting a potential alliance impact over and above symptom relief as well as the importance of ascending alliance scores, continuous assessment of the alliance appears warranted.

Using client feedback to improve couple therapy outcomes: a randomized clinical trial in a naturalistic setting.

Despite the overall efficacy of psychotherapy, dropouts are substantial, many clients do not benefit, therapists vary in effectiveness, and there may be a crisis of confidence among consumers. A research paradigm called patient-focused research--a method of enhancing outcome via continuous progress feedback--holds promise to address these problems. Although feedback has been demonstrated to improve individual psychotherapy outcomes, no studies have examined couple therapy. The current study investigated the effects of providing treatment progress and alliance information to both clients and therapists during couple therapy. Outpatients (N = 410) at a community family counseling clinic were randomly assigned to 1 of 2 groups: treatment as usual (TAU) or feedback. Couples in the feedback condition demonstrated significantly greater improvement than those in the TAU condition at posttreatment, achieved nearly 4 times the rate of clinically significant change, and maintained a significant advantage on the primary measure at 6-month follow-up while attaining a significantly lower rate of separation or divorce. Mounting evidence of feedback effects with different measures and populations suggests that the time for routine tracking of client progress has arrived.

The partners for change outcome management system.

A number of systems provide feedback regarding client progress and experience of the therapeutic alliance to clinicians. Available evidence indicates that access to such data improves retention and outcome for clients most at risk for treatment failure. Over the last several years, the team at the Institute for the Study of Therapeutic Change has worked to develop an outcome management system that not only provides valid and reliable feedback, but also is as user-friendly as possible for therapists and consumers. In this article, we describe the system and summarize current research findings.