A review and critical appraisal of measures of therapist-patient interactions in mental health settings.

OBJECTIVES: To assemble and to appraise critically the current literature on tests and measures of therapist-patient interactions in order to make recommendations for practice, training and research, and to establish benchmarks for standardisation, acceptability and routine use of such measures. DATA SOURCES: Major electronic databases (including PsycINFO) were searched from inception to 2002. REVIEW METHODS: A comprehensive conceptual map of the subject area of therapist-patient interactions was developed through data extraction from, and analysis of, studies selected from the literature searches. The results of these searches were assessed and appraised to produce a set of possible therapist-patient measures. These measures were then evaluated. RESULTS: The contextual map included the various concepts and domains that had been used in the context of the literature on therapist-patient interactions, and was used to guide the successive stages of the review. Three developmental processes were identified as necessary for the provision of an effective therapeutic relationship: 'establishing a relationship', 'developing a relationship' and 'maintaining a relationship'. Eighty-three therapist-patient measures having basic information on reliability and validity were identified for critical appraisal. The areas of the conceptual map that received most coverage (i.e. over 50% measures associated with them) were framework, therapist and patient engagement, roles, therapeutic techniques and threats to the relationship. These areas relate to the three key developmental processes outlined above. Of the 83 measures matching the content domain, 43 met the minimum standard. A total of 30 measures displayed adequate responsiveness or precision. None of the 43 measures that met the minimum standard was fully addressed in terms of acceptability and feasibility evidence. The majority of these measures had three or fewer components described. Therefore, out of a total of 83 measures matching the content domain, no measure could be said to have met an industry standard. CONCLUSIONS: The findings indicate that the therapist-patient interaction can be measured using a wide range of instruments of varying value. However, due care should be taken in ensuring that the measure is suitable for the context in which it is to be used. Following on from this work, it is suggested that specific research networks for the development of therapist-patient measures should be established, that research activity should prioritise investment in increasing the evidence base of existing measures rather than attempting to develop new ones, and that research activity should focus on improving these existing measures in terms of acceptability and feasibility issues.

Service profiling and outcomes benchmarking using the CORE-OM: toward practice-based evidence in the psychological therapies. Clinical Outcomes in Routine Evaluation-Outcome Measures.

To complement the evidence-based practice paradigm, the authors argued for a core outcome measure to provide practice-based evidence for the psychological therapies. Utility requires instruments that are acceptable scientifically, as well as to service users, and a coordinated implementation of the measure at a national level. The development of the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) is summarized. Data are presented across 39 secondary-care services (n = 2,710) and within an intensively evaluated single service (n = 1,455). Results suggest that the CORE-OM is a valid and reliable measure for multiple settings and is acceptable to users and clinicians as well as policy makers. Baseline data levels of patient presenting problem severity, including risk, are reported in addition to outcome benchmarks that use the concept of reliable and clinically significant change. Basic quality improvement in outcomes for a single service is considered.

Value of HoNOS in assessing patient change in NHS psychotherapy and psychological treatment services.

BACKGROUND: Little research on the value of Health of the Nation Outcome Scales (HoNOS) has occurred in out-patient settings, particularly psychotherapy services. AIMS: To determine whether HoNOS provides an adequate assessment for psychotherapy services which is sensitive to change. METHODS: HoNOS ratings from 1688 patients from eight out-patient psychotherapy services were collected. Of these, 362 also had ratings post-treatment. Mean scores, pre-to post-treatment differences, and reliable and clinically significant change criteria were calculated for HoNOS items and for total scores. RESULTS: The mean total HoNOS rating was 8.93, which is comparable to psychiatric out-patients. Only three items showed sufficient variability to use in assessing pre- to post-treatment change. CONCLUSIONS: Significant limitations were found in rating items that commonly present to psychotherapists. The lack of variability in most items limits HoNOS's usefulness in this population.

Measurement and psychotherapy. Evidence-based practice and practice-based evidence.

BACKGROUND: Measurement is the foundation of evidence-based practice. Advances in measurement procedures should extend to psychotherapy practice. AIMS: To review the developments in measurement relevant to psychotherapy. METHOD: Domains reviewed are: (a) interventions; (b) case formulation; (c) treatment integrity; (d) performance (including adherence, competence and skillfulness); (e) treatment definitions; (f) therapeutic alliance; and (g) routine outcome measurement. RESULTS: Modern methods of measurement can support 'evidence-based practice' for psychological treatments. They also support 'practice-based evidence', a complementary paradigm to improve clinical effectiveness in routine practice via the infrastructure of Practice Research Networks (PRNs). CONCLUSIONS: Advances in measurement derived from psychotherapy research support a model of professional self-management (practice-based evidence) which is widely applicable in psychiatry and medicine.