Attitudes Towards the Use of Routine Outcome Monitoring of Psychological Therapies Among Mental Health Providers: The EBPAS-ROM

The time has come to implement routine outcome monitoring in mental health services across Latin America

This perspective highlights the transformative potential of routine outcome monitoring in mental health care and public health, advocating for its adoption in Latin America to enhance data-driven decision-making and service quality across the lifespan. The discussion examines global advancements alongside local efforts to implement routine outcome monitoring, addressing key challenges such as infrastructure limitations, clinician engagement, and the need for contextual adaptations. Central to these efforts are strategies like utilizing digital platforms, fostering political commitment, securing financial investments, and prioritizing person-/patient-centered approaches. By integrating routine outcome monitoring into public health systems, policymakers and practitioners can better monitor mental health trends, allocate resources effectively, and design interventions that address community needs. While significant barriers remain, we urge the adoption of digital routine outcome monitoring solutions in Latin America and call for collaborative efforts to fully realize the potential of routine outcome monitoring in improving both mental health services and broader public health initiatives.

Consultation Content and Techniques for measurement-Based Care Implementation in Youth Community Mental Health Settings

Measurement-based care (MBC) is an evidence-based practice (EBP) focused on regularly administering outcome measures to clients to inform clinical decision making. While MBC shows promise for improving youth treatment outcomes, therapist adoption remains low. Clinical consultation is one strategy that improves MBC implementation, but our limited understanding of consultation hinders the ability to optimize its impact. This research explored the content of, and techniques used during MBC consultation calls. Therapists (N = 55) in a randomized controlled trial treating adolescents with anxiety and/or depression were trained to utilize MBC with usual treatment using the Youth Outcome Questionnaire (YOQ) through an online measurement feedback system (MFS). Weekly ongoing consultation followed an initial workshop training in MBC. Case discussions (N = 294) during consultation calls were coded using a developed codebook, including 12 content and 10 consultant techniques. Results indicated that content focused predominantly on interpretation of client symptom and alliance report, planning for YOQ administration, and discussion of data with clients in session. Common consultant techniques included modeling and eliciting report viewing and interpretation, making clinical suggestions, and didactics about clinical and technical issues. Notably, role-play/behavioral rehearsal was not used. The prevalence of passive consultation techniques (suggestions, didactics) suggests a focus on teaching rather than active techniques (behavioral rehearsal, modeling), potentially influenced by the novelty of MBC and MFS. Technical aspects of MBC, such as measure administration and system usage, emerged as key consultation content, highlighting an unanticipated emphasis on logistics over clinical implementation. These findings underscore the evolving role of consultation in supporting MBC implementation and suggest that addressing technical challenges early in training might enhance adoption.

The Relationship Between Therapist Perceptions and Engagement in Measurement-Based Care

Measurement-based care (MBC) is an evidence-based practice that has been supported by the American Psychological Association for almost two decades (APA 2006; Boswell et al. 2023). However, the widespread dissemination of technology-enabled platforms supporting the implementation of MBC in routine clinical settings has failed to significantly increase therapist rates of engagement in MBC. The present study was designed to examine the relationship between therapist perceptions of and their engagement in MBC, an area of inquiry that has yet to be pursued. A sample of 196 therapists and their respective clients (N = 12,166) was extracted from the therapist pool of a technology-enabled, digital mental health platform offering an automated MBC system. The sample of therapists was administered a previously validated measure assessing their perceptions of different aspects of MBC. Additionally, their frequency of viewing client outcome scores was assessed as an indicator of engagement in MBC. Analyses failed to detect a direct relationship between therapist perceptions of each aspect of MBC and their frequency of viewing client scores. Nonetheless, a subsequent cluster analysis identified a three-cluster solution. The cluster displaying the most positive perceptions of all aspects of MBC was associated with higher frequency of viewing client score. These findings suggest that therapist perceptions of MBC's clinical usefulness could have a unique impact on therapist engagement in MBC.

Barriers to Progress Feedback Adoption in Outpatient Geriatric Mental Healthcare: Exploring Age-Related Factors - A Qualitative Study

Monitoring treatment progress through progress feedback is recognized for its efficacy and demonstrated value. However, its integration and utilization within treatments still need to be improved. Insufficient understanding exists regarding the factors within geriatric mental healthcare influencing the adoption of progress feedback. This study aimed to explore the determinants impacting the utilization of progress feedback within outpatient geriatric mental healthcare, specifically focusing on age-related perspectives and patient group characteristics. This qualitative investigation employed semi-structured interviews involving clinicians (N = 14) selected from four outpatient geriatric teams. The findings revealed both inhibiting and facilitating perspectives concerning progress feedback. Clinicians preferred user-friendly, specific, and tailored measures. Challenges included organizational support, integration in work processes, training, and the digital progress feedback system. Age-related perspectives such as older adults' diverse issues, limited digital skills, and cognitive problems hindered implementation, particularly in the oldest generation of older patients. In outpatient geriatric mental healthcare, many factors and attitudes influencing progress feedback align with those observed in adult psychiatry literature. Moreover, this study highlights specific age-related factors that impede the adoption and implementation of progress feedback, shedding light on the specific barriers within this context.

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 from Psychotherapists' Perspectives: A Framework Analysis Study of Expected Benefits and Difficulties

Psychotherapists' attitudes and expectations towards routine outcome monitoring can impact the likelihood of its fruitful implementation. While existing studies have predominantly focused on Europe and North America, research in Latin America remains limited. The aim of this study is to explore therapists' expected benefits and difficulties prior to implementing a routine outcome monitoring system in a university psychotherapy service in Ecuador. An exploratory and descriptive cross-sectional qualitative study was carried out with 20 participants aged 21 to 47. Semi-structured interviews were conducted to explore participants' knowledge about routine outcome monitoring, their expectations of the difficulties, benefits, usability and risks of using a monitoring system, as well as their expectations about their role in the process. The data analysis adhered to the framework analysis methodology, leading to the identification of six overarching themes, 36 specific themes and 82 subthemes. The interviews highlighted a spectrum of positive and negative expectations at several levels: institutional/general, therapeutic process, therapists, and clients. Perceived benefits encompassed various aspects, including the availability of supplementary information, continuous adaptation of the therapeutic process, facilitation of organization and treatment planning, opportunities for professional development, and fostering patient trust and empowerment. On the other hand, anticipated difficulties comprised concerns such as discomfort among therapists and clients, increased workload, system usage and technical difficulties, and the risk of excessive quantification. Overall, participants expressed more anticipated benefits than difficulties. We present recommendations that can support and optimize the current local implementation efforts of routine outcome monitoring, both within this service and in other settings. These recommendations consider ways to meet positive expectations and address or mitigate negative ones.

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.

Individual-Specific Animated Profiles of Mental Health

How important is the timing of the pretreatment evaluation? If we consider mental health to be a relatively fixed condition, the specific timing (e.g., day, hour) of the evaluation is immaterial and often determined on the basis of technical considerations. Indeed, the fundamental assumption underlying the vast majority of psychotherapy research and practice is that mental health is a state that can be captured in a one-dimensional snapshot. If this fundamental assumption, underlying 80 years of empirical research and practice, is incorrect, it may help explain why for decades psychotherapy failed to rise above the 50% efficacy rate in the treatment of mental-health disorders, especially depression, a heterogeneous disorder and the leading cause of disability worldwide. Based on recent studies suggesting within-individual dynamics, this article proposes that mental health and its underlying therapeutic mechanisms have underlying intrinsic dynamics that manifest across dimensions. Computational psychotherapy is needed to develop individual-specific pretreatment animated profiles of mental health. Such individual-specific animated profiles are expected to improve the ability to select the optimal treatment for each patient, devise adequate treatment plans, and adjust them on the basis of ongoing evaluations of mental-health dynamics, creating a new understanding of therapeutic change as a transition toward a more adaptive animated profile.

Feasibility of Recovery Assessment Scale - Domains and Stages (RAS-DS) for everyday mental health practice

Introduction

Routine use of self-rated measures of mental health recovery can support recovery-oriented practice. However, to be widely adopted, outcome measures must be feasible. This study examined the feasibility of Recovery Assessment Scale - Domains and Stages (RAS-DS) from the perspectives of mental health workers.

Method

Mental health workers who had previously sought permission to use RAS-DS (n=58) completed an online survey that explored three aspects of feasibility: practicality, acceptability and applicability.

Results

The highest-rated feasibility items related to applicability, or usefulness in practice, with over 90% of participants reporting that RAS-DS helps "promote discussion" and covers areas that are "meaningful to consumers". Acceptability items indicated that the purpose of RAS-DS is clear but length was an issue for some participants. At a practical level, RAS-DS was seen as easy to access but training was seen by many as necessary to ensure optimal use.

Conclusion

Results suggest potential usefulness of RAS-DS as a routine outcome measure and identify aspects that can be addressed to further enhance feasibility including provision of training materials and opportunities, wide-reaching promotion of its use as a collaborative tool, and further investigation of issues around instrument length.

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.

Implementation facilitation strategies to promote routine progress monitoring among community therapists

Despite substantial support for the importance of routine progress monitoring (RPM) as part of evidence-based practice, few providers utilize measurement-based care. This study sought to identify the relative importance of facilitation strategies viewed as most helpful for increasing intention to use RPM among 388 ethnically diverse community therapists serving children and families. Four types of facilitation strategies were examined: language/interpretability, automation, staffing/access, and requirements. Mixed analyses of variance found that therapists' reported intentions to use RPM were more influenced by strategies of automating assessment administration, provision of clerical assistance, and agency requirements than by making linguistically appropriate measures available. However, the importance of strategies differed depending on therapist race/ethnicity and current RPM use. Language/interpretability of RPM assessments was less emphasized for non-Hispanic White therapists and therapists who have not yet or only minimally adopted RPM compared with ethnic minority therapists and therapists who regularly use RPM, respectively. Furthermore, therapists who were not current RPM users emphasized automation more than staffing/access. Results may inform prioritization of implementation facilitation strategies for agencies to encourage RPM. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Improving the Quality of Children's Mental Health Care with Progress Measures: A Mixed-Methods Study of PCIT Therapist Attitudes

Progress measures are an evidence-based technique for improving the quality of mental health care, however, clinicians rarely incorporate them into treatment. Research into how measure type impacts clinician preference has been recommended to help improve measure implementation. Parent–Child Interaction Therapy (PCIT) is an assessment-driven treatment that serves as an ideal intervention through which to investigate measure preferences given its routine use of two types of assessments, a behavioral observation (the Dyadic Parent–Child Interaction Coding System) and a parent-report measure (the Eyberg Child Behavior Inventory). This study investigated PCIT therapist attitudes towards progress measures used within PCIT and children’s mental health treatment generally. A mixed-method (QUAN + QUAL) study design examined PCIT therapist attitudes towards two types of progress measures and measures used in two contexts (PCIT and general practice). Multi-level modeling of a survey distributed to 324 PCIT therapists identified predictors of therapist attitudes towards measures, while qualitative interviews with 23 therapists expanded and clarified the rationale for differing perceptions. PCIT therapists reported more positive attitudes towards a behavioral observation measure, the DPICS, than a parent-report measure, the ECBI, and towards measures used in PCIT than in general practice. Clinician race/ethnicity was significantly related to measure-specific attitudes. Qualitative interviews highlighted how perceptions of measure reliability, type of data offered, ease of use, utility in guiding sessions and motivating clients, and embeddedness in treatment protocol impact therapist preferences. Efforts to implement progress monitoring should consider preferences for particular types of measures, as well as how therapists are trained to embed measures in treatment.

Applying behaviour change theory to understand the barriers to implementing routine outcome monitoring

BACKGROUND

Routine outcome monitoring (ROM) is a valuable tool for monitoring client progress and pre-empting deterioration, however, there is considerable variation in how data are collected and recorded and uptake in clinical practice remains low. The aim of this study was to develop a self-report measure of practitioner attitudes to ROM in order to better understand the barriers to successful implementation in Child and Adolescent Mental Health Services (CAMHS).

METHODS

An anonymous survey was completed by 184 CAMHS practitioners in the United Kingdom. The survey was designed using the Capability, Opportunity, and Motivation Model of Behaviour (COM-B). Practitioners who reported using ROM frequently in their clinical work (53%) were compared to those who used ROM infrequently (47%) across dimensions of the COM-B survey subscales.

RESULTS

Confirmatory factor analysis confirmed the proposed four-factor structure, showing acceptable model fit, with high factor loadings and good reliability for all subscales. Frequent users of ROM exhibited significantly higher psychological capability, physical opportunity, social opportunity, and motivation, compared to infrequent users F (4, 140) = 14.76, p < .0001; Pillai's Trace = .297, partial η²  = .30. Results highlight several barriers to ROM, including the belief that there is not a strong evidence base for ROM, not receiving external training, and not discussing feedback and outcome data in supervision.

IMPLICATIONS

In the hope of improving the successful implementation of ROM, this research provides an evidence-based tool for assessing practitioners' attitudes to ROM, which map on to intervention functions and represent targets for future implementation efforts.

PRACTITIONER POINTS

The value of routine outcome monitoring (ROM) as a means to measure client progress and to elevate the efficiency and quality of mental health care is well-documented in the research literature, however, uptake in practice remains relatively low. This study applied behaviour change theory to develop a psychometrically sound self-report measure of practitioners' perspectives and practices to understand the barriers to implementation in child and adolescent mental health services in the United Kingdom. The complex and multifaceted nature of the barriers to implementation requires multilevel behaviour change strategies at the client, clinician, and organisational level. Recommendations for practice include the need for integrated, multilevel strategies aimed at improving practitioners' capabilities and motivations, strong organisational leadership and a culture of data gathering and sharing, and implementation interventions, which are tailored to target local barriers.

MFA and ASA-MF: A Psychometric Analysis of Attitudes Towards Measurement-Based Care

Measurement based care (MBC) improves client outcomes by providing clinicians with routine mental health outcome data that can be used to inform treatment planning but is rarely used in practice. The Monitoring and Feedback Attitudes Scale (MFA) and Attitudes Towards Standardized Assessment Scales-Monitoring and Feedback (ASA-MF) (Jensen-Doss et al., 2016) may identify attitudinal barriers to MBC, which could help trainings and implementation strategies. This study examines the psychometric properties of the MFA and ASA-MF, including the factor structure, longitudinal invariance, and indicators of validity, in a sample of community mental health clinicians (N = 164). The measures demonstrate adequate fit to their factor structures across time and predict MBC use as captured in a client's electronic health record. Given that clinician attitudes are associated with MBC use, using instruments with psychometric support to assess attitudes fills a research to practice gap.

Introducing a Measurement Feedback System for Youth Mental Health: Predictors and Impact of Implementation in a Community Agency

Measurement feedback systems (MFSs) that routinely collect and report client progress to mental health therapists have demonstrated beneficial impact on outcomes in numerous studies, with evidence that there is a dose-response relationship related to the implementation of the MFS. The current study examined the impact of MFS implementation (Implementation Index) on youth symptom outcomes separately by caregiver and youth self-report. Additionally, we tested the extent to which Implementation Index rates varied by individual therapists and clients, and whether therapist and client characteristics predicted MFS implementation. Methods: Administrative data (client charts, youth- and caregiver-reported Youth Outcome Questionnaires) for 229 youth (52.83% Latinx, 42.79% girls, M age = 10.33) treated during a 1-year period at a community mental health organization in Central Texas were analyzed using multi-level modeling. Caregiver-reported symptoms decreased faster for those with a higher MFS Implementation Index. Between-group differences among therapists accounted for a significant proportion of variance in the Implementation Index for caregiver report, whereas client differences accounted for most of the variance in the Implementation Index for youth self-report. Therapist trainee status predicted a significant increase in the Implementation Index for caregiver-report data. Youth symptom improvement as reported by caregivers varied with the extent of MFS implementation fidelity, and MFS implementation fidelity was higher for clients treated by trainees relative to staff therapists for caregiver report of symptoms.