Outcomes Monitoring and Canadian Psychotherapists


By Terra Kowalyk, Gabriela Ionita and Marilyn Fitzpatrick 12


How do we know when we are effective as psychotherapists? Do we wait for clients to tell us they are doing better? Do we use clinical judgment? Many professions have objective measures that evaluate success. For example, educators can point to the grades of students, physicians to symptom improvement, and courtroom lawyers to ju- dicial decisions. Psychotherapists typically deal with ambiguous data and have a proud tradition of developing and refining clinical judgment to assess progress. In 2011, the CPA Task Force on Evidence-Based Practice of Psychological Treatments underlined the continuing importance of clinical judgment to evidence-based practice (EBP), “practitio- ners are required to exercise their profes- sional judgment when providing treatment”. However, the CPA’s definition of EBP also includes the idea of progress monitoring (PM) and feedback. The Task Force called for “the monitoring and evaluation of services provided to clients throughout treatment”.


The developing emphasis on PM can be traced to emerging evidence that clinical judgment is skewed toward what we want to see. As clinicians, it is normal to want all our clients to benefit. However, clinicians are not skilled at identifying deteriorating cli- ents. Hanson, Lambert and Forman looked at outcome rates of over 6,000 patients across a variety of settings, and found an average deterioration rate of 8.2%, from 3.2% to 14.1%. When comparing clinical judgment to a systematic outcome (PM) measure, Han- nan and colleagues found that the empirical method correctly predicted 100% of clients who were reliably worse or deteriorated at termination; 86% were identified by only the third session. In comparison, clinicians using their subjective clinical judgment predicted that only 3 out of 550 clients would deteriorate at termination, and only 1


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of these predictions was accurate. A further study by Hatfield, McCullough, Franz, and Krieger found that only 32% of therapists recorded patient deterioration in their case notes in situations where clients reported symptom worsening.


Not only do clinicians systematically fail to identify client deterioration, they tend to overestimate client improvement. Walfish, McAlister, O’Donnell, and Lambert asked 129 clinicians to rate their ability to help clients compared to other psychotherapists, and the extent to which they believe their clients im- prove, remain the same, or deteriorate. On average, clinicians viewed their skills to be at the 80th percentile (no respondents’ self- rating was below the 50th percentile). The majority believed that 77% of their clients improved as a result of their treatment and 3.66% deteriorated; almost half indicated that none of their clients regressed. These numbers defy statistical possibility. In the face of such positive self-assessment bias, the need for empirical outcome measure- ment is clear.


Progress Monitoring Measures


In psychotherapy, the focus is increasingly shifting to PM systems. The clinical utility of these systems has repeatedly been dem- onstrated to improve practice. For example, after the implementation of a tracking sys- tem, a centre for family services found that cancellation and no-show rates dropped by 40% and 25%, respectively, and the num- ber of clients in long-term treatment who experienced little or no improvement fell by 80%. In one year, the centre saved nearly half a million dollars, money used to hire additional staff and provide more services. Another community health and counseling organization experienced similar reductions


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