Optimising the therapy experience

The importance of using outcome measures within therapy

One of the best ways to enhance clients’ experience, reduce the likelihood of dropout and improve your own practice is to ask for feedback. Completing outcome questionnaires at the start of treatment and at regular intervals throughout therapy are a very good way of doing this. 

Some therapists hesitate to use outcome measures because they fear clients will find them onerous, or believe measures are unlikely to be sensitive to detecting change. In fact, research suggests that clients value periodic reviews of therapy. An outcome measure can also highlight positive or negative change. It has been demonstrated that clients who complete regular outcome measures have significantly better clinical outcomes (Lambert, 2007). This may be for a number of reasons:

  • Regular outcomes tracking may detect ‘off-track’ clients (i.e. those who are deteriorating unexpectedly) before they deteriorate so far that they drop out of therapy.
  • Monitoring changes may give therapists a prompt to discuss a client within clinical supervision and/or amend their approach.
  • ‘On-track’ therapies tend to show steady improvements, which can be morale-boosting for both client and therapist.
  • Returning to the outcome measures may assist client and therapist in staying on-track.

How can I introduce outcome measures into my clinical practice?

At assessment

  1. Find a good general measure of psychological problems and make sure it has been well researched. There is no point in inventing your own as they are unlikely to be as good as those already in existence.
  • One good example would be the CORE-10 measure available for free at www.coreims.co.uk/forms_mailer.php.
  • Condition-specific measures for a particular problem (depression, OCD, trauma, etc.) can also be useful.
  1. Give the questionnaire to every client in their first session with you. Read the questionnaire immediately with your client as this is a form of communication. There is no need to score it straight away but examining the items they have scored most heavily as these might be priority areas for therapy. Many measures, like the CORE, have some risk items; if a client endorses any of these, it is important information and needs further discussion.
  2. After the session, score it according to the CORE-10 scoring instructions and keep a record in your notes, along with the original questionnaire.

Every month or so thereafter

  1. Give another copy of the questionnaire and follow the same procedure as above. You can compare the current and previous questionnaires during the session to see which scores have changed and which have not. This may prompt further discussion.
  2. After the session, score the measure again. Now you have two scores, you can plot them on a time graph. There is a commonly held belief that clients get worse before they get better in an effective therapy; this is not so. The best predictor of eventual outcome is early outcome so improving scores are a good sign and worsening scores are a warning.
  3. In the next session, discuss the graph with your client. Improving scores should be encouraging. No change is not necessarily a cause for alarm, but you should continue to monitor this. However, deterioration needs to be discussed with your client and within clinical supervision.

At the end of therapy

  1. Give the client a final outcome measure, compare this with the initial measure and discuss it with the client. Do the changes in the questionnaire match their experience? Have there been changes which the questionnaire does not pick up? Calculate the score in the session and plot it on the time chart so you and the client can see the whole trajectory of therapy. You might consider giving the client a copy of the chart to take away.
  2. After the session, enter the start of therapy and end of therapy scores in a simple caseload spreadsheet/ Jacobson plot. This will help you to: 
  • discuss your overall caseload in supervision
  • identify outliers (unexpectedly good and poor outcomes)
  • persuade managers and commissioners about the effectiveness of your work.