Is Routine Outcome Feedback Informing Your Practice? (Part 2 of 2)

Is Routine Outcome Feedback Informing Your Practice? (Part 2 of 2)

Last week we learned about Dr. Tony Rousmaniere’s heartbreaking experience with Grace – a client that unexpectedly died of a drug overdose, prompting a career crisis for Tony, which drove him to find routine outcome monitoring (ROM) to measure mental health vital signs using client feedback.

Many years after Grace’s death, Tony began work with a client named June. At that point in his career, being inspired by brilliant researchers that developed what is essentially psychotherapy’s version of “Moneyball” – ROM using predictive algorithms – he had embraced a new, empirical approach to therapy.

June had been suffering from symptoms of anxiety, depression and social isolation her entire life. She’d recently dropped out of community college, and her parents were controlling, religious fundamentalists.

Therapy sessions with a shy and quiet June seemed to start off well enough for Rousmaniere. She seemed truly interested in learning skills to reduce her anxiety, reported practicing her skills, but never made eye contact with Tony. When called upon for feedback at the end of each session, June carefully told him therapy was helpful.

But when Tony checked the graph on her clinician report one session, he did not anticipate that June’s chart would show a red alert status – her case was off-track. The system had predicted she was at high risk of experiencing a negative outcome that could include deterioration or suicide.

Skepticism was Rousmaniere’s gut reaction since the algorithms had contradicted his instincts. June had repeatedly told him that therapy was helpful. So at the beginning of their next session, Tony asked her how she was doing, and after some persistence, was able to get June to admit uncomfortably that she thought she was getting worse and blamed herself. June had deteriorated, and Tony realized without the program, he never would have identified she was at-risk.

Dr. Rousmaniere’s experience with June is a common one for therapists all over the world. The success of OQ Measures’ founder, Dr. Michael Lambert’s, research in measuring mental health vital signs ignited a flood of practitioners to adopt use of routine outcome feedback using metrics that studies show have significantly improved effectiveness of psychotherapy, reducing dropout rates and shortening the length of treatment.

But not all therapists have buy-in. Like the widespread adoption of the thermometer to the medical field back in the 19th century – 250 years AFTER its invention – use of psychotherapy metrics and feedback systems has been slow. Despite dozens of studies being published that heavily support the benefits of measuring mental health vital signs (many of them led by Dr. Michael Lambert and Dr. Gary Burlingame from OQ Measures), many therapists are still skeptical that a web-based software program like the OQ®-Analyst can capture the nuances of psychotherapy, and are fearful to have a light shown on their outcomes.

In 2003, Ann Garland of UC San Diego, led a study and found that among a sample of therapists in San Diego County who received outcome scores from client feedback, ninety-two percent did not use the data. A 2013 paper by the University at Albany’s James Boswell and associates found “Surveys spanning different countries indicate that few clinicians actually employ [routine outcome feedback measurement] in their day-to-day work.”

There are very few, if any, recent studies that contain any solid data on therapists measuring mental health vital signs, but Rousmaniere maintains from his own anecdotal impression that usage of metrics and feedback remains lamentably low among therapists. So he went looking for examples of clinics implementing routine outcome measurement and feedback and was led to Robbie Babins-Wagner, the CEO of the Calgary Counselling Centre, a large community mental health organization in Western Canada.

Babins-Wagner has over 40 years of clinical experience. She began her search for new and innovative ways to improve the CCC upon her hiring back in 1992, when she found Lambert and Burlingame’s OQ system, and implemented psychotherapy metrics across the organization with the hope the data from their routine outcome feedback would help create a “climate for therapist improvement.”

Babins-Wagner analyzed and aggregated the CCC’s data collected from a four-year trial, and found that only half of their therapists were using the OQ system – even though everyone had been instructed to. Skepticism was rampant at the CCC for those who mistrusted metrics, opting for the habitual comfort of their own professional intuition. This was easy for the skeptics to get away with over the course of the trial, due to the traditionally private and protected nature of the therapy room.

Patiently, Babins-Wagner listened to her therapists’ concerns, and applied their feedback to improve and streamline implementation of the OQ system, then made collecting outcome data mandatory.

Forty percent of the therapists resigned within just a few months.

Babins-Wagner’s perseverance paid off, however; steadily improving the CCC’s clinical effectiveness each year, for seven years, according to a study led by Simon Goldberg of the University of Wisconsin at Madison. Yet despite the conclusive evidence that using data improves outcomes, adjusting to a new way of working remains difficult for many therapists, even today.

A counselor at the CCC, Michelle Keough, told Rousmaniere that she had been one of the skeptics, but over time, she realized the system actually improves communication and she can’t imagine not using it in her practice now. According to Keough, many of the trainees she supervises follow the same path of apprehension she did, and eventually embrace the OQ system.

Dr. Rousmaniere understands intuitive reluctance to measure outcomes with metrics very well – it’s unpleasant, humbling, and sometimes even humiliating to have blind spots brought to light, he says. It requires diligence for any therapist to fight their own assumptions and expectations, and put their trust in the data.

But while the difficulty to override gut instincts persists, Rousmaniere, Babins-Wagner, Michael Lambert, Gary Burlingame, and other proponents of measuring mental health vital signs are paving the way for therapists, from interns to psychologists, to harness the ability to predict deteriorations and dropouts among their patients using routine outcome feedback systems like the OQ®-Analyst.

In June’s case – unlike Grace – her life was likely saved by metrics and performance feedback when she triggered a red alert one day.

Tony trusted the data despite his intuition, dug deep into her case notes, got her permission to record a session, analyzed the video with an expert, and was advised that he was in a “top-down relationship” with June. Rousmaniere had positioned himself into a teacher role, with June attempting to be a “good student by minimizing her symptoms.” She had been holding her stomach during sessions, indicating that her anxiety was causing nausea. And like a good student, she carefully practiced the skills Tony had taught her, but never actually communicated how she felt when she did so. June had not been telling Tony about her discomfort out of deference.

So Rousmaniere went back to the drawing board. He approached June as an equal, helped her acknowledge her pain and anxiety rather than defer to him, though she struggled with the constant pull to shift back into the submissive role of a good student. Tony struggled himself with the pull to teach her skills rather than listen more carefully as her equal. But they worked together using the routine outcome feedback program as their guide when they found June’s symptoms would worsen, and her responses to questionnaires would trigger alerts. Tony would video tape more sessions and fix any errors he identified, and June’s anxiety steadily lessened over the following year.

Two years later, June graduated from college with honors, and had her final session with Rousmaniere. Spanning the years of Tony’s career, the Grace and June cases are positioned at two ends of the psychotherapy outcome spectrum: one stands as a warning, and the other stands as a success. The OQ®-Analyst has the power to save lives.

We highly recommend a demo of the OQ®-Analyst, widely considered the world’s gold standard routine outcome feedback web-based monitoring solution. OQ Measures not only offers adult outcome questionnaires, but youth/adolescent and group outcome questionnaires as well, in addition to clinical support tools designed to be used in conjunction with OQ instruments.

You can email us at, or select an available date and time here to have a demonstration:

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