Ethical implications of routine outcomes monitoring for patients, psychotherapists, and mental health care systems.

Abstract

Although psychotherapy is generally efficacious, a substantial number of patients fail to improve meaningfully, whereas still others deteriorate. Moreover, psychotherapists have difficulty forecasting which patients are at risk for nonresponse or deterioration, especially when relying predominantly on their judgment. These limitations have implications for the ethical practice of psychotherapy, and they call for remediation strategies. One such strategy involves the use of routine outcomes monitoring (ROM), or the regular collection of core patient progress information that can be fed back to the clinician and patient in real time. ROM-informed analytics outperform clinical judgment in predicting patients who are on or off track for treatment success, which can help psychotherapists plan and responsively adjust their interventions. Additionally, research demonstrates that ROM-generated feedback improves treatment outcomes for the average case who receives versus does not receive it. ROM data can also uncover between-therapist differences in general efficacy, as well as scientifically highlight clinicians' own relative strengths and weaknesses in treating different mental health problems. In light of such evidence, we submit that the research on ROM has matured to the point that it should occupy a central role in discussions of, and guidelines about, the ethical practice of psychotherapy. In this vein, we discuss ROM at patient, psychotherapist, and mental health care systems levels; namely, for each of these stakeholders, we review the extant empirical support before turning to possible ethical implications. Finally, we offer concluding thoughts on the expanding relevance of ROM for helping psychologists fulfill their ethical practice obligations. Clinical Impact StatementQuestion: After surveying relevant research, we discuss the growing role of routine outcomes monitoring (ROM) for helping psychotherapists and mental health care systems fulfill their ethical practice obligations, including maximizing patient benefit and minimizing harm. Findings: There is expanding evidence that ROM-generated information has the potential to improve treatment outcomes at the patient level (e.g., by identifying patients at risk of nonresponse or harm and informing clinician responsiveness to this signal), psychotherapist level (e.g., by helping to establish clinicians' objective strengths and weaknesses that could inform their selective practice and personalized training foci), and mental health care systems level (e.g., by referring patients to empirically good-fitting clinicians within a care network). Meaning: Research on ROM suggests that it should be considered in any discussion about the ethical practice of evidence-based psychotherapy. Next Steps: It will be important for clinical and research efforts to concentrate on increasing ROM implementation to fulfill ethical demands at the patient, psychotherapist, and systems levels.

Complexity and potentials of clinical feedback in mental health: an in-depth study of patient processes

“…The participants in this study described a potential for ROM/CFS to raise self-awareness and reflexivity, enhance therapeutic conversations by identifying important topics, and allowing patients more influence over their therapies. This echoes the themes of collaborative practice and empowerment [ 12 , 13 , 31 – 35 ] and supports the claim that ROM can enhance therapists’ awareness and enable better adjustment to patients’ needs [ 3 , 4 ]. One explanation for the variable findings on ROM/CFS efficacy could be that ROM/CFS in itself does not enhance psychotherapies.…”

“…An estimated 60–65% of patients in psychotherapy show significant positive change in therapy, but 30–35% show no change and 5–10% deteriorate [ 1 , 2 ]. ROM/CFS provides feedback to therapists about patients’ progress, allowing therapists to improve their skills and adjust their approaches to patients who are not progressing [ 3 , 4 ]. Several CFS have been developed in the past decades, and ROM/CFS practices are becoming increasingly prevalent in the US, Australia, New Zealand, and Europe [ 5 , 6 ].…”

Longitudinal measurement invariance of the Behavioral Health Measure in a clinical sample.

“…Yet in the current sample, therapy was most effective for treating alcohol/drug-related issues within the first four sessions, with subsequent sessions' alcohol/drug use improvement leveling off and scores being maintained after the fourth session. Indeed, ROM has matured to a point in which constant refinement of feedback measures is needed to sustain ethical standards of providing effective treatment and monitoring outcomes to identify clients who are worsening or failing to improve (Muir et al, 2019). In general, as the popularity of the BHM grows, so does the prevailing need for refined and comprehensive ROM measures in service of conducting ethically sound research and in the practice of psychotherapy (Guise, Savitz, & Friedman, 2018;Jensen-Doss et al, 2018;Muir et al, 2019;Peterson & Fagan, 2017).…”

“…Indeed, ROM has matured to a point in which constant refinement of feedback measures is needed to sustain ethical standards of providing effective treatment and monitoring outcomes to identify clients who are worsening or failing to improve (Muir et al, 2019). In general, as the popularity of the BHM grows, so does the prevailing need for refined and comprehensive ROM measures in service of conducting ethically sound research and in the practice of psychotherapy (Guise, Savitz, & Friedman, 2018;Jensen-Doss et al, 2018;Muir et al, 2019;Peterson & Fagan, 2017). Training clinics, counseling centers, and primary care settings in which client feedback data is collected have an ethical obligation to use the data in a way to increase the benefit of the clients and communities whom they serve (Guise et al, 2018).…”

Using feedback tools to enhance the quality and experience of care

“…A second ethical question has been raised more recently, from the perspective of feedback systems as health technologies and parts of an evidence-based approach to care provision. If feedback systems improve the quality of care processes in this sense, does this generate an ethical imperative to use them (as for example recently argued by [64])? And if they are used, what do stakeholders accessing the feedback actually do?…”