Sophisticated survey gives therapists, patients immediate feedback

Some people who seek counseling worry they don't get enough attention from their therapists. Others are afraid they are paying for too much therapy. And up to 1 in 10 clients finish therapy worse off than when they started.

But repeated studies continue to show that these concerns can be resolved when psychologists use a patient survey called the Outcome Questionnaire, or OQ, a creation of Brigham Young University professors Michael Lambert and Gary Burlingame. A team of BYU psychologists summarize three studies showing that using the OQ reduces treatment failures in the current issue of the journal "Clinical Psychology: Science and Practice."

"Some people think of psychotherapy sessions as doses of medicine, so along these lines the OQ measures what dosage a person needs," said David Smart, a clinical professor and research committee chairman at the BYU Counseling and Career Center.

At the beginning of each therapy session, patients take an extra 3-5 minutes to report their levels of mental distress during the last week. The score from the first session gives the therapist an idea of how severe the problem is and serves as a reference point to monitor progress as treatment continues.

"Drs. Lambert, Smart, and their BYU colleagues are conducting cutting-edge, patient-focused research – distinctive research that advances both the science of psychotherapy and the health of individual patients," said John C. Norcross, past president of the American Psychological Association's psychotherapy division and a psychology professor at the University of Scranton.

With the OQ, therapists can also predict the results of treatment for an individual patient. When the BYU researchers analyzed a database of past patients' scores and treatment outcomes, they found the patterns of scores for patients who failed treatment were easily distinguishable from those of patients who did well in therapy.

"We can tell by the second or third visit if a patient is on track for successful treatment," said Smart.

The core component of the OQ is the feedback it gives to therapists, which is coded on a scale of white, green, yellow and red. White feedback indicates a patient has achieved normal functioning, green means adequate progress is underway, yellow signals less than adequate progress, and red warns that the patient is in danger of failing or dropping out of treatment. This feedback enables therapists to tailor their approach to the patient's needs and focus on struggling patients.

In addition to improving the BYU counseling center's quality of service, the OQ provides training and research opportunities for psychology Ph.D. students at the center. One intern decided to share the feedback directly with patients and found that they liked knowing the results. A subsequent study confirmed that patients who get the feedback do better than patients whose therapists do not share the OQ results with them.

"Clients know how much they are suffering, but they don't really know how that suffering compares to other people, what the typical response to therapy is, or how long it takes to recover," said Lambert. "They can start to self-manage their problem when they have that kind of information."

Lambert noted the OQ works equally well for mild cases – like usual campus clinics' clientele – and more severe cases seen in community and hospital-based clinics.

Because the system tracks every patient's outcome, therapists can monitor their own performance. Smart and his colleagues used their data to test whether they were serving clients from different ethnic groups equally and found that improvement rates were indeed the same for all ethnic groups.

"We have a commitment to improving therapy by giving feedback," said Smart. "The OQ is a gold mine for understanding psychotherapy outcomes. This is a new step forward."

The OQ is now used across the country in HMOs, university medical centers and hospitals, including Intermountain Health Care, the University of Utah's University Hospital and the Utah state division of mental health. Lambert hopes the growth continues because he believes the OQ brings needed accountability to the field of mental health.

"The Outcome Questionnaire itself is a very sound measure, highly reliable and valid," said Charles Gelso, a University of Maryland psychology professor who judged a presentation on the BYU counseling center's work in August at the annual APA conference. "I think it would be a great idea for other centers to adapt the system used at BYU."

Co-authors on the article appearing in "Clinical Psychology: Science and Practice" are Michael J. Lambert, Jason L. Whipple, Eric J. Hawkins, David A. Vermeersch, Stevan L. Nielsen and David W. Smart, each from the BYU Department of Psychology or the Counseling and Career Center.

Writer: Joseph Hadfield