What’s it like to incorporate routine outcome measurement into your practice? Professional counsellor, TMN reader and Facebook group member Helen Breakwell offers her experience of involvement in BACP’s AdaPT project and makes the case for why we should consider getting involved in building the evidence base for our profession.
Building an evidence base for therapy
Research has the potential to transform how mental health is prioritised in the UK. This is why I’m keen to help build evidence through initiatives like the Advancing Practice through Tracking (AdaPT) project. As a qualified counsellor who is enthusiastic about research, I was pleased to find the project. It’s run by the BACP and is a long-term programme looking at the use of an online platform to record routine outcome measurement in private practice, and to contribute to the evidence-base for counselling and psychotherapy. Now in its third year, it’s running till 2022.
The ADaPT project is compiling data from therapists in private practice using the Pragmatic Tracker platform by recording outcome measures such as GAD7, PHQ9 or CORE-10, in order to understand clients’ progress over time. No names or addresses are recorded, and identifiable information like email or phone contact details are encrypted.
The baseline requirement of therapists in the AdaPT project is to use the same measures regularly – for example by using CORE-10 at every session. This consistency gives a more accurate picture of how the client is doing whilst having therapy and helps with the methodology (e.g. using the same, replicable measures over time).
The other required measure is the Session Rating Scale (SRS) which asks the client to give feedback to the therapist on their experience of each session, using standard questions such as ‘I felt/did not feel heard, understood and respected.’ This helps measure the therapeutic alliance and can help clients have more influence over the direction of therapy.
How is it integrated into practice?
I signed up for the study over 18 months ago as a private practitioner and member of BACP. I was keen to take part in research that contributed to a broader, data informed understanding of the benefits of therapy. I took part in the online training that was provided and set about familiarising myself with the Pragmatic Tracker platform.
Practitioners need to familiarise themselves with the platform database, especially the baseline routine measure and SRS. As with most things there is a learning curve, but potential barriers have been thought through by the developers and they have attempted to streamline the process of data gathering . For example, clients can be sent a link by email to the SRS and other measures to enable them to be completed remotely. Their responses are automatically input into clients’ records and are also shown in graph form which makes trends easier to visualise (see header image).
There is also other functionality that can be helpful, including the ability to record risk, clinical notes, and clients’ goals and sessional progress towards them. There is flexibility within the system so that the practitioner can use these tools in ways that suit them and their way of working with clients. As part of the AdaPT project therapists need to gain informed consent from the client in order to record their data. I’ve been used to doing this in other roles, but it can take some practice and confidence. Generally, if you feel comfortable with the aims of the research and are clear that clients can opt out, this helps.
What are the benefits and drawbacks?
Gathering the data gives me a tangible reflection of the work I’m doing with clients. Tracking this progress, which is not always linear, builds an insight into client experience. Many times therapists will see a consistent improvement in how most clients are presenting, which reflects on the impact of therapy and is rewarding. Using measures also helps me to identify risks that may not always come up during a session. Additionally, it encourages self-reflection and feedback from clients, which in turn supports greater transparency and accountability in therapists.
Being part of a study does take more work, but not a lot more. Not every single client may make progress in the way you would like – they may finish abruptly, they may dip – and collating this data helps to uncover this experience.
It can be hard when a client attends only one session and that shows up as ‘no improvement’. But the data can help practitioners consider what’s happening in the relationship. And it may prompt important questions like, are there any barriers that the therapist is contributing to? Is there ambivalence from the client? Or, as the pandemic has shown, is the social context having a detrimental impact?
Ambivalence in practitioners
Effectiveness is not an easy thing to measure. In the past, practitioners may have been compelled to record outcomes that are aligned to unrealistic targets or SLA’s. And services may have been constrained by measures in the past, which explains why some practitioners may be sceptical. I feel it’s important not to have a rose-tinted view of measures as being the definitive answer, but as part of understanding the client and can help to demonstrate you’re providing a high-quality service.
For me, it is about trusting in good faith measurement where we don’t always see a straightforward improvement but one which reflects the reality of the client. And attempts to offer a consistent way of practicing which prioritises client wellbeing.
Investing in our own evidence base
Clearly the pandemic has had a critical impact on mental health. When working for a research organisation I saw big improvements in patient outcomes (which sadly are being challenged with the impact of coronavirus). The potential of research to inform therapists and the mental health community is something that I would like to see develop momentum in the future, so we can work with more people who would benefit from our support.
Without research, talking therapies would not have the reach and credibility they have today. For me, being part of ADaPT is a positive step in contributing to wider research into counselling and psychotherapy, whilst also having more tools to use when working with individual clients.
Practicing therapists have the potential to be key collaborators to shift this paradigm – where research is utilised, funding is unlocked, and peoples’ lives are improved by having accessible talking therapies. If you feel able to – get involved.
Find out more and participate
As part of the AdaPT project BACP is offering members the opportunity to use Pragmatic Tracker with their private practice clients at no cost.
You can find out more about the ADaPT project here or by emailing research@bacp.co.uk.
Helen Breakwell MBACP is an integrative counsellor in private practice, working with private clients, students, carers and employee assistance programmes. She also works as a consultant, including running wellbeing sessions and speaking at events. Go to wellspring-therapy.co.uk or contact helen@wellspring-therapy.co.uk.
Leave a comment
Just like you we thrive on feedback. Please leave your thoughts on what you’ve read in the comments section below.
I see the routine use of standardised outcome measures, particularly those developed by pharmaceutical companies, as a form of abuse. One reason for their popularity is for professionals to help justify their position in the market place. Whatever happened to the concept of “recovery”
‘abuse’ is a very strong term, that i dont feel your comment has backed up….. plus what do you mean by ‘recovery’? Of course someone can tell you they have recovered….but the idea of client centred outcome measures is to help with the journey, not just determine the end.
Specifically the PQ9 and GAD7 are illness measures, inferring to people they are ill can have serious consequences, look at all the issues regarding antidepressants.
Perhaps I should have said potentially abusive, to me if I see a counsellor about for example a relationship problem and at the end of the session I get given a routine PQ9, I would feel hurt. It is the standardisation and routine use of measures that is fundamentally wrong. How can you have a standardised person centered measure?
You can ask ,what do you want to achieve and how can we measure it. I have suggested to a client the PQ9 as it actually fitted in with their goals.
Re meaning of “recovery” my experience is in line with Anthony, Pat Deegan etc.
I think you are right that when inappropriate measures are used, or are mandated in a certain way, then they are not helpful. I wouldnt go as far as abusive though, or even potentially abusive. Seeing PHQ9/GAD7 as ‘illness measures’ is also your perspective, and others could perceive them as wellness measures. And from a pure person centred perspective, yes, measures dont really fit. But i could also have a very strong case for saying that treating trauma from a person centred perspective doesnt fit either! I havent heard of Pat Deegan, so cant comment. But it is great to share views, and i understand (or at least hope to) where you are coming from.
I also probably use measures less now that i am more experienced. I also never used measures after every session, although the Session Rating Scale could be something that i believe would be productive.
I think this conversation illustrates the many different ways in which we can (and do) view the principles and practices of using measures. I’m in the process of asking some myself questions about which types of clients it is unnecessary with, and which it is useful, as well as which measures are useful. I’m tending to use CORE measures more routinely than the symptom specific measures like GAD and PHQ as I feel like I get a much more rounded sense of the client at an early stage and it supports how I work.
So maybe it’s as much about the intention behind the use of measures as it is the measures themselves?
I can’t really comment on Core, I did work in a service that used them but it was soon replaced by the CCG/IAPT requirement to use PQ9 and GAD7. When you have a client expressing their problems, surely, one should have the flexibility to use an outcome measure appropriate to them and agreed with them. Unfortunately I now see routine use of specific outcome measures as a service need rather than a client need.
Yours is a familiar story to me Michael. I worked with many fine services when I was with CORE IMS, the support organisation for CORE System users. I knew they were high quality because I saw their data. Though most could have out-performed virtually any IAPT service, virtually none still exist.
I think the strength of the global measures of distress like CORE and OQ45 is that they are just that – global. As we know, clients seldom come just with ‘depression’ or ‘anxiety’. I think it’s easier therefore to provide a rationale their use, without, of course, imposing anything on anyone.