Using outcome measures in practice is not part of core training for most therapists. So why would we want to travel that road at all? And if we do, how do we make their introduction with clients natural and seamless? We outline here some key principles and a process you can make your own.
‘How are we actually going to do this? How are we going to persuade clients to fill in these measures?’ Thus ran the conversation in my team at the Royal College of Nursing (RCN) Counselling Service 20 years ago, after we’d decided to adopt the CORE System to help us evaluate our work. It wasn’t easy. We were a relatively early adopter, and there weren’t many examples to guide us.
What I’ve learned over these 20 or so years is that successfully introducing measures into your practice is a combination of two things. The first is your rationale, and this may be a combination of factors. The second is the process by which you introduce to the client that part of that rationale that is relevant to them.
I never dreamed that I’d find myself quoting a leading Brexiteer in this blog, but the words of David Davis at the time of his resignation from the Cabinet seem particularly apt here:
“I was the person who had to present it……and if I don’t believe in it, then I won’t do as good a job as someone who does believe in it.”
DD was talking about his lack of belief in the Cabinet’s newly hatched plan for Brexit, but he could equally well have been talking about introducing measures into therapy practice. And he’d have been quite right. He wouldn’t have done as good a job as a believer, and neither will we when it comes to using introducing and using measures successfully. At some level, you have to believe.
Without further delay, then, I offer you a few reasons why we might want to adopt the principle of using measures routinely in our practice or service.
Enhancing outcomes. I’ve written before about the potential for tracking client progress to enhance outcomes (i.e. reduce dropout and lift improvement rates) for clients that may be at risk of a poor outcome. I won’t rehearse the arguments here.
Demonstrating accountability. I’m not a commissioner but if I were I’d be more sympathetic to a service that shows me its commitment to evidencing its impact and continually building on it. By that I mean more than telling me that they ‘use CORE’ and have five years’ worth of CORE measures gathering dust in a corner.
Developing practice and services. By systematically benchmarking dropout and improvement rates the RCN Counselling Service was able (over the course of two years) to halve dropout and significantly lift improvement rates. It wasn’t that difficult, and the story is in another blog.
Protecting and marketing. By the time I left the RCN in 2005, my service was one of the highest performing services in the country. I could say that because I had the evidence (planned endings = 84%, recovery or improvement = 85%). These outcomes and our commitment to improvement were key reasons why the service remained internally provided after a rigorous independent review process which considered outsourcing among the options.
Serving your clients. Perhaps this should have come first, but the improvements we were able to make at the RCN were far more than statistics. They were people who we were better able to serve. If you force me to choose just one of these five, this has to be it.
If you are left unconvinced by the arguments above, then perhaps routine measurement isn’t for you. You may work in a setting where you don’t have a choice, of course. If this is the case, then pick the argument you object to least and construct an argument that you can plausibly present to clients.
I hope you would never say ‘My service asks me to ask you to complete these measures at the start and end of therapy, so can we get that out of the way and then we can get on with the real work?’ I’ve met plenty of therapists whose attitude is exactly that, however, and that attitude will communicate itself to clients. It is not valuing of the investment that we are asking them to make in completing measures.
There are a range of reasons that you might use when asking clients to complete outcome measures. You may use any and all, but my advice would be: a) to keep it brief, and b) to use the rationale which most clearly conveys the benefit to the client. They will be more interested in ‘how this may help me’ than helping you with your service marketing efforts.
Below you’ll find a couple of possible scripts, based on using CORE outcome measures. If you don’t already have your own, or are considering alternatives, I suggest developing three or four options whose merits you can test, starting with yourself, then colleagues if possible, and finally clients. What I can absolutely promise you is that if you can articulate a compelling rationale in a compelling way, your clients will buy in.
Here is one starting point:
‘In addition to us talking here about what’s brought you today, I also use a standard scale that’s used widely in therapy. This helps us get a wider sense of the areas you’re facing right now and how much they’re affecting you. I’ll ask you to fill one in now, and if it seems appropriate, to complete one at the beginning of each session to see how you seem to be progressing. That can help us to know whether we’re focusing on what is really going to make a difference for you. How does that sound to you?’
In this example I’m considering using the 34 item CORE Outcome Measure. The CORE-OM is a global measure of distress which covers the four domains of Wellbeing, Problems or Symptoms, Functioning and Risk. Hence the statement ‘This helps us get a wider sense of the areas you’re facing right now….’ Different measures, such as the GAD-7, PHQ-9 or Outcome Rating Scale (ORS), for example, will require a different introduction that reflects what they are seeking to measure and the way that they are constructed.
I’m also suggesting that we might use a measure at the start of each session ‘if appropriate’. So, if the client were scoring highly overall or on specific domains, and if one of their goals were symptom reduction, it would feel entirely appropriate to use sessional measures to monitor their progress. If this is the case then I’ll use the shorter, ten item CORE-10.
If the client’s initial scores are low, however, or symptom reduction is not their priority, then monitoring their progress session by session may be less appropriate, unless they show a marked deterioration during therapy. Either way, I find an initial baseline score helpful at the start so I have an objective measure of the level of distress I may be working with. Hence, I’ll be aiming at the very least for a pre and post therapy measure, but more commonly, using measures session by session. I recognise, of course, that if you’re engaged by a service you may not have a choice.
In giving the client guidance on filling in measures I’ll say something like this (for the CORE-OM):
This scale is known as the CORE measure. It measures a range of areas that include your wellbeing, problems and concerns you may have and how well you’re coping with life at the moment. For each statement there’s a range of possible responses from ‘Not at all’ to ‘Most or all of the time’. Can I ask you to think back over the last week, and for each statement, tick the box which feels closest to your experience?
Share your experience?
So long as you are briefly and clearly explaining the benefit to the client, and what you are asking them to do, there are endless ways in which you might go about introducing the measures into your work with clients. Just make sure that you’ve rehearsed your script enough so that it sounds both fluent and unapologetic!
I asked Tony Jordan from Pragmatic Tracker, the progress monitoring system being used in the BACP pilot study of routine outcome monitoring in private practice [i] to outline his approach. Tony was one of the first practitioners in the UK to use session by session measures as part of the development of CORE Net, another well established online system that supports the CORE and other measures. This is what Tony said:
This is the point when you can introduce the notion of ‘measuring’ whether the client is making progress towards what they need. Find a word that feels right for ‘measuring’. It could be ‘gaining a sense of’ or ‘seeing’ or ‘tracing the ups and downs’. There are any number of possibilities here, language is rich.
‘It’s important you gain real benefit from our work together’
‘That we can both have a sense of things getting better’
‘It’s nice to do this in a way that easy to see … there may be ups and downs along the way’
‘I use a simple questionnaire to help us with this … a kind of psychological thermometer’
‘It asks a set of simple questions about how you have been over the last week’
‘It only takes a minute or two…. and we will look at it together … and see if it captures how things are for you’
‘If we can do it each week a trend (pattern) sometimes emerges … it’s good to explore what it tells us about how you are doing’
I like it all, but particularly point 6 and the stress that this will be a collaborative endeavour. The idea of a ‘psychological thermometer’ also appeals.
If you’re using or contemplating using the four item Outcome Rating Scale (ORS) as part of the Feedback Informed Treatment (FIT) approach, you can find the introduction recommended by the authors of Feedback-Informed Clinical Work: The Basics by scrolling to page 10.
What’s your approach? We’d love to know so please feel free to share in the comments section how you approach that first introduction, as well as any other thoughts and questions.
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