The CORE-OM was the first outcome measure that I used in my practice. Along with the shorter CORE-10, it remains my measure of choice. In this blog I explore both: how they were developed; what they measure; how you can understand the numbers and where you can find them.
Given that most counsellors and psychotherapists are not trained in the use of outcome measures it is almost inevitable that we should have misconceptions about them and their use. CORE probably suffers more than most in that the CORE measures are part of the wider CORE System, and these tools sit alongside a broader quality evaluation framework for psychological therapy.
In this blog I’ll be focusing on two of the CORE measures that are most commonly used in therapy: the 34 item CORE-OM and the ten item CORE-10. Before that, however, I’ll say a few words on each of the main components of CORE so that it’s clear where the measures sit within the wider system. If you want to skip that and go straight to the detail of the CORE-OM click here.
The CORE-OM
34 item global/generic distress measure
Scoring range 0 – 4
Covers domains of:
Wellbeing (4 items); Problems and symptoms (12 items); Functioning (12 items) and Risk (6 items)
Includes positively and negatively framed items
Includes high and low-intensity items
Clinical cut-off: 1 (0 – 4 scale); 10 (0 – 40 scale)
Reliable change index (RCI): 0.5 (0 – 4 scale); 5 (0 – 40 scale)
The CORE measures
The CORE measures are measures of psychological distress (more on that later). The CORE-OM is the parent measure for a wider family of derivative measures that meet specific needs in terms of length of measure or client population. These include the CORE-10; CORE-5; CORE-LD (for people with learning disabilities); YP-CORE (for younger clients) and two short forms for use in research or general practice settings.
The CORE System
The CORE measures sit within a wider system designed to aid the evaluation of service quality and outcomes. The main elements of the system are the CORE-OM, and the practitioner completed Therapy Assessment Form (TAF) and End of Therapy Form (EOT). The TAF is designed to support assessment and captures information about the client and their circumstances including key dates; presenting problems and their severity; current and previous use of services; risk and whether or not the client entered into therapy.
The EOT captures post-therapy information that allows data from the client completed CORE-OM to be seen in context. It includes session attendance; therapy model; a review of presenting problem severity and risk and how therapy ended (i.e. planned or unplanned ending)
The CORE quality evaluation framework
In March 2006 Counselling and Psychotherapy Research published a range of CORE related papers. [i] Six of these provided benchmarks (based on NHS primary care provider data) for key indicators of service quality against which individual services could be benchmarked. The benchmarks were: waiting times; outcome measure completion rates; assessment outcomes; congruence between practitioner rated and client indicated risk; therapy ending types and rates of recovery and improvement. Taken together, these indicators form the basis for a simple but robust framework for evaluating the quality of therapy service provision.
You can read more about the development of the CORE System and its philosophy on the CORE System Trust website here
The CORE Outcome Measure (CORE-OM)
What is it?
The CORE-OM is a 34-item global measure of distress. It was developed in the 1990’s in response to a widely perceived need for a short, and free, outcome measure which fulfilled a number of key criteria. These were that it should be:
* Free to use
* Capable of capturing a range of ‘core’ concerns that present in therapy settings, including subjective wellbeing, problems/symptoms, functioning, and risk of harm to self or others
* Sufficiently short to be used in practice settings
* Applicable to both research and practice settings
* Acceptable to service users and practitioners alike
What does it measure?
The 34 items of the CORE-OM capture distress or severity of symptoms across four key domains:
Subjective wellbeing (4 items)
Problems and symptoms (12 items)
Functioning (12 items)
Risk (6 items)
The domain to which each item belongs can be determined (on paper versions of the measure) by the letter to the right of the furthest right box (the OFFICE USE ONLY column). Hence W = Wellbeing; P = Problems and symptoms; F = Functioning; R = Risk. This is illustrated below.
Within each domain (save for wellbeing) there are clusters of items, as follows:
Problems: this domain contains four clusters (Depression, Anxiety, Physical and Trauma)
Functioning: this domain contains three clusters (General, Social and Close)
Risk: this domain contains two clusters (Risk to Self and Risk to others)
The CORE-OM, its domains and symptom clusters also contain both high and low intensity items. As an example, the risk of harm to self cluster contains the low intensity item I have thought it would be better if I were dead and the high intensity item I have made plans to end my life. In assessing risk, therefore, careful attention needs to be paid item scores in the context of whether they are attached to high or low intensity items.
Scoring the measure
The scoring range of the CORE-OM is between 0 and 4, with 4 being the highest level of severity. As can be seen from the image above, some items are positively framed (items 3 and 4). For these items the scoring range is reversed.
The client is guided to consider each statement and how often they have felt like this over the past week. They are asked to then tick the box which corresponds most closely to their experience, using the categories at the top of each column from Not at all to Most or all the time.
Working with paper forms the score for each statement can be written in the adjacent OFFICE USE ONLY box. From here there are three ways of obtaining a meaningful overall score:
Add the scores for all items in the box circled in the image below (Total Scores * All items) to derive a total score between 0 and 136.
Divide the total score by the number of completed items (normally 34) to obtain a mean score between 0 and 4. (E.g. a total score of 56 / 34 will yield a mean score of 1.64). Some practitioners prefer using a simpler 0 – 40 scale where the 1.64 is multiplied by 10 and converted to a whole number i.e. 16.
In the absence of a calculator or better long division skills than I possess, multiply the total score by 3 and divide by 100. This will yield a ‘good enough’ working mean. (E.g. 56 * 3 / 100 = 1.68)
In the same way it is possible to use steps 1 and 2 to obtain total and mean scores for each of the four domains. For a mean score for the wellbeing domain, for example, simply add the four wellbeing items and divide by four.
What do the numbers mean?
A higher score on the CORE measures, domains or individual items indicates a higher level of distress or symptom severity.
The clinical cut-off [ii] for the CORE-OM is 1 (using the 0 – 4 scale), or 10 (using the 10 – 40 scale). This is represented in the image from CORE Net below by the blue dotted line. The image shows the session by session progress of a demonstration client within CORE Net, the online monitoring and tracking system provided by CORE IMS. The client starts with an overall score (solid blue line) of 21, considerably above the dotted blue cut-off at 10. By session six they have improved and are scoring below the cut-off. Red lines represent the risk cut-off and scores.
The reliable change index (RCI) for the CORE-OM is 0.5 (or 5 using the 0 – 40 scale). This is the degree of change required for it to be classed as reliable i.e. change greater than might occur due to chance or measurement error. The client in the chart below has therefore achieved reliable and clinically significant improvement (RCSI).
CORE-10
What is it?
CORE-10 is a ten-item measure of general psychological distress. The ten items are derived directly from the CORE-OM parent measure. It was developed to respond to the need for a brief screening and progress monitoring tool that could be used to track session to session progress.
The aspiration of the developers of CORE-10 was to:
“…enable measurement of depression while retaining coverage of general psychological distress within a measure that could be used easily by practitioners and clients at screening as well as used for ongoing review during the course of therapy.” [iii]
What does it measure?
The criteria for inclusion of items in CORE-10 included that it should contain (from the CORE-OM) two items each for depression and anxiety and one each covering trauma and physical problems; should include high and low intensity items; aim to cover the each of the three functioning clusters (social, general and close); include both positively and negatively framed items and include at least one risk item.
The wellbeing items in the CORE-OM were dropped as they display high correlation with the problem domain items. Items with lower response rates from the CORE-OM were dropped and regression analyses conducted on the remaining items to optimise correlation with the full CORE-OM. The items finally chosen for CORE-10 include:
Problems and symptoms (6 items; 2 anxiety, 2 depression, 1 trauma, 1 physical)
Functioning (3 items; 1 each close, general and social functioning)
Risk (1 item)
Scoring the measure
Scoring the CORE-10 could not be simpler: simply add together the individual item scores to arrive at a total score (between 0 – 40).
Those of you more familiar with using the mean score from the CORE-OM need simply to divide the total score by the number of completed items to determine the mean score. Caution should be exercised where less than nine items are completed, and I’d recommend checking with clients the significance of non-completed items, especially risk. The only risk item in CORE-10 is the high intensity item I have made plans to end my life, and we should not assume that clients will always feel able to complete this item entirely honestly.
Cost, copyright and obtaining the measures
Copyright of all the CORE instruments is held by the CORE System Trust. All have always been free to reproduce on paper provided they were not changed in any way, their reproduction was not for profit and copyright was acknowledged.
Since 2015, organisations are also free to reproduce the instruments in software, as well as on paper, under a Creative Commons Attribution-No Derivatives 4.0 International (CC BY-ND 4.0) licence without payment of any licence fee. Under the terms of this licence the instruments may not be changed in any way.
The measures may be downloaded in PDF format via the CORE IMS website.
References
[i] Mellor-Clark J (ed). 2006. Special Issue: Developing CORE System benchmarks. Counselling and Psychotherapy Research. March 2006.
[ii] Cut-offs are statistically derived points which differentiate between what are known as clinical and non-clinical populations. In other words, if a client scores above 10 on the CORE-OM, their score is said to be more representative of a clinical population. These population norms, as they are known, exist for any measure that has statistical validity. While their characteristics vary from measure to measure depending on the sampling carried out, they are derived from large samples of a) clients receiving therapy or some kind of mental health intervention, and b) wider population samples.
[iii] Barkham M et al. 2013. The CORE-10: A short measure of psychological distress for routine use in the psychological therapies. Counselling and Psychotherapy Research · March 2013. DOI: 10.1080/14733145.2012.729069
Related blogs
How to choose a therapy outcome measure
http://therapymeetsnumbers.com/how-to-choose-a-therapy-outcome-measure/
Introducing measures into working with clients
http://therapymeetsnumbers.com/introducing-measures-into-working-with-clients/
We thrive on feedback, so please let us know what you think about what you’ve read in the comment section below. Only the name you use to identify yourself will be shown publicly. Thank you!
Through client work, it dawned on me how much we need to track changes and get the data, for client safety as well as to demonstrate the value of counselling.
Although my supervisor and a TA trainer are fans of CORE, I’ve had scant support on this.
TMN explains why it works. Thank You!
& thanks to my peer supervision colleague for telling me about TMN. I’ll spread the word.
Hi Kayvasiddhi, thank you so much for the feedback. It’s really appreciated! I’m glad we’ve been able to make things a little clearer for you.
And thank you for spreading the word!
Best wishes
Barry
Great article! How often would you use the CORE-OM with clients for routine monitoring? Using it every week seems like it might be a burden for clients. Would it be acceptable to give it once every 4 sessions?
Max, thank you so much for the feedback. Generally I’d be using the CORE-OM at the beginning and end of the therapy, and a shorter measure like the CORE-10 at every session to track progress. Why not look at our new post on core 10 https://therapymeetsnumbers.com/moving-measures-online/. 34 items is a lot for every session to be sure. I think a shorter measure at every session makes sense given that so much of the improvement that clients make takes place early (if it’s going to take place at all), and also that’s when clients are most likely to drop out. So if it’s working it’s nice to have the feedback, and if it’s not working then hopefully we get an early warning in the sessional measure scores. There’s nothing more frustrating than an empty chair we could have prevented!
Thanks again
Barry
Thanks Barry. I’ve come across your website and Facebook group while researching more detail on CORE which I find hard to identify on the CORE website. Specifically, how to better understand the Domains and Dimensions totals. Also, as I use a Mac, I haven’t been able to move from paper to online for this measure. Before I consider dropping and moving entirely to FIT Outcomes, do you have any suggestions for reproducing the coloured chart you show above, on my Mac? Thank you,
Hi Jen!
Great to be able to welcome you to both the TMN readership and also the Facebook group. Three of four dimensions (wellbeing, problems/symptoms and functioning) that underpin the structure of the CORE measures are based on what’s known as the phase model of psychotherapy outcome developed by the late Ken Howard. The idea is that in terms of the development of distress, we first start to experience impacts on our wellbeing, and if continues, we start to develop problems or symptoms. If these continue we may start to find our life and social functioning compromised. Improvement also comes in that order with the right interventions. This is one of the seminal papers on this https://psycnet.apa.org/record/1993-46207-001. Let’s talk more on this and CORE on Facebook shall we?
Are you familiar with the BACP / Pragmatic Tracker software trial? The screenshot in the blog is from CORE Net, but Tracker also has a similar chart. It’s free to BACP members. Happy to share more info on Facebook.
Hi, I feel a total ‘dunce’ as I just cannot figure things out! I am struggling to understand how to arrive to clinical score, simple score, etc. I get (obviously…) to the raw score, but I may be overthinking this or been given a wrong calculation list…
Hi Kostana, let me see if I can help. It sounds like you have got to the raw (total) score by adding all the individual scores (a number between 0 and 136?). If you want a simple mean score, then divide the raw score by 34 (if all items are completed). So if the raw score is 86, the simple mean score is 86 / 34 = 2.53. The minimum mean is 0 and the max is 4. Multiply the mean by 10 for what’s known as the clinical score if you prefer whole numbers, so 2.53 simply converts to 25. I’m used to the simple mean score, so that’s what I tend to use, but some don’t seem to like the decimal point!
I hope that’s helpful – let us know if you need more.
Cheers
Barry
Thanks so much for the clear and informative presentation of the CORE measurement, this was really helpful.
Hi Reham, thank you so much for the feedback. It’s very much appreciated!
Barry
Hi Barry, I’ve found this really helpful as during training my placement used a core calculator which meant no working out. I’ve struggled with this since but this has made it much clearer. The bit I’m still a bit clueless with is the final calculation on core 34, 2 blank boxes, the lower one says “all minus R”, is it possible to show a sample of the calculation from a core?
Jane, let me see if I can help. If I understand you correctly, you’re not quite sure how to do the final mean scores calculations?
For each dimension, namely Wellbeing (W), Problems and symptoms (P), Functioning (F) and Risk (R), sum all the scores for the items with the corresponding letter in the Office Use Only column. So there are 4 W items. Sum those, place in the Total scores box in the first W column. Divide by the number of W items i.e. 4 to get the mean score, and place that in the box below. Do the same for the 12 Problem and Functioning items and the 6 Risk items. All items is the total of all the items/34, and All minus R is the total minus the scores for the 6 risk items (if you wish to have that, which not everyone does).
Have I illuminated or muddied the water? Fingers crossed!
Barry
Good afternoon, I’m a University student using the CORE-general population questionnaire as a measure in a study I’m leading, would I calculate the individuals’ scores the same way as you would for the CORE-OM & would the measure for distress and clinical cut off be the same for the CORE_GP as shown in the graph? Sorry to ask a lot, it’s just I have read so many papers trying to find out how they simply analyse the CORE-GP but a lot of the papers go into detail about testing the validity and reliability of the CORE-GP measure.
Hi Shaan and thanks for the question. I’m advised by one of the CORE measure originators that a key issue is that the 34 items of the CORE-OM are deliberately tuned very differently (for example high intensity/low intensity items). That means that different item selections will have different mean scores depending on the proportion of high to low intensity items so the GP-CORE, with no risk items and a big skew to low intensity items, will
generally have a much higher mean score than the mean score of the CORE-OM.
Probably the definitive reference to the GP-CORE is this Sinclair, A., Barkham, M., Evans, C., Connell, J., & Audin, K. (2005). Rationale and development of a general population well-being measure: Psychometric status of the GP-CORE in a student sample. British Journal of Guidance & Counselling, 33(2), 153–173. https://doi.org/10.1080/03069880500132581
I hope that’s helpful!
Thanks so much for this wonderful comprehensive article. This article is just so helpful. I’m a student Psychotherapist progressing into my final year this September….
Many thanks Evelyn. Wishing you well in chosen profession and glad to be of help!
Best wishes
Barry
This has been really helpful, thank you. Can I check one small detail though? Is there any consensus on how many decimal places to calculate the mean to (and does that include rounding up/down) and then if you use the x10 multiplier how many decimal places again (with or without rounding)? Is there any generally accepted norm?
Hi Lynne and many thanks for your question. My advice is keep the decimal points to a minimum. Use either 1.43 ) if using the the 0 to 4 range or 14.3 if using the 0 to 40 range. If using it in practice anything more is unnecessary. This view is supported by a paper published in 2006 which gives the different scoring options with examples. I´ll send this to your direct over email. Hope that´s helpful!