Real-Time Monitoring of Psychotherapy Treatment Response: An Evidence- Based Practice Michael J. Lambert, Ph.D. Brigham Young University 1

Overview 1.Monitoring client treatment response and providing alerts for off-track cases is an evidence-based practice 2.It takes us WELL beyond accountability by surpassing administrative solutions such as provider profiling and benchmarking 2

OQ-Analyst Solution: An evidence- based practice A family of measures that are sensitive to treatment effects across a wide variety of clients Automated method to repeatedly assess clients without involving clinician time Immediate graph of client change in relation to scientifically derived expectations Immediate feedback to therapists and consumers that improves outcomes 3

Measure of Outcome: OQ-45  45 items across 4 domains  Yields a total score reflecting amount of distress a person has been experiencing during the last 7 days  Scores range from 0 to 180  Higher scores signify more distress  64 represents the cutoff between functional and dysfunctional populations 4

OQ-45 Domain and Sample Questions Measures SELF-REPORTED CHANGES IN: –Symptoms-anxiety, depression, somatic  I feel hopeless about the future.  I feel no interest in things.  I have thoughts of ending my life.  Disturbing thoughts come into my mind that I cannot get rid of. 5

OQ-45 Domain and Sample Questions Measures SELF-REPORTED CHANGES IN: –Interpersonal Problems  I feel lonely.  I have frequent arguments.  I have an unfulfilling sex life.  I have trouble getting along with friends and close acquaintances. 6

OQ-45 Domain and Sample Questions Measures SELF-REPORTED CHANGES IN: –Social Role Functioning  I have trouble at work because of drinking/drugs.  I feel angry enough at work/school to do something I might regret.  I feel that I am not doing well at work/school.  I have too many disagreements at work/school. 7

OQ-45 Domain and Sample Questions Measures SELF-REPORTED CHANGES IN: –Quality Of Life  I get along well with others.  I am satisfied with my life.  My love relationships are full and complete.  I enjoy my spare time. 8

There are two very important clinical problems that clinicians need help with 9

 1. A portion of clients are worse at the end of treatment and many fail to benefit  2. Clinicians are overly optimistic and fail to recognize who is deteriorating 10

Benchmarking Outcomes (n = 6062) Hansen, Lambert, Forman (2002) SiteSessionsDeteriorationNo ChangeImprovedRecovered Employee assistance %58.5%19.7%15.2% University clinics %57.6%20.1%12.6% Local outpatient clinics %53.9%20.5%11.4% National outpatient clinics %48.1%28.5%15.9% Clinical trainees %45.6%31.2%20% Community mental health center %60.7%20.5%8.6% TOTAL 4.3%8.2%56.8%20.9%14.1% 11

Identifying Cases for Review Little or No Need (50%) Moderate Need (43%) Great Need (7%) 12

How well do practitioners predict treatment failure?  Final outcome was predicted for 550 Clients  3 were predicted to have a negative outcome  40 had a negative outcome  Staff were accurate 1 time  Algorithms identified 85% of those who deteriorated, but over predicted deterioration Hannan, Lambert, Harmon, Nielsen, Smart, Shimokawa, Sutton (2005) 13

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Hatfield (in press)  Examined case notes of patients who deteriorated to see if therapists noted worsening at the session it occurred.  If the patient got 14 points worse was there any recognition? 21%  If the patient got 30 points worse was there recognition? 32% 15

Clinician Report Red Alert – Part 1 16

Clinician Report Red Alert – Part 2 17

OQ-A provides Clinical Decision Support Tools for failure risk cases Consumer report of: 1.THERAPEUTIC RELATIONSHIP (I was willing to share my innermost thoughts with my therapist) 2.SOCIAL SUPPORT (I felt accepted by someone other than my therapist) 3.MOTIVATION FOR THERAPY (Honestly, I really don’t understand what I can get from therapy) 4.RECENT LIFE EVENTS (I had difficulty adjusting to an occurrence in my life) 18

Research Program  Six CLINICAL TRIALS IN WHICH WE ATTEMPTED TO REDUCE DETERIORATION RATES BY PROVIDING PROGRESS FEEDBACK TO PSYCHOTHERAPISTS Lambert, et al Lambert, et al Whipple, et al Hawkins, et al Harmon, et al Slade, et al  Random assignment of patients to experimental condition blocked on therapist (every therapist had patients for whom they received feedback and were denied feedback) N = 4,000 19

Typical randomized feedback study Every person on a therapists’ caseload provides self-report functioning. Therapists receive feedback with OQ-A on only half of their cases controlling for differences between therapists/consumers The effect of giving feedback can then be compared across consumers. About one thousand consumers are studied in each investigation. 20

Results-CST Feedback 21

Recovered or Improved No ChangeDeteriorated NOT-NFb (n = 286) 60 (21%)165 (58%)61 (21%) NOT-Fb (n = 298) 104 (35%)154 (52%)40 (13%) NOT-Fb+CST (n = 239) 121 (51%)102 (43%)16 (6%) 22

Clinical Value : Provider Profile Providers can profile real time change metrics for themselves—percent of cases recovered, improved, no change & deteriorated—to determine strengths & areas for improvement Providers can view aggregate cases by diagnosis, gender, etc. for differential effectiveness in case load Providers contrast differential effectiveness (e.g., diagnosis) with peers 23

Harmon, S.C., Lambert M.J., Smart, D.W., Hawkins, E.J., Nielsen, S.L., Slade, K, et al. (2007). Enhancing outcome for potential treatment failures: Therapist-client feedback and clinical support tools. Psychotherapy Research, 17, Hawkins, E. J., Lambert, M. J., Vermeersch, D. A., Slade, K., & Tuttle, K. (2004). The effects of providing patient progress information to therapists and patients. Psychotherapy Research, 31, Lambert, M. J., Whipple, J. L., Smart, D. W., Vermeersch, D. A., Nielsen, S. L., & Hawkins, E. J. (2001). The effects of providing therapists with feedback on client progress during psychotherapy: Are outcomes enhanced? Psychotherapy Research, 11, Lambert, M. J., Whipple, J. L., Vermeersch, D. A., Smart, D. W., Hawkins, E. J., Nielsen, S. L., Et al. (2002). Enhancing psychotherapy outcomes via providing feedback on client progress: A replication. Clinical Psychology and Psychotherapy, 9, Slade, K., Lambert, M. J., Harmon, S. C., Smart, D. M., & Bailey, R. (2008). Enhancing psychotherapy outcomes: The effects of immediate electronic feedback and Clinical Support Tools. Clinical Psychology & Psychotherapy, 15, Whipple, J. L., Lambert, M. J., Vermeersch, D. A., Smart, D. W., Nielsen, S. L., & Hawkins, E. J. (2003). Improving the effects of psychotherapy: The use of early identification of treatment failure and problem solving strategies in routine practice. Journal of Counseling Psychology, 58,