Real-Time Monitoring of Psychotherapy Treatment Response: An Evidence-

Based Practice

Michael J. Lambert, Ph.D.

Brigham Young University

www.OQMeasures.com

michael_lambert@byu.edu

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Overview1. 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

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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

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Measure of Outcome: OQ-45Measure of Outcome: OQ-45

45 items across 4 domains45 items across 4 domains Yields a total score reflecting amount Yields a total score reflecting amount

of distress a person has been of distress a person has been experiencing during the last 7 daysexperiencing during the last 7 days

Scores range from 0 to 180Scores range from 0 to 180 Higher scores signify more distressHigher scores signify more distress 64 represents the cutoff between 64 represents the cutoff between

functional and dysfunctional functional and dysfunctional populationspopulations

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OQ-45 Domain and Sample OQ-45 Domain and Sample QuestionsQuestions

Measures SELF-REPORTED CHANGES Measures SELF-REPORTED CHANGES IN:IN:– Symptoms-anxiety, depression, somaticSymptoms-anxiety, depression, somatic

I feel hopeless about the future.I feel hopeless about the future. I feel no interest in things.I feel no interest in things. I have thoughts of ending my life.I have thoughts of ending my life.Disturbing thoughts come into my mind that Disturbing thoughts come into my mind that

I cannot get rid of.I cannot get rid of.

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OQ-45 Domain and Sample OQ-45 Domain and Sample QuestionsQuestions

Measures SELF-REPORTED CHANGES Measures SELF-REPORTED CHANGES IN:IN:– Interpersonal ProblemsInterpersonal Problems

I feel lonely.I feel lonely. I have frequent arguments.I have frequent arguments. I have an unfulfilling sex life.I have an unfulfilling sex life. I have trouble getting along with friends and I have trouble getting along with friends and

close acquaintances.close acquaintances.

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OQ-45 Domain and Sample OQ-45 Domain and Sample QuestionsQuestions

Measures SELF-REPORTED CHANGES Measures SELF-REPORTED CHANGES IN:IN:– Social Role FunctioningSocial Role Functioning

I have trouble at work because of I have trouble at work because of drinking/drugs.drinking/drugs.

I feel angry enough at work/school to do I feel angry enough at work/school to do something I might regret.something I might regret.

I feel that I am not doing well at work/school.I feel that I am not doing well at work/school. I have too many disagreements at I have too many disagreements at

work/school.work/school.

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OQ-45 Domain and Sample OQ-45 Domain and Sample QuestionsQuestions

Measures SELF-REPORTED CHANGES Measures SELF-REPORTED CHANGES IN:IN:– Quality Of LifeQuality Of Life

I get along well with others.I get along well with others. I am satisfied with my life.I am satisfied with my life.My love relationships are full and complete.My love relationships are full and complete. I enjoy my spare time.I enjoy my spare time.

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There are two very important clinical

problems that clinicians need help

with9

1. A portion of clients are worse at 1. A portion of clients are worse at the end of treatment and many fail the end of treatment and many fail to benefitto benefit

2. Clinicians are overly optimistic and 2. Clinicians are overly optimistic and fail to recognize who is deterioratingfail to recognize who is deteriorating

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Benchmarking Outcomes (Benchmarking Outcomes (n = n = 6062) 6062) Hansen, Lambert, Forman (2002)Hansen, Lambert, Forman (2002)

Site Sessions Deterioration No Change Improved Recovered

Employee assistance

3.6 6.6% 58.5% 19.7% 15.2%

University clinics

5.8 9.7% 57.6% 20.1% 12.6%

Local outpatient clinics

3.3 14.1% 53.9% 20.5% 11.4%

National outpatient clinics

5.1 7.5% 48.1% 28.5% 15.9%

Clinical trainees

9.5 3.2% 45.6% 31.2% 20%

Community mental health center

4.1 10.2% 60.7% 20.5% 8.6%

TOTAL 4.3% 8.2% 56.8% 20.9% 14.1%1111

Identifying Cases for ReviewIdentifying Cases for Review

Little or NoNeed (50%)

ModerateNeed (43%)

GreatNeed (7%)

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How well do practitionersHow well do practitionerspredict treatment failure?predict treatment failure?

Final outcome was predicted for Final outcome was predicted for 550550 ClientsClients

3 3 were predicted to have a negative were predicted to have a negative outcome outcome

4040 had a negative outcome had a negative outcome Staff were accurate Staff were accurate 11 time time Algorithms identified Algorithms identified 85%85% of those who of those who

deteriorated, but over predicted deteriorated, but over predicted deteriorationdeterioration

Hannan, Lambert, Harmon, Nielsen, Smart, Shimokawa, Sutton (2005)Hannan, Lambert, Harmon, Nielsen, Smart, Shimokawa, Sutton (2005)1313

0

100

200

300

400

500

600

Positive No Change Deteriorated

TherapistPredictedOutcome

ActualtreatmentOutcome

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Hatfield (in press)Hatfield (in press)

Examined case notes of patients Examined case notes of patients who deteriorated to see if therapists who deteriorated to see if therapists noted worsening at the session it noted worsening at the session it occurred.occurred.

If the patient got 14 points worse If the patient got 14 points worse was there any recognition? 21%was there any recognition? 21%

If the patient got 30 points worse If the patient got 30 points worse was there recognition? 32%was there recognition? 32%

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Clinician ReportClinician Report Red Alert – Part 1 Red Alert – Part 1

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Clinician Report Red Alert – Part 2Clinician Report Red Alert – Part 2

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OQ-A provides Clinical Decision Support Tools for failure risk cases

Consumer report of:1.1. THERAPEUTIC RELATIONSHIP (I was willing to THERAPEUTIC RELATIONSHIP (I was willing to

share my innermost thoughts with my therapist)share my innermost thoughts with my therapist)2.2. SOCIAL SUPPORT (I felt accepted by someone SOCIAL SUPPORT (I felt accepted by someone

other than my therapist)other than my therapist)3.3. MOTIVATION FOR THERAPY (Honestly, I really MOTIVATION FOR THERAPY (Honestly, I really

don’t understand what I can get from therapy)don’t understand what I can get from therapy)4.4. RECENT LIFE EVENTS (I had difficulty adjusting to RECENT LIFE EVENTS (I had difficulty adjusting to

an occurrence in my life)an occurrence in my life)

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Research ProgramResearch Program

Six CLINICAL TRIALS IN WHICH WE ATTEMPTED TO REDUCE Six CLINICAL TRIALS IN WHICH WE ATTEMPTED TO REDUCE DETERIORATION RATES BY PROVIDING PROGRESS DETERIORATION RATES BY PROVIDING PROGRESS FEEDBACK TO PSYCHOTHERAPISTSFEEDBACK TO PSYCHOTHERAPISTS

Lambert, et al. 2001Lambert, et al. 2001Lambert, et al. 2002Lambert, et al. 2002Whipple, et al. 2003Whipple, et al. 2003Hawkins, et al. 2005Hawkins, et al. 2005Harmon, et al. 2007Harmon, et al. 2007Slade, et al. 2008Slade, et al. 2008

Random assignment of patients to experimental condition Random assignment of patients to experimental condition blocked on therapist (every therapist had patients for whom blocked on therapist (every therapist had patients for whom they received feedback and were denied feedback) N = they received feedback and were denied feedback) N = 4,0004,000

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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.

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455055606570

7580859095

Pre-test Feedback Post-test

OQ

Tot

al S

core

Not on Track-Treatment as Usual

Not on Track-OQFeedback only (NoCST)Not on Track-OQFeedback + CST

Results-CST Feedback

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Recovered or Improved

No Change Deteriorated

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%)

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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

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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, 379-392.

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, 308-327.

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, 49-68.

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,

91-103.

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, 287-303.

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, 59-68.

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