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Using routine outcome measures

Why collect routine outcome data?

Routine outcome data can be used to answer questions regarding the effectiveness of an intervention. It is necessary to collect this type of data on a large scale and, collate the data, which can then be analysed using statistical methods to provide what is known as an ‘effect size' for how effective the therapy has been. At a higher level, it is possible for this kind of data to be combined with other information such as the therapists' modality (eg. Humanistic, CBT, Psychodynamic etc.) and the clients' demographic information (eg. gender, age, ethnicity, presenting issues etc.) which can be analysed to help answer the question of ‘what works for whom?' 


Ethical considerations

All research ought to be conducted in accordance with the BACP Ethical guidelines for researching counselling and psychotherapy.

The use of evaluation and outcome measures should be practised in accordance with the BACP Ethical Framework. Outcome measures should be used as part of routine therapy, rather than as an adjunct to it; in a manner in which they are of benefit to each client and enrichment of each clinical engagement. The principle of Beneficence within the BACP Ethical Framework supports the process of using routine outcomes in therapy:

"Ensuring that the client's best interests are achieved requires systematic monitoring of practice and outcomes by the best available means".

This principle, however, is tempered in this context by that of Autonomy, dictating that data gathering and measuring must be in full accordance with the client / service user.

Routine outcome measures support the therapeutic process by enabling the therapist and the client to monitor progress (Harmon et al., 2007; Lambert and Shimokawa, 2011; Simon et al., 2012), and can play an important role in measuring service quality and lead to improvements.

An additional benefit is to provide evidence of the effectiveness of counselling and psychotherapy which has the potential to influence commissioners and policy-makers.


Gaining informed consent from clients

Counsellors often at first feel reluctant to use questionnaires in therapy sessions, fearing that they may interfere with the therapeutic process or take valuable time away from the session. Experience from services across the UK however tells us that clients are generally much less reluctant and are happy to complete measures when asked. However, it is necessary for clients to consent to completing measures in sessions and should a client refuse, this should in no way affect their therapy. It is also important to explain to clients what information is being collected and why and how the information will be used.


How to collect routine outcome data

It can be a relatively straightforward task to collect routine outcome data. All you need is to have a set of questionnaires, of which there are many, monitoring some form of progress in therapy. Then, there are some forms that you will ask the client to complete every session, ideally at the beginning although it is important that professional judgement is used as to if/when it is appropriate to ask a young person to complete these measures during a session. And then, at the very final session you ask the client to complete the same forms they completed in the first session.


How often should measures be used?

In ‘real world' settings as opposed to being part of a randomised controlled trial, clients often do not complete all therapy outcome measures (Barkham et al., 2012), which poses a real challenge in being able to fully understand the effectiveness of an intervention, as typically those who do complete outcome measures may have better outcomes or have attended more sessions of counselling. Therefore, for data to be meaningful and valid, it is essential for as many clients as possible to complete both pre and post outcome measures.

Using measures at every session
It is important to use at least one outcome measure every session to ensure that even in the case of unplanned endings there is a post-counselling measure for clients. A client may choose to no longer attend for a variety of reasons, and therefore not have a planned ending to their counselling. In this event it would be less likely that post-counselling outcome measures would be able to be completed.

Without a post-counselling measure clients cannot be included in any analysis of the data collected - reducing the validity of the results. In contrast, if outcomes are collected at every session then both start- and end- point measures for all clients can be guaranteed. Measures can be selected which are relatively brief and non-intrusive.


Which measures to use?

There are a vast number of different outcome measures to use. In order for data across services to be collated for central analysis, thus increasing the power and validity of the dataset, it is essential that there is some consistency across all services contributing to a dataset.

Working with adults
Measures currently being used as part of the IAPT data standard include the Patient Health Questionnaire (PHQ-9) and Generalised Anxiety Disorder - GAD7. The IAPT data standard provides information about these measures as follows:

Patient Health Questionnaire (PHQ-9)

The nine item version of the Patient Health Questionnaire (PHQ-9) was designed to facilitate the recognition and diagnosis of depression in primary care patients. It can be used to monitor change in symptoms over time and provides a depression severity index score as follows:

0 - 4 None
5 - 9 Mild
10 - 14 Moderate
15 - 19 Moderately Severe
20 - 27 Severe

Generalised Anxiety Disorder (GAD7)

Though designed primarily as a screening and severity measure for generalised anxiety disorder, the GAD7 also has moderately good operating characteristics for three other common anxiety disorders - panic disorder, social anxiety disorder, and post-traumatic stress disorder. The index scores are as follows:

0 - 4 None
5 - 10 Mild Anxiety
11 - 15 Moderate Anxiety
15 - 21 Severe anxiety

Working with children
If you are working with children and young people you may find it useful to read the Children and Young People Practice Research Network Toolkit for the Collection of Routine Outcome Data which includes the measures incorporated into CYP IAPT.


Where can I get support in using measures?

The BACP information sheet R4 ‘Using measures and thinking about outcomes' by Dr Tony Roth, gives an overview of many of the most commonly used outcome measurement tools available. Dr Roth: "Not everyone who practices as a counsellor has a background in research methods. The idea of this  information sheet is to give some background information about measures and outcomes, and to give practitioners some confidence in thinking about how they could set about monitoring outcomes." Please contact research@bacp.co.uk to request a copy.

e-Learning materials are also available on the Counselling MindEd and MindEd e-portal and additional resources can be found on the CORC website.


Further information

Useful resources

Miranda Wolpert's Keynote presentation at the 20th BACP Annual Research Conference: 'Outcome measurement and the therapeutic relationship: help or hindrance?' The presentation is on the Evidence Based Practice Unit (EBPU) website. 

Michael Lambert's pre-conference workshop presentation at the 19th BACP Annual Research Conference: 'Using clinical support tools to enhance outcomesfpr cases at risk for treatment failure.'

Michael Lambert's Keynote presentation at the 19th BACP Annual Research Conference: 'How to double client outcomes in 18 seconds: using mental health vital signs feedback and problem-solving tools.' 

Professor Mick Cooper's 2013 presentation to Place2Be counsellors: 'Systematic outcome and process feedback: a relational perspective.'  You can view the presentation slides or watch the presentation