What Is Measurement-Based Care and What Are Its Benefits to Practitioners?

I’m three sessions in with my new therapist, when she shares what looks like an intake form I’ve already completed. 

The form is the GAD-7, the self-reporting tool to measure generalized anxiety disorder (GAD). 

Although I’m no stranger to this form—I recently restarted therapy to address a resurgence of anxiety—I’m not sure why I’m being asked to fill it out again. 

Previously, I’d only seen forms like the GAD-7 at the onset of treatment, intake questionnaires to be filled out once and then promptly forgotten.

Confused, I asked my therapist if she meant to resend this form. She reassured me that she did, and that she would be resending it for me to fill out at a regular cadence throughout my treatment to gauge my progress. 

Apparently my experience isn’t uncommon—measures like the GAD-7 are widely used to collect client-reported feedback, however, many clinicians struggle to standardize their use of these measures. 

 

In a SimplePractice survey of 578 practitioners, 86% reported using measurement-based care—also known as MBC or evidence-based care—to some degree. However, of those who use MBC, only about 29% use it with all their clients. 

Of practitioners who use MBC with all their clients, 44% say MBC is at least “nearly always effective,” with 38% reporting it is “usually effective.” Overall, 82% of practitioners surveyed say they believe in the general efficacy of evidenced-based practices. Research has long supported this same sentiment—that measurement-based care is effective.

In a 2016 paper published in the journal of Cognitive and Behavioral Practice, researchers noted that “adding MBC to usual care can result in significant improvement in client outcomes with respect to psychological disturbance, interpersonal problems, social role functioning, and quality of life.”

So, why aren’t more clinicians using it?

Our survey concluded that the top three barriers to adopting a measurement-based care framework were: client fit (42%), lack of tools (31%), and how much work it takes to implement (23%). 

In this article, I will address clinicians’ concerns about the universal applicability of MBC, discuss implementation strategies, present its benefits, and alleviate some of the practical challenges associated with outcome tracking—by introducing SimplePractice’s newly integrated measurement-based care solution (pictured below).

What is measurement-based care (MBC)?

In addition to evidence-based care, practitioners also refer to measurement-based care as patient-reported outcomes or patient-informed feedback. All of these terms refer to client treatment measurement systems.

According to the American Psychology Association (APA), measurement-based care has three components: collecting, sharing, and acting.

Clinicians use measurement-based care to collect self-reported data from their clients by regularly administering forms or questionnaires throughout treatment. In fact, the GAD-7, the form I filled out before my first and third therapy sessions, is one of many MBC tools that a practitioner can use to track the treatment of their clients. 

Clinicians then share the scores, or results of their clients’ feedback, to discuss progress and areas of improvement with their clients. 

Finally, clinicians act in collaboration with their clients—assessing and reassessing their treatment—in light of this information. 

Examples of evidence-based care

Evidence-based care tools are wide-ranging—used in the screening and monitoring of symptoms, diagnoses, and behaviors. 

The most common tools that behavioral health professionals use include the Patient Health Questionnaire (PHQ-9), which is used to measure depression severity, and the GAD-7, used to measure symptoms of anxiety. 

These measures are included in the new SimplePractice measurement-based care tools. You can also download a PDF version of the PHQ-9 and GAD-7 below.

 

There are some measurements that can be administered indiscriminately, to collect general metrics on a client’s well-being, like the Outcomes Questionnaire (OQ-45). While there are others that are attuned to measure specific psychological conditions, like the Obsessive Compulsive Inventory-Revised (OCI-R)—for measuring symptoms and treatment progress of obsessive compulsive disorder (OCD). 

Measurement-based care tools can also vary depending on the client’s age. For example, a clinician may screen for post-traumatic stress disorder (PTSD) in adults with the PTSD Checklist for DSM-5 (PCL-5), but use the Child and Adolescent Trauma Screen (CATS) for minors. 

Furthermore, there are certain tools that are exclusively used for screening or to aid diagnosis. Some questionnaires are only administered subsequently, to monitor the ongoing symptoms of an established condition or diagnosis. Then, there are the tools that can be used for both screening and monitoring. 

The PHQ-9, GAD-7, OCI-R, and the PCL-5 fall into the latter category—they’re used for both monitoring and screening purposes. Although the OQ-45 is a general measurement, it’s intended to be used on an ongoing basis to monitor progress in therapy, not as an initial screening tool. And the CATS is only used for screening trauma in children and adolescents.

How to implement MBC and use patient-reported outcomes

As clinical psychologist and SimplePractice Education Director Lindsay Oberleitner, Ph.D, points out, “MBC is not just the use of an assessment form at one point in time.” 

Oberleitner views outcome-based care as a dynamic tool to use throughout the therapeutic relationship. “The true value of MBC can be experienced when it is viewed as an integral part of the clinical process,” Oberleitner says.  

Researchers tend to agree, a study published in the Psychiatric Services Journal explored the frequency at which providers collected patient-reported feedback. They found that infrequent administration of questionnaires, and even regular administration of assessments without addressing results in session, were not effective. 

Conversely, the study confirmed that “frequent and timely feedback of patient-reported symptoms to the provider during the clinical encounter significantly improved outcomes.” 

Understanding the value of MBC and believing in its efficacy is also crucial to its successful implementation. This application of MBC contributes to the strengthening of clinical outcomes and builds the therapeutic relationship between client and clinician. 

With this in mind, SimplePractice held an educational webinar to show clinicians how to create a system for the widespread implementation of MBC in their practice. You can view the recording on YouTube: How to Use Measurement-Based Care to Strengthen Therapeutic Alliances. 

In the meantime, here are steps you can take to ensure you’re standardizing care—by using validated measures and curtailing your therapeutic interventions to the client’s individual needs:

1. Screen your client: At the start of a therapeutic relationship, you’ll want to screen your client to assess their mental health and introduce the assessment tools you’ll be using—explaining the clinical purpose of administering the screening measures. 
2. Share initial assessments: Clinicians can share initial assessments in the client’s intake before the start of the first session. Clinicians should include the rationale for collecting this information in the screening call or in the intake documentation. 
3. Use the results to inform your first session: After client-reported feedback is collected, you can use the results to inform how to proceed with your first session: what diagnoses to screen for, what issues are concerning, the severity of the client’s symptoms, and surmise what additional information that could better inform the initial treatment plan. 
4. Reiterate the purpose of the assessments: In the first session with your client, reiterate the purpose of the assessments used and share any findings that may be relevant in guiding treatment. Learn about the experiential and emotional factors that contributed to the client’s responses: if there have been any recent changes in their life, what they are struggling with, and what they’d like to get out of therapy. 
5. Create an initial treatment plan: After screening for symptoms and, if applicable, making a diagnosis, you’ll want to create an initial treatment plan and communicate these details to your client. 
6. Administer relevant assessments on an ongoing basis: As the treating clinician, you’ll administer relevant assessments and continue to share your treatment adjustments with your clients based on the feedback they’re submitting.
7. Track the scores from the client’s responses over time: Feel free to share the client’s progress, or decline, in their self-reported measures with them. For example, you can ask a client who scored high on the PHQ-9 over the last couple weeks—compared to earlier sessions—why they think they’re experiencing higher symptoms of depression. Collaborate with your client on what could be affecting their mood and what has been helpful in alleviating depressive symptoms. Then,change the course of treatment or make adjustments as needed. 

Benefits of measurement-based care for practitioners and clients

There are many benefits to evidence-based care, chief among them are: accountability, strengthening therapeutic alliances, and improved client outcomes. 

We’ve detailed each of these benefits below. 

Improved client outcomes 

A 2020 study, published in the Psychotherapy Research journal, tested the effect MBC had on treatment objectives, against a control group of patients receiving treatment as usual (TAU), among 1,733 outpatients, over a year. Researchers frequently and systematically administered the OQ-45 tool to track patients’ anxiety and depression throughout treatment. 

They found that those whose treatment was supplemented by measurement-based care, experienced a 26.8% greater reduction in their scores and symptoms than those in the control group. 76.4% of improvement was made within the first three months of treatment. Furthermore, MBC improved patient retention rates, with less patients dropping out of treatment early. 

Many clinicians agree that measurement-based care can be very valuable, especially at the start of treatment. 

Matthew Coffman, LPC and founder of the group practice Unpacked Care, finds measurement-based care questionnaires “very helpful when [first] meeting clients.” Then, during subsequent visits with clients, he believes MBC helps him to “get better at assessing the needs of each client, what modalities or scales might work, measure what’s happening, what’s working or not working, and how to adjust treatment.”  

Accountability

According to a meta-analysis of 51 research papers on evidence-based practices, relying on clinical judgment alone isn’t an accurate basis for mental health treatment. 

In fact, mental health providers who don’t consider patient-reported feedback “detect deterioration for only 21% of their patients who experience symptom severity.” 

Los Angeles-based psychologist and founder of Beachfront Anxiety, Max Maisel, Ph.D, specializes in OCD and PTSD. Maisel believes MBC is necessary for most of his clients. 

“Some things you need to track, behaviorally,” he says. For example, “hair-pulling needs more specific [and consistent] tracking.” 

“You need objective measures to hold yourself accountable,” Maisel says.

San Diego therapist Vanessa Villaseñor, LMFT, and co-owner of group practice A Place of Growth, says “medical professionals are automatically measuring, [so] there has to be some sort of measurement with mental health.” 

Coffman agrees with Maisel. “If you can track it, you can change it,” he says, quoting the old adage.  

 

Therapeutic alliance  

Villaseñor, Coffman, and Maisel agree that measurement-based care can keep clinicians on track, but Coffman sees another benefit to measurement-based care. He observes that MBC “empowers clients to do their own tracking on their progress.”  

Facilitating rapport with clients by regularly assessing their self-professed needs and giving them the opportunity to take an active role in their treatment ultimately improves outcomes. 

Yale Assistant Professor of Psychiatry Amber W. Childs, Ph.D.—who serves on the American Psychological Association’s (APA) Advisory Committee for Measurement-Based Care in Mental and Behavioral Health—believes in MBC’s fortifying effect on the therapeutic alliance as a listening and collaboration tool. 

“What makes MBC so powerful is that it is an invitation for both the client and the clinician to get curious about their work together,” Childs says. 

According to Oberleitner, “MBC is a continual process that elevates the client’s experience in driving treatment.” 

“Clinicians have this added opportunity to listen with an even wider ear to their client and how these data [points] fit or do not fit with their experience and perspectives regarding care,” Childs elaborates.  

Weak therapeutic alliances and disagreements throughout the course of treatment—between client and clinician—are amongst the highest recorded reasons for treatment failures.

In a study comparing treatment as usual (TAU) to therapy that integrated routine outcome monitoring (ROM), significant increases in therapeutic alliance ratings, recorded over two months, were responsible for 23% of the increase in treatment efficacy.  

Similarly, when researchers studied the effects of measurement-based care in substance use treatment, patients reported feeling more engaged in their treatment, heard and respected by their care providers, and committed to their treatment outcomes when measures were routinely administered and shared with them. 

Clinician and client resistance 

Although there are many documented improvements to client care, there are understandable concerns clinicians have about measurement-based care that may prevent widespread use and adoption. 

Are standardized measures one-size-fits-all?  

Sometimes resistance to measurement-based care can come from clients. “Some clients don’t like it and it can be awkward to administer a form, especially when a client is in crisis or distress,” Maisel reports.

However, client resistance can often be thwarted if MBC is established early on and routinely discussed with the client. 

A qualitative study, analyzing clinician-patient dyads, found that establishing the importance of measurement-based care at the onset of treatment, reestablishing this rationale during multiple visits, and connecting therapy goals discussed in treatment to the outcomes measured in assessments increased patient buy-in and improved therapeutic alliances. 

Maisel also points out that many studies proving the effectiveness of MBC may be biased. 

“Groups of people these studies were originally based on may not be a diverse population,” he explains. Furthermore, Maisel says the administration of measurement-based care questionnaires aren’t always accessible, especially for those with executive functioning issues.

However, it’s important to note that despite the origins of evidence-based care, the effectiveness of the tool isn’t biased—it’s actually considered a strong method of raising voices and elevating the client’s perspective. The administration and application of evidence-based practices should be specifically tailored to the client’s needs.  

Oberleitner affirms this point. “MBC goes hand-in-hand with a person-centered treatment planning approach, allowing extra space for the living, evolving treatment plan to flex and meet evolving client needs,” she says.

The data agrees with Oberleitner. Cultural adaptations for specific demographics need to be considered to address discrepancies in MBC’s effectiveness for populations that lie outside those the tools were originally based off of. 

“At the end of the day, being heard, understood, and being able to count on the chance to participate in making changes are the foundations upon which strong working alliances are built,” says Childs. 

Childs’ clinical work is dedicated to innovative implementations of MBC that improve the quality and access to care for marginalized communities. 

Childs and Oberleitner aren’t the only ones purporting the benefits of evidence-based care in treating clients with diverse backgrounds. 

At its core, evidence-based care is a listening tool that can be curtailed to the client demographic being served. 

The National Library of Medicine published a paper examining the effectiveness of evidence-based care in treating ethnic minorities, and found that cultural awareness and responsiveness was crucial in the successful implementation of MBC. 

In another study, of Latinx clients’ responsiveness to evidence-based practices, researchers found that culturally responsive therapists, particularly those who shared cultural identities with the clients, were able to curtail measures and implementation to their clients’ specific experiences—resulting in improved outcomes. 

For the most comprehensive and individualized care, well-touted therapeutic frameworks suggest integrating idiographic assessment procedures (like live observation and behavioral analysis) with nomothetic assessment procedures (like measurement-based care and client-reported feedback). 

The issue with accountability 

As a group practice owner, Villaseñor appreciates measurement-based care. “MBC adds a bit of accountability and dictates how [therapists can] do their jobs,” she says. However, she points out that “there’s complexity in being measured and seeing dips and spikes.” 

Maisel also acknowledges that, while accountability in therapy is important, therapists could be fearful of potential ramifications to utilizing measurement-based care. “Clinicians don’t want insurance companies looking and judging, but we need to be accountable and show we can do good therapy,” he says.

However, this fear may be relatively unfounded. In the survey SimplePractice conducted, clinicians who use measurement-based care with all clients were more likely to accept insurance. 

Workload and lack of technological tools 

In the same survey, over 50% of clinicians leveraging MBC are using pen and paper to collect data and track trends, while those using technology are relying on several different tools. 

The manual, analog, unstreamlined, process of outcome tracking that many clinicians have had to rely on, deters the widespread use and implementation of measurement-based care. 

After researching the need for and value of measurement based care, SimplePractice has released its own streamlined solution—which is available to all customers, across all subscription plans. 

How to use SimplePractice measurement-based care (MBC) tools

Of practitioners with early access to the new SimplePractice measurement-based care solution, 94% agree that automatic scoring makes their job easier. And over 80% of early adopter participants noted that the integrated feature makes them more likely to use measurement-based questionnaires in the future.

The SimplePractice measurement-based care solution allows customers to repeatedly and regularly share the PHQ-9 or GAD-7 with their clients to complete online. 

Client scores are automatically recorded and appear in their client file. Each entry will be logged into a report and graph, for easy tracking over time. 

You can use the aggregated data to determine if you should change the treatment plan or therapeutic approach for each client.

For more information on the SimplePractice measurement-based care solution and how to use it, check out this help center guide on Measurement-Based Care. 

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