Behavioral Health Technology Platforms and the Implementation of Measurement-Based Care in Psychotherapy

Measurement-based care (MBC) is a data-driven approach to delivering health care services. MBC encompasses an array of clinical tools, such as routine outcome monitoring (ROM), feedback informed treatment (FIT), and measurement feedback systems (MFS). Collectively, these practices center around the routine administration of treatment outcomes measurement and processing the scores with clients about treatment progress. As such, these tools can inform therapists’ clinical judgment and support clinical decision-making. While originating in the medical field, it did not take long for MBC to become a topic of interest in mental health. MBC was introduced to psychotherapy research by Howard et al. (1996), whose seminal work established the patient-focused research movement. This approach prioritized the examination of inter-individual variability to elucidate how and for whom psychotherapy works (or does not work) (Norcross & Wampold, 2011). This choice of emphasis was driven by research identifying widespread inter-individual heterogeneity of response to treatment (e.g., Boswell et al., 2014; Boswell & Bugatti, 2016; Castonguay et al., 2013; Owen et al., 2015). 

Over the course of the past two decades, patient-focused research has contributed to a body of strong evidence supporting the efficacy and effectiveness of MBC (see Lambert et al., 2018; Miller et al., 2020). The strength of this evidence has also been acknowledged by the American Psychological Association’s Presidential Task Force of Evidence-Based Practice (2006), which elevated MBC to the status of evidence-based practice (EBP). However, MBC’s actual utilization in routine clinical settings remains sporadic (Ionita & Fitzpatrick, 2014). Research examining clinician-reported barriers hindering the implementation of MBC has highlighted the presence of several concerns related to its practicality, such as the addition of paperwork, the time required for its administration and interpretation, the lack of resources (e.g., financial and personnel) required to maintain this practice, and the burden placed on clients (Hatfield & Ogles, 2007). Luckily, recent technological advancements allow for the circumnavigation of many of these logistical issues. For instance, the development of computerized adaptive testing (CAT) promises to minimize the burden placed on clients by the routine administration of measures (e.g., Carlo et al., 2021). More importantly, the advent of behavioral health technology platforms promises to offer therapists and clients efficient means for engaging in MBC. These platforms allow therapists and clients to complete several clinical tasks, including scheduling, billing, documenting, as well as administering, completing, and reviewing routinely collected outcomes measures. These features should promote the frequency of clinician engagement with MBC, which previous research has found to be positively associated with client outcomes (e.g., Bickman et al., 2011; Bickman et al., 2016; Slade, 2011). 

This brief report aims to extend this line of nascent research on therapist use of MBC in routine clinical settings. We utilized a dataset from a behavioral health technology company that assists therapists and clients match for mental health services while also providing clinical support tools (i.e., MBC), clinical training, and administrative support. A sample of 6,108 clients diagnosed with depression and 8,273 clients with an anxiety disorder were included in the study. Their therapists had access to the Patient Health Questionnaire-9 (PHQ-9; Kroenke et al., 2001), administered to depressed clients, and the Generalized Anxiety Disorder Scale-7 (GAD-7; Spitzer et al., 2006), administered to anxious clients. Both measures were routinely administered to clients every two weeks. We examined whether clinician frequency of engagement with MBC (i.e., the number of times therapists viewed patient scores) would predict their clients’ likelihood of achieving clinical recovery, defined as a score of 9 or below on the PHQ-9 and of 7 or below on the GAD-7.

There were significant differences between those clients who reached clinical recovery and those who did not based on the number of times therapists had accessed their scores (ps <.01). That is, therapists who engaged in MBC more frequently were more likely to have their clients achieve clinical recovery on the PHQ-9 and/or GAD-7. Additionally, higher initial severity was also related to therapists accessing patient scores more often. The difference in the number of times patient scores had been reviewed by clinicians was characterized by a small effect size, suggesting that it does not take a lot more effort on behalf of therapists to realize significant gains for their patients. 

These findings are perfectly aligned with those presented in the literature (e.g., Lambert et al., 2018): clinician engagement in MBC enhances psychotherapy outcomes. Furthermore, the present study corroborates the presence of a dose-response relationship characterizing the frequency of clinician use of MBC tools and the likelihood of their clients’ achievement of positive treatment outcomes. The present study also provides useful insights regarding clinicians’ interaction with and use of MBC in primarily private practice settings assisted by technology-based platforms. Data from the present examination suggest that clinicians are more likely to employ MBC tools when encountering more challenging cases, such as those characterized by higher baseline severity. This finding implies that clinicians might perceive MBC as more useful to aid their clinical judgment in these cases, which may be a window into motivations for using MBC. It may also be hypothesized that the nature of the measures supported by this MBC platform might have had an impact on the purpose for which they were used by clinicians. Both the PHQ-9 and GAD-7 are symptom-focused, standardized assessment tools, and it appears that clinicians were more likely to turn to them when assessing symptom severity. Thus, it remains to be seen whether alternative types of routine measurement and feedback (e.g., individualized patient-reported outcome measures) would affect clinician use of MBC. Nonetheless, this area of inquiry has, so far, only been explored by a few pioneering studies producing mixed findings (e.g., Bugatti & Boswell, 2022; Jensen-Doss et al., 2018).

Overall, the conclusions drawn from the present study are clear: MBC is an EBP that demonstrates significant clinical utility, relevance, and practicality in routine clinical settings supported by technology-based platforms.