The Partners for Change Outcome Management System (PCOMS): The Heart and Soul of Change Project.

Abstract

Two continuous monitoring and feedback models have demonstrated gains in randomized clinical trials (RCTs): Lambert's Outcome Questionnaire (OQ) System and the Partners for Change Outcome Management System (PCOMS). This article chronicles the evolution of PCOMS from a simple way to discuss the benefit of services with clients to its emergence as an evidenced based practice to improve outcomes. Although based in Lambert's model, several differences are described: PCOMS is integrated into the ongoing psychotherapy process and includes a transparent discussion of the feedback with the client; PCOMS assesses the alliance every session; and the Outcome Rating Scale, rather than a list of symptoms rated on a Likert Scale, is a clinical tool as well as an outcome instrument that requires collaboration with clients. The research supporting the psychometrics of the measures and the PCOMS intervention is presented and the clinical process summarised. Examples of successful transportation to public behavioural health are offered and an implementation process that values consumer involvement, recovery, social justice, and the needs of the front-line clinician is discussed. With now nine RCTs and American Psychological Association endorsements to support it, it is argued that client-based outcome feedback offers a pragmatic way to transport research to practice. Keywords: client-based outcome feedback, patient-focused research, PCOMS, practice-based evidence The only man (sic) I know who behaves sensibly is my tailor; he takes my measurements anew each time he sees me. The rest go on with their old measurements and expect me to fit them. - George Bernard Shaw It is often reported that the average treated person is better off than approximately 80% of die untreated sample (Duncan, Miller, Wampold, & Hubble, 2010; Lambert & Ogles, 2004), which translates to an effect size (ES) of about 0.8. In short, the good news is that psychotherapy works. Unfortunately, Ulis is a bad, and ugly situation. The bad is twofold: First, dropouts are a significant problem in die delivery of mental healdi and substance abuse services, averaging at least 47% (Wierzbicki & Pekarik, 1993). Second, despite the fact that the general efficacy is consistently good, not everyone benefits. Hansen, Lambert, and Foreman (2002), using a national database of over 6,000 clients, reported a sobering picture of routine clinical care in which only 20% of clients improved compared with the 57%-67% rates typical of randomized clinical trials (RCTs). Whichever rate is accepted as more representative of actual practice, the fact remains that a substantial portion of clients go home without help. And the ugly: Perhaps explaining part of die wide range of results, variability among dierapists is me rule radier than the exception (Beuder et al., 2004). Some dierapists are simply much better man others. In a study of managed care treatment, for example, Wampold and Brown (2005) reported that 5% of outcome was attributable to therapist variability. In addition, dierapists overrate dieir effectiveness. Dew and Riemer (2003; reported in Sapyta, Riemer, & Bickman, 2005) asked 143 clinicians to rate dieir job performance from A+ to F. Two-tfiirds considered themselves A or better; not one dierapist rated him or herself as below average. So despite overall efficacy, dropouts are a substantial problem, many clients do not benefit, and dierapists vary significantly in outcomes and are poor judges of dieir effectiveness. A relatively new research paradigm called patient-focused research (Howard, Moras, Brill, Martinovich, & Lutz, 1996) addresses diese problems. Howard et al. (1996) advocated for die systematic evaluation of client response to treatment during die course of tiierapy and recommended diat such information be used to determine die appropriateness of die current treatment . . . [and] die need for further treatment . …