Doing More With Less": Optimizing Psychotherapeutic Services in the Mental Health System

Routine Outcome Monitoring Routine Outcome Monitoring (ROM) enables systematic assessment of treatment outcomes at regular intervals for monitoring the progress of patients during treatment. ROM was originally developed for clinical studies, thus providing quality feedback for research and clinical purposes. There is accumulated evidence that ROM has positive effects for supporting care, for research and for management.

As of the beginning of the previous decade, ROM projects have developed and integrated into national health systems (e.g. Australia and New Zealand, England, etc.) and in various research groups around the world (e.g. Holland, Italy, USA, Canada, (Ruggeri, 2002; Burgess et al., 2012; Mellor-Clarket al., 2006) .In recent years, computer software has been widely used to collect, analyze and manage information in a secure, efficient and accessible manner, providing ongoing feedback to caregivers (Barkham et al., 2001; Barkham & Mellor-Clark, 2003; Margison et al., 2000).

Routine outcome monitoring can enable achieving several goals that directly contribute to treatment (De Beurs et al., 2011). It provides quality feedback to clinicians and patients in real time about the progress of the treatment and the early identification of various problems such as negative response to therapy. This increases the positive response to the treatment, balances the therapist's biases in an optimistic or pessimistic direction, supports decisions in treatment and improves the cooperation between the therapist and the patient. Hence, patients' involvement in the therapeutic process, their commitment to it, and their satisfaction (Whipple & Lambert, 2011), Lambert, 2010 (Priebe et al., 2002) also improve. A group of studies has shown that frequent monitoring of the evaluation of the therapeutic relationship during psychotherapy enables better real-time identification of therapeutic ruptures that can be corrected (Muran et al. 2009; Safran et al., 2011). In psychiatric work with more severe patients, it was demonstrated that there was a correlation between ROM and a significant reduction in the number and duration of hospitalizations, a finding that has a significant economic significance (Slade et al., 2006). In a meta-analysis review published in 2009 (12 studies, 2001-2006) a significant short-term symptomatic improvement and some long-term improvements was shown in monitored therapies. In another review (Shimokawa et al., 2010), a weekly measure of personal well-being measures had a significant positive impact on the quality, duration and outcome of treatment, especially in patients prone to dropout. Despite initial objections among teams to introduce quantitative measurements into their work, various attempts have shown that after assimilation, staff satisfaction from the systems is great and serves as a complement to individual work and staff meetings (de Beurs et al., 2011).

The collection of the broad information in the ROM is also used for managerial purposes (Trauer, 2010). For example, the accumulated information can be used for ongoing epidemiological research of treatments as they actually occur in a heterogeneous clinical environment and may maximize resources utilization (Coombs et al., 2011). The information produced (on the organizational, local, regional or national levels) is more likely to have higher predictive validity than information extracted from incidental questioning patients for improvement. Effective evaluations of various treatment approaches have also been made, and it is important to consider that treatments are indeed effective in the particular clinical setting they are provided, and not only in controlled studies under very different conditions (Stiles et al., 2008). Applying ROM appears to be more effective when integrated in a formalized and structured manner (Krägeloh, 2015). In such terms, it may be a powerful managerial tool, balancing between the patient's expectations and needs and the mental health care capacity. It is thus surprising, as recently noted by Jensen-Doss (2018), that ROM rarely used in practice, even though it is viewed favorably.

Despite current enthusiasm, advances in implementation, and the growing belief among some proponents and policymakers that ROM represents a major revolution in the practice of psychotherapy, other research has suggested that the focus on measurement and monitoring is in danger of missing the point (Miller et al., 2015). Research from the field of expertise and expert performance provides guidance for realizing the full potential of ROM. One crucial element in optimizing the effect of the ROM is that the decisions derived from continuously collecting the outcome measures will be taken with the patient (and not just shared with him/her). As shown by Clarke et al. (2015), more active involvement in decision-making than the patient stated as desired was associated with higher satisfaction. A clinical orientation towards empowering, rather than shared, decision-making may maximize satisfaction and optimize the effect ROM may have on clinical practice.