MBC Education  |   Jan 15, 2025  |   8 minute read

Measurement-Based Care: A transformative approach to treatment

This article was featured in the American Psychological Association’s January 2025 issue, authored by Tori DeAngelis. To view the original article, visit the APA website.

Measurement-based care (MBC)—the use of patient data to inform treatment goals and progress—is squarely in line with the aim of evidence-based practice: using science and data as a key part of good treatment.

But because this kind of measurement is still not routinely taught in graduate school, many psychologists are only tangentially aware of it, so it remains a source of mystery and confusion. Common concerns are that MBC will cut into valuable clinical time, that patients will dislike filling out data forms, and that adding this process will disrupt the natural flow of treatment. Some clinicians also worry that insurers and managers will use the data from measurement-based care to penalize them if they don’t think patients are progressing quickly enough.

However, such concerns can prevent psychologists from employing a tool that can empower patients, clarify treatment goals, strengthen the therapeutic alliance, and improve outcomes, said Ruben Martinez, PhD, an assistant professor at Brown University and member of the APA Advisory Committee for MBC and MBHR (Mental and Behavioral Health Registry).

“Like anything else you start that is new, learning this approach can be challenging and anxiety-provoking,” said Martinez, who practices, studies, implements, and trains others in the use of measurement-based care. “But in my experience, once you’ve learned it and you employ MBC with consistency and care, your patients and practice will benefit.”

 

How it works

Measurement-based care is “a clinical process that uses quantitative data to allow clinicians and patients to track patient progress,” explained Jessica Barber, PhD, an assistant clinical professor at the Yale University School of Medicine and associate director of the Measurement-Based Care in Mental Health Initiative in the Veterans Health Administration (VHA) Office of Mental Health. “Measures are administered regularly and repeatedly, and that information helps inform treatment decisions and goal setting.”

Here’s how it works: Ideally, patients fill out a short electronic questionnaire before every session or two that provides a snapshot of how they are doing psychologically, emotionally, socially, and functionally. Many measurement systems assess the relationship between the clinician and patient, as well. With the click of a button, the data are transferred to the clinician, who reviews the results via easily interpretable graphs and metrics. At the beginning of a session the clinician then references the findings, and the clinician and patient have a brief chat about the patient’s progress and about any issues in their relationship. If the data indicate any significant improvements or declines, the two mutually decide whether to continue discussing the area of change, stay on the therapy path they were taking, or even terminate therapy if they both feel the patient has made enough headway toward reaching their goals.

Over time, the data provide objective information about patient progress—whether someone is becoming less anxious or depressed or more comfortable socially, for example. It can also show when a patient remains stuck and a different tack or even provider is needed, said Barber, who is also cofounder of the Yale Measurement Based Care Collaborative, dedicated to advancing the understanding and implementation of high-quality MBC.

“MBC can be really useful for detecting inertia in treatment and prompting the clinician and patient to decide together about what treatment options might be helpful to get back on track,” she said.

Research on measurement- based care is positive: It shows that employing the technique helps to modestly but significantly reduce symptoms and lower dropout rates, according to a meta-analysis by Kim de Jong, PhD, of Leiden University in the Netherlands and colleagues (Clinical Psychology Review, Vol. 85, 2021). Another study points to specific factors that can make MBC a success: In semi-structured interviews with 26 patient-therapist dyads, Stephanie Brooks Holliday, PhD, of the RAND Corporation in Santa Monica, California, and colleagues found that in dyads that valued MBC the most, clinicians provided clear and repeated rationale for the practice, discussed data with patients each time they received them, and connected observed scores to patients’ learned skills or strategies (Psychotherapy Research, Vol. 31, No. 2, 2021).

Gains from measurement occur for both patients at risk for treatment failure and those on track to do well, added Matteo Bugatti, PhD, an assistant professor at Oregon State University who studies MBC. That’s good news on two fronts: It’s rare to find new therapy processes that make an appreciable difference for the better, and it’s unusual to find an intervention that benefits all types of patients, he said. That said, further tailoring MBC to the unique process of psychotherapy promises to further contribute to the achievement of good outcomes, he said.

[Related: Options for skill-building in measurement-based care]

 

More collaborative therapy

In addition to these basics, a central aim of the measurement approach is to make the therapy process more transparent and collaborative, Barber noted. The “Collect, Share, Act” model, developed by the VHA’s MBC in Mental Health Initiative and further operationalized by Barber, highlights the ingredients that go into the optimal use of this approach: collecting data from the patient, sharing what the data may indicate, and acting collaboratively on the data with the patient. The model also emphasizes the importance of explaining the rationale behind the system so that patients understand why they’re doing the task.

Using data forms as an integral part of treatment “operationalizes the therapeutic alliance by inviting patients to repeatedly and regularly let us know what they’re thinking,” said Barber.

In a related vein, MBC offers patients the opportunity to be more honest about how they’re doing, said Bruce Wampold, PhD, emeritus professor of counseling psychology at the University of Wisconsin–Madison and chief clinical officer at Making Therapy Better, an MBC-related platform sponsored by the behavioral health care company CarePaths.

“Many patients just want to please their therapist,” he said, “so if I ask them if they think they’re making progress, they’re likely to say yes.” Providing hard data “allows them to give a more objective answer to that question.” In fact, in collaboration with CarePaths, Wampold has created a free MBC-based app, Making Therapy Better, that patients can share with their therapist whether or not their therapist uses measurement-based care. “This app empowers patients to improve their therapy,” he said.

In understanding what MBC is, it is also important to understand what it is not, Wampold added. For one thing, it is not intended to be a rigid system that requires psychotherapists to use one or two specific questionnaires in specific ways. Although many clinicians and agencies rely on a few well-vetted measures that address common concerns like depression, anxiety, and post-traumatic stress disorder, there are hundreds of measures to choose from, including those that assess factors like functionality, well-being, loneliness, and therapy relationship factors such as confidence in the therapist and in the treatment. Some clinicians also use idiographic measures, which track patient progress on issues of individual importance, for example, how often they fight or do enjoyable things with their partner.

In addition, psychologists can use more than one measure to assess and address different problems, for example, if a patient has both depression and insomnia, or obsessive-compulsive disorder and problems in social functioning. “You can pick one or several measures that are appropriate for a particular patient, their context, their disorder or problem, and their individual goals,” Wampold explained.

MBC also does not mean changing your theoretical orientation, noted Simon Weisz, president and cofounder of Greenspace Health, a company that uses technology and training to help organizations and individuals implement MBC in ways tailored to their culture and needs.

“If anything, MBC should fit easily and flexibly into your workflow to enhance your practice and inform your clinical decisions with objective insights,” said Weisz, who is also a member of APA’s MBC advisory committee. “First and foremost, MBC is about providing clinical value to both clinicians and their patients.”

 

Tailored uses

Measurement-based care is still vastly underused: Less than 20% of clinicians have adopted it despite advances in technology that have made measurement easier to implement (Jensen-Doss, A., et al. Administration and Policy in Mental Health and Mental Health Services Research, Vol. 45, No. 1, 2018).

But many of those using the methodology underscore that it has strengthened their practice by clarifying treatment goals, putting more agency in the hands of patients, and providing an evidence-based way to keep improving how they work with patients. Thanks to the flexible nature of MBC, they’ve also been able to tailor it to meet the needs of diverse patients and settings.

Martinez, for example, worked at a therapeutic day program for children and teens that strongly involved parents as well. He used standard depression and anxiety screeners to assess young people’s symptoms but also worked with a care team to incorporate a brief idiographic measure called Youth Top Problems, which asks young people and their parents to list the top three issues each wants to work on.

Because parents and kids pick the issues themselves, it is easy for both parties to see tangible progress in areas that make an immediate practical difference, such as kids getting along better with siblings or parents not yelling at their kids as much. It also gives therapists and nurses clear goals to track over time.

“Treatment can meander, it can wander, and using MBC in these ways helps to define our focus,” Martinez said.

Meanwhile, Ajeng Puspitasari, PhD, a clinical professor and director of clinical training at the University of Wisconsin–Milwaukee and a member of the APA advisory committee for MBC, has used the modality not only with patients who have depression and anxiety but also with those who have serious mental illness or suicidal thoughts and behaviors. Like Martinez, she supplements symptom measures with other measures, for example, those that assess more internal factors like emotion regulation and mindfulness.

“Because these patients often struggle with ‘big feelings,’ they tend not to see how much progress they’re making,” she said. “But if we use measures that look at more than just symptoms, we can say, ‘Okay, maybe your depression is not going down, but look at how far you’ve come in your ability to manage symptoms, to be mindful, to regulate your emotions.’” Such input gives patients who are struggling hope and confidence that they are improving, she said.

On a larger scale, Robbie Babins­Wagner, PhD, chief executive officer at the Calgary Counselling Centre in Alberta, Canada, first implemented MBC in 2004 and has been refining it ever since.

All 120-plus members of the clinical staff use the same measurement system, making it relatively easy to study how the system is working overall, Babins-Wagner explained. Before each session, patients fill out a form called the Outcome Questionnaire, a checklist that asks about symptoms of distress, social role functioning, and interpersonal relationships. With the best practice use of MBC, the findings are consistently used as a fulcrum for communication and intervention, resulting in a slow but steady increase in patient improvement (Psychotherapy, Vol. 53, No. 3, 2016).

The ability to analyze long-term data also means that center clinicians have discovered ways to improve treatment they might not have noticed otherwise, Babins-Wagner added. For example, one therapist grew curious about factors that influenced the center’s depression rates. She used 10-year data to compare the effects of individual therapy and group therapy. To the therapist’s surprise, patients who underwent individual counseling followed by 14 weeks of group therapy were no longer depressed at the end of treatment, while those who only undertook individual counseling were less depressed but did not meet the cutoff score for depression.

The center is now changing its program to make group therapy a regular part of depression and anxiety treatment. “We don’t care if the data are good or bad because we learn something no matter what they tell us,” Babins-Wagner said.

 

Increasing uptake

While research and experience suggest that MBC could be a significant boon for the field, there is more work to be done to convince psychologists that it’s a wise investment of time and energy. More work is also needed to educate mental health agencies, health care systems, and insurance companies about the proper use of MBC in the mental health context, Bugatti said. In many settings, it’s still used more for administrative purposes—a box for therapists to check to indicate they’re using the system—than as a tool for clinical improvement. There is also a big need to develop measures that reflect the more nuanced realities of psychotherapy rather than those of medicine, where there is a direct, causal relationship between, for example, a drug intervention and a medical outcome, he said.

APA is starting to address many of these issues through its advisory committee for MBC and MBHR. Subcommittees are working to engage with third-party payers to educate them about psychology’s unique makeup as it relates to MBC and to train psychologists in measurement who can then train others in the approach. A related workgroup is also writing a professional practice guideline that will detail optimal ways to incorporate MBC into psychological practice.

Research on MBC is also still in its infancy, especially as it relates to mental health. Terms for the practice are all over the board, and research needs to evolve so it better defines and addresses the processes and outcomes of MBC, as well, Barber said.

Challenges notwithstanding, it’s important that practitioners consider adopting a measurement approach, both because of its value for patients and because it is increasingly on the radar of insurers and regulators, said Weisz.

“We’re seeing significant growth in its utilization among providers, and the momentum is promising,” he said. “When we know what is working, what is not working, and why, we can continually improve care and innovate, using the same standards that are already in place across other health care specialties.”

At its core, measurement-based care is about enhancing why psychologists went into the field in the first place, Barber added.

“With this little clinical process that anybody can weave into their practice,” she said, “we can confer this extra benefit—this above-and-beyond improvement—in how our patients are responding to care.”