This article reviews the benefits, obstacles, and challenges that can hinder (and have hindered) implementation of routine outcome monitoring in clinical practice. Recommendations for future routine outcome assessment efforts are also provided. Spanning three generations, as well as multiple developed tools and approaches, the four authors of this article have spent much of their careers working to address these issues and attempt to consolidate this learning and experience briefly here. Potential "elephants in the room" are brought into the discussion wherever relevant, rather than leaving them to obstruct silently the field's efforts. Some of these topics have been largely ignored, yet must be addressed if we are to fulfill our promise of integrating science and practice. This article is an attempt to identify these important issues and start an honest and open dialogue.

In 1994, the American Psychological Association and the Society for Psychotherapy Research convened a Core Battery Conference to develop a set of criteria for the selection of a universal core battery that could be used as a common outcome tool across all outcome studies. The Treatment Outcome Package (TOP) is a behavioral health assessment and outcome battery with modules for assessing a wide array of behavioral health symptoms and functioning, demographics, case-mix, and treatment satisfaction. It was developed to follow the design specifications set forth by the Core Battery Conference, but also to ensure the battery's applicability to naturalistic treatment settings in which randomization may be impossible. In this article we discuss a number of studies that evaluate the initial psychometrics of the items that comprise the mental health symptom and functional modules of the TOP. We conclude that the TOP has an excellent factor structure, good test-retest reliability, promising initial convergent and discriminant validity, measures the full range of pathology on each scale, and has some ability to distinguish between behavioral health clients and members of the general population.

Significant therapist variability has been demonstrated in both psychotherapy outcomes and process (e.g., the working alliance). In an attempt to provide prevalence estimates of "effective" and "harmful" therapists, the outcomes of 6960 patients seen by 696 therapists in the context of naturalistic treatment were analyzed across multiple symptom and functioning domains. Therapists were defined based on whether their average client reliably improved, worsened, or neither improved nor worsened. Results varied by domain with the widespread pervasiveness of unclassifiable/ineffective and harmful therapists ranging from 33 to 65%. Harmful therapists demonstrated large, negative treatment effect sizes (d= -0.91 to -1.49) while effective therapists demonstrated large, positive treatment effect sizes (d=1.00 to 1.52). Therapist domain-specific effectiveness correlated poorly across domains, suggesting that therapist competencies may be domain or disorder specific, rather than reflecting a core attribute or underlying therapeutic skill construct. Public policy and clinical implications of these findings are discussed, including the importance of integrating benchmarked outcome measurement into both routine care and training.

Clients are likely to experience differential benefit depending on the particular therapist and his or her strengths. Clinical outcomes may be improved by developing the best possible prediction model for each new client and then providing that client with referrals to therapists with well-matched strengths. (PsycINFO Database Record

IMPORTANCE Psychotherapists possess strengths and weaknesses in treating different mental health problems, yet performance information is rarely harnessed in mental health care (MHC). To our knowledge, no prior studies have tested the causal efficacy of prospectively matching patients to therapists with empirically derived strengths in treating patients' specific concerns.OBJECTIVE To test the effect of measurement-based matching vs case assignment as usual (CAU) on psychotherapy outcomes. DESIGN, SETTING, AND PARTICIPANTSIn this randomized clinical trial, adult outpatients were recruited between November 2017 and April 2019. Assessments occurred at baseline and repeatedly during treatment at 6 community MHC clinics in Cleveland, Ohio. To be eligible, patients had to make their own MHC decisions. Of 1329 individuals screened, 288 were randomized. Excluding those who withdrew or provided no assessments beyond baseline, 218 patients treated by 48 therapists were included in the primary modified intent-to-treat analyses.INTERVENTIONS Therapist performance was assessed pretrial across 15 or more historical cases based on patients' pre-post reporting across 12 problem domains of the routinely administered Treatment Outcome Package (TOP). Therapists were classified in each domain as effective (on average, patients' symptoms reliably improved), neutral (on average, patients' symptoms neither reliably improved nor deteriorated), or ineffective (on average, patients' symptoms reliably deteriorated). Trial patients were randomly assigned to good-fitting therapists (matched group) or were assigned to therapists pragmatically (CAU group). There were multiple match levels, ranging from therapists being effective on the 3 most elevated domains reported by patients and not ineffective on any others (highest) to not effective on the most elevated domains reported by patients but also not ineffective on any domain (lowest). Therapists treated patients in the matched and CAU groups, and treatment was unmanipulated.MAIN OUTCOMES AND MEASURES General symptomatic and functional impairment across all TOP domains (average z scores relative to the general population mean; higher scores indicate greater impairment), global distress (Symptom Checklist-10; higher scores indicate greater distress), and domain-specific impairment on each individual's most elevated TOP-assessed problem. RESULTSOf 218 patients, 147 (67.4%) were female, and 193 (88.5%) were White. The mean (SD) age was 33.9 (11.2) years. Multilevel modeling indicated a match effect on reductions in weekly general symptomatic and functional impairment (γ 110 = −0.03; 95% CI, −0.05 to −0.01; d = 0.75), global distress (γ 110 = −0.16; 95% CI, −0.30 to −0.02; d = 0.50), and domain-specific impairment (γ 110 = −0.01; 95% CI −0.01 to −0.006; d = 0.60), with no adverse events. CONCLUSIONS AND RELEVANCEMatching patients with therapists based on therapists' performance strengths can improve MHC outcomes.