Feedback About Progress Can Improve Patient Outcome

“Measurement is the first step that leads to control and eventually to improvement. If you can’t measure something, you can’t understand it. If you can’t understand it, you can’t control it. If you can’t control it, you can’t improve it.” –H. James Harrington, author of business books.

Patients with eating disorders have a high risk of treatment failure, due to the high incidence of relapse and multiple medical complications. And, even with treatment, the condition of many eating disorder patients tends to deteriorate or they may prematurely drop out of treatment. An ongoing feedback program for patients and therapists may help reduce treatment failure, according to results of a recent preliminary study (Psychotherapy Res. 2013; 23:287).

Drs. Michael J. Lambert, of Brigham Young University, Provo, UT, and Witold Simon and colleagues at the Institute of Psychiatry and Neurology, Warsaw, Poland, recently tested a feedback intervention program for eating disorders patients and therapists. They theorized that giving patients and therapists feedback during treatment would reduce the rate of treatment dropout. This concept, which has been used in other fields as well, involves a feedback intervention program that includes suggestions for problem-solving or targeting problematic aspects of treatment so that both client and psychotherapist can act before the patient drops out of treatment.

In a randomized clinical trial, Dr. Lambert and colleagues tested the value of feedback among 137 adult patients seeking inpatient treatment. Individuals were diagnosed with anorexia nervosa (AN), bulimia nervosa (BN), or eating disorder not otherwise specified (EDNOS). The patients were randomly assigned to one of two treatment groups: treatment as usual, without the addition of feedback, and an experimental feedback condition where therapists were provided with feedback about the patients’ progress. The feedback element traced treatment progress, indicted response as expected or sent an alert when patients appeared to be at risk for treatment failure. Four patients were excluded from the final data analysis because they completed only a single session and then withdrew from the hospital. The questionnaire and feedback were distributed by OQ-Analyst software (OQ®-Analyst). This software program compares session-by-session progress against expected progress based on the level of disturbance as measured by the Outcome Questionnaire-45.2 (OQ-45). The OQ-Analyst intervention has undergone peer review and is an evidence-based practice.

The OQ-45 was completed by all patients on a weekly basis, whether or not their clinicians were assigned to the feedback group. If patients’ actions differed from the expected treatment path, they were given the Assessment for Signal Clients (ASC) questionnaire prior to the next individual treatment session. The ASC was not administered again at any subsequent session.

The 40-item ASC was delivered to clinicians via their computers, which highlighted subscales and specific areas that suggested a potential problem. The OQ-Analyst software also provided a problem-solving decision tree. The ASC specifically targets problems with the therapeutic alliance, motivation, social support, and stressful life events.

Therapists working with clients in the feedback treatment group received a direction sheet and were encouraged to share the progress information with patients during each treatment session. Each therapist was also asked to intervene with any patient who seemed to be at risk. Therapists were free to follow their own intuition and clinical judgment while using the ASC feedback and to use the information in any way that seemed helpful to their clients.

Feedback was helpful for some patients

Patients improved considerably with regard to their self-reported mental health functioning, whether they received feedback through the OQ-Analyst or not. The authors reported that 118 patients completed treatment. At the 5-session point in the study, more clients had dropped out of the feedback group than the treatment-as-usual group. At the end of the study, however, more clients were lost from the treatment-as-usual group than from the feedback group.

Overall, clients exposed to the feedback condition met the criteria for clinically significant change more often than did clients in the treatment-as-usual group (52.9% vs., 28.6%, respectively). Three-fourths of patients whose therapists received feedback reliably improved or recovered, compared with 68.3% of those in the non-feedback group.

The authors also analyzed weight changes, measured by the body mass index (BMI, kg/m2), to see if changes in BMI reflected improvement in mental health functioning. Patients in both treatment groups made significant and essentially equivalent improvements in BMI. The authors were disappointed to find very little difference between the two groups. Patients with AN whose therapists had received feedback appeared to benefit more from treatment than did patients with BN or EDNOS. The very positive findings for AN patients resemble the results from a recent meta-analysis (Hartmann et al., 2011). In that study, patients with AN changed, on average, from a BMI of 14.9 to 18.2 kg/m².