Measurement-based care (MBC), or the practice of incorporating client feedback on progress in therapy into treatment decisions, is a highly impactful tool — but one that less than 20% of behavioral health providers integrate into their care.

Historically, this has been due to various concerns: Even if clients are asked to participate, they may not understand how providers use the data; therapists tend to believe that measures are no more effective than clinical judgment, despite the prevailing evidence.

At Two Chairs, we’ve found that therapy is most effective when therapeutic alliance is strong and when clients have tools to reflect on their progress and take an active role in their care. So we’ve put MBC at the core of our care model. 

More behavioral health organizations should adopt MBC to achieve better outcomes and improve the therapy supply and demand issue we’re all witnessing. Hear from our Chief Clinical Officer Colleen Marshall to learn more about why and how to do it.

What kinds of assessments should be included in an MBC model, and is there a standard for what these measures should look at?

Colleen Marshall: There are several measures that providers can use to see how a client is progressing in therapy, and they should be chosen based on their ability to assess client symptoms, quality of life, and therapeutic alliance. 

At Two Chairs, we use the following measures taken through brief — but comprehensive — client questionnaires prior to each session to capture the best data to inform a holistic and collaborative care approach.

For symptom assessment, we recommend the Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) to measure anxiety and depression, respectively. These are clinically validated, industry standards that are reliable, well-established, responsive to changes in symptoms, and easy to compare across payers and markets. Because anxiety and depression are two of the most common mental health problems, and because symptoms are comorbid with other issues like posttraumatic stress disorder (PTSD), using the GAD-7 and PHQ-9 enables you to capture progress in a large breadth of clients.

Beyond symptoms, it’s also essential to look at quality of life to help you see how your clients are doing overall. Often, the impact of mental health problems on a client's overall quality of life is more salient than their specific symptoms. Although changes in symptoms are related to changes in quality of life, they do not always change at the same rate and may vary in importance to clients. 

High-quality therapy will treat the person as a whole. So we need to include measures that assess overall functioning beyond specific mental health symptoms to create a truly comprehensive MBC system. To do this, organizations can include measures like the Mental Health Quality of Life (MHQoL), which captures things like self-image, independence, mood, relationships, and physical health, and is a relatively new measure. We recently adopted it and we’re looking forward to evaluating its impact on the care we deliver — already, our therapists applaud it for its ability to assess things that are important to their clients’ well-being not captured by our symptom measures. 

And finally, because therapy is a relationship-based intervention, it’s essential to constantly monitor therapeutic alliance, or the relationship between the client and therapist. While a strong match is the first step in establishing strong alliance, it’s crucial to monitor alliance throughout care. By doing this, therapists can identify when there has been a rupture in the relationship that needs to be repaired, give the client the opportunity to provide feedback and have targeted conversations about their relationship with their therapist, and ultimately make adjustments to care that are responsive to this feedback.

While these measures cover the basics, there are more out there, and we continually evaluate our own MBC model to ensure that it is meeting the ever-evolving needs of our providers and clients. 

How does MBC improve the client experience and lead to better outcomes?

Colleen Marshall: MBC provides clients and providers with the ability to monitor progress in real time and make collaborative and data-informed decisions. However, it’s crucial to implement it well and embed it into the organizational culture so that clinicians feel prepared and supported to use it in a way that creates true value for their clients. 

MBC gives clients an opportunity to reflect on their well-being week-to-week with our mental health snapshots and see progress in care, which can be empowering. Through MBC, they get a deeper understanding of their progress and a shared language for communicating about it with their therapist, which is difficult for many. 

By engaging in MBC, clients also have a chance to take a more active and involved role in their care. Importantly, MBC gives clients a way to identify connections between changes they’ve made and how they’re progressing in therapy, which is key for achieving desired outcomes. Most people can tell they’re getting better generally, but the data can help support that observation. 

When clients are actively engaged in their mental health care, it helps them get clear on goals and desired outcomes and enables a strong collaborative process. The information, discussions, and collaborative decision-making that are a part of MBC can also strengthen the therapeutic alliance, which research has shown leads to better outcomes. 

At Two Chairs, 100% of our clinicians engage with MBC, which has helped give us clear insights into the clinical outcomes our care is achieving. You can learn more about how our care model is driving exceptional behavioral health outcomes — with 74% of our clients showing clinically meaningful improvement at the end of care — in our 2024 Clinical Outcomes Report.

What impact can greater adoption of MBC have on the behavioral healthcare system at large?

Colleen Marshall: First and foremost, we want our clients to achieve their mental health goals and reach a point where they no longer need therapy, and MBC is a critical component of the collaborative path to graduation from care. When implemented well, it gives both therapists and clients tools to engage in conversations about care that can help clients achieve their goals in a data-driven way. 

Additionally, MBC plays a role in improving accessibility of care: It can help clients progress more quickly and gives clinicians a better sense of when someone is done with care, or if they need a higher level of care. All of this can contribute to reduced dropout rates and overall time in care.

And finally, when data is aggregated across an entire behavioral health organization, it can provide invaluable information about the effectiveness of its services. This data can be used to help an organization improve its effectiveness by allowing it to better diagnose a population, highlight strengths and weaknesses, and identify needs for supervision and training. It can also demonstrate the value of behavioral health services to payers, which can inform reimbursement policies and improve funding allocated to mental health care across the country. 

How can behavioral health organizations improve adoption of MBC?

Colleen Marshall: To improve adoption of MBC, organizations need to look at things like software and data teams, organizational culture, and culturally responsive care.

First, it’s important to have great software that’s easy for both clients and clinicians to use — that means partnering with clinicians in software design to ensure it supports their work, as well as conducting multiple rounds of user testing. You need to make sure it’s part of the entire system and that managers and their managers are all bought in. Having strong product, engineering, and data teams can help you create the tools you need and look at data in a psychologically safe way. 

While it starts with software, you also need to create a clinical culture that works to point everything in the right direction and embed MBC in the care model. We know that there is a lot of clinician skepticism around MBC, which is understandable. To overcome that, it’s important to create a sense of safety, hire therapists who have the right mindset for working with MBC, and communicate clearly how the different measures are used. It’s critical to listen to clinicians and create a culture where their voices actually matter.

You also need to look at your MBC model through a holistic and cultural lens and delve into clients’ lived experiences. While data can offer valuable snapshots of someone’s symptom severity, functioning, and progress, these are only one facet of a client’s complex reality. It’s essential to practice culturally responsive care and acknowledge the diverse ways different cultures express and experience mental health challenges. By applying cultural humility and acknowledging holistic needs, we move beyond a narrow focus on scores and embrace the collaborative journey that uses data as a starting point to explore the depths of clients’ unique stories. 

Once all these pieces are in place and moving, your clinicians can see how useful the tools are and how they help evolve their care plans for their clients. 

At Two Chairs, we look forward to evolving our own MBC model and look forward to wider adoption among more providers so we can reach better mental health outcomes for all.