Establishing an Evidence-Based Practice, One Client at a Time

A couple in therapy look at one another optimisticallyWhen it comes to evaluating psychotherapy, there is good news and there is bad news. The good news is that research has unequivocally demonstrated that therapy works. The bad news is that, despite overall efficacy, many clients do not benefit, dropouts are a problem, and therapists vary significantly in success rates, can be poor judges of client negative outcomes, and rarely have a clue about their effectiveness.

A solution to these problems may be found in systematic client feedback: the continuous monitoring of client perceptions of progress and the therapeutic alliance throughout the course of therapy. It involves real-time comparison of client views of outcome with an expected treatment response, which serves as a yardstick for gauging client progress and signaling when change is not occurring as predicted. Armed with this information, clinicians and their clients have an opportunity to shift focus, revisit goals, or alter interventions as needed.

Although it sounds like hyperbole, identifying clients who are not benefiting is the single most important thing a therapist can do to improve success—doubling positive outcomes for clients who may be headed for drop out or other negative conclusions. In fact, 12 randomized controlled trials (RCT) combining Michael Lambert’s Outcome Questionnaire System and Partners for Change Outcome Management System (PCOMS) now support this assertion.

The Substance Abuse and Mental Health Administration (SAMHSA) lists PCOMS as an evidence-based practice, as a result of the RCTs conducted by the Heart and Soul of Change Project. But it is not your average evidence-based practice, because it’s not a specific treatment model for a particular diagnosis. Regardless of therapist theoretical orientations or client diagnoses, PCOMS has demonstrated significant improvements for both clients and therapists. More importantly, because PCOMS is employed at the individual client-therapist level, it promotes a partnership that monitors whether this approach provided by this therapist is benefiting this client. In other words, it is evidence-based practice one client at a time.

It almost seems contradictory—that tailoring services to the individual client’s needs, preferences, and culture can result in an evidence-based therapy practice. PCOMS allows therapists to deal directly and transparently with clients, involving them in all decisions that affect their care and keeping their perspectives the centerpiece of every decision made and action taken in therapy. In addition, PCOMS serves as an early-warning device to identify clients who are not benefiting, so that the client and therapist can chart a different course. This, in turn, encourages us to step outside routinized ways of working, and continue to grow as therapists. PCOMS helps us focus every session with every client on the therapeutic alliance, so that we tailor therapy to the client’s expectations. Finally, tracking client outcomes and the alliance also enables proactive efforts to improve, without guesswork or waiting for the platitudes about experience to manifest. It enables our clients—especially those who aren’t responding well to our therapeutic business-as-usual—to teach us how to work better.

A recent meta-analysis of PCOMS studies provides a good summary of what client feedback brings to the table: Those in the feedback (PCOMS) group were 3.5 times as likely to experience reliable change and less than half as likely to experience deterioration. All that’s needed to triple your clients’ chances of having successful outcomes is a four-question survey that takes about five minutes at the beginning and end of each session. What’s more, PCOMS measures are available in 23 languages and can be downloaded and used by clinicians at no charge. What could be simpler?


  1. Duncan, B. (2012). The Partners for Change Outcome Management System (PCOMS): The Heart and Soul of Change Project. Canadian Psychology/Psychologie canadienne, 53, 93–104.
  2. Duncan, B. (2014). On becoming a better therapist: Evidence-based practice one client at a time (2nd ed.). Washington, DC: American Psychological Association.
  3. Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48, 72–79.

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  • james


    October 21st, 2014 at 4:32 PM

    It is hard to feel judged even when you wnat to know the truth.

    It is like that old saying that the truth hurts, which is sometimes true, but often something that most of us need to hear. It might not feel good at the time but it could help you make a lot of beneficial improvements in the future, and that can only produce good things for everyone involved.

  • GB


    October 23rd, 2014 at 3:58 AM

    I would be very intimidated if I thought that my therapist was not listening to my own specific needs and was trying to treat me in a one size fits all kind of manner. But evidence based practices seem to take a step away from that and lean toward looking at the individual and determining from there what his or her own unique strengths and weaknesses are and tailoring the treatment plan to meet that individual. I think that there will be a lot of people who are confortable with that method and approach.

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