PPRNet Clinical summary: Barriers to Implementing Routine Outcome Monitoring

 Routine outcome monitoring (ROM) is a method of systematically tracking treatment progress with standardized measures and providing the therapist with feedback about their client’s progress. This method has been used to provide therapists with feedback on patients' symptoms and the working alliance, sometimes for each session. Research has shown that ROM improves treatment outcomes and the therapeutic alliance, reduces dropouts, and identifies patients who are worsening. ROM and feedback to the clinician allow the therapist to adjust their approach to the client, increasing the likelihood that the therapy will be helpful. The method is thought to supplement therapists’ clinical decision-making. Despite the evidence of its effectiveness, ROM in clinical practice is the exception, not the rule. In this meta-analysis of qualitative studies, Jonasova and colleagues synthesized 58 studies that examined clinicians' perspectives on barriers to implementing ROM in psychotherapy. The analysis yielded five thematic clusters of barriers and facilitators to ROM from the clinicians’ perspective. First, perceived clinical relevance refers to clinicians’ concerns that ROM sometimes conflicted with their preferred therapeutic approach, that the measurement process was not valid, that the utility of ROM to supplement clinical judgement was poor, and that ROM might interfere with the therapeutic relationship. Second, institutional aspects include clinicians’ concerns that organizations may not buy into the process, may misuse ROM data to evaluate clinicians, and may not provide sufficient training to use ROM. Third, practical aspects include clinicians’ concerns about the time burden of using ROM, data security, and a lack of skill and experience with ROM. Fourth, client variables reflect clinicians’ views that some clients lack enthusiasm or cognitive skills to use ROM and technology, and that some clients’ mental health conditions (psychosis, dementia) and cultural expectations (unwillingness to express negative feedback) may make ROM unsuitable. Fifth, clinicians’ personal reactions suggest that some therapists were concerned that implementing ROM would devalue their clinical judgment and authority; they feared their work would be negatively evaluated, and they struggled with negative feedback. On the other hand, some therapists were reassured by positive feedback and appreciated when areas for training and professional development were highlighted. 

Practice Implications 

ROM is an effective method for improving client outcomes and therapists’ effectiveness, but clinicians differ widely in their reactions to it. For some, ROM is a natural extension of their clinical work, but for others, it is an attack on the integrity of the therapeutic relationship. For ROM to be implemented successfully, therapists must have sufficient control over the process, clients must understand the benefits and be reassured about confidentiality, and institutions must provide clinicians with sufficient training, time, and technical support and assure therapists that ROM will not be used as a therapist evaluation tool but rather a clinical support tool. 

Jonášová, K., Čevelíček, M., Doležal, P., Aas, B., & Řiháček, T. (2025). Barriers and facilitators in the implementation of routine outcome monitoring from the clinicians’ perspective: A qualitative meta-analysis. Psychotherapy. Advance online publication. https://dx.doi.org/10.1037/pst0000605