Estimated cost savings for mental health agency – $494,600 WITH increased benefit to therapy clients

The letter below was written to the Departemnt of Health in Florida to being their attention to the benefits of systematic client feedback (CDOI) to therapy clients and agencies.  I am not sure of the outcome. References may be interest to some.

DOH colleagues and Dr. Nelson-Gardell:

In my brief talks with some of you, I’ve mentioned our agency’s use of the Client Directed Outcome Informed (CDOI) approach to therapy.  Because this approach is utilized at our entire agency, including in the SAFE Kids program, I wanted to share some information I think you will find helpful in understanding our commitment to this approach.  The DOH grant stipulates that we must use an evidence-based practice as well as assessment tools.  Since CDOI is evidence-based and utilizes measurement tools, I am hopeful that this approach as well as our instruments will be accepted as part of your standards of practice under this grant.

Below you will read an explanation of the approach created by our Chief Operating Officer, David Claud, LMHC, CAP. After an extensive search for evidence-based practices, David has been instrumental in bringing the CDOI approach to our agency.  CFS is the first and only agency inSouth Floridato use this approach and our agency outcomes have improved dramatically as a result of its implementation.  Here are some highlights of our success as a result of using CDOI and the ORS/SRS:

Based upon 2100 Cases at CFS in all counseling programs from 2001-2002

(Some items updated with 2004 data):

Ø       Decreased average number of sessions by 40% while increasing successful program outcomes by 7%

Ø       Increased retention, thereby decreasing dropouts by 40%

Ø       Decreased no-shows by 50%

Ø       Decreased long-term null outcomes cases by 80%

  • Improved client satisfaction with “effectiveness” of the therapy by 20% and

       the “therapist’s ability to understand and be helpful” by 15%

Ø       Total costs saved estimated at $494,600.00

I’ve also attached copies of the measurement tools: the ORS and SRS.  (go to  The ORS would be most relevant to this grant as it assesses a client’s subjective level of psychological distress.  This may capture their personal experience of bothersome traumatic symptoms.  Our Bio-Psychosocial assesses specific traumatic reactions such as sleep disturbances, eneuresis/encopresis, behavioral problems, etc., so it can be argued that using an instrument that assesses mere symptoms associated with trauma is a duplicative effort.   

David and I would be happy to answer any questions you may have about this approach and/or the measurement tools.  Please note that David will not be available during the August 8th site visit so any questions you may have would be best forwarded via email so we can respond thoughtfully and thoroughly.

We are looking forward to this new partnership and thank you for your guidance, support, and commitment to the SAFE Kids program.

Here are just a few references from a rather large body of research upon which the client-directed, outcome-informed perspective is based.  The case for the common factors as determinants of client outcome in psychotherapy is probably the single most replicated finding spanning the last 40-50 years of studies.  The findings are extremely compelling because it involves analyses of thousands of studies, includes hundreds of researchers most of whom had an allegiance to their specific models and with very few exceptions the researchers were trying to show differential efficacy for their model.  Instead researchers found no difference among approaches when all the confounding factors were properly controlled including researcher allegiance.  Despite this significant body of evidence from the field there are many professionals and stakeholders in the industry who still believe that some models of therapy have proven to be more effective than others and furthermore that the specific ingredients presumed to be therapeutic in those approaches are responsible for the variance of change or outcome in persons receiving treatment.  Models are important but not for the reasons purported by their adherents and not to the degree that most people think, at best specific models of therapy contribute about 15% to the variance in outcome (Lambert, 1992) and in a more recent meta-analysis only about 1% (Wampold, 2001).  

There are many, many research articles and publications that provide the evidence for using a common factors approach such as “client-directed, outcome-informed therapy” and I have included just a few. Additionally, the Outcome Rating Scale (ORS) and Session Rating Scale (SRS) are measures that tap into the common factors and therefore relate to that body of evidence.  As you know these tools have been standardized and the initial research is published as well (see references below).  Since these instruments do measure the client’s subjective level of psychological distress and they are sensitive to change in a clinical population then they are quite applicable to the types of clients you are seeing.

These measurement tools (ORS/SRS) are also related to other psychotherapy outcome research which shows that when therapists get routine feedback, in real time, from clients about outcome and the alliance factors and then adjust treatment accordingly those outcomes do improve as much as 65%.  In other words, we may use various evidenced-based practice models but we apply them in an individualized manner using a paradigm (CDOI) that recognizes and operationalizes the common factors and maximizes their respective contribution to successful outcomes.  We are actively managing the outcome with the client as a full partner in the process. Not only does this method significantly improve outcomes, as has been shown across various settings and clinical populations around the world, but it saves money because we don’t waste precious resources on treatment that isn’t working for a particular individual recipient.  Those cases at risk for a negative or null outcome are identified early and the approach tailored to fit the client’s needs and frame of reference. 

Here are a few research references, publications on the subject and a partial list of practice sites that have successfully implemented a CDOI approach and use the ORS/SRS as an outcome management system. If you need more there is plenty.  Hope this helps to show our commitment and diligence in knowing the research as well as basing our clinical practice upon what is the most compelling evidence to date.

Common factors:

Lambert, M.J. (1992). Implications of outcome research for psychotherapy integration. In J.C. Norcross & M.R. Goldstein (Eds.)

Handbook of psychotherapy integration. (pp. 94-129).New York: Basic Books.

Bergin, A.E., & Garfield, S.L. (Eds.). (1994). Handbook of psychotherapy and behavior change (4th ed.).New York: Wiley

Wampold, B.E. et al. (1997).  A meta-analysis of outcome studies comparing bona fide psychotherapies: Empirically, “All must have prizes.”   Psychological Bulletin, 122(3), 203-215.

Asay, T.P., Lambert, M.J. (1999). The empirical case for the common factors in therapy: Quantitative Findings. In M.A. Hubble, B.L. Duncan, & S.D. Miller (Eds.) The heart and soul of change: What works in therapy (pp. 33-56) Washington, DC: American Psychological Association

Wampold, B.E. (2001). The great psychotherapy debate: Models, methods, and findings.Hillsdale,NJ: Erlbaum

Relationship or “Alliance” factors as a predictor of therapeutic outcome:

Bachelor, A., & Horvath, A. (1999).  The Therapeutic Relationship.  In M. Hubble, B. Duncan, & S. Miller (eds.).  The Heart and Soul of Change. Washington,D.C.: APA Press.

Project MATCH Group (1997).  Matching alcoholism treatment to client heterogeneity.  Journal of Studies on Alcohol, 58, 7-29.

Connors, G.J., & Carroll, K.M. (1997). The therapeutic alliance and its relationship to alcoholism treatment participation and outcome.  Journal of Consulting and Clinical Psychology, 65(4), 588-98.

Elkin, I.(1999). “Patient-treatment fit” and early engagement in therapy.   Psychotherapy Research. 9(4) 437-451.



Using Formal Feedback to Improve Treatment Outcomes:

Lambert, M.J., Whipple, J.L., Hawkins, E.J., Vermeersch, D.A., Nielsen S.L., & Smart, D.W. (2003) Is it time fro clinicians to routinely track patient outcome? A meta-analysis. Clinical Psychology: Science & Practice, 10,288-301.

(The above study reported that those relationships at risk for a negative outcome which received formal feedback were, at the end of therapy, better off than 65% of those without feedback (Average ES = .39, p < .05).) 

Whipple, J.L., Lambert, M.J., Smart, D.W., Nielsen, S.L., & Hawkins, E.J. (2003) Improving the effects of psychotherapy: The use of early identification of treatment and problem-solving strategies in routine clinical practice. Journal of Counseling Psychology, 50, 59-60

(The above study found that clients whose therapists had access to outcome and alliance information were less likely to deteriorate, more likely to stay longer, and twice as likely to achieve a clinically significant change.)

Miller, S.D., Duncan, B.L., Sorrell, R., & Brown, G.S. (February, 2005). The Partners for Change Outcome Management System.  Journal of Clinical Psychology, 61(2), 199-208.



Outcome and Session Rating Scales:

Miller, S.D., Duncan, B.L., Sorrell, R., & Brown, G.S. (February, 2005).  The Partners for Change Outcome Management System.  Journal of Clinical Psychology, 61(2), 199-208.

Miller, S.D., Duncan, B.L., Brown, J., Sparks, J.A., & Claud, D.A. (2003) The Outcome Rating Scale: A Preliminary Study of the Reliability, Validity, and Feasibility of s Brief Visual Analog Measure, Journal of Brief Therapy Vol.2 (2) Spring/Summer, 91-100.

Miller, S.D., Duncan, B.L., Brown, J., Sparks, J.A., Claud, D.A Reynolds, L.R., Brown, J. &. Johnson, L.D. (2003) The Session Rating Scale: Preliminary Psychometric Properties of a “Working” AllianceMeasure Journal of Brief Therapy Vol.3 (1) Fall/Winter, 3-12.


Agencies and/or Practice Settings where a client-directed, outcome informed approach is being utilized:

  • The Center for Family Services of Palm Beach County, Florida – using CDOI since 2001 w/ children & families, diverse populations
  • The State ofArizona Behavioral Health System– the state deemed the CDOI approach as a best practice, used statewide plus using the ORS/SRS
  • The Center for Alcohol and Drug Treatment –Deluth,MN. – using CDOI and ORS/SRS since 1997 with substance abusers
  • Community Health & Counseling Services –Bangor,ME- community mental health setting w/ severe mentally ill, CDOI since 1999
  • PrimariLink – State ofVermont– a managed care company using CDOI principles in their system of care with MH/SA providers
  • The Center for Child & Adolescent Mental Health, Eastern & Southern Norway – using CDOI in their national MH care systems
  • Family Service ofRhode Island– using CDOI since 2003 in their family services system various populations, children & families
  • Resources for Living –Austin,TX/. – a large, international EAP serving diverse clinical populations, children & families
  • JFKUniversity,Santa Cruz,California– uses CDOI in their community counseling clinic & in their graduate counseling curriculum

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4 Responses to “Estimated cost savings for mental health agency – $494,600 WITH increased benefit to therapy clients”

  1. Self Help Online | All On Audio Books Says:

    […] Mental Health Drop In Center – Mental Health Articles, Self Help Resources, Support ForumSelf EsteemLive Better With These Great Self-Help TipsEstimated cost savings for mental health agency – $494,600 WITH increased benefit to therapy c… […]


  2. Old Fussbudget Says:

    Bad link to scales – missing ‘t’ in “hear[t]andsoul…”


  3. diddly Says:

    thanks D


  4. Cinda Says:

    This excellent website definitely has all of the information and facts I wanted about this
    subject and didn’t know who to ask.


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