What Stories Does Routine Outcome Monitoring Tell? Contrasting Psychological Distress Scores With In-Therapy Narratives

Abstract

Introduction

The use of outcome measures in psychotherapy has grown substantially as a method for tracking change. However, the exclusive reliance on quantitative measures may neglect contextual and relational factors affecting client experiences. This study explored how therapist perceptions and contextual factors may play a role in the interpretation of routine outcome monitoring (ROM) scores. The aim was to critically examine two therapy cases where ROM scores indicated no reliable change, yet clients demonstrated narrative improvements from the therapist's view.

Methods

This naturalistic study was conducted in a university-affiliated psychotherapy centre. Two clients undergoing narrative therapy completed the CORE-OM before therapy and CORE-10 session-by-session to monitor psychological distress. The Reliable Change Index (RCI) was used to assess the statistical significance of CORE-10 score changes. These outcomes were contrasted with information derived from therapist observations.

Results

Neither client showed statistically significant or reliable change in psychological distress across therapy. However, the therapist's analysis of clients' narratives revealed significant improvements in self-concept and relational dynamics. Themes such as expected family roles, sociocultural expectations and gender norms were key in shaping clients' experiences of psychological distress.

Conclusions

ROM scores can be useful for tracking clients' change, but their potential is amplified when integrated within a broader monitoring framework that includes therapist observations, and an understanding of the influence of systemic factors on psychological distress. We advocate for multimodal monitoring in psychotherapy research and practice to address the heterogeneity and diversity of change in therapy.