Health Systems and Policy Research

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Commentary - (2021) Volume 8, Issue 5

Feedback-Informed Treatment in Mental Health Services with Spanish-Speaking Patients: From Outcome to Process Monitoring

Danilo Moggia*

Department of Clinical Psychology and Psychotherapy, University of Trier, Trier, Germany

*Corresponding Author:
Danilo Moggia
Department of Clinical Psychology and Psychotherapy,
University of Trier,
E-mail:[email protected]

Received Date: October 8, 2021; Accepted Date: October 22, 2021; Published Date: October 29, 2021

Citation: Moggia D (2021) Feedback-Informed Treatment in Mental Health Services with Spanish-Speaking Patients: From Outcome to Process Monitoring. Health Sys Policy Res Vol.8 No.7: 103.

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Feedback-Informed Treatment (FIT) represents a relevant development in providing psychological therapies in mental health services. FIT can be considered a practice of measurement-based care in which clinical decisions are informed by patients’ data collected throughout treatment [1]. FIT involves using standardized measures for routine-outcome monitoring with a computerized system throughout the whole treatment process [2]. The patient’s response to treatment is measured session by session, and this information is then relayed to the therapist and the patient in real-time [3]. The outcome reported by the patient is compared with an expected treatment response [4] which is used for gauging a patient’s progress and alerting when change is not occurring as predicted (not-on-track-NOT-response). With this risk signal, the therapist and patient can identify and resolve the obstacles to improvement. In this regard, FIT is aimed to tailor the intervention to the individual patient allowing the therapist to make empirically-based decisions to adapt the focus of the treatment throughout the therapeutic process [5].

Numerous studies have demonstrated FIT’s effectiveness and its clinical usefulness, especially for patients at risk of being NOT or dropout. The most recent and comprehensive meta-analysis to date [6] found a small but significant effect of FIT on symptom improvement, NOT cases and patients at dropout risk. This meta-analysis included 58 studies. In these different studies, diverse feedback systems were used. In these feedback systems, outcome measures are prominent, while process measures (those designed to assess specific factors that work as change mechanisms and mediators of treatment outcome) are considered secondary.

One process variable identified as one of the main contributors to treatment outcome is therapeutic alliance [7]. Therapeutic alliance comprises three factors: therapeutic bond, agreement between therapist and client in the goals of therapy and agreement in the tasks to be developed to achieve the previously agreed goals [8]. One brief instrument designed to assess these three factors is the session rating scale [9]. The SRS is an ultra-brief, a four-item visual analogue measure developed explicitly for use in everyday clinical practice. The items of the SRS assess the three factors of therapeutic alliance, adding a fourth item aimed at evaluating the patient’s perception about the overall session. The SRS is designed to be answered by the patient (in no more than two minutes) at the end of each therapy session. From the patient’s answers, the therapist can start a conversation to obtain feedback from the patient regarding the therapeutic relationship and the session content. These conversations aim to solve any obstacle to therapy development and the patient’s improvement. Implementing alliance measures in feedback systems constitutes a step forward in implementing process measures beyond the outcome ones. Process measures can contribute to obtaining information on which therapeutic processes make more sense for the patient and which are related to the patient’s improvement.

In the meta-analysis before mentioned, only one study was conducted with spanish-speaking patients [10]. This is a striking fact considering that spanish is the world’s secondmost spoken native language [11]. How is it possible that a technology that has come of age [12] and has a demonstrated contribution to better treatment outcomes has not a more significant extension in spanish-speaking contexts? The answer to this question can be addressed from different perspectives, and several factors should be considered. Nevertheless, outcome measures to be used in FIT with spanish-speaking patients are available [13], and just a few of the feedback systems have a Spanish version [14]. However, there is still a lack of process measures.

For instance, a number of different instruments for assessing the therapeutic alliance have been adapted to Spanish: The revised helping alliance questionnaire the working alliance inventory, and the working alliance theory of change inventory [15-17]. All they have good psychometric properties. However, they are also quite long and developed for research purposes, generating complaints from patients and clinicians on the time needed for completion.

Considering the need in Spanish-speaking countries for an alliance measure ready to be used routinely in everyday clinical practice, we studied the psychometric properties of the SRS in a Spanish clinical sample. The sample comprised 165 adult psychotherapy patients from different primary care centers of Barcelona (72.7% were woman; Mage=43.57, SD=13.3). The results showed that the measure has good reliability (Cronbach’s alpha of.93) and good convergent (correlations between 0.50 and 0.60 with the Spanish WAI and WATOCI), discriminant (correlations between 05 and 13 with outcome measures) and predictive validity (the SRS at 3rd session explains 4.2% of the outcome variance at last therapy session). We concluded that the instrument is a valid and reliable tool for monitoring therapeutic alliance during psychotherapy with Spanish-speaking patients. In fact, this instrument can be used with its brother outcome measure: The Outcome Rating Scale (ORS), which its Spanish version was also validated by our team.


To conclude, we encourage clinicians, researchers, and public funders from Spanish-speaking countries to invest in developing, adapting, and implementing these kinds of measures and feedback systems. The research aimed in this direction should consider the particularities of each region where Spanish is spoken, looking for adapting these tools to its respective contexts for the benefits of Spanish-speaking patients.