To Change or Not to Change? When to Change a Client's ORS Score

| April 24, 2017

To Change or Not to Change - ORS

Thousands of agencies, practitioners, and their clients have found MyOutcomes' web-based application of the Outcome Rating Scale (ORS) to be a powerful tool. The process is simple. Using MyOutcomes' extensive database, the feedback of all clients with the same initial intake score is used to predict an expected course of therapeutic progress. Deviations from the predicted path of successful treatment alert the therapist of issues needing to be addressed.


As the client's predicted progress is predicated on the initial intake score, the first score is crucial in interpreting client change during the therapeutic process. Errors involving this first score can lead to erroneous conclusions and ill-advised decisions.

There are two types of errors involving the initial intake score that warrant correcting. One is an administrative error that occurs when scores are entered manually. These errors can be corrected by MyOutcomes' IT staff. A second error involves the client deciding their first ORS score is wrong. For example, during the second session, the client may realize that they didn't completely understand how to use MyOutcomes the first time. They may feel that the initial score doesn't accurately reflect their reality. This type of error can also be fixed by MyOutcomes' IT staff.

Practitioners may see errors where there are no errors. For example, mandated clients typically enter the therapeutic context not seeing themselves having any problems or issues. Their initial ORS score, therefore, is usually high. After a few sessions, however, the client becomes engaged in the therapeutic process and their ORS scores drop.

Therapists may want to “correct” this “measurement error,” using the lower ORS score as the new initial baseline. A therapist may believe that such a change more accurately reflects the client's psychological state. Alternatively, a clinician might be concerned that this drop might be seen by others as a poor reflection on their clinical skills. Neither of these notions are accurate nor are they beneficial to the client. Regardless of the motivation, changing the intake score in these circumstances reflects seeing the ORS scores as only numbers, rather than seeing the ORS as the client's voice.

The client's initial ORS score and all subsequent scores are an accurate reflection of the client's psychological state. Changes in the scores reveal the process of change that the client is undergoing. This is what the clinician should work with. If the therapist changes the baseline ORS to what they think it should be, then they're imposing their beliefs on top of the client's needs. The ORS no longer reflects what is going on with the client. This completely contravenes the power of the ORS and it's ability to provide the client a voice in the therapeutic context.

It is the client's voice that's valued in feedback-informed therapy. When a mandated client reports that they are “okay,” the therapist should ask them, “Why are you here?” When they reply that someone sent them, the therapist should set up the person as a feedback source for the client, then ask the client to complete the ORS for the feedback source. Using a “collateral rater” allows the therapist to honor the client's voice while at the same time acknowledging that issues exist.

If the therapist disregards what the client reports simply because they are mandated, the therapist may stop believing what the client says and ignore the client's voice. This puts the therapist at risk for doing things clinically that will lead to client deterioration, which might be misinterpreted as the client “self-correcting.”

MyOutcomes IT support won't change scores in these situations. There are, of course, strong statistical reasons why they won't manipulate the data without strong theoretical reasoning to support it. If therapists could change willy-nilly any data as they wished, an unknown source of variability would be introduced into the database. Put differently, clinicians deciding on what the correct score should be would introduce an error into the database that would compromise the ability of MyOutcomes', or any similar tool, to make valid predictions. The validity of prediction models is contingent upon consistent data collection. Changing ORS baselines because the therapist doesn't feel it's correct is no different than tossing outliers from a dataset simply because you don't like them. In either situation, your predictive model is going to begin to reflect therapist's feelings rather than reflect the actual process of change clients are undergoing.

To change or not to change, that is the question. At least, according to Hamlet, it is. Although Hamlet engaged in a complicated argument regarding life and death, for MyOutcomes, the answer is quite simple. If addressing a data entry error, change is appropriate. Change is not appropriate if the driving force behind it is a whim and a feeling that ignores the client's reality.

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Category: Outcome Rating Scale

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