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SCORING MANUAL
FOR THE
OQ
-45.2
(OUTCOME QUESTIONNAIRE)
IMPORTANT NOTICE!
BEFORE BREAKING THE SEAL ON THIS MANUAL
READ THE AGREEMENT ON THE BACK OF THIS MANUAL
J ANUARY 2004
AMERICAN PROFESSIONAL CREDENTIALING SERVICES, L.L.C.
(Toll Free) 1-888-MH SCORE (1-888-647-2673)
E-MAIL: apcs@oqfamily.com
WEB: www.oqfamily.com
Copyright 1994, 1996, 2004 by
American Professional Credentialing Services L.L.C.
Administration and Scoring Manual
for the
OQ
-45.2
(Outcome Questionnaire)
Michael J. Lambert, Jared J. Morton, Derick Hatfield, Cory Harmon, Stacy Hamilton,
Rory C. Reid, Kenichi Shimokawa, Cody Christopherson, and Gary M. Burlingame
BRIGHAM YOUNG UNIVERSITY
American Professional Credentialing Services L.L.C.
(Toll Free 1.888.647.2673)
Revised J anuary 2004
Copyright 1994, 1996, 2004 by
American Professional Credentialing Services L.L.C.
Acknowledgments
We wish to recognize individuals and organizations that have contributed and acted as partners
in the development of the OQ
-45.2. Funding for this project came from the College of Family, Home,
and Social Sciences, Brigham Young University. Without the kind support of the University, a project of
this size could not have been undertaken.
Human Affairs International (HAI), and particularly Betty Lynn Davis, LCSW, ACSW (Vice
President of Quality Management & Training), Wayne Neff, Ph.D. (Implementation Manager, Clinical
Management), and J eb Brown, Ph.D. (Director of Clinical Programs) were highly supportive in the
initial development of the OQ.
Under the direction of Curtis W. Reisinger, Ph.D. at Intermountain Health Cares Psych-Resource
Network of Salt Lake City, the members of its Center for Behavioral Healthcare Efficacy demonstrated
unabated commitment to a variety of projects related to the OQ
-45.2 as a means of improving the quality of patient care. In particular we want to thank Drs.
David Smart, Stevan Nielsen, J ohn Okiishi, David Vermeersch, and Ronald Chapman for their support
and leadership in showing how outcome research can be used to affect clinical practice. Without the
commitment of the fine clinicians at the Counseling Center developing methods to implement quality
management and test their effects would not have been possible.
We would also like to thank the many students who, as members of the Center For Psychotherapy
Outcome Research Group at Brigham Young University, helped with data collection and analysis; with-
out their painstaking efforts the OQ
-45.2 would only be an idea. Thanks also to the many people who
gave their time and effort by taking the OQ
45.2 is
now in use with the public. It is a pleasure to offer it at a low cost to the professional community for
unlimited use. We ask that OQ
- Total Score........................................................... 4
Table 2: Normative Groups for the OQ
- Domain Scores..................................................... 4
Table 3: Comparison of Gender Scores on the OQ
-Total Score.......................................... 4
Table 4: Comparison of Gender Scores on the OQ
-Domain Scores.................................... 5
Table 5: OQ
................................................................................ 9
Table 11: Validity Data from Patient Populations................................................................... 9
Table 12: Amount of Improvement Demonstrated by the OQ
after
Seven Sessions of Therapy....................................................................................................... 11
Table 13: Average Slopes, t and d Values Based on Comparisons between
Average Slopes, and Allocation by Sensitivity to Change for Clinical
and Nonclinical Samples on the 45 Items, Subscales, and Total Score
of the Outcome Questionnaire................................................................................................. 12
Table 14: Average Slopes, t and d Values Based on Comparisons Between
Average Slopes, and Allocation by Sensitivity to Change for Clinical
and Nonclinical Samples on the 45 Items, Subscales, and Total Score of
the Outcome Questionnaire(Counseling Center Samples) ....................................................... 14
Table 15: Comparison of Level of Psychopathology as Measured by the OQ
across
Patient and Nonpatient Samples .............................................................................................. 17
Table 16: Sensitivity and Specificity of the OQ
45................................................................ 17
Table 17: Outpatient Benchmarks for the OQ-45................................................................... 29
Table 18: Number of Patients, by Site, Who Demonstrated Reliable Negative
Change (Deteriorated), Did Not Demonstrate Reliable Change
(No Change), Demonstrated Reliable Positive Change (Improved),
and Demonstrated Reliable Change into the Functional Range (Recovered) .......................... 30
LIST OF FIGURES
Figure 1: Mean OQ-45 scores in Mainland, Hawaii, Pacific, Asian/Chinese,
Korean Samples................................................................................................................... 6
Figure 2: Outcome Questionnaire (OQ) Item Response Curves for Item 42:
I feel blue.............................................................................................................................. 15
Figure 3: Outcome Questionnaire (OQ) Item Response Curves for Item 35:
I feel afraid of open spaces, driving, being on buses, subways, & so forth. ......................... 15
Figure 4: Outcome Questionnaire (OQ) Total Score Response Curves ................................. 16
Figure 5: Relationship Between Number of Sessions of Therapy,
Pretest OQ
-45.2
Administration and Scoring Manual
for the OQ
-45.2
INTRODUCTION
The OQ
makes
it tolerable to patients and suitable for repeated testing
while providing clinicians with data that can be used
for decision making. Preliminary information on the
basic characteristics of the OQ
was published by
Burlingame, Lambert, Reisinger, Neff, and Mosier
(1995).
The rationale behind selection of each of the three
domains (subscales) constituting the OQ
is described
below. Results of a large scale facor analysis can be
found near the end of the manual in Technical Report
#1.
Symptom Distress (SD)
This subscale, measuring subjective (symptom) dis-
tress, was derived from: 1) a 1988 NIMH study (Regier
et al., 1988) that identified the most prevalent types of
mental disorders across five U.S. catchment areas; and,
2) a review of a nationwide insurance companys records
on the frequency of diagnosed DSM-III-R disorders. The
1988 epidemiological study of 18,571 people across the
United States showed that 15.4% of the population over
18 years of age fulfilled diagnostic criteria for a mental
disorder. Approximately 12% of the total population
received either an anxiety diagnosis or an affective dis-
order classification. The insurance company data re-
porting codes given to 2,145 patients indicated nearly
one-third of the diagnoses given involved a form of af-
fective disorder. An additional third dealt with some
kind of anxiety disorder, including posttraumatic stress
disorder. These data suggest that the most common in-
trapsychic symptoms to be measured are depression and
anxiety-based, particularly when adjustment disorders
are also taken into account. However, considerable re-
search suggests that the symptoms of anxiety and de-
pression cannot be easily separated and tend to occur
simultaneously and across a wide variety of patients
who are diagnosed with a variety of other disorders (e.g.,
Feldman, 1993). Therefore, the OQ
.
Interpersonal Relations (IR)
The OQ
can be ad-
ministered orally. If the patient is unable to read, physi-
cally unable to write, or if the test is administered by
phone, for example, in a follow-up study, completion of
the test can be accomplished by reading items to the
patient. This can be accomplished by giving the patient
a card with a 0-4 numerical scale (i.e., never to almost
always), or by asking them to write the scale out and
refer to it while the administrator reads the items. The
administrator may then enter the item responses on the
blank test or directly into a data base. This procedure,
however, will often increase the time of administration.
SCORING
Scoring the OQ
pro-
vides a total score and three individual domain scores.
Each item is scored on a five-point Likert scale (range
0-4). Special attention must be given to nine items that
are scored in reverse (1, 12, 13, 20, 21, 24, 31, 37, &
OQ
. A
letter was sent under the signature of the primary au-
thor to each of the employees. The purpose of testing
was explained and they were asked to complete the OQ
scores. This
is true in both patient and non-patient samples. Thus, it
does not appear to be necessary to have distinct male/
female norms or interpretative graphs. Callahan and
Hyman (2002), on the other hand, reported some differ-
ences based on gender (with females scoring higher)
within patient samples but no differences within their
non-patient samples. While reporting some statistically
different mean scores, they did not report scores in a
form that allowed interpretation of the extent to which
differences were clinically relevant.
Age Differences
The OQ
Domai n Scores
Sample N Mean S.D.
Undergraduate 238 42.33 (16.60)
Male 91 42.73 (15.89)
Female 147 42.1 (17.21)
Community 102 48.16 (18.23)
Male 46 49.2 (17.59)
Female 56 48.43 (18.48)
Employee Assistance Program 504 73.02 (21.05)
Male 198 73.52 (21.87)
Female 306 72.7 (20.70)
University Outpatient Clinic 76 78.01 (25.71)
Male 23 76.27 (26.53)
Female 53 81.82 (23.58)
TABLE 3
Comparison of Gender Scores on the OQ
Total Score
OQ
score.
Exemplary data on this topic are presented in Table 5.
These data are from the Employee Assistance Program
database.
Callahan & Hynan (2002) have reported some age
differences in a study of undergraduates, people in an
internet sample, and clinic clients. They reported no dif-
ferences in the normal samples, but among patients, those
under 20 years of age were significantly more disturbed
than other age groupings. Those in the age group from
20 to 39 had the lowest scores.
Ethnicity and Cross-Cultural Considerations
The OQ
- Domain Scores
Distress Interpersonal Social Role
Age Range N
Age = <20 21 71.95 (22.72) 42.10 (15.41) 15.62 (6.56) 14.95 (4.73)
Age = 20-39 303 73.44 (21.08) 41.99 (14.02) 17.50 (6.06) 13.73 (4.76)
Age = 40-59 172 72.49 (21.49) 41.37 (14.46) 16.80 (5.84) 13.76 (4.82)
Age = >60 8 71.75 (13.86) 45.37 (10.24) 14.50 (7.23) 11.38 (7.56)
TABLE 5
OQ
Score by Age i n a Sampl e of EAP Patients
Soci al Rol e Performance
Mean (S.D.)
Interpersonal
Rel ati ons Mean (S.D.)
Symptom Di stress
Mean (S.D.)
Total Score Mean
(S.D.)
OQ
scores
and response patterns, the OQ
was designed to
measure clinical change resulting from therapy, partici-
pants scores from repeated administrations of the OQ
was admin-
istered to a sample of 56 undergraduate students on a
weekly basis for a period of 10 weeks. These data were
collected primarily to assess the stability of OQ
scores
over time in a non-patient sample to compare with clini-
cal participants undergoing treatment. Table 9 presents
the correlation coefficients between OQ
scores at week
one and each subsequent OQ
Total
and Domain Scores
Internal Consistency
2
Week One - Week Two 0.82
Week One - Week Three 0.86
Week One - Week Four 0.82
Week One - Week Five 0.77
Week One - Week Six 0.73
Week One - Week Seven 0.72
Week One - Week Eight 0.71
Week One - Week Nine 0.67
Week One - Week Ten 0.66
TABLE 9
Correl ation Coeffi ci ents Between Weekl y Testi ng on the
OQ Over a Ten Week Peri od
Validity
Concurrent validity was estimated for the student
sample by calculating Pearson product-moment corre-
lation coefficients (Cohen & Cohen, 1983) on the OQ
, Symptom
Checklist 90 R, Social Adjustment Rating Scaleself-
report form, and the Inventory of Interpersonal Prob-
lems. The validity coefficients from this analysis are
presented in Table 11.
OQ
.
j
FW B =Friedman Well Being Scale, composite score
1
Figures in parenthesis are froma study of German normative sample (Lambert, Hannover et al., 2002)
Sample SCL-90-R (GSI) IIP (Total Score) SAS (Total Score)
College Counseling Center
OQ
Total Score
0.78 0.66 0.79
OQ
Symptom Distress
0.82 0.6 0.75
OQ
Interpersonal
0.45 0.49 0.53
OQ
Social Role
0.55 0.63 0.73
Outpatient Clinic
OQ
Total Score
0.84 0.74 0.71
OQ
Symptom Distress
0.84 0.7 0.65
OQ
Interpersonal
0.62 0.64 0.62
OQ
Social Role
0.55 0.55 0.57
Inpatient
OQ
Total Score
0.88 0.81 0.81
OQ
Symptom Distress
0.92 0.86 0.79
OQ
Interpersonal
0.68 0.57 0.69
OQ
Social Role
0.51 0.54 0.54
* All values significant (p < .05).
Tabl e 11
Val i di ty Data From Pati ent Popul ati ons*
GSI (SCL-90R)
a
.61* (.76)
1
(0.53) (0.47) .78*(.73)
BDI
b
.63* .80*
ZSDS
c
0.88 0.88
ZSAS
d
0.81 0.81
TMA
e
0.88 0.86
STAI
f
(Y-1)
.50* .64*
STAI
f
(Y-2)
.65* .80*
IIP
g
(0.64) .62(.55) (0.51) .54(.66)
SAS
h
0.4353 0.65
SF-36
i
0.8 0.48 0.81
FW-B
j
0.77 0.81
TABLE 10
Val i di ty Esti mates for The OQ
Total Score
correlated highly with the General Severity Index (GSI)
of the SCL 90R in each of the patient samples (range
.78 - .88). This finding was similar to the correlations
found between the GSI and the Symptom Distress
Subscale of the OQ (range .82 - .92). These results
suggest considerable overlap between these indices of
patient symptomatic complaints and related distur-
bances.
Results from the Social Role and Interpersonal
Subscales were less convincing. The Interpersonal
Subscale correlated significantly with the measure of
interpersonal problems (IIP) (range .49 - .64) across
the three samples, but just as highly or even more highly
with the Social Adjustment Rating Scale. The reverse
was equally true. The Social Role Subscale correlated
moderately across samples on the SAS (range .54 - .73)
but also correlated with the IIP. This finding suggests
that all three scales measure similar constructs despite
attempts to distinguish functioning in different areas.
It appears from these data (in combination with those
collected from college students) that the OQ
has high
to moderately high concurrent validity with a wide vari-
ety of measures that are intended to measure similar
variables. Correlations are strongest with the Total
Score. Clinicians can be confident that the OQ
Total
Score provides an index of mental health, one that cor-
relates quite highly with a variety of scales intended to
measure symptom clusters of anxiety, depression, qual-
ity of life, social adjustment, and interpersonal func-
tioning. The status of the three subscales is less certain.
The Symptom Distress subscale correlates very highly
with measures of symptomatic disturbance (correlations
typically in the mid 80s). Both the Interpersonal Rela-
tions and Social Role Subscales show modest correla-
tions (.60s) with symptomatic scales as well as scales
aimed at measuring problems in other areas of func-
tioning.
A recent study compared the utility of the OQ
and
the BASIS-32, a self-report questionnaire that assesses
symptoms and social functioning in inpatients. Factor
analysis yielded five subscales in the BASIS-32: de-
pression and anxiety, impulsive and addictive behav-
iors, psychosis, daily living and role functioning, and
relation to self and others. The intake and release scores
of 261 patients on these two measures were compared.
Results indicated the total scores of the two measures
were correlated (r=.64), with the two measures sharing
41% of the variance. The OQ
Interper-
sonal Relations scale significantly correlated with the
BASIS-32 Relation to Self and Others subscale (r=.43).
However, the correlation between the OQ
Social Role
Subscale and the BASIS-32 Daily Living and Role Func-
tioning Subscale (r=.28) was unexpectedly weak
(Doerfler, Addis, & Moran, 2002).
Kaufman (1997) provided correlations between
patient reports on the OQ
(after the sixth session) and
therapist rated Global Assessment of Functioning Score
(completed after the third psychotherapy session) in a
doctoral dissertation study. She found therapist ratings
on the GAFS correlated .78 with the OQ-45, suggest-
ing fair correspondence between estimates of disturbance
from these two independent sources.
Along similar lines, Lueck (2003) correlated OQ-
45 scores with screening diagnoses based on a com-
puter administered SCID interview given to over 300
clients. He found a correlation of .87 between the num-
ber of diagnoses that a client screened for (zero to six)
and intake OQ. Results were interpreted as indicating
that both measures reflect the severity of disturbance
experienced by a client.
In a follow-up study of 302 former clients, Nielsen
et al. (2003) compared results obtained on the OQ-45
with those obtained with items from the Consumer Re-
ports (CR) effectiveness scale. Consistent with other
research examining satisfaction ratings and ratings based
on outcome scales, this study found a correlation of .52
between OQ-45 change scores and CR retrospective
ratings of amount of change. The OQ-45 also corre-
lated significantly with CR ratings of emotional state.
Sensitivity to Change
The OQ
OQ
data on every
employee that asked for assistance. It was possible to
collect data on 78 patients who took the completed the
OQ at pretreatment and had at least two therapy visits.
Of the 78 patients, 58 (74%) had pretreatment scores
that placed them in the dysfunctional range. Their pre-
treatment mean was 82.34 (SD =15.82) whereas the
posttreatment mean was 66.01 (SD =22.46). These
patients had a mean of three sessions of treatment and a
maximum of eight sessions.
The number of participants who met criteria for
clinically significant improvement (i.e., passing the cut-
off of 63 and improving by at least 14 points) suggests
that patients improve in very brief treatments even when
the standard of improvement is rigorous. The total num-
ber of participants who significantly improved within
eight sessions was 22 of 58 (38%): 9 Recovered after 1
session, 6 Recovered after 2 sessions, 5 Recovered af-
ter 3 sessions, 1 Recovered after 4 sessions, 1 Recov-
ered after 5 sessions.
Five additional patients (8.6%) improved by at least
14 points but did not pass the cutoff. Two patients (3%)
got worse (i.e., at least a 14 point increase), and 50% of
the patients did not meet the criteria for having changed
in either way. Of those participants beginning in the
functional range (20 of 78), nine improved by at least
14 points.
Doerfler et al. (2002) also reported that the OQ
in
outpatient settings, may make the OQ
an advantageous
instrument for outcome assessment across various lev-
els of care (e.g., inpatient, day treatment, outpatient)
(p. 19).
Sensitivity to Psychopathology
Support for the construct validity of the OQ
was
also sought by comparing the EAP and outpatient psy-
chotherapy clinical samples scores on the OQ
with
those of the community and undergraduate non-clinical
samples. It was assumed that statistically significant
OQ
could dis-
tinguish between these groups. Further, it was expected
that the mean scores for the groups would be ordered
from the most pathological to least pathological. We
expected the outpatient psychotherapy group to be most
disturbed, followed by the EAP sample, the community
sample and the undergraduate sample. A one way
ANOVA was conducted to determine the difference be-
tween sample means. Comparisons between the clini-
cal and non-clinical samples were significant at the .001
level. T tests were conducted following the ANOVA for
the purpose of post hoc comparisons as well as to quan-
tify the differences between the various samples. These
results are presented in Table 15.
The data in Table 15 clearly suggest that the OQ
is
.83 (see Table 16), indicating that 83% of the true mem-
bers of the abnormal group (patients) were placed in the
abnormal group using the cutoff score of 63.
Compar ison Gr oup N Mean (S.D.) t -Value (D.F.)
1.15
(1251)
Community(non-patient) 815 45.19 (18.57)
24.52*
(1254)
Employee Assistance Program 441 73.61 (21.39)
6.05*
(781)
Outpatient Clinics 342 83.09 (22.23)
TABLE 15
Comparison of level of psychopathology as measured by the OQ across patient and nonpatient samples
F Rat io = 274.2 (signif icant , p < .001)
Undergraduate(non-patient)
438 46.49 (19.82)
Employee Assistance Program
441 73.61 (21.39)
Community(non-patient)
815
45.19 (18.57)
Criterion Group Normal Sample Abnormal Sample
Normal Sample 0.84 0.16
Abnormal Sample 0.17 0.83
TABLE 16
Sensi tivi ty and Speci fici ty of the OQ
Predicted Group
CALCULATION OF CUTTOFF SCORES
FOR RATING RECOVERY, IMPROVEMENT,
AND DETERIORATION
Defining normal functioning, dysfunction, and
meaningful change are central purposes of outcome
measures. Clinically significant change refers to change
in patient functioning that is meaningful for individuals
who undergo psychosocial or medical interventions. This
concept has considerable value in research aimed at clas-
sifying each individual patients status with regard to
normative functioning. In this regard it allows research-
ers to focus on the functioning of each patient rather
than on group averages and statistical significance of
between group comparisons. Research using
operationalizations of clinical significance has been es-
pecially useful in estimating dose-response relationships
(e.g., Anderson & Lambert, 2001), and in outcome
management systems that employ it as a marker for re-
covery and deterioration (Lambert, Whipple, Smart,
Vermeersch, Nielsen, & Hawkins, 2001). In addition, it
has been used to estimate the relative value of empiri-
cally supported therapies as examined in clinical trials
(Hansen, Lambert, & Forman, 2002).
In all these uses, it is the degree of change in the
individual that is of primary interest. Such a focus is
thought not only to be of scientific importance but also
to lead to narrowing the gap between clinical research
and clinical practice. Thus, the concept and its
operationalization have generated considerable interest.
Following its introduction by J acobson, Follette, and
Revenstorf (1984), it was regarded as an important ad-
vance in methodology (Lambert, Shapiro, & Bergin,
OQ
,
which is 0.93, and a pooled standard deviation value
(SD). The resulting S
E
value is inserted into the stan-
dard error of difference formula (S
diff
). This value is
then multiplied by the z-value of the significance level
desired, in this case 1.96 (p <0.05). The resulting value
represents the size of the change needed to achieve reli-
able change.
As with the cutoff score, we recommend using the
RCI presented here for most general purposes as it is
based on large and diverse normative samples. If spe-
cialized or more specific RCI values are desired, ap-
propriate norms can be gathered and new RCI values
can be derived using the formulas given above.
Distribution cutoffs for the OQ
and the
SCL-90-R (Derogatis, 1983), the SAS-SR, SAS-OR
(Weissman, Prusoff, Thompsom, Harding, & Myers,
1978), the IIP-S (Hansen, Umphress, & Lambert, 1998),
and the QOLI (Frisch, 1988) were administered to par-
ticipants in pre- and post-treatment assessments. It was
found that at pretest the mean concordance rate for clas-
sifying patients as functional or dysfunctional was 75%;
at posttest it was 77.5%, with one-third to just less than
one-half (43%) of the clients being classified perfectly
across all six measures at pre- and post-testing. At pre-
test, at least three out of the five comparative measures
agreed 85% of the time with the OQ
classification as
clinical or non clinical. At posttest, the percentage was
82.2%. Finally, regarding clinically significant change,
64.6% of the time at least three out of five measure-
ments agreed with the OQ
classification as meeting or
not meeting criteria for clinically significant change.
The results suggested similarity between the OQ
and
the other measures in the study, which offers prelimi-
nary support for the use of the OQ
alone (instead of a
battery of measures) to classify clients as functional or
dysfunctional and to detect clinically significant change.
Lunnen and Ogles (1998) also reported a study that
simultaneously used the OQ
in clinical settings
is to compare a patients score with different normative
samples. Ideally, normative data from inpatients, out-
patients, community samples and asymptomatic indi-
viduals would be available. At this time, only cutoff
scores comparing patient and non-patient samples are
available for the OQ
.
Extremely low scores (<20) from those who are
entering treatment is an uncommon occurrence; such
scores indicate that the person is admitting to little dis-
turbance. It is possible that they have a problem that is
so specific and limited that it causes them little diffi-
culty and therefore it is reflected accurately by their score
on the OQ-45. It is more likely that they are not being
open about their concerns. Low test scores in treatment
samples are not uncommon in people who take the test
under duress, such as involuntarily committed patients,
and substance abusing patients referred in by employ-
ers or spouses.
Subscale Scores
To identify specific problem areas, subscale scores
can be consulted. The OQ
score (using
intake as the baseline) are used in conjunction with other
information to form additional algorithms for treatment
planning and decision making regarding the patient. For
example, changes in OQ-45 scores can be used to trig-
ger decisions regarding termination, step down to less
intensive and costly treatments, or shift to other alter-
nate treatments such as medication. In addition, the
early discovery of negative change can be very helpful
in sparking reviews of current treatment strategies, thus
preventing or reducing patient dropout, as well as ulti-
mate negative effects from treatment. Some evidence
suggests that the best predictor of dropout from outpa-
tient treatment as well as ultimate patient outcome is
negative change from intake to session three. Consid-
erable research is necessary before we can be confident
that the OQ
was
formulated in accordance with Lamberts (1983) orga-
nizational scheme for outcome assessment, suggesting
that three dimensions or content areas be evaluated:
intrapersonal (subjective discomfort) or symptomatic
distress, interpersonal functioning, and social role per-
formance. Use of this conceptualization seems justi-
fied in that its breadth affords a comprehensive review
that encompasses both the patients inner life as well as
functioning in applied situations like work and school.
In addition, some items were included to tap positive
states of mental health and life functioning. It was be-
lieved that these items would not only assess quality of
life as perceived by the client, but also increase the range
of measurement so that the test did not suffer from an
artificially low ceiling as is true in tests that only mea-
sure the presence or absence of psychopathology and to
exclude aspects of healthy functioning.
Essentially, the OQ
administra-
tions may be used in a wide range of applications. Fre-
quently clients will ask what purpose the measure serves
and inquire as to their personal results. The course of
action to be followed here is typically left up to the cli-
nician to determine, and may even include a full disclo-
sure of the results. Such an inquiry is essentially the
equivalent of a client asking the question How am I
doing . . . am I getting better? and should be handled
accordingly on a case-by-case basis. Charting the
progress of a specific client may also be quite informa-
tive to a clinician and can even provide validating feed-
back as to therapeutic setbacks, stagnation, or rate and
pattern of progress. Hawkins et al., (2004) studied the
effects of providing therapists and patients feedback on
patient progress. This treatment condition was contrasted
with a no-feedback condition (treatment-as-usual), and
therapist feedback only condition. Results suggested the
value of patient/therapist feedback.
For a third-party provider, the most meaningful feed-
back is typically provided by an aggregate of clients
and sessions. Once OQ
-45),
which will be used with individuals who are persistently
and severely mentally ill.
Foreign Versions of the OQ
The OQ
-45.2
Study Conducted by Reed M. Meuler, Summarized by Cade Napierski and Ian Kellems
INTRODUCTION
Many of the current outcome measures focus on
one of three domains: participantive discomfort, inter-
personal relationships, or social role performance (Lam-
bert & Hill, 1994). Even though these areas are impor-
tant to assess, there is a general lack of research assess-
ment of the interpersonal and social role functioning in
favor of evaluating only participantive distress (Lam-
bert, Ogles, & Masters, 1992). It would be time and
cost effective to use a measure that attempts to evaluate
all three of the above domains concurrently. In addi-
tion, a single measure that assesses the above areas at
one time could be use across studies and would assist
researchers in assessing all three of the important con-
tent domains (Lambert, Ogles, & Masters, 1992).
Another important consideration in outcome re-
search is how often to measure change occurring in a
patient while she or he is undergoing psychotherapy. It
may be an asset to the outcome researcher to be able to
measure change at many different occasions. Doing so
with a measure that is sensitive to change would allow
the researcher to study the effects of therapy on a dose
response basis as well as evaluate the quality of ongo-
ing treatment for quality assurance reasons (Burlingame,
Lambert, Reisinger, Neff, & Mosier, 1995; Lambert &
Hill, 1994). In regard to dose response studies, some of
the multiscale measures presently available are far too
long to administer frequently and those which are short
enough to administer on a per session basis may not
assess the three crucial domains suggested above (Lam-
bert & Hill, 1994).
Because of the considerations already discussed, it
seems important in the field of outcome research and
quality assurance that a self report questionnaire be
developed that will assess participantive discomfort,
interpersonal relationships, and social role performance
in patients over frequent administrations. These areas
of functioning suggest a continuum from how the per-
son feels inside, how they are getting along with signifi-
cant others, and how they are doing in important life
tasks such as work and school (Lambert et al., 1994b,
1). The measure should also be sensitive to clinically
significant change. The OQ
s manual,
with all items loading upon their theoretical scales.
Review of the analysis reveals a model with no gross
errors regarding the appropriateness of the solution; the
model solution was appropriate. However, two items,
14 and 32, were very poorly loaded on the Social Role
factor. In order to improve the global fit of the model
the above items were eliminated.
Review of the data suggests that the model is suffi-
cient with regard to the solution derived. The correla-
tion between the factors was very high. Participantive
Discomfort was correlated at .92 with Interpersonal
Relations and .89 with Social Role. Interpersonal Re-
lations and Social Role correlated at .84.
The model exceeded cutoff scores on two of the six
fit indicators. Because the integrity of the model solu-
tion was established, all items contributed to the appro-
priate constructs in a significant manner, more than one
cutoff statistic was surpassed, and this general construct
system has been endorsed in the OQ
manual.
Model 2. The factor correlation matrix observed in
the first model suggested that the Social Role and Inter-
personal Relations scales could be collapsed into one
scale as they were highly correlated. These two subscales
also appear to have similar content domains. Due to
these observations, Model 2 was constructed with two
factors: (1) Participantive Discomfort (i.e., the patient
reporting on his/her internal world), and (2) Life Func-
tioning (i.e., the patient reporting on his/her external
world).
The model derived a solution in an appropriate
manner. Three of six global fit indicators surpassed
their cutoff marks, and one more (Chi-Square/df) ap-
proached it cutoff of 2.0. There was a correlation be-
tween the two factors of .96. It appears that this model
is sound, is adequately loaded on the appropriate fac-
tors, and has support of fit indices.
Model 3. This model, which collapsed all items
into one factor, was constructed based upon the intro-
duction and findings in the previous models. More spe-
cifically, the high correlation between the two factors in
Model 2 led to the construct used in model three. To
make this a more accurate model, three items were ex-
cluded from this analysis due to a factor loading below
.30 (11, 14, and 32).
The solution obtained was appropriate for further
examination. Three of six global fit indicators (RMSR,
AGFI, & CN) were significant, suggesting that this
model is appropriate for inclusion in the cross valida-
tion phase of the research.
OQ
.
Model 1 is closest to the original structure of the
OQ
,
one problem with the model is the high correlation be-
tween factors (subscales). A possible explanation for
this is that the items on both the Interpersonal Relations
and Social Role Performance scales involve the evalua-
tion of aspects of a persons external situations. In other
words, the participant is evaluating his or her life situa-
tion on these two scales while questions from the
Participantive Discomfort scale prompt answers regard-
ing the persons internal state. Thus, there appears to
be a dichotomy in the questions as they selectively fo-
cus on either external (life situation) or internal
(participantive distress) events.
Model 2 was developed because of high correla-
tions between Interpersonal Relations and Social Role
Performance scales. It maintained the whole of the
Participantive Discomfort factor while incorporating
both the Interpersonal Relations and Social role Perfor-
mance items into one Life Functioning factor. Model 2
was adequate with regard to goodness of fit criteria when
used in both haves of the sample. Thus, it appears that
Life Functioning may be an adequate construct to pro-
vide a foundation for combining the two scales.
As was found in Model 1, a high correlation was
observed between the factors. It is possible, then, that
the OQ
is unidimensional has
not been disproved at this point in the study. Most highly
loading items included those from the original
Participantive Discomfort scale and suggest that the one
factor solution might best be seen as a global severity
factor.
Overall, two of the three models tested (1 and 2)
were multifactorial in nature. While the multidimen-
sional models of the OQ
may still be
of use to the interested clinician.
References
Allen, M. & Yen, W. (1979). Introduction to mea-
surement theory. Belmont, MA: Wadsworth, Inc.
Breckler, S.J . (1990). Applications of covariance
structure modeling in psychology: Cause for concern?
Psychological Bulletin, 107, 260273.
Burlingame, G.M., Lambert, M.J ., Reisinger, C.W.,
Neff, J ., & Mosier, J . (1995). Pragmatics of tracking
mental health outcomes in a managed care setting. Jour-
nal of Mental Health Administration, 22, 226236.
Cole, D. (1987). Utility of confirmatory factor
analysis in test validation research. J ournal of Consult-
ing and Clinical Psychology, 55, 584594.
Comrey, A. (1988). Factor analytic methods of scale
development in personality and clinical psychology. Jour-
nal of Consulting and Clinical Psychology, 56, 754
761.
Cronbach, L. (1984). Essentials of psychological
testing (4th ed.). New York, NY: Harper and Row Pub-
lishers.
J oreskog, K. & Sorbom, D. (1989). LISREL 7: A
guide to the program and applications (2nd ed.). Chi-
cago, IL: SPSS, Inc.
Kazdin, A. (1992). Methodological issues and strat-
egies in clinical research. Washington, DC: American
Psychological Association.
Kline, R.B. (1991). Latent variable path analysis
in clinical research: A Beginners tour guide. J ournal of
Clinical Psychology, 47, 471 484.
Lambert, M.J ., Burlingame, G.M., Umphress, V.,
Hansen, N., Yanchar, S., Vermeersch, D., & Clouse, G.
(1994). The reliability and validity of Outcome Ques-
tionnaire. Clinical Psychology and Psychotherapy, 3,
106116.
Lambert, M.J . & Hill, C. (1994). Assessing psy-
chotherapy outcomes and processes. In A.E. Bergin and
S.L. Garfield (Eds.), Handbook of psychotherapy and
behavior change (4th ed., pp. 72113). New York: J ohn
Wiley and Sons.
Lambert, M.J ., Ogles, B., & Masters, K. (1992).
Choosing outcome assessment devices: An organiza-
tional and conceptual scheme. J ournal of Counseling
and Development, 70, 527539.
Loehlin, J .C. (1992). Latent variable models: An
Introduction to factor, Path, and structural analysis (2nd
ed.). New J ersey: Lawrence Erlbaum Associates, Pub-
lishers.
Mulaik, S.A., J ames, L.R., VanAlstine, J ., Bennett,
N. Lind, S., & Stilwell, C.D. (1989). Evaluation of good-
ness of fit indices for structural equation models. Psy-
chological Bulletin, 105, 430445.
Reise, S., Widaman, K., & Pugh, R. (1993). Con-
firmatory factor analysis and item response theory: Two
approaches for exploring measurement invariance. Psy-
chological Bulletin, 114, 552556.
OQ
in Spanish
A Spanish language version of the OQ
is presented
on the following page. Although it is identical to the
OQ
is intended
to be straightforward and efficient. Following each of
the item statements are five small boxes for the patient
to mark a response. To the right of each patient re-
sponse box is a numerical score value assigned to each
possible reply. To score the OQ
,
please be aware of those items that are reverse scored,
with the score values running from four to zero rather
than zero to four. Improper scoring of those items will
result in an inaccurate assessment score.
Appendix A
Scoring the Outcome Questionnaire (OQ
-45.2)
Appendix B
Sample of OQ
-45.2)
NAME:____________________________________________________________ ID NUMBER:_________________________________
AGE:_____________ SEX: M F SESSION #:_____________ DATE: _____________
INSTRUCTIONS: Looking back over the last week, inlcuding today, help us understand how you have been feeling. Read each item and
mark the answer that best describes your current situation. For this questionnaire, work is defined as employment, school, housework,
volunteer work, and so forth. Please do not make any marks in the column DO NO MARK BELOW.
1. I get along well with others ...............................................................................................
2. I tire quickly. .......................................................................................................................
3. I feel no interest in things.. ...............................................................................................
4. I feel stressed at work/school.. ........................................................................................
5. I blame myself for things. .................................................................................................
6. I feel irritated. .....................................................................................................................
7. I feel unhappy in my marriage/significant relationship. ..................................................
8. I have thoughts of ending my life. ....................................................................................
9. I feel weak. ........................................................................................................................
10. I feel fearful.. ......................................................................................................................
11. After heavy drinking, I need a drink the next morning to get going
(If you do not drink, mark never) ....................................................................................
12. I find my work/school satisfying. .......................................................................................
13. I am a happy person. ........................................................................................................
14. I work/study too much. ......................................................................................................
15. I feel worthless.. ................................................................................................................
16. I am concerned about family troubles. ............................................................................
17. I have an unfulfilling sex life. ............................................................................................
18. I feel lonely. ........................................................................................................................
19. I have frequent arguments. ...............................................................................................
20. I feel loved and wanted .....................................................................................................
21. I enjoy my spare time. .......................................................................................................
22. I have difficulty concentrating. ..........................................................................................
23. I feel hopeless about the future. .......................................................................................
24. I like myself. .......................................................................................................................
25. Disturbing thoughts come into my mind that I cannot get rid of. ...................................
26. I feel annoyed by people who criticize my drinking (or drug use.)
(If not applicable, mark never) .......................................................................................
27. I have an upset stomach. ..................................................................................................
28. I am not working/studying as well as I used to.. .............................................................
29. My heart pounds too much. ..............................................................................................
30. I have trouble getting along with friends and close acquaintances. ..............................
31. I am satisfied with my life. ................................................................................................
32. I have trouble at work/school because of drinking or drug use
(If not applicable, mark never) .......................................................................................
33. I feel that something bad is going to happen ..................................................................
34. I have sore muscles ..........................................................................................................
35. I feel afraid of open spaces, of driving or of being on buses, subways and so forth. ..
36. I feel nervous .....................................................................................................................
37. I feel my love relationships are full and complete. .........................................................
38. I feel that I am not doing well at work/school ..................................................................
39. I have too many disagreements at work/school ..............................................................
40. I feel something is wrong with my mind. .........................................................................
41. I have trouble falling or staying asleep ............................................................................
42. I feel blue. ........................................................................................................................
43. I am satisfied with my relationships with others .............................................................
44. I feel angry enough at work/school to do something I might regret ..............................
45. I have headaches ..............................................................................................................
Almost
Never Rarely Sometimes Frequently Always
4 3 2 1 0
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
4 3 2 1 0
4 3 2 1 0
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
4 3 2 1 0
4 3 2 1 0
0 1 2 3 4
0 1 2 3 4
4 3 2 1 0
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 2 2 3 4
0 1 2 3 4
4 3 2 1 0
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
4 3 2 1 0
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
0 1 2 3 4
4 3 2 1 0
0 1 2 3 4
0 1 2 3 4
DO NOT MARK
THIS SECTION
SD IR SR
Total=
r
r
r
r
r
r
r
r
r
+ +
Developed by Michael J. Lambert, Ph.D. and Gary M. Burlingame, Ph.D.
Copyright 1999, 2003 American Professional Credentialing Services, LLC
All rights reserved. License Required For All Users.
P.O. Box 970354, Orem, UTAH 84097-0354 PH: 888.647.2673
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Appendix C
Interpretive Graph for OQ
-45.2
Applicant:
Applicants Address:
Telephone: ( )
INSTRUCTIONS:
1. Read Application and License Agreement
2. Complete and Sign Application
3. Return Application with Fee to:
American Professional Credentialing Services LLC
PO BOX 970354
Orem, UT. 84097-0354
4. If the Application is not accepted, the Fee will be refunded.
TERMS AND CONDITIONS:
Applicant has read the License Agreement on the reverse side of this Application and accepts and agrees to the
License Agreement. The IHC Center for Behavioral Healthcare Efficacy of IHC Hospitals, Inc. (the Center)
accepts this Application and grants this License to Applicant participant to the License Agreement. The License
is not effective or granted unless this Application is signed by an authorized officer or representative of the Center.
AGREED TO AND ACCEPTED BY:
_____________________________________________
Applicant
_____________________________________________
Authorized Signature
_____________________________________________
Print Name and Title
_____________________________________________
Date
OQ
-45.2. OQ
-45.2 means the mental health care protocol, outcome tracking measures, and
work of authorship provided by APCS to Licensee under the designation OQ
-45.2.
3. License. Participant to the terms and conditions of this Agreement, APCS grants to Licensee a
license to use, copy, and distribute OQ
-45.2, but only in connection with Licensees bona fide mental health care
practice (the License) as the Applicant has applied and been approved for.
4. Modifications. Licensee may not modify or change the content, wording, or organization of
OQ
-45.2 or put it
into other formats, provided that the content, wording and organization are not substantively modified or changed.
5. Copies, Notices and Credits. Any and all copies of the OQ
-45.2 to
other persons for use by other persons. Such other persons should apply to APCS for a license to use OQ
-45.2.
Licensee may not charge any client, patient, organization or other entity for use of the OQ
-45.2.
7. Responsibility. BEFORE USING OR RELYING UPON THE OQ
-45.2 to APCS within 30 days of purchase for a full refund of the Fee.
In the event of a return, the licensee shall terminate. LICENSEE ACCEPTS THE OQ
-45.2 AS IS WITHOUT
WARRANTY OF ANY KIND. APCS DISCLAIMS ANY AND ALL IMPLIED WARRANTIES, INCLUDING
IMPLIED WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, AND
NONINFRINGEMENT. APCS DOES NOT WARRANT THAT THE OQ
-45.2.
11. Governing Law. This Agreement is made and entered into in the state of Delaware and shall be
governed by the laws of the state of Delaware. In the event of any litigation or arbitration between the Parties,
such litigation or arbitration shall be conducted in Delaware and the Parties hereby agree and submit to such
jurisdiction and venue. Notice to commence any litigation or arbitration should be directed to: American Profes-
sional Credentialing Services LLC,
12. Modification. This Agreement may only be modified or amended in writing and must be signed
by both Parties.
OQ