Evidence and Results
Evidence across validity, observational, randomized trials, dissemination, and policy.
Overview
Behavioral health research has traditionally defined success as partial symptom reduction (30-40%), with high relapse rates. Express Access is built on the Treatment Outcome Package (TOP) and TOP-Match, which establish a higher bar: sustained full recovery. The evidence below documents the scientific foundation, clinical trials, and policy dissemination that make strengths-based referral achievable at scale.
Unlike new treatment protocols that may rise and fall over time, TOP-Match operates on a different plane. It measures outcomes across multiple domains, risk-adjusts for case mix, and continuously identifies which providers are delivering the best results. This allows the system to adapt as new treatments emerge, giving patients and health systems a dynamic, evidence-based referral layer above all interventions.
The studies presented here span several designs. Validity and observational work establish construct validity, reliability, and the presence of therapist effects. Randomized clinical trial evidence (JAMA Psychiatry 2021) provides causal proof that strengths-based matching improves outcomes. PCORI pages summarize federally funded trials and dissemination projects, while dissemination studies (2020–2023) show implementation in real-world systems. Together, they form a coherent arc from measurement validity to clinical effectiveness to policy adoption.
Key findings across publications:
- TOP demonstrates strong construct validity across age versions, uniquely suited to detect therapist strengths.
- Observational studies confirm therapist effects are large, domain-specific, and stable after risk adjustment.
- A randomized clinical trial showed patients matched to provider strengths doubled recovery rates and avoided relapse.
- Patients value access to provider track records, supporting transparency.
- PCORI-funded dissemination and recent publications show that strengths-based referral is feasible, scalable, and relevant for policy and health system design.
Foundational People
Leaders and pioneers backing our mission.
John Hickner, MD, MSc
“This Match system has the potential to revolutionize patient referrals and case assignments.”
Founding leader of Family Medicine in the U.S.
Emeritus Professor, Michigan State University; Former Chair of Family Medicine, Cleveland Clinic; Founding Editor, Journal of Family Practice
As a founder of the discipline, Dr. Hickner's endorsement situates EA at the core of primary care.
Industry Recognitions
Recognitions from professional societies and employer coalitions.
American Academy of Family Physicians (AAFP)
“Express Access is the first scientific referral process in health care that helps patients find the right behavioral health support based on their unique needs.”
Official AAFP benefit page
Visit LinkAmerican Psychological Association (APA) — Practice Directorate
“The results of your comparative effectiveness trial provide data that reduce the gap and translate directly into clinical usage. The benefit of a Match system is more pronounced for racial and ethnic minority patients and those entering treatment at higher severity.”
Letter of Support
Primary Care Collaborative (PCC)
“TOP Match has demonstrated a fivefold increase in patients returning to full health. Its integration into Express Access offers a scalable, cost-effective, and patient-centered way to improve care delivery and support workforce well-being.”
Letter of Support
Represents the major U.S. primary care societies, including AAFP, ACOFP, and others — the unified national voice of primary care.
Florida Alliance for Healthcare Value
“TOP Match has demonstrated a fivefold increase in patients returning to full health, and its integration into Express Access offers a scalable, cost-effective, patient-centered way to improve care delivery and support workforce well-being.”
Employer coalition
Gateway Business Health Coalition
“Gateway enthusiastically supports this effort and looks forward to shaping the path to broader adoption of evidence-based behavioral health solutions.”
Employer coalition
HERO (Health Enhancement Research Organization)
“Coupled with Express Access, TOP Match promises a scalable, cost-effective, patient-centered enhancement to care delivery—one that can measurably support workforce well-being and resilience.”
National employer coalition
National Alliance of Healthcare Purchaser Coalitions
“National Alliance … supports this effort and looks forward to shaping the path to broader adoption of evidence-based behavioral health solutions.”
Letter of Support
Represents 45+ million Americans, with member employers spending over $400B annually on healthcare.
Midwest Business Group on Health (MBGH)
“MBGH supports this effort and looks forward to advancing employer adoption of evidence-based behavioral health solutions.”
Employer coalition
North Carolina Business Coalition on Health (NCBCH)
“NCBCH enthusiastically supports this effort and looks forward to shaping the path to broader adoption of evidence-based behavioral health solutions.”
Employer coalition
Advocacy & Patient Organizations
Voices supporting strengths-based referral for better outcomes.
Clare Miller
“TOP Match offers the opportunity to drastically expedite improvement in care, steward scarce clinical resources, and most importantly, radically improve patient experience and outcomes.”
Workplace Mental Health Leader
Formerly led workplace MH at APA and Business Group on Health
NAMI (National Alliance on Mental Illness)
“TOP Match demonstrated a fivefold increase in people returning to full health and its integration into Express Access offers a scalable, cost-effective, and person-centered way to improve care delivery.”
Darcy Gruttadaro, JD — Chief Innovation Officer
J. Greg Merritt
“TOP Match has demonstrated a fivefold increase in patients returning to full health and its integration into Express Access offers a scalable, cost-effective, and patient-centered way to improve care delivery and support workforce well-being.”
Founder, Patient is Partner, LLC
Care Networks & Platforms
Networks adopting outcomes and matching at scale.
Grow Therapy
“We are committed to using TOP to assess and track outcomes and create therapist-level effectiveness profiles; activating TOP-Match will connect patients with empirically well-suited clinicians.”
Letter of Support (PCORI Phase 2)
13,000+ clinicians across all 50 states
Refresh Mental Health (now part of Optum)
“We believe TOP is the best outcome system yet developed, and your scientific matching process delivers the type of results that can double, if not triple, treatment outcomes.”
Letter of Support
Acquired by Optum; now the largest in-person BH platform in the U.S., with 3,500+ clinicians nationwide.
Grow Therapy
“We expect that using a scientifically derived product like Express Access will improve patient outcomes and maximize limited resources. If Phase II shows improvements in outcomes, access, and satisfaction, Grow would be interested in continuing to use Express Access.”
Letter of Support (NIH SBIR Phase II)
13,000+ clinicians across all 50 states
Press & Coverage
Selected coverage and announcements.
Talkspace Press Release
“Talkspace adopts Express Access, an AI-powered referral infrastructure designed for PCPs and employers to speed individuals to personalized mental healthcare faster than ever.”
Business Wire / Yahoo Finance coverage
Official adoption announcement covered on Yahoo Finance.
Visit LinkBehavioral Health Business
“Talkspace doubles down on patient matching in deal with Outcome Referrals.”
Industry media article
Independent trade media coverage highlighting Talkspace's partnership with Outcome Referrals and Express Access.
Visit LinkPublications
Selected validity, observational, randomized trial, and dissemination studies underpinning strengths-based referral.
A measure of mental health outcomes: Initial psychometric properties of the Treatment Outcome Package
Kraus DR, Seligman DA, Jordan JR • 2005
Journal of Clinical Psychology
Introduces TOP and reports reliability and validity across multiple clinical domains; establishes a multidimensional structure for outcome monitoring.
The Treatment Outcome Package: Facilitating clinically relevant research and practice
Kraus DR, Wolf LB, Castonguay LG • 2006
Psychotherapy
Describes TOP’s domains, sensitivity to change, and use in practice-based research networks.
Construct validity and clinical utility of multidimensional outcome measurement
Kraus DR, Castonguay LG • 2010
Psychotherapy
Outlines rationale and evidence for multidimensional assessment; notes CFA support and clinical utility across age versions.
TOP structure and factor validation across age versions
Kraus DR, Boswell JF, Wright J, Castonguay LG, Pincus AL • 2010
Psychotherapy Research
Reports CFA/fit statistics supporting TOP’s multidimensional structure in adult, adolescent, and child versions; establishes construct validity across age groups.
Training clinicians to use practice-based outcome data
Castonguay LG, Constantino MJ, Boswell JF, Kraus DR • 2010
Psychotherapy
Discusses clinician training and feedback loops to drive better care using multidimensional ROM.
The Treatment Outcome Package (TOP): Facilitating Practice and Clinically Relevant Research
Youn SJ, Kraus DR, Castonguay LG • 2012
Psychotherapy
Details adult, adolescent, and child versions; 12 scales; risk-adjusted benchmarking for identifying provider strengths.
Errors in Treatment Outcome Monitoring: Implications for Real-World Psychotherapy
McAleavey AA, Nordberg SS, Kraus D, Castonguay LG • 2012
Canadian Psychology
Explains Type I/II errors in outcome monitoring; argues multidomain measures reduce missed detection compared with single-factor screens.
Implementing routine outcome monitoring in clinical practice: Benefits, challenges, and solutions
Boswell JF, Kraus DR, Miller SD, Lambert MJ • 2013
Psychotherapy Research
Synthesizes ROM adoption barriers and solutions; positions multidomain ROM as reducing deterioration and enhancing outcomes when used well.
Validating the rapid responder construct within a practice research network
Nordberg SS, Castonguay LG, Fisher AJ, Boswell JF, Kraus D • 2014
Journal of Clinical Psychology
Identifies rapid-responder vs. non-responder trajectories with repeated multidomain outcomes; supports predictive utility of higher-resolution measures.
The Treatment Outcome Package (TOP): A multi-dimensional level of care matrix for child welfare
Kraus DR, Baxter EE, Alexander PC, Bentley JH • 2015
Children and Youth Services Review
Illustrates using TOP across supervisory, psychological, medical, and academic needs to inform level-of-care decisions; emphasizes sensitivity to change and multi-informant use.
Attachment history as a moderator of the alliance–outcome relationship in adolescents
Zack SE, Castonguay LG, Boswell JF, McAleavey AA, Adelman RW, Kraus DR, Pate GG • 2015
Psychotherapy
Alliance effects were strongest for adolescents with poorer caregiver attachment histories, underscoring the value of nuanced, multidomain tracking.
Treatment Outcome Package: Measuring and facilitating multidimensional change
Boswell JF, Kraus DR, Castonguay LG, Youn SJ • 2015
Psychotherapy
Summarizes TOP’s 12-domain structure, risk-adjusted benchmarking, and ROM feedback; positions TOP as an infrastructure for practice and training.
The expanding relevance of routinely collected outcome data for mental health care decision making
Boswell JF, Constantino MJ, Kraus DR, Bugatti M, Oswald JM • 2015
Administration and Policy in Mental Health
Reviews evidence that ROM and feedback improve outcomes and reduce deterioration; argues ROM data inform patient, clinician, and system-level decisions.
Therapist effectiveness: Implications for accountability and patient care
Kraus DR, Castonguay LG, Boswell JF, Nordberg SS, Hayes JA • 2011
Psychotherapy Research
Across 6,960 patients and 696 therapists, substantial between-therapist variability emerged; many therapists effective in some domains and ineffective or harmful in others, supporting domain-specific strengths.
View DOIPredicting therapist effectiveness from their own practice-based evidence
Kraus DR, Bentley JH, Alexander PC, Boswell JF, Constantino MJ, Baxter EE, Castonguay LG • 2016
Journal of Consulting and Clinical Psychology
Using risk-adjusted outcomes for the first 30 clients to label therapist strengths, labels predicted outcomes for the next 30 clients—showing past, domain-specific performance prospectively predicts future performance.
Are high-performing therapists both effective and consistent? A test of therapist expertise
Owen J, Drinane JM, Kivlighan M III, Miller S, Kopta M, Imel Z • 2019
Journal of Consulting and Clinical Psychology
Subsequent client outcomes were highest when a therapist’s aggregate outcomes were high and consistency across the first 30 clients was also high—supporting expertise as effectiveness plus consistency.
View DOIPatterns of therapist variability: Therapist effects and the contribution of patient severity and risk
Saxon D, Barkham M • 2012
Journal of Consulting and Clinical Psychology
Therapist effect about 6.6% at average severity, rising near 10% at higher severity; individual therapist recovery rates ranged widely (23.5%–95.6%).
Roadmap for a scientific referral infrastructure in behavioral health
Kraus DR • 2020
White paper / perspective
Proposes the measurement-first architecture enabling strengths-based referral and continuous learning across treatments and settings.
Practice-based evidence and therapist strengths: Preparing for a randomized test
Kraus DR • 2020
Practice-based research note
Describes assembling risk-adjusted therapist profiles and operational considerations ahead of a randomized test of strengths-based referral.
Patient preferences and outcome measurement in psychotherapy
Boswell JF, et al. • 2018
Journal of Consulting and Clinical Psychology
Examines how patient preferences and outcome tracking intersect; informs design choices for matching and monitoring.
Therapist–patient matching RCT: Design and protocol papers
Boswell JF; Constantino MJ; Kraus DR; Bugatti M; Castonguay LG (various) • 2016
Methodology series
Pre-trial publications detailing design, hypotheses, and analytic plans for the matching RCT and related mechanisms.
Therapist–patient matching RCT: Additional design extensions
Boswell JF; Kraus DR; Constantino MJ; Bugatti M; Castonguay LG • 2017
Methodology
Additional design details and measurement considerations supporting the randomized test of strengths-based referral.
Therapist–patient matching RCT: Process and preparation papers
Boswell JF; Constantino MJ; Kraus DR; Coyne AE; Castonguay LG • 2017
Methodology and perspective
Series refining process variables and the analytic plan that informed the RCT.
Effect of matching therapists to patients vs assignment as usual on adult psychotherapy outcomes
Constantino MJ, Boswell JF, Coyne AE, Swales TP, Kraus DR • 2021
JAMA Psychiatry
Performance-based matching using TOP produced significantly greater reductions in impairment and distress vs usual assignment; first randomized evidence of causal outcome gains from strengths-based referral.
View ArticleTherapist-level moderation and process findings from the matching RCT
Coyne AE, et al. • 2021
Journal of Consulting and Clinical Psychology
Explores therapist-level moderators (e.g., alliance, expectations) clarifying why matching by empirically measured strengths yields better outcomes.
What patients want to know about clinicians: Preferences for performance information
Boswell JF, et al. • 2021
Psychiatric Services
Shows patients value access to provider track records and outcome information—supporting the transparency rationale for strengths-based referral.
RCT-related analyses and extensions
Boswell JF, et al. • 2021
Follow-up analyses
Additional trial-era analyses and narrative synthesis related to the matching study.
PCORI Research Project: Matching Patients with Therapists to Improve Mental Health Care
PCORI Research Project • 2015
PCORI Research Results
PCORI project page describing the study evaluating therapist–patient matching using outcome-based strengths.
View ArticlePCORI Dissemination: Implementing Matching of Patients to Mental Healthcare Therapists by Strengths
PCORI Dissemination Project • 2022
PCORI Research Results
PCORI dissemination page describing implementation of matching patients to therapists based on empirically measured strengths.
View ArticleDissemination study: Implementation outcomes and policy implications
Kraus DR, et al. • 2023
Peer-reviewed dissemination
Reports on dissemination of strengths-based referral and implications for policy and network design.
Dissemination study: Patient and clinician experience in real-world rollout
Trudeau, et al. • 2023
Peer-reviewed dissemination
Describes patient and clinician experience and adoption metrics during real-world rollout.
Post-trial synthesis: Clinical and system-level outcomes of strengths-based referral
Constantino MJ, et al. • 2023
Peer-reviewed dissemination
Summarizes clinical, operational, and equity implications of strengths-based referral following the RCT.
Dissemination brief: Scaling scientific referral in health systems
Boswell JF, et al. • 2023
Peer-reviewed dissemination
Outlines key steps and barriers to scaling strengths-based referral across diverse care settings.
Frequently asked questions
Answers to common questions about our evidence, methods, and matching.