Raise your hand if you’ve:

• Gotten a doorknob confession from a client about a totally new symptom or problem they’re experiencing (surprise!). 

• Had a client engage in avoidance during a session by talking about their Problem of The Week, rather than their actual presenting problem. 

• Had clients feel discouraged about a perceived lack of progress. 

• Felt discouraged, confused, or unsure about how your client is responding to therapy.

• Felt stuck on where to go or what to address next.

I’m guessing we’re all raising our hands right now.

One of the challenges about therapy is that it can be hard for both clients and clinicians to have an accurate sense of if, when, and how change is happening. After all, our time together is often limited to 50 minutes, during which our clients try to remember everything that’s happened since their last session, while we try to make sure that we’ve covered everything we need to cover.

Add in the fact that our information tends to be biased by how clients are feeling at the moment, and it makes complete sense that this challenge exists. So how can we manage this?

With Measurement Based Care.

What is Measurement Based Care?

If you’re familiar with evidence-based therapies, you’re probably not very surprised to see measurement-based care pop up here. Measurement based care consists of three major components, each of which can address the challenges above:

1. Clients regularly complete empirically validated symptom or process measures.

2. Therapists and clients collaboratively review clients’ scores and answers to track change over time.

3. Therapists and clients collaboratively make decisions about therapy, using clients’ scores and answers as a guide. 

Notably, this process not only helps both therapists and clients stay focused, but also helps them track and understand changes over time and engage in collaborative treatment planning - all of which can improve symptom outcomes, working alliances, and client engagement! (1-5)

Measurement Based Care Keeps Us Focused

Because clients typically take measures before you dive into sessions, measurement-based care gives both clients and therapists less biased data on where clients are struggling at the moment. This means that therapists and clients have a more accurate understanding of clients’ symptoms and can use sessions more productively - all of which improves clients’ outcomes faster and more effectively. (1, 6-7) 

For example, let’s say that a client struggling with generalized anxiety reports that they’re unable to stop or control worrying “nearly every day” on the GAD-7. Thanks to the measure, the client and therapist now have data on the specific symptoms of anxiety that the client is primarily struggling with, which allows them both to quickly see how the client’s anxiety is currently presenting. The client and therapist also now have data on what their next session should focus or follow up on.

This not only helps them stay focused in session (particularly when the client feels distracted by a different issue - e.g. a fight with a friend) but can also be helpful in tackling any avoidance a client may have about bringing up a topic. Because the client and therapist are able to quickly assess symptoms and use sessions more productively clients are not only more likely to experience improved outcomes but are also more likely to experience those improvements faster.

Measurement Based Care Helps Us Track Change Over Time

Because clients regularly take symptom and process measures, measurement-based care also allows you to track the speed and direction of change in symptoms over time. This is especially important when considering that, despite our best intentions, both clients and clinicians often miss these changes. 8-9 Having data over time thus enables clients to see concrete evidence of their own progress, as well as helps therapists adjust treatment targets over time - all of which, again, improves client outcomes. 

For example, let’s say that a client struggling with depression feels like they aren’t getting better because they still feel down or depressed. Rather than trying to convince the client that there have been improvements, the therapist may instead pull up the client’s history of PHQ-8 scores and highlight that scores have been decreasing over time, and that the client has been reporting feeling depressed “more than half the days” rather than “nearly every day” for several weeks now.

Having this concrete evidence can subsequently give clients hope about treatment, increase their self-efficacy to manage their depression, and keep them focused and engaged with the therapeutic process. 

Alternatively, let’s say that a therapist and client think that a client is getting better because they’ve been “feeling happier.” However, rather than relying on subjective mood, they take a look at the client’s PHQ-8 scores and see that while the client is feeling less down, their scores are actually increasing due to their troubles with sleeping, eating, and concentrating.

In this case, the therapist and client are able to use the scores as an opportunity to address these new targets quickly, which means better client outcomes and working alliances.

Measurement Based Care Helps Us Treatment Plan Collaboratively

Finally, measurement-based care can help us work collaboratively with clients to develop and adapt treatment plans. This can be crucial in helping demystify the therapy process - after all, therapy can often feel like a complete mystery for clients!

In bringing empirically validated measures into the treatment planning and outcome assessment process, clients can easily understand what, why, and how symptoms are manifesting, see how they are working with their therapists to address those symptoms, and assess how therapy is going. This not only increases clients’ agency over the therapeutic process, but also improves the working alliance between therapist and client - one of the biggest predictors of client engagement and outcomes. (10)

For example, let’s say that a therapist has a client coming to therapy to work on their depression. Although the client meets criteria for Major Depressive Disorder, the client also meets criteria for Post Traumatic Stress Disorder, which the therapist suspects is driving the depressive symptoms. However, because the client does not feel ready to work on their PTSD, the therapist and client agree to work on their depression instead.

As the weeks go by, however, the therapist and client can see that their PHQ-8 and PCL-5 scores simply aren’t getting better. In fact, some of the symptoms seem to be getting worse. With this data in hand, the therapist and client agree that a change in treatment plan to focus on the PTSD symptoms is best. In this case, the therapist and client are able to collaboratively shift their treatment targets as a result of the data they are both seeing on the effectiveness of their current treatment targets.

This collaborative treatment planning, again, gives the client psychoeducation on the importance of focusing on the right targets, as well as enabling the client and therapist to shift targets collaboratively, thus improving client outcomes and working alliance. 

References

1. de Jong, K., Conijn, J. M., Gallagher, R. A. V., Reshetnikova, A. S., Heij, M., & Lutz, M. C. (2021). Using progress feedback to improve outcomes and reduce drop-out, treatment duration, and deterioration: A multilevel meta-analysis. Clinical Psychology Review, 85, Article 102002. https://doi.org/10.1016/j.cpr.2021.102002 

2. Dowrick, C., Leydon, G. M, McBride, A., Howe, A., Burgess, H., Clarke, P., Maisey, S., & Kendrick, T. (2009). Patients’ and doctors’ views on depression severity questionnaires incentivised in UK quality and outcomes framework: Qualitative study. BMJ: British Medical Journal, 338(7697), 1–9. https://doi.org/10.1136/bmj.b663 

3. Eisen, S. V., Dickey, B., & Sederer, L. I. (2000). A self-report symptom and problem rating scale to increase inpatients' involvement in treatment. Psychiatric Services, 51(3), 349–353. https://doi.org/10.1176/appi.ps.51.3.349 

4. Moltu, C., Veseth, M., Stefansen, J., Nøtnes, J. C., Skjølberg, Å., Binder, P.-E., Castonguay, L. G., & Nordberg, S. S. (2018). This is what I need a clinical feedback system to do for me: A qualitative inquiry into therapists’ and patients’ perspectives. Psychotherapy Research, 28(2), 250–263. https://doi.org/10.1080/10503307.2016.1189619 

5. Brattland, H., Koksvik, J. M., Burkeland, O., Klöckner, C. A., Lara-Cabrera, M. L., Miller, S. D., Wampold, B., Ryum, T., & Iversen, V. C. (2019). Does the working alliance mediate the effect of routine outcome monitoring (ROM) and alliance feedback on psychotherapy outcomes? A secondary analysis from a randomized clinical trial. Journal of Counseling Psychology, 66(2), 234–246. https://doi.org/10.1037/cou0000320 

6. Guo, T., Xiang, Y. T., Xiao, L., Hu, C. Q., Chiu, H. F., Ungvari, G. S., Correll, C. U., Lai, K. Y., Feng, L., Geng, Y., Feng, Y., & Wang, G. (2015). Measurement-based care versus standard care for major depression: A randomized controlled trial with blind raters. American Journal of Psychiatry, 172(10), 1004-10013. https://doi.or/10.1176/appi.ajp.2015.14050652 

7. Fortney, J. C., Unützer, J., Wrenn, G., Pyne, J. M., Smith, G. R., Schoenbaum, M., & Harbin, H. T. (2017). A tipping point for measurement-based care. Psychiatric Services, 68(2), 179–188. https://doi.org/10.1176/appi.ps.201500439 

8. Constantino, M. J., Boswell, J. F., Bernecker, S. L., & Castonguay, L. G. (2013). Context-responsive integration as a framework for unified psychotherapy and clinical science: Conceptual and empirical considerations. Journal of Unified Psychotherapy and Clinical Science, 2, 1–20.

9. Walfish, S., McAlister, B., O’Donnell, P., & Lambert, M. J. (2012). An investigation of self-assessment bias in mental health providers. Psychological Reports, 110(2), 639–644. https://doi.org/10.2466/02.07.17.PR0.110.2.639-644 

10. Horvath, A., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). The alliance in adult psychotherapy. APA Psychotherapy, 48, 9-16.