Articles
April 10, 2020

The case for weekly assessments in therapy: Three reasons it's worth your time

Dr. Russell DuBois, PhD

I am a psychologist specializing in the areas of eating disorders, mindfulness, and data science for personalized medicine. I write for Psychology Today under the column The Digital Doctor.

Throughout my work as the clinical director at Blueprint, I have had the privilege of collaborating with clinics across the country to help them begin to integrate outcome measurement into their practices and improve their quality of care.

For some, this process is seamless and familiar, with clinical staff already holding a strong understanding of the importance of routine assessment and knowledge of the process for using this information to practice measurement-based care.

For others, the very idea of measurement-based care feels foreign and they may have previously never used any kind of routine assessment in their practice. Despite the wide range of variability across these types of clinics, one notion that takes both sides of the spectrum by surprise is the importance of using measurement on a weekly basis.

Yes – I really do mean weekly!

The vast majority of clinicians have been introduced to the concept of outcome measurement through lengthy, paper-pencil assessments that clients hate to complete and clinicians hate to score. This form of outcome measurement is traditionally administered on multi-month intervals (every 3, 4, or 6 months) and used for treatment plan updates and then swiftly tucked away in a file cabinet or electronic health record. The very thought of maintaining this practice on a weekly basis is enough to scare away even the most seasoned psychometrist.

Luckily, there is a new game in town.

With advances in technology, combined with improvements in the creation of brief, focused assessments, a new form of outcome measurement has emerged which truly does revolutionize the practice of psychotherapy. Patients can now complete outcome measures on their own time through digital platforms, eliminating the awkwardness of breaking up a heavy session to hand your client a lengthy form to complete. Furthermore, even rather comprehensive outcome measures have now been reduced in scale and length such that clients can easily complete them in under 5 minutes in between their binge-watching of Game of Thrones and scrolling through Twitter. In fact, when considering the amount of time the average person spends on their phones (~7 hours for teens!), this is merely a tiny fraction of their digital experience.

In this way, it’s now easier than ever to collect valuable health information from your clients on a regular basis. Once a frustrating and annoying practice, routine measurement can now become (…dare I say…) a fun and exciting new feature to add to your clinical toolkit.

But why is this weekly outcome measurement so important in the first place?

This newfound stream of valid and reliable client health information begs the question of what clinicians can do with it. In this way, here’s the top three reasons why you should begin collecting weekly outcome measurement today.

1. Measurement-based care

The majority of us have a pretty good understanding of our clients’ experiences and progress throughout the duration of treatment. We are trained to ask the right questions and use narrative information gathered through conversation to determine if someone is making progress or not. However, does this mean we have a complete and holistic understanding of each and every one of our clients at all times? Absolutely not.

Yeah, yeah…we all like to think that we are the best, most empathetic clinicians out there and that our clients feel safe and supported in sharing all parts of their lived experience with us. But the truth is - this isn’t always the case. Some clients may not feel comfortable breaching a difficult topic on their own if not asked directly. Some clients may not feel safe endorsing important information with a partner or family member in the room. Some may have never spoken about a particular issue and simply don’t know how to appropriately verbalize their experience. Heck, some clients downright lie!

This is where routine measurement-based care comes in.

Simply put, measurement-based care is the practice of integrating results from routine assessments into your understanding of client progress in order to better detect when something in therapy needs to change. In other words, measurement fills the gaps where our knowledge lacks. Sometimes these gaps are small, like a minor setback that a client may not feel is important to tell you. Sometimes they are large, like a significant increase in the prevalence of suicidal thoughts. In both cases, measurement simply adds an additional avenue from which this information can come to your attention. And when integrated into your clinical decision-making progress, this additional information can have a significant impact on the way you go about working with your clients and striving for continuous positive change.

2. Deliberate practice

Have you ever wondered why dance studies have mirrors wall to wall?

No, it’s not because all dancers are self-absorbed and narcissistic. It’s because they need to observe themselves in order to improve. They use the mirrors to observe their movements from multiple angles and points-of-view in order to identify the ones that work and throw out the ones that don’t.

This phenomenon, referred to as deliberate practice, is the process of purposefully and systematically improving a particular behavior or act through focused attention and continuous feedback. While this self-reflection seems rather obvious in the context of most performance-based activities, it is nearly non-existent in the therapeutic profession once you move past your training and educational years. The problem with this lack of feedback is that it has created a culture in which therapists, on average, don’t improve in their effectiveness over time.

Weekly assessments provide a metaphorical mirror for you to reflect on the effectiveness of your own actions and behaviors toward your client. You can determine, with granular precision, if what you are doing is working on a case by case basis. If it is, keep it up! If it’s not, throw it out and try something new. In fact, this process of deliberate practice in psychotherapy is one of the only proven ways of improving therapist effectiveness across the span of one’s career. In this way, routine measurement quite literally improves the behaviors of both clients and their clinicians.

3. Patient safety

According to the CDC, there is approximately one death by suicide in the US every 12 minutes. Even more, there are approximately 25 suicide attempts for every one death by suicide, and data suggest that roughly fifty percent of the population, at some point in their lives, have or will experience some form of suicidal thought. Combine these facts with the high prevalence of self-injurious behaviors, extreme substance abuse, and the vast array of other high-risk safety issues that are often experienced in a lifetime and it becomes clear that we in the mental health profession are truly at the front lines of keeping our communities safe, both emotionally and physically.

It is our duty to ensure that all individuals who come into our care get screened for any high-risk or safety related issues. Although asking our clients directly, and frequently, is a wonderful place to start, it’s not enough. Some clients may be afraid to endorse these experiences verbally, a fact that is especially true among adolescents and young adults. Furthermore, just because it doesn’t come up naturally in a session doesn’t mean it’s not there.

Taking the step toward weekly measurement is a great way to safeguard against missing this type of drastically important information among your caseload. More times than not, I’ve heard clinicians say that they have been surprised by the amount of clients who have endorsed certain behaviors or experiences that they as the therapist would have otherwise never thought about or noticed. Introducing regular screening into your practice is an essential step toward promoting community and population health and wellness.