January 29, 2020

The connection between measurements and the therapeutic relationship

I would like you to imagine the last time you were supporting a friend or family member who was going through a very difficult time. Take a moment to bring yourself back to that time.

How did they look like?

What was their tone of voice?

What emotions came up for them?

Who else was in the room?

With this image fresh in your mind, consider this question: How do you think it would go if you responded to this person’s struggles by handing them a symptom measure and said “Would you mind answering these questions so I can better understand your experience right now?”

If the answer isn’t obvious - this would likely go pretty darn poorly. Personally, if I asked my wife to fill out the GAD-7 next time she told me she was stressed at work, I’d be at least slightly scared for my own personal safety.

All joking aside, being there for a friend or family member during a time of need means showing up to listen to them, supporting them unconditionally, and offering advice whenever possible. The formality that comes from measurement simply doesn’t have a place in this context - it comes off as cold, removed, and borderline disrespectful. In other words, there’s clearly no place for measurement when helping family and friends with their struggles.

But what about with clients - does measurement carry the same sentiment in the context of therapy?

One of the most frequent concerns that clinicians face when integrating measurement into their practice is how it will affect the relationship with their clients. These clinicians worry that clients may react in the same way as a friend or family member would, viewing routine outcome measurement as a cold and disconnected practice that isn’t respectful to their lived experiences. While I’ve long advocated that this is not the case in the slightest, there has been a paucity of empirical research looking into the relationship between routine outcome measurement and the therapeutic alliance.

However, a recent study published in the Journal of Counseling Psychology found that not only does routine outcome monitoring have a significant positive influence on the therapeutic relationship, but that this effect acted as a primary mechanism of change in improving psychotherapy outcomes. More specifically, the researchers randomly allocated treatment-seeking individuals to one of two groups: a measurement-based care (MBC) group or a treatment-as-usual (TAU) group. Those in the MBC group started each therapy session by completing a routine outcome measure and collaboratively discussing their results with their provider in order to understand how it relates to their subjective experiences and progress made over the week. Those in the TAU group received no routine outcome measurements and simply progressed through therapy as usual.

Results found that when compared to the TAU group, individuals in the MBC group experienced greater symptom reductions and endorsed higher quality relationships with their therapist. Moreover, using a meditational design, the researchers found that improvements to the quality of the therapeutic relationship accounted for the relationship between condition and treatment outcome. That is, research subjects who received routine outcome measurements felt better faster because of improvements to the therapeutic relationship.

This study elucidates important information that challenges the commonly held belief that measurement can be a detriment to the therapeutic relationship. In direct opposition to the lesson we learned from the brief experiential exercise above, measurement in the context of psychotherapy can be viewed as a critical component of therapy that enhances the relationship and ultimately improves your quality of care. These findings resonate when considering the limitations that we all have when it comes to understanding our clients as best as possible. On average, we spend roughly one hour per week with each of our clients. Furthermore, by the time a client does come in for a session, we have already worked with many other clients who are struggling in their own unique difficulties. The truth is that keeping up with each client’s unique clinical presentations is difficult.

Measurement can assist with cutting through the noise, keeping things focused, and ensuring that your clinical judgement is consistent with additional sources of information. Reflecting on my own clinical experiences, routine outcome measurement that is integrated in a compassionate and collaborative way allows me to ask better questions. These questions, in turn, lead to more meaningful conversations. These meaningful conversations bring myself and my clients together through the shared pursuit of continual self-improvement.

So while you should probably hesitate before you hand your loved one a GAD-7 next time they complain about the stress in their life, you might want to consider using it to kick off your next therapy session.