January 4, 2023

Providing the care in measurement-based care

Your client completed their assessments. Now what?

You’ve explained the purpose of objective assessment. Your client is fully on board. You’ve picked a few brief measures to incorporate into your sessions and your client completed them just as you asked. Great! This level of compliance is every therapist’s dream. But, what you do next with this information is what separates measurement from measurement-based care. 

It’s important to maintain your client’s enthusiasm for measurement-based care by rewarding their efforts. The best way to do that is to demonstrate the utility of the information your client provided by making it a central focus of your sessions. 

Here are some examples of how to do this, depending on your client’s stage of care:

If it’s early on in treatment:

Step one is to offer your client praise, praise, and more praise for taking the time to complete these measures. Never underestimate the power of positive reinforcement!

Next, review the measure with your client collaboratively. If you’re doing teletherapy, it’s helpful to share your screen so that you both can see the measure your client just completed. If it’s a short measure, like the PHQ-9, it’s feasible, and often helpful, to go through each item one-by-one. This can be especially important for certain items that assess changes in sleep and eating, but don’t require the client to specify whether they are sleeping or eating more or less than usual. 

When you’ve finished reviewing, summarize your impressions and demonstrate how these items can be used to shape the agenda, while leaving room for their input, too. You might try something like: 

“Based on your responses here, it seems like low energy, low self-esteem, and trouble falling asleep are symptoms you’re experiencing nearly every day over the past two weeks. We should definitely add these to our session agenda. We may not get to all of them today, so I’d like to ask you, which feels most important to discuss?”

Of course, for the PHQ-9, there is one item that is always important to check - item #9 - that queries suicidal ideation. It might be tempting to assume that just because your client hasn’t ever spontaneously endorsed suicidal ideation that they don’t experience it, but don’t fall into this trap. Plus, for clinicians who struggle to find their footing when assessing suicidal risk, leaning on objective data can be a big relief. 

If it’s further along in treatment:

Lucky you! You’ve likely got several data points to use to judge progress. After all, you’ve probably been reminding your clients (and yourself) that it’s difficult to evaluate scores in isolation, but now with several scores over a longer period of time, you and your client can evaluate trends together. 

If you’ve been plotting total scores each time your client completes a measure, pull up that graph! Ask your client what they notice, and use this information to guide your conversation. If symptoms are decreasing, to what does your client attribute their success? Was there a specific skill or strategy that seemed to make a big difference? If symptoms have plateaued, what hypotheses does your client have about why this might be? 

Taking stock in this way can also be a useful opening for clients to engage in self-reflection about their own role in treatment progress. For example, if scores have remained unchanged or worsened, could it be that the client has not been as diligent as they were in the beginning of treatment about completing homework? Perhaps they have missed sessions altogether (and, by the way, session attendance is a form of objective data you can track!). Or, maybe your client is extremely conscientious but hasn’t been implementing skills learned in therapy because they don’t fully understand how (even though they’ve been nodding their head at you for months on end!). Tracking progress during periods of high and low treatment engagement can help the client and therapist make a plan for getting back on track. 

Remember, measurement is the steering wheel, and care provision is the gas pedal; the two should work together in synchrony. Allowing each individual session, as well as treatment as a whole, to unfold based on assessment results can help you feel confident in your clinical decision-making. And, transparency is key! By giving your client a glimpse into how you use their data to structure your sessions, you are helping to teach your client to become their own therapist.