March 28, 2023

Using ecological momentary assessment (EMA) to supercharge your measurement-based care practice

Measuring symptoms using recall alone might mean that you’re sacrificing accuracy without even realizing it. Blueprint can help.

Mental health professionals spend a great deal of time and effort trying to elicit behavior change. They work hard to strengthen motivation, break larger changes down into smaller steps, and remove barriers impeding progress. 

But all this change talk happens in the context of a weekly 1 hour session, leaving 167 more hours in the week for your client’s target behaviors to occur (or not). Clinicians know this, and many explain to their client’s outright that real change happens between sessions, not within. When 99.4% of your client’s week happens outside of the therapy office, it’s easy to see why. 

So, how do we keep track of these behaviors to know if they are changing? Well, we ask our clients to tell us, of course! But how you ask this question can significantly impact the quality of the information your clients provide.  

Starting your session with “How was your week?” is good for building rapport, but not so good for gathering objective information. That’s because recall is flawed and inherently biased. And, it’s not our fault! Our brains have a finite memory capacity. When we can’t remember every single thing that happened, we tend to remember that which happened most recently or was associated with intense emotions. For example, a client might report that their mood was low this week due to getting into an argument with their partner two days ago, and may not remember that their mood had actually been good up until that fight. 

Fortunately, there is an assessment method, called ecological momentary assessment (EMA), that addresses these issues. You might have heard EMA used in the context of complicated research studies, but the concept is simple. EMA is the practice of monitoring behaviors in real time and in the setting where the behavior occurred. 

EMA has been around for centuries. Imagine a scientist in the 1700s observing a plant growing in nature with the goal of understanding how the plant grows and propagates. Would the scientist observe the plant once and report back? If they did, they wouldn’t know how the plant changed over time. Would they pluck it from the soil and bring it to the lab? If they did, how are they to know how the plant responds in its own ecosystem? Most likely, the scientist would take repeated observations of the plant in its natural environment and record them for reference. 

All that’s really needed to monitor behaviors using EMA is a pencil and paper. Blueprint offers a wide range of therapeutic worksheets to help make it easy to log daily behaviors. Alternatively, smartphone-based logging makes EMA even more convenient. Smartphones are usually within reach, which makes it more feasible to log many data points throughout the day. And, in addition to making active ratings about mood, energy level, and social connectedness, Blueprint’s app collects passive data (with the client’s express permission, of course) tracking known mood influencers like sleep and physical activity. 

What difference can this make in clinical care? After all, these behaviors may not be dissimilar to those you routinely ask your clients to describe. But it’s important to remember that EMA is a tool to help collect the same data we collect already, just more accurately. This small change can have a dramatic impact. 

Consider this example from the Nashville Collaborative Counseling Center, a Blueprint customer since 2020. Founder Amy Green shared a story of a client with depression who made use of the Blueprint app and discovered with their therapist that they were also experiencing poor quality sleep. After the client began taking medication to help with sleep, their sleep improved. After about 3 weeks, their mood followed suit. 

But, of course it did! That’s not surprising. What made a lasting therapeutic impact, however, was the ability of EMA to help change the story the client had been telling themselves for years. “It’s not me; it’s my sleep! I always thought I was the problem. And now not only do I see that things can change, I see why things changed.” Watching data unfold in real time helped motivate the client to maintain good sleep hygiene even after they were feeling better. 

EMA allows therapists and clients to peek behind the curtain in the recovery process. Measurement-based care works best when the data that inform the care are as accurate as possible. So, the next time your client says, “Can’t I just tell you about my mood next time I see you? I have a great memory!”, you’ll be prepared.