Nov 2, 2018
By Joe Grasso, PhD
We know that talk therapy can be highly effective and life-changing for people grappling with mental health concerns. But for providers and clients alike, there remains a critical question that still sparks much debate: How do you know when therapy is effective?
It turns out the answer isn’t always intuitive. We could all use some help in answering this question.
If you’re a client, you may be thinking “I’ll know it worked when I’m feeling good again.” While you surely have a sense of when things are going well and when you’re feeling low, you may not realize when you’re improving in certain aspects of functioning (e.g., social activity, sleep habits) even though you’re not feeling 100 percent better.
If you’re a therapist, you may be shocked to learn that despite our extensive training and clinical experience, we may not be as accurate as we think in detecting when therapy isn’t working and client symptoms are deteriorating.
An outcome survey is a simple, straightforward tool for helping to determine the effectiveness of therapy. These questionnaires help providers understand how their clients think, feel, and behave by asking them to rate how they’re doing in various aspects of life (e.g., work, relationships, physical activity) and to rate the frequency and severity of the symptoms that brought them to therapy (e.g., worry, hopelessness, sleep difficulties). Surveys can also be used to evaluate the quality of the relationship between the therapist and client — a predictor of therapeutic success.
These surveys (also called “measures”) are designed to take just a few minutes to complete but provide invaluable, detailed information about client functioning and therapy progress. They help clients reflect and express themselves in a more precise manner about their constellation of symptoms, which can be difficult during a therapy discussion.
But outcome surveys can do more than just evaluate effectiveness. Ideally, they’re used to improve effectiveness.
When outcome surveys are routinely used to inform treatment planning, treatment effectiveness significantly improves. This particular finding is for adults in one-on-one therapy, but research with children and couples shows similar results, as do studies in which the treatment approach is medication.
Outcome survey results, in the form of numerical scores, can be compared (and even graphed) over time so therapists and clients can easily track how things are going with greater specificity and precision.
For example, if a client fills out a survey about his depression symptoms in our first session and the score is 14, that tells me he’s experiencing moderate symptoms of depression. His responses to questions about sleep, energy level, appetite, and emotions can guide me in how to customize treatment. The initial score also gives me a benchmark from which to track how things are progressing. In this example, I can compare the client’s scores after future sessions to his baseline score of 14.
If symptom scores significantly improve over the next few weeks (e.g., from 14 to 4), the client and I can reflect on the efforts he’s taken to reduce his symptoms, such as increasing exercise, improving sleep habits, or practicing mindfulness skills.
It’s possible that he doesn’t even realize how far he’s come. In that case, outcome survey results can serve as a motivational tool to highlight important progress and encourage even more effort toward behavior change.
Of course, it’s not always smooth sailing. Sometimes symptom scores stagnate or worsen. In those instances, it’s time to talk about what’s not working and what to do next.
Maybe new life stressors have popped up, like adjusting to a new job, or longstanding stressors have worsened, like a deteriorating health condition. That could mean the focus of therapy needs to shift to prioritize coping strategies for these new challenges.
Or perhaps it’s time to try a different treatment approach altogether. For example, a client with anxiety may not find relief in relaxation techniques, but challenging her worry thoughts could be the answer. Medication or more intensive treatment might be needed.
There’s also the possibility that the therapist and client may not be well matched and a referral could be the answer. Responses to survey questions about the quality of the therapeutic relationship can add helpful context to determine if there are concerns about the degree to which the therapist and client are well aligned or matched.
Lastly, if the therapist and client aren’t able to easily figure out what needs to change, the outcome scores can motivate the therapist to seek consultation from another clinician.
Now that we’ve established just how beneficial outcome measurement can be, let’s look at some common barriers to use for both clients and providers. See if you identify with any of these concerns.
“Surveys take valuable time away from my therapy session.”
Many therapists ask clients to complete surveys in between sessions. Your therapist will get the results after you submit your responses, so he or she can review them in preparation for your next session, when the two of you can discuss your results and progress to-date.
“I don’t want to only focus on my depression or anxiety in therapy. I have other goals too.”
There may be multiple reasons you decided to see a therapist. Maybe you’re depressed but also have goals of improving the quality of your romantic relationship. Maybe you have anxiety but also want to communicate better with co-workers. These are excellent goals. Measuring your depression and anxiety symptoms doesn’t mean that your treatment is focused exclusively on those conditions. But those conditions can certainly get in the way of meeting your goals, so therapy should be utilized as an effective way to remove those barriers.
“Surveys don’t capture what my depression and anxiety are really like.“
Some clients feel that survey questions don’t exactly capture the breadth of their experience. But even if the questions don’t perfectly match what you feel, the survey can still be helpful to identify the intensity and severity of some key symptoms. I encourage you to ask your therapist how best to think about the intention or meaning of questions if you’re having trouble figuring out how to respond. Also, note that these surveys are different from the typical surveys you might take in a magazine or online. They have been extensively researched with people who have similar problems and have been found to reliably measure the problem they describe, as well as changes within that problem.
“My clients will be annoyed if I ask them to fill out surveys.”
Although a small amount of effort is required to complete an outcome survey, these measures are brief and can be filled out quickly from a computer or smartphone. Education around their value and the ease of filling them out can go a long way toward enhancing rates of completion.
“I don’t need a survey to tell me how my client is doing. I’m already skilled in clinical assessment.”
As a provider myself, I get it. We went to school for a long time and have countless clinical hours under our belt. But take a moment, use your cognitive reframing skills, and think of outcome survey results as one piece of data, not the sole piece of data, in your assessment. The more data we have in making clinical decisions, the better. And as noted earlier, research does suggest that we can have blind spots when it comes to assessing treatment progress. So in the interest of putting the client first, why not err on the side of using this tool to help minimize those blind spots?
“I don’t want a survey dictating my clinical practice.”
It’s helpful to remember that outcome surveys aren’t prescriptive. They aren’t designed to dictate how you care for your clients — your clinical judgment can never be replaced by a simple survey. To use a cooking metaphor, outcome surveys are utensils not recipes. They’re designed to signal when therapy is working and when it’s not, or when it’s time to discuss your client’s perceptions of how they’re progressing in treatment.
If you’re a client, I hope this convinces you to complete your brief outcome surveys. Next time you receive a survey, remember just how helpful your results will be — for you and your provider.
If you’re a provider, I hope I’ve convinced you to incorporate outcome measures in your practice. Below are some strategies for implementing measurement-based care as a mental health provider.
Use brief, validated surveys.
It’s important to use outcome surveys that have been validated to measure what they’re supposed to measure and generate reliable results. For example, Lyra has selected the PHQ-9 and GAD-7 as the standardized measures for depression and anxiety symptoms, respectively.
Have a discussion with the client about what they can expect from measurement-based care.
Clients may be more likely to complete surveys if they understand what they are, how the results will be used, and most importantly, how they’ll benefit. Let them know that these surveys help you understand how they’re functioning in specific aspects of their life and that they’re a valuable tool for tailoring treatment to their unique needs.
Explain what the results mean in easy-to-understand terms.
Help your clients understand the meaning of their scores in the context of the most recent survey and in terms of change over time. For example, “Your depression scores were in the severe range when you first came in but today they’re showing your symptoms are mild. That’s a big improvement, Let’s talk about what’s working.” Or, “Your depression scores are showing that you’re still dealing with some severe symptoms, like hopeless feelings and low energy, and that’s been the case for the past few weeks.”
Inquire about whether the results match their perception.
Debriefing is an opportunity to reconcile how scores fit with your client’s own subjective experience. For example: “What have you noticed about your improvement in these areas?” Or, “Does it feel like those depression symptoms have stayed the same (or gotten worse) to you, too?” If there’s a discrepancy, it might indicate that the client may not be accurately interpreting the questions on the survey, or that they haven’t been able to articulate the status of some of their problems during the course of therapy discussions.
Initiate a discussion about the implications of the results.
Here’s your chance to talk to clients about how their outcome results help inform care and to start a conversation about what comes next in the treatment plan. For example, “Now that you’re feeling better, let’s talk about which strategies have been most useful and how you can keep up the great work you’ve been doing.” Or, “It seems like what we’ve been doing in therapy over the past few weeks isn’t leading to the progress we hoped for, so let’s talk about what we can do to change course.”
We all share a common goal of ensuring that clients receive the most effective, highest quality of care. Outcome surveys can help clients articulate when treatment is effective and when it’s not, which in turn helps inform treatment planning for providers. They’re only a tool, but a powerful one that can lead you and your clients to answer that critical question, and know when therapy is truly effective.
If you need support, Lyra can connect you to a behavioral health solution. You can get started today if Lyra is offered by your employer. Sign up now.
DISCLAIMER: The content of this blog is not intended to be a substitute for professional medical advice, diagnosis, or treatment.
ABOUT THE AUTHOR
Joe Grasso, PhD is the Manager for Clinical Quality at Lyra Health and a licensed clinical psychologist. He specializes in mixed-methods research and evaluation, health care quality improvement and implementation science, and program development. Dr. Grasso also provides evidence-based psychotherapy for adults in San Francisco.