Clinical Measures in CBT – A Hassle or a Help?
By Torrey A. Creed, PhD
Beck Institute Faculty
The use of symptom and functioning measures at the beginning of each treatment session can evoke a range of reactions (or automatic thoughts) from therapists. Although some therapists intuitively see clinical measures as helpful, other therapists think things like, “My clients will hate it!” “I work with kids – they can’t do that!” “It will get in the way of our session!” or “That’s not client-centered!” And yet, the emphasis on measurement-based care increases with each passing year. Why is there such a push for the use of clinical measures, if they create such problems? And how can therapists use measures to improve clinical care?
Evidence-based practice refers to “the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (American Psychological Association, 2006, p. 1). The integration of measures to guide CBT is a critical component of providing evidence-based care. Use of psychometrically sound clinical measures can help to monitor progress and guide treatment by providing a window into a client’s symptoms and functioning. Consistent use of a measure at the beginning of each session helps to monitor weekly changes and guide session content, and systematic (but less frequent) use of measures allows a wider-lens evaluation of progress. Ideally, a therapist would combine both types of measurement to get a fuller and more objective picture of a client’s status.
Consider the mood check – a core feature of CBT session structure. A mood check with an adult may be as simple as asking the client to rate their experience of a specific mood on a scale of 1-10. An adult presenting with depression might be asked to rate how depressed they are at the beginning of session, their most intense experience of depression over the past week, or other clinically relevant information. For children and adolescents, we may modify the mood check. For example, a younger anxious client may be asked to point to a spot on a Feelings Thermometer to indicate their experience of anxiety, give a SUDs (subjective units of distress) rating, or point to a visual representation of the intensity of their anxiety. Best practice is to use the mood check information to help inform the session agenda, and to track changes in mood ratings over time as an indicator of progress.
Clinical measures can be used in a similar way, but they come with inherent advantages. We can have more confidence that scores from psychometrically-sound measures actually represent how our clients are feeling, beyond the confidence we might have in a single-answer mood rating. Clinical measures have been developed and tested to meet more rigorous standards for measuring what they intend to measure, and they can reduce bias in our interpretations of a simple mood check. Clinical measures will also indicate the age ranges for which they are appropriate, so that clinicians can feel confident that they are asking for clinical information in a manner that is appropriate for their client. A number of free, brief and validated measures are available online, including many that are listed in a 2014 article by Beidas et al.
Give careful thought to which weekly measure(s) is appropriate for your specific client. Therapists in specialized clinics that focus on one type of presenting problem might use the same measure across their clients, but in more general practice, be sure to use a measure that reflects the primary presenting problem. For example, with an adult with depression, we might choose the Patient Health Questionnaire-9, a free, psychometrically-sound, 9-item measure of depression symptoms. For an adolescent with disordered eating, we might use the Child Eating Attitudes Test, a free, 26-item self-report measure of a child’s thoughts about eating. Alternatively, we might select a measure of life satisfaction, general functioning, or overall mental health like the Recovery Assessment Scale for adults or the Peabody Treatment Progress Battery for youth. (More on these more global measures in a moment.)
Using an Excel spreadsheet or other tracker, therapists and their clients can track changes in scores over time, which can prompt great agenda items. If scores are improving, that offers an opportunity to reflect on what has improved, how those changes impact the client’s overall life satisfaction, and what remains as a focus of treatment. If scores aren’t noticeably improved, therapist and client can discuss whether changes to their treatment plan might be needed. If scores indicate worsening symptoms, therapist and client might need to consider a referral to a higher level of care or other change, along with changes to the treatment plan. Be sure not to react to every small change week to week, but instead look for patterns (like steadily increasing scores over time) or significant changes (like a sudden drop or rise in scores).
Pragmatically, weekly measures can easily be incorporated into session. Often, forms can be completed in a waiting room prior to session. The experience can be similar to receiving a clipboard with a form to complete at a medical appointment. Front desk staff can be trained to provide appropriate assistance with measures as needed, and clients can discuss any further questions they may have when they enter the therapy room. If reading is a challenge (i.e. for younger children or adults with reading difficulties), therapists might have the client complete the form in the beginning of session the first few times. The questions remain the same week to week, so many clients move quickly to being able to answer them on their own. Front desk staff can score the measures, or therapists may quickly score the measures at the beginning of session. Scores can be used the same way we might typically use a mood check – for example, “I noticed that your scores suggest that you’re feeling a little more down this week. Does that fit with what you’ve noticed? Is that something we should add to the agenda?”
In addition to tracking weekly changes, therapists might use other measures to track broader functioning that may change more slowly. These measures may be given every other month, each time treatment planning is updated, or based on another regular, but not weekly, timeline. Periodic measures may evaluate life satisfaction, overall wellness, or other global aspects of functioning to provide a wider perspective than just tracking symptom change. For example, the Recovery Assessment Scale for adults or the Peabody Treatment Progress Battery for youth mentioned above can provide broader information about how well clients are coping and functioning in their lives, separate from changes in their symptoms. Scores on these broader measures can also be very helpful in determining a client’s readiness for discharge from therapy, along with the client’s more direct feedback and consideration of their treatment goals.
Therapists or organizations that are interested in tracking treatment outcomes across clients may find these more global measures particularly helpful, because they are more likely to be relevant to broad groups of clients. Tracking across clients can provide important information about whether the overall mission of the work is being accomplished – do my clients (or our organization’s clients) tend to improve, stay stable, or worsen over time? Are we helping people reach their goals and function well in their lives? Answers to these questions can help identify any need for additional training, supervision, or other support for therapists.
Like most strategies in CBT, the real power in what we do is understanding what we’re trying to accomplish, and then choosing a tool or strategy that has been shown to be effective in that situation. Anxiety disorder? Consider exposure. Depression? Consider behavioral activation. When we are working with clients to help them reduce distress and increase quality of life, clinical measures are an important strategic tool to help us understand whether CBT skills and strategies are helping an individual move toward their goals. Without that rationale, clinical measures can feel like one more piece of paperwork to add to the pile. Used effectively, measures can help therapists and clients understand changes in the client’s progress, and course-correct if needed. Scores, combined with feedback from the client, can help us become more effective therapists, in turn strengthening our relationship with our clients and supporting them in moving toward their goals.
Beidas, R. S., Stewart, R. E., Walsh, L., Lucas, S., Downey, M. M., Jackson, K., … & Mandell, D. S. (2015). Free, brief, and validated: standardized instruments for low-resource mental health settings. Cognitive and Behavioral Practice, 22(1), 5-19.