What do we know about monitoring progress that will improve our patient outcomes?
A central feature of good CBT is the week-to-week assessment of patient progress. This generally occurs in the form of a “mood check” or assessment of diagnostic symptoms. Such a procedure allows the therapist to assess the degree to which symptoms are improving and whether the events of the week have been associated with increased or decreased symptoms. Often this exploration leads to problems to solve and an illustration of the cognitive model.
A variety of assessment methods exist to help us obtain data about patient progress. Many clinicians do a “scale of one to ten” approximation. Some CBT therapies have specialized assessment tools. DBT, for example, has diary cards. Some therapists use validated rating scales like the BDI to evaluate patient symptoms. Data about progress monitoring would underscore how important it is to use such rating scales. Multiple studies demonstrate that we are not capable of “just knowing” how a patient is progressing by either their self-report or our clinical acumen. Measurement based care truly improves outcomes. Cognitive biases are present in all of us, including talented therapists, and can prevent us from an accurate assessment of the patient’s condition. Second, significant session time may be invested in determining the patient’s symptoms if it is not done with a rating instrument, resulting in a loss of therapeutic efficiency. In borderline personality disorder, for example, verbal retelling of the most difficult situation of the week, associated with the most behavioral disturbance, may take so much time and produce so much mood dysregulation that the therapist has insufficient time to work on the problem. In addition, there exists an ample body of work that indicates that progress monitoring, when coupled with feedback to the patient about progress, increases the effectiveness of therapy and decreases negative or adverse responses to therapy. In the UK IAPT program, surveys regarding patient progress are administered in every session. An article in the Globe and Mail in Canada indicates that deployment of feedback measures is happening in their National Health Service in a number of centers.
What feedback should we obtain and discuss? Several areas are critical in assessing patient progress. First, assessment of the symptoms and severity of the diagnosis is of significant importance. In order for recovery to be durable across many diagnoses, true remission of a disorder must occur. Second, measuring the strength of the therapeutic alliance is quite important to therapeutic progress. In CBT, we generally ask for feedback regarding the patient's reaction to the session. This may help us as a global measure of the strength of the alliance. However, we may not always “just know” about this, either. Jackie Persons, in her work with lack of therapeutic progress, suggests measuring the therapeutic alliance in situations where the patient is not progressing as expected. We may all benefit from using session feedback measures that help assess the therapeutic alliance, if not in every patient, then in those patients with whom the therapeutic alliance could pose particular challenges.
In addition to measuring patient symptoms, even more critical is having a conversation with the patient regarding the scale scores. A discussion of the facts at hand should include how we account for progress or the lack of progress. Such dialogue may lead us to discussions of therapeutic impasses, alliance ruptures, incorrect case conceptualization or unrecognized comorbidities. The patient may develop a better relationship with the therapist and a renewed resolve regarding the work of therapy.
Providing therapists and clients with session-to-session progress measures determines patients at risk for treatment dropout and can increase positive outcomes for patients who are not improving. In outpatient practice, therapists are more likely to commit to the process if they develop a simple way to routinely measure outcomes. Printing out forms in advance or developing a HIPAA-compliant method whereby patients fill out forms electronically is quite useful. The weekly use of symptom measures seamlessly integrated into clinical care and discussed with the patient would improve outcomes. Countless patients receiving therapy in research trials complete such scales routinely (and generally have superior outcomes). Those of us caring for patients in practice would improve our care by doing the same.
Donna Sudak, MD, will be leading an interactive virtual workshop on Supervising CBT this May 28-29. This live, online training is designed for mental health professionals who teach and supervise mental health professionals in CBT. Participants will learn how to identify key learning needs and micro skills for CBT training, and how to effectively provide feedback to students and trainees.