Beyond Clinical Judgment: Using Progress Monitoring to Guide Treatment and Improve Outcomes

By Tonya Swartzendruber

A recent article in The Atlantic featured a topic near and dear to us at the Center for Anxiety: Using data to inform evidence based treatment. The author, Tony Rosmaniere, argues that the field of psychotherapy, and our clients, benefit greatly when therapists are willing to routinely look at progress through data generated from patient self-report assessments.

We know that assessing progress in treatment is essential. Evidence suggests that tracking progress in treatment through patient report increases therapist’s capacity to identify those patients benefiting (or not) from the treatment process and adjust their treatment plan accordingly. Just imagine if an oncologist or cardiologist or surgeon didn’t consider data when performing their clinical duties!

However, most therapists use a blend of experience, knowledge and intuition to determine how well treatment is addressing the problems of their patient. While general clinical judgment based on these factors is very useful, it is not always sufficient when dealing with the complexity of human experience and psychology. In evidence-based practice, established treatment methods, such as a Cognitive Behavioral Therapy, go a long way in organizing a treatment plan in the face of this complexity. Using progress monitoring in addition to evidence-based principles can make treatment even more flexible and responsive to individual and contextual factors that we know have a huge impact on treatment outcomes.

So, what is progress monitoring, and how should we use it? Progress monitoring is the ongoing use of data generated from the assessment of indicators that reflect progress in treatment: Quality of life, functioning, severity of symptoms and aspects of the therapeutic relationship. At it’s best, the patient and the therapist use reported information collaboratively to guide the treatment process and when necessary, address and prevent potential early termination of treatment and worsening of symptoms.

Progress and outcome monitoring increase accountability in the mental health profession, because it becomes clear when patients are and are not getting better. Accountability for therapists addressing mental health problems is extremely important. Other professional fields, such as medicine, demonstrate competence through good outcomes. The field of mental health should be no different. Using outcome monitoring helps ensure that mental health clinicians are aware of how their intervention is impacting their patients in an objective way.

Interestingly, just measuring outcomes can improve the effects of care. In a series of studies, Harmon, Slade, Whipple, Hawkins (2005), found objective feedback to therapists on patient response to treatment produced better patient clinical outcomes. That is, when patients had an opportunity to communicate indirectly with their therapists about how they were doing, they got better more often and more quickly. Of particular importance, when given information about when patients were worsening or the patient therapist alliance needed improvement therapists are able to adjust treatment as needed to prevent drop out or deterioration.

The Center for Anxiety has a rigorous progress-monitoring system in place. Using Mentegram software, patients complete a set of brief questionnaires assessing current symptoms related to mood and anxiety both prior to treatment and at each session. In addition to these routine questions, we regularly assess for risk items and if a patient reports a severe change in symptoms, their therapist and our patient care manager is notified immediately by email. The data generated from these questionnaires are routinely reviewed by therapists and can be viewed with the patient as well.

Center for Anxiety clinicians use this data for a wide range of purposes: To review data with clients on a regular basis; to discuss treatment termination when appropriate by pointing to progress; to encourage more engagement in therapy by showing that progress is slower than it could be; to demonstrate that a valued life can be created even when experiencing symptoms; to more accurately identify stressors and their relationship to increase or decrease in symptoms; and perhaps most importantly, to address any increase in symptoms through a possible change of the treatment plan.

In summary, progress and outcome monitoring is an essential and effective way to increase accountability, improve outcomes, augment clinical judgment when making decisions in treatment and more flexibly respond to the changing and dynamic needs of our patients.

 

When It’s More Than Just a Little Stress

 

Written by Talia Kaplan

Consider the following three people:

Joseph is a 35 year old married man whose father died from stomach cancer 5 years earlier. Recently, Joseph has begun to worry that he too may develop cancer. He has gone to several medical doctors and has had numerous scans, all indicating that he is healthy. Joseph continues to worry despite his doctor’s, his wife’s and his family’s reassurances. Any time Joseph feels nauseous or pain in his stomach he begins googling the symptoms to see if it is possibly stomach cancer. Joseph severely has limited the type of food he eats, stopped exercising, and stopped working due to his fear of stomach cancer. Recently, he has noticed that he is worrying about a hernia and other types of medical problems. When he went to see his general practitioner, he was referred to a therapist.

Nancy is a 60 year old divorced mother of three children who has a fear of flying on planes. Her three children live all across the United States, but Nancy has never been to visit her children due to her fear. She has never met her grandchild, and has become depressed as a result of her strained relationship with her children. Nancy’s daughter will be getting married in 2 months and she would like to be able to attend the wedding.

Michael is a 25 year old single male who obsessively worries about the remote possibility that he might kill someone, despite the fact that he has no desire to do so and zero history of violent behavior. Michael works as a barista in a coffee shop, but recently had to take a leave of absence because he kept thinking that he may have accidentally put detergent in a person’s coffee which might kill them. Michael would therefore re-do each cup of coffee he made three times before handing the cup to the customer. Michael’s supervisor noticed what he is doing and has threatened to fire Michael as a result of his inefficiency.

The three people listed above experience debilitating levels of anxiety. Their anxiety has moved beyond regular daily stress. It has moved beyond the frustration of frequently experiencing anxiety in difficult situations. For the people in these vignettes, anxiety has become the thing to fear, and a significantly inhibitory factor in their lives. The first person, Joseph, experiences hypochondriasis (health anxiety); Nancy has a specific phobia of airplanes; while Michael has OCD. While it is expected for all people to worry at times, anxiety can prevent people from living their life in the way they would want to. In cases like these intensive outpatient treatment involving exposure therapy, can help people make rapid gains in treatment over a short period of time.

Exposure therapy works on the premise of behavioral learning models. By avoiding the feared stimulus, people’s anxieties tend to get worse because their fears take over their life decisions. Exposure therapy re-teaches people that they can fully engage in life. Sometimes the feared outcome takes place, and sometimes it doesn’t, but their fear does not dictate whether it will happen. In intensive exposure-based treatment, the therapist and patient first work to ensure understanding of the core fear. For example, for some people the fear of flying in an airplane is that the plane may fall out of the sky, for others it may be that the airplane may hit turbulence and the passenger may experience nausea. Second, the therapist and patient collaborate to develop a hierarchy of feared situations. This hierarchy serves as a map for treatment progress. Patient and therapist then spend a series of half- or full-days together to move in a linear fashion to tackle areas of avoidance for each patient. An example of a first stage in a hierarchy for Michael might be thinking about a person spilling hot coffee on themselves and thereby slightly burning their hand because of a hot cup of coffee that he gave them. The therapist and patient work methodically to help the person re-engage fully in their lives despite feared situations. In many cases of intensive treatment, patients have seen significant improvement in their ability to live the life they want to be living within a week.

One important aspect of doing this type of short-term intensive treatment is attending to bodily sensations. For a patient like Joseph, bodily sensations are often interpreted as dangerous or scary. Through the use of mindfulness techniques, therapists work to teach patients how to re-interpret the daily aches and pains of daily life. Research suggests that intensive treatments can be used to help a person meet a short term goal that they have been struggling with for years. It can help a person reconnect and rebuild interpersonal relationships, allow a person to keep their job, and help people feel more satisfied with their lives.

Five Rules for Giving Instructions that Children Will Obey

Written by Jacquelyn Blocher

Previous blog posts have addressed several strategies to decrease your child’s problem behaviors, from being consistent with discipline (link) to the power of praise and attending to positive behaviors (links). Learning to give attention to the behaviors you like and minimizing attention for behaviors you don’t like can solve most of your child’s minor behavioral problems. There are some instances though when you need to tell your child to do something that cannot be ignored.

All too often though, many parents find themselves at a bit of a loss for how to best tell their child to do something that really needs to be done. The same instructions are repeated more than once. Negotiating or bending the previously enforced rules becomes the norm. Frustrations increase as children whine, stall, or plead in response to parental commands or limit setting.

So why has giving effective directions to your child become something that is so challenging? Often, parents and their children have fallen into a pattern in which their words no longer carry the same meaning they were intended to have. This happens when a parent does not consistently follow through on what he or she says, and over time the child learns that he does not always have to do what he is told. Bottom line, as with other parenting techniques, consistency is crucial. If you say it, mean it, and show your child you mean it by always following through. If you don’t have time to be consistent or follow through, avoid giving instructions, and in turn avoid teaching your child that they do not have to do what you say.

Are you ready to consistently follow through on your instructions? To increase the likelihood that your child will do what you tell him to, follow these five rules below. While they may seem simple, it takes practice and consistency for them to work effectively.

  1. Your statement of instruction should make it clear that your child is being told to do something, and she/he is the one expected to do it. For example, imagine that you have just finished coloring pictures with your daughter. She needs to put away the crayons from the table so there is room for you and your family to eat dinner. An effective command in this situation would be, “Sarah, please put the crayons back in the drawer.” This is a direct statement in which you told her exactly what you expected her to do. Avoid instructions that ask a child to do something like, “Could you please out the crayons back in the drawer now?” Additionally, stay away from directions that make it unclear who is expected to perform the action such as, “Let’s put the crayons back in the drawer,” or “We’re going to put the crayons away now.” In these statements, it is unclear if the task will be a joint effort between you and the child. Also, instructions that begin with question words or words like “let’s” or “we” imply a suggestion or choice rather than something that is non-negotiable.
  1. Make your command positively-stated and specific. Make sure your command tells your child what to do, and avoid telling them what not to do. If you give an instruction by telling her what you don’t want, how does she know what you are expecting her to do? Going back to the crayon example, I did not say, “Please, stop coloring” or “Don’t color anymore pictures.” Negative statements can lower your child’s self-esteem, and also increase negativity in your parent-child relationship. Additionally, do you want your child to just stop coloring? No, you want her to clean up and get ready for dinner. Think about what it is that you want your child to Be specific and positive in your phrasing.
  1. Only tell your child to do one thing at a time. When you give instructions that have multiple parts, and a child only obeys a portion of what you tell her, it is hard to know if the child forgot or if she is deliberately disobeying. To prevent this problem, give only one instruction at a time. If you want your child to put away the crayons and then set the table, first give one command about the crayons. Then, after she obeys, give a second command about putting the silverware on the table. This way you’ll avoid having to deliberate about how to follow through if your child only does part of your two-part command.
  1. Give your command in a normal, neutral tone of voice. Teach your child that all commands are expected to be followed. By teaching your child that polite commands are optional or can be ignored, you will stay away from teaching her only to obey instructions when you use raise your voice. Further, instructions given in an angry tone lead to unpleasant interactions. Keep in mind that as your emotions rise, it becomes more difficult to think and act clearly, which can lead to less consistency and ultimately ineffective commands.
  1. After you give a command, avoid speaking and watch and wait. Be ready to give a warning and to then follow up with a consequence. If you give a command and don’t watch and wait for it to be completed, you are essentially telling your child that you do not expect it to be done. If after some waiting, the child doesn’t obey, reinforce your command by giving a warning “If you do not put the crayons in the drawer, then you will not be able to play with them tomorrow,” or “If you do not put the crayons in the drawer, then you will not get dessert tonight.” After the warning, watch and wait once more. Then, follow through with your consequence if your child does not do what you told her to do. Avoid saying anything else, including answering questions or negotiating, until after your child has obeyed or the consequence has been delivered. Say your warnings and consequences with as few words as possible. If you give into negotiating or changing your consequence, you have taught your child that you do not mean what you say. You have also started the cycle of making your commands less effective.

Consistency is key to teach your child to obey your commands. Remember, once you say an instruction, show your child you mean it by following through!