3.C.1
Monitoring response session by session
Énoncé de compétence 3.C.1 d’ASPPB : Continually monitor client responses to treatments/interventions
Monitoring means checking throughout treatment whether the client is improving, staying the same or getting worse, and why. Measurement-based care uses brief standardized measures before or during sessions to inform treatment, alongside attention to the alliance, risk and functioning. Feedback from routine monitoring helps most when a client is off track, because it helps clinicians recognize a poor response. What is monitored should match every goal in the plan, not just one symptom count.
Notions clés
- Measurement-based care
- The systematic evaluation of patient symptoms before or during an encounter to inform treatment (Lewis and colleagues, 2019). The scores are meant to guide decisions with the client, not simply to be filed.
- Progress feedback
- In a meta-analysis of 24 studies, routine outcome monitoring with feedback reduced deterioration and nearly doubled clinically significant or reliable change among clients predicted to have a poor outcome (Lambert and colleagues, 2018).
- Alliance ruptures
- A rupture is a deterioration in the alliance: disagreement on goals, poor collaboration on tasks or a strain in the bond. Resolving ruptures related to better outcome, r = .29 across 11 studies (Eubanks and colleagues, 2018).
- Several streams of data
- Track each target in the plan: symptoms, avoidance, functioning and practice between sessions. A falling symptom count can hide growing avoidance and safety behaviors, which work against the new learning that exposure aims to build (Craske and colleagues, 2014).
Exemple commenté
A 33-year-old in CBT for panic disorder reports that her panic attacks have fallen from five a week to one over four sessions. Her diary also shows she has stopped driving on highways, shops only with her sister and has skipped the planned exercises that bring on bodily sensations.
- Read all the data, not only the panic count: the drop coincides with new avoidance and safety behaviors, the kind of behavior change DSM-5-TR includes in panic disorder.
- Interpret: fewer attacks bought with avoidance is fragile progress, because she is not learning that the feared sensations and places are safe.
- Share the pattern with her in plain terms and ask what made the exercises hard, checking whether the pace has strained the alliance.
- Agree on the next step, such as a graded highway drive alone, and add an avoidance rating to what is tracked each week.
Monitor every target in the plan; one improving number can hide the process that keeps the problem going.
Vérifiez vos acquis
In Lambert and colleagues' (2018) meta-analysis, for which clients did progress feedback make the largest difference?
Sources
- Lewis, Boyd, Puspitasari and colleagues (2019), Implementing Measurement-Based Care in Behavioral Health: A Review, JAMA Psychiatry (PMID 30566197), Abstract; definition
- Lambert, Whipple and Kleinstäuber (2018), Collecting and delivering progress feedback: A meta-analysis of routine outcome monitoring, Psychotherapy (PMID 30335463), Abstract; results
- Eubanks, Muran and Safran (2018), Alliance rupture repair: A meta-analysis, Psychotherapy (PMID 30335462), Abstract; definition and first meta-analysis
- Craske, Treanor, Conway, Zbozinek and Vervliet (2014), Maximizing exposure therapy: an inhibitory learning approach, Behaviour Research and Therapy (PMID 24864005), Abstract; removal of safety signals
- American Psychiatric Association (2022), Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision, Panic disorder, Criterion B