Measurement-Based Care: Screening Is Not Assessment

Although I’ve never been a “short-term, solution-focused” therapist, I’ve always seen therapy as a means-to-an-end rather than a lifestyle choice. Therefore, like a lot of therapists, I often incorporate formal, evidence-based assessment tools into my practice. These tools don’t define my approach to assessment, but do make up one small piece of a much more complex assessment picture.

Over the course of my career, I’ve seen greater and greater emphasis put on evidence-based practice and measurement-based care, also known as value-based care. The phrase “evidence-based practice” (EBP) covers a variety of approaches that have been formally studied to rate their effectiveness. Sounds great, right? No more seeing a therapist week after week to have the same kinds of conversations you could have with a friend for free, or with the tree outside of your home, for that matter. Measurement or value-based care refers to how we track a client’s progress in therapy. The word value, in this context, specifically refers to financial value – what we’re getting for our money. Again, I don’t want to shell out hundreds or thousands of dollars for a service that isn’t helping me accomplish anything, so the idea of measuring the value of a therapy service makes some sense.

I’m not going to say much about EBPs here because that’s not what this article is about, but I do think it’s important to mention that the only therapeutic approaches that are likely to be deemed “evidence-based” are the ones that can be broken down into fairly specific steps that can be studied in a research setting. Often, the most healing experiences don’t fit into that kind of box. Some of the same problems inherent in evidence-based practice are also inherent in measurement-based care.

Measurement based care generally uses screening tools. I like screening tools because they can provide a concise entry into beginning to understand what someone is experiencing at a given point in time. I use them to open up conversations, to help people become aware of possible connections among different experiences they’re having, to promote self-reflection, and to help people notice where progress is or isn’t being made. I might ask a client to complete a screening tool independently and then review it with them, or I might ask them to answer the questions together with me. Either way, checking a box is not how we assess well-being or distress. How a person answers a question is absolutely dependent on how it’s presented, and there’s at least as much information in the tone, facial expression, and body language of a respondent as there is in the number they assign an item on a questionnaire.

For context, I’ll name some of the screening tools I’ve used pretty regularly over the years: the Patient Health Questionnaire (PHQ-9) for depression, the Generalized Anxiety Disorder scale (GAD-7), the PTSD Checklist (PCL-5), and the Dissociative Experiences Scale (DES-II). Each of these tools, which you can find quite easily on the internet, lists several common experiences among people who have a given condition. You assign a number to each experience that reflects the frequency or intensity of that experience in your life during a given time period. This can be really helpful for putting words to your experiences, for learning what is common among people with similar conditions, and for building insight into what troubles you and what you’d like to change. At the same time, there’s no checklist and no number that will ever be sufficient to describe the totality of your experience. Screening is not assessment.

Assessment is a broad, nuanced, collaborative process that develops over time. You may, for example, come into therapy for help with your anger. You know you have anger issues. An initial screening confirms that you have anger issues. So do you go straight to a treatment protocol to hurry up and fix those anger issues? I hope not, because anger issues stemming from a primary insomnia will likely respond to an entirely different treatment approach from anger issues stemming from substance misuse, or from PTSD, or from abuse that you’re experiencing in the present. It’s the collaborative assessment process that helps us to know what is actually going on with you, the unique individual sitting across from me. We don’t pick a treatment protocol based on one aspect of your experience, but rather develop a flexible treatment plan together that’s most likely to address the totality of who you are and what you need most at this time. As you change, and as we both come to understand you better over time, our work together changes.

Measurement-based care can easily become too rigid, lack nuance, and ultimately create a barrier to accessing helpful care simply because our growth doesn’t fit some prescribed notion of when and how we’re supposed to change. Psychotherapy is about improving quality of life, and that’s not an easy thing to measure. For most people, growth and healing aren’t linear; there are ups and downs and loop de loops along the way. Ultimately, healing happens through experience, and everyone’s experience is unique. Assessment accounts for this uniqueness, while the screening used in measurement-based care doesn't. If it’s helpful for you to use screening tools to get yourself thinking and learning, by all means do that! But please also recognize how limited these tools are and how little they have to offer in terms of actually understanding and responding to human experience.