Mental Health Assessment Test For Clients Using Outcome Measures [Show Notes]

Learn how to help clients use outcome measures as Mental Health Assessment Test to gauge treatment progress. Watch video here:

Transcript for “Mental Health Assessment Test For Clients Using Outcome Measures”

Note: This video is transcribed using AI therefore some errors have occurred in the transcription of this video.

Hi everyone, I am Alex from Stressless therapist and I wanted to pop on to talk a little bit today about outcome measures when you were doing your clinical work with clients. Now, don’t run away Jessica, I know that sounds really scary and really kind of nerdy and data-y but it is a really important part of the work that we do

and some of us use it, some of us don’t, and it’s something that I found really helpful in my work, so I want to talk a little bit about not only what it is but how I use it and how I incorporate it into my clinical documentation in hopes that it will help you as well. Let’s look at the basics of it.

What are outcome measures? Essentially, outcome measures are tools that you can use to have some type of objective data on the client’s well-being. Now, this could be something as simple as a SUDS or maybe it’s not really objective, it’s more likely the PHQs right.

So, like looking at like the depression and wellness or generalized anxiety scale, but there’s some kind of research and scientific data that’s gone into evaluating what are the symptoms that someone’s feeling and then they can do through self-report some type of measuring where they’re usually kind of picking like a one to five, one to ten scale of how intense they’re feeling these symptoms and you can use those numbers to know where they are from a baseline perspective, say when they’re walking in the doors with you.

You can use those numbers throughout treatment to see what’s working, what’s not working, if things are getting better or worse or changing, maybe new things are popping up. It’s really nice to use it on discharge to kind of show the full story of where they started, where they ended and also it’s really good legal CYA that shows that hey I am helping this person, justifies that your work with them is good.

It shows that like when you discharge, hey this person was at a really good level and this way if God forbid something happens later on, you can say well during my care with them they were in a good spirit, they were in good headspace.

What happens outside of discharges is not something that you could be held responsible for, so things like that. I’m curious how many of you are actually using it in your practice or have you kind of learned about it in your grad school and that’s been the end of it. I personally use three rather frequently. So, the first that I use as I mentioned before that GAD skill and that is looking at the symptoms of anxiety and how frequently and intensely someone is feeling them. I also use the PHQ-9 which is a depression screener. I’ve also used the Beck full for depression and for anxiety.

They have two different versions to measure depression symptoms. Another one I use on occasion, I don’t use it all the time, but there is the PCL-5 which is for trauma and PTSD. So, if I’m suspecting someone has a trauma history or someone is maybe experiencing PTSD and I kind of want to confirm it a little bit more, I’ll give them the scale and then I can see for sure where they’re feeling things.

A lot of these scales, they are basically taken directly from the verbiage that’s used in the DSM. So when you’re looking to put evidence in your clinical record of why someone completely classifications for say trauma PTSD, you could say criteria a they’re meeting these symptoms. Criteria would be either meeting these symptoms which is really helpful when it comes to treatment planning.

Another one that I use that’s not an objective measure kind of thing, although I mean technically it’s all self-reported, so there is some kind of trust that’s going on with what the client is saying, but even just the basic subscale like if you’ve never done any of these resources before and are looking just to kind of get your feet wet with using some type of outcome measure, I would do a basic subjective units of distress scale.

It’s like that one to ten how strong are you feeling? At one being not so much 10 being oh my God and see where the client is at and obviously the goal of treatment is if they’re feeling a 10 out of 10 anxiety when they walk in for them to leave with a lower number and to teach them how to get that number to be lower using different strategies and tools that you’re working on in session. I find that doing these outcome measures is a great conversation starter for me to have with my clients. It’s a great way to build awareness.

Sometimes they have no idea that their symptoms are really trauma symptoms and are not just typical anxiety, so it’s a good place for me to do some psycho-education and to help them understand why they might have been struggling with something for so long because they were treating something that it wasn’t. It’s a great chance for me as a therapist to learn more about the client. Sometimes people aren’t very chatty and it’s not that they’re being manipulative or withholding, it’s just that it was one really scary to talk about things in therapy. Two, they might not know.

We know what the symptoms that we’re looking for, but this is a whole new world for them so it helps to give them language to talk about it, and it gives us as a therapist some kind of cue points to check in as to what to ask questions about.

With knowledge comes great opportunity for growth and great kind of avenues that we can then explore, and it’s not until both the therapist and the client have that knowledge and that shared language that then kind of treatment can really start to soar and I mean that’s the whole point of why we do this right is to help people get better to help people get out of pain and suffering and struggle, and using measures such as this is a really great way to help them soar.

When it comes from a documentation perspective, I will put outcome measures pretty much all over the place. If I do it on intake right giving it as part of my intake paperwork I will document it in my intake assessment. I will periodically kind of use them throughout treatment and so I will either put it in my progress note or in my treatment plan review depending on kind of where in the process I am using it and kind of how formally I’m using it. If I’m using it like a size I might use it more in the progress note if I’m doing like a full on scale that is usually more of a treatment plan thing.

I will definitely put it in discharge and usually I make a nice little chart that kind of outlines all the different times I have done it so people can see the progress or end the plateaus as it goes. Sometimes it’s not always in the positive direction that it’s going meaning like people are always reducing their numbers sometimes the numbers unfortunately do increase and then that’s again a great place for her conversation starting about where do additional resources need to be put into play

whether it’s something supplemental to therapy or maybe they have maxed out on the benefit that they’re receiving from me and it’s time to refer them to a higher level of care or a specialist that is going to help bring them to the next level.

I hope this has given you some ideas as to what outcome measures are how they can be used in your practice and really how they can be used to benefit not just you but your client as well. No matter what you do and how you do it make sure you document it. It doesn’t count if it doesn’t get documented.

I mean yes it’s great for the therapist and the client but just like anything if you don’t document it and you don’t record it it didn’t happen so make sure that you include it in your intake your treatment whatever kind of documentation you’re doing at that time. If documentation is something that you’re struggling with I do offer a digital course on that that has been a tremendous help for me I’m hoping it’ll be a tremendous help for you as well. I have templates for everything that I do that helps speed up the process.

I’ve been able to get my soap note down to about six minutes which I complete in between session which has been a godsend. But that’s enough of me kind of talking about that for now if that’s something you’re interested in click the link below there’ll be more details on it you can read all about it but I just wanted to let you know what is out there

because again knowledge is power and I hope with this new knowledge about outcome measures that you can really use it to empower yourselves but more importantly Empower your clients and help them really Thrive and Excel at what they might be struggling with and turn the corner into a better life that’s all for now take care and I hope this helps.

Mastering Clinical Documentation With Speed and Efficiency (includes templates) https://www.stresslesstherapist.com/documentation-course

Progress Note Planners (affiliate links)

• The Child Psychotherapy Progress Notes Planner
• The Adolescent Psychotherapy Progress Notes Planner
• The Adult Psychotherapy Progress Notes Planner
• The Severe and Persistent Mental Illness Progress Notes Planner

Treatment Planning Planners (affiliate links)

• The Family Therapy Treatment Planner
• The Complete Adult Psychotherapy Treatment Planner
• The Adolescent Psychotherapy Treatment Planner
• The Addiction Treatment Planner
• The Child Psychotherapy Treatment Planner
• The Couples Psychotherapy Treatment Planner
• The Parenting Skills Treatment Planner
• The Severe and Persistent Mental Illness Treatment Planner
• The Crisis Counseling and Traumatic Events Treatment Planner
• The Co-Occurring Disorders Treatment Planner
• The Family Therapy Treatment Planner
• The Group Therapy Treatment Planner
• The Social Work and Human Services Treatment Planner
• The Suicide and Homicide Risk Assessment and Prevention Treatment Planner
• The Veterans and Active Duty Military Psychotherapy Treatment Planner
• The Juvenile Justice and Residential Care Treatment Planner

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