With the publication of the DSM-5, for the first time practitioners are provided with tools specifically developed for use with the manual. While there is no requirement that these tools be used, a clear signal is being sent that measuring change is going to be part of how practitioners are expected to practice. Depending on your level of training, you may have had extensive exposure to the use of assessments and measures in determining diagnosis and informing treatment plans. Or, perhaps you only had a class or two and have never considered using measures such as the WHODAS 2.0 or the Level-1 Cross-Cutting Symptom Measures as part of your intake, evaluation, and treatment plan.
If you fit into the latter category, it is important that you familiarize yourself with the challenges of implementing these tools in your practice, whether it be as a solo practitioner, someone who works in an agency or group, or who works with several different systems. It is also important that you understand the limitations of these tools, as well as their applications.
The DSM-5 does not provide training or support in using these tools. That is the focus of this book.
How do you get started incorporating assessment measures into your practice? As noted above, this takes a bit of planning and thought, but follows the well-established format of continuous quality improvement: plan, do, study, act.
Planning will address several different areas depending on how you practice. If you are a sole practitioner, it may include determining which of the measures fits your practice profile. For example, you may wish to use the WHODAS 2.0 and the Level 1 Cross-Cutting Symptoms for all your clients, or maybe just some. You will also need to decide when you want to begin using these measures. Will you begin using them only for new clients or will you ask current clients to complete the measures? How will you share the results? How will you track when you re-administer the measures? An implementation checklist for private practice is provided in Appendix B.
If you are working in an agency or a group, you will need to get buyin from your colleagues. Additionally, you (or someone) will need to review policies and procedures related to gathering information. This can be time-consuming, but it will pay off in the end. Having alignment between policy and practice is essential to insuring the success of implementing change. The balance of the planning stage mirrors that found for private practitioners. You will need to add in training on the instruments, and determine who will do the scoring and interpretation.
Since there are more individuals who will be involved in “touching” the information, you will need to identify how this information flows through the system. For example, while the clinician may administer the measure, there may be another individual who bills for the time, another individual who collects the data, another individual who scores and produces the results, and several other individuals who review the chart. Systematically identifying everyone who “touches” the data and determining their responsibility for managing that information is necessary in insuring there are no data drops or gaps in the system.
Many people are now using computerized systems to gather information. You may need additional code written for incorporating forms into electronic health records (EHR) and uploading results. Policies need to be reviewed to insure that they are consistent with the administration needs for these measures, specifically regarding qualifications of who can and cannot administer, score, and interpret the results.
Training of staff on how to administer, score, and interpret the results will need to be done. Planning for this would include all current staff as appropriate, and any new staff who come on board after this process is implemented. Handbooks and/or guidelines will need to be written, if that is usual for the agency or practice. It is always prudent to have written policies and handbooks to document the purpose and use of this information whether you are a sole practitioner or working in an agency or group.
While the measures are free, there are a number of costs associated with implementing them. As noted above, computer code may need to be written, staff will need to be trained, and training materials created and provided. Costs for reproducing the materials (unless downloaded each time from APA) are also a consideration. Budgeting for these and other ancillary costs should be part of the planning process.
Depending on the configuration of your agency or group, key individuals who should be involved include clinicians, finance staff, computer programmers, quality improvement staff, supervisors, training staff, coders/billers, chartroom personnel, and stakeholders. More information on this can be found in Chapter 7.
Planning when to implement the change is important. You will need to take into consideration new clients, and former clients who may come back. You will need to think about ‘grandfathering’ in current clients. Setting a “date certain” is a useful strategy. That way, everyone will know when the process is going to start and how to address current, new, and former clients. In my own practice, I put a note in each chart when I began using the measures. This went into every chart, even the ones where I did not actually provide a measure. That way, when I open the chart up, I know where I stand. This is a more challenging aspect of implementation when working in an agency or group.
This is actually more like a shake-down cruise than an actual implementation. In implementing this in my private practice, I made several false starts before I found a way to incorporate these measures that was consistent with the way I practice and met the needs of my clients. Expecting there to be glitches and problems is actually the most realistic way to approach this phase.
In an agency or group setting, you would most likely want to do at least one pilot before actually implementing the process full-on. The pilot would probably consist of your most enthusiastic users and one or two folks who are not supporters. That way you can get a feel for what may actually occur. Having buy-in here is crucial.
Give the pilot a reasonable amount of time and a reasonable number of clients so that the information you gather is representative of what may actually happen. Use this information to make adaptations to the process. You may need to do several pilots in order to maximize your data gathering and save money on full implementation. The advice here is: “Be Patient”. It will save you money and good will in the long run.
The third phase, “study”, oftentimes is simultaneous with “doing.” In my own practice, I noticed that there were several parts of the process that needed adjustment. I only learned this after actually administering these measures to several different clients over the period of several months. My first discovery was that I couldn’t just give the measures to the client and expect them to read through the questions and bring it back to me. I had to explain what the measures were for and what information I hoped to get from them. Then I had to think about how I would share the results. I tried several different ways until I determined that I would create charts that descriptively explained the results. This is what I finally settled on and am now using regularly. I have provided Excel spreadsheets with scoring and interpretive guidelines for the WHODAS and the Level-1 Cross-Cutting Symptoms in the Forms section.
Because this was being done simultaneously with my other clients, I needed to go back to the first set of folks I had used the measures with and ask them to respond again. This resulted in some new information, as well as confirming that the process I finally arrived at was going to be the one I would use.
The study phase in an agency or group should be a collaborative experience. All participants (including stakeholders) should be able to share their experiences and insights and then contribute to streamlining the process so that it actually accomplishes what it sets out to do: provide the clinician and client with useful information for treatment planning and interventions. It may be obvious, but it is worth stating; if only one individual (or a small group) interprets the results and then hands down a protocol, the buy-in from the rest of the group is likely to be small, and the effort will result in poor implementation or worse.
A wonderful process to use in this stage is something called the “QFocus Technique” (Rothstein & Santana, 2012). I encourage you to visit the Right Question website (http://rightquestion.org/make-just-one-change) to become more familiar with this process. I present it below in brief, modified for use in an agency or group practice. The process can take as little as 30 minutes if the group is cohesive and the facilitator has thought through what the QFocus question is. This is true even in a large group. I have used this process in a number of different settings and generally find that the median time for the process is closer to 45 minutes.
The process is designed to access and integrate divergent thinking, convergent thinking and metacognitive thinking skills. It is done in a group setting with a facilitator and small groups. The facilitator provides encouragement and guidance, but does not direct or interpret. The small groups increase the intensity of the thinking and the larger group incorporates the metacognition and conclusions reached. The process is found in Appendix A.
The final phase, “act” implies that changes and/or modifications are made and implemented. Just how long this process takes is entirely dependent on who is on-board and how specific you are in your goals. Vague goals typically result in vague outcomes. If you use the QFocus process described in Appendix A, you may find that the last step actually creates the blueprint for implementation. If you use another process, you would want to come up with both “next steps” and assignment of responsibilities for accomplishing the implementation.
To achieve a positive result, you might want to follow this slightly modified CQI plan. 1) take the time to get the buy-in from all stakeholders and participants; 2) try a pilot first to see where unexpected problems lie; 3) collaborate on fixes and approaches; 4) take what you’ve learned and set a target implementation date; 5) Monitor to see how things are going; 6) share results and make necessary changes.
To make this information gathering process complete, it is important we share the information with our clients. But what does that mean? Do we just give them back their measures? Well, you could, but I want to suggest that you make the sharing of information a part of the CQI process, as part of the ‘study’ phase. This is where the meaning of the results emerges. The measure itself, unlike the Oracle at Delphi, does not tell “truth” – it merely reflects back, in an organized way, what the individual who completed it said on a particular day at a particular time in their lives. This is an important point to contemplate.
Depending on when you take a look at it, things may have changed dramatically or hardly changed at all. These are entrées into your client’s world. Use them as passports to gain access, then explore how your clients function and think.
This process fits in nicely with the case conceptualization portion of your diagnosis and treatment planning. Based on what is uncovered, and the meaning your client ascribes to this, you can then go about tailoring your treatment plan to address the issues, while measuring the change.
Measurement of change typically consists of re-administering the instrument at several different points. Each of the instruments in the DSM-5 has good test-retest reliability, which means you can administer them again and again and the responses will provide useful information. When you decide to administer the instruments depends on several factors including how frequently you see the client, what levels of variability in change are expected, and your client’s capacity to complete the instruments. It is a good idea to establish a baseline measurement, which is typically done at intake or shortly thereafter. You can then decide if you want to monitor based on symptom change or at regular intervals. Finally, completing a discharge evaluation, if possible, is also useful.
One of the unstated effects of using measures is that both the client and the clinician may assume that these are measures of improvement. That is not the case. These are indicators of change. This may seem a fine point, but it is an important one to grasp. Change can be interpreted in many ways. If you have a fever and your temperature is going down, that is an indicator that your body is returning to normal. If you are underweight and you eat more calories and you step on the scale and the numbers go up, that is an indicator that you are putting on weight.
In the realm of DSM-5 measures, indicators include levels of distress (none to severe), numbers of symptoms (the more symptoms, the more likely impairment exists), domains of impairment (cognition, communication, self-care, participation in society), and experiences of culture. These do not lend themselves to quantitative measurement, thus they should not be considered measures of “progress” or “getting better”, but indicators of where to begin and directionality (moving toward or away from). To assess that, these indicators are given numeric equivalents that can be used to detect change.
For example, the Likert scale used in the Level 1 Cross-Cutting Symptom Measure consists of “None”, “Slight”, “Mild”, “Moderate”, and “Severe”. The numeric equivalents are 0, 1, 2, 3, and 4. Baseline measures of the symptoms consist of identifying the highest domain score as well as the total number of domains that have scores above 1. Directionality is determined by comparing the baseline scores within domains, and the total number of domains with scores above 1 with subsequent administrations. If the following administrations show a reduction in either number of domains impacted and/ or lowering of the scores, then the indication is that the client’s experience of distress is diminishing.
If the scores are not going down, or the total number of clusters impacted remains high, you can explore several different hypotheses. Perhaps there are situational variables (poverty, stress, environmental catastrophe) that can’t be addressed through therapy alone, or perhaps there are contributing issues that haven’t been identified, or perhaps the intervention and/or treatment is ineffective. When the variables are identified, you can then use the measures to see if the adjustments you have made are effective.
Making the decision to incorporate these new tools into your practice is just the start. How you decide to do this will take some advance planning, whether you are in private practice or in an agency or group setting. If you take the time to do this intentionally, I believe you will find the benefits are useful and practical. Making measurement a regular part of your practice will impact your clients in many positive ways. It will give them a voice in their process, it will give you insight into their experience, and it will provide you both with opportunities to reflect on what has been accomplished, where adjustments need to be made, and indicators for how those adjustments are working.