Gathering accurate data about symptoms and problems is an essential first step in overcoming them. This self-help guide will teach you about symptom monitoring in CBT.
Why do I need to monitor symptoms?
Cognitive behavioral therapy is an evidence-based treatment. This means that therapists’ practice is guided by what scientific research says is most effective, but also that the course of each person’s therapy is guided by what works for them. One good way of knowing whether a course of therapy is working is to monitor a person’s symptoms as they change over time. Psychological therapists use outcome measures to monitor symptom change.
When Andrea began therapy her score on a clinical measure of depression were 34/40 – this indicated that she was severely depressed. By the end of therapy her score was down to 7/40 and she was feeling much more positive.
Sally came to therapy bothered by anxiety that got in the way of her living the life she wanted. She and her therapist monitored her symptoms of anxiety every week. She was pleased to see her anxiety scores reduce as the weeks went by.
At the start of therapy Mike’s therapist asked him what his goals were. One of his most important goals was to sleep through the night without having the terrifying nightmares that interrupted his sleep. Mike and his therapist knew the end of therapy was near when he hadn’t had any nightmares in the last month.
How are symptoms monitored?
There are a huge range of psychological assessment instruments used to measure symptoms in many mental health conditions. These can range from general instruments used measure things like well-being, to specific measures for particular disorders such as anxiety and depression. Psychology Tools maintains a list of frequently used outcome measures for use by professionals. Some common ways of monitoring symptoms include:
Self-report questionnaires are used very often by cognitive behavioral therapists as a way of measuring treatment outcomes. There are specific instruments used to assess most mental health conditions including anxiety, depression, trauma, and OCD. Sometimes a therapist and client will create their own measure to assess a problem that is uniquely important to that individual.
Self-report measures might ask questions like “On a scale of 0 (not at all) to 10 (very much) how often have you felt low or worthless in the past week?” or “How much have unpleasant thoughts bothered you in the past month?”. Responses are often tallied to produce a total score indicating symptom severity. Measures can be administered at repeated intervals to allow assessment of symptom change.
Clinician or observer rating scales
Psychologists, psychiatrists, and other mental health professionals often use special diagnostic interviews or rating scales to make a formal assessment of symptoms or functioning. The clinician may have to ask specific questions in a particular order in order for the assessment to be valid. These instruments are often used to help clinicians diagnose the presence of absence of a condition.
Observer rating scales are also used for some conditions. These might ask parents or teachers to rate a child’s behavior in everyday situations, or a partner to rate their loved one’s behaviour at home. They can be used in combination with other measures to gain an accurate impression of a person’s difficulties across a range of situations.
Neuropsychologists perform tests that can be used to identify changes brain function, or to diagnose conditions such as autism or attention deficit hyperactivity disorder. Neuropsychological tests are not often used in therapy itself, but their results may be used to help clinicians anticipate and overcome obstacles to treatment. If you have a neuropsychological assessment you might be asked to complete specific tasks which test particular aspects of brain function.
Tom had been in a motorcycle accident three years ago which had left him with memory problems. When he sought treatment for anxiety his therapist read the report from his neuropsychologist and made adjustments to their treatment plan to help make sure that Tom got the most from therapy. What Tom found most helpful was a written summary of their sessions so that he knew what tasks he had agreed to practice.
Common questions about symptom monitoring
Q: Can questionnaires be used to make a diagnosis?
A: Diagnosis of mental health conditions is a complex field. Psychological instruments are often used by clinicians to guide diagnoses but they normally only form part of the information that a clinician uses to inform their judgement.
Q: Can I use these instruments to diagnose myself?
A: Psychological assessments should only be administered and interpreted by professionals with appropriate training. Professionals such as psychologists and psychiatrists have specialist knowledge and experience which allow them to minimise chances of making an error when using psychological instruments.
Q: I have completed a psychological assessment questionnaire. What does my score mean?
A: When mental health professionals use psychological assessment instruments they will often compare an individual’s scores to validated ‘norms’. These norms allow them to gauge whether a particular score is significantly above or below the average scores for a particular population. Some scales may have a cut-off where a score above a particular point indicates that a problem is clinically significant.
Q: Should my therapist be using outcome measures?
A: There are lots of reasons why the routine use of outcome measures by psychological therapists is a good idea:
- Hatfield and Ogles (2006) found that outcome measures are particularly helpful in leading therapists to alter treatment in situations of potential treatment failure. 
- Hannan et al. (2005) found that therapists were quite ineffective at detecting client deterioration and potential treatment failure. 
- Paul Meehl (1996) and Robin Dawes (1996) suggest that systematized assessment protocols can provide valuable information that clinical judgment alone does not.  
 Hatfield, D. R., & Ogles, B. M. (2004). The use of outcome measures by psychologists in clinical practice. Professional Psychology: Research and Practice, 35, 485–491.
 Hannan, C., Lambert, M., Harmon, C., Nielson, S., Smart, D., Shimokawa, K., & Sutton, S. (2005). A lab test and algorithms for identifying clients at risk for treatment failure. Journal of Clinical Psychology, 61(2), 155–163.
 Meehl, P. E. (1996). Clinical versus statistical prediction: A theoretical analysis and a review of the evidence (New Preface). Lanham, MD: Rowan and Littlefield/Jason Aronson.
 Dawes, R. M. (1996). House of cards: Psychology and psychotherapy built on myth. New York, NY: Free Press.