This article outlines strategies and tips therapists can use to address discrepancies between clients' scores on measurement-informed care (MIC) surveys and how they present in session.
Strategies for addressing discrepancies between survey scores and clinical presentation
Here are some strategies and tips for navigating any discrepancies between clients' scores on MIC surveys and their presentation in session.
Acknowledge the client's effort
Completing self-report measures about mental health symptoms can be difficult, requiring honesty and vulnerability. Some clients may also find it challenging to read and understand the questions. Always express appreciation for their effort in completing the measures despite any concerns you may have about the accuracy of their responses. This builds trust and rapport, regardless of the scores themselves.
Express curiosity about the misalignment
When our clinical observations in session differ from a client's responses to the self-report measures it may be tempting to call it out in a very direct way. We may suspect under-reporting (symptoms seem severe in session, but measures show few or no symptoms) or over-reporting (measures suggest severe distress, but the client reports feeling well). Instead of directly confronting these discrepancies, we can use a collaborative and curious approach.
Here are some ideas for exploring the reasons behind the differences together:
Under-reporting
“I was a little surprised today to see that in your responses to the anxiety survey (GAD-7), you answered “not at all” on every question. This tells me you haven't been dealing with any anxiety symptoms since our last session. But I also noticed today how worried you seem about your relationship and how it's left you with some pretty heavy thoughts, which sounds like that might be symptoms of anxiety.
Talk me through what it’s like to answer those questions about your anxiety on the survey. In other words, do you feel like the questions “fit” with how anxiety shows up for you? Is it difficult or uncomfortable to answer those questions? Have you found it hard for you to acknowledge when things are tough?
Over-reporting
“I noticed on the check-in survey that you completed, that it looks like your depression has become really intense recently. Every single day you are struggling with poor sleep, loss of appetite, and feeling worthless. Does that still sound accurate? I ask because you shared at the start of the session that you “feel pretty good” today, which is a shift from your responses on the PHQ-9. I would love to learn more about that shift for you. I’m curious, do you feel like the questions on the measurement surveys accurately capture your symptoms and experiences?”
Use the discrepancy to develop clarity and a plan
Self-report measures are valuable tools, but they don't always capture the full picture. By exploring discrepancies between a client's score and their presentation, like the examples above, we can uncover the reasons behind the misalignment. This deeper understanding helps us tailor treatment plans to better meet the client’s needs.
Case study of a discrepancy between survey scores and clinical presentation
Client X has been engaging in therapy and medication management for the treatment of depression for the past several months. When treatment began, her initial PHQ-9 score was 18 (indicating moderate-severe depression), but after 8 weeks of treatment, it dropped to a score of 6 (indicating mild depression). In sessions, she consistently reported doing well and denied symptoms and stress. However, over the next 4 sessions, her PHQ-9 score gradually rose back to the low teens. When this discrepancy was discussed, she revealed feeling overwhelmed by work stress impacting her marriage and worsening her depression. She admitted difficulty acknowledging this because of her initial progress and not wanting “to feel like a failure”. This opened an opportunity for the therapist to:
- Normalize the ups and downs of recovery and healing.
- Highlight the client's overall progress since starting treatment.
- Explore options for the client to discuss medication adjustments with their prescriber.