Applying Measurement-Based Care (MBC) in Session with Youth Clinical Screeners
General points:
- Youth typically appreciate when service providers have an easy and informal communication style. (Hawke et al., 2019). It is important to genuinely listen to youth and validate their feelings and thoughts. Provide a safe atmosphere for youth.
- Try to review, remember, and reflect back the reasons young people came to YWHO. (Repeating their stories over and over again can be discouraging).
- Reviewing results is a way of starting conversations with youth and ensuring accuracy. Youth may have misunderstood a screener, been anxious when they completed them, or possibly angry, leading to inaccurate responses.
- In light of questionnaire results, provide youth with relevant information about how treatment is expected to help them.
- Recognize young people’s strengths and encourage them to take a role in addressing their concerns - they have choice and control.
Introductory process:
- Hub staff will have already gone through the importance and benefits of MBC with young people prior to youth completing the MDS. (Please see Engaging Youth at their first YWHO Visit and Tips for Building Rapport with Youth for details). Each question has a purpose - which is to understand what’s most important to youth and how YWHO can best help them. Reviewing and interpreting results with youth can help youth - and service providers - feel more empowered to make collaborative informed decisions.
- Thank youth for completing all of the forms (these include sociodemographic questions and clinical screeners).
- During the first (and possibly only) visit, reflect general information you have as to why youth are seeking YWHO service. (Ideally, you do not want youth repeating their story but you want to clarify their reasons for service, and they may want to add pieces). Let youth know that, in addition to conversations with hub staff, it is beneficial to review their responses to the questions about their feelings, thoughts, and behaviours.
- If it has been agreed upon with youth that their treatment plan involves more than a single session, you are encouraged to spend some time with youth discussing their goals and expectations of change over time. Understanding youth’s anticipated paths of growth and where they hope to see change will help recognize areas to monitor for progress and flag any obstacles.
Possible Service Provider Talking Points/Responses:
- “I know you answered a lot of questions (on the iPad/paper/online via a survey link), and I’m sure someone already explained the reasons why. I just wanted to summarize why filling out forms and us reviewing them together is helpful - how using that information is beneficial to meet your needs today and possibly in future sessions.”[1]
Why are we looking at screener results/scores?
- “The answers you provided to the questions not only help us to get to know you better, and not make assumptions about you, but together we can make the best decisions as to what services might best meet your needs, today and throughout any future care here.”
- “Based on your responses, your goals, and talking together - we can develop a treatment plan (it may be just today, it may be several sessions focusing on one particular issue or type of therapy - there are different options). You have a say and choice in this - it’s important that your voice is heard. The treatment plan would continue until you feel any concerns are addressed, or it might be changed in discussion with you if you feel it’s not meeting your needs (e.g., if we see no real change in future questionnaire responses. When we know from your responses how you’re doing, we’re in a better position to offer you the help that you need. So we can monitor how you’re doing by looking at your questionnaire answers every now and then to confirm that you are getting the help here that you came to get. Does that make sense?”
- “These questionnaires were chosen because they’re brief, and many have been used with tens of thousands of young people, so we can compare your answers to cut-off points that have been set based on research with individuals your age. For example, if we look at questions you answered about feelings like worry/sadness/distress, if your overall score is below 20 on these questions (K-10/K-10W), it typically means things are going okay; If your score is above 30, it may be that you’re struggling quite a bit with your mood, and feeling quite distressed, and you might benefit from talking with someone, like me. So for instance, your “score” on this questionnaire (K-10) is X, which indicates that XXXXX….What do you make of that? Does that sound right to you? Can you tell me more?”
- “We can look at some of the other results from the questions you answered and see if there are any patterns or other issues that come up, and then can see what you’d like to focus on. I see you also noted several goals you have (GBO) so we can focus on those (if relevant).”
- Can also briefly review results from SRH/SRMH and PHQ-9[2] - GAIN-SSS/YSMF (substance use) - ORS (self-perceived life functioning); Note patterns and if things are going well in some areas and not optimal in others.
- “The way you rated this scale indicates a high level of distress. Is that right? It looks like you rated this scale lower than the others, is that right? Can you tell me about that?”
- “People who score in this low range like this are often looking for some change in their life…”
- “It’s important to keep in mind that one single result/score or data point does not, in isolation, mean there is any type of diagnosis. Scores don't recommend on their own how many sessions might be most beneficial, or a particular service or program. Each result gives us clues as to what might be going on and, with your input, goals, and our conversations, that all helps figure out what may work best to address any of your concerns. Basically, each result is a snapshot that is part of a bigger picture.”
- “Hearing what you’ve said and looking at your results, it looks like we could address XXXX today (e.g., your sadness, worry, alcohol use etc). (If relevant, “We could also monitor XXXX (e.g., your sadness, worry, alcohol use etc) and see if there are changes over time in these areas, and a feeling of general improvement in functioning.) The great thing about filling out these questionnaires is that you can think about and reflect on your answers each time you answer them, set goals based on what you may want to change, and then monitor your progress. We can see any changes in symptoms based on how you answer, which is why we ask you to answer the same questions at different points in time.”
- “Looking at XXXX result, what will help move your score just one point down/up? To the right of the scale?” (Can mention that certain other YWHO services may help address specific responses from questionnaires).
- Please note that specific low/medium/high intensity services vary across hub network sites. In examining youth questionnaire results, general guidelines regarding relationships of these results to such services can be found in the Clinical Screening Questionnaires Reference Table. If youth’s scores are changing over time, conversations may include whether youth could be ‘stepped up’ or ‘stepped down’ to a more or less intensive form of intervention.
Other considerations:
- Address information apart from clinical screeners:
- “We know that feelings or thoughts and behaviours don’t exist in a vacuum/on their own. We want to consider other factors apart from your responses to the survey questions - things like family history, current living situation, past trauma, culture. So we look at some of the other answers you provided (e.g., sociodemographic information), as well as any other information that you think would be helpful to share now.”
- Address possibility of non-therapeutic YWHO services:
- “We know that sometimes young people may feel stressed or worried or drinking/using drugs for a number of reasons. For example, sadness/depression can be associated with underemployment, or lack of social support, or poor physical health, etc. We also have services at YWHO that address work, school, housing, and physical health if you are interested”
How can I help youth with barriers to completing questionnaires?
- There may be times when youth have not completed the questionnaires, for a range of reasons, prior to their sessions. You can use the opportunity in session to address what may have prevented the completion of forms. Related information can be found in Tips for Building Rapport with Youth (How can we speak with youth about completing forms on the iPad (or in hard copy form) while maintaining rapport?/What can we pay attention to in youth during this process?)
- “I just wanted to check in with you about the questionnaires (on the iPad/paper/that were emailed out to you) as I’ve noticed you haven’t filled them out (e.g., for today/the last couple of times they were presented…etc). It’s nothing to worry about, but I wanted to get a sense of what is going on. Do you have any questions I could help answer? Is there anything I can help clarify, or can you let me know what I can do to help in this regard?”
MBC at end of treatment:
- MBC can also be applied when transitioning youth from treatment plans. Termination of YWHO interventions typically occurs after a set, pre-specified number of sessions discussed at the start when treatment goals are clarified, and youth respond to relevant questionnaires. At the completion of individual or group treatment, questionnaires can be re-administered, with results reviewed by youth and service providers. Responses (e.g., improved functioning, goals met) can support the success of the interventions (with youth always welcome at the hub for service). Alternatively, young people may experience exacerbations of symptoms (sometimes due to termination), which can also be addressed.
References:
https://academic.oup.com/psychsocgerontology/article/69/Suppl_2/S99/604538
https://nursekey.com/termination-and-outcome-evaluation/; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4910387/
Courtney, D., Bennett, K., Henderson, J., Darnay, K., Battaglia, M., Strauss, J., Watson, P., & Szatmari, P. (2020). A way through the woods: Development of an integrated care pathway for adolescents with depression. Early Intervention in Psychiatry, 14, 486–494.
Hawke, L.D., Mehra, K., Settipani, C., Relihan, J., Darnay, K., Chaim, G., & Henderson, J. (2019). What makes mental health and substance use services youth friendly? A scoping
review of literature. BMC Health Services Research, 19, 257-273.
[1] Please note that italicized portions represent possible service provider talking points/responses.
[2] Please note that a positive response on the last item of the PHQ-9 (and/or your clinical judgement) warrants the completion of the C-SSRS in session.
