Skip to main content
Headway

Compliance and documentation

Using measurement-based care in therapy

Administering assessments to diagnose and treat a client’s evolving symptoms can provide a picture of how your client is doing over time.

December 9, 2024 • Updated on August 29, 2025

5 min read

Creating the ideal treatment plan for your clients involves many factors, such as utilizing your therapeutic experience and preferred modalities as well as incorporating their biopsychosocial history and current presenting symptoms. Measurement-based therapy, which involves using assessments to diagnose and treat a client’s evolving symptoms, can provide a picture of how your client is doing over time, since they’re often distributed at the beginning of a session, and then again at periodic intervals (such as biweekly, monthly, bimonthly, etc.).

With this clear understanding, you can better create and enact a plan that effectively meets their needs. Below, learn more about measurement-based care and how you can use it to strengthen your therapy practice.

What is measurement-based care?

Measurement-based care, or MBC, is the practice of using objective measurements — most commonly, assessments — to gain information about mental health clients and guide treatment decisions. Common examples of assessments include the GAD-7 for anxiety and the PHQ-9 for depression. 

MBC is important because it can make therapy more effective and efficient by improving the treatment decision-making process for mental health providers. While MBC isn’t a guarantee of clinical efficacy, it can and should help guide your work as a therapist. 

“Just like a doctor takes a patient’s vital signs and uses them to inform an understanding of their care needs each visit, you can use assessments in mental health care to better treat your clients,” says Anne Jackson, a licensed therapist and Headway’s Senior Associate of Clinical Quality Education.

The benefits of using assessments in your practice

Detect issues early.

By tracking changes in a client’s concerns or well-being through assessments, you can quickly see areas that need the most attention, whether it’s specific spikes in anxiety or similar feelings that show up repeatedly on assessment results.

Assess treatment effectiveness.

Sometimes it can be difficult to say how effective treatment has been, even after many months. Measurement-based care gives you a specific and numerical way to assess exactly how much progress your client has actually made toward their treatment goals, and any symptom reduction.

Make necessary modifications.

Therapy often involves a series of separate interventions, mood logs, or other approaches, where success varies from client to client. Measurement-based care can help you track which ones are working and which aren’t based on how client scores change following each new type of activity.

Give clients a sense of progress.

Even when a client is making great progress, it’s often difficult for them to see or acknowledge it. Improving assessment scores help provide encouragement to continue working toward goals.

Improve mental health access.

More effective and efficient care may mean expanding access to mental health support for more new clients. A targeted approach can also decrease the cost of therapy by meeting clients’ mental health needs sooner. 

Practice in-network with confidence

Simplify insurance and save time on your entire workflow — from compliance and billing to credentialing and admin.

Talk to a practice consultant

How to use assessments during therapy

Knowing what to do with data you collect from assessments is just as important as conducting the assessments. 

After reviewing the assessment your client completed, go over the results with your client in session to explain how they may affect their treatment plan going forward. Then, use the results in tandem with your clinical assessment to tailor your care plan. 

For example, if your client took the GAD-7 for anxiety, you’d interpret the scores and compare them to previous assessments. You would then discuss the change in score, if applicable, with your client in session and discuss your thoughts on what may be needed in order to continue to progress toward goals—perhaps by increasing session frequency or incorporating a different therapeutic approach.

MBC doesn’t always mean clinical efficacy

Measurement-based care is a useful way to improve clinical outcomes, but keep in mind it’s just one indicator of clinical efficacy. “Many factors can impact a client’s symptom severity, and these factors may transcend what you as a therapist can control within the therapeutic relationship,” explains Jackson. (For example: Unexpected loss, medication changes, a medical diagnosis, or treatment for symptoms that often get worse before they improve, such as in PTSD.)

While assessments are a highly valuable source of clinical data, they must always be viewed within the full context of other factors that inform assessment and interpretation of symptom changes and care needs. If a client is “stuck,” then you have a responsibility to take steps that may help them meet their mental health goals. “It's important to capture contributing factors to symptom severity in your clinical documentation, tweak your clinical approach, modify treatment goals, and if needed, refer someone to alternative care,” says Jackson. 

Do you want to incorporate MBC in your practice? Along with support for insurance credentialing and billing, Headway providers can access assessments directly in Headway’s provider portal, making it simple to understand a client’s progress and needs and provide the best possible support for their goals.

Stay organized with Headway

Using assessments and measurement-based care is key to tracking progress‌ — ‌but documenting that progress is crucial. Headway streamlines progress notes with AI-powered tools and templates designed for compliance. Our platform helps you stay organized and focused, so you can deliver data-informed care with less administrative stress and more time for meaningful client work.

Talk to a practice consultant

This content is for general informational and educational purposes only and does not constitute clinical, legal, financial, or professional advice. All decisions should be made at the discretion of the individual or organization, in consultation with qualified clinical, legal, or other appropriate professionals.

© 2026 Therapymatch, Inc. dba Headway. All rights reserved. No part of this publication may be reproduced without permission.

Compliance and documentation

How to write progress notes

Progress notes are the core piece of documentation a provider should write after each client session, but it’s more than just a record of what happened.