Last month, Evolve Treatment Centers Clinical Director Dr. Lauren Kerwin, Ph.D, conducted a companywide training on diary cards. Diary cards are a tool used in Dialectical Behavior Therapy (DBT) to track specific treatment goals and measure clients’ progress towards these goals.
On a standard diary card, teens are asked to rate, on a scale of 0-10, the current intensity of their emotions such as sadness, anger, anxiety, and loneliness. Another part of the card asks teens about the coping skills they used that day to deal with unwanted emotions and urges, such as urges to self-harm or attempt suicide. There are dozens of DBT coping skills on the card, and teens circle the ones they practiced. Teens are also encouraged to write down a little bit about notable things that happened that day.
At residential treatment centers and partial hospitalization/intensive outpatient programs that incorporate DBT, such as at Evolve, adolescents are instructed to complete diary cards daily.
Benefits of Diary Cards
Dr. Kerwin often compares a diary card to a map.
“The start of a session is often chaotic. There are many issues and sub-issues the client might be struggling with, and a clinician is often not sure where to start. The diary card, I like to think, is the road map out of hell. Using the diary card, clinicians can establish major targets and variables for the client to focus on. Then, looking at the diary card offers a quick, efficient snapshot of the client’s progress that week.”
Interestingly enough, research shows that the simple act of self-monitoring negative behaviors actually reduces the same behaviors.
“When we are aware of the behaviors, and we start tracking them, studies show that they eventually decrease,” Dr. Kerwin says.
Which is why the diary cards are so helpful for teens struggling with self-injurious, suicidal, or acting-out behaviors. Simply monitoring the frequency of maladaptive urges and actions can help an adolescent eventually eliminate them.
The goal of the training was to strengthen Evolve clinicians’ skills in diary-card instruction. Through a mix of lecture and role-play, Dr. Kerwin explained how to secure client buy-in – i.e. how to get adolescents motivated to fill out the diary cards on a regular basis. One important strategy for earning this commitment, Dr. Kerwin shared, was genuine empathy and care on the clinician’s part.
“Many of our clients are stuck in hell,” said Dr. Kerwin. “They need to know that you’re in hell with them. If they don’t feel that you fully understand their struggles – that you really, truly empathize with their pain – they’re not going to do anything you tell them, including filling out the diary card. You need to earn their trust first.”
Dr. Kerwin also discussed the technical side of diary card instruction. For example, she emphasized the importance of accurately choosing which target goals to list on clients’ diary cards.
“If you focus on the wrong variables, you end up with an inaccurate or incomplete assessment of the client’s progress,” she explained.
Diary Cards Help Answer the Question: Does Treatment Work?
In addition to their clinical utility, diary cards are valuable on a larger, broader scale for mental health treatment centers like Evolve.
“It’s been more and more apparent that we need to be able to understand, and accurately answer, the question of whether or not treatment works,” Dr. Kerwin says. “One way to do this is by using data and outcome measures that target this question.”
This is where diary cards come in.
By measuring the data from diary cards over time, clinicians, families, and the clients themselves can determine whether or not a particular treatment is working for the individual.
“If we’re collecting data that shows that what we’re doing is effective, that means we should continue treatment,” Dr. Kerwin says. “If not, we should readjust.”
In addition to diary cards, Evolve Treatment Centers administers several other assessments that measure the efficacy of its treatments. For example, clients are asked to fill out an emotion dysregulation assessment and a coping skills assessment at intake. Clients complete the same assessments at discharge.
“Strong, ethical treatment centers need to be constantly evaluating their treatment model,” Dr. Kerwin says. “That’s why there is a necessity for data. Statistically, data can predict outcomes. To be able to say with confidence that our treatment works, we need to have the data to back it up.”