Informed Outcomes: Self-rating measures and their use in psychodynamic therapy with adolescents
About the article
Angie Doran led on an A Space and University of Essex research study looking at the ways in which psychodynamic counselling can best meet the needs of young people accessing therapy in the school setting. As part of the study, she looked at the main outcome measures used in work with adolescents in clinics, the community and voluntary sector and in education settings. In this article, she looks at the process of assessment, including the use of written self-rating outcome measures with young people. She critically reviews a selection of these and reflects on their application in practice. She goes on to consider how collaborative written assessment procedures may be more appropriate for use by psychodynamic therapists working with school-based clients, given the challenges of delivering therapy in the education sector. You can read Angie Doran’s study Beginnings and Endings: A Study of How UK Secondary School-Based Psychodynamic Therapists at Different Stages of Their Careers Approach Initial and Final Phase Practice on the A Space website.
A Space for Creative Learning and Support was set up as a research and development project in 1997 by The Glass-House Trust (a Sainsbury Family Charitable Trust), the Social Science Research Unit (Institute of Education, University of London) and Hackney Education. A core aim is to deliver psychodynamic therapies in the school setting, adapting and evolving current models of child and adolescent psychotherapy where necessary both in response to the educational context and to ensure that the needs of children and adolescents are best met. In 2010, A Space and The Centre for Psychoanalytic Studies, University of Essex began a formal study into school-based therapy. Funded by The Glass-House Trust, this research will run through to 2013. A conference will be held in 2014 so that the findings can be more widely disseminated.
There is growing interest in building an evidence base across all therapy models both to ensure that public funds are used more effectively and that client needs are met. For this reason, many practitioners are looking at ways of gathering information during assessment at the start of therapy that can be used to assess outcomes in the final phase of the work. In common with practitioners from all psychological therapies psychoanalytic and psychodynamic therapists are strongly encouraged to create an evidence base in order to secure their position in future healthcare policy and planning.
In the UK today, young people access psychological support in the public sector through their school or college, through community and voluntary sector organizations and via child and adolescent mental health services in the NHS. Therapists in all environments use assessment to achieve a number of fundamental objectives, including gathering background information, forming an initial impression of the underlying issues and the degree of disturbance, assessing motivation, establishing the possibility of risk to self and/or others, clarifying what is being offered, describing the limits of confidentiality, exploring treatment options and engaging the young person’s curiosity and participation. As well as building a picture of her client in order to inform the quality and length of the proposed counselling work, the therapist is also using assessment to establish a starting point from which she and her client can later identify what has been achieved through their work together.
In clinical settings where therapists working within different theoretical models are part of a multi-disciplinary team, a psychodynamically informed clinician will include in assessment an exploration of the client’s psychological mindedness. In her book Psychodynamic Counselling with Children and Young People (2010), Sue Kegerreis gives a clear exposition of the process of psychodynamic assessment with a young client group. She unpacks what is a complex task and offers a set of useful questions to be posed as part of the therapist’s ‘assessment thinking’ (2010: 164-75). Kegerreis also makes the point that in a clinical setting assessment is most commonly carried out by an experienced professional (p.164). Psychodynamic assessment is conducted through sensitive exploration and when undertaken by an experienced practitioner can be seamlessly woven into the first phase of the work. Established practitioners often allow the first sessions to unfold at the client’s own pace, using skilful questioning techniques that elicit the required information at the same time as allowing the client to take the lead. In clinics, assessment may be conducted by a single experienced practitioner or by two or more clinicians (rarely by a novice practitioner on her own) and feedback is given in a multi-agency meeting in which treatment options are considered and formulations discussed. Frequently the therapist who has conducted the initial assessment phase or session will not be the therapist who then takes on the case. In school and community settings, however, it is common for the therapist – even a trainee or a recently qualified one – to undertake the assessment and then see the client for on-going therapy. This means that in community and education sector practice, the initial phase is used to conduct all aspects of assessment, including establishing an alliance for the subsequent therapy and, increasingly often, administering intake/outcome measures.
We are aware from research (for example, Guarjardo and Anderson, 2007) that well-considered induction procedures contribute to reduced client drop out, increasing both positive outcome and overall attendance. Outcome research indicates that change is most significant in the early stages of successful therapy (Howard et al 1986; Brown et al 1999) and in one study (Whipple et al 2003) incorporating continuous feedback into therapy, such as evaluating the therapeutic relationship and showing therapists client ratings of the progress of therapy, resulted in a 65% improvement in the success of cases most at risk of negative outcomes. In another study of 3,000 cases conducted in a single agency continued use of outcome information over a year resulted in 150% improvement in overall effectiveness of the service (Miller et al 2003a).
Increasingly, then, as part of the initial phase of therapy and in order to organise information gathering, to support formulation and to identify areas of measurable outcome, therapists are choosing (or indeed being required by their services) to incorporate written assessment procedures into their practice. Most clinics, including the Anna Freud Centre and the Tavistock Clinic, now adhere to intake, monitoring and exit procedures endorsed by CORC (the CAMHS Outcome Research Consortium), which include both client self-report and post-session clinician-rated measures. The practitioner may ask the client to complete a self-report form before, during or after the first meeting, and/or she may complete a form herself after the session on the basis of what she has heard the client say. Psychodynamically informed assessments aim to gather information about the new client through structured and responsive conversation, generating a relational experience that allows unconscious material to emerge. For many psychodynamic practitioners and psychotherapists the use of a written assessment and outcome evaluation procedure within the session itself is thought to obstruct and distort the transference and divert attention from the relational dimension of the work. These are valid concerns and need to be thought about. However, given the growing interest in documenting evidence of change for psychodynamic psychotherapies and the move towards greater accountability for all psychological interventions, the inclusion of written routines within assessment deserves consideration.
A number of self-report measuring tools have been developed for use with children and young people, although fewer than for adults and the choice for use with adolescents is relatively small. Education-based therapy services sometimes develop their own paperwork to record information regarding clients’ presenting circumstances, but below I consider the relative merits and disadvantages of written routines that are in the public domain, are widely used and have been designed specifically for use with young people. The fact that there is no standard assessment and outcomes practice across services prevents us from collating findings across modalities and building a common knowledge base. As Kazdin (1994) noted, the use of standardized measures would serve to profile children and adolescents in a consistent way and help researchers to integrate studies about specific types of problems. Nevertheless, some assessment measures are widely used in all settings (the Goodman Strength and Difficulties Questionnaires, for example) and the CORE-IMS System hopes to standardize assessment by the development of a suite of measures for a variety of client groups.
An overview of commonly used self-rating measures
Questionnaires and scales should cover individual, relational and social aspects of functioning as changes in these areas are considered valid indicators of successful treatment outcome (Kazdin, 1994; Lambert & Hills, 1994). Baruch at al (1999: 261) show that the level of agreement between adolescent client self-report data and information gathered about the client from significant others varies depending on who the informant is (partner, parent, professional, peer, for example), and that informants overall tend to rate clients’ internalizing (moods and mental states) and externalizing problems (acting out, disruptive behaviour, for example) higher than the client himself rates them. Self-report tools are commonly used as a way of supplementing information brought together from other sources such as parents/carers and other involved professionals, including teachers, so that a fuller account of the young person’s life and historical context can be arrived at. In addition, some behavioural problems are highly situational – a young person’s behaviour at home and at school can be markedly different, for example. Gathering collateral information can be less straightforward in secondary education, however, where students come into contact with many more members of staff so none may know them that well. In addition, adolescents are inclined to have increased concerns about confidentiality and, in some services, parents or carers are not contacted other than to obtain consent for the student to see the counsellor.
Assessment routines vary in their focus: some are diagnostic tools designed to measure specific areas of dysfunction, for example anxiety, depression, ADHD, while others attempt to record a fuller account of presenting issues and circumstances. The forms discussed here are used in clinics, community and school settings and are considered valid, reliable and normative for general use with young people over the age of 11. They all aim to gather presenting information about the client directly from the client. The instruments examined all attempt to identify young people’s current and past emotional and life circumstances in order to inform subsequent intervention pathways and measure change. The practitioner decides if the self-report form is to be completed in the session together with the young person. In general, the forms I consider in the following section are completed between the first few sessions by the client on his own. It will be seen that, as well as highlighting issues broadly common to the use of self-report procedures, each of the instruments raises important issues about the process of administering intake/outcome routines, and their content.
The Achenbach Youth Self-Report (A-YSR) is a 4 page self-report form developed in 1991 for young people aged 11 to 18 year olds and derived from the Child Behaviour Checklist (Achenbach,1991). The form, which takes about 15 minutes to fill in, is completed by the adolescent either before the first meeting with the therapist or between meetings in the first phase of assessment. The adolescent provides demographic information including parents’ occupation. Suggestions include ‘home-maker’, ‘laborer’ and ‘lathe operator’, which illustrates how rapidly forms of this kind can become outdated in language and in content. The first page focuses on forms of social interaction and includes scales rating peer-comparative success at participation in areas including sports, hobbies, clubs, jobs and ‘chores’. American language is used in the form (e.g. ‘paper route’). As alluded to above, this wording might be viewed as socially and culturally idiomatic, and perhaps even meaningless, to many twenty-first century teenage respondents. Questions about hobbies, for example, suggest ‘cards’, ‘crafts’ and ‘piano’.
The second page covers peer and family relationships, general physical health, overall concerns and a question designed to identify any form of positive self-regard. Some of the questions on this page may be difficult for adolescents to answer accurately or truthfully without feeling exposed and found lacking. For example, questions such as ‘How many close friends do you have?’ and others which strongly encourage peer-comparative scoring (‘Compared to others of your age, how well do you…’) could trigger shame or feelings of low self-worth. Comparison with others is a measure that is learned during childhood (research shows this to be specifically between the ages of 7 and 9, James, 2008) and reinforced by our education system. Perhaps asking a client if he is personally satisfied or happy with these areas of his life might produce more meaningful answers.
Self-scoring for performance in individual academic subjects is also requested, with no mention given to non-academic areas of functioning in school. The 3rd and 4th pages consist of 112 questions covering affect, behaviour, somatisation, cognition, risk and self-image, which must be rated by the young person as Not True, Somewhat or Sometimes True or Very or Often True. The likelihood of 112 questions being answered accurately by an apprehensive adolescent client may be fairly low, suggesting that the form is used by the clinician to gather an impression of the client’s difficulties rather than to identify specific areas that are problematic. Indeed, guidelines for clinicians highlight that it is important to look particularly at questions that identify areas of risk in the completed form. This questionnaire is rarely used in school counselling but is used in clinical and research settings (for example, the Young Person’s Consultation Service, Tavistock Clinic; Searle et al., 2011). The BPM-Y (Achenbach Brief Problem Monitor-Youth) form has recently been developed for use in conjunction with more comprehensive initial and outcome assessments (Achenbach et al, 2011).
The Goodman Strength and Difficulties Questionnaire (SDQ) was developed in the late 1990s in response to the Rutter Questionnaire, a parent/carer measure, which was considered outdated. Goodman and his colleagues wanted to create a new format that offered a chance for client self-report. Three versions of the questionnaire exist, including a self-report form for ages 11-16 year olds containing 25 items. In development it was considered important that both strengths and difficulties should be represented, and that the questionnaire should cover 5 relevant areas: conduct disorder, emotional symptoms, hyperactivity, peer relations and pro-social behaviour. Many consider it more appropriate for the client group than the Rutter and Achenbach measures because it is compact, focuses on strengths as well as difficulties and covers peer relationships, pro-social and problematic areas of functioning more effectively. The questionnaire is generally completed alone by the client before therapy commences or between the first and second session and takes approximately 5 minutes to fill in. The SDQ is a behavioural screening tick-box measure and for this reason there are concerns about how accurate a young person may be when completing it (see Baruch 1999 for discussion of self-reporting of behavioural problems). Some of the questions come across as pejorative while others may be felt to be applicable only in certain situations. There is also a two-sided version of the questionnaire which contains an ‘impact’ supplement aimed at identifying self-reported distress, levels of social impairment and burden to others. The post-therapy version of the form contains the original assessment questions, the impact questions and 2 follow-up questions: ‘Has the intervention reduced the problem?’ and ‘Has the intervention helped in other ways, e.g making the problems more bearable?’ Critics of the SDQ suggest that it measures a number of stable ‘traits’ that wouldn’t necessarily be expected to change much post-therapy and therefore gives a rather flat picture of progress. There are no evident questions in the SDQ self-report that cover risk concerns or hopes for what might be achieved by the work. The Goodman self-report (endorsed by CORC) is designed and intended to be used in conjunction with collateral information gathered from parents and teachers and is widely used in all settings, because of its proven validity and reliability, but also because it is easily obtainable and support for use is readily available from the SDQ website.
Young Person’s Clinical Outcomes in Routine Evaluation (YP-CORE) This assessment form was designed specifically for brief interventions in schools and community settings with adolescents. It was developed in response to increased government investment in the first decade of this century in school-based mental health interventions and it was proposed as a nationally adopted outcome measure. Designed to document information in a context where it was thought that presenting issues would be less severe than those in clinics, it was ‘particularly geared towards counselling services’ (Twigg et al., 2009). In fact the recently published evaluation survey of school counselling in Wales showed that the levels of young people’s initial distress when presenting at school-based counselling are similar to those recorded at Child and Adolescent Mental Health Services (Welsh Government Social Research, 2011:12). The YP-CORE form is intended for completion alone by the young person before and after therapy. The form asks specifically if ‘assistance’ has been given in its completion, which is considered undesirable (Twigg et al, 2009: 164). This measure was derived from the CORE-OM (a measure of adult global distress) and the questions included were developed in consultation with practitioners and the adolescent target client group. A shorter, 5-question version (CORE-5) can be used weekly during therapy to track ongoing changes. Like the CORE-OM, the responses to YP-CORE refer to the client’s feelings over the previous week, making it suitable for brief interventions in the authors’ view. However, it is unclear how not enquiring about longer-term patterns of behaviour and thinking actively supports a short-term intervention. Choosing to limit the focus to current difficulties may support organizational aims to address problems in the ‘here and now’ which impact on present day functioning over and above historic issues. However, psychodynamic practitioners’ skills and competencies mean that they are able to incorporate historic detail into short-term work. The authors’ rationale for developing the YP-CORE was that existing measures (they name Achenbach, HoNOSCA and SDQ among others) target ‘more severe’ cases (Twigg et al, 2009: 160). This point seems to overlook the fact that the assessments carried out by school and community counsellors can reveal deeper or more complex difficulties and their work might function as a first step towards making a clinical referral.
The scoring system is clear and the measure is short, consisting of 10 items (the first version of 18 items was considered too burdensome in trials) and sensitive to change. In a recent evaluation of School-based Counselling in Wales (WGSR, 2011), larger effect sizes were associated with use of YP-CORE rather than the SDQ measure. Questions cover risk, physical symptoms, trauma and positive/negative functioning domains. Twigg et al’s conclusion is that the current version of the YP-CORE is the starting-point for further work and that work should continue to generate a questionnaire that addresses age-specific norms. In addition, the researchers identify one of the main difficulties inherent with tick-box measures, saying that ‘Young people mature at varying rates and their responses may be influenced by developmental issues which will affect different young people at different ages’ (Twigg et al, 2009: 167). YP-CORE is frequently used in clinic and community settings and, like the SDQ, is widely used in school counselling. In March 2011 CORE published its first version of a standard Therapy Assessment form and an End of Therapy form specifically for therapists working with young people; both of these forms are completed by the practitioner.
The Adolescent Well-being Scale (AWS) is used to assess young people between ages 11 and 16. Originally called The Self-rating Scale for Depression in Young People (Birleson, 1981), it has been validated for children aged between 7 and 16, and has been adopted by the DoH as part of the Common Assessment Framework. Accompanying guidance notes explain that before completion young people need to understand the aim of the Scale and how it fits in with any wider assessment. The 18 questions are clear and the scoring ‘Most of the time’, ‘Sometimes’ and ‘Never’ is straightforward. The questions cover risk, peer and family relationships, somatisation and self-image. Although used in routine assessment, it is particularly aimed at picking up symptoms of depression. Guidelines accompanying the Scale note that adolescents may prefer to use a questionnaire than talk face-to-face about feelings. This observation acknowledges the way in which use of a well-considered questionnaire may offer teenage clients a way to move from the more defended ways of relating and talking used in everyday life to the personal and nuanced language of therapy. However, it also highlights a concern raised by psychoanalytic and psychodynamic practitioners. A commonly held view is that a questionnaire can unconsciously be used defensively by the client, providing a way of avoiding the transference experience and possibly even influencing the counter-transference. DoH guidance accompanying the scales states that ‘In most instances the way a young person responds to the different questions will be as important and as valuable as any score, because they can give an insight into that particular young person’s needs’ (DoH, 2000). This comment suggests that information about the young person may be gathered from the transference and counter-transference experiences during assessment even when a written form is used. The practitioner can carefully observe how the client responds to the idea of using a questionnaire; in another words, the transference to the questionnaire itself is noted. For example, is the form seen as a supportive structure, providing a welcome focus for the session or is it regarded with suspicion, perhaps because information is being documented? The client’s feelings about the questionnaire will be reflected in his attitude to it and the kinds of answers provided (for example, whether or not questions are answered in full; whether or not the client conveys relief at sharing his difficulties or is patently holding back).
The DoH guidenotes clearly state that ‘assessment has many purposes but the process should be therapeutic… the way in which the assessment is carried out is important’ (DoH 2000: 114) and goes on to say that ‘Practitioners will need to integrate a multi-faceted knowledge of child development into their assessments and, in particular what is relevant from psychodynamic theory and learning theory’ (DoH 2000: 5). It is noted that during assessment three key relationships that underpin psychodynamic theory are important for the practitioner to hold in mind – the relationships between self and others, between past and present and between inner and outer worlds.
The research study piloting the AWS came to the following conclusions. Young people were pleased to contribute in this way to the assessment. Conducting the assessment gave clinicians an overview of their client in a short space of time. It also provided an opportunity for the young people to reflect on their circumstances. The AWS was seen to be useful at initial assessment but also as a valuable tool for monitoring progress and that, at times, the use of scaling pointed to particular issues, which could become the focus of the work. The AWS can be talked through by the clinician with the client, however, the recommendation is that it should ‘ideally’ be completed by the adolescent in the presence of the clinician but without the clinician’s active engagement. Guidelines suggest that there should be no discussion initiated by the clinician during completion, although it acknowledges that ‘significant’ comments made by the client need to be picked up by the clinician during the process or on completion. It was noted during piloting that adolescents talked as they were filling in the scale and guidelines suggest that following up on comments made by the young person may ‘provide a good opportunity to promote conversation, or establish rapport’. During piloting of the measure, completion, including giving some context to the questionnaire and explaining its aims, took about 15 minutes and ‘ensuing discussion takes longer’.
Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). The clinician’s version of this scaling procedure was developed in 1998 by the Department of Health and from this the adolescent self-report version was developed about 4 years later. The HoNOSCA clinician-rated version is widely used in the NHS. The self-rated form contains 13 items and takes about 8 minutes to complete. The presentation of the form is fairly dense and clients are offered the choice of one of five possible answers: ‘Not at all’, ‘Insignificantly’, ‘Mild but definitely’, ‘Moderately’ or ‘Severely’. This language seems fairly complex and the distinctions between the possible responses may seem rather hard to fathom for some young teenage respondents. The purpose of the form is to measure outcome of therapy and guidelines note that the questionnaire should be completed without any assistance by the clinician, but a member of staff who is not directly involved in treatment may offer the client help if difficulties in answering the questions come up. The time-span for answers is the last fortnight and instructions note that an attempt should be made to answer all 13 questions. Clients are asked to rate the most severe difficulty identified in a question and some questions range over very broad symptomatic expression, for example ‘Have you suffered from self-induced vomiting, head/stomach aches with no physical cause, bedwetting or soiling?’ or ‘Have you been feeling in a low or anxious mood, or troubled by fears, obsessions or rituals?’
The form is completed at assessment and usually at six week intervals and then at discharge. In a study in 2002, however, Gowers et al. (2002) compared the self-rated version against the clinician-rated version and showed that although the self-rated version indicated satisfactory reliability and validity, correlation between clinicians’ and users’ total scores was ‘poor’ (p. 268). The study found that adolescents with mental health problems report similar overall levels of difficulty to those noted by clinicians, but Gowers et al. point out that ‘it is noteworthy that adolescents themselves do not see difficulties in the same areas as their treating clinicians’ (Gowers et al., 2002: 268). The observed discrepancy reminds us of the arbitrary responses which may be given by some young people (particularly those who are initially suspicious of or reluctant to engage with therapy) when faced with a questionnaire like this and also of the dangers inherent in clinicians ‘diagnosing’ difficulty very early on in treatment. The author says that this discrepancy ‘highlights the importance of therapeutic engagement in identifying difficulties and hence common treatment aims’ (p. 268). The practitioner-completed version is one of the measures suggested for use by the CAMHS Outcome Research Consortium (CORC).
Goal-Based Outcomes Record Sheets (GBOR) The GBOR was developed by the CORC Think-Tank on Goal-Based Outcomes and is described by CORC as ‘another piece of information to assess the success of an intervention’. The form is completed during the first phase of work with a therapist (usually during the first three sessions) and is not a diagnostic assessment or numerical measure but serves to add focus to the therapy and supplements other self-report measures and clinician-completed routines. CORC advises that the GBOR should be used in conjunction with other measures because of the pitfalls inherent in collaborative goal setting, what it refers to as ‘perverse’ (that is, too complex or too easy) goal setting. The element missing from the majority of self-report procedures is the chance for the client to identify what he hopes to get from the experience and the GBOR addresses this omission. In addition discussion with the therapist is considered an essential component of completing the form. In the school setting young people sometimes feel obliged to attend their counselling appointment, at least at first, and may have different ideas to the referrer about why the are attending and what counselling can offer them. The GBOR is designed for use by young people with the practitioner’s help and parental input, but can also be used in individual therapy with adolescents. The client identifies what he wants to gain from contact with the service as a narrative description, and completes a second sheet measuring on a 10-point scale how close he currently is to achieving those goals. The form is then revisited at intervals of 6 months and at case closure, with completion of the measurement sheet on each occasion. Goals can be as small as the client wishes and the significant aspect of this is that they are client-identified aims. CORC states that the strength of GBOR ‘is that in much work with young people it is their subjective view of change that is arguably a vitally important measure of success’. Evidence that agreeing goals at the start of therapy is essential to good outcomes is mixed (see Cooper 2008: 105), but research does show that the client’s level of active participation is one of the strongest predictors of outcome (Cooper 2008: 62). The aspect of this measure that also offers something different is that it gives the client an opportunity to think of therapy as relevant outside the therapy room. It reminds the client that the impetus for change evolves from the collaboration and reflection that takes place with the therapist in the sessions and from linking this analysis to real life experience. It also underlines the fact that the process is not based on being given ‘answers’ by the therapist but on working out experiences and responses together. The Goal-based Outcome Record Sheet is used in clinical settings and is recommended by CORC for use with any other client-generated outcome data.
The self-report routines I have reviewed all have in common the function of eliciting information directly from the client as a way of building a picture of his current circumstances and establishing a context for the work. Research confirms the importance of the initial interview and its association with outcomes (Cooper 2008: 26) and that developing clear and realistic expectations of what will happen in therapy as well as what can be achieved may be useful features of the initial phase (Cooper 2008: 66). Completing a self-report form is frequently the first experience a young person has of articulating or identifying their difficulties with the expectation of being understood, and is increasingly becoming one aspect of the first phase of all therapies, including psychodynamic practice.
The forms I have looked at in this article raise a number of points that are worth noting about the outcome routines currently in use. We have seen how outdated or inappropriate language may present an unnecessary barrier to communication. Forms can be dense and lengthy, which may affect their accuracy and might account for at least some of the discrepancy between clinician- and client-rated scoring for individual cases. Forms sometimes omit important areas that need to be thought about at the start, such whether or not there are risk factors present, the client’s personal strengths or what he wants to get from the experience. The opportunity to set goals and identify a focus for the work is often missing even though this aspect of assessment is now viewed as increasingly important as it provides a baseline to return to at the end of the work, making it possible to identify where progress has been made.
Short forms may be experienced by clients as cursory and could miss serious concerns or deeper difficulties. Tick box procedures and scales have their limitations; some make a virtue of their brevity and the fact that they are completed alone is considered advantageous, but this means the potential benefits of a collaborative intake procedure are missed. One view is that self-reporting forms in general are at odds with the key maturational tasks of adolescence. As individuation and subjectivity characterize the adolescent client-group, being asked to give what amounts to ‘a snapshot account of themselves’ may be counter-intuitive at this developmental stage.
There has traditionally been resistance among therapists working with a relational model to making generalizations about the early phase of a new therapeutic relationship. It is a clinical principle underlying psychodynamic work that the individuality of each client is respected and that the material he brings is worked with in a unique way. For some clinicians, using the standardized measures that exist is incompatible with this principle. There is a danger that, rather than offering a route to meaningful conversation and gathering information that is relevant to the work, measures may be used defensively, obscuring the transference and becoming bureaucratic exercises for both the therapist and the client. If outcome tools are not seen to offer real clinical value, psychodynamic practitioners will resist using them.
Collaborative written assessment in school-based psychodynamic therapy
Students in school are often referred for counselling by school staff but at the same time staff are often unaware of a student’s relevant personal history or current circumstances. Adolescent clients are widely perceived to be difficult to engage in therapy (Baruch 2001) and, although counselling may not be the school’s first attempt to address a pupil’s difficulties, it may be the first time the young person has been offered a chance to talk openly about his concerns. One reason for teachers referring young people to counselling is for challenging behavior, which usually proves to be linked to personal circumstances such as difficulties or changes at home or with peers. This can mean that students are ambivalent about attending and, in addition, on arrival at the first session, may be unclear about what counselling can offer, why they were referred and might not even be certain that they want or need emotional support at this time. Moreover, school staff and service commissioners sometimes have expectations about how the client will, or even should, use the therapy. Student clients arrive with a wide range of presenting issues and expectations as well as varying levels of motivation. School-based therapy can function as a kind of triage experience with the therapist often attempting to identify and assess the young person’s emotional health needs with very little information to go on while at the same time providing containment.
It is widely agreed that the period of assessment is more explicitly demanding for the therapist than the rest of therapy (Jacobs 1988; Holmes 1995). The patchy referral information and initial resistance to, even suspicion about, engaging in therapy that can characterize school counselling, mean that thorough sensitive assessment, which includes orientation to the work, is of particular importance. Any assessment routine used in school-based counselling, just like those conducted in other service settings, should be generic enough to screen for a range of significant difficulty and need, but be specific enough to be meaningful to the client within his context. As evidence gathering and accountability increasingly become part of the initial phase, information about the client from the client needs to be gathered and recorded. As psychodynamic therapists, the way in which we do this must be clinically appropriate and fit with the principles of our practice.
For most experienced psychodynamic professionals the areas that need to be covered in assessment are internalized over time and inform the way they work. They are able to weave questions and collateral information provided by other adults into their discussion and thinking, while still responding spontaneously to the client. However, the challenges of offering therapy in schools (and some of these differ from those faced by therapists working in clinical settings) mean that both counsellors and adolescent clients new to therapy may find collaborative written assessment questionnaires that respect the realities and complexities of young people’s experience helpful to their work. Young people are likely to have a limited understanding of therapy and Shirk and his colleagues’ research (Shirk et al 2011) suggests that early alliance formation with young people depends on the therapist’s ability to achieve a balance between active listening and describing the roles, tasks and relevance of therapy to the client. Glass and Arnkoff (2000: 1469) found that the more collaborative the relationship is seen to be by the client, the less likely he is to leave therapy prematurely.
It is possible, therefore, that a well-considered collaborative assessment questionnaire could provide a clear focus for the first phase of the work and, as a transitional framework, could support the development of a therapeutic relationship through which the experience of therapy can be made accessible and relevant to the client. Such a questionnaire might also be felt to normalize difficulties and troublesome feelings making it less difficult for first-time clients to discuss issues that might feel too exposing. These points are particularly relevant to the school counsellor working within a psychodynamically informed model of practice. The psychodynamic counsellor will be less concerned with formally diagnosing new clients. Instead, the focus is usually on engaging them in the process in order to ensure that an attachment develops and that the client feels able to commit to the work. Getting a sense of the transference and of a client’s ‘idiom’ (Coren 2001: 72) is still possible when using written procedures. As already noted, key features of the young person’s internal world will be revealed in their response to the questionnaire and to the counsellor’s role in taking them through the form (DoH 2000). In fact adolescent clients may find a sensitive collaborative assessment routine a useful and manageable bridge into the work, particularly when they are in an environment such as school in which the language and practice of therapy is unfamiliar to most.
As Kegerreis notes, the end of the assessment phase should result in ‘something resembling a map to guide the two participants on their way’ (Kegerreis, 2010: 175). According to Cooper and Witenberg when treatments become bogged down after a period of therapy, it is often because the practitioner has failed to elicit a comprehensive overview of the patient’s situation at the start of the treatment. They suggest that if a full and collaborative assessment is made initially the clinician can use knowledge he has gained at the start to refocuse and revitalize a ‘stuck’ therapy (Cooper and Witenberg 1985). If essential material is omitted or overlooked during the early phase of the work, the clinician may find he risks never having crucial information about the client’s circumstances or that he must intervene further on into the therapy to request specific material that he has never elicited. Cooper and Wittenberg claim that theory is ‘not a substitute for the painstaking understanding of the person’, which must be undertaken right at the start of if breakdown is to be avoided later (Cooper and Witenberg, 1985: 40).
The A Space/University of Essex research project currently underway is developing good practice frameworks and effective service protocols for therapy delivered in the education sector. It is the view of A Space that, in most cases, taking a young person through a collaborative assessment questionnaire or structured interview allows essential information (self- and school-identified needs, personal circumstances, life history, scales capturing the client’s current functioning and issues which may or may not be known by the school) to be gathered and noted down. This information can be returned to if necessary during the course of therapy and then, paired with an ‘end of therapy’ questionnaire, revisited during the final phase of the work. In addition, a structured approach to assessment using a printed questionnaire can effectively frame conversation that might otherwise feel too uncontained or too anxiety provoking for the client, particularly at the start. Using such a tool may help the counsellor to get a clearer impression of the nature and extent of the young person’s motivation, what he hopes to get from the experience, his perspectives on why the problem exists and what can be done, whilst observing the unconscious processes at play. The collaborative written assessment routines we are developing aim to offer the adolescent school-based client a manageable way into the experience of psychodynamic therapeutic support, creating a comprehensive picture of his situation, his views and his expectations, which can be reflected on throughout the period of the work and then referred back to at the end to identify progress and change. In addition to supporting the new client, these assessment and exit routines are tools for the therapist, scaffolding her psychodynamic thinking, addressing many of the complexities inherent in delivering school-based therapy as well as going some way towards creating an evidence base for our work.
I’d like to thank Lyn French,Director of A Space for Creative Learning and Support, for her feedback and suggestions during the writing of this article.
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Angie Doran works as a counsellor and psychotherapist for A Space for Creative Learning and Support seeing students and staff. She was the lead researcher on a PhD research project set up by A Space with the University of Essex, Centre for Psychoanalytic Studies. She received an MSc in Psychodynamic Counselling with Children and Adolescents from Birkbeck College, University of London.