Questioning the Employment of Universal Assessments

The Ontario Child and Youth Mental Health Lead Agency Consortium released a priorities report in 2019 outlining the focus for the future of Children’s Mental Health in Ontario.  Among some useful and sensible recommendations was one that is becoming ever more difficult to reconcile with the movement towards contemporary anti-oppressive, collaborative, competency-based services.  

Specifically, the LAC recommended to implement the Inter-RAI screener across the province.  The Inter-RAI is a device to “ assess, respond to, and monitor the status and needs of vulnerable populations of children and youth”, as stated on its  website.  The LAC sought a standardized assessment tool with “components of screening, assessment, outcome measurement and follow-up that can be utilized across the lifespan”. 

Children’s Mental Health in Ontario has seen many standardized assessment devices come and go over  the years, such as the CAFAS, and BCFPI.  All these devices have attempted  to screen for problems, to assist with prioritizing distribution of services to those viewed most at risk,  and to gather information for data-informed planning.  As such these devices are in-part employed to serve the funders/Ministry overseeing the mental health portfolio and in-part to stream children, youth and families into the stepped care model of service.  Unfortunately these devices have been part of a CMH system long plagued by lengthy wait lists and processes drawing capacity away from direct service - the actual product that families are asking for.  

Screening/assessment devices are historically widespread and embedded in the field, spawn from  the tradition of medical science.  The rationale has been to discern risk, seek to get people the intensity of service the data indicates is needed, and most recently to ensure economical services.  It’s a practice that says clinical judgement alone is not enough as it takes experience to develop. New practitioners may not have that skillset when they start working with children and youth. 

In practice I have rarely found these devices useful in the clinical process.  I have always felt concern for families’ experience of these tools.  In particular I worry families may be colonized into unhelpful medicalized understandings of distress and children into negative identities. Like many I prefer generative conversation, formal feedback (Lambert, M. J., & Shimokawa, K., 2011) and individualized measures (Jensen-Doss, A., Smith, A.M., Becker-Haimes, E.M. et al., 2018). These  practices align with ethics of collaboration, non-pathologizing conversation and anti-oppressive practice. These sentiments are certainly shaped as I locate my practice within postmodern, post-structural, narrative, collaborative streams of influence. 

Through a critical lens and “from a constructionist standpoint… the process of all individual and systemic assessment is thrown into question” (R. Iversen , K. Gergen, 2005, p.7).  It’s a question inviting conversation that gives attention to the effects of submitting families to the assessment device and how that process shapes meaning making, potentially obscures the effects of systemic oppression, and consumes capacity that could be put towards direct service.       

Through a Relational Ethics Lens:

Relational Ethics (McNamee, 2009) is a category of ethics that has service providers consider the real life effects of their actions on shaping people's lives and identities. This is a genre of ethics that recognizes how people come to know themselves is a relational process.  The meaning people make of their experience is  socially and relationally shaped.  Through a relational ethics lens several concerns with the employment of global assessment tools arise. 

These tools are NOT neutral when administered.  That is, they do things to people!  First, they orient people towards problems and a negative focus. For instance, an examination of the categories of inquiry in the Inter-RAI goes as follows: Distraction/Hyperactivity, Mood Disturbance, Anxiety, Psychosis, Negative Symptoms, Substance Use, Harm to Self, Behaviour Symptoms, etc.  What might your experience be answering questions that shape a deficit centred telling of your story?  What would it be like for a young adult? 

Thomas Zimmerman (2018) speaks to noticing the effects of problem focused screening questions in their article Dancing Around the Unspeakable at Intake. They note:

Have you ever been emotionally, physically, or sexually abused?”…  If I am honest, I had abundant evidence of how activating that question can be from my initial clients: some clients burst into tears; some simply went blank; some nodded “yes,” but refused to say more; and some clients nodded “no,” only to come back a session or two later and tell me through tears how guilty they felt for “lying to me.

In answering any question, a person is invited to research their experiences to recall circumstances that  inform their answer.  In answering they are re-experiencing those circumstances and negative events.  A possible effect of this is to render people vulnerable in their earliest contact with services.  At worst the process may re-traumatize people.   In this way administration of this tool can harm people.  

Orienting people towards the negative events of their lives also orients them away from other experiences - those of competency, coping, distress as resistance, and context.  It renders experiences of competence, coping and resistance as secondary if not invisible.  The greatest contributor to the process of change involves - extra-therapeutic factors - the material that people bring with them to the process – strengths, abilities, competence, supports, environment, etc.  - see Miller, S. D., Duncan, B. L., & Hubble, M. A. (1997) & Hubble, M. A., Duncan, B. L., & Miller, S. D. (1999).  Why would we want to orient away from this material with global assessment rather than tending to this material and building off of it through generative conversation?    

Individualizing Distress:

Generally the categories of questions are filtering people’s experiences and medicalizing their distress, coping, and acts of resistance to become consistent with DSM categories.  As such these questions define problems as individual health problems, located within the child/youth as some dysfunction on their part- as a medical problem. This individualized focus inherently leaves out of the conversation the context of people’s  lives. These contexts can involve past and/or ongoing experiences of marginalization, oppression, racism, colonization, violence, lack of access to resources, poverty, that their distress is a response to. 

Questions that implicitly assume the person is the problem not only scribe a spoiled identity but  make the context of oppression and injustice invisible.  These universal assessments risk colluding with oppression and can be experienced by populations as creating barriers to trust in service providers leading to disengagement. Speaking about the experience of Indigenous youth Clark (2016, p.8) frames these Eurocentric practices as ongoing colonization noting:

These medical model approaches towards mental health issues further label and pathologize Indigenous children and youth, and result in increased criminalization or medicalization. These approaches often do not address the long-term wellness needs of children and youth who have experienced structural and individual acts of violence, nor the intersecting factors of age, gender, and rurality that put Indigenous children and youth at risk for violence. 

While the Inter-RAI document does try to check off Life Events, this section is background against the focus on individualizing and medicalizing distress.  Locating the problem within the individual consequently narrows any space to name and address violence, colonization or structural oppression. 

Capacity Consuming:

At minimum administration of this device  may take upwards of one hour.  Also include the time calling and returning phone calls to set a time to administer the process.  If these tasks are positioned at the front end of service, all this time from the consumers’ end is spent just getting in the door to service.  Upon completion they still haven’t received what they are wanting – that is to begin to address their most pressing concerns. 

This process consumes a significant amount of direct service capacity that could be allocated to meeting face-to-face with people to address what they are coming for.  So not only are participants  being oriented towards the negative possibly rendering them more vulnerable, after they complete these questions they still haven’t received the product they want.  It is this kind of process that has contributed to the proliferation of wait lists across the sector.  We simply do not have the capacity to allocate  to information gathering in this way.  At the same time I recognize agencies are being funded to provide assessment.  What I am suggesting is that there are far more beneficial and less intrusive ways to do this.   

Adult Centric:

Lastly, these tools are adult centric in language and process.  Given that youth 12 and up can self-refer, it would be important to run this process by youth for their feedback.  Any tool needs “participatory co-design with diverse stakeholders to ensure equitable implementation” (Sukhara J., personal communication).  The voice of youth needs to be at the centre of service design supported by adult allies. 

In Closing: 

There is a great deal more to explore such as how these devices and the focus they privilege shape the view and practices of the clinicians themselves.   Madsen points out that,‘...what we attempt to measure and how we attempt to measure it have effects on clients, workers, and therapeutic relationships’ (Madsen, 2007, p. 345).  However I am merely trying to get the conversation going with this piece.  

Capacity may be better placed in face-to-face generative access/intake conversations. These conversations recognize the social construction of experience, are interventive in themselves, honour distress, and get on to competency and resilience.  They seed the material for change and assist people to develop concrete next steps to immediately begin to address their concerns in ways that problem-focussed assessments such as the Inter-RAI cannot.  Rather, these conversations are in the genre of change-focused assessment that foregrounds what people want different and their ideas to achieve that difference. 

To me we need processes that offer safe entries into services, without further medicalizing responses to social trespass.  Children and families may be better served by individualized progress measures, and formal feedback loops eliciting their input and experience of service, sense of progress, and usefulness of service.  Quantitative scaling for example provides self anchored scales for people to situate their experiences and are easily understood by children and youth.  This is a part of contemporary collaborative, competency-based, person-centred approaches.  We can collaborate with participants about risk and safety, discuss service fit, intensity, and timing of services with families, and engage in conversations that generate possibility rather than document decontextualized problems.  In this way we would embrace what White (2015) refers to as ethics of accountability within the screening/assessment process where we are accountable to what we do and the consequences of those interactions with the people that consult to us.

Similarly,  Iversen and Gergen (2015) offer sound ideas to bridge the space between traditions of assessment with relational ethics calling for “…process that would remain continuous, collaborative, generative and client-empowering…” (p.17). This re-visioning is already underway - we just need some space for the conversation.  


References:

Valenstein Jeffrey Berlant M.D., M., M.D, Adler, D. A., M.D, Berlant, J., M.D, Dixon, L. B., M.D, & Dulit, R. A., M.D. et. al. (2009, October 01). Implementing Standardized Assessments in Clinical Care: Now's the Time. Retrieved January 04, 2021, from https://ps.psychiatryonline.org/doi/full/10.1176/ps.2009.60.10.1372

Iversen, R. R., Gergen, K. J., & Fairbanks, R. P. (2005). Assessment and Social Construction: Conflict or Co-Creation?. Retrieved from http://repository.upenn.edu/spp_papers/27

Jensen-Doss, A., Smith, A.M., Becker-Haimes, E.M. et al. Individualized Progress Measures Are More Acceptable to Clinicians Than Standardized Measures: Results of a National Survey. Adm Policy Mental Health 45, 392–403 (2018). https://doi.org/10.1007/s10488-017-0833-y

Lambert, M. J., & Shimokawa, K. (2011). Collecting client feedback. Psychotherapy, 48, 72–79.

Madsen,W.C. (2007). Collaborative therapy with multi-stressed families. New York, NY: Guilford Press.

Hubble, M. A., Duncan, B. L., & Miller, S. D. (1999). The heart and soul of change: What works in therapy? Washington, DC: American Psychological Association.

McNamee, S. (2009). Postmodern psychotherapeutic ethics: Relational responsibility in practice. Human Systems, 20(2), 55-69

Miller, S. D., Duncan, B. L., & Hubble, M. A. (1997). Escape from Babel: Toward a unifying language for psychotherapy practice. New York: Norton.

Sukhera, J. I., Dr. (2020, December 28). Personal communication [E-mail to the author].

White, M. (2011). Power, Psychotherapy, and New Possibilities for Dissent. In 1144573862 861283632 D. Denborough (Ed.), Narrative practice: Continuing the conversations (pp. 45-70). New York, NY: W.W. Norton.

Zimmerman, T. (2018, April 29). Dancing Around the Unspeakable at Intake. Retrieved January 04, 2021, from https://gowiththat.wordpress.com/2018/04/28/dancing-around-the-unspeakable-at-intake/?fbclid=IwAR1D6jSQSgBbsSTuXjPGoYUTur8cC_Y-SbWWMs37U4EeAk60wK3jRJAy5_o


Conribute to the conversation


© Scot J. Cooper Inc. 2021