Conducting PWP Assessments
How to conduct PWP assessments effectively
Hi there!
Welcome to this week’s blog post on This is How We Do at Step2.
I hope you’re well today.
Many of you reading this are either aspiring PWPs, a trainee, newly qualified, or even close to qualifying. This week, I want to delve into defining assessments, differentiating between triage assessment and problem-focused assessment (PFA), and most importantly, how to conduct them effectively and efficiently.
What are PWP Assessments?
When a client/patient accesses talking therapy services, whether they have self-referred or been referred by a healthcare provider (GP, nurse, healthcare assistant, etc.), the first stage is the assessment stage. This is the first point of contact with a psychological wellbeing practitioner (trainee or qualified) or clinical support worker. There are three types of assessment: triages, initial assessments, and problem-focused assessments (PFA). Some services conduct triages, then a PFA after clients have been placed on a treatment waiting list and allocated to a practitioner. Other services combine the triage and PFA in an initial assessment (IA) before deciding the next step for treatment. For those of you who are trainees and qualified PWPs, assessments (especially, triages and IAs) can feel like you’re working for a call centre. Many PWPs don’t like triages because of how it feels, including time constraints and complex cases that come forward through referrals. Nevertheless, the skills you acquire and experience dealing with complex cases over the phone (or face-to-face) and risk are worthwhile. Moreover, these assessments require supervision afterwards (or referral management in some services).
Allow me to explain these three types of assessments below and how we can make them effective.
What’s a Triage Assessment?
It’s a 30-minute assessment where we gather information about the main problem they are experiencing, what problem they want to focus on in treatment, the impact of the problem, and finally, setting clear goals. Part of the assessment is assessing risk and safety. This comprises risk to self (suicidal ideation and self-harm, risk to others, medication, drugs and alcohol, smoking (tobacco, vaping, cannabis), nicotine, and any other relevant information that would help assess their safety. Finally, after assessing risk, they will be emailed or texted (via SMS) a safety plan to keep themselves safe, unless they have their own safety plan which needs to be confirmed during the assessment. When we explore the main problem, we use the 4 Ws (What, When, Where, and Who). For those of you reading are aspiring PWPs, the 4 Ws mean (What is the problem? When does it occur? Where does it occur? Who makes it better or worse?). We can reword them to “What got you to reach out to our service?” “When is it at its worst (Morning, Afternoon, Evening/Night)?” “Where is it at its worst (Home or Outdoors, Work)?”. The five areas model (situational framework looking at thoughts, emotions, physical sensations, behaviours, avoidance, and things they have stopped doing) is key to understanding the main problem. It is very easy to get confused especially when symptoms are mixed up (Mixed Anxieties, Depression and Anxiety, Depression and Stress, Anxiety and Stress). I had a client once who had symptoms of depression, panic, stress, and anxiety, and I had to repeat the five areas model a few times to decide on a clear treatment intervention. So a tip here would be to use this wisely and be mindful that they might not always know what to put on thoughts and guide them on it (for example, when you feel this way, what comes to mind? or When this happens, what comes to mind or what do you tell yourself?”. With practice and time, you will be a lot better at this.
What’s a Problem-Focused Assessment (PFA)?
After a client has been allocated to a practitioner in many services (not all), they are booked in for a second assessment called the problem-focused assessment (PFA) (usually for 45 minutes). This assessment is similar to the triage in addition to getting a shared understanding of the main problem, formulating the problem summary statement (PSS), and setting clear and SMART goals to focus on in treatment. There’s also an opportunity to check in and recap what was mentioned in the triage if they had one before, for perhaps they may have noticed a change in their symptoms or their risk and safety (such as reduction in suicidal ideation, self-harm, alcohol, drugs, etc). Before ending the session, it’s essential to discuss treatment options and use the COM-B model to assess their readiness for treatment (such as working in groups, one-to-one, cCBT), duration of the course of treatment (six weekly sessions), and taking into account of any adaptations that may need to be made.
What’s an Initial Assessment (IA)?
This can be seen as a combination of the above two assessments conducted for an hour. You gather information about them (living situation, lifestyle, and others), assess their risk and safety, explore the main problem and its impact, and finally, formulate the PSS and set goals for treatment. After this assessment and discussion in referral management/supervision, a client/patient is placed on a waiting list for treatment either at step 2 or step 3 (or step 4 for services that provide it).
What are the challenges faced by PWPs when conducting assessments?
Sticking to time.
Clients/patients want to vent all their problems out.
Complex cases
Risk and safety issues
Interpreter work
Limited English for those who speak another language (English is not their first language or mother tongue)
Having to complete scores during the call because clients/patients have not completed them beforehand.
PWPs find it difficult to interrupt and remind clients/patients about time.
Having empathy and using other interpersonal skills during assessments (most are good at this, but others may struggle).
Using non-jargon language (breaking down psychological terminologies).
Assessing the elderly can take time.
Expectations of gathering all the information.
Perfectionism (wanting to get everything right).
How can we conduct assessments effectively and efficiently?
You’ve set the agenda clearly for the appointment, remember to follow it to your level best.
Ask them for their preferred name and the best way to pronounce it (I know many of you know this but some may need to practice it).
Seek support from peers and trainees before you including qualified, seniors, mentors, and your supervisor.
Be ready to complete the questionnaires with clients/patients as many have not filled them out for whatever reason. Learn to explain these questionnaires in a way that sounds easy to understand because they can be confusing to fill out (for example, PHQ9 and GAD7). Find your way of explaining them if clients/patients don’t understand what they mean, both questions and the answers.
Not everyone will understand the meaning of MDS scores (mild, moderate, severe), hence, find a way to explain them in non-jargon language.
Have a look at their referral data (reason for referral) and other information on their clinical contacts (previous episodes, risk and safety, previous assessments, etc). This will help you (a) have a clear idea of the client/patient you’ll be dealing with and (b) be more prepared for the assessment.
When assessing risk, normalise their feelings and let them know that the information is kept confidential, however, you have a duty of care to breach that confidentiality if their safety is questionable (or high risk). Let them know that your questions can seem uncomfortable or triggering and allow them to notify you if they find it difficult to disclose information (let your supervisors be aware of this). If they disclose thoughts of suicide or self-harm, gather as much as you can. For example, with suicidal ideation, the thoughts, duration of thoughts, intention (is it building up with they have thoughts (0-10)?), are there any plans or methods they have thought about or considered? Any history of attempts? are they likely to attempt again? How many attempts in the past and when were they? For self-harm, gather information about current thoughts as well as past thoughts, and behaviours (what did they do? where would they harm themselves (area of the body)? what would they use to harm their body? Has that increased now or decreased? Have they needed any medication attention? When are they triggered? How likely are they to harm themselves (0-10)? Here is a tip for risk: When asking them about intent, ask two extra questions (What would it increase it? What would decrease it?) This gives you an idea of what might lead them to act on their thoughts or reduce the likelihood of them acting on them.
Have a signposting material/resources ready at hand, or ask your service what they use for suicide and self-harm (for example, services in London may signpost or refer to The Listening Place for suicidal intervention and send clients/patients the Calm Harm App for reducing the urge to self-harm).
Risk from others: Be mindful here as they can be hesitant to disclose information. Let them know how important safety matters to our service and explore what you can. Always seek support from peers, supervisors, referral management, etc.
When you assess drugs, alcohol, and substances, use what your service has provided on their assessment scripts (some services use AUDIT-C). Explore their behaviour towards these areas (How much do they consume? How long have they been consuming? Have they had a sober period? Are they reducing or increasing their consumption? Have they been admitted to the hospital? Have they had any treatment for them before and did it help? Are they interested in getting support to reduce or stop?).
When you get to the main problem focus on the Ws, onset, five areas (ABCEs), FIND, and the impact of their problems. I usually advise trainees to gather what they can and utilise the five areas which help decide on treatment. This is the same advice given to me by my mentors during training and as a qualified practitioner.
Learn to have supplementary questions ready at hand. These are questions for PTSD, OCD, Health Anxiety, Social Anxiety, Panic, etc. These questions help us understand the problem and if a step up is needed. Check with your service.
Set clear goals. Most clients/patients struggle to set clear and specific goals (for example, I want to be better). Ask them, “What would that look like for you?” or “What would you like to see differently at the end of treatment?”. Help them gain clarity.
Tip of the Week:
With experience and time, you will become better. No one started great with assessments. Sometimes, it helps to write your own script alligned with what your service has provided you with. Keep learning, keep growing.
What’s Coming Next
In the coming week, I aim to write about working with interpreters and how to make these appointments effective. I will write about assessments and treatment when using interpreters and how to be prepared and provide quality work.
Also, write down in the comments what you would like to be mentioned in this newsletter.
You’re Not Alone
Recently, a trainee PWP reached out and enquired about how to stick to timing when conducting an assessment. I replied, “Sticking to time can be tricky but it is possible. We have to be more in control, despite things popping up like risk, complex cases, etc. Every trainee faces the same challenges. We learn and grow as the year passes by. It needs practice and it helps when you have a way to structure your script in a way that fits well with you and makes you feel comfortable. I like to ensure I know where I am from start to end. But, I can get sidetracked, which happens, but let’s learn from our experiences and work harder to improve.”
Thanks for being part of the community. If you’re new here, then welcome to the Step2 community!
Remember to take good care of yourself at work, when you’re off duty and on the weekend.
Yours truly,
Hashil