The instrument instructs the client to tell how they have been doing for the past 7 days. Since we are having them fill it out only every 30 days and the past week may be a good one but the previous three were not, how accurate is this in telling us how they are doing?
The time period we are asking people to reflect on probably matters and should not be changed because all the norms for predicting problems are based on this time period. We want to use the most recent point of measurement in the session that is about to occur. Missing weeks would be nice to know about and would undoubtedly change the picture of how we see peoples progress. But if the data are not collected we may not get a perfect picture of change over time. Even when clients try to think back over the past 7 days and they complete an instrument they are probably telling you how they feel in the very recent past and this is the most important information.. It could be just as likely they have had a bad week when the previous three were good as the opposite. It is self report and gives you a picture of how they are right now and how they are doing across time. We all have some variability in how we feel day to day and week to week.
With youth who are also substance abusers the first YOQ does not seem to be very good at giving an accurate picture of where the client is. The SASSI seems to be a better instrument with these youths.
The research shows the SASSI and YOQ are negatively correlated at the beginning of treatment, but as you get into treatment and the client become less resistant the YOQ provides usefulinformation. Indeed, underreporting scores on the YOQ can provide fodder for clinical work. Youth often underreport symptoms on the first YOQ, but as they progress in treatment they look worse and then begin to show positive changes. A portion of youth who seriously under report their problems at intake should be noted in the record.
What about youth who have come to our facility in the care of a DCFS worker and a Foster Parent who have just taken over the care of the youth?
It is best to have the youth complete and not have a parent or other worker complete the instrument until they have known the youth for 6 to 12 weeks. If a residential facility is going to have a staff or case worker complete the instrument it should always be the same person rating the youth each time.
How can we handle non readers or cognitively impaired clients?
You can have a staff read it to the client but training and supervision are necessary to ensure that we do not introduce bias into the answers. It is important if someone does not understand what you asked them to clarify the question if they have not gotten the point. Some of the questions are intentionally vague and a subjective response is desired, ie., the clients perception of what is being asked. How you phrase a question is very critical to creating an atmosphere where the client wants to present the most accurate impression of how they are doing.
What about the fact that some clients score all over the place, up and down and you get alerts at every point?
Some clients and especially ones with a borderline personality disorder will have score profiles that are up and down and giving lots of alerts. It is important to pay attention to these changes but only red alerts are cause for particular attention. One way to use the instrument is to point out these swings and probe to see what has changed or happened with emphasis on exploring what was occurring when improvement occurred. Multiple red warnings increase the likelihood that a patient will have a negative outcome if the warnings are not attended to by the clinician.
How can we possibly use this instrument with some of our long term clients who have been in treatment for 20 years and now we have them taking this instrument that suddenly shows them if they are getting better or worse?
With clients who have been in our system for a long time and we don’t have a starting instrument, predicting change will be of less value than someone just beginning treatment. However, it can be used to facilitate discussion about the progress they are making and give opportunities to explore changes that will occur across time. To the degree that people show no improvement over weeks of care one must consider the possibility of changing the ongoing treatment.