“A dream is just a dream. A goal is a dream with a plan and a deadline.” — Harvey Mackay
The goal of assessment is not to create a diagnostic label, but rather to provide a profile of functioning that will yield concrete guidelines for selection of intervention strategies.
We are predisposed to see order, pattern, and meaning in the world, and we find randomness, chaos, and meaninglessness unsatisfying. Human nature abhors a lack of predictability and the absence of meaning. As a consequence, we tend to ‘see’ order where there is none, ……
Often we impose order even when there is no motive to do so.
Thomas Gilovich, 1991.
Gilovich goes on to point out that the tendency to impute order to ambiguous stimuli is built into the cognitive machinery we use to apprehend the world. This predisposition is what leads to discovery and advance. The problem, however, is that the tendency is so strong and so automatic that we sometimes detect coherence even when it does not exist. In fact, he says that many times, we treat the products of this tendency not as hypotheses, but as established facts.
Thus, one of the most fundamental tasks that we face in accurately perceiving and understanding our world – that of determining whether a phenomenon ‘out there’ warrants attention and explanation – is a task that we perform imperfectly. This imperfection is never more dangerous for human beings as when we assess them, looking for imperfections or defects.
The reason that assessment is so dangerous is that people exhibit a tendency to focus on positive or confirming instances when they gather and evaluate information relevant to a given belief or hypothesis. When trying to assess whether a belief is valid, we tend to seek out information that would confirm the belief, over information that might disconfirm it. This tendency for confirmation need not stem from any desire for the hypothesis to be true.
Unfortunately, once a person has misidentified a random pattern as ‘real phenomenon, it will not exist as a puzzling, isolated fact about the world. Rather, it is quickly explained and readily integrated into the person’s pre-existing theories and beliefs. These theories, furthermore, then serve to bias the person’s evaluation of new information in such a way that the initial belief becomes solidly entrenched.
When a child is referred to a person for evaluation, s/he is referred with specific imperfections already identified. The resident expert is more likely to confirm than disconfirm this expectation. Thus, it is very important that the expert takes actions that will, at minimum, buffer this tendency.
One method of doing this is for the assessor to be very clear about what s/he believes, what theories s/he is defending and identify specifications regarding the process. While we will be dealing with the belief system of cognitive behavior management and will attempt to define the specifications for it, the same process can be followed for any belief system. Part of the concern is that while we believe certain things to be true, we have not deeply examined them.
Aristotle pointed out that any body of knowledge must start with a fundamental assumption that can be neither proved nor disproved.
People are the sum total of what they think – one cannot act different than the way they think [unless, of course, they are ‘acting’!].
It is not the experience that shapes the person, but his/her interpretation of the experience that matters. Attribution theory, developed as an approach to social perception, is concerned with analyzing the cognitive processes that underlie causal explanations. It is a theory of the ways people try to ‘make sense of’ events by setting them in a causal framework.
When individuals engage in an activity, they may attribute their outcomes to the operation of one or more causal factors. A growing body of research has focused on the conditions that influence the tendency to ascribe responsibility to personal forces (e.g., ability and effort) or to impersonal forces over which the individual has little control (e.g., situation and bad luck).
One personality dimension that would appear to play a major role in influencing the nature of causal attribution is internal-external control of reinforcement (I-E). The I-E variable represents a generalized expectancy that reinforcement is causally related to one’s own behavior. At the one end of the I-E dimension are individuals who believe that reinforcement is contingent upon their own behavior (internals), while those at the other extreme believe that reinforcement is independent of their actions and is controlled by luck, chance or powerful others (externals).
When a child is identified as having a disability, being mentally ‘ill’, or delinquent – how they interpret that experience is highly contingent upon how others think about it, particularly others with authority. How the assessor thinks about the characteristics of the child can be decisive. Is an obstacle or barrier something to be overcome or something that cannot be overcome?
Substantive Improvement in the Quality of Living
The manner in which intervention is thought to be related to intended outcomes for a particular population is considered a ‘theory of change’. This requires that one be very clear about the outcome expectations. What outcome do you intend? Are you attempting to change behavior, help the client change behavior, diminish symptoms or improve the quality of life?
The question of outcome expectations will need to be addressed before you can be clear about a theory of change. Outcomes can be conceived on several different levels. At base, it is likely that there is a specific behavior or set of behaviors that is causing a problem in living. Obviously, you want to diminish or resolve the problem in living, but do you need to address the behavior in order to do that? In fact, we suggest that to be consistent with the fundamental assumption and cognitive theory [thought influences emotion, which influences behavior], we would be better off addressing the thought.
However, it is unlikely that simply changing thought sufficiently to diminish or resolve the problem in living is substantive enough to achieve or exceed the client’s expectations [which is what Eduard Deming of Total Quality Management fame recommends]. We need a substantive change in the child’s quality of life – ergo, we will need to replace the problem in living with achievements in living. The outcome expectation at a higher level may need to be defined not just as ‘stop irritating everyone’ , but to supply the child with the skills to achieve mutually gratifying and satisfying relationships. This then would need to be specifically stated for each case: ‘make a best friend’. Since best friend is a complex equivalent, having many variable meanings, the child him/herself, will need to define [with the help of the change worker and others] the revealed preference characteristics of a ‘best friend’.
Theory of change
The theory of change of cognitive behavior management is that people will only change when they change the way they think.
While we cannot make them think something specific, we can and do influence how people think. Our influence is powerful, but often nonconscious. We send messages through our words, our emotions and our behavior that we are not even aware of.
Social learning theory
Most human behavior is learned observationally through modeling: from observing others one forms an idea of how new behaviors are performed, and on later occasions this coded information serves as a guide for action.
Children have never been very good at listening to their elders, but they have never failed to imitate them.
Children are natural mimics–they act like their parents in spite of every effort to teach them good manners. Unknown
System of communication
The child in a system –
adult family members
teachers and other school staff
The child is an interactive part of a system of information and communication, both contributing to and absorbing the thoughts, feelings and behaviors of those around them. It is incoherent to say that a child has certain characteristics such as aggression, since aggression can only occur between two  entities.
PLEASE NOTE: The intent of this technique is to create a comprehensive plan of change for the entire community of interest. This is beyond the present expectations of developing a plan of change only for the target child. If the latter is the intent, the material is still applicable, but the final document is limited.
Assessment cannot be separated from the development of a Plan of Change [POC]. In order to develop an appropriate POC, it is necessary to have specific, definitive data in regard to the presenting problem, the antecedents [internal and external to the target child and the internal logic of the child manager], the frequency, intensity and duration of the behavior, the consequences [including the internal interpretation of the consequences by the target child and the child manager], as well as any physical characteristics and the thoughts about those characteristics. If the reader is well versed in the other Cognitive Behavior Management Assessment Techniques, s/he may scan to PROCESS on page 21.
1. DETERMINE THE INTENTIONS OF THE CHILD/FAMILY.
This process is neither before nor after the exploration and definition of characteristics, but is simultaneous. The determination of intentions occurs at two levels: the development of a vision statement that articulates the goals for the future; and the process of data gathering.
The very process of asking questions about the future has the reciprocal response of thinking about the future. It may be, however, that neither the child nor the family has ever given conscious consideration to this direction before. One definitive characteristic of people with severe and persistent problems in living is their tendency to define themselves by the past. The future often remains unexplored, Therefore, exploration may include a process of building intentions, goals and objectives. In order to widely expand the areas of conscious consideration, it is important to cover all life domains, including, but not limited to: home, community, legal, physical, vocational, etc. There is a full outline of goal development [CBT#27 – Motivation & Goal Development] available that can be reviewed for this purpose.
It is only with a negotiation of goals and a determination of outcome definitions that one can define a change target and expect that the process of change will work, unless you intend to control the person.
The conventional question is “What do you want?” In other words: What do you want to change about yourself? However most of the time the outcome as stated by the client will need modification in certain ways. An effective outcome expectation must satisfy the following six  conditions in order to be a useful basis for changework. The outcome expectation must be:
1. Stated in the Positive
Most often a client’s outcome statement will have the form “I want to stop doing X.” This is especially likely if instead of asking “What do you want?”, the clinician asks “What’s your problem?” or “What’s bothering you?”. The wording of the questions needs to be considered closely. Language is a process of assumptions. Interpreting the meaning of utterances is only possible because listeners implicitly assume that speakers intend their utterances to be responsive to the surrounding discourse, relevant, and [for the most part] truthful. More importantly perhaps, we also use a process of symbolic ‘shorthand’.
The clinician must learn to ask questions that evoke the proper answers [See for example CBAT#03 – the Meta Model]. In addition, s/he will probably need to probe the answers to ensure that his/her understanding of the answer is full and correct. In order to change what is, for example, you must replace it by something else. It’s important that this replacement behavior be a deliberate client choice and not one simply made by default. Therefore, the clinician will specifically need to ask what is a preferred replacement to the thought/behavior that the client wants to change.
Finding an outcome stated in the positive often isn’t easy, but it can be very powerful in helping a clinician know how to proceed. When a client says “I want to stop being jealous about my boyfriend”, the clinician can ask “How would you like to feel when you see your boyfriend with another woman?”, seeking to define the replacement. But the client is likely to ‘draw a blank’ when this question is asked. The question ‘does not compute’ for him/her. The client’s lack of a positive outcome is part of what keeps her in the problem state. Therefore, helping the client think about and define an answer to this question becomes a major part of the helping process.
2. Appropriately specific and contextualized:
Typically, clients will say things that are vague. A client’s initial outcome may be: “I want to make decisions more easily”. If the clinician merely assumes that s/he knows what the client is talking about (especially likely if decision making is or has been in the past one of the clinician’s own problems), a great deal of time may be wasted until the client finally says “Yeah, but that’s not my problem”. The clinician needs to ask “What are some examples of times when you have trouble making decisions? And what happens when you try to make a decision? And what do you mean by the word ‘easily’?”
Carlson indicates that clinical information processing like human information processing is error-prone. Simon suggests that human beings do not have the cognitive capacity to seek optimal answers to real questions. Instead, we:
- artificially simplify the question to a level that is comprehensible
- accept the first answer that is good enough to satisfy recognized demands, or
- use a shortcut that has been acceptable in similar contexts.
Carlson goes on to suggest that haphazard detail, the influence of experience [been there, done that] and the need to ignore complexity and seek closure leads to inadequate self correction. Experienced clinicians [‘experts’] are particularly prone to accepting answers that meet their own experience and respond to the ‘standard answers’.
If the clinician is to make the outcome expectation appropriately specific to the individual client and the context of the situation, s/he will need to find ways to question that go beyond traditional methods. While these information processing errors may not be burdensome in the day to day world, they have specific significance when trying to help an individual deal with their problems in living. Partially, this is because thought errors are a major contributor to the difficulties they present. It is precisely how they think about a situation that leads to the problems in living. Thus, it is imperative that the clinician understand clearly what this thought process is, so that s/he can help correct it with additional information.
The typical question is: “If this change actually does occur, how will you know it?” Once the client is able to answer this question they often realize that they already knew how to make the change in themselves.
All change must be measured against a standard criterion. The usual standard for the ‘expert’ is the ‘dead man test’ meaning that the more the subject acts like a ‘dead man’, the closer they are to cure. If we can only stop this irritating behavior that has brought this individual to the attention of the clinician in the first place, then everything will be all right. Of course, such a standard is not helpful for the person receiving the service. If we intend to institute a new process of change, we will also need to have a new standard. As Eduard Deming said: Quality is determined by the customer. What this means is that only the client can determine what is an acceptable outcome of the service. And if the change cannot be determined in some way by the client, the outcome will always be unsatisfactory.
4. Initiated and maintained by the client
The purpose of changework is to bring about changes in the client, not in the client’s environment. An example of an outcome that is not well formed in this respect is “I want my boyfriend/husband to love me”.
This well-formed condition is very frequently violated by a client’s initial outcome. Often a client asks not for a change in him/herself per se, but a change in his/her life that would presumably result from changes in him/herself. For instance, “I want to earn more money”, or “I want to be successful with women” or “I want people to appreciate me more”. Such outcomes are not well formed. The main task then lies in identifying those changes in behavior that might have the desired result. Once these changes in behavior have been identified, they can be used as outcomes for changework, if necessary. (Or once the client realizes what changes in him/herself are necessary for his/her desired result, s/he may decide that it’s not worth it.)
5. Secondary gain taken care of
Often efforts to solve a problem are frustrated because if the client no longer had his/her problem, s/he would lose various side benefits the problem gives him/her. This is called secondary gain.
It is hard sometimes to talk about the gains that occur within the context of pain, but this is a fact. While on the one hand the client may have a desire to no longer be sad and helpless, such a condition is often used to get other people to care for him/her. Unless the client and clinician are ready to identify and address such secondary issues, clients may ultimately sabotage their own growth and development.
Of particular concern is when the secondary gain accrues to a secondary client [e.g., family member]. Families often maintain negative thoughts and behaviors because the child’s behavior play an important part in their own gain.
One should think of a person as being a system. A change that seems desirable in and of itself will have ramifications throughout that system, and perhaps also throughout the relationships and other systems the subject is a part of. It is essential for a clinician to check not only that the desired change be worthwhile, but that all its consequences be worthwhile. Any changework training needs to use a multitude of examples to make subjects sensitive to this important issue.
For example: The teenager who is unwilling to perform well in school because it is not acceptable to his/her peer group.
Outcome is a complex equivalence
It is important to understand, however, that outcome is a complex equivalence that has many levels. There is the broad outcome embodied in the vision for the future and there is the specific outcome concerned with a barrier to some immediate goal. While the selection of outcome is the prerogative of the client, it is not solely so.
For example, in the videotape ‘Lasting Feelings’, Leslie Cameron-Bandler works with a client on the issue of jealousy. Although Cameron-Bandler never explicitly states her intended positive outcome, it seems clear that it is something like the following:
“The client should be able to remember that her husband loves her and that she is not replaceable for him, even when she sees him talking to another woman. Furthermore, she should have effective and accurate ways of knowing whether jealousy is appropriate in a given situation or not.”
Having an explicit outcome in mind makes it easier to check that the direction one is going in is really appropriate for this particular client.
If the intention were simply to ‘fix’ the client’s jealousy, then Leslie Cameron-Bandler could have taken the client through a desensitization process. A changeworker who did this may not even be aware of the default outcome s/he had chosen, which might be expressed as:
”I want the client to be indifferent to seeing her husband interact with other women.”
Both the changeworker and client might, in fact, have been satisfied with this result and might have regarded the work as a major success. But desensitization would not have enriched the client’s relationship and self-esteem in the way that Cameron-Bandler was able to do by working from the basis of a much richer and more ‘ecological’ outcome.
What is most important in the selection of outcomes is that the changeworker and the client have sufficient dialogue that both the broad and narrow objectives are clear. The closer the ultimate outcome can come to moving the client toward the broad goal the more substantive it is likely to be. In the case presented by Cameron-Bandler, the woman certainly wanted to overcome her possessiveness and jealously and these characteristics were a barrier to her reaching her broader goal of being comfortable with the love of her husband.
In like manner, when working with a child, the immediate issue may be fighting and the barrier the thoughts and behaviors that lead to fighting. But the broader goal is more likely to be the creation of mutually satisfying and gratifying relationships [social success]. To simply stop the child from the fighting behavior does very little to move him/her toward the goal. You will need to teach the child how to make and maintain friends for the latter to happen. Thus, the outcome expectation stated in a well formed way might be to develop a ‘best’ friend of a socially positive peer.
2. DETERMINE THE NATURAL SUPPORTS AVAILABLE TO THE CHILD/FAMILY.
Social isolation of children and/or families creates a propensity for a dysfunctional social system. The creation of a community that cares or a circle of friends is a vital part of enhancing the child/family ability to function optimally in life. Where there are no natural supports, they must be built. Where there are natural supports, they may need enhancement through training in techniques or help to renew the vigor of their involvement.
3. IDENTIFY STRESSORS
Families have many sources of stress, physical illness, unemployment, underemployment, credit problems, etc. These should be identified as they impact on how people think about themselves, others and future prospects. A parent who is responding to the turmoil of losing a job may not be as supportive of a child as s/he would normally be.
4. GATHER DATA
a) Data to gather
Gather data that is consistent with the operational Fundamental Assumption, Outcome Expectations and Theory of Change.
Consistent with the CBM assumption and theory, you must start with the premise that the child is part of an information/ communication system [ecosystem]. The child’s thoughts, feelings and behaviors are not isolated from this ecosystem and, in fact, are responsive to it. Other people often initiate and maintain the thoughts of the individual. Therefore, data must not only be collected from the ecosystem, but about the ecosystem.
b) Collect the data [thoughts, feelings and behaviors]
Use a Community Assessment/Support Team [CAST], [See CBAT#05]that is defined as being inclusive of the predominant participants in the child’s ecosystem.
Use a Functional Cognitive Behavior Assessment [See CBAT#01] that includes:
- Initial Inquiry
- Observation of the child
- Observation of the child managers
- Individual surveys
Use Sociometry [See CBAT#02] to define the interpersonal status of the child within life domains.
Other data can, of course, be collected. However, the presence of a characteristic [e.g. tactile defensiveness] cannot be assumed to be a deficit. It is not the presence of the characteristic, but the interpretation of the experience that matters. Too often, a learning disability is seen as having a deficit rather than an opportunity. Assessors, having identified a potential ‘deficit’, need to determine how the child explains this characteristic to him/herself and others to determine whether or not it will affect his/her quality of life.
c) Organize the data
The BASIC assessment and intervention framework was inspired by the work of Lazarus. The main differences presented here are: 1) the elimination of the drugs category, coding the taking of tobacco, alcohol, medication and other substances as a behavioral activity, and 2) including all physical functioning variables [including the sensations of vision, touch, taste, smell and hearing] under somatic functioning.
BASIC Personality Profile
Behavioral Patterns of work, play, leisure, exercise, diet [eating and drinking habits], sexual behavior, sleeping habits, use of drugs and tobacco, presence of the following: suicidal, homicidal or aggressive acts.
Customary methods of coping with stress.
Affective Feelings about any of above behaviors; presence of feelings such as anxiety, anger, joy, depression, etc.; appropriateness of affect to life circumstances. Are feelings expressed or hidden?
Somatic General physical functioning, health.
Presence or absence of tics, headaches, stomach difficulties and any other somatic complaints; general state of relaxation/tension; sensitivity of vision, touch, taste, hearing.
Interpersonal Nature of relationship with family, friends, neighbors, and co-students [workers]; interpersonal strengths and difficulties; number of friends, frequency of contact with friends and acquaintances; role taking with various intimates [passive, independent, leader, co-equal]; conflict resolution style [assertive, aggressive, withdrawn]; basic interpersonal style [congenial, suspicious, manipulative, exploitive, submissive, dependent].
Cognitive Current day and night dreams; mental pictures about past or future; self image; presence of any cognitive errors, attributions of success/failure, hallucinations, irrational self talk, rationalizations, paranoid ideation; general [positive/ negative] attitude toward life.
Assessment is built on the following suppositions:
- The BASIC subsystems, though assessed separately, are interrelated so that change in one can be expected to lead to change in others.
- It is important to assess both strengths as well as weaknesses in BASIC functioning.
- Assessment of an individual must include the contextual variables of family/social environment, community and culture, since these suprasystem variables have a direct bearing on the success or failure of intervention strategies.
- Assessment procedures must be organized to allow for evaluation at the end of the intervention and at various follow up points.
- The goal of assessment is not to create a diagnostic label, but rather to provide a profile of functioning that will yield concrete guidelines for selection of intervention strategies.
It is important that data be secured in each of the following areas:
The data collection specifically seeks to identify maladaptive thoughts [cognitive errors] in the child and the other members of the ecosystem. Therefore, the assessor will want to organize the data around such factors as:
- Filtering: You focus on the negative details while ignoring all the positive aspects of a situation.
- Polarized Thinking: Things are black or white, good or bad. You have to be perfect or you’re a failure. There’s no middle ground, no room for mistakes.
- Overgeneralization: You reach a general conclusion based on a single incident or piece of evidence. You exaggerate the frequency of problems and use negative global labels.
- Mind Reading: Without their saying so, you know what people are feeling and why they act the way they do. In particular, you have certain knowledge of how people think and feel about you.
- Catastrophizing: You expect, even visualize disaster. You notice or hear about a problem and start asking, “What if?” What if tragedy strikes? What if it happens to me?
- Magnifying: You exaggerate the degree or intensity of a problem. You turn up the volume on anything bad, making it loud, large, and overwhelming.
- Personalization: You assume that everything people do or say is some kind of reaction to you. You also compare yourself to others, trying to determine who is smarter, more competent, better looking, and so on.
- Shoulds: You have a list of ironclad rules about how you and other people should act. People who break the rules anger you, and you feel guilty when you violate the rules.
- Externalizing: The person explains the cause of success and/or failure as external forces such as task difficulty or luck over which s/he has no control, instead of to his/her own effort. “It’s his fault! She doesn’t like me.”
- Prophecizing: The person has negative and relatively stable expectancy or generalized beliefs about a lack of self competence in achievement situations. “I’m going to fail this test. Nobody is going to talk to me.” Prophecizes negative outcomes.
Another list for child manager characteristics may include issues regarding interpersonal expectancy effects, or self-fulfilling prophesies [SFP]. “An SFP is said to occur when one’s belief concerning the occurrence of some future event…makes one behave in a manner…that increases the likelihood that the expected event will occur [Eden – 1990].
Webster’s New Universal Unabridged Dictionary  defines expect as ‘to look for as likely to occur or appear’. It is this likelihood-of-occurrence sense that triggers SFP. Webster’s also defines expect as ‘to look for as due, proper, or necessary; as your homework is due and immediate submission is expected’. This is a normative definition of expectancy. This object of normative expectancy is what ought to occur in the future. This is not the type of expectancy that produces SFP; it is the stuff of which role expectations and other normative concepts are made. While it is important that children understand how they ought to perform in the roles that they inhabit, it is more important that they sense from others, particularly their child managers, that they can perform those roles. The child managers estimation of the probability that the child can succeed is the critical issue.
These two meanings of expectancy – likelihood [probability] of occurrence and ought to [normative] – are sufficiently different that they can be contradictory. If the teacher tells a student that s/he is expected [in the normative sense] to report in on time, but in his/her heart the teacher actually expects [in the probability sense] the student to be late, it is the latter expectation, not the normative one, that will be unwittingly communicated and initiate an SFP that may result in tardy behavior on the part of the child. Thus, it is expectancy in the sense of that which the expecter believes is likely to occur, rather than that which a person believes ought to occur, that leads to the behavior that fulfills the prophecy. In particular the use of ‘performance expectation’ refers to the level at which the manager believes the subordinate is likely to perform” [Eden – 1990].
It has been demonstrated that if the child manager believes that a child is less likely than other children to succeed, s/he is likely to behavior in a manner that supports his/her belief, by reducing the quality and content of the following events. Observation of the child manager in relationship with the target child [and perhaps other children as well] will enable the assessor to determine the internal logic of the child manager’s interpersonal expectancy in regard to the target child.
1.Response Opportunities: This is a characteristic of providing the child the opportunity to participate, built around the following factors.
• equitable distribution
• individual help
• higher-level questioning
2. Feedback: After answering a question or performing in some way, children want to know what the adult child manger thinks of their performance. Several sources noted that less accurate, less detailed feedback was provided for perceived low achievers.
• reasons for praise
• accepted feelings
3. Personal Regard: Perhaps the most important impact upon any child is the feeling of personal regard or rejection from a child manager. Such attitudes are not only conveyed by language, but through the behavioral aspects listed below.
• personal interest and compliments
These are interactive characteristics that define how the child managers relates to this child. For many children with problems in living, parents and teachers do not display these characteristics.
Other interactive characteristics of child managers might include:
1) adult to adult
2) parent to child
3) child to parent
b. directive: gives direction and instruction
1) describe the problem
2) give information
3) offer a choice
4) say it with a word or gesture
5) describe what you feel
6) put it in writing
7) be playful
8) join in
9) state your expectations
c. pejorative: blaming, accusing, calling names, threatening, giving orders, lecturing and moralizing, warning, playing the martyr, comparing, being sarcastic, prophesying – questions child’s
d. acknowledging: acknowledges feelings
1) accepts and reflects child’s feelings and states/checks how the child is feeling instead of criticizing, questioning and giving advice.
2) active listening
a) eye contact
d) beginner’s mind
e) no interruptions
3) express child’s wishes in fantasy [give in fantasy what cannot be given in reality]
e. positive internal attributions
2. Management Styles
c. laissez faire
3. Monitoring Methods
a. asks for itinerary
b. checks up
4. Discipline Attitudes
a. Noun: self discipline must be learned
1) type of teaching
2) quality of style
3) consequential strategies
4) reinforcement strategies
5) separates behavior from child
b. Verb: command and control must be imposed
1) type of reward/punishment
2) quality of style
• psychologically attacking
3) consequential strategies
4) reinforcement strategies
It must be emphasized that the list of limited thinking patterns or cognitive errors identified above is developed for and to be a measure of ALL MAJOR CONTRIBUTORS to the child’s ecosystem.
The people in the family, social, vocational and/or academic environments are secondary and tertiary clients of the Plan of Change.
The concern for these contributors are directly addressed by the Plan of Change only in those areas that can be clearly justified as having impact upon the progress of the child. Thus, if the method of discipline in either the family or the school can be directly determined to impact negatively on how the child perceives self and/or others in a maladjusted manner, this is an appropriate condition to address. If, on the other hand, the food, clothing, seating arrangement, etc. that the family or school choose to provide the child is simply not satisfactory to either the child or the worker, but cannot be directly justified as related to the progress of the child, it is not usually within the authority of the service to even address the issue.
When an area of concern is identified, the worker has a responsibility to bring this information to the attention of the parent/teacher, discuss their perspective concerning the issue and to offer specific and succinct alternatives, providing, if necessary, the training and reinforcement to carry out the new strategies.
The organization of the data thus should result in a list of characteristics [of the child and other people in the ecosystem] that seem to need change in order for the child to create mutually satisfying and gratifying relationships.
d) Analyze the data?
The data must be analyzed by the CAST members using the scientific method. It must be understood that the CAST may be receiving information about their own contributions to the disruption in community and that this process needs to be couched in terms of remedy, not blame. The CAST must undertake the responsibility for the serenity of the community and see to it that all aspects of the disruption are addressed.
An hypothesis is developed about how and why the characteristic is causing difficulty and a plan to test the hypothesis is developed [a Plan of Change]. It is important to note that the child and/or other potential recipient of services must be a part of the process of examining, analyzing, hypothesizing and selection of characteristics to be change and the determination of CRITERIA for measurement of outcomes.
Generally, a person’s own ‘revealed preferences’ are taken as data, so that any change in usage resulting from an enlargement in an individual’s choice set [the set of feasible combination of goods] is regarded as proof of betterment. Essentially, this means that if the target child and/or a contributing member are willing to accept and use the help offered, this, in itself, is proof of improvement. This reverence for CUSTOMER SOVEREIGNTY is natural when consumers are well informed and preferences are stable. Further, assessors should be typically wary of social decisions to overrule individual preferences, for fear that this opens the door to the worst kind of paternalistic excess.
4. CREATE A PLAN OF CHANGE [POC]
The POC may have several client plans – one for each person in the ecosystem whose thoughts and behaviors are initiating and/or maintaining maladaptive thoughts in the child as well as one for the target child.
In addition, the POC should address the following aspects.
- vision statement – As Yogi Berra once said, “If you don’t know where you are going, you may not get there”. The full vision statement as developed with the child/family should be included as a part of the POC.
- characteristics – these are the identifiable features of the BASIC [behavioral, affective, somatic, interpersonal and cognitive] listed on CBAT#04-002. Each of the first four [behavioral, affective, somatic and interpersonal will also include a cognitive feature. While the characteristic may need to be addressed directly [e.g., poor eyesight may require glasses], the intervention must also consider the interpretation.
- interpretation – these are the cognitive aspects of the characteristic. What does the child believe about him/herself, other people and future prospects in regard to the identified characteristic. If, for example, the child wears glasses and believes that s/he is inferior because s/he wears glasses, this is an important factor that must be addressed. It is not the wearing of glasses, but the personal interpretation that is problematic.
- outcome expectation – these goals must provide a description of the expected impact of the intervention and be consistent with the vision statement. The goal should be defined in substantive terms and may not, in and of itself, be easily measurable.
- objectives – this should be a list of elements that are measurable and which are believed, if achieved, will result in the appropriate outcome expectations.
- intervention methodology – this includes three components:
- the specific techniques and/or procedures that will be used to address the characteristic and/or it interpretation.
- the protocol – the systematic sequence of techniques and/or procedures to address both a class of characteristics and/or interpretations, and the organization of the entire POC.
- the estimated time required – usually considered a part of the protocol, for purposes of most funding sources, this is listed for each technique and/or procedure and accumulated for the protocol.
- frequency of service – this would indicate in terms of a day, week or month the limits of intervention. If a protocol would take sixteen hours, this may be accomplished an hour per week for sixteen weeks or in a single encounter of sixteen hours. How the intervention should be structured is a part of the POC.
- goal attainment – there must be a method of measuring progress toward the attainment of each goal, and the description of that method should be included in the POC.
a) List the characteristics to be addressed
Using a Matrix Table [CBAT#04-001], create a worksheet with columns, rows and cells for each person whose thoughts, feelings and behaviors are to be addressed. There is a list of characteristics in the Appendix [CBAT#04-002], that is not necessarily inclusive, but can be used for decision support to ensure that you have examined all aspects of each potential client. In the left hand column of the Matrix Table [MT], list the characteristics that have been identified as maladaptive and for which the person has indicated a personal preference for change. It is important to remind the CAST that it is not the characteristic itself that is the problem [at least interpersonally], but that it is the interpretation of that characteristic that is problematic. This suggests that it is the thought that accompanies the characteristic that must be addressed. If a child manager does not give feedback to a child, it is the interpersonal expectancy effects that will need to be addressed. Therefore, in the second column of the MT, list the nature of the cognitive error that affects the person in regard to the characteristic.
NOTE: there may be other characteristics that the assessor and CAST believe to be maladaptive, but which have not been selected for change. These should be kept available for discussion, but not listed on the chart.
Once you have a set of work papers [Matrix Tables] that include all persons who have agreed to participate, you are ready to discuss intervention strategies . For each approved characteristic or each worksheet, you will identify techniques or procedures that can effect the outcomes required. The Resource Manual may be used for decision support in regard to potential techniques and procedures. If you understand the principles of CBM well, you may innovate a technique or procedure to address the impact of the characteristic. If that is the case, you will need to be specific with the client as to what you intend to do, how long you expect it to take before outcome expectations are met, and specifically what outcome expectations are to occur.
b) List the interpretations or cognitive errors
Except where the original characteristic is a cognitive error, the assessor must ensure that the interpretation of each characteristic is identified and listed. The interpretation may not be maladaptive, and if it is not, the POC will want to reinforce that interpretation.
c) List the outcome expectations [goals]
For each characteristic and/or maladaptive interpretation, there will need to be an identified outcome expectation. For poor eyesight, the outcome expectation may be to see better. These outcome expectations are not necessarily measurable, but must be capable of being broken down into measurable parts.
d) List objectives
These are the measurable elements of the outcome expectations. For example to ‘see better’ may mean to see at a 20/20 level with or without glasses. This also sets in motion what the constraints of intervention might be. For someone with poor eyesight to see at a 20/20 level without glasses may require either a cognitive rehabilitation of the eyesight, an operation, or contact lenses.
e) List the techniques and procedures to be used
After consideration of the constraints imposed by the goals and/or objective, you can begin to list any technique or procedure that will be used to address a maladaptive thought, belief or attitude in regard to the characteristic or to address the characteristic directly. The prospective client should understand the technique and/or procedure fully and agree to its use. You will list at least one technique for each characteristic that is to be addressed.
f) Create a protocol
A protocol requires a specific sequence of activities. Not all characteristic interpretations can or should be addressed at once and some will require prerequisite intervention. The protocol is a plan of action that can be changed and adjusted as you proceed. But at least in the beginning you should be able to identify the following aspects:
1. The order of the intervention strategies
2. The outcome expectations of each technique and/or procedure – remember that this is a client prerogative.
3. The length of time projected to reach the outcome expectation
The client should be able to identify with the expected outcomes as preferred preferences that will improve his/her quality of life either directly, or if a secondary or tertiary client, indirectly through the change in interpersonal relationship with the primary client.
g) Define the goal attainment documentation process
Goals and objectives are not valid without some progress notes indicating the rate of achievement. Too often, changeworkers talk about working toward a goal which they are really not committed to – in the sense of NOW!
“One of the more common illusions of Freudian orthodoxy is that the durability of results corresponds to the length of therapy.” [Gutheil].
The length of intervention cannot be infinite. If the intervention is not working, it must be changed.
h) Define a Change Order process
Changes in the POC are not arbitrary and not in control of the clinician alone. While the clinician may, and is likely to, identify that a particular technique or procedure is not working and should be adjusted, modified or replaced, s/he has no prerogative to do so without the permission of the client being served. Thus, a specific process should be spelled out as to how and when a change will occur.
i) Develop specifications
The specifications on the Plan of Change will include, but not be limited to:
• well formed outcomes [criteria for measurement]
• responsibility charting [who will be responsible for what?]
• time schedules [who will allocate what time?]
• measurement tools [how will we know when we succeed?]
The specifications may cover responsibilities of the provider agency, the adult family members, the child, the school, and other natural supports.
j) Write up a Plan of Change
A POC may contain a single protocol for the primary client, several protocols for the primary and other secondary and/or tertiary clients; or multiple protocols for a single client. [e.g. a secondary client may need to work on his/her own feelings of sadness, helplessness, hopelessness as well as learning new child management strategies.]
A POC might include all of the work papers, but is not the work papers. It is a clearly defined outline of all that is expected to occur, who it will occur with, who is specifically responsible for what aspects, etc.
The POC must be clear as to the outcome expectations and time to achieve such outcomes. The CAST should sign off on the POC.
5. BUILD THE BRIDGE BETWEEN THE PRESENT AND THE FUTURE AS INTENDED.
It is the expert’s responsibility to design a set of experiences and supports that will enable the child/family to reach their goals. It is not the expert’s prerogative to suggest that the goals are unreachable, only to identify what needs to be done to attain the ‘impossible dream’. If doing so requires a lot of truly difficult tasks, the ‘dream’ will be changed by the client who is unwilling to sacrifice sufficiently to achieve. As a dramatic example, if a child with no hands want to learn to type – figure out how s/he can do it with his/her feet, mouth, nose, etc. Don’t suggest that such a goal is stupid or impossible.
6. DEVELOP A CONTRACT.
This contract will outline what the provider(s) of service [both professional (clinical and educational) and natural] will do and when, and what the child/family will do and when? The contract also will state specifically how change orders will be authorized [this can only be done by child/family] and how this process will work. The contract will indicate how the execution requirements will be monitored. In the final analysis, the child, the family, and the natural supports need to learn the skills necessary to enhance the quality of life in a substantive way without continued professional involvement.
Remember, the customer is always right – and the child/family are the customer. This is not a resistant family, it is a family you failed to satisfy.