GUIDELINES FOR WRITING UP A PIECE OF GROUP WORK

When writing about joint work in a case report of group work, make clear your own contribution to the work.

Theoretical framework:

When writing up a group for a Case Report, it is essential that the theoretical framework used is made explicit. It is not sufficient simply to describe the content of group sessions. Reference should be made as to how models were implemented and their rationale based upon current evidence. For example, if a CBT framework was used, which specific cognitions (e.g. attitudes, schemas, beliefs) were focused upon and why? Illustrate how cognitions were elicited and addressed (perhaps with case examples), and demonstrate how this linked with theory? If the intervention included an educational component, what was its evidence base? Theoretically speaking, what is the ‘vehicle’ for change?

Assessment and Engagement:

Although detailed individual assessments of group members may not be possible, you certainly need to show how the issue of assessment and engagement for a group was addressed. Specific inclusion and exclusion criteria should be specified, with reference to theory. It is essential to summarise individual group members, approximate ages and significant features (e.g. diagnosis, reason for referral). This is most helpfully presented as a Table.

Formulation:

A formulation of group members’ presenting difficulties is as essential for group work as it is for individual work. This section should certainly address the rationale for a group, including research findings and theoretical literature about group work (e.g. for anxiety disorders, loss and bereavement in older people, children of divorced parents). Has such a group been run before, if so can you draw on an evaluated research base?

Group processes:

Reference to group processes isessential, irrespective of the theoretical framework used. These might include, for example, modelling amongst group members, or evidence of processes specified by Yalom (1986) to be indicators of ‘successful’ groups in adult populations. Yalom (1986) considers, for example, "the struggle for honesty" and "people starting to take responsibility for themselves" as indicative of positive group process. Write about your role in the group and how you made and maintained relationships with the group members. Was the group co-facilitated? How did you share your responsibilities?

Intervention:

Difficulties encountered within a group should be clarified, with discussion of how these difficulties were managed, using theory to underpin this discussion.

If this is an account of a structured piece of Group Work, Appendices should include a brief outline of the structure of each group session and examples of any diaries completed by group members.

If you are writing up an unstructured, time-limited psychotherapy group, it remains essential to describe the theory/research base underlying why this work was a suitable intervention. As for individual work, this section might summarise the main themes that emerged from the group, or highlight key phases.

Evaluation:

The issue of Evaluation of Outcome remains as important as for individual work and needs to be considered from the outset.

123 Professional and ethical issues:

There are also professional and ethical issues that must be thought about. For instance, how can confidentiality amongst group members be negotiated? How are group members informed of the potentially distressing and exposing nature of the group setting? How was consent for group work explored?

Useful Reading:

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7.4 GUIDELINES FOR CASE REPORTS FROM PLACEMENTS FOR PEOPLE WITH LEARNING DISABILITIES

You should read these guidelines in conjuction with the general guidelines for Case Reports, as these are supplementary rather than replacement guidelines, and we have not addressed every section.

Assessment:

Remember to make an holistic assessment of the client, rather than just focusing on the referral problem, which all too frequently is concerned simply with aspects of the client’s behaviour which other people are finding worrying or a problem. Areas to include in the assessment, as well as those indicated above (in section titled background history) are:

a. Communication skills

b. Cognitive skills-memory, problem-solving etc. c. Social skills

d. Self help and community living skills.

e. Social network and significant others/quality of relationships f. Pattern of daily life, likes and dislikes, activities, employment g. Physical health

h. Mental health i. Medication

j. Life events and losses, resources and resilience

k. History of professional input and care received e.g. changes in residential home, day centre etc. l. Wider social and cultural factors e.g. discourses of disability

m. The professional network n. Risk issues

Sources of information:

In working with people with learning disabilities you are particularly likely to get information from a variety of sources (e.g. case notes, ABC charts, staff, family, members of a multidisciplinary team etc.) as well as the client him or herself and your own observations. Make it clear in your write-up where the information you are referring to has come from, and how you paid attention to the development of therapeutic/working alliances in complex family-professional systems. Make it clear how you understand the working of the professional system and how that forms a context for the identification of any difficulties.

Psychometric tests:

Many of these are not designed for use with this client group and you need to acknowledge this, discuss why you are using the test and then be very careful how you discuss and interpret the results.

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Remember using an intelligence test with a client indicates whether or not they have an intellectual impairment, not whether or not they have a learning disability.

Terminology:

It is more respectful to talk about people with a learning disability/people with learning disabilities than PLDs. Think about whether you refer to your client by his/her first name or Mr/Ms/Miss (suitably anonymised of course). The terms man or woman are preferred to male or female which are very depersonalising in any area of work.

Interventions:

Interventions are frequently multifaceted when working with people with learning disabilities. Ensure the basis for each aspect of the intervention is made clear and that the results are outlined in the outcome section. If you have had to adapt a particular type of treatment, indicate how and why you did this. Discuss how you tried to work collaboratively, how you paid attention to strengths, coping and resilience, and how you positioned yourself within the professional system.

126 7.5 GUIDELINES FOR EXTENDED ASSESSMENTS

The purpose of an extended assessment is to formulate a clinical problem on the basis of information gathered from a wide range of sources. For an assessment to qualify as an extended one, you need to demonstrate that you have used a wide range of methods and sources in gathering the information on which the presented assessment is based. More than simply using multiple questionnaires, this means using assessments of different types, drawn from for example self-report, clinical rating, behavioural observation and permanent products, and assessments drawn from different perspectives, for instance from the client, carer, clinician or “objective” markers. These should be used to “triangulate” on the presenting problem, exploring it from multiple perspectives with different types of data.

Purpose of an Extended Assessment

The purpose of the assessment is to devise a formulation from which an action plan, possibly involving further psychological assessment or intervention, can be derived. The action plan needs to address the psychological, health, relational and social and cultural needs of your client and/or significant others, as relevant. You need to give a clear rationale for the extended assessment. Examples of extended assessments are:

a. Assessment of suitability for a given treatment.

b. Comprehensive risk assessments for specified behaviour(s). c. Assessments for eligibility for particular services

d. Assessment of your client’s current or future needs and the extent to which current service provision can meet them.

Possible Sources of Information

All extended assessments should begin with an examination of existing available information about the individual (e.g. past and current case notes, previous assessment reports), and a clinical interview where possible (structured, semi-structured or unstructured) with the client as well as carers, family members, spouses, agencies and referrers as appropriate. This should be used as part of developing the initial hypotheses about the factors leading to the development, maintenance, exacerbation or amelioration of a clinical problem.

Sources of information used to assess these hypotheses should attempt to cover a range of assessment types and a range of assessment perspectives.

The available assessment methods include (but are not limited to):

1. Questionnaires about social and psychological functioning, eg. degree of psychological symptoms, personality traits, defense style . This may include Likert-style ratings of distress or confidence made as part of therapeutic diaries.

2. Structured, focused interviews about symptoms, well-being, life functioning, personality traits, cognitive impairment, etc.

3. Behavioural tests, for instance distance the client can approach towards a phobic object 4. Behavioural observations e.g. number of positive activities engaged with over a week, or

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best “metric” for these, e.g. rate versus duration versus frequency of a particular behaviour. These should also be carried out across a range of contexts, and there may be deliberate manipulation of the context in order to evaluate potential triggering and maintaining factors. 5. Qualitative data, for instance client’s recorded thoughts, content analysis of recorded therapy

sessions or of team discussions, process notes from therapy meetings

6. Standardised achievement and ability tests, for instance reading level, short versus long term memory.

7. “Real-life” measures. This may include such things as “permanent products” left behind as markers of a clinical problem (e.g. number of new scars inflicted by self-harm, weight of soap used in cleaning per week). It may also include markers of social functioning such as return to employment, use of A+E departments, contact with friends and relatives, etc.

The available assessment perspectives include (but are not limited to): 1. Self-report

2. Carer, family, spouse, child and/or other family member 3. Clinician or agency staff member (e.g. teachers, nurses) 4. Therapist rating, for instance of counter-transference reactions.

5. “Objective” assessment (i.e. a measure which is not explicitly gathered from one individual’s perspective). This may include for instance behavioural counts or permanent products as noted above.

As a guide, at minimum an extended assessment case report should be based on at least two assessment methods and at least two assessment perspectives, in addition to a general clinical interview.

Structure of the Report

Structure the report so that up to one third is devoted to the report up to the action plan; approximately one third for the extended assessment and one third for formulation, recommendations and critique. Write up the report in the same format as other Case Reports up to and including the initial formulation (i.e. to include presenting problem, referral route, your initial assessment, and the initial formulation). Then the format should change as follows:

Initial Action Plan

The initial action plan needs to present the rationale and justification for a further detailed assessment of the problem as now defined, with reference to supporting literature. In this section pay particular attention to issues of social and cultural diversity and professional and ethical issues, e.g. developing a working alliance, confidentiality, consent, risk, cultural issues. The action plan would in part be determined by the examination of dilemmas in this area. Within the action plan, outline the specific hypotheses about the clinical problem which the extended assessment is designed to address. The assessment should clearly and logically relate to these initial hypotheses.

Based on this, describe the assessment plan. Your selection should be justified in terms of psychometric properties (where appropriate), coverage of important perspectives and data types, expected consistency or otherwise of the measures etc. as well as their direct relevance to your clinical hypotheses. You may also want to comment on the practical constraints which may have influenced your choice of assessment method, especially if these have forced a sub-optimal assessment approach.

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Make sure you give a clear description of your assessment methods, and that all standardised methods are appropriately referenced.

Extended Assessment

This section will inform the reader of the assessment work that was carried out. This is the place to mj on the impact on the client (and significant others) of the assessment process and his/her views on it. You should specify the number of sessions taken to complete the assessment and the context/s in which the assessment took place. Comment on the working alliance and how that facilitated/constrained the assessment process. This is the place to make any relevant observations about the behaviour of those contributing to the assessment which might materially affect their interpretation. For instance, a patient might only answer every other question on a questionnaire, or might clearly be taking a random approach to completing it.

Assessment Outcomes and Extended Formulation

Discuss in this section the main results, scores, themes, etc which emerged from the various assessments. Bring all the qualitative and quantitative data together with your initial hypotheses, the referral information, the background information and the initial clinical interview. Use these to develop an overall formulation of the clinical problem.

This section needs to address how information subsequent to the initial formulation furthered or changed the understanding of the case. It may be that the extended assessment radically alters the initial formulation.

You should address within this section issues of concordance or discordance between the assessments used – i.e. the degree to which they appear to trend towards the same or towards different conclusions. Consideration should also be given where appropriate to alternative explanations for particular assessment results or conflicts, for instance social desirability bias in self-report, or confirmation bias in clinical reports. Also comment on whether results from one assessment deepen, challenge or change the possible interpretations of another assessment.

Recommendations for Intervention

This needs to be logically derived from the extended assessment and formulation. Further consideration should be given to any ethical, professional or cultural diversity issues or dilemmas in recommending the intervention action plan This action plan should detail the rationale for the approach to be taken and wherever possible, be supported by theory and research evidence. Be sure existing services have the resources to implement your recommendations and put forward ideas to help implement your recommendations.

Critical Evaluation of Work

The critical evaluation should include the following:

1. An evaluation of the process of the assessment. Relevant process variables would include: a. attendance/non-attendance issues

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b. the nature of the evolving relationship between you and your client and significant others

c. the impact of relationships with other professionals d. issues of difference and diversity

2. Reference to professional and ethical issues that may have arisen.

3. An evaluation of the methods used, with reference to pertinent literature (i.e. the theoretical and evidence base for the assessment procedure, formulation etc).

4. A discussion about the strengths and limitations of the assessment, including a discussion of what, if anything, you would do differently.

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