Principle 5. The What, not the Why
Principle 5. Items found in the TCOM tools are descriptions and generally do not include attributions of cause.
by: Dr. John S. Lyons
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Concept: We generally describe this principle as “it is about the what, not about the why.” This means that the focus of most items on a communimetric measure is description. The items are intended to communicate a common or consensus understanding of the focus of a helping effort. There are a small number of items that can be found on various communimetric tools that have some etiology (i.e. why) embedded in the logic of the item. This is done when the concept to be measured cannot be described without an attribution to a cause-effect relationship. Thus, the Adjustment to Trauma item that can be found on both the ANSA and the CANS implies that a traumatic experience has led to current adjustment difficulties. There is no way to describe a trauma response without an attribution of a cause-effect relationship. Other than these rare items, all items are descriptive. In this way, it doesn’t matter, for instance, why you are not going to work; if you are work age and not working, then you are a ‘3’ on Employment. Also, children could be rated a ‘2’ on School Behavior because they have ADHD and cannot sit still, OR because they do not want to be in school and are intentionally trying to get themselves kicked out, OR because they are being bullied and the teacher is responding to the child’s response to the bullying, OR because they remind the teacher of someone she did not like last year and she is purposefully triggering the child’s behavior. It doesn’t matter why the child is having trouble behaving at school; the item only describes that they are.
Background: There are two pathways that led to the inclusion of this characteristic. The first reason why we included a focus on the descriptive is that we wanted to create a strategy based on consensus. We learned early on that there is far less contention or disagreement among people if you can keep the focus on describing things. As soon as you get more than one person in a room, you are likely to have more than one theory of why something is the way it is. Three psychologists are likely to have three different theories to explain a person’s behavior. Different cultural groups have different ways of thinking about cause and effect as well. All cultures recognize the phenomenon we usually describe as depression, but there is enormous variation on the causes of this very common human condition, from biological substrates, to self-talk, to a loss of connection to the land, to a loss of faith. Trying to jump to the ‘why’ before clearly agreeing on the ‘what’ is less effective in building a consensus.
The second pathway to this characteristic was the work with treatment planning that emerged out of early uses of the CANS in both Canada (Regina) and the San Francisco Bay area. Generically, treatment planning processes can be considered as following a “What” to “Why” to “How” and then back to “What” process. What is going on in the life of this person? Why do we think this is going on? How are we going to help them change it? Then returning to the original ‘what’ to determine whether we have been successful in helping them change it. This process is simultaneously simple and profound..
Proof of Concept: Using a consensus-based strategy has proven to be possible with this approach. Most mature implementations report that 98% to 99% of the time a consensus can be agreed upon. Rarely does one perspective have to be an over-ride because of an inability to agree. There is emerging research in the collaboration demonstrating that consensus-based assessment is more effective than when no effort is made at consensus (Israel, 2017). Further, the treatment planning approach developed from both the CANS and ANSA has proven to be quite helpful for people to see the value of these tools in facilitating more effective practice.
An interesting challenge to this treatment planning approach has emerged from evidence-based practices (EBPs). EBPs have a ‘baked in’ theory of change. For example, Cognitive Behavioral Therapy (CBT) makes the clear assumption that how you think influences or even determines how you feel and what you do. There is very limited scientific support that this is uniformly true, but you can’t do CBT without that assumption. Since schools and training programs increasingly emphasize learning EBPs as the training focus, increasingly, young professionals are entering the job market with limited or no ability to actually formulate an individualized theory of change. We have to then train them on the job with how to think about cause-and-effect in their work with others because they have been told what the cause-and-effect is based on the EBPs for which they trained. Since even the most applicable EBPs are recommended for only a small percentage of people who actually seek help, this is quite a limiting workforce challenge.
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