It Depends:
Embracing the Ambiguity of the TCOM Tools
By BETHANY BLANK, LMSW
TCOM Human Services Program Specialist at Center of Excellence Bureau Division of Behavioral Health
My team waits excitedly for the chance to ask Dr. Fernando questions at our annual meetings. By that time, we have debated amongst ourselves about which way to rate an item. We bolster our arguments by focusing on the minutiae of some anchor text in the reference guide. We pose the question and Dr. Fernando says, “It depends…”.
My TCOM journey started in 2018 with the implementation of the Jeff D. Settlement in Idaho. I learned to use the CANS for the first time that year. When I was hired with the Idaho Department of Health and Welfare, I made one of my goals to be mastering the CANS. I jumped at the chance to become a trainer and subject matter expert. Six years later I am still learning more about TCOM. I still have daily revelations about TCOM and each day the mission gets clearer in my head.
I have never been a black and white thinker; loopholes are one of my favorite things in the world. Each of my supervisors has likely asked “why?” when I ask what the boundaries of my assignments are. I am aware that the world operates in varying shades of grey. Despite my love of questioning, the ambiguity of the TCOM tools has always been hard for me to grasp. Although I coach new TCOM users to not be so attached to the anchor text that they lose that ability to be flexible, I still find myself comforted by the defined boundaries of a rating.
My Aha moment finally came while providing coaching for a youth crisis center. The director had brought a few of their rated CAT’s and was having a lighting question round with me and my partner. It felt like being in a game show. The director would give thirty seconds on the context and then state the rating that was indicated. We would respond with the rating we felt was accurate. Three fourths of the way through this questioning the director brought up a unique situation.
The youth in question was living at a residential treatment facility. They left the facility without permission to take a walk and came back. The clinician rating the CAT had marked this as a need for action in the runaway/flight-risk domain. The director was concerned this was over-rating. The youth had come back on their own and hadn’t taken a long walk. I asked for some more information about the situation and further learned that, despite the youth returning on their own, the youth was at risk of being expelled from the facility due to that walk. There was no other facility willing to take them. In a black-and-white world, this youth was not a runaway, but in the grey mental health world…this kiddo had run away and was at risk of losing their placement due to it. The circumstances made the item actionable.
I appreciate that the TCOM tools allow us, as raters, to exercise some ambiguity about ratings. When collaborating with families and youth it helps us to not let our own biases, or the tool, get in the way of determining what is seen as a need. The TCOM tools support the work of all levels of the system, and anything can be actionable. “It depends”, while not a concrete answer, is more about opening up our own minds to the situation and working with individuals to see what concerns are affecting them in their daily lives and what their needs are.
This revelation has affected the way I train and interact with trainee’s actual and hypothetical questions. I don’t automatically go to the anchor text ratings. Instead, I inquire about the possible outcomes from the need they are describing. After sitting for a moment in the information, I often say “It depends…”
Bethany Blank, LMSW, is a TCOM Human Services Program Specialist with The Center of Excellence, Idaho Department of Health and Welfare. She also has served as a CANS Trainer since April of 2020 and has been CANS certified since 2017. Her job with the IDHW involves providing mental health assessments, training use and comprehension in the CANS, and providing support to the community. Bethany is working on her doctoral degree in education with the goal of expanding her training capabilities and extending her influence into mental health policy. She works with children and their families in Idaho as she completes assessments and helps to identify necessary services and tools. As an active team member and trainer, she helps others in the Department expand their skills. Additionally, her strong background in technology use allows her to support team members in their use of new technologies.