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The measure at the end of the rainbow: Or, knowing what you do works – or not


25 Jun 2015

Like Tim Aldridge, I have been searching for the perfect measuring tool.

If there is blame in this, and why not, then I blame my social work training. After a year of psycho-dynamic thinking and teaching a new professor arrived, Brian Sheldon, who simply asked us how good we were in practice, how on earth would we know, and whether would we recommend each other to someone who needed help. These are the questions that stay with me, they may be the ones in your ears too.

To answer Tim’s first question, I decided I would hunt down the most useful ‘before and after’ measures I could find and that were safe in my hands. ‘Safe’ matters, as it is always possible to do some harm. In fact some of our practice may well be harmful – and, again, how would we know? Perhaps not so harmful that someone dies or is injured, although that can happen, but harmful over the longer term, if our intervention was wrongly focused or mistimed. Given that for every family we work alongside we could do at least five things in response to any issue they raise with us, we may well do the least useful thing, if it just so happens that it is the one we feel most comfortable with or have done many times before. One of the things we can do most usefully for some families is nothing at all. That sounds perverse when people are seeking out our help but, for example, GPs have discovered that waiting for a period of six weeks or so when a patient asks for help with low mood or depression allows the patient to recover without any further NHS treatment. Some depressions and some family problems resolve – and have the added virtue of being self-managed and, of course, in times of austerity, relatively low-cost for good effect.

This is not an argument for doing nothing. It is an argument for doing the best thing, or if we are unsure what that might be, then the thing with the most research evidence behind it, the least intrusive and the easiest thing. This is not because we are idle and uncaring – rather the opposite. Most practitioners I know come to work each day hopeful that they will help and support others in some improvement in their wellbeing, family functioning, family relationship quality and resources or avoidance of harm.

Interestingly we can measure all these things. Really we can measure anything, but we don’t need to. We need to find ‘measures of meaning’. They need to have meaning for the family members who give their time and trust in completing them with us, not once but twice, and may be more. Perhaps more importantly, they have to have meaning for us as practitioners. If they don’t then they become another annoying piece of paper that we feel is imposed upon us by others, to be rattled through and the answers ignored.

To have that importance of meaning, the conversation that the questionnaire or scale or tool enables must be of significant use in helping us help a family best. The issue here, of course – and why Tim’s dream of a universal measure remains a long way away – is that every family is a different helping proposition from the ones we met yesterday. So our approach to measurement can go different ways. We either decide that a topical and specific, well-tested and reliable tool is the one to use as what this family is presenting is a seemingly singular issue – for example, arguments between parents about children’s behaviours, routines and reducing family stress.

We might decide to measure the quality of the parents’ couple relationship, not because we are trampling on their privacy, but this is where strong research suggests our best efforts should lie. We have spent a long time ignoring this relationship, calling it private and seeming to put it beyond our competence. In fact, when we can and do attend, parents, living together or apart, are wise as to why their conflicts are affecting their children, you engage them in a parental couple conversation with a tool like the Quality of Marriage/Relationship Index.

On the other hand, we might decide, faced with this set of family issues, to use a tool like the Daily Hassles Scale: it is a good tool for this purpose, and it will give us and the parents a useful starting point or baseline. Watching parents tackle answers and hearing their thinking is usually very illuminating too. After all, those of you who are parents of more than one child, how would you score yourself on the two dimensions of frequency and ‘hassle-dom’ of question seven? To return to my perseveration on the parental couple, if we ask parents to score themselves separately then their ‘troubles’ usually emerge swiftly from differences in their capacity to tolerate – or not – hassles.

EVENT How often it happens Hassle (low to high)
7. Sibling arguments or fights require a ‘referee’ Rarely      Sometimes    A lot      Constantly 1   2   3   4   5

This is a good example of a scale that will help support changes in parenting. The authors and developers looked at a great deal of research on what troubles most parents and constructed a scale that they tested to make sure it was good enough to rely on. For this requirement to be satisfied, tools should be able to help us distinguish the troubled population from the less or not troubled one.

The developers were also interested in being able to get two answers in the same question area: you can see from the box that parents are being asked to respond with answers on frequency and aggravation. It is always helpful to know, when parents are struggling to manage family life, if the trouble lies in lots of smallish problems occurring often or a few more significant ones happening less often. Of course, this tool will also identify parents who are living with lot of hard problems all the time, but these parents are likely to be fewer in number.

Scoring the tool is simple, and most parents are able to look at it and get a sense themselves without our help. This information should then form the basis of a plan of intervention, along with the other assessment work and – most importantly – observation, as no amount of measuring can replace the intelligent enquiry of a thoughtful practitioner. It is just a tool after all.

The trick though, as Tim suggests, is to find a tool, like the Score 15, that is able to tell us and the families we are working with something useful about the nature of the trouble, indicate areas of work, and then be sensitive enough to the changes families have made to be able to detect these changes when we come to use the tool again at the end of our work – or at regular intervals if the work is a long-term intervention.

The SCORE 15 is designed for family therapists to measure the quality and effectiveness of family therapy interventions in, most often, CAMHs settings so it may well not be appropriate for an Early Help Practitioner who is trained to use another modality. It is always worth contacting developers about using their tools as they may have ideas about changes that are possible and those that are not.

Score 15 is a good introduction to the basic rules around tools: the tool must be designed and tested to measure the area of work you are interested in seeing change in (improvements or reductions), you need to be confident to introduce and use it with families at the very start of your work, and no, you don’t need to form a relationship of trust before asking questions – just watch someone who has used these types of scales before introducing them and gain proper consent from families. Choose a tool that you are entitled by your training to use: I would not feel confident tackling a palliative care family support questionnaire, but then I am not a doctor or at work in a hospice.

Another important ‘rule’ is that we don’t change the tools: we must not re-order questions, change the wording or interpret the words for families. If we do, we are making subtle and unknowable changes to the validity of the measure, and are certainly making it unreliable. The very first word that parents have to tackle on the Goodman Strengths and Difficulties Questionnaire (Goodman SDQ) is, ‘considerate’. Now, a parent may ask me what it means, and I might decide that I think it means being able to think about how others feel and take notice of that – you will likely have a different interpretation. We simply have to grin and bear it, and help families come back to questions they felt uncertain about.

Finally, thinking back to our family living in conflict about parenting, we may decide to use a much more non-specific tool. Some local authorities and others are using the Outcomes Star tools: whilst I can see why, as they are engaging for families and workers – after all, watching something grow is grand – I cannot see how it can answer the all-important reliability question.

Tim chose the SCORE 15; I have been using adult mental health measures. This is because the research is clear that our capacity to parent well is inextricably linked to our emotional and mental wellbeing, and that an improvement in one correlates very strongly with an improvement in the other. This means I don’t need to measure both aspects: one can easily and reliably stand as a proxy for the other. Mental health improvement matters, not only because it is a personal and societal good but because it is a condition that has had more analysis of the cost of the ‘burden of mental ill health’. In an age of social and other impact bonds and a demand for the better share of positive returns in early intervention, knowing what we do works, and what it all costs and saves, is going to matter all the more: to families, to us as practitioners and to commissioners.

I am so delighted we are having this conversation, let’s think as Tim suggests, about what will work for you. And yes, I do know that measuring is not doing but it should be a serious part of asking what needs to done and to the answer we give when we are asked, “Did that work?”