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CORE | CORE Net Procedures.

CORE | CORE Net Procedures

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Policy and Key Information

Monitoring Outcomes in Clinical Practice
1. Introduction

The introduction of CORE Net to our service has come at a time when we have been unable to work within our familiar routines. In view of this, these notes have been compiled to help further your understanding of the new system and bring to your attention the importance of reporting accurate data, in order that the service can gauge its overall effectiveness in delivering good therapeutic outcomes, both within the general and forensic communities.

Services are increasingly opting to collect client data at every session, rather than simply at the start and end of therapy (or at irregular intervals), in line with current UK primary care policy (IAPT, 2011). Analysis of recent CORE-OM data has brought home the fact that high quality outcome measure data is even more important for session-by-session data than for simple pre- and post-therapy data.

Data analysis can only be as good as the data which is collected: data which is incomplete, or which is erroneous, can dramatically change a service’s reported outcomes. If a service wants to evaluate its performance, it is crucial that the data reflect the true outcomes of the service and not just a subsample of outcomes. For instance, a service seeing 100 clients in a year, with outcomes for only 35 clients out of the 50 with planned endings for therapy, can only report a maximum of 70% recovered as the remaining 30% of clients have no outcome data recorded.

2. Client-completed Outcome Measures

Clients should complete outcome measures immediately before their session so that, if necessary, the content can be used for discussion in the session. If a measure is completed at the end of the therapy session, the data may reflect more on the success of that session rather than the overall therapy. Completing the measure too far in advance of the session is also not ideal as the client’s psychological wellbeing may have changed prior to the start of therapy.

Clients should complete an outcome measure at the start and end of therapy. For our forensic services using the CORE system, it is recommended that clients complete the 34-item CORE-34 at the start and end of therapy as a minimum and, that the shorter 10-item, CORE-10, be used at the intervening sessions, if agreed with the service manager and risk allows. While the CORE-10 is shown to have a good correlation with the CORE-34, which means that clients’ scores on the CORE-34 and CORE-10 are likely to be similar, its brevity, coupled with the inclusion of only one risk item, makes it less suitable than the CORE-34 for use as a screening tool.

The service manager will determine what will be appropriate to meet the needs of their service. Community services typically use the CORE-10 throughout the therapy process unless risk warrants a more in-depth CORE -34 assessment.

3. Therapist completed forms
  • It is necessary to complete a Therapy Assessment Form (TAF) for every client you see. If a client is accepted for therapy, then you will need to complete an End of Therapy Form (EOT).
  • Both the TAF and the EOT need to be completed as close as possible to the therapy session, while your memory of the session is still fresh. This should be within 48 hours of a session.
    It is important to ensure that the TAF and the EOT are completed as fully as possible as they provide valuable data to be used in conjunction with clients’ outcome measure data.
  • When asking a client to complete an OM, your attitude can easily influence how willing they are to do so.
  • When explaining the process to clients, it is important to make them aware of the value of collecting the data, both in terms of the therapeutic process and in helping the service maintain or improve standards.
  • If you are using paper forms and transferring the information onto your computer, there should be a regular, designated time set aside for this task, whether that be straight after the session or at the end of the therapy day. If possible, avoid letting your cases stack up into a daunting pile to be faced on a Friday afternoon or worse at the end of the month.
  • If your service uses session-by-session measurement, measures need to be collected at every session. If a client attends a session but does not complete a measure, the session data should still be entered in CORE Net. Otherwise, session-by-session data loses a lot of its value.
  • Evaluation of session-by-session data involves looking at a client’s progress and outcomes as a specific point in therapy and therefore data needs to be tied to the correct therapy session. For example, if a client fills in a CORE 10 at session 2, 3 and 7 but you do not record the sessions in between, the session 7 data will be taken as relating to session 4.
Summary: Key points

Data should be completed as fully as possible. The therapist completed Therapy Assessment and End of Therapy forms provide valuable information to be used alongside the client’s outcome measure data. CORE Net recommends that the data listed below should be the minimum completed by therapists for all clients. However, best practice would be to complete all the data on the forms.

Assessment: End of Therapy:
  • Age and gender
  • Assessment outcome
  • Medication
  • Referral/Assessment/Start of therapy dates
  • Referral source
  • Presenting problems
  • Relationships
  • Risk
  • Medication (review)
  • End of therapy date
  • Review of presenting problems
  • Risk
  • Type of therapy ending
  • Number of sessions attended/unattended

To be able to have faith in the results of outcome research, data quality (both client and therapist-completed) must always be high.

High quality data means full data is recorded at the appropriate times, both by the therapist and client. If therapist-completed data is not entered correctly, or not entered at all, then the client’s data may not be used when looking at service performance and comparing service performance against national benchmarks

Clients should complete a CORE-34 at assessment and end of therapy. If therapists are using session-by-session measures then they may opt to use the CORE-10 for all other sessions, or to use a combination of CORE-34 and CORE-10. In the community pathway, clients can use CORE-10 from start to finish.

4. The Therapy Assessment Form (TAF) – Collection and clinical use of demographic and contextual data
4a. Demographic data

The TAF requires the collection of a range of demographic data including age, gender, employment status, ethnic origin and referrer/s.

The rationale for including this demographic data in the CORE System is that it enables you to use the data to profile clients in order to provide a context for the interpretation of their Outcome Measure source i.e. the CORE 34 and CORE 10 forms.

Please note that it is not intended that the TAF is completed during the session with the client. The skill is to familiarise yourself with the specific data required for the assessment and keep this in the back of your mind as you go through the assessment session with the client. If the client does not volunteer the information, then use open questions to elicit the required information. The TAF is then completed at the end of the session.

4b. Contextual data – dates and episodes

Contextual data begins with the identification of important dates, i.e. the referral date and the assessment date. These dates all refer to this episode of therapy (an episode of therapy is a discrete block of therapy sessions with a clear beginning and ending). These dates are vital for understanding how long clients have waited before being seen. You may need to obtain the referral date from administrative staff (This may arise for Community therapists only).

The first assessment date is all you will need if your assessment takes place over one session only. It is vitally important that information of this kind is recorded accurately as missing information can make it difficult to interpret the client’s journey through the service, make it time consuming to analyse the data and make the results of the data analysis less useful.

Equally important is whether the client has been seen before in the service. If this is a second or subsequent episode, it is worth exploring with the client what brings them back to therapy, how successful those previous episodes were, and what problems they had in those therapies that need to be avoided in the current therapy.

4c. Contextual data – what other support has the client got access to?

The next three sections of the TAF are designed to profile the support that the client has access to. For example, does the client live alone or with family? This contextual data may well be provided spontaneously by clients, if not you should gently inquire so that you are able to gain a full understanding of the resources that may be available to them. Equally, you may be able to determine what may be causing stress in their life. If clients appear to be isolated with little support, it may be necessary to explore with them how they might access further support. In the forensic setting, if a client has been homeless, this information helps to highlight the added physical and psychological distress they may have experienced.

It is also important to explore with clients what other psychological services they are currently accessing or have done in the past. This will give some indication of the severity of clients’ difficulties and their previous attempts to get appropriate help.

Finally, is the client taking prescribed medication? Again, this should be explored with the client if not volunteered. For example, “You have mentioned that you have seen your GP several times about feeling depressed. Has your GP prescribed any medication? If so, has this helped?

5. Exploring clients’ problems/concerns and other clinical data

Taken together with the description of the reason for referral above, this part of the TAF (side two in the paper version) starts with a focus on the client’s problems, drawing on all the evidence available to the therapist at the time. This will include what the client tells you in the assessment session, any information from referrers, the client’s scores and domain profile on the CORE Outcome Measure (CORE-34) and your own experience and clinical skill.

5a. Brief description of reason for referral

This free text box allows you to summarise the reason why the client has come for therapy. It will often be a response to the common question, “What brings you here today?” Your notes should be brief (it is not intended to be a summary of the assessment session) and care should be taken not to include any information which could identify the client. The skill is including sufficient information to make the client “come alive” when their case is reviewed.

For example, in reviewing a client outcome where there has been no change over a period, or where the client has deteriorated, the reason for referral may help to explain that outcome. It can also help identify the client to you as a therapist when otherwise all you may have is the client ID. In the forensic setting, this may be useful especially when one therapist is responsible for the assessment session and the client is then transferred to another therapist for ongoing therapy.

5b. Exploring clients’ problems/concerns

This part of the TAF allows a more detailed profile of the client’s difficulties and has several purposes.

  1. It collects together a range of information about the client’s difficulties which may come from a referral letter, what the client tells you in the assessment session about why they have come, from the client’s responses to the CORE-34 and from the therapist’s own observation and clinical judgement. It therefore helps to provide a more detailed picture of the client’s difficulties and concerns than could be ascertained from the OM alone.
  2. It helps with case mix adjustment. For example, a client with psychosis or personality problems may be expected to have poorer outcomes than clients with other difficulties.
  3. It allows the service to summarise the main presenting problems and concerns that bring clients into therapy.
    Therapist completing the TAF are asked to rate the severity of each of the identified problems and concerns on a 4-point scale. It is important to note that this is not intended to be diagnostic but rather to identify the impact that the problem is having on the client on a range that goes from ‘causing normal difficulty’ and not affecting day to day functioning to ‘causing severe difficulty’ and severe impairment in all areas of functioning.
5c. Assessing and managing clients at risk of self-harm or suicide.

This is a very important section of the TAF and should be completed whilst considering all the evidence available to you, including, crucially, the client’s self-report of risk on the CORE-34/CORE-10. In those instances where there is a discrepancy between the client’s self-report (i.e. risk score) and the therapist’s risk assessment on the TAF then this should be clearly recorded and the reasons for the discrepancy explained.

Risk is recorded on the Therapy Assessment Form (TAF) under four categories: None, Mild, Moderate or Severe. There are no hard and fast rules about correlating the risk score on the CORE-34/CORE-10 with that of the TAF. However, therapists are expected to use their clinical judgement in assessing risk and to make clear what action they are taking when they believe a client is at risk.

5d. Assessing suitability for therapy and motivation for change

The final section of the TAF is the Assessment Outcome. It is very important that this is completed accurately so that there is an accurate record of the clients who have been accepted into therapy. Clinically, it is important to assess the client’s motivation prior to accepting them for therapy. In other words, you should assess not just suitability for the therapy offered in your service, but also the client’s motivation and willingness to engage in further sessions.

A common problem in services, highlighted in CORE datasets, is the large number of clients who are recorded as ‘accepted for therapy’ because the therapist considers that they would benefit, but who fail to take up any further sessions. These cases are effectively ‘unplanned endings’ and lead to wasted resources and a failure for the client to obtain the help they need. By exploring with clients their motivation and willingness to engage right at the beginning you can do much to reduce this wastage.

Please refer to the ‘Training’ menu on CORE Net and video number 14 for an example.

6. Identifying the severity band of a CORE-OM score

The severity levels on the CORE-OM can be determined as follows:

  • 0-4 = healthy non-clinical
  • 5-9 = mild non-clinical
  • 10-14 = mild level
  • 15-19 = moderate level
  • 20-24 = moderate to severe level
  • 25-40 = severe level
6a. Clinical Change

When change is described as ‘clinical change’ it simply means that a client’s score has moved from the ‘clinical range’ (i.e. of 10 or more) into the ‘non-clinical range’ (i.e. a score of less than 10).

This means that if the client scores 20 at the beginning of therapy and 9 at the end of therapy this would count as ‘clinical change’. Likewise, if a client scored 10 at the beginning of therapy and 9 at the end of therapy this would still be ‘clinical change’ as the client has moved from a clinical score to a non-clinical score (even though they have only improved by one point). If a client scored 40 at the beginning of therapy and then 10 at the end of therapy, although this is a huge difference, it would not count as ‘clinical change’ because the client’s score still puts them in the clinical population (i.e. the score remains at10 and 10 is the benchmark as the cut-off score for clinical change).

6b. Reliable change

In the CORE measure a change of 5 points or more is considered ‘reliable’. In other words, if your client improves by 5 points or more it is likely that there has been meaningful improvement in their wellbeing.

A client’s score reducing from 10 at the start to 8 at the end of therapy is not reliable change because it has only changed by 2 points (although it would be clinical change as the client has moved from the cut-off score of 10). However, a change in score from 8 to 3, or 17 to 11, would be reliable as there is reduction of 5 or more points.

A reliable change for the worse (e.g. a change from 10 to 15) is considered a ‘reliable deterioration’.

7. The End of Therapy Form (EOT)

The End of Therapy Form marks the end of an episode of therapy and provides details and information from the therapist about the nature, course and ending of treatment.

When the EOT is completed, the client’s journey in the service can be considered to have ended, the client can then be ‘closed’ as a case and their data can be reviewed and audited.

Completing the EOT form is vital. For example:

  1. It provides information which may help in the interpretation of a ‘poor outcome’ case
    We can learn how the therapist rated the client’s motivation, psychological mindedness and the therapeutic alliance
  2. It lets us know whether the ending of the therapy was ‘planned’ or ‘unplanned’, in other words whether the client dropped out of treatment.
  3. It gives us an indication of whether the therapist believes that the client benefited from treatment – perhaps in ways which are not reflected in the Client’s CORE-34/CORE-10 score.
  4. All these factors can influence how we interpret the ‘outcome’ of the client’s therapy and, having them recorded in this way enables your service to ‘drill down’ into the data in order to answer important questions such as, “Which clients does this service benefit the most?” “What is the profile of clients with unplanned endings in this service?” And so on.

It can be easy for a therapist to forget to fill in the EOT. This is a serious problem, if we do not know how a proportion of therapies ended, the data we do have cannot be interpreted with any confidence. In other words, we have no idea whether the data we have is representative of the service. It is therefore important that all clinicians and service managers place the highest importance on ensuring that the EOT is filled in for ALL clients who have been accepted for therapy.

It is perhaps hardest to do this for clients who drop out of treatment, because dropping out may happen over a period (for example, with sporadic attendance) and the requirement to fill out the EOT may disappear over the horizon with the client. For this reason, it is advisable for all clinicians to periodically review all of their active cases and ensure that all clients who they are no longer working with have a completed EOT (and also ‘closed’ cases if CORE Net is being used).

Clients who have been accepted for therapy but who then drop out before therapy starts are perhaps the hardest of the hard to remember in this context. An example of this, particularly in the forensic setting, would be if one clinician did the assessment and TAF and passed the client to another clinician for their ongoing therapy, then the second clinician will have to complete an EOT for someone he or she have never met. In this instance, the EOT would have to be completed with the data determined on the TAF.

The following areas should be completed:

  1. The End of Therapy Date would be the same as the Assessment Date
  2. The type of therapy that would have been used
  3. The modality of therapy
  4. An explanation for the ending of therapy
  5. The Identified Problems/Concerns
  6. Risk assessment

Clearly, there would be areas that the clinician would not be able to complete such as:

  • Contextual factors i.e. motivation, working alliance and psychological mindedness
  • Benefits of therapy

Managers and administrators should ensure a good system for supporting clinicians in the task of completing the EOT. This may take the form of ensuring that paper copies are available, or that clinicians are properly trained in the use of CORE Net; providing reminders to clinicians to review their case load and making this a topic to review in supervisory and management meetings. A system of regular caseload reviews and reminders can greatly increase the proportion of clients for whom the EOT is completed, resulting in data which is more trustworthy. Trustworthy data can then be used to understand more about the work the service is doing and help define areas that can be improved.

Please refer to the ‘Training’ menu on CORE Net and video number 15 for an example.

8. Closing Cases Appropriately

It is of the utmost importance that you remember to close cases and know when to do them. First and foremost, if you don’t close your cases promptly, then the work you have done will not be reflected in audits carried out by the service.

For example, if you finished working with a client in February but only get round to closing their case during a quiet moment in summer, then the service audit reports for February will have already been run and the report will be distorted by your missing data. Data will be missing from the report even if your cases are in every other way perfectly recorded – but have not been ‘closed’. Remember – CORE Net only knows a case is ‘closed’ when you tell it so.

Secondly, closing a case and completing the End of Therapy Form (EOT) on CORE Net, is an opportunity to reflect upon how the case went. Therapists tend to remember the cases that have either gone well or badly. The discipline of closing all your cases, filling in the EOT and checking all the data is complete on CORE Net is an opportunity to reflect on each client you have treated. If you can get in the habit of closing your cases promptly and spend time reflecting while doing so, then you have a final chance to learn from the journey you have made with each client.

8a. How to close a case

This is done on the Client Home Page by selecting the ‘closed’ option (instead of the ‘in progress’ option) under the status bar at the top right side of the page. Once you have done this remember to ‘save’ by clicking ‘save’ at the bottom of the page.

If a client attends their last scheduled session then it is relatively easy to review the ending, write up your final notes, enter the client’s last CORE scores and close the case promptly. However, some clients fail to attend their final appointment and in response your service is likely to try to contact these clients, perhaps with an email or telephone call. This action would be taken in the community setting. In the forensic setting a client’s failure to attend their final session may be due to their release or transfer to another prison and this information may not be immediately available to the therapist.

As you do not know what is happening with these clients, you are likely to leave them as clients who are ‘In Progress’ and as a consequence may forget to close them on CORE Net (meaning the data will be lost to any audit run on the service data for that period). Therefore, it may be useful for therapists to note these particular clients with a view to monitoring the information needed in order to close their cases.

As time passes, it becomes harder to close cases. This is because the longer the delay, the more difficult it can be to remember or locate the information you need. The take home message here is ‘the sooner you close cases after you finish working with them, the better’. This, though, is more difficult if the ‘ending’ of the therapy is complicated and unclear.

8b. Closing cases where therapy has not started

It is perhaps hardest to remember to close cases where therapy has not truly started. This situation occurs when a client is assessed but either has not been accepted for therapy or has subsequently not returned to start therapy. These cases still need to be closed.

Please refer to the ‘Training’ menu on CORE Net and video number 16 for an example.

8c. Using the ‘Need Closing Filter’, under the ‘Filter by Flags’ function to ensure you have closed all cases which require closing

A useful means of checking whether you have closed all cases that need closing is to use the ‘Need Closing’ Flag under the ‘Filter by Flags’. This prompts you to close clients you have not seen for a time.

Please refer to the ‘Training’ menu in CORE Net and video number 12 for an example.

9. Risk Management – Introduction

Within our service, we seek to help people who are sometimes desperate and often angry and there is a real danger that they will harm, or even kill themselves or someone around them. We therefore must routinely assess and help to manage this risk, lending our skills to the task of helping clients stay safe or be safe.

There are several ways that the CORE system can assist therapists in this difficult but potentially lifesaving task. In this section, we will explore how the client rated CORE outcome measures systematically address risk in the CORE-34 and the CORE-10 forms.

We will also look at how the Therapist’s Assessment Form (TAF) prompts clinicians to make their own assessment of risk and the benefits of ‘triangulating’ this information. Finally, we will see how CORE Net can be used both to track risk at an individual case level and to highlight cases where risk issues are present and therefore need to be regularly reviewed at a caseload level. These features in CORE are designed to assist, rather than to replace, existing assessment and risk management procedures in your service,

9a. Knowing and using the CORE-34 risk items

There are six risk items nestled in amongst the 34 items that make up the CORE-OM

They are:

  • Item 6 ‘I have been physically violent to others’
  • Item 9 ‘I have thought of hurting myself’
  • Item 16 ‘I have made plans to end my life’
  • Item 22 ‘I have threatened or intimidated another person’
  • Item 24 ‘I have thought it would be better if I were dead’
  • Item 34 ‘I have hurt myself physically or taken dangerous risks with my health’

Each item is rated on a five point scale as, ‘not at all’, ‘only occasionally’, ‘sometimes’, ‘often’, or ‘most or all of the time’.

As can be seen, two items address risk to others, two items explicitly address suicidality – one focussing on what could be termed ‘passive suicidal ideation’ (‘I made plans to end my life’). The remaining two focus on self-harming behaviour, with one tapping into ideas of physical self-harm or self-neglect (‘I have hurt myself physically or taken dangerous risks with my health’). This latter category could, for example, include drug abuse, failure to take medication for a life-threatening condition, driving recklessly and so on.

We strongly advise therapists to scan the client’s CORE-34/CORE-10 measure in the first session to identify indications of risk on these items. If any item is scored above ‘not at all’, therapists should make a point of going back to the CORE questionnaire at some point during the assessment and asking the client to describe the nature and context of the risk.

If the client has disclosed the presence of risk on their questionnaire, it is now the job of the therapist to develop an understanding of that risk with the client and to work with the client on ways of managing it. It is worth noting that, if the client has failed to fill in the risk item (for example, all of the questionnaire is filled in except for the question ‘I have thought it would be better to be dead’), then it is important to ask the client about this item and about why they didn’t complete it in the questionnaire.

When the CORE-34 is repeated in therapy it can be used to track fluctuations in the various kinds of risk. Using the questionnaire items to screen for problems saves time as it is much quicker than asking the client verbally about the diverse risk and symptom areas covered in the questionnaire. It enables the client to rapidly indicate the presence, absence or salience of issues. This in turn enables the therapist to rapidly funnel attention and time to where it is most needed.

It is worth noting, that CORE-34 does not have a specific item on substance misuse, but that this often emerges in client’s responses to item 34 (‘I have hurt myself physically or taken dangerous risks with my health’). If you are using the CORE-34 as a tracking tool with clients who are prone to substance misuse. It might we worth explicitly linking their problems with substance misuse to this item (i.e. telling them that this question can include taking risks to the self as a result of substance misuse), so that it can become a vehicle for the client to feedback ongoing problems or progress in this area.

It is also worth considering how other areas covered in the questionnaire are related to risk. For example, risk of suicide may be more likely if a client also indicates a high score on item 23 ‘I have felt despairing or hopeless’ and item 26 ‘I have no friends.

9b. Knowing and using the CORE-10 risk items

CORE-10 is the ten-item shortened version of the CORE-34, which is designed for session-by-session tracking of client progress. In CORE-10 the six risk items in CORE-34 are reduced to just one and this is the item addressing suicidal intent.

‘I have made plans to end my life’ (item 6 on the CORE-10, item 16 on the CORE-34).

The reason for choosing this one item is that suicide is the gravest and most common risk faced by clients of most psychological services and this is the question that gives us the best opportunity of discovering what the client’s intentions are in this regard. Once again, any score above ‘not at all’ requires further enquiry on the part of the therapist. In practice, some clients interpret the question somewhat loosely and will tick ‘only occasionally’ on this item if they have been suffering from passive suicidal ideation with no actual suicidal intent.

Therapists using the CORE-10 on a session-by-session basis have realised that this item often highlights a heightened level of suicidal risk for a client, which they don’t believe they would have learned without the systematic enquiry provided by the questionnaire. Since there is only one risk item in CORE-10, it may be helpful to think with the client about any risk which may be associated with other items on the CORE-10, particularly item 2 ‘I have felt I have someone to turn to for support when needed’ and item 8 ‘I have felt despairing and hopeless’.

If risk to others or risk of self-harm needs to be tracked, CORE-10 is less useful as the CORE-34 items pertaining to risk of self-harm and risk to others are not included in CORE-10. In such cases the therapist could use the full CORE-34 as a tracking questionnaire.

As is the case with the CORE-34, the CORE-10 increases the likelihood of detecting risk of suicide (you often don’t learn if you don’t ask, due to the client’s feelings of shame) and when repeated it becomes a systematic means of ‘checking in with’ the risk without this taking undue time and emotional resource at the beginning of each session. Once a risk issue has been identified, then the therapist can engage in normal risk management and planning with the client. If risk is not detected it does not need to be a focus (unless there is other information suggesting it might be an issue).

10. The Therapist rating of risk in the Therapist Assessment Form (TAF) and the End of Therapy (EOT) Form.

In the CORE system the therapist completing the TAF is also required to assess risk. In short, the assessor is asked to judge whether there is risk of suicide, self-harm, harm to others, or’ legal/forensic’ risk and to indicate whether there is no risk, mild risk, moderate risk or severe risk. There is also a box to indicate if there is ’no data’ relating to these risks. Although this is not mandated by the CORE system, it is possible to link these severity levels with service risk procedures. For example, a ‘moderate’ risk score may indicate that a clinician should discuss this client’s risk with their supervisor.

One indication of the quality of a clinician’s use of CORE Net is the degree of agreement between client assessed risk and therapist assessed risk. Sometimes this may indicate that the therapist and client have different perspectives, both of which are important. This would be the case, for example, if a therapist indicates that there is risk of suicide, as a result of the client’s mental health history, which includes numerous and comparatively recent suicide attempts, but the client indicates that they are not experiencing any risk, perhaps because they have been doing well in recent weeks.

On the other hand, if the client has highlighted risks in the CORE questionnaire and the therapist has indicated that there is no risk in the TAF, then it is important for the therapist to consider and make sense of the client’s disclosure of risk in the questionnaire. It is possible that this discrepancy follows from the client misinterpreting the form and believing that it is referring to suicidal plans at any time in their life (rather than the last week). However, therapists obviously also need to check whether there is a previously undisclosed risk that needs to be discussed and managed. It is therefore essential for the therapist to look carefully at the client’s risk item on the CORE-34 when conducting the assessment and summarising risk information on the TAF.

It is worth reiterating that, even if the client has not indicated the presence of risk on the questionnaire, this does not mean that there is no risk. As always, the therapist needs to intelligently interpret the information they have and use what they know about the client’s context to make sense of the data.

Finally, the therapist is also required to re-rate the TAF risk items in the EOT Form at the end of the episode of treatment. As well as recording this information for the purposes of audit, this offers an opportunity for the therapist to reflect on any changes in the level of risk and also any risk issues which need to be discussed in relation to the ongoing management of the client’s risk (for example, letting the client’s GP know about the risk and discussing with the client ongoing ways of managing the risk – this would apply in the Community setting). In the Forensic setting this information would be shared with the appropriate body monitoring risk within the prison community.

10a. Using Risk Flags to identify who is at risk on your caseload

Client’s with self-identified risk in their most recent outcome measure are ‘flagged’ in the Client List page of CORE Net by a sad red face which appears towards the right-hand side of the page. (A score in the ‘clinical range’ for a client is denoted by a sad white face). A list of all clients presenting with risk can also be created by clicking the ‘flags’ button on the left of the Client List page. Flags can be created to identify various categories of client, but ‘at risk’ is the default display under the ‘flags’ button. This enables therapists, supervisors or managers to quickly identify clients who have risk issues for the purpose of supervision, case management or audit.

Please refer to the Appendix.

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