Forensic Document Information
APPENDIX
Whilst we all endeavour to obtain accurate and meaningful data on the clients we engage with, at the heart of our work is the quality of the therapeutic relationship we create with our clients. It is easy to get lost in data, but data itself can generate ways in which we can deepen these relationships
For example, in the area of the Therapy Assessment Form (TAF)
4b Contextual data – dates and episodes
If the client is attending for a second or third episode, we may have a better understanding of their problems if we explore why they have returned to therapy. This may be useful in both the Community and Forensic settings. Some areas to explore in the Community setting: –
Has their personal situation changed, or does it remain the same?
What didn’t work for them in the therapy they have had?
Did they have a problem with the therapeutic relationship?
Did they feel they could engage with the process at the time?
In the Forensic setting, the client may have been released or moved to another prison. In this instance questions like: –
“How was it for you to have to adapt to being with new inmates (if transferred) or being back outside in the community (if released)? How stressful was this for you?” or “How pleased were you to be outside again?”
“How did you feel when you were transferred/released when you knew you couldn’t get the therapy you wanted?”
“How did you find the therapeutic process that you had?”
4c. Contextual data – what other support has the client got access to?
Again, in the Forensic setting, the support a client has can be a valuable insight into the client’s psychological wellbeing.
If the client states, for example, that he was homeless, there are questions that can help you to explore his experience of this.
How long was he homeless for?
What support did he have access to, for example, could he go to a night shelter, did he have access to food on a regular basis or did he encounter violence on the streets? What was the impact of this on him? Did he feel particularly vulnerable with the Police knowing he had a criminal record?
Does he feel trapped in prison but also fears release back into homelessness?
Does he have information on services that can help him when he is released?
The following organisations deal with homelessness and the information may be useful to pass on to clients:
Centre Point – Tele: 0808 800 0661
Citizens Advice – Local number
Crisis – 0300 636 1967
Shelter – 0808 800 4444
These organisations will direct people to local areas for help.
For ex-servicemen there is the British Legion, The Veterans Charity and the Soldiers, Sailors, Air Forces Family Association (SSAFA). All have local branches for information.
In the Community setting the support a client may have can also give a useful indication about the client’s psychological wellbeing.
If a client lives alone, is this by choice, or have they been forced into this situation, for example, by divorce or poor family relationships? How isolated are they feeling?
Do they have any family or friends nearby that can offer support?
Are they estranged from their family? If so, what impact is this having on them?
Have they been able to seek help from their GP? If so, what help did they get, for example, what medication, if any?
5a Brief Description of reason for referral
The data included in this area can be very useful in providing information when reviewing a case, especially if some weeks have elapsed since you last saw your client.
For example:
In the Community setting –
If the description merely says, ‘Client is low in mood,’ this can be enhanced by the Therapist writing ‘Client was low in mood due to present disruptive family situations’ This gives more detailed information as to why the client’s mood is low at present.
‘Client is depressed’ could change to ‘Client is depressed due to threat of redundancy or deteriorating health etc.’
A more meaningful description may be particularly helpful in the Forensic setting when a client may be seen by more than one therapist.
One of the most ticked boxes on the CORE Measures, other than depression and anxiety, is the one that relates to bereavement.
Examples:
If the description says, ‘Bereavement issues,’ this could be clarified further by saying ‘Bereavement issues related to loss of child/wife 2 years ago’
A client who is still grieving 10 years after a death, may require the therapist to do some further gentle exploration as to what may be continuing to trouble the client after this length of time. For example, are they feeling guilt about something they may have done? Was the relationship with the deceased a difficult one?
The CORE-34 and the CORE-10 Forms
The client’s response to the questions on these forms can form a large part of the Assessment session as they indicate the problems the client is currently experiencing and although the forms explicitly request information of what the client has experienced over the last week, the therapist may well find that the client has been dealing with these problems a great deal longer.
Questions like-
‘I have felt tense, anxious or nervous’ (No. 1 on CORE-10, No 2 on CORE-34)
‘Why do you become anxious, what makes you tense or anxious?’ ‘What happens when you get anxious?’ ‘Does your body react in any way?’
‘I have felt despairing or hopeless’ (No. 8 on CORE-10, No. 23 on CORE-34)
‘What is it like for you not to feel any hope for the future?’ ‘What would need to change for you to believe that your future could be different?’
‘I have felt I have someone to turn to for support when needed’ (No. 2 Core-10, No. 3 CORE-34)
If the client answers ‘not at all,’ what is his/her sense of aloneness right now? What family or friends did they have that they can’t contact now and why?
As you explore the questions on both these forms no doubt you will realise the kind of potential there is for enriching that first session with the client and how much information can be obtained in the process. Perhaps going through the notes have inspired your own thoughts as to how you may work in the future. However, although the above examples have been given to support therapists in their work, there will inevitably be situations that will not allow therapists to work in a way that they would like, so please don’t become anxious in any way. The key is to complete as much data on CORE Net and keep this data updated with each client session.
