Training

Core OM – Questionable use of questions in therapy?

This year I had an increasing number of clients referred to me after first completing a psychotherapy evaluation. I began to notice that a number of them commented that they felt significantly more distressed after the evaluation. This then led me to look into what kinds questions that were being used during these assessments and as somebody who is aware of the impact of language I was quite shocked to see how many of these questions were framed.
Nick Kemp bw
In my opinion the questions used are often poorly formulated in that it is very likely to either reinforce the client’s problematic behaviour or worse still generate additional distress on top of what they are already experiencing.
One example of an evaluation questionnaire is the CORE-OM. These questions known as “The CORE-OM have been widely adopted in the evaluation of counselling and the psychological therapies in the UK.
Before you read on, let me make it 100% clear that there are many excellent psychologists and this is an observation and discussion about how these questions are framed, not a criticism of the psychotherapy field as a whole! I also fully accept that no system is perfect, but I do think that this is a useful subject for discussion and that all professionals involved in mental health have a duty to constantly be revising and reviewing what they say and how they communicate with clients.

The Core OM and the Core 10 Questioning Systems

Core 10The Core – om system has 34 questions* The stripped down Core 10 version (those highlighted in bold below are the Core 10 questions) is described as “part of a minimum data set that will enable services to meet the requirements of the Balanced Score Card with the least burden to clients and services.” Clients are asked to score each question on a “most likely to not at all scale”
Here are some of the instructions given to the practitioner in order to evaluate the client
“The CORE-10 is very easy to score and with a little practice you can do it almost instantly, in-session with a client, without needing to wait until afterwards. It comprises ten questions about how the client has been feeling over the past week.
1. When the client gives you back their completed questionnaire, check they have answered all ten questions. If they have missed one, check whether this was deliberate (and ask them to complete it if it was a mistake).
2. Each answer has a number next to it between 0 and 4. Simply add up all ten numbers to give you a score between 0 and 40. This is the total score
If your client declines to answer a question, you’ll need to calculate the average of the remaining answers and multiply by ten to get a comparable 0-40 score. For example, a client answers only nine questions for a total of 21. Their average is 21÷9, or 2.33. Multiplying by 10 gives 23.3 as their total score.”

How Core OM is used (taken from www.coreims.co.uk)

“Independent users typically introduce CORE into their service through the use of the CORE Outcome Measure rather than the full CORE System. It’s understood that this appears an attractive start to service evaluation as it has minimum impact on practitioner’s time, whilst providing an opportunity to collect data that profile therapy outcomes. In practice this typically means that either a service administrator or practitioner invites each client to complete a CORE Outcome Measure when they attend their first session, and again when they attend their last. On average this takes the client little more than 5 minutes on each occasion and provides a clinical profile of the symptoms, quality of life, and subjective well-being of the client, as well as an assessment of the clients’ risk to self and/or others.
Unfortunately, talking to independent users it appears common that the results of outcomes monitoring can often be something of a frustration. Firstly, this is because practitioners have differing levels of comfort and (hence) success in introducing routine outcome measurement to their clients, Secondly, on average less than half of those completing a CORE Outcome Measure at the beginning of therapy complete a measure at the end of therapy 10, and thirdly, the proportion of people who cannot be shown to have demonstrably benefited from therapy can be higher than expected and raise questions that require more detailed evaluation. The combined impact of these three findings can mean that as few as one-in five clients can demonstrably be shown to have benefited from therapy,”

Why I see this might be problematic in helping the client

core 10I fully appreciate that that any talk therapist or coach needs to get information from the client, BUT there’s a fine line between doing this and unwittingly creating even more problems for the person seeking help! Also how this information is communicated will make a massive difference on the feedback. If clients are handed a form and simply read the information you’ll get one set of information, whereas if these questions are asked by phone or in person (and let’s remember voice inflection will also be a massive bias) you will get an entirely different response. Yes as I have already said, no system is perfect, but I have to ask whether those who constructed these questions might want to review how these questions are constructed.
Many of the questions listed below are standard psychotherapy questions but in my opinion a large number of them are linguistically very poorly framed. Many of them would in my opinion be highly likely to take the client even further into the very problem state they are seeing to resolve! In this internet age increasingly clients self-diagnose and form erroneous conclusions, fueled by focusing increasingly on “what else” might be problematic.  When a client is in a state of distress they become very susceptible to any suggestions made by therapists and practitioners. One of the keys to assisting a client is to be able to move their focus of attention from the unhelpful old ways of thinking and feeling, to something more useful.
This means what Frank Farrelly (the creator of Provocative Therapy) wonderfully described as avoiding “the psychotherapeutic archeological dig” (Frank worked in clinical practice for 50 years having originally trained with Carl Rogers.)
These Core OM questionnaires also only focusses on the last 7 days, so is essentially a very brief snapshot of what the client may report experiencing.

*The Full list of 34 Core – OM questions

Here are the standard 34 questions that can be asked.
Over the last week
1 I have felt terribly alone and isolated
2 I have felt tense, anxious or nervous
3 I have felt I have someone to turn to for support when needed
4 I have felt O.K. about myself
5 I have felt totally lacking in energy and enthusiasm
6 I have been physically violent to others
7 I have felt able to cope when things go wrong
8 I have been troubled by aches, pains or other physical problems
9 I have thought of hurting myself
10 Talking to people has felt too much for me
11 Tension and anxiety have prevented me doing important things
12 I have been happy with the things I have done.
13 I have been disturbed by unwanted thoughts and feelings
14 I have felt like crying
15 I have felt panic or terror
16 I made plans to end my life
17 I have felt overwhelmed by my problems
18 I have had difficulty getting to sleep or staying asleep
19 I have felt warmth or affection for someone
20 My problems have been impossible to put to one side
21 I have been able to do most things I needed to
22 I have threatened or intimidated another person
23 I have felt despairing or hopeless
24 I have thought it would be better if I were dead
25 I have felt criticised by other people
26 I have thought I have no friends
27 I have felt unhappy
28 Unwanted images or memories have been distressing me
29 I have been irritable when with other people
30 I have thought I am to blame for my problems and difficulties
31 I have felt optimistic about my future
32 I have achieved the things I wanted to
33 I have felt humiliated or shamed by other people
34 I have hurt myself physically or taken dangerous risks with my health

So what might be better questions worth asking?

core omOf course it’s easy to criticize any approach or series of questions, as any intervention can introduce bias, but without intervention it is also hard to assist, or to demonstrate that assistance has occurred, but here are some other suggestions that are not so leading for the client. I have listed the original core 10 question and then follow it by a possible alternative. The alternatives are simple suggestions framed to get the client to focus on something other than the previous problem state.
I have felt tense, anxious or nervous becomes “I would have liked to feel less tense, anxious or nervous”
I have felt I have someone to turn to for support when needed could be “I would have liked to have more people to support me when I need support
I have felt able to cope when things go wrong becomes “I would have liked to be able to cope even better when I experience challenges in life”
Talking to people has felt too much for me could be “I would have liked to be more confident in talking to people”
I have felt panic or terror could be “I want to feel more confident in situations when I used to feel panic or terror”
I made plans to end my life could be “I have in the past considered ending my life”
I have had difficulty getting to sleep or staying asleep could become “I want to be more able to sleep in a restful manner”
I have felt despairing or hopeless becomes “I want to move on from any feelings of despair or hopelessness”
I have felt unhappy could be “I want to learn how to focus on what makes me happier in life”
Unwanted images or memories have been distressing me becomes “I want to learn how to free myself from old memories and images that have distressed me to date”

Final Thoughts

When clients seek help, they are in a distressed state. It’s useful to gather information, but crucially getting the client to only focus on the past is not helpful in changing the client’s responses and behaviours. When I asked the psychotherapist about the client who felt worse after being asked the core 10 questions the response was “Yes they are not great, but it’s what we have to ask” I respectfully disagree and would politely suggest that there are far better alternatives worth considering…
Nick Kemp
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