Need Assessment: II Making an assessment, 1970

Barbara Dockar-Drysdale.

The particular kind of need assessment which I shall be discussing came into being as the result of a collection of experiences, working in a consultant role in a school for deeply disturbed and deprived children (the Mulberry Bush) and in a therapeutic community which has evolved from an approved school (the Cotswold Community). At the Mulberry Bush I evolved a type of reporting which I called ‘context profiles’. When making a context profile, the whole team consider one child, chosen by the team, for a week. Each member describes any actual personal experiences which he has had with this child: observations are not allowed. I myself have a therapeutic session with the child concerned during the week. All notes are brought to the school secretary, who then types the material and circulates the notes to the team and to me, so that we can meet at the end of the week to discuss our experiences, drawing conclusions from the material and gearing a treatment programme to the needs which become apparent. Donald Winnicott made the valuable comment that, by using this method, the team can for an instant see the whole child, because all the ‘bits’ are brought together in the profile – not only the bits of the child, but also all our feelings about him. Following the discussion, all the notes are arranged in a classification on context: thus all ‘getting up’ experiences are together and ‘mealtimes’ and ‘bedtimes’ are treated in the same way. Since each person may have very different experiences, the outcome is a study in depth of the child and ourselves, attempting to avoid the snares of pseudo-objectivity.

From the work on one child, light is often thrown on the needs and treatment of others. The context profile discussion is recorded on tape (the notes are typed in advance) and the whole profile is arranged as described, by our secretary, Mrs Connie Barrett. Ultimately we have something valuable both to us, to psychiatrists, and to newcomers to the team. The work, however, is time consuming, and nowadays we decide to do a profile only when we are especially puzzled and concerned about a particular child. I found that in order to make use of a context profile (at a clinic, for example), I needed to make an analysis. This I did by asking myself certain questions, to which I found answers in the material. Working in parallel at the Cotswold Community, I showed the teams of the various houses how to make context profiles. Here there are four teams (instead of one, as at the Mulberry Bush) and very little secretarial help. There is, inevitably, more coming and going of the adolescent delinquents (because of court orders, up to the present) and in any case, I only meet these groups at the Cotswold once weekly, whereas I meet the Bush team twice weekly. All these factors made the task of writing profiles very difficult.

At the Bush, selection has always been based on primary deprivation, so that we are carefully selecting unintegrated children for treatment. At the Cotswold, referrals are mixed – integrated and unintergrated – with a much larger unintegrated group than we originally realized. We have found that it is essential to classify boys on arrival as integrated or unintegrated as soon as possible, and it was in order to make this possible that I tried to plan a need assessment. I hoped this would categorize, consider the stage of integration reached, and formulate needs and the treatment to meet these needs.

I decided to use exactly the question which I ask myself when analysing a profile. This meant employing a certain amount of terminology, but I improvised a glossary (I find terms necessary as a kind of shorthand; otherwise one is employing essays instead of term). I reached the decision to use these particular questions because I had arrived at them through actual relevant experience: in the event, they proved of use. No doubt in time, we may ask some more questions and omit existing ones: the whole idea is still at a workshop stage, but perhaps for that reason it calls for discussion and experiment. We may also find clearer terms, but since these words are the ones which I employ at present, I have let them stand, with explanation.

Classification

The process of arriving at a need assessment is described in detail below. I have tried to approach the problem of meeting the child’s needs – whatever these may be – by classification (rather than by considering his symptoms). I think it will always be necessary for a senior worker to lead such a group discussion, asking and explaining the questions, and recording the answers. There can be no ‘yes’ or ‘no’ answers: all replies must be based on actual experiences with the child. We have found that this kind of assessment helps us in planning for the child’s management and care. A need assessment in no way replaces other assessments (case history, intellectual ability and so on), but I find it a valuable addition to other information.

The questions in the assessment can only be answered for the first time by a group of people who are living with the child, and have been doing so for at least three or four weeks: they must understand that this is a first need assessment – others will be necessary in order to meet the child’s evolving needs. Only a group of resident workers can draw on the kind of experience essential to this type of assessment.

The questions may seem odd at first, but they seem to obtain the kind of information necessary, and workers quickly become accustomed to this approach. A need assessment usually takes an hour of group work to complete. Is this child integrated as a person, or is he unintegrated?

To judge this, one should ask oneself:

• Does he panic? By panic, I mean a state of unthinkable anxiety – almost a physical condition. (Many so-called ‘temper tantrums’ are panics.)
• Does he disrupt? By this, I mean does he disrupt a group activity or a happening between two other people?

It would appear, from evidence so far, that the presence of panic and disruption fairly frequently in a child’s life justifies us in considering him, for the present, as being unintegrated.

If you are sure that panic and disruption are rarely experienced, then go on to the next section, in which the needs of integrated children are considered.

Unintegrated Children

If he seems to be unintgrated, go on to the next question.

1. What is the syndrome of deprivation?

   This can be judged by answers to the following questions. What is the state of feelings in this child in regard to:

   • Personal guilt
     This refers to concern; to what one could call healthy guilt-not a fear of being punished or found out, but an acceptance of a personal responsibility for harm done to others, of a kind which can lead to making reparation.
   • Dependence on people or a person
   • Merger
     This is the way in which some children become merged with one other or with a group (a typically delinquent phenomenon).
   • Empathy
     I like to think of this as being a capacity to imagine what it must feel like to be in someone else’s shoes, while remaining in one’s own.
   • Stress
     How does this child appear to deal with feelings of stress?
   • Communication
     Does he really communicate, or does he just chatter in a stereotyped way?
   • Identification
     Does he, for example, seem to model himself on a grown-up he admires, or on another child? Be careful not to confuse this with merger.
   • Depression
     Is he sometimes very depressed, or is he indifferent, or always apparently cheerful? Is he at times deeply sad? There is a kind of state of low level of consciousness – just ‘ticking over’ – some – times even in deprived children, which I call ‘hibernation’ and which should not be confused with depression.
   • Aggression
     -verbal and physical

2. What is his capacity for play?

   • Narcissistic
     Does he play a lot alone, with pleasure?
   • Transitional
     Does he, for example, make use of a transitional object?
   • Pre-oedipal
     Does he usually like to play with one other, usually a grown up?
   • Oedipal
     Does he play with more than one grown up at a time?
   • Post-oedipal
     Does he play with other children, able to keep rules, and so on?

3. What is his capacity for learning – in every sort of learning situation?

   Does he learn from experience?

4. What is his capacity for self preservation?

   Is he accident prone? Does he take care of himself and his belongings? Does he seem to valve himself?

From the material it is usually quite possible to make a good guess at the stage of integration reached. The stages are as follows:

a) Frozen
b) Archipelago
c) False-self
d) Caretaker-self

(On this ‘inside diagnosis’ a need assessment can be made. There is nothing absolute about such recommendations; we cannot be certain, but this assessment gives us a foundation for a treatment programme.) In general, one could say that the needs of these categories are as follows:

Frozen.
Containment, especially of self-destructive areas. Mergers to be interrupted.

• Delinquent action to be anticipated – essentially, confrontation in advance, i.e. knowing what the child is going to do.
• Acting out to be converted into communication.
• Dependence on grown – ups to be established.
• Delinquent excitement to be changed into oral greed.
• Depression to be reached, and supported, following a capacity for personal guilt.
• Open communication – with one; with others.

Archipelago.
To relate one ego-functioning islet to others, through communication.

• Containment of non-functioning areas, e.g. panics.
• Support and encouragement of any functioning areas.
• Provision of localized regression where needed, with reliable adaptation.

False-self.
Containment of chaos within the shell. Provision of regression, always planned and localised, with reliable adaptation. Symbolic communication.

Caretaker-self.
Provision for localized regression, reached through cooperation with the ‘caretaker’, in the care of the real self.

• Symbolic communication.
• Localized adaptation with as much communication as possible between grown-ups and child.
• Functioning areas should be strongly backed.

The particular form which primary provision should take will depend on the personality of the child and on what he indicates, however indirectly. There will need to be the verbal and pre-verbal communication.

There must be reassessment quite frequently – whenever fundamental evolvement is noted, or indeed any real change for better or worse.

Integrated Children

Where the original classification indicates that the child is integrated, the position is very different and need assessment is more complex. We can say with certainty, however, that an integrated, neurotic child will need from us:

• Ego support, especially where there is under-functioning: e.g. with doubtful, anxious children.
• Reliable parental figures, on to whom he can transfer the unresolved conflicts in regard to his parents.
• Ways in which he can make positive use of aggression.
• ‘Open’ communication, and the opportunities for conversation of acting-out into verbal communication.
• Encouragement and opportunity to accept responsibility as an individual in a group (here ‘shared responsibility’ becomes very important).
• Acceptance of reparation, and help to reach this reparation.
• Help in modifying a harsh super-ego.

Nevertheless, need assessment for the integrated children will be far more individual and must be considered in great detail.

Notes

1. I have considered especially the needs of unintegrated children, because so many of the children we are trying to help are in fact only partially integrated, and these are the ones who present the greatest problems of management.
2. Please bear in mind that this is only an experimental draft which will need to be developed as a result of experience. Suggestions and alterations will be needed.
3. I have said nothing about symptoms, because this fails to reach needs, not their symptoms.

Here is a need assessment on Lilian, carries out by the Bush team working with me. (At the Cotswold Community, some teams are doing need assessments by themselves, so that we can discuss the material when we meet.)

Lilian’s Need Assessment

Classification

What is the state of feelings in Lilian in regard to:

Guilt (guilt really means concern). There is a compunction in regard to wrong or hurtful things which she has done, which does not seem to stem from fear of punishment.

Dependence on person or people (this category includes trust). Lilian is able to be independent on individuals and also is able to be dependent on the Mulberry Bush. (Example: it is not now necessary for her to be sick on returning to the school; she does not have to test all the time, because expectations are established.)

Merger. Yes, she does merge. More with individuals, but occasionally with the group. One could use the term ‘passive merger’-she passively accepts being used.

Empathy. There is a possible capacity for empathy. Sometimes, perhaps, it might be projective identification.

Stress. Under stress, Lilian is liable to break down in to states of panic rage, although this is rather less in evidence than at an earlier stage. (When in one of these states she will bite, she will spit-it will be all over her face, she will throw around everything in the room.) She can sometimes contain and communicate stress.

Communication. Lilian is capable of direct communication: at certain stages it is possible for her to communicate even when under stress.(Example of direct communication: when the group came back from a school outing, when the children were very tired, Lilian said, ‘The trouble is, I hate my sister and she hates me.’)

Query as to whether her long monologues are communication or a defence against communication. There is considerable – sometimes there are flights of associations based on the immediate context or environment. Sometimes mode of communication resembles that of one very old.

Identification. Her mannerisms, the way she walks, seem very like those of an elderly person. Lilian does not much appear to be identified with people here; identifications (what there are) come from her past and her background, rather than from anything that has happened here.

Depression. Very sad a lot of the time: tinged with self-pity. She rather enjoys sorrowful, tearful, woeful things; enjoys the feeling of being sad. (When the saddest things are on television her face is lit up with pleasure!) This is more likely to be primary masochism.

Aggression. Her form of movement could be seen as fairly aggressive. Not really aggressive unless provoked-aggression seen in self defence. (Example: Sheila slapped Lilian’s face and Lilian called Sheila a ‘black bitch’, Sheila slapped her face then for this, Lilian again called Sheila a black bitch, and this just went on and on.) Lilian displays a certain courage to the point of living dangerously, but seems quite unaware of the place in the hierarchy of children. The worlds ‘angry’ and ‘outraged’ apply to her attitudes.

What is her capacity for play?
Narcissistic; mainly narcissistic, just beginning to be able to play on her own but in a group – but this is still alone.

What is her capacity for learning?
She does not seem very able to learn from experience; she cannot avoid disaster even when shown step by step what is going to happen to her; she goes on with her basic assumptions. There is some learning capacity in group: she can do simple sums and write figures, although she is unable to read or write. Although there is some learning capacity for number work, in general she has a very low capacity in all areas. Must take into consideration her low I.Q. and deafness – both of these factors could aggravate this inability to learn. (With very high motivation, some learning has taken place – she can now decide what she wishes to spend her 5p on in the tuck shop.)

What is her capacity for self preservation?
Lilian shows signs of physical self preservation, but not of emotional self preservation. She does use adults to protect her, is not accident prone.

Stage of integration reached

False–self. This after much discussion but within the confines of the headings; given, the collected data indicated false-self child, but with some evidence of a real core.

Need assessment recommendation

We should support any area that is functioning. Containment of chaos within the shell. Provision of regression, always planned and localized, with reliable adaptations. Symbolic communication.

Other recommendations

This child’s I.Q. is so low that this could be the wrong school for her; there is the added problem of her deafness. One cannot overlook, however, that whatever her problems here, they will be equally valid in, say, an E.S.N. school.
The strain, for Lilian, of being here with children of higher intelligence, could be too great and her need could be somewhere where the whole thing would be geared to a lower I.Q. and to deafness.

Despite the handicaps she has clearly benefited from being here, and it might not be in her best interests to lose what she obviously gains from the Mulberry Bush School and us.

How much regression has Lilian had here, and has she indicated a need for regression? We assume that for a false-self child to recover, there must be regression – they have got to go to bits and then come together and start off again. From the fact that she tries to get in on the act (i.e. wanting to have German measles when Susan had them: saying she had wet the bed, etc.) it could well be that she is looking for some means of regression.

Is Lilian able to indicate adaptations, and are there any available for her? Felt she would like a good adaption made available: there is quite a bit of regression going on around and she takes full advantage of this.

The position is that is she going to need a real regression, a lot of adaptation and a lot of very early experience, very definite focused primary provision for quite a time; this would be the only way in which this particular syndrome would evolve: equally, we may feel that this isn’t something that we here can provide because of the added factors of the low I.Q. and the deafness, which may make it really impossible, if so, then we will have to think of other placement. If, however, she is to stay here, it could only be on a basis of real regression, and to what extent this is possible, and how, with someone like this, I don’t know. One would say the need assessment is adaptation leading to regression with the beginning of integration following: a very big regression and then reforming, not reaching conceptualization (so many children do, after regression) – she would realise what she had been through, but she wouldn’t be able to think it out. But she could make use of a regression.

You may be interested to know that, after the assessment, the team was in a better position to understand and meet Lilian’s needs, and progress has been made in her treatment, so that it seems likely that she will stay with us, and that her regression will be reached.

You will notice that the first classification – whether integrated or unintegrated – is made on the presence or absence of panic and disruption. There is a further clue in the question relating to ego functioning, ‘Is there a capacity for empathy?’ (not to be confused with projective identification). Should one at that point find clear evidence of empathy, one should return to the question of panic and disruption, since it may be, for example, that acute but contained states of anxiety have been mistaken for panic.
You will also have noticed that we are primarily concerned with state of mind rather than behaviour. Symptoms turn up in discussion, but these-especially acting out-are considered as broken-down communications of state of mind; our treatment plans being based on the needs which the broken-down communications indicate.

Of course, in using need assessment within a residential unit, we assume that other appropriate information is already either in our possession, or at least readily available. A series of need assessments can only be used in a residential place by a team working together and living with the child. I suspect, from my own experience as a consultant, that a wealth of valuable material is available in any children’s home, but that child care workers need a professional structure and discipline in order to communicate and organise reports which will lead to appropriate treatment programmes. This is equally true both in approved schools and in schools for maladjusted children.

Here is another need assessment, on a recovering boy, who was so unintegrated and dangerous on referral that we wondered whether we could hold him. He was on referral what I have termed an ‘archipelago’ child, who progressed to become a ‘care-taker self’, and is now precariously integrated. It is very interesting to see phases of development belonging to the first year of life, turning up during treatment.

Bruce’s Need Assessment

Classification

Integrated: Perhaps barely. Does not panic (psychotic area could be quite large). Disrupts in a very conscious way.

Guilt. Yes

Dependence. Yes

Merger. Very much diminishing – certainly meeting him, one gets a very clear impression of identity.

Empathy. Yes

Stress. Depends very much on the relationship formed with grown-up with him at particular time. If he meets a stressful situation involving other children, he will now preserve himself: with a grown-up he can on occasions tend to trust in the grown-up to cope with the situation for him.

More and more, when he is anxious, frightened or angry, this results in an inturned situation where he goes silent (what one could call an ‘inplosion’) and takes the trouble in with him, then, with encouragement, it comes out with a rush, shouting, i.e. an explosion. (He is further ahead than we could have ever hoped, when we think of all the ghastly things he used to do at the slightest stress.)

Communication. Pretty good, both verbal and non-verbal: particularly non-verbal. He uses looks as a very conscious tool, gestures – he knows he has an expressive face, and uses it.

Identification. Yes, in a positive sense. (With his group teacher and with his father, but as two clear and distinct things; he consciously separates group teacher (Brian) and father.)

Depression. Yes – quite sad. Suggestion that manic flight could come in here, when he throws things, etc., much laughing, all a flight from feeling personal guilt and depression.

Aggression. Yes. Incident with Bill and a very angry Bruce chasing him with a piece of glass: Robin felt on this occasion that Bruce would have used it if there had not been intervention. Still doubt really as to what Bruce may or may not do – and to what extent intervention on all occasions is justified. (this is a child who has been given cause for murderous rage at home; what this step-mother has made his father into is one of many reasons.) He is still capable of what seems to be less than conscious destruction.

Comment from myself: A psychotic area of a person is something that is not capable of evolvement. The violent bit of him even might eventually be accepted by him and others as a mad bit, rather than an unintegrated bit.) He tolerates his step-mother now, for the pleasure of being with his father.

What is his capacity for play?

Narcissistic. No longer: does not now play on his own with his soldiers, no longer plays with lots of little pieces but prefers one larger thing – a bike, a gun or a football.
Post-oedipal. Not over good, but he does manage.

What is his capacity for learning?

Academic. Had his step-mother not destroyed his pleasure in learning, he would be much more receptive. He could do with time entirely alone with a teacher, when he is capable of learning a great deal very quickly. One needs to overcome his unpleasant associations with learning, and combine this with skillful teaching and he should flourish.

Reading. Reading age has gone up 1 ½ years in the last year, and 2 years the
previous year.

Numbers. He likes number work and is prepared to do it. He uses it as a medium of identification with his father (who is in electronics). He still has a relatively short attention span, which is a handicap.

Learning from experience. He is wily, aware, and knowledgeable, very quick. An example was concerned with the sheepdog trials at the church fete. Brian set out to explain the routine to Bruce as he might to his own son, who is aged six. Bruce interrupted, saying, ‘Don’t go on, it’s a code.’ He can pick up the whole notion or idea immediately – a great capacity for learning.

He provokes other children: he calls it ‘starting trouble’ I suggested that this is the only way he can get attention from his father at home, by ‘starting trouble’. Father appears a very detached man. Feeling is that Bruce can now relate to a man, father is getting a transference as it were; evidence of more warmth from father on recent visit here. So able to communicate with father, and father is able to respond: emotional change in Bruce (rather than maturation has made this possible. (I recalled the first meeting with Bruce and his father: it was chilling. There was no connection whatever between these two: this great tall man and this tiny little shrivelled up tadpole sitting at some distance from his father; and one couldn’t see what on earth they had in connection with each other … although his father was concerned, worried about him, wanting to do something.)

What is his capacity for self preservation?

Very much more self preservation than he was. This seems to stem from when he deliberately cut himself deeply with a sharp balsa knife. Group teacher would have like to have made it a significant thing but was wary of doing so. When Bruce starts trouble now, it is consistently pointed out that he does more harm to himself than to other people: recently he has been able to say ‘Why?’ and we are able to go through the things that he is doing to himself when he started these situations: now he is able to give up with a smile, grin or wink as a communication that he has not finally, irrevocably hurt himself that time. (I wondered if a lot of the going-on was to gain attention…. At one time he may have felt that the only way he could obtain attention from his father, or any man, was to hurt himself; hence his quite accident-proneness when he first came to us. We really felt it was too dangerous for him, for us to keep him here.)

Capacity for self-preservation is now quite good, although there are moments when he contemplates suicide quite consciously: before it was not conscious but was as if something overwhelmed him; so there are still suicide elements which could come into the mad bit of him. The suicide bit now tends to come when he is depressed or sad: he is fascinated by death. He is attempting to preserve himself, but the battle to maintain himself is great.

There is a refusal to grow, a refusal to get better.

Summary

From the above material this would seem to be a more or less integrated child, with a mad area, who would be left permanently with a suicidal tendency, or a tendency to murder (this would be incredibly impulsive). These are dangers of which he must gradually, as he grows older and stronger, become more aware and be something of which he is conscious and can take precautions against.

The acquisition of knowledge is very important to him and with this he will achieve a great deal in his own eyes: a great boost to his morale. He has an incredible agility of mind.

Felt that if he could win an intellectual argument with his mother, this would make the world of difference to his self-esteem in the home situation: or, if he could teach his mother something (say, chess) and she could stand being taught by him – if this could be ‘sold’ to her as the most beneficial thing she could do, to allow him to teach her something . . . John doubted that she wanted to do anything beneficial. He has got to be put in a position where he is independent of her from this sort of standpoint, and able to hold his own.

I went through the listed needs of integrated children. Extra comment on ‘Help in modifying a harsh super-ego’, i.e. help in replacing the punitive super-ego, which he has certainly got, by a more benign one, which one hopes he will incorporate from his experiences with us.

Group teacher commented on his responsibility within group which is showing signs of developing. He was asked by another child in the group what the difference between a Big and a Small was. Bruce’s reply was a ‘small somebody starts something, and a big somebody stops it’.

About reparation, as this could be important: he will give a grudging ‘sorry’ with no heart in it whatsoever; there is evidence that he feels concern.

One of the main things then is to help him to obtain, contain and make use of, as much knowledge as possible as is going to be of use to him in living his life, and to modify the super-ego as far as we possibly can; and to find ways of helping him to reach a capacity for making reparation, because this is something he is going to need to find – and it has got to do with the depressions, of course, because the suicidal bit has partly got to do with the impossibility of making reparation (there are all sorts of other side issues as well). He must feel that what he has done is irretrievable . . . in fantasy he must have committed many murders, so anything one can do that makes it possible for him to feel that reparation can be reached would help him more than any one other single thing. This will help him to tolerate consciousness of the bit of himself that may remain dangerous to himself and others.

Our aim is to need assessment files, which will include the whole of the current population of a unit. These will be followed by later assessments, whenever these seem appropriate. We shall then be in a position to consider grouping in terms of emotional compatibility, and to avoid – what happens only too often – the disruption of an integrated group through the presence of a couple of ‘frozen’ ones, who are not only unable to get help themselves in this setting, but who will make it impossible for others to be helped.

I am well aware that there is a time factor involved, and that, as a consultant, my discussion groups with staff are built into the framework of the organisation. Nevertheless, I cannot feel that these are the only circumstances in which need assessments can be made; and indeed, groups working under the leadership of the head of the house have been able to produce excellent assessments. All the same, I incline to the view that every residential unit should have consultancy available to help and support staff in their difficult task. I would suppose that one of these days there will be a training for consultancy in residential work, for which many social workers would be suitable candidates – but that is another story!

It would seem that in undertaking the task of assessment, no one person should be asked to do this alone; and that assessors, avoiding omnipotence in themselves, should not drift into collusion with the omnipotence of others as a means of escape from an intolerable load of responsibility.