Step 1: Re-Design Your Referral Qs

Families come to us when they are lost.


They’ve been on a journey, and the road has been different than they imagined. Or, they’ve stumbled along the way. Now they aren’t sure exactly where they are. They don’t know which way to turn. They can’t envision the road ahead.


By sharing their stories with us, families trust us to help them pinpoint where they are. They trust we can point them in the right direction. They want guidance from someone who knows the landscape, and who has helped travelers like them before. They want perspective. A bird’s eye view. Signposts.


Families want a map.


We use our evaluations to show families the way forward. Our reports are travelogues and travel guides. They are verbal atlases, charting where their child has been, where she is now, and where she’s going. They are maps.


What I’ve discovered over years of writing these maps is an idea that changed my professional life:

There are many ways to make a map. How you choose to make your maps changes how you help families and how you write reports.

Here are four different ways we can guide families, which I’m going to call the “Four Mapmaking Frames.” When we guide families, we can be a scout, a surveyor, a cartographer, or an explorer.


Each frame has a different perspective, and different ways of helping a family. While all four frames are helpful, each successive frame gets a little deeper, more comprehensive, more helpful. So when you can, go deep.

The Four Mapmaking Frames

Each frame also leads to directly to different referral questions.


Let’s take a look at how that works.


When families come in to see us, we know our first goal is to translate their worries, fears, secret questions, agendas, and requests for help into a Reason for Referral.


We combine the words they say with all that they cannot say, and all that they communicate to us nonverbally. We mix that with our intuition and clinical experience, and shape it into questions our assessments can answer.



The frame we think from implicitly guides how we shape the family’s concerns into specific referral questions.


Let’s think for a moment from each frame.

Scout:

A scout is familiar with the landscape (or has peeked ahead), and she tells the group what she knows. A scout draws a basic map of the route, labels important places and landmarks, and points out the path that seems like the best way forward.


When we think as a scout, we shape the parent’s referral concerns into questions about diagnostic clarification and treatment planning. This is the perfect frame if there is a very narrow and specific question our testing can answer. This may also be the right frame if we are screening individuals in the community, or if we are deciding who needs to have access to a program or services.

Some specific questions we might collaborate with the parents to ask when we’re thinking as a scout are:

  • Does this child meet criteria for a specific learning disability (or autism, ADHD, anxiety, etc)?

  • Is she eligible for this specific program or service that helps children with her diagnosis?

  • What are the standard best-practice recommendations for the diagnoses she meets criteria for?

  • What information and resources can I provide about those diagnoses or point the family towards?

When we hold these kinds of referral questions in mind during our assessments, we naturally focus the interviews, the testing, and our reports on DSM-V/ICD-10 criteria or service eligibility criteria. When we use this frame, we match our recommendations to the diagnoses we provide.


In practice, the scout’s recommendations are usually a long list (sometimes multiple pages’ worth) of suggestions for each diagnosis we’ve provided. This list is often something we’ve borrowed from other psychologists, books, or websites. We lightly edit our list for each report to match the child’s demographic characteristics, such as her age. We also include a long list of other books, websites, and resources the parent can consult.


These recommendations are easy to "write" because usually we're just using 'cut & paste.' Yet the psychologists I speak with tell me these are the hardest recommendations to feel satisfied with.



Surveyor:

A surveyor maps the landscape by taking precise measurements. She quantifies the ups and downs, and outlines the boundaries of the area. She uses sightlines to look both ahead of and behind the property. She provides the numerical data most relevant to the client’s needs.


When we think as a surveyor, we shape the parent’s referral concerns into referral questions about quantifying the child’s profile of vulnerabilities and needs. This is a good fit for evaluations for young children, when it may be too early to be more specific. This would also be a good frame for specific referral questions and service eligibility questions, if you have the time and space to do more than a screening evaluation.


Some specific questions we might collaborate with the parents to ask when we’re a surveyor are:

  • What are this child’s specific psychological and neuropsychological vulnerabilities, as expressed in numerical terms?

  • How do this child’s vulnerabilities explain her difficulties meeting her goals and fulfilling expectations?

  • How does her profile rule out other diagnoses that have been considered?

  • What recommendations and resources best fit her specific profile of weaknesses?

When we hold these kinds of referral questions in mind during our assessments, we focus the interviews, testing, and report on quantifying the child’s profile, using standardized tests and rating scales and comparisons to a normative group. We match our recommendations to the child’s deficits.


In practice, the surveyor’s recommendations look quite like the scout’s recommendations described above. That is, we provide a long list of suggestions. However, from the surveyor frame, we match our list to the child’s deficits and needs, in addition to her diagnoses. We more carefully edit or add to our list to better match the child’s specific profile of weaknesses.


Psychologists I talk with tell me they still worry these long lists of suggestions are overwhelming for parents. They also tell me they worry the recommendations seem impersonal even though the list has been edited with the child's profile in mind.



Cartographer:

A cartographer compiles a vast array of data to create a rich map of the landscape. She shows the immediate area in beautiful detail, while hinting at the areas upstream and downstream of the current location. A cartographer considers the landscape from many angles. Her map conveys the many forces that have shaped, and that continue to affect, the land.


When we think as a cartographer, we shape the parent’s referral concerns into questions about identifying the child’s weaknesses and her strengths. We use on the quantitative tools of a surveyor, and add in the nuanced data we gain from qualitative methods. This frame is a nice fit for children who have medical conditions that we can connect to their cognitive profile. Many psychological and neuropsychological evaluations use some combination of the surveyor or cartographer frame as well, though I am going to encourage you to consider going deeper (becoming an explorer) when you can.


Some specific questions we might collaborate with the parents to ask when we’re thinking as a cartographer are:

  • What are this child’s specific strengths as well as her specific vulnerabilities?

  • How are her problems connected, and how did they arise?

  • What other unsuspected concerns might be present?

  • How do we personalize her recommendations to account for her strengths and full profile?

When we hold these kinds of referral questions in mind during our assessments, we focus our interviews, testing, and report on the whole child. We assess for resiliency as well as challenges. We consider her environment – her family, school, community, and peers. We look at her physical health, her developmental needs, and her history. We match our recommendations to the child’s full profile.


In practice, the cartographer’s recommendation often section is much shorter than the scout’s or surveyor’s (perhaps 5 to 10 recommendations rather than 15+). However, the recommendations are more personalized, and they are carefully prioritized.


Most psychologists find the cartographer’s recommendations the hardest to write. Those boilerplate lists of recommendations we’ve spent years collecting just don’t fit this kind of report. Yet thinking of personalized recommendations to replace the lists with is time-consuming and challenging.



Explorer:

An explorer goes beyond what is already known. She discovers new territory or finds places that have been overlooked. She considers the old route from fresh angles. If the old routes don’t work, she envisions a new path or blazes new trails. An explorer takes risks in a systematic way, keeping her team safe even when the stakes are high. She shares what she’s found with the wider world in a detailed map so that others can reach the same sites.


An explorer is curious:


When we think as an explorer, we shape the parent’s referral concerns into questions the whole child, her journey, and the conditions under which she thrives. We use qualitative and quantitative methods, and supplement those with insights gleaned from the process of testing.


We consider how a child got a particular test score, why she approached a situation in this particular way, and how she responded to techniques we tried during testing. This is the ideal frame to think from if you’re conducting a comprehensive psychological or neuropsychological evaluation.


Some specific questions we might collaborate with the parents to ask when we’re thinking as an explorer are:

  • What are the conditions under which this child thrives, and what are the conditions under which she has more difficulty? How do we create more of the conditions under which she thrives?

  • What has this child’s journey been? What specific developmental disruptions, structural weaknesses, trauma, or learning that is no longer serving her have contributed to her problems? (This framework, which we’ll talk about more when we get to “Make a Rectangle”, is from Baum & Peebles’ Psychological Testing That Matters).

  • How does this information fit into the picture we’re creating of the whole child? How do we support this child in rebuilding, resolving, or stabilizing the disruptions that have contributed to her problems?

When we hold these kinds of referral questions in mind during our assessments, we do our best to enter the child’s full world and see it through her eyes. While there, we look for a fresh perspective on where she is. We seek out new stories that more completely describe her journey so far. We search for hidden reservoirs of strength.


We search for the conditions under which she is successful, and the conditions under which she stumbles. We join with her to identify different paths she can take, and we try them out with her. Our recommendations are those new paths we’ve found together – the ones that show promise in helping her reach her goals.


In practice, the explorer frame usually looks like 3-5 practical and unique recommendations. They are recommendations that we have high confidence will work. They are recommendations we know will be immediately useful to the family. They are recommendations we know the child, family, school, or treatment team will be able to implement. Because we’ve already tried out these recommendations or seen them work for the child, these recommendations are easy to write.



Here’s much of the same info, condensed into a handy graphic:


All four frames are useful.


Families benefit from reports written from all of these frames. Which frame you use will depend on the time, training, practice setting, and the evaluation goals. You can’t be an explorer on every evaluation. But if you can go deeper, do.


I’ve found that:

The closer I get to thinking like an explorer, the easier it is to conceptualize cases and craft personalized, useful recommendations

Let’s get a little more practical and look at an example.


Changing my mapmaking frame helped me go from reports that sound like the one on the left, to reports that read like the one on the right:


Both excerpts are about 85 words long, and obviously just one part of a longer summary.

You might have spotted a big difference in the reading level between these excerpts (12th grade vs. 7th grade). But I wasn’t thinking about the reading level when I wrote either one.

I was thinking about my referral questions.


For the first excerpt, you see that my referral questions were “diagnostic clarification and treatment planning” and “numerically quantifying her profile of vulnerabilities.”


My map is roughly that of a surveyor. I’ve pointed out some important features of the landscape (anxiety and processing speed variability), and applied a label to each. You can sense a dotted line between the labels, showing the general route on a basic map. And I’ve made a reasonable recommendation for the path ahead, based on what we know about supporting students with variable processing speed.



For the second excerpt, I had different referral questions. Here, some of my referral questions were:

  • What are the conditions under which Andi’s problems with anxiety and slow work completion increase?

  • What are the conditions under which she thrives? What helps her feel more comfortable? What helps her work at a faster pace?


Thinking as an explorer shaped my interviews with Andi, her parents, and her teachers. To answer those referral questions, I had no choice but to listen and look for examples of when Andi was most resilient. The times when she compensated with her strengths. The situations where her problems did not impact her so heavily. And I had to listen to, and explore, those times when she stumbled despite everyone’s best efforts.


During testing, the only way to answer my referral questions was to hypothesize, test, and try out new theories, interventions, and accommodations. Right there in the test session.

I systematically observed the “conditions under which” Andi was able to meet her goals during testing. I recorded the “conditions under which” she suffered less, and the times when her difficulties were more pronounced. I tracked the “conditions under which” she used her strengths to approach a problem from a different angle.


When I went to write recommendations for Andi, there was truly only one option. I simply recommended enhancing the “conditions under which” Andi thrives, while reducing those conditions that are not helpful to her.


The best part is, this happened without much effort on my part. Simply by changing our frames, we naturally answer questions at a deeper level and help families in more personalized and practical ways.


How we set out on the road determines where we end up.


This road is almost as long as this post (which is written at the 8th grade level BTW).

We've been using a straightforward case to keep the spotlight on the frames rather than the case. With this 'simple' case, hopefully it's easy to see how we can go from scout questions ("What is Andi's diagnosis?"), to those plus surveyor questions ("How substantial is Andi's problem?"), to those plus cartographer questions ("What other concerns or strengths does Andi have?"), to those plus explorer questions ("Where did this problem arise from, and what are the conditions under which the problem improves?").


But this frame is incredibly resilient.


Stephen Finn, who developed Therapeutic Assessment, writes in In Our Client's Shoes about how rewarding it was when a referral source who has learned about the power of this frame asked the following referral question: "When does Mr. Smith act more schizophrenic, and when does he act less so?"


The explorer frame also helps us easily partner with individuals, families, referral sources, and others to develop deeper questions. To re-design our referral questions, all we need to do during the intake is use two of the explorer's main skills:

  1. Listening

  2. Asking Questions

As Baum & Peebles remind us, our primary job during intakes is simply to listen:

Once we hear the themes, or the contradictions, or the stuck points, we ask about them.


"What's your take on why Andi completes tasks more quickly when you're with her?" "Have you noticed any other times when she slows down more than you expected?""Would it be helpful if we could figure out why everyone gets so frustrated during homework?"


"What is your best guess?" "What is your worst fear about why this is going on?" "I'm curious about why that happens - what do you think about exploring that question during the testing?" "That does sound like a puzzle - is that a question we should try to answer during our time together?"


Finn describes this as "the practice of asking clients - in the initial assessment sessions - what puzzles, questions, or quandaries they had about themselves, and then making these questions the focus for treatment" (In Our Client's Shoes, p. 10). He notes on the next page that:


Many clients or families "report that they feel relief immediately after an initial assessment session, simply from having translated their inner turmoil into concrete questions."

Perhaps you've noticed this too. The happy confluence is that the same frame that leads us to richer conceptualizations and easier-to-write recommendations also helps families before testing has even begun.


And all we had to do is listen and ask.

©2018 by Stephanie Nelson, Ph.D.