Assessing the mental health needs of older people
Firth M T (1999) Conversing with clients: a generic approach to mental health needs assessment Practice 11 (2) pp.35-44
Prescriptive approaches to engagement and assessment can impersonalise interactions between assessor and client and fail to accommodate real world unpredictability. Academic concepts of 'need' have been challenged by the capacities of workers and clients to fit rigid assessment processes in fluid, everyday practice.
Needs assessment should centre on the communication of the strengths deployed and the difficulties experienced by clients in managing their lives, which will involve both client and worker value systems.
The Manchester Care Assessment Schedule (MANCAS©)
The Manchester Care Assessment Schedule (MANCAS) is a 20-item generic screening tool for mental health needs, incorporating a guide to interviewing. It is based on the 'developmental, biopsychosocial' model of mental health which describes the interaction of various influences (biological, psychological, inter-personal and environmental) on mental health and the 'vulnerability', 'precipitating' and 'maintaining' factors. MANCAS tries to redress the balance by focusing on external factors when needed.
MANCAS is not a standardised instrument, but is valid as a contemporaneous assessment of clients' capacities, needs and wishes in their social contexts. Its open format encourages a conversational approach to assessment and acts as a starting point for continuing negotiation. Conversing with clients is the central principle, while identification of need is an outcome. The conversational approach is essential to facilitate the 'user voice'.
Use of MANCAS©
The order of the 20 items is incidental, as starting where the client 'is' remains the best point of opening. Each item has a 5-point rating scale which helps workers to prioritise client need before negotiating care plans. While preserving discipline-specific skills, MANCAS encourages workers to think beyond the scope of their profession.
The MANCAS assessment process does not have an exclusive focus on risk, but contains items to help determine whether a specific risk assessment is needed.
Issues in needs assessment
Some key issues needs assessment practice include:
- Timing: assessment can be protacted over many weeks and involve many sub-assessments.
- Premature problem-solving: Some clients need immediate help, but most can engage in a discussion of needs and future care.
- Misapplication: impersonal, over-formal interviewing style and form-filling.
- Needs vs. strengths: Assessment away from vulnerabilities and focus on strengths and future directions for positive change.
- Expectation and shortfall: Honesty about what can and cannot be done to help.
- Irrelevance: Unnecessary or intrusive questions for which there may not be a solution or resource. Clients should have the choice not to speak.
- Trust and privacy: Workers' projected fears should not excuse avoidance, but clients have a right to privacy.
- Self-representation: Assessment of need may occur when a client is least likely to be able to represent themselves, but this should not discourage opportunities for them to be heard from the start
- Confidentiality and thoroughness: Tensions may exist between the client's wish for minimum disclosure and the assessor's preference for information.
- Assessment as intervention: therapeutic opportunities are inherent in an assessment 'conversation'.
The recognition of the workers' own motivations and attachment to clients is central to the development of MANCAS. Shared subjectivity, more than technical expertise, often informs the motivation of the worker. Thus the rationale for assessment should be to include no question for which a good reason cannot be given, and to be able to ask and answer the same questions as workers. The human process between client and worker is primary.