1 Diagnosis and sense-making

Tanya Byron: Well in a sense when I’m working with my colleagues, when I’m working with my teams, and we are assessing a young person, we tend to think in sort of blocks of theory, and in a sense through careful assessment, both qualitative assessment with the young person, with their family, often with schools and teachers. And sometimes with their friends. I mean if the young person, for example, is very depressed, or unable to communicate, friends are often a very useful resource of information. We are literally sort of kicking down different hypotheses that we may have about why this young person is presenting in crisis. So, to begin with we might wonder whether there are some neuro-developmental issues, is there something actually at a brain level that is making life increasingly challenging through this complex time? We obviously want to know what is going on at home, is there a specific amount of stress, risk factors, whether it is abuse or domestic violence, or just discord, marital breakdown and discord in the home that is contributing to this young person’s difficulties. Some young people may show very context-specific difficulties. So if I’m meeting young people where they are generally doing okay, but struggle really specifically at school, and are getting a lot of negative feedback, beginning to feel like they have failed, maybe becoming the person that they are being told they are, so it becomes a self-fulfilling prophecy, they stop thinking, they stop learning, they misbehave. We might then want to explore specific learning difficulties, you know, finding young people with very good IQs, but actually with learning difficulties, whether they are to do with sensory integration, or to do with dyslexia, or dyspraxia. Whatever we are looking at, it would help us explain why this young person, understandably struggles in that particular learning context.

John Oates: So that sounds pretty wide in the sorts of theoretical orientations you are drawing on, but are there specific therapeutic approaches that you take, or would you say you really have to match that to the case?

Tanya Byron: We do have to match therapeutic approaches to the case, which is why the most effective way of working with a young person, because of the system that they bring with them, is within a multi-disciplinary team. So, even though I would lead the team, I would rely on the expertise of my colleagues, who come from different skillsets, to be able to contribute to the assessment. And then sometimes themselves do further specific assessment, for example educational assessment, or neuro-developmental assessment. Sometimes you know much more sort of specific – we might have to scan some young people’s brains, erm, or even more psychotherapeutic colleagues, who might want to work with families and understand the family narrative. So it is quite complex, and in a sense as a consultant my role is to sort of navigate that, and to … what we do as clinical psychologists is we create what we call a formulation. In a sense we are creating an evidence-based narrative to the presenting difficulties. And actually just explaining to a young person, and their family what we think might be behind what is going on for them can be a very empowering experience, because once you understand a problem, to some degree you are almost in a much better position to try and solve it. So, yes, it is about navigating the complexities, sticking with an evidence-based model, and evidence based therapeutic approaches. And always working collaboratively with the young person, because obviously they need to be very much central to the treatment, they need to take ownership of it. It is their life, and so they also need to inform us and help us understand where we might not be quite hitting it in the right place for them. Communication is vital really.