Experiences with using an idiographic assessment procedure in primary mental health care services for adolescents.

Purpose: This article aims to explore counsellor experiences using an idiographic assessment procedure implemented in adolescent mental health services. The procedure, Assert, is based on asking the adolescents the question "What matters to you?" to define important topics to address in treatment.
Methods: Focus groups and interviews were conducted with counsellors who used Assert (N = 27), and the data were analysed with thematic analysis.
Results: Five themes were identified: (a) "What Matters to You?" (b) "Professional Responsibility," (c) "Empowering the Adolescent," (d) "Practical Utility of Assert in Treatment," and (e) "The Implementation of Assert." Each theme had a number of associated sub-themes.Conclusions: Assert was perceived by the counsellors as enhancing collaboration and conveying to the adolescents that the counsellors took their concerns seriously. It also provided structure by giving the sessions a concrete focus. However, some counsellors found it difficult to surrender control to the adolescents, and finding a balance between helping and directing the adolescents to define topics could be challenging at times. Assert was generally considered a useful and simple way to assess adolescents' concerns, and it was accepted by the counsellors as a positive contribution to their existing methods.

Introduction

Mental health problems are estimated to affect between 10% and 20% of children and adolescents (Kieling et al., 2011), and recent research has shown that adolescent mental health is declining in high-income countries (Bor et al., 2014; Patton et al., 2016; Potrebny et al., 2019, 2017). Providing quality mental healthcare adolescence is an important factor for preventing mental illness later in life (Clark et al., 2007; Fergusson et al., 2007; Pine et al., 1998). Primary mental healthcare services are important, as they are often the first point of contact (Patton et al., 2016) and are needed to supplement specialized services (World Health Organization [WHO], 2008). Therefore, strengthening these services could have large public health benefits.

One useful strategy to improve treatment delivery and follow-up is to implement systematic outcome measures (e.g., Fortney et al., 2017). However, traditional standardized diagnostic assessment often requires extensive training and may be too time-consuming for these services. An idiographic approach to assessment could, therefore, be more suitable. Idiographic assessment tools are psychological measurement tools adapted specifically for each individual respondent (Haynes et al., 2009), ensuring client participation and gathering information to assess the success of an intervention (Law, 2006). Idiographic measures for monitoring progress in psychotherapy have been of increasing interest over the last decades (see, for example, Barlow & Nock, 2009; Godfrey et al., 2019; Sales & Alves, 2016; Weisz et al., 2011; Wolpert et al., 2012).

Idiographic measures can support practice in several ways distinct from standardized measures. They can give a closer picture of a particular client’s experience during treatment (Sales & Alves, 2016), making the voice of the client and what they deem important an integral part of the assessment, giving them an opportunity to shape the therapeutic agenda and goals of treatment. Identifying the main concerns of young clients often occurs at the beginning of an intervention and can help build a working alliance and establish mutually defined goals. Establishing goal consensus and collaboration through exploring and defining topics has been shown to have a strong beneficial effect on treatment outcomes (Tryon & Winograd, 2011). It is also related to a strong therapeutic alliance, a common factor across therapeutic approaches associated with positive treatment outcomes (Wampold, 2015). However, this information is not always used consistently during treatment, and counsellors or parents often define the treatment agenda (Weisz et al., 2011). This is of concern since adolescents may drop out of treatment if they do not feel that topics important to them are being addressed (Chorpita et al., 2008; Weisz & Chorpita, 2011). As idiographic measures give an indication of whether a treatment can address the problems most relevant to young clients, they can be used to guide treatment planning (i.e., finding the right approach, when to change to a different approach, and when goals have been met) (Law, 2006; Sales & Alves, 2016; Weisz et al., 2011).

Letting adolescents have a greater part in defining the treatment agenda can increase their sense of control over their own mental health (Tollefsen, Neumer, & Berg-Nielsen, 2020). In addition, experiencing control over the circumstances that affect one’s mental health is associated with better mental health outcomes (e.g., Kurtović et al., 2018).

One example of an idiographic approach to assessment is Assert, the focus of which is the most important concerns that individual adolescents present to their counsellors. Assert is a repeated-measure idiographic assessment procedure designed to systematically measure the needs, goals, and concerns of adolescents and young adults aged 12–23 years (called adolescents for the remainder of the article) in primary care counselling. Assert was originally developed by the Norwegian Knowledge Centre for the Health Services (see Nordheim & Vege, 2016) and was further developed and adapted by the current research team. How Assert is used in treatment is further described in the Methods section.

The use of an individually focused assessment (i.e., idiographic) fulfils the need for systematic follow-up and feedback during treatment while honouring the unique perspective of each adolescent client. Also, because there are several idiographic assessment approaches that are not linked to a specific therapeutic approach, it can be more fitting in a service setting where several approaches to treatment are used.

Implementation science research has revealed that the successful implementation of new interventions or routines in mental health-care services is facilitated by clearly specified implementation strategies (Fixsen et al., 2015). These strategies are often categorized as “top-down” or “bottom-up” (Ogden & Fixsen, 2014). In a top-down approach, the intervention is administered from a central source (Hyde et al., 2009), whereas a bottom-up approach is characterized by a stronger sense of ownership among stakeholders in the community (Price & Lorion, 1989). A top-down strategy can fail to address local needs and concerns and may be perceived as a threat to professional autonomy (Ferrer-Wreder et al., 2003; Palinkas & Soydan, 2012). In contrast, bottom-up approaches can increase the likelihood of increased commitment among practitioners and strengthen the adoption and community ownership of an intervention (Castro et al., 2004; Sullivan et al., 2008). However, a balance between the two approaches likely facilitates successful implementation, as leadership support promotes bottom-up change (Fixsen et al., 2013; Ogden et al., 2009; Ogden & Fixsen, 2014). To further strengthen the adoption of new interventions or routines, in-service training and ongoing coaching and consultation are essential (Fixsen et al., 2009).

Both barriers and facilitators of implementation have been strongly associated with the characteristics of the intervention, the practitioner, the client, and the inner and outer context of the service (e.g., Durlak & DuPre, 2008; Forman et al., 2008; Greenhalgh et al., 2004; Ogden & Fixsen, 2014). The interventions’ advantage and benefits compared to other interventions, compatibility with current routines and ideals, as well as complexity and flexibility must be considered when a new intervention is implemented (Greenhalgh et al., 2004; Rogers, 1995). These aspects influence the intervention’s acceptability—that is, whether the professionals using the new intervention consider it agreeable or satisfactory (Proctor et al., 2011). A high degree of acceptability is considered necessary but not sufficient for successful implementation (Sekhon et al., 2017); appropriateness, the intervention’s perceived fit or relevance for a service context, is also an important factor in successful implementations (Proctor et al., 2011). Low acceptability poses a challenge to the implementation (Davis, 1993) and may influence the delivery of the intervention, possibly impacting the effectiveness of the treatment being implemented (Borrelli et al., 2005; Proctor et al., 2009).

Assert aims to uncover adolescents’ unique knowledge about themselves, to help them express this knowledge as a goal or topic in counselling, and to enable a more systematic follow-up of their concerns. Through emphasizing the adolescents’ experiences and following their individual concerns, the client’s perspective is maintained throughout counselling. The main aim of this study was to investigate counsellors’ experiences regarding the use of Assert with adolescents in their services. Secondarily, the intervention’s perceived fit or relevance for this service context was examined.

Methods

Participants

Assert was implemented in 11 municipalities in Norway that included 52 counsellors with diverse training and experience. However, one municipality with seven counsellors withdrew from the study prior to the interviews. Of the 45 remaining counsellors, 27 volunteered to participate in the interviews; 19 were specialized nurses, six were social workers, one was a family therapist, and one was a psychologist. The sample consisted of experienced counsellors; 21 of them had over 10 years of experience, and 12 of these had worked in the field for more than 19 years. The counsellors were between 25 and 64 years old, and their average age was 47.1 years. Of the 27 counsellors, 26 were female.

Service setting

Primary healthcare often represents adolescent clients’ first point of contact with mental health services. In Norway, primary health services are of three main types (Table I) and are provided by various health professionals, most commonly nurses, psychologists, and social workers. In this article, the term “counselor” will be used to describe this group. All three service types offer free short- to medium-term counselling. Treatment modalities range from informal, unstructured counselling sessions to more structured interventions (e.g., cognitive behaviour therapy). For a longer and more intensive treatment, adolescents are commonly referred to as specialized services. These factors add up to a group of services that are highly accessible but also very heterogenic in terms of length of treatment, problem severity, and counsellor background.

Table I.

Characteristics of primary care mental health services for adolescent patients

Service name	Service type	Appointments	Age group	Staff
School health services	Physical and psychosocial help for children/adolescents in school	Walk-in, short-term follow-up	6–19	School nurses
Preventive mental health	Mental help for children, adolescents, and adults	Short-/medium-term follow-up	0–99	Nurses, psychologists, social workers
Health clinics for adolescents	Mental, physical, and sexual health for adolescents	Walk-in, short-term follow-up	12–23	School nurses, physicians, psychologists

Assert

The Assert assessment focuses primarily on asking adolescent clients one question: “What matters to you?” The counsellor asks this question in the first session with the adolescent. Working with the counsellor, the client determines up to three important concerns, topics, or goals he or she would like to address during their sessions. Topics are broad subject areas, while goals describe more specific changes to work towards. A topic might be “It matters to me to be able to feel good about talking to my mother,” while a goal could be “It matters to me to get a 4.0 grade point average.” These topics or goals are then written down in the Assert measure, giving each adolescent his or her own unique assessment of progress in counselling. In each subsequent session, the counsellor presents the Assert measure to the client and asks, “In the last session you said it was important to you to be able ‘to feel good about talking to my mother.’ Is this still important to you?” If the adolescent answers “yes,” they move on to scoring, where the counsellor asks, “On a scale from one to ten, how do you feel about this topic now?” The adolescent then gives a score ranging from 1 (not good at all) to 10 (very good). The score should reflect the change on that specific topic; if the score is higher in this example, the adolescent feels better about talking to her mother. If the topic had been “It matters to me to have more control over my negative thoughts,” an increase in the score would indicate a heightened sense of control. If the topic is no longer important, the adolescent can replace it with a different topic or remove it.

Procedure

Implementation of Assert

Assert was implemented in 11 municipalities as part of a randomized controlled effectiveness study in which outcome data were collected from 150 adolescents over a period of 18 months (Tollefsen et al., 2020). The greater study was designed to examine the effects of Assert in a naturalistic setting; therefore, the implementation could not unnecessarily interfere with the services’ procedures and routines. Thus, the implementation strategy had to be pragmatic and adaptable to the heterogenic context of primary mental healthcare Therefore, the implementation strategy was based on establishing acceptability and appropriateness, which are associated with the successful implementation of new interventions (Proctor et al., 2011; Sekhon et al., 2017). This was achieved by anchoring the intervention firmly with the counsellors through a bottom-up approach. Assert was established as a routine with the leaders of the services to maintain a balance between the top-down and bottom-up approaches, which is crucial for successful implementation of new interventions (Fixsen et al., 2013; Ogden et al., 2009). Furthermore, in-service training and follow-up were included to facilitate commitment and adoption, thus strengthening the bottom-up perspective (Castro et al., 2004; Fixsen et al., 2009; Sullivan et al., 2008).

The implementation of Assert started with a three-hour training in each municipality. The content of the initial training was equal for all participants regardless of the individual counsellor’s experience or education. The rest of the training was organized in follow-up meetings; the counsellors partook in one- to two-hour consultation meetings every four to 6 weeks for the duration of the study. These meetings were loosely structured and included discussion of specific cases, the challenges faced in using Assert, and problem-solving of the research procedure. Both the initial training and follow-up were conducted by the first author. No formal communication occurred between the first author and counsellors in between the follow-up sessions, but support through phone or email was provided upon request from the counsellors.

Data collection

Focus groups were planned at the end of the study in all 11 municipalities; however, one municipality withdrew from the study prior to the interviews. Focus group interviews were selected as the mode of data collection because they can create a permissive environment that nurtures different points of view (Krueger, 2014). As the groups were naturally organized according to the municipality, the counsellors were familiar with both the physical environment where the interview took place and the other group members. Such collegial support can make it easier to convey negative feedback about the intervention to the interviewer and reduce self-censoring bias (Krueger, 2014).

However, due to attrition during the study and to practical barriers, two municipalities had only one participating counsellor each, and four municipalities had only two counsellors who could participate. The last four municipalities had four or five participants. Thus, focus groups were conducted in these last four municipalities, while interviews with one or two counsellors were held in the other municipalities. Focus groups and interviews were conducted at the service sites except for one interview that, for practical purposes, was completed at the research institution. Regardless of the number of participating counsellors, the same interview guide was used for all interviews, which were carried out by the first author. In total, the data material from all interviews consisted of nearly 80 hours of audio recordings.

Rather than providing specific questions, the guide gave an outline of the five following themes, which the groups were asked to discuss: (a) practical use of Assert (consequences of using a systematic approach in this service context), (b) facilitation of user involvement (Assert’s contribution to involving adolescents in their own counselling), (c) Assert as a help or a hindrance in treatment (experiences with the positive and negative aspects of using Assert with adolescents), (d) participation in research (how the research context could impede or facilitate the use of Assert), and (e) future use of Assert (to what degree Assert would be used after the end of the study).

Analysis

The audio recordings were transcribed verbatim and coded by hand by the first author. The interviews were analysed using thematic analysis, as described by Braun and Clarke (2006). Thematic analysis offers a theoretically flexible framework for coding qualitative data and identifying patterns based on these codes (Braun & Clarke, 2014). It is suitable for data-driven analyses of people’s experiences of phenomena within a specific context (Clarke & Braun, 2013). In addition to providing a framework for the analysis of the interview data, the data-driven approach made an open and flexible interview guide, rather than specific questions, essential.

The data were coded with two codes: one describing what participants said, and one describing how they addressed the particular subject. These coded extracts were grouped, reviewed, and refined, discarding and replacing some of the codes. The groups of coded extracts were sorted again into candidate themes and sub-themes. The data within each theme were reviewed and refined until there was an adequate degree of internal homogeneity within each theme (including sub-themes) and external homogeneity between the themes. This step was done in collaboration with the third author. When the themes had been defined, the most salient extracts were selected to illustrate the content of the theme before the extracts were translated from Norwegian to English.

The analysis was founded in a realistic epistemology; the main goal was uncovering semantic themes from the participants’ experiences. However, as most interviews were conducted in groups, the stance was not purely realistic; the counsellors’ responses were also influenced by the other counsellors. Since Assert is a novel approach and few details are known about how it is experienced, the focus of the analysis was achieving a rich, thematic description of the interview data. The goal was to conduct an inductive analysis; the data were not analysed within a specific theoretical framework. To achieve this type of analysis, the analyst had to be mindful of his own perspectives and beliefs during analysis so that these did not bias his understanding of the counsellors’ narratives. Additionally, the statements made by the counsellors were re-examined after the initial coding to explore alternative understandings or meanings, rendering the results as close to the counsellors’ experiences as possible. Lastly, the results were discussed with other colleagues who were experienced in qualitative methods and had little previous knowledge of the Assert study.

Reflexivity

The Assert study was designed and implemented by the first author, who believes that Assert could be useful for adolescents and those who work with them. Since erasing one’s own ideas and beliefs is not possible, reflection on how these could influence the interview guide, the analysis process, and the presentation and interpretation of the results was necessary. Thus, to reduce bias and maintain reflexivity during the interviews, the interviewer assumed a non-directive role. The main objective of the interviewer was to let the counsellors share their experiences and reflect upon these experiences with the other counsellors in the group. This reflection was not possible in the interviews that included only one counsellor. In these cases, the interviewer had to be even more mindful of the non-directive role. Additionally, the interview guide included broad topics to stimulate an open reflection rather than influence the counsellors by providing specific or leading questions. Moreover, care was taken by the interviewer not to let preconceptions about the effect of the intervention influence how follow-up questions were posed. If a counsellor’s statement was unclear to the interviewer, clarifying questions were asked using the counsellor’s own words.

Results

Through the analysis, five main themes were discovered, each with a number of sub-themes (Table II). The five main themes were as follows: (a) “What Matters to You?” (b) “Professional Responsibility,” (c) “Empowering the Adolescent,” (d) “Practical Utility of Assert in Treatment,” and (e) “The Implementation of Assert.” Each main theme will be described before the associated sub-themes are presented. The sub-themes will be demonstrated by a relevant extract in addition to the analysis.

Table II.

Schematic overview of the themes and sub-themes discovered through thematic analysis

Main theme	Sub-theme
Theme 1: What Matters to You?	1.1: A simple, universal question
	1.2: A familiar focus
Theme 2: Professional Responsibility	2.1: Counsellor’s responsibility vs. adolescent’s needs
	2.2: Closure or avoidance?
	2.3: Counsellor’s responsibility to stabilize in a crisis.
	2.4: The counsellor’s role: helping or directing?
	2.5: “Nothing matters to me.”
Theme 3: Empowering the Adolescent	3.1: Focus on the adolescents’ perspective—user involvement in practice
	3.2: Letting the adolescent take control
	3.3: Facilitating a stronger voice for the adolescent
	3.4: Creating responsibility
Theme 4: Practical Utility of Assert in Treatment	4.1: Defining tangible topics
	4.2: Creating a starting point for treatment
	4.3: Accessing the core of the adolescents’ difficulties
	4.4: Observing change motivates further change
	4.5: Facilitating continuity in treatment
	4.6: Creating structure
Theme 5: Implementation of Assert	5.1: Distribution of the workload
	5.2: Regular follow-up by the research team
	5.3: Something that we should do
	5.4: Sense of community
	5.5: The nature of the services
	5.6: Resistance towards using measures
	5.7: Assert feels different than traditional measurement paradigms
	5.8: A useful, evidence-based measure for the future

Theme 1: What matters to you?

This theme relates to how the counsellors perceived Assert, both in terms of how it was adapted to their existing methods and how they understood the question “What matters to you?”

1.1: A simple, universal question

Several counsellors perceived the question “What matters to you?” as a universal question that could be asked of anyone at any time and conveyed a validating attitude towards the adolescent—that what matters to you matters to me:

I think that it [Assert] would be suitable for everyone really. No matter the situation. It’s about that person. You are taking them seriously and asking what matters to them. That question in itself is so good. I also think that setting tangible goals can be … having a concrete thing to work towards, so it won’t be only empty talk. That we have sort of a guidance tool that they themselves have defined. I think that is very good. (Social worker, 55 yrs.)

In the extract above, the counsellor perceives this question to signify that the counsellor took the adolescent’s story seriously and cared about what that individual had to say. Further, the counsellor describes how the adolescent’s putting their story into words made it tangible and clear that they, as the client, controlled the direction of the treatment.

1.2: A familiar focus

Most counsellors believed that using Assert is similar to the way they used to work before Assert was implemented. That it was perceived as something familiar made it understandable and increased the acceptability of using it. Most counsellors did not feel that using Assert drastically changed how they worked but found that Assert contributed to an increased focus on what mattered to the adolescents:

I think the question “What matters to you?”—I’ve asked that a lot of times now and sometimes without the measure, just asked it, it has done something to me as a clinician too. And I think that I used to explore their inner world and what they were thinking of and what mattered. But to ask it, just straightforward, especially at the start, I think that has felt very appropriate and helpful. That’s what I believe. (Psychologist, 53 yrs.)

The counsellor experienced that using Assert had changed her perspective as a clinician, noting that she customarily used to be explorative and open, but that being more straightforward in getting to the adolescent’s perspective was useful.

Theme 2: Professional responsibility

This theme highlights the conflict between being responsible for the treatment and simultaneously maintaining a focus on the adolescent perspective.

2.1 Counsellor’s responsibility vs. the adolescent’s needs

Some counsellors experienced that the topics or the scoring of the topics did not match their professional opinion. As the adolescent perspective is strongly emphasized, they found it difficult to challenge the adolescents when they had a different understanding of the situation. In one case, a counsellor experienced that the scores on Assert did not match her impression of how this adolescent was doing:

If it hadn’t been for the fact that she was a part of the study, and in the intervention group, I would have put this away. Because the one goal was to feel better in relation to schoolwork, to think more positively about herself in relation to schoolwork, or to think more positively about herself when it comes to schoolwork … She had no motivation and didn’t want to do anything, and so on. “So, you won’t go to school in the fall then?” I started to ask a bit like that, and then it became apparent that—yes, she has gotten fours in some subjects and that was very good, but mathematics was still a problem, you know. So, I think with that adolescent, I experienced that I was contributing to making her focused on what was terrible, that there’s no hope. So, I try to explore more, I think that she should have scored a four [on that topic in Assert], but it [the score] is determined. She decides, and it is her answer that is right. So, in that case I think it was a bit complicated [to use Assert]. It made me wish that I had more control and could suggest that “Maybe we should put this away and think differently about things?” (Social worker, 44 yrs.)

In the extract above, the counsellor experienced that using Assert contributed to a focus on the adolescent’s negative attitudes about her own performance in school. Even though this adolescent did well in school, she consistently scored herself lower than what the counsellor thought reflected her performance. The counsellor’s responsibility to administer good care was challenged by letting the adolescent endorse a more negative view of her progress. The feeling of having to choose between letting the adolescent be in charge and taking control of the situation created a conflict in the counsellor that she wanted to resolve by using methods other than Assert.

2.2 Closure or avoidance?

In some cases, the topic would no longer be important to the adolescent, as they felt that they had progressed and felt better about the topic. However, in some cases, the counsellors experienced that a topic stopped being important not because it was better, but because external factors made it less relevant:

I had one adolescent that had a goal to participate in swim class. And she only scored ones and twos. And suddenly—they didn’t need to have swim class anymore. Problem solved. (Nurse, 50 yrs.)

As seen in the extract, the adolescent chose to close the topic not because she was comfortable with participating in swim classes, but because she did not have to participate in swim classes any longer. The counsellor was put in a difficult position, balancing her responsibility as a health professional and the needs of the adolescent. The counsellor was aware that this could be a potential problem in similar situations for the adolescent, but now felt that she was no longer in a position to address the issue without infringing on the adolescent’s right to define what matters to her. The problem was still there, but the adolescent had found a way to avoid it, leaving the situation unresolved.

2.3: Counsellor’s responsibility to stabilize in a crisis

Several counsellors found that using Assert as a structured measure could be perceived as insensitive when the adolescent was in a situation of acute trauma or crisis and in need of stabilization. One counsellor exemplified this with the loss of a family member:

Are there types of people you see or types of situations where you wouldn’t use Assert?

Hmm. If the mother has committed suicide and the children come in to a session. But I can still have it in the back of my head, “What matters to you now?” But I wouldn’t ask it in that way. Because it’s a crisis and I’m in a different mode. But you can have it in the background: “What’s important right now? Is it to talk about your mother, or is it to relax and create some distance? Find some happiness?” But I wouldn’t have presented it like, “Now we’re going to score this and … ” That would’ve felt … not very empathic, maybe a bit non-empathic. (Psychologist, 55 yrs.)

This counsellor felt that in such a situation, Assert’s focus on defining topics and scoring them, rather than on containing the adolescent’s emotions and supporting them, would seem mechanical and insensitive. It does not feel right to concentrate on a measure when a client is in crisis. Still, she felt that the question itself could help find the right way to address the adolescent’s needs in the moment. Other counsellors also thought that introducing it later in the process, when the adolescent is stabilized, was an acceptable procedure.

2.4 The counsellor’s role: helping or directing?

The adolescents sometimes needed help defining the topics; this task was experienced as something meaningful, requiring the counsellors’ attention and presence. Through the use of examples and exploration, they facilitated the definition of topics. However, helping with this process sometimes felt uncomfortable. They were afraid to involve themselves too much in the process, as the topics should reflect what mattered to the adolescents, not the counsellor:

Regarding defining goals or topics, how participatory do you have to be in that process, as the helper in that situation?

I felt that in some cases you had to be … almost like it became a bit awkward. Almost like: “But it has to be something?” That I almost put words into their mouths. “I don’t know what to write, and what should my goals be?” “What about, for example, what about school? Could you have some goals there?” Then it’s me who’s sort of guiding it, right? I had one who was like … he didn’t have a clue. So how real those goals were, I don’t really know. (Social worker, 44 yrs.)

This counsellor described a case where the adolescent found it difficult to define topics and the counsellor felt that she controlled the process. She felt uncomfortable trying to coax topics out of the adolescent, and doing so made her question the adolescent’s ultimate commitment to the topics.

2.5 “Nothing matters to me”

A few counsellors found that asking “What matters to you?” implied some expectations; it came across as though the adolescent “should” have something that matters to them. If the adolescent did not have an answer, expressing that “nothing matters to me” might make them feel inadequate. This highlights the counsellors’ responsibility not to be bound by a method when not appropriate:

It may be hard for some of the adolescents to answer the question. The ones who are a bit quiet and careful. These are adolescents that find it hard to talk. And for them, I think it’s very overwhelming, then you need to help them at least. And you might have to talk a bit about other things as well. It might get too concrete? (Nurse, 41 yrs.)

This counsellor experienced that some adolescents felt overwhelmed by the question, perhaps because the adolescents’ difficulties became too concrete. This was especially true with adolescents who had a hard time translating their experiences into words. The counsellors’ responsibility and the main focus were to help the adolescents find a way to express themselves.

Theme 3: Empowering the adolescent

The third theme emphasized how Assert can contribute to empowering adolescents through strengthening their voice and building responsibility.

3.1 Focus on the adolescents’ perspective—user involvement in practice

Most counsellors perceived Assert as an operationalization of the concept of user involvement. Asking the question “What matters to you?” and following up throughout treatment was perceived as a way to ensure that the adolescents’ voices are continuously heard throughout a treatment:

Would you say that Assert is a good alternative to ensure user involvement?

I’m thinking that it is. It’s a very good alternative and it makes it [user involvement] more concrete and tangible, as I said earlier, to the adolescents. Maybe they get a stronger sense of ownership to it in a way. That “these are my sessions, there is that measure again where I have written my topics, it’s mine.” (Nurse, 41 yrs.)

In the extract above, the counsellor points out that Assert contributed to making user involvement into something tangible, not just a formality. The counsellor believed this was achieved because the adolescents gained an increased sense of ownership and control of their own difficulties. The adolescents’ needs are in focus and the counsellor accepts this at face value, validating them by maintaining this focus throughout treatment.

3.2 Letting the adolescent take control

Giving the adolescents the opportunity to control the direction of the treatment was seen as a novel way to think about treatment progression:

That was something we discussed early on, how changeable or dynamic these goals are. That you can just change the goal next session. You can continue to work with the same, just change the goal. That’s a new way of thinking. To us who are preoccupied with documentation and what we are doing: “But, what about the old goal? Is that supposed to be kept somewhere?” No, we just have to move on. That’s a bit liberating in relation to the idea of always focusing on what matters to you. (Nurse, 48 yrs.)

The counsellor in the extract above describes how the dynamic nature of Assert could challenge her idea of who has the control over the treatment process. Changing the topics disturbed the established balance by forcing her to surrender some of her control of the process in order to maintain a steady focus on what mattered to the adolescent. Still, through giving up some of this control, she felt liberated.

3.3: Facilitating a stronger voice for the adolescent

Most counsellors had experiences with cases where the parents’ or teachers’ idea of what the adolescent needed was very different from what the adolescents themselves presented. Using Assert to get a clear understanding of what mattered to the adolescents, the counsellors experienced that it was easier to differentiate between the needs of the people involved:

It [Assert] is very good when you’re working with adolescents. Often, they come in with complex cases, and a lot of it can be the parents’ “order,” or an “order” from someone else, but then you get straight to what matters to that child. (Social worker, 41).

This counsellor experienced that Assert could help ensure that it was the needs of the adolescent that were addressed, as they were able to get straight to the heart of the matter, in the words of the adolescent and not the other people involved.

3.4 Creating responsibility

Several counsellors found that Assert gave some of the responsibility to the adolescent, making them an important part of the process of defining long-term goals and the direction of the treatment. However, this was not experienced as abandoning their own professional responsibility, but as a way of empowering the adolescent:

I like the idea of or the awareness that it [Assert] implies—maybe a view on humanity, almost. Regarding that one has the responsibility for one’s life and “what do you want to do with it?” (Social worker, 37 yrs.)

This counsellor experienced Assert as something founded in a specific view of humanity—that we have a personal responsibility to decide how we want to live our lives.

Theme 4: Practical utility of Assert in treatment

The fourth theme concerns how the counsellors experienced using Assert and in what ways it could be considered a useful approach when working with adolescents.

4.1 Defining tangible topics

A major part of using Assert is the process of defining the topics in collaboration with the adolescent. Most counsellors found this process easy, as the adolescents often had a clear idea of what mattered to them:

That, I actually really liked about it [Assert], that it’s the adolescents themselves, and we have talked about this a lot, who should define the topics. And whatever we might think about the measurability of that topic, this is what they are defining as a topic. And this highlights that these topics are most important to them, right? When they define it themselves. I’ve been working within big themes, but it’s still some sort of a concretization of something. Because they have to put their own experiences into words. So, to me, it’s like a combination of goals and topics. (Social worker, 60 yrs.)

Here the counsellor points out that the adolescents should be in charge of defining the topics. Central to this is that their experience was put into words, which was considered more important than defining specific, measurable goals. Further, the process of defining topics seemed to provide the adolescents with a clearer idea of what they wanted to discuss or with what they needed help. Their goals became more tangible and visible to the adolescents.

4.2 Creating a starting point for treatment

The topics were often regarded as a starting point for treatment, leading the way in further exploration of the adolescents’ concerns:

I’ve used it [Assert] specifically with one adolescent that was 16 years old, who was very quiet in the sessions. So, to have those goals defined as a starting point for the session made it very easy to remember to use it, because it was sort of nice to have that as a starting point for what we were going to talk about. I think this was because she had so few words to describe how she was feeling and how quiet she seemed [in the sessions]. (Social worker, 37 yrs.)

This counsellor experienced that Assert was helpful with a quiet adolescent by allowing her to use her own words to define topics that were important to the treatment. The counsellor felt that these topics were helpful to get into a position where she could help the adolescent.

4.3 Accessing the core of the adolescents’ difficulties

Several counsellors found that they got to the core of the adolescents’ difficulties faster by using Assert. This meant that they could work with elaborating the adolescents’ stories earlier, enabling them to make the stories both more saturated and relevant to the adolescent:

How do you know when you have gotten to the core?

The instant feeling of, “Wow, I got access to something different.” That I got there faster than using several sessions on it … One could clearly see an improvement. That can also mean that you are on to something which is … that you are measuring something that matters. (Social worker, 41 yrs.)

In the extract above, the counsellor explains that she achieved a different understanding of the adolescent’s perspective than when she didn’t use Assert. She believed that following up on the topics helped her observe a clear improvement in the adolescent.

4.4 Observing change motivates further change

Most of the counsellors found that the process of scoring the topics was an important and useful way to continuously address the adolescents’ topics. Setting the score gave both the counsellor and adolescent insight into whether the adolescent experienced progress since the last session. Observing positive change related to the topics they identified as important helped demonstrates the utility of treatment to the adolescents as well as assured counsellors that the treatment they were providing was appropriate. Little or negative change was also perceived as useful, as it gave an opportunity to explore reasons for the lack of progress, which potentially led to trying different methods:

It’s a good feeling when you see the cases where they have scored higher after a few sessions. I had one who had a lot of anxiety who scored herself as: “Now I’m back again, it’s actually really better.” At least this was a period where things were better and where she managed to set some goals and such. And then it was very good to see, both for her and me, that it had some effect. (Nurse, 64 yrs.)

Here, the counsellor emphasizes that seeing positive change was a motivating factor for both the adolescent and the counsellor. The repeated scoring of the topics on the Assert measure made the change more tangible and visual, elicited positive feelings in both, and demonstrated that the treatment was helpful.

4.5 Facilitating continuity in treatment

As it is possible to change the topics in every session, the continuity and stability of topics were discussed among the counsellors. However, there were only a few instances where the adolescents had a desire to change their topics, as these continued to be relevant. When the adolescents changed their topics, it was mostly perceived as a development of the original topic. The topics were only rarely changed to something completely different:

You describe Assert as quite similar to how you worked before. Are some things different when using Assert in treatment?

It’s maybe easier to hold on to a topic for a longer time. Especially for those who tend to fluctuate a lot, and often have new ones. So that you have to change the topic. To tell them that, “So, now you do not want to work more with this topic,” instead of just saying, “OK, so this is what’s important today.” You jump around less then. It at least makes it clearer for the adolescents. And it’s less speculation from me. (Social worker, 44 yrs.)

In the extract above, the counsellor emphasizes how Assert made it easier to follow up on the adolescents’ concerns over time. By referring to the concrete topics in every session, the counsellor experienced that the adolescent stayed on track and was less inclined to change them.

4.6 Creating structure

Several counsellors reported that Assert was helpful in creating a structure for the adolescents, helping to narrow down chaotic situations, broader themes, or multiple concerns into topics that were manageable to the adolescent:

If there’s a lot of chaos, then it’s important to find out fast what’s important to address first. Just to start somewhere. And then it [Assert] is very tidy: “Now we’re going to find three things you should work with first.” And you can address the rest afterwards. It would be very messy to work with everything at once. (Nurse, 49 yrs.)

This counsellor experienced that Assert helped to create a structure in a chaotic situation by helping the adolescent prioritize what they wanted to address first. The approach was considered helpful for the organization of the treatment.

Theme 5: The implementation of Assert

The last theme refers to the counsellors’ experiences regarding implementation. More specifically, it addresses what facilitated and what challenged the successful implementation of Assert in these services.

5.1 Distribution of the workload

One prevalent sub-theme regarding the implementation of Assert was that the workload was appropriately distributed between the counsellors and the research team, and most counsellors indicated that the use of Assert in treatment was generally experienced as something that did not make their work more difficult:

I think that it was decisively important for us out in the municipalities that you [referring to the interviewer], early and all through the project, took care of everything regarding follow-up, reminders, looking after and so on. That is your job, right? Our job is to recruit the adolescents, and you do the rest. All the data collection and … because if it had been a burden, if we had to start looking after and having an overview over who should or should not, and “he hasn’t replied, should we get him to reply?”—we haven’t done any of that work. And that was important to us, to not expect that much from us. In that way it has been a limited amount of extra work. (Nurse, 48 yrs.)

The counsellor reported that it was helpful that most tasks regarding data collection and support were done by the research team, leaving only the recruitment of adolescents and the actual use of Assert to the counsellors.

5.2 Regular follow-up by the research team

Each municipality was visited by the researcher once every four to 6 weeks throughout the data-collection phase. This was perceived by several counsellors as an important aspect of the implementation of Assert. They found it motivating to have regular meetings that gave them a chance to discuss cases, share experiences, and repeat how to use Assert. Follow-up was also believed to be essential for them to continue using Assert in their services when the project was terminated:

I think it was important that you came out here. There is something about “now he’s coming and what have we done since the last time.” Sort of a reminder. Even though we might have seemed dismissive—“Eh, we don’t know if it’s necessary to come now”—you replied, “oh yes, I’ll be there.” And there was always a lot to talk about. And useful to get the repetition. (Family therapist, 46 yrs.)

The counsellor points out that the follow-up was important both as a reminder that they were part of a study and because of the content of the follow-up meetings. The follow-up meetings were considered useful, perceived to help keep the focus on the participation in the project, and increased motivation for using Assert.

5.3 Something that we should do

In two cases, Assert did not seem to be thoroughly implemented into the service. In these cases, the service leader had agreed that the service should participate in the project without consulting their employees. This sense of being forced into the project seemed to create some resistance with regard to participation and led to Assert not being used systematically by all counsellors. However, this concern was only reported in the municipalities where the leader was not involved. In most municipalities, the leader was an active part of the team, often with clients of their own:

We haven’t established it [Assert] fully as something that we should do. It has been more up to the individual. So, it’s like that in regard to this service. Yeah, everything that is a bit … it is always demanding to do something other than you [are used to]. [pause] Something new, something different. So, it has kind of … there was a resistance there, and it contributed to several quitting [the study]. Unfortunately. (Social worker, 41 yrs.)

This counsellor points out the importance of anchoring the new intervention soundly in the routines of the employees. Her experience was that Assert was not perceived as well enough established as something “they should do.” In these cases, it felt like it was more up to the individual counsellors to establish it as a method they wanted to use. This could be due to leaders not clearly emphasizing that Assert was a method everyone should use when seeing new adolescents. This counsellor also pointed out that it is challenging to start using new methods and to change existing routines, especially when they are seen as optional.

5.4 Sense of community

Several counsellors pointed out that participation in the study and working together with a new method created a sense of community. It seemed that sharing this experience and feeling part of something was important to the successful implementation of Assert. However, collaborating with others in the service or other services not using Assert could pose a challenge for using Assert routinely, as they felt they would have to explain the method:

If everyone [in the service] had been informed [of the study], then … But it was only us who were. We tried to inform the rest too, but I think that the others, they did not have the same sense of ownership to the project. It may have been important to create that sense of ownership in all here in this service. (Psychologist, 53 yrs.)

The counsellor in the extract above points out the lack of community around Assert at her service. She felt that Assert was not implemented widely enough in the service, resulting in too few counsellors having a sense of ownership of Assert and being outside of the group using it. Thus, establishing a professional community, both within services and between services and municipalities, was seen as essential to the continued use of Assert after the completion of the study.

5.5 The nature of the services

Even though most counsellors found that participating in this study was fairly straightforward, some counsellors experienced challenges, especially related to the follow-up of topics over time and particularly since it was common that the adolescents only want or feel they need one session:

I believed in the start that it would be easier than what it was. Because it seemed so … I really was excited about the project, I thought it was spot on. And it seemed easy. It seemed very easy. Because it made us more conscious of the adolescents, to find out what really mattered to them. Because we are too eager to define that for them. But in real life it was harder. And a lot had to do with that revolving-door function we have. That we are available for the adolescents, and then they come in and out, and in and out, and … I saw that the adolescents liked this way of working. But it was the follow-up that was … I didn’t really … They are not so concerned with coming back. You have to follow the adolescents where they are, right? So, when we first had that conversation [Assert], they were very present. But to follow it up? It was not that important to them to come back, you know. (Nurse, 35 yrs.)

Here, the counsellor found using Assert more challenging than anticipated. She seemed to attribute this to the nature of the services, as it can be challenging to follow up with the adolescents who did not return to the counsellor after one session or sessions that were weeks apart. These irregularities made it difficult to get into the habit of using Assert over time and following up on the topics from the last session.

5.6 Resistance towards using measures

Not all counsellors perceived utility in using measures during treatment with adolescents. For many, it was common to not use any measures and, in some cases, they believed that measures were more useful for the counsellors and the services than for the adolescents. They reported several examples where adolescents were frustrated with the specialized services, as they were too focused on assessment and measures and not focused on what was important to the adolescent. The idea of relying too much on measures was perceived as something contrary to the flexibility in the primary healthcare services, fearing that it might interfere with the therapeutic alliance:

Assert is a measure, as you mentioned. Considering this, could Assert influence or increase the barriers to seek help?

That was what the school nurses said, because I presented this [Assert], and we have these other measures, and they said, “Another measure?!” So, they did not have a lot of motivation and thought that it would do something with the relationship to the adolescents. And were a bit sceptical to start with. (Psychologist, 53 yrs.)

Here, one counsellor experienced negative attitudes from her colleagues towards using measures in treatment with adolescents. She found that they believed that using measures could get in the way of forming a good working alliance between the counsellor and adolescent, and that these attitudes might have affected their motivation to use Assert.

5.7 Assert feels different than traditional measurement paradigms

Even though there was a marked resistance towards using too many measures in general, several counsellors also emphasized that they would like to incorporate some measures in the treatment in order to make treatment more targeted and precise. Sometimes treatment can have too little direction, and measures can be a way to structure the treatment. Most counsellors did not experience that Assert got in the way of establishing an alliance with the adolescents. Some hesitation still remained regarding presenting an actual paper measure in treatment with adolescents; some counsellors thought that it would be more natural to use the question itself but not the actual measure:

Of course, we should have some tools, we should have some assessment programs and such, but if it’s too much, I think we’ll lose some of the most vulnerable. Who feel assessed and they feel almost under surveillance, right? … And this [Assert] is a simple measure, there’s like no comprehensive, big things here. It’s easy and clear. So, it’s tools like this that might be easiest to implement and get people to use properly. At least, that’s what I’m thinking. While measures where you have a lot of questions and lots of things you have to do before you get down to business … you know what I mean? I think that there should be some balance to this. (Nurse, 64 yrs.)

A prevalent opinion among the counsellors was that Assert differed from other measures with which they had the experience. Assert was seen as easier to use and implement in these services, being a more flexible way to assess difficulties. The question “What matters to you?” was thought to be more personal and open, did not disturb the session, and felt like a more natural or integral part of treatment, especially at the start.

5.8 A useful, evidence-based measure for the future

Most counsellors reported that they were more motivated to continue using Assert after the study was completed. The main reason counsellors planned to continue using Assert after the study was that it was a useful, evidence-based addition to their existing methods. Also, one leader remarked that if Assert was documented to be evidence-based, it would be more reasonable for her to demand that they use Assert and to establish it as a common procedure in that service:

Because I want to say, that if the results tell us that this is a useful instrument, then it’s good for us in the primary health care services to say that it is research-based. To feel the gravity of that. It gives us security and importance in our jobs. As an instrument, it could be useful to give us that. I’m hoping that you’ll find some good results in this project. Everyone is so preoccupied with that it should be research-based, right? We get that all the time, that it’s important to have something research-based. And we know this is working, and it gives us a sense of security. (Nurse, 52 yrs.)

The counsellor explains that it was important to introduce evidence-based methods to primary health services. Using methods that are evidence-based gave her a sense of importance that what she was doing mattered to her clients. She also experienced a feeling of security in that the methods she used were safe to use with adolescents, effective, and thus helpful.

Discussion

The results indicate several positive aspects regarding the use of Assert in treatment, as well as highlighting situations where using Assert could be challenging, and vital considerations regarding the implementation of Assert in this service setting.

Using Assert contributed to an attitude where the counsellors were more open and receptive to the unique concerns that mattered to the adolescents. This attitude also gave the adolescents a stronger ownership and responsibility over their own concerns, thus empowering them. From a developmental perspective, one could argue that helping clients take more responsibility and facilitating autonomy is especially appropriate for adolescents. Adolescents are expected to gradually take more responsibility for their well-being and develop better self-regulation to lower their dependence on others. To achieve this, it is essential that adolescents’ environments are supportive and foster independence. When the counsellors adopt the attitude that Assert conveys and are open to exploring and taking seriously what the adolescents present, this could help create such an environment. In turn, the adolescents see that they are taken seriously, that their voice matters, and that they get to be active in shaping the treatment agenda. This process of empowering the adolescents can contribute to making the adolescent perspective more evident to both themselves and their counsellors in a more tangible way than before.

However, to maintain this perspective, the counsellors had to relinquish some control of the treatment agenda. This challenged the idea of who had the control over the treatment process and gave way to a conflict between the counsellors’ responsibility as health professionals and the feeling of surrendering control to the adolescents. When the counsellors experienced that they had a different perception of what “should” matter to the adolescent, they felt that it was hard to go back, as they had committed to letting the adolescent’s perspective be the guiding principle during treatment. However, most counsellors found it possible to combine a strong focus on the adolescent’s perspective with professional and ethical practice through continued exploration of the topics and scores and by presenting their own views in a respectful and thoughtful manner.

The findings also emphasize that the Assert measure itself could be perceived as inappropriate or insensitive in specific situations (i.e., the loss of a family member). To focus on defining topics and scoring them, rather than containing the adolescent’s emotions and supporting them, would seem mechanical and insensitive. The authors agree with this perspective and suggest that Assert, or any other method, should not be used mechanically. Rather than prioritizing fidelity to any method, clinicians should be flexible to meet client needs, consider their clinical expertise, and allow the context to guide the application of evidence-based interventions. The ability to prioritize the needs of the client rather than the fidelity to any method has been discussed extensively in previous research (e.g., Ackerman & Hilsenroth, 2003; Cook et al., 2017; Fuertes & Nutt Williams, 2017; Goodyear et al., 2017).

The process of exploring and defining the topics in collaboration with the adolescents helped the counsellors to get to the core of the adolescents’ concerns. Reaching the heart of the matter early helped create a shared starting point for treatment that both parties were motivated to address, thus supporting the counsellors in sessions that could otherwise be difficult to initiate. The sessions were given a concrete focus and structure by means of revisiting and scoring the topics.

The services where Assert was implemented are characterized by heterogeneity in the types of concerns that the adolescents presented, the number of sessions, and the therapeutic approaches. It would, therefore, be valuable to provide continuity without impeding the flexibility of the services. Assert was generally accepted by the counsellors as a positive contribution to their existing methods despite the fact that several counsellors initially harboured a negative attitude towards using standardized measures or questionnaires in treatment. However, they did not perceive Assert to be a measure in the traditional sense and found that it was more flexible and more fitting to their services, indicating that Assert has a higher degree of appropriateness for these services compared to traditional standardized measures. As one counsellor put it, “I think that Assert is so brilliantly simple. It would be stupid to not use it!”

Building a sense of community among those counsellors using Assert was another salient sub-theme regarding implementation. The counsellors reported this as a motivating factor. They received a close follow-up by the research team, which gave them a setting where they could discuss cases, share experiences, and repeat how to use Assert. Implementing Assert with close follow-up, a bottom-up strategy and the establishment of a professional community, both within and between services and municipalities, will contribute to both feasibility and sustainability of this method within this service context.

Taken together, Assert can be construed as an appropriate method for facilitating systematic user involvement in treatment while allowing for flexibility. The counsellor transfers more of the responsibility to the person who is the centre of the treatment, validating their perspective and following up on their needs systematically over time. Transforming the concept of user involvement into something more than a formality and into something concrete is especially important in this service context where the clients have a legal right to be involved in planning and decision-making regarding their treatment (Pasient- og brukerrettighetsloven, 1999).

Limitations

Using a single researcher may have biased the results of the current study. However, some qualitative researchers have argued that being highly involved in both the collection and the analysis of data is beneficial (Gubrium, 2007; Malterud, 2001). Still, the counsellors may have withheld some negative feedback as a result of the researcher’s involvement. On the other hand, most of the interviews were conducted in a familiar setting and in groups where the participants found support from their colleagues for their views. The interviewer was well known to all counsellors, and a trusting relationship developed between them during the training and study period. Moreover, both positive and negative experiences with Assert were presented by the counsellors regardless of the interview setting. These factors, in combination with the attention paid to reflexivity, hopefully minimized the counsellors’ socially desirable responses.

Another limitation was the skewed gender distribution of the sample; only one male counsellor participated in the interviews. Still, the proportion of male counsellors included in this sample matched the number of male counsellors in the study as a whole. Thus, the sample that was interviewed was likely representative of the counsellors included in the study. Furthermore, the majority of counsellors working in Norwegian primary mental healthcare are female, making the assumption that the gender distribution of this study would not limit the generalizability of the results reasonable.

Concluding remarks and future directions

The findings from this study indicated that Assert could be considered a useful, acceptable, and appropriate addition to the methods utilized in primary mental healthcare services. The application of a simple intervention that can facilitate positive therapeutic outcomes, empower adolescents, and stimulate increased involvement should be considered beneficial for adolescents, health professionals, and service leaders. Future studies that gather adolescent perspectives and examine additional barriers and facilitators to implementing Assert will complement these results and help better illuminate how introducing systematic idiographic measurements could improve such services.