Questionnaire revolution? I don’t think so!

A few days ago, I read about the Outcome Questionnaire (OQ) which, the article title suggested, revolutionise mental health care in Canada. Wow! I thought. That must be a questionnaire and half. And so, as I have written before on questionnaires, I thought I would have a look and see this wonder of wonders.  I am delighted to say that I was able to download the sample of the questionnaire from its website.

So, the questionnaire itself (here is the link) apparently is:

a self-report Outcome Measure designed for repeated measurement of client progress while in therapy and following termination.

and I have no reason to doubt it. I just want to have a look at the language.

Apart from 2 items (number 25 and 29), all statements put me, the respondent, in the position of speaking about myself, that is to say the statements put the pronoun ‘I’ as the subject of the sentence. All of them apart from item 11 even start with the pronoun ‘I’. In this questionnaire, I am supposed to speak as myself and for myself.

I tend not to like questionnaires which put me in such a position. I always feel that that I am being played. This is because somebody is putting words in my mouth and I cannot reject them. I am happy to answer questions, but I am considerably less happy to own statements that were prepared for me. Note that I am not even trying to make a point that has been made a number of times (for example by Leslie Swartz in the 1990s), that the form of the questionnaire item can (and does) impact on how people answer it. My point is more social, if you like. We very rarely simply repeat what others say and pass it as our own. It always reminds me of being a child who had messed up and her or his parent is requiring them to utter particular words of apology. The OQ becomes embodiment of a ‘What do you say?!’ situation. So, whenever I am asked simply to own the questionnaire through its use of the pronoun ‘I’, I feel somewhat violated.

But before I offer comment on the I-statements, let me first deal with the two odd ones, the statements where ‘I’ is not at their centre. Here they are:

  • Disturbing thoughts come into my mind that I cannot get rid of
  • My heart pounds too much

It is the first of those sentences which is more interesting. This is because I tend to think that thoughts do not occur in nature, in fact, I would even go as far as saying, and I am being brave here, that people think all the thoughts that there are. So, my question is whose thoughts come to my mind? Are they not mine in the first place? Is it not I who thinks them? Or, and that worries me, the questionnaire suggests that I could actually think someone else’s thoughts. And that is scary, to be honest.

Now, I understand that the item probably is a way of asking about the so-called intrusive thoughts and I appreciate the difficulty. Still, I am having trouble with thoughts as unfettered agents which simply come to my mind. Of course, I accept that people can actually say such things, in fact, Justyna Ziółkowska in her book on suicide writes about stories which construct suicidal ideation in such a way. But it is one thing for me, a patient, to say something, it is quite another for a questionnaire to pick it up and make it an ‘official’ way of constructing thinking. And I am not even going to start talking about the fact people don’t do thoughts. People think. And I do wish psychology and others started understanding it. Or perhaps, specially for psychologists, I should say:

I do have a wish that psychology made a start of having an understanding it.

I do have a hope that it has a better ring to it.

Now, having got rid of the odd ones out, let me start the rest of the discussion of the Outcomes Questionnaire with another general observation. What struck me the moment I started reading it was that all the statements in the instrument are constructed as absolutely certain. There are no qualifications, no hesitations, I’m simply supposed to be completely convinced of what I say. In other words, there is no possibility of me saying for example:

  • I sort of get along well with others.
  • I am a fairly happy person.
  • I like myself for this.
  • I am not certain, but I kinda feel something is wrong with my mind.

which, to my mind, is a more realistic way of describing such highly ambivalent, contested and contextual categories as getting along or happiness. Instead I must say:

  • 1. I get along well with others.
  • 13. I am a happy person.
  • 24. I like myself.
  • 40. I feel something is wrong with my mind.

The authors of the questionnaire assume that there cannot be any nuance in my life and/or in thinking about it. And given that it asks me to own the statements, I reject this. I simply cannot say that I am a happy person without a number of reservations and contexts. The same is with liking myself. Maybe I am complicating things, but do people really simply say: I like myself, without any reservation.

Or let me put it differently, do you, psychologists and psychiatrists, really speak like that? If I asked you about liking yourself, the only thing you will say is the time frame of that liking. Verily, verily, your life must be very simple. Bloody hell.

And here we come to the lack of context. The OQ assumes it is possible to say something like:

  • 7. I feel unhappy in my marriage/significant relationship.
  • 17. I have an unfulfilling sex life.
  • 37. I feel my love relationships are full and complete.

In contrast, I think that such sentences, especially in looong-term relationships, are more often than not just about meaningless. Because you cannot summarise, say, 20 years of marriage with one statement. Take the statement about sex. Yes, it might be very pedestrian, bordering on non-existent now, but it used to be stellar, but age and illness have taken their toll, but we still look at each other with love. I heard quite a few stories like that from men in depression and, gosh, how impossible it is to put them into one statement which has the time frame of a week (I will come back to it).

And then you have a statement such as this:

23. I feel hopeless about the future.

And I would say: who doesn’t?! Trump in America, Brexit in the UK, add Poland and Hungary to the picture and I start despairing. Is this what the questionnaire asks me about? No? Am I supposed to guess?

A final example on this point. What does

3. I feel no interest in things.

mean? All things? Like, I don’t get dressed because I have no interest in things? And, could I just ask: what on earth are those things?

My final comments on the questionnaire are, again, about the linguistic form. Consider these two pairs of items:

  • 14. I work/study too much
  • 28. I am not working/studying as well as I used to

 

  • 13. I am a happy person
  • 7. I feel unhappy in my marriage/significant relationship

Why is the first pair in different tenses? In other words, why I can only say that I work, and I must say that I am not working. I suspected that the questionnaire was asking me about similar things, but the difference in tenses suggest that it might not. And to be honest I am both confused and being confused. Why are different verbs used in the second pair? Does it mean anything?

Consider now two sets of items.

  • 8. I have thoughts of ending my life
  • 19. I have frequent arguments
  • 22. I have difficulty concentrating
  • 30. I have trouble getting along with friends and close acquaintances

 

  • 23. I feel hopeless about the future
  • 35. I feel afraid of open spaces
  • 4. I feel stressed at work/school
  • 7. I feel unhappy in my marriage/significant relationship
  • 40. I feel something is wrong with my mind

In the first group of items, the authors seem to avoid using verbs and substitute them with the ‘have + noun’ constructions, in other words, I cannot simply argue, I must ‘have arguments’, I cannot think, I must ‘have thoughts’. The two other items are more complicated. Still, I could simply say that I can’t concentrate, rather than ‘have difficulty concentrating’.

There is no clear answer as to how to explain this. I will suggest that such items do serve a purpose. They point to negative things and/or symptoms. Take thoughts, for example. It seems that thinking is OK, but having thoughts is less OK. It is thoughts which are a symptom, rather than thinking itself.  Similarly, ‘having difficulty’ or ‘having trouble’ not only potentially pathologises what can be perfectly normal situations and, more importantly, shifts the responsibility of the problem squarely onto the questionnaire respondent.

Let’s look at the ‘feel’ group now. There is actually quite a lot of feeling in the instrument, the authors seem to like the verb. And I wonder why it’s only ‘feel’. Apart from item 40 (which is confusing as it uses ‘feel’ in a different meaning from the rest), in the remaining ones you can change ‘feel’ with ‘am’ and I wonder about the insistence on ‘feel’.

So, let’s compare them with the group of items that do contain the verb ‘am’ (I think these all of them):

  • 13. I am a happy person
  • 16. I am concerned about family troubles
  • 28. I am not working/studying as well as I used to
  • 31. I am satisfied with my life
  • 43. I am satisfied with my relationships with others

It’s quite uncanny, isn’t it? Apart from item 28, the remainder refer to positive things. In contrast, if you feel something, it seems to refer to bad/negative things. I must admit that that I was quite taken aback by it.

Explanation? I have a (weak) suggestion, though. The verb ‘be’ might suggest a more objective account of reality, while the verb ‘feel’ suggests that the respondents only ‘feel’ that, while reality might be different. ‘Feel’ introduces more subjectivity which, in turn, is more subject to challenge. If this is the case, however unconscious and unlikely, then I think this is an instrument of manipulation rather than anything else. I do want to stress that this is only a suggestion.

Before I end, I would like to make one more point. Here is part of the instruction for the respondents:

Looking back over the last week, including today, help us understand how you have been feeling. Read each item carefully and fill the circle completely under the category which best describes your current situation.

Well, for one, this instruction does explain the frequent use of ‘feel’. It seems to be founded on an assumption that if I am to tell you how I feel, I must use the verb ‘feel’, an assumption that I cannot really comment on with a straight face. The instruction also introduces ambivalence between thinking about a week (including today) and the current situation. But what really strikes me every time with such a questionnaire is that, it seems, the week is the clinically significant unit of time. Two units – i.e. two weeks – allow you to be depressed, here, just for monitoring purposes, a week will do.

And I wonder why a week. Is there really some significance to 7 days, as opposed to, for example, 10 days, a nice rounded numbers. I doubt very much that people’s memories somehow stop after 7 days and the three additional ones become a mere blur (unless you’re depressed, of course). So, what’s in the week? British (US?) universities’ calendars are presented in weeks, some wages are weekly, there are of course all sorts of religious connotations of the week. It might of course be also driven by the common weekly therapy schedule.

But is the week medical, though? Or is it just thrown in because you just think in weeks. Me, on the other hand, I don’t. I tend to measure time in days and months, weeks are less important. And so, I started wondering whether I qualify for doing the OQ. In any case, I would appreciate any insight into the medical week or any other clinically significant units of time.

Conclusions? I don’t know. I think there are more problems with the questionnaire than solutions it offers. I also would prefer that people, let alone questionnaires, should not speak for me.

 

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