Assessment in Psychotherapy

[Eric Rutberg]

Adam and all !

I appreciate these thoughts around assessment and diagnosis. I was discussing "ethics of assessments" today with a colleague. I'm always working on how to assess clients in a way that clearly identifies presenting and underlying issues (ie: spirituality, support systems etc.) to treatment and leads to an accurate diagnosis. 

At the agency with whom I am affiliated, we are asked to complete an initial "psychosocial assessment" form supplied by the agency. It's like 8 pages long and asks many questions from substance abuse and family history of mental illness to childhood abuse and vocational aspirations. From the assessment, we are then to form a treatment plan. 

Some clinicians feel compelled to interview the client with the hopes of answering all the Q's. I find this method questionable on several levels. 1st, I don't like documenting in writing the details of the lives of clients, especially if such details are not directly related to the subject at hand. I find clients typically arrive to counseling with a problem or issue on their mind. I talk with them about the various aspects/perspectives presenting and document those on the initial assessment and leave the rest as n/a. I also find that if I answer all the Q's on the assessment, the treatment plan becomes unweildy. (We are supposed to address all issues from assessment in the treatment plan.) Insurance constraints, and resources of money and tie in general compel "us" to treat in a most consice, brief way. ALSO, the assessment tool we are asked to use digs into areas that were not brought to the fore by the client, but by the clinician asking the
 q's. This does not seem client-centered and feels awkward/intrusive to me, in the sense that I want things to unfold more naturally. 

Am I making sense?

BTW: I have been working on transferring the differential decision trees from the DSM-IV to an interactive web-based process. Check it out at http://yourwellbeing.org/DiffDiagTree.htm

Thoughts?
Eric

  
________________________________
From: Adam Blatner <ablatner at verizon.net>
To: list at grouptalkweb.org
Cc: DRAMATHERAPYLST at LISTSERV.KSU.EDU
Sent: Sun, December 27, 2009 4:07:51 PM
Subject: Assessment in Psychotherapy


Dear Colleagues, I've been thinking about the general theme of diagnosis---not the finding of labels, but of really understanding. Perhaps "assessment" might be a better term. How to find out what's going on, what formulation might lead to the most rational construction of a general treatment approach; which elements to include in which order, and how to sequence the gradation of complexities? 
 
So, in light of developments in the fields of psychiatry (in its best sense---there's a lot going on in practice that I don't like)--- we need to update our evaluation to include things that weren't taught back in the 1960s when I was in specialty training, and these are the kinds of things that if you don't ask, people won't tell you. 
 
    a. Co-morbidity. Whatever the problem, there's a chance that there's an un-reported co-morbid addiction or near-addiction, a distraction, a way of numbing-down, and these can includ not only drugs and alcohol, but sex, food, binging, thin-ness, news, work, clutter, debt (shopping), gambling, television, video games, etc. 
    b.Supportive relationships   often primary live-in or spouse may be more abusive or neglectful or exploitative and if you don't ask, the client is so oppressed that it doesn't occur to them to volunteer it... it's just the way life is, isn't it? 
    c Sexuality---often more complex than one might assume
    d. Spirituality---folks don't expect you to ask about this, and sometimes forget that it's important. If not religious, what is source of grounding? Often nothing, and often this is more of a lack than people know---they just assume that the world is this way. If there is a religion, it may be a source of support and could possibly be worked to serve more in this way; or it could be a source of distress---hell being a bigger theme in some people's lives than they want to admit.
    e. Sources of talent, strength, optimism, etc.--- the impact of positive psycholog--should be recognized... 
 
2. In the current climate of ambivalence towards psychiatry, there are many non-medical therapists who are excessively anti-medication. 
      A measure of wariness is appropriate. Many psychiatrists diagnose too readily and prescribe excessively, with lack of close follow-up. A significant portion of people on meds don't need them at all or don't need as much. Some of the people not on meds should be offered a trial, gradually trying one or another type, working collaboratively among therapists, prescribing psychiatrist, and empowered and informed client. Some folks in medium-term therapy are greatly benefitted by some meds.
 
    About "diagnosis"--- people are right to look at the DSM-4 with suspicious eyes. Many docs use it as a blunt instrument. In many people's cases it hardly describes what's going on. 

    Any thoughts? Warmly, Adam Blatner


      
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