Assessment in Psychotherapy

[Katherine Morris]

Dr. Blatner, I like your ideas about assessment! :) What you offer is a wise
and thorough approach to to the biopsychosocial model of assessment. It
reminds me that what is taught as 'biopsychosocial' in school really isn't
actually, because when the model is applied, it fails. At least that was my
experience after I went through a training program in addictions counseling,
and had to learn how to do assessments using the ASAM biopsychosocial model
that is about 15-pages long, evaluating people in 5 different areas, but not
the areas that you list below. It was designed to include homeless people
and persons detained in mental institutions, etc. so it is on a lower level
and never reaches the points you make below, and it does not include
recognition of clients' strengths.

Then I began an internship in a drug-rehabilitation agency for adults and
adolescents. I was the 'assessment specialist' and my entire job was just to
do assessments of adults and adolescents all day long, so as you can
imagine, I did some thinking about these forms they were using, and what was
actually really happening to people after their diagnoses. I was told that
each assessment should take about 1 hour at the most, but I took between 2
and 3 hours for each one, and even then it felt like a very rushed and
unnatural process, and in every assessment I did, I discovered that drug or
alcohol use was only a symptom of an ontological disturbance. So, what they
were treating was just the symptom of an underlying disturbance that your
areas b, c, d, and e, below would address, except that none of those were
ever addressed; not in assessment, and not in treatment, except for b, and
even then only superficially.

I think your area c below is particularly important, because in my view,
actually an entire assessment can be done on a person by examining only
their sexuality, using a phenomenological method of inquiry. Everything that
is unbalanced appears through a person's sexuality, in the physical,
fantastical, and thoughtful realms of sexuality. Also, how emotionally
mature or immature a person is, appears through their sexuality. Even how
healthy they are physically; I can't think of anything about people that
does not appear in their sexuality, including lack thereof whether chosen or
otherwise. It is a good way to get a 'close up view' of a person because it
is a symbolic language that reveals far more than words ever can. So, if we
want to really know about a person, we should examine their sexual
fantasies, longings, partnerships, the content thereof, what they pursue,
desire, etc., then we can see what sort of disturbances we are dealing with
because sexuality is a heavily symbolic language, and it reveals everything
about a person once we learn to read the symbolic language. It is a symbolic
language and should be treated as such.

Also, area d that you list below I think is as crucial as area c, yet both
of these are largely ignored by psychologists and psychiatrists. If a person
lives with a deep, pervasive emptiness, or forlornness, or meaninglessness
about life, that is what should be addressed, because the behaviors that you
mention, you are wise to recognize that they are just 'cover ups' for the
lack of a feeling of meaning and depth in life and relationships and
exchanges. The behaviors you mention are symbolic languages also, yet they
are treated literally by the enterprise of clinical psychology. This is why
I am an advocate of using philosophy as the foundation of psychology,
because it excels where clinical psychology fails. That reminds me, I read
somewhere recently that Albert Ellis said that if he had it all to do over
again, that he would have studied philosophy, not psychology (well, he did
study philosophy, but gave it up at the master's level in favour of
psychology, which he apparently felt later was a mistake).

Well, if you create a Blatner assessment model, I will use it in my future
practice! :D

-Katherine

On Sun, Dec 27, 2009 at 1:07 PM, Adam Blatner <ablatner at verizon.net> wrote:

>  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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