Assessment in Psychotherapy

Mon Dec 28 20:11:12 CST 2009

Eric, what you say makes perfect sense to me! I think that assessments are
rather silly actually, unless a person is entering into a long-term
treatment program. Otherwise, they are a waste of time, because if a person
is limited to 8 or 12 hours of psychotherapy, even if they do have some
deep, underlying disturbance that is revealed through a thorough assessment,
it cannot be adequately addressed in such a short time; it can only be
placed in a larger context at best. I think that detailed information about
people who make it clear that they are interested only in short-term therapy
is more of an irritation than anything else because it cuts into time that
is already too short. I think if a therapist is skilled, s/he can start
where-ever the client is immediately, with no paperwork at all, and if there
are recurring threads, they will appear as discussion ensues, then those can
be be explained to the client as they come up, that way, the assessment
occurs during therapy, not before. That way, it is meaningful and useful for
the client, rather than just being some mysterious, secret thing that the
therapist does not actually discuss with the client, but only uses in order
to assign a diagnosis. I guess as long as it is necessary to assign a
diagnosis before therapy can begin, then lengthy assessments will be
necessary, even though they irritate the client and interfere with the
fragile trust being established in the beginning. I don't think I will ever
be willing to deal with insurance companies because of these sorts of things
they insist on that I think damage the therapeutic relationship.

Katherine

On Mon, Dec 28, 2009 at 1:39 PM, Eric Rutberg <ericrutberg at yahoo.com> wrote:

> 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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>

-- 

Katherine

"Education is not the filling of a bucket, but the lighting of a fire."  --
W.B. Yeats
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