Assessment in Psychotherapy

[Eric Rutberg]

Hi grouptalkers,

As I was falling asleep last night another thought about assessments popped up for me. I think I am struggling with distinguishing between collecting "patient history" and actually assessing for a particular "thing."

For instance, I like to assess for a person's learning style, as that helps me and the client undertand the most effective ways to present information. I like the MBTI wen doing work with career development because it helps me and the client narrow a search to a career that is congruent with personality. 

Hence, the distinction between an "initial assessment," or structured interview to gather a history and build therapeutic rapport and specific assessments.

Thoughts?
eric




________________________________
From: Adam Blatner <ablatner at verizon.net>
To: Eric Rutberg <ericrutberg at yahoo.com>
Sent: Tue, December 29, 2009 4:52:38 PM
Subject: Re: Assessment in Psychotherapy


Hi Eric, I don't know if I can do it, because I start with a very broad field---the whole medical model--- meaning somatic symptoms, life situations, etc. And what Katherine said has some validity in that many patients only want brief therapy, patch 'em up. And of course in military settings that's what you're supposed to do. So there's some modification from the get-go. 
     Eric Berne introduced the contract, which I think is a great idea: What does the client think she wants to change. How will we know when that's done?  Versus the interminable process of unfolding. (I've been doing an introspective and with my spouse and earlier on with some therapists a lifelong process of addressing and cleaning up residual neurotic patterns and it continues. They're "smaller" (as Ram Das put it), but they're there. So potentially psychotherapy will always have something to work on.
     Ann Hale's theme of priority is good in a way, but again there are a few clients who come in to use therapy as a deeper form of personality reworking; they want to go deep. Even then, though, they have their priorities.
      
   Many aspects of "therapy" really have their own "ripe-ness," times when they're ready to be addressed. It's possible to pick up unfinished business and themes that "could" be worked on---and if clever, one can discern scores of these---but that shouldn't imply that any of them "should" be worked on!  Who's paying, what's the client's priorities, and other aspects matter. Have you seen my paper on my website about the real diagnostic variables? One of those categories is voluntariness, and that in turn can have many sub-types.
      Sometimes, as I may have suggested, what patients think they want is yet far from what they need, so that itself becomes an interesting challenge in negotiations. 
       Physician-psychiatrists are in a particularly vulnerable role as gatekeepers of drugs that some patients want without having to face themselves----and some are out-and-out drug abusers. 
          
 
    So it's not entirely linear. I said it: What's the chief complaint? Dig around and what's probably the main cause? Allow for some error and re-negotiating the contract as one progresses. The idea that this shouldn't be necessary if you do it right the first time is shallow and aligned with an archery rather than cybernetic model: Archery: as you aim, so you hit. Cybernetic: The rocket to the moon was off course 98% of the time, but there were a thousand mid-course corrections, a little this way, a little that way, so that the degree of error was reduced each time, again and again, so that near the end point the accuracy was very high. 
 
    About the defensive function scale... well, I don't know about "scale"  -- it all strikes of trying to pin folks down. I find many people operate differently with different roles--- with parents, spouse, work-mates, acquaintances--- each role constellating different attitudes, regressive archetypes, etc. 
         but I have come to a similar conclusion about the defenses and will be presenting on them this coming April at the conference. Will you be at ASGPP in Philadelphia? Panel on psychoanalysis. 
 
    yes, I think most of those defenses can be enacted as if they were little assistants or seducers or phony doubles whispering illusions to the person...    and the point---applying this in my dream of teaching psychology in high school or college in a practical way--- is to help people to recognize the thousand seductions into self-deceptive thinking.
 
   (I consider advertising, propaganda, rhetoric, logical fallacies, and a host of other self-deceptive tendencies described in the last twenty years by research psychologists in various books to be further variations of the defenses; plus interpersonal "games people play," manipulations, etc. So it's not just the defense mechanisms within the individual.)
 
     Warmly, ADam
----- Original Message ----- 
>From: Eric Rutberg 
>To: Adam Blatner 
>Sent: Tuesday, December 29, 2009 12:30 PM
>Subject: Re: Assessment in Psychotherapy
>
>
>Team !
> 
>I would warmly welcome feedback on developing a decision tree that actually works and makes sense. The one on my website reflects that which can be found in the DSM. It can of course be improved upon. Adam, can you describe your time-tested decision tree in more detail? Can you see it being formalized for others to use or do you feel it is honed to your personal style? Do we all need to create a personalized decision tree??
> 
>I too bekieve that the conitions with which people present in sessions are more likely a conglomertae a several disorders. Nothing fits neatly so to speak. 
> 
>Also, Adam, your point about the assessment tool being a medium for establishing therapeutic alliance rings so true for me. The Assessment process may lead to  diagnosis, which is important for billing and discussion of cases and research but the dialogue betwen counselor and client also helps to prioritize matters, set goals and identify barriers to reaching those goals. ie: Being better and being neurotic (grin).
> 
>Another tool I find interesting from the DSM is the defensive functioning scale (attached). I review this at length with clients and pend may the session dealing with therapy intefering behaviors and barriers to "stated" goals. I think this too is a dream tool for developing role-plays and action therapies !
> 
>Thoughts?
>Eric
>
>
>
________________________________
From: Adam Blatner <ablatner at verizon.net>
>To: Katherine Morris <morris.katherine at gmail.com>; Eric Rutberg <ericrutberg at yahoo.com>
>Cc: Adam Blatner <adam at blatner.com>; list at grouptalkweb.org; DRAMATHERAPYLST at listserv.ksu.edu
>Sent: Mon, December 28, 2009 9:51:35 PM
>Subject: Assessment in Psychotherapy
>
>
>Hi all, this discussion gives me a chance to reflect on the deep problem of assessment. I confess to being biased by my training that included reading Harry Stack Sullivan's "the Clinical Interview." Really, this process went on for months, and much of the "therapy" involved simply clarifying the story in many aspects. It was somewhat structured for Sullivan, but we don't have to use that---nor do I. The point is that Katherine is right that exploration can go on for a long time.
>          Eric brings up the pressures by agency managers to micromanage the behavior of therapists, which distorts the whole process. The problem of naming the condition according to the APA diagnostic manual is amusing and may have to be done for administrative purposes, but is often not clarifying. I went to Eric's website and began the decision tree on anxiety and immediately got hung up on the first question. (Ha! thanks, Eric!) I realized that many patients will attribute symptoms to a new medication, and the problem of the prevalence of co-morbidity---several things feeding into the problem---can be short-circuited by an easy answer right off. Many if not most patients suffer from an interplay of several different problems (some not clearly mentioned by the APA, as I noted in my earlier letter).
>          The other thing I'll confess: I don't do thorough assessments (following checklists), but rather do a quick process of decision tree (not via the APA, but like it in some ways). Chief complaint +age, gender, marital status =  hints at a differential diagnosis. Questions are asked that narrow that differential down. Many other questions don't get asked right off. This simple process (that yet takes in my estimate about 7 years of experience) gets you into the ballpark in 85% of cases. When things don't fit, I get more clues, sharpen differential further, and reiterate the process. The feedback helps shape it. 
>        I don't try to be accurate or precise---and doubt that such goals are useful. The words belie the squishiness of the individual nature of real people, their individuality. The key isn't the perfect assessment, but building up a therapeutic alliance, and a willingness of the therapist to use ongoing feedback and re-formulation and reiteration to sharpen the process. 
> 
>      Katherine, I sort of agree, but wouldn't dismiss the complexity of the system with the word "silly." It's good to question, but different people in different professional roles are more or less subject to varying degrees of bureaucracy---and some of these are not easy to shift. I do agree with the need to recognize the pressures of the system and also the desires of many (but not all) patients for short term therapy. Sometimes, Fritz Perls' saying (if he did say this) seems germane: Most people don't want to really get better. They just want to get better at being neurotic. 
>       I interpret this as follows: Many people seeking therapy are seeking relief of depression or anxiety that is a reaction to family or employer or other stresses giving up on them, leaving them, getting fired, not rescuing, etc. The idea that their own way of setting up such life catastrophes is unthinkable---they are in their own minds pitiful victims. They further deny this and are very clever in setting up the therapy so that they can get whatever secondary gains possible---disability diagnoses and payments, time off from work, drugs, etc.  I wonder if this constitutes 20% or 70% of the general population seeking "help" --- I'm pretty sure it's over 60% of those being forced into "getting help," either because of the court, a family threat, or in an institution. 
> 
>       It is too bad that patients are expecting to use medical insurance and that third-party process imposes all sorts of constraints. There are a few therapists who can afford to hold out and still make a living. I'm not sure what will be the climate in the coming years as new laws are passed. So it's complicated.
> 
>    Warmly, Adam
>----- Original Message ----- 
>>From: Katherine Morris 
>>To: Eric Rutberg 
>>Cc: Adam Blatner ; list at grouptalkweb.org ; DRAMATHERAPYLST at listserv.ksu.edu 
>>Sent: Monday, December 28, 2009 8:11 PM
>>Subject: Re: Assessment in Psychotherapy
>>
>>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
>>>
>>>Grouptalk mailing list
>>>List at grouptalkweb.org
>>>http://grouptalkweb.org/mailman/listinfo/list_grouptalkweb.org
>>>
>>>
>>
>>
>>-- 
>>
>>Katherine
>>
>>
>>"Education is not the filling of a bucket, but the lighting of a fire."  -- W.B. Yeats
>>
>


      
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