Assessment in Psychotherapy
Peter Howie
peterhowie at macquariehouse.com.au
Sun Jan 3 17:45:18 CST 2010
Hi Adam and colleagues,
I am caught up in the reminder that an assessment process is not
(usually) designed to assist the client directly. Assessments
processes are (usually) designed as part of a problem solving exercise
that have a range of underlying assumptions. Amongst these assumptions
that I can imagine as I write but which is not exhaustive are: a)
There is a describable condition for which this person can be neatly
enough fitted into; b) How this person seems from their behaviour is
how they are; c) A condition is something that exists; d) a plethora
of related assumotions more to do with finances and getting the best
for the dollar outcomes. The one I am most interested in is b) because
it relates to a person's internal experience of themselves. It is this
experience that is most often left out of an assessment but which, I
hypothesise, is the most relevant factor. It is the factor that in a
psychodrama I work with, validate and produce - a person's sense of
themselves.
Cheers
Peter
On 29/12/2009, at 12:51 PM, Adam Blatner wrote:
> 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
> Grouptalk mailing list
> List at grouptalkweb.org
> http://grouptalkweb.org/mailman/listinfo/list_grouptalkweb.org
Peter Howie B.Sc, TEP
Managing Director
The Moreno Collegium for Human Centred Learning, Research and
Development
0411 873 851
www.morenocollegium.com.au
-------------- next part --------------
An HTML attachment was scrubbed...
URL: <http://grouptalkweb.org/pipermail/list_grouptalkweb.org/attachments/20100104/5e8f9733/attachment.html>
-------------- next part --------------
A non-text attachment was scrubbed...
Name: pastedGraphic.tiff
Type: image/tiff
Size: 30674 bytes
Desc: not available
URL: <http://grouptalkweb.org/pipermail/list_grouptalkweb.org/attachments/20100104/5e8f9733/attachment.tiff>
More information about the List
mailing list