Assessment in Psychotherapy

Tue Jan 5 14:47:14 CST 2010

I do confess that one of the better tools for relationship-building and assessment is the technique of having a client make up a social network diagram (aka social atom) and talking about it with the client. The sense is not that i-psychiatrist am analyzing/judgin you-patient, but more we together are looking at the situation, a social network, and exploring several things: Just what seems relevant; what is obviously left out and why; how you feel towards x or y or z; how you suspect they feel towards you; where there may be conflict, etc.
       Generally, though, I work from chief complaint, just trying to get from descriptions of abstract generalities to situations. I don't know what anyone is talking about unless I have at least one and preferably several examples, described vividly enough that I can picture the scene, hear the dialogue, see the action. Professionals as well as patients tend to talk in abstractions, quite unconscious of the defensive nature of such a tendency. 
       Just going over what the complaint is, and then gradually expanding it. What are other major complaints. Which roles are relatively conflict free? Touching on the idea of wanting to know strengths ,too; there's a place for a bit of self-affirmation, helping the client not overly identify with the role of patient, client, sick-one, but rather as a person with strengths who happens to be going through a rough spot now and could do with a bit of consultation and coaching. 

       And working outward. One of my favorite mottoes: If you feel like you're not sure what's going on, take the history again. Each time you go over the story (1) the client appreciates that you're really trying to listen; (2) are not so prideful and quick to judge (a la Dr. Phil or Dr. Laura) but rather humble enough to really think about what you're hearing; (3) open to what the client thinks is the problem; (4) planting the suggestion that behind the first version of the story there may be details that have more significance than the client recognizes (5) having the client join you in a detective game just like in the detective mystery stories, etc. 

      So just thought I'd comment on this about assessment. Warmly, Adam
  ----- Original Message ----- 
  From: georgia rigg 
  To: Adam Blatner 
  Sent: Monday, December 28, 2009 11:22 PM
  Subject: Re: Assessment in Psychotherapy

  Hi Adam, This is an interesting discussion--I taught assessment as a process that covered all aspects of the clients life, to social work students for 25 years, and evolved a process that insisted that the core to understanding the person was in the relationship, and that understanding the person in their home situation was vital--and, we social workers were usually the ones sent out to see what that home situation was about--and that needed to include not just the family, but the neighborhood and the impinging community--there is quite a difference between considering a person neurotic, and thinking of their ways of feeling, thinking and behaving as survival strategies.  I do like using Mosher's Healing Circle model for both assessing, and sharing information with the client about those survival strategies.  Working in a psych hospital for five years was interesting as they used the APA checklists, etc.  Maybe in Philly we can talk about how to sneak relationship building into the process in such places!  All my best to you, Georgia

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  From: Adam Blatner <ablatner at verizon.net>
  To: Katherine Morris <morris.katherine at gmail.com>; Eric Rutberg <ericrutberg at yahoo.com>
  Cc: DRAMATHERAPYLST at listserv.ksu.edu; list at grouptalkweb.org
  Sent: Mon, December 28, 2009 7:51:35 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

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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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