The Function of Assessment Within Psychological Therapies

A Psychodynamic View

Luigi Caparrotta, Kamran Ghaffari

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781855759541
• eBook ISBN: 9780429920851
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

There are various different psychological therapies but their shared aim is to help the sufferers of mental disorders. The role of assessment and the decisions following that are crucial in the treatment process. The first encounter between the patient and the assessor defines the problem and shapes the possible treatment model. However, formal training in assessment is non-existent. This volume attempts to offer guidelines for assessment and it also offers general information on assessment in a concise form, with the help of clinical vignettes and case examples. The purpose has been to keep the book as simple as possible so that it may be easily accessible to beginners as well as to provide an initial structure and overview for more experienced practitioners. We therefore hope that this work may serve as a useful guide for referrers, trainees and therapists practicing in a variety of psychotherapeutic settings, including those in the National Health Service and in private practice, and begin to foster further debate in this field.

Chapter One
Definition of assessment

First interview, consultation, diagnostic evaluation, therapeutic encounter, assessment interview, and clinical interview are some of the terms employed to describe the process of assessment.

Before defining and examining the various components of the assessment procedure, it may be informative to examine the etymology of the word “assessment”. The derivation of “assessment” comprises both the Latin ad-sedere (to sit at or by) and the French assise (to size) representing a standard of conduct, an extent, a magnitude, etc. (Partridge, 1966). Viewed within this context, assessment seems to have very definite legal connotations that could be associated with an intrusive, judgemental attitude.

Hence assessment, in a clinical setting, can be defined simply as a process of sitting together and spending time with a professional to establish the nature and the extent of the presenting problem in the context of one’s own narrative at a particular stage of one’s own life. This interaction should afford the patient an opportunity for self-exploration with another person in a safe, non-judgemental atmosphere.

In practice, however, such a process requires professional skill and presents numerous challenges. Moreover, it is well recognized that the assessment of a patient for psychotherapy is a very complex procedure. Coltart (1986), in her seminal article on assessment, makes it very clear that the clinical interview exploits a combination of diagnostic efforts and skilful interaction to search for the subtle nuances which should lead to “a psychotherapy prescription”. Even the best-conducted psychotherapy consultation cannot escape the delicate, intricate, and subtle interaction that is often a source of apprehension for both the assessor and the interviewee. Indeed, this interaction may be the source of the most valuable information (Davies, 2003).

Definition and function of the assessor

The New Oxford Dictionary defines “assessor” as “a person, who is knowledgeable in a particular field and is called upon for advice”. When applied to psychological therapies this definition requires expansion. In 1979, Malan cogently pointed out that

the preliminary enquiry can only be carried out effectively by someone [assessor] well grounded in theoretical knowledge … as well as experienced in the different possible kinds of intervention and the consequences of applying them in many different situations.

Milton (1997) stresses that the definition of the assessor within psychological therapies is not only beset by questions regarding training, experience, and theoretical positions, but also by those relating to individual style.

Ideally, the assessor conducting the initial assessment should be a senior clinician, highly trained, familiar with local facilities, and informed by research. The recent document from the NHS Executive (2000) stresses the importance of assessments being conducted by widely experienced psychological therapists and sets out minimum requirements for training. These are:

(i) a core professional training in mental health and at least 6 months experience of working therapeutically with the severe and enduring mentally ill; (ii) a foundation training (minimum 30 hours incorporating theoretical and clinical seminars for each model) in a broad range (>3) of major psychological therapies with “practitioner” status (minimum 2 year training) in at least one.

We agree with the NHS Executive’s recommendation of minimum requirements for training, but believe that for the purpose of assessment a longer and more intensive training is to be highly recommended (minimum four years).

The attitude of the assessor and the style in which the diagnostic interview is conducted are vital components of the assessment process and its outcome. We believe, therefore, that the diagnostician should attempt to create a safe space for the patient to explore his/her difficulties by adopting a warm, flexible stance and by working as an active and intuitive participant. Furthermore, the assessor should actively engage the patient with empathy, flexibility, elicit his/her collaboration, convey that he/she is valued and acknowledge his/her uniqueness and point of view (Gabbard, 2000). The initial assessment is a joint venture and should be “patient-centred” rather than “pass or fail” interview to fit in with the assessor’s view (Davies, 2003). As illustrated below, it is not uncommon for some assessing clinicians to adopt a detached, cold, and even silent posture.

After 10 minutes of silence, Mr A asked the assessor, tongue-in-cheek, whether they were waiting for the tea to arrive, as it was teatime. The assessor interpreted this statement by telling the patient that he was obviously very hungry to be fed by him. Mr. A, renowned for his humour, responded by asking the assessor whether they were waiting for biscuits to arrive with their tea. After a few more minutes of silence, Mr A eventually walked out saying that he would rather prefer the warmth of the canteen.

As Coltart (1988) emphasizes, this stance is very often adopted by assessors, based on the unfortunate assumption that such a stance might encourage the expression of patients’ anxieties, thereby facilitating access to deeper unconscious conflicts. Kohut (1996), in his 1975 lecture, ventures beyond this to point out that the artificial absence of an empathic response is not only depriving but clearly unhelpful. He claims that it is a mistake to interpret the consequent rage generated in the patient as an expression of “… his true self coming out”! In our experience, an unresponsive and detached posture can increase the patient’s already heightened anxieties about exposure, which can be counterproductive and possibly lead to premature foreclosure. Furthermore, the assessor may form an image of the patient that is partial, if not distorted (Coltart, 1988; Diatkine, 1968; Limentani, 1972). Similarly, the patient may be left with a flawed impression of how this type of first encounter could be useful, let alone lead to a therapeutic endeavour.

While excessive detachment on the part of the assessor can be unhelpful, it is equally important that we avoid either inviting the patient to like us (to satisfy our own narcissistic needs), or making it so comfortable that the assessment becomes little more than a cosy chat with a friend. Within this context, the need to respect the patient cannot be emphasized enough.

Clinical experience, including training, and, to some extent, the theoretical allegiances and cultural background of the assessor, are important contributors to the assessment. Other assessor variables include gender, age, religious beliefs, and socio-economic background.

While some factors are inherent to the assessor, there are also factors that are brought to the assessment by the patient, as well as factors deriving from the interaction between the two.

The following examples serve to illustrate some of these factors.

A patient was offered an appointment for assessment by one of us (KG). On receipt of the appointment letter she rang the secretary declining the consultation because she did not want to see anyone with a foreign name.

Cultural awareness and sensitivity, as part of a broader dimension of individual sensitivity, have become increasingly important in our multicultural society and should therefore be included in any training.

A Muslim woman with depression and anxiety was referred for assessment for psychological therapy. The assessor, unaware of the cultural conventions, tried to shake the patient’s hand when introducing himself. This oversight caused the woman to be defensive and unhelpful during the assessment. “If he can not understand my cultural background how can he help?”

While shaking hands may create problems, not shaking hands can just as easily lead to misunderstandings, leaving the patient asking him/herself why the assessor seemed so rude and dismissive.

To disclose one’s own inner world to a “stranger” is not an easy accomplishment. Such intimate disclosure is often accompanied by fears of being judged and found out, which may give way to a mixture of dread and anticipation and ultimately hamper the patient’s ability to convey freely the extent of his/her difficulties. Milton (2001), for example, emphasizes that a good assessor should be able to gauge the patient’s capacity to tolerate intrusion. He/she should not be afraid to ask questions (Busch, 1986), but equally, bombarding patients with too many questions can be disconcerting and lead to uncomfortable recoil. This fear of intrusion can be detected even before meeting the patient.

A questionnaire was sent to Miss K before her initial assessment. She returned it blank aside from her name and address. She arrived for her appointment with her boyfriend and agreed to be interviewed only if he was also present. She started by saying that she found it very difficult to write anything or even to talk about herself to a total stranger. It took three consultations before she felt relaxed enough to leave the boyfriend sitting in the waiting room and to trust the assessor.

At the opposite end of the spectrum it is not uncommon to encounter an eagerness to talk and express strong emotions during the first interview. The opportunity to talk about oneself in the presence of a “listening ear” is a unique opportunity, which can be perceived not only as liberating but also as satisfying a long-standing need to be taken seriously.

Mrs B was referred by her general practitioner for panic attacks. When questioned about her difficulties, she started to talk painfully about the past twenty years of her life. At the end of the assessment, she left smiling, thanking the interviewer for being the first person to give her the space and attention she had been longing for.

In conclusion, we would like to emphasize that assessment is an intricate and delicate interplay between two individuals with their own unique life histories. As Anna Freud (1954) points out, it amounts to “two real people of equal adult status and in real relationship to each other” involved in a process of mutual exploration into the known and the unknown, the links, the fears, and the hopes, and the wish both to know and not know. Invariably this new experience will draw on the life experiences, or the lack thereof, of both the interviewee and the assessor. Furthermore, it will always combine the skills, talents, and expertise of the assessor with the attributions and expectations of the patient that define the journey.

Chapter Two
The referral process

Pre-referral stage

We consider it pertinent to highlight this “pre-referral stage”, for we believe that it may have an impact on the patient’s decision regarding whether or not to attend a psychotherapy consultation.

The referral process evolves from the interaction between patient and referrer. The decision to initiate the referral process may be taken by the referrer, the patient, or both. Experienced referrers tend to discuss the process and merits of “talking therapy” with the patient, which may help them to reach a decision. On the other hand, referrers with a very limited knowledge of psychotherapy may set the process in motion by prescribing “psychotherapy”, without giving an adequate explanation of the reasons for this decision or of the benefits the patient may derive from such an intervention. Increasingly, patients tend to request a psychotherapy referral.

Having mutually decided that “talking therapy” would be helpful, the referrer needs to choose the most appropriate setting; e.g. in-house counselling, specialist hospital based services, private referral. For example, in the Primary Care setting, the majority of cases in which problems are mild and stress-related could be dealt with by the in-house counsellor, particularly if the patient prefers not to be referred to a hospital-based specialist service. However, the ability to make such a decision is determined by the availability of properly trained and supervised counsellors within the practice.

Referral source and reasons for referral

Referrals usually come from psychiatrists, general practitioners, Community Mental Health Teams (CMHTs), psychologists, social workers, and other medical or non-medical sources. Broadly speaking, more than half of referrals to our busy specialist psychotherapy out-patient services tend to be made by general psychiatrists, approximately 40% by general practitioners, with the remainder coming from professionals within the service and other sources.

The reasons for referral, upon which we will expand in the next chapter on pre-specialist assessment, include the following:

• for assessment for treatment of choice
• as an adjunct to the overall management
• as an alternative to drug therapy
• poor compliance with medication
• therapeutic stalemate
• when disturbance of personality hinders treatment progress.

However, this list of reasons is not exhaustive and very often patients are referred for a combination of these reasons.

Referral letter

A letter continues to be the most frequent mode of referral. This can be addressed either to a named specialist or to a named service.

The content of referral letters is wide-ranging. It can vary from non-informative statements, such as “please see and treat”, to very detailed histories that might include an indication of suitability for psychological therapy and suggestions regarding appropriate psychotherapy types and modalities.

In our opinion a helpful letter should contain, in addition to demographic data, at least the following information:

• presenting problems
• a brief history of the onset
• previous contact with mental health services
• relevant medical history
• reasons for referral
• brief note indicating that patient has been fully informed.

Such information facilitates the preliminary screening and appropriate assessment route. It allows for the gathering of relevant details, ...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• CONTENTS
• Dedication
• ACKNOWLEDGEMENTS
• PREFACE
• FOREWORD
• Introduction
• CHAPTER ONE Definitions
• CHAPTER TWO The referral process
• CHAPTER THREE Pre-specialist opinion
• CHAPTER FOUR Specialist assessment
• CHAPTER FIVE Suitability for psychological therapy
• CHAPTER SIX Psychodynamic assessment
• CHAPTER SEVEN Case formulation
• CHAPTER EIGHT Post-assessment routes
• CHAPTER NINE Concluding remarks
• APPENDICES
• REFERENCES
• INDEX