The Integral Intake

A Guide to Comprehensive Idiographic Assessment in Integral Psychotherapy

Andre Marquis

• Publisher: Routledge
• Year: 2012
• eBook ISBN: 9781135907006
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Using formal assessment instruments in counseling and psychotherapy is an efficient and systematic way to obtain information about clients and to subsequently tailor a counseling approach most likely to serve clients optimally. The more information a counselor obtains during the initial interview and first sessions, the more likely the client will be deeply understood by the counselor, which in turn increases the likelihood that an appropriate course of counseling will be taken, and ultimately leading to a more successful outcome. The Integral Intake is an idiographic, biographical, multidimensional assessment instrument based upon the Integral Psychology pioneered by Ken Wilber. From the perspective of Integral theory, comprehensive and holistic conceptualization of clients seeking counseling and psychotherapy includes knowledge of four distinct perspectives (quadrants) of each client: the client's experience (the individual viewed subjectively/from within), the client's behavior (the client viewed objectively/from without), the client's culture (the client's system viewed subjectively/from within), and the client's social system (the client's system viewed objectively/from without). The intake form is designed to provide the practitioner with a range of background information that can then be used to more quickly and effectively formulate a counseling/treatment approach. The assessment form and accompanying materials will be included on a downloadable resource, formatted to be printed and reproduced for use with each new client. The book will provide an overview of the Integral Psychology model, describe the development of the assessment form and its use, and provide general guidelines for the evaluation of responses and planning for an appropriate counseling approach. A series of case examples, based on actual completed intake forms, will provide insight into the use of the Integral Intake.

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SOME GENERAL ASSESSMENT FOUNDATIONS

The Role of Assessment in Counseling and Psychotherapy

Most counseling theorists and practitioners agree that comprehensive assessment, in which counselors obtain as much information encompassing as many aspects of clients as is reasonable, is essential and crucial to successful counseling (Cavanagh, 1982; Eckstein, Baruth, & Mahrer, 1992; Hood & Johnson, 1991; Lazarus, 1995, 1997; Mosak, 1995; Shertzer & Linden, 1979; Wilber, 2000e). Moreover, “the ability to assess an individual is a basic skill required of all counselors regardless of the setting in which they practice” (Shertzer & Linden, 1979, p.3). Exceptions to this perspective come from the humanists, exemplified by Carl Rogers (1957, 1961) and, late in his career, Heinz Kohut (1984), both of whom posited that regardless of what the client’s problems were, the most important thing the therapist could do is communicate accurate empathy, thus rendering assessment relatively unnecessary or even a diversion from what is most beneficial to clients.

Rogers’ and Kohut’s perspectives on assessment, however, may be in need of revision. This can be demonstrated by considering an unfortunately not too uncommon situation: poverty-stricken, alcoholic parents whose children are growing up in an inner city and are attempting to navigate the gang scene and other forms of social oppression. Are we truly to believe that such clients need empathy more than anything else? Moreover, at times a simple change of diet, an increase in exercise, taking an antidepressant, or other biophysical—as opposed to psychological—interventions can be as effective as, or more effective than, psychotherapy (Lazarus, 1995; Leonard & Murphy, 1995; Wilber, 2000b).

Using intake assessment instruments (the term instrument is used synonymously with the term inventory) in counseling and psychotherapy is an efficient and systematic way to obtain information about clients and to subsequently tailor a counseling approach most likely to serve clients optimally (Van Audenhove & Vertommen, 2000; Beutler & Rosner, 1995; Palmer, 1997). The more information a counselor obtains, the more likely it is that the client will be deeply understood by the counselor, thus increasing the likelihood that an appropriate course of counseling will be taken, ultimately increasing the likelihood of successful outcome (Karg & Wiens, 1998).

The preceding paragraph presumed that some form of counseling or psychotherapy would necessarily be the most appropriate course of action for a given client. The intake assessment process not only includes elaborate, theoretically driven questions, as can be found in the Integral Intake, but also requires such fundamental questions as “Does this person need professional help?” If the answer is yes, the next question is “Is counseling or psychotherapy the most appropriate form of help for this person?” If the answer is yes again, the questions are “What theoretical approach and what specific interventions are optimal for this person with the struggles he is facing?” and “Can I competently serve this person and his needs?” Van Audenhove and Vertommen (2000) point out that the first two of these important questions are often forgotten or bypassed by many clinicians. They, and I, urge clinicians to take those questions seriously with each new potential client.

That being said, assessment also stimulates the consideration of various issues, helps elucidate the nature of the client’s problem(s), may lead to alternative approaches to the problem(s), may offer potential solutions, and often allows a means to evaluate the success of counseling (Hood & Johnson, 1991; Lambert & Cattani-Thompson, 1998; Ruddell, 1997).

Without obtaining information from clients, effective counseling is impossible (Persons, 1991; Shertzer & Linden, 1979). Even existentialists (May & Yalom, 1995) and humanists who do not formally assess clients with assessment instruments are continually receiving and encoding information gleaned from their interactions with their clients. Seen in this light, how one conceptualizes this information is a function of one’s guiding theory of counseling, regardless of how conscious or unconscious the counselor is of this assessment process (Fall, Holden, & Marquis, 2004; Shertzer & Linden, 1979). The question, then, is not whether or not clinicians should assess their clients, because even Rogers (1961) made assessments of his clients—along dimensions of how open to their experience they were, to what extent their ideal selves and self-concepts were congruent, and so forth: “For the person-centered therapist, the ability to conceptualize [assess] the relative degree and the specific content of one’s own and one’s client’s relative congruence/incongruence is central to the process of counseling and psychotherapy” (cited in Fall et al., 2004, pp. 191–192). Rather, the question seems to be one of how formally, and with what degree of theoretical consistency, the practitioner approaches the process of assessment.

The issue of how formally or informally one performs initial assessments is an important one. As previously stated, all psychotherapists assess their clients in one way or another. I refer to informal assessment as the gathering of information through the process of relating to, or interviewing, the client in session, without the use of an assessment instrument or other formal structure explicitly guiding the process. Some mental health professionals opt for a more formal/structured interview in which an assessment instrument is used to guide the questions and queries the therapist asks in the interview. In contrast to informal assessment, formal assessment involves the use of assessment instruments, whether nomothetic or idiographic, that subsequently will be discussed in detail. Considering the premium assigned to brief therapy by managed care, initial assessment instruments that efficiently gather as much information as possible—ideally without requiring much time during the counseling session itself—may have considerable value for many practitioners and clients (Beutler & Rosner, 1995). According to the author of the Handbook of Psychological Assessment, “Managed healthcare emphasizes the cost-effectiveness of providing health services, and for interviewing, this means developing the required information in the least amount of time. This may mean streamlining interviews by maximizing computer-derived information or paper-pencil forms” (Groth-Marnat, 1999, p. 71; italics added).

Assessment as a Process

Although assessment begins with the initial contact between therapist and client, it certainly does not end there. That is to say, assessment and the entire course of therapy are inextricably and tightly linked (Persons, 1991). “Actually,” writes Garfield, “assessment and treatment are intertwined and continue throughout therapy” (2003, p. 175). Moreover, in many ways, assessment is a form of intervention; it is the beginning of a process of evaluation of how clients feel, how they experience themselves, what they think is disturbing them, and what their strengths, resources, and best options are (Persons, 1991; Mahoney, 2003). Based upon an initial—and, one hopes, comprehensive—assessment, the therapist constructs a tentative treatment plan. As the therapy progresses, client and therapist periodically evaluate (an ongoing assessment process) how well the treatment is working and “revise the treatment plan as needed, using an empirical hypothesis-testing approach that involves a continual interplay between assessment and treatment” (Persons, 1991, p. 100).

My approach to assessment is highly resonant with Persons’ (1991) “case formulation” approach in which the information gleaned from the initial assessment process is used to construct a working hypothesis regarding the nature of the potential factors, issues, and/or mechanisms underlying the client’s presenting symptoms and problems. The case formulation provides the basis from which the therapist chooses the particular approach and specific interventions that the therapist deems optimal for this specific individual with these specific issues. Importantly, the case formulation is a working hypothesis that should be continually reassessed based upon information that is obtained from each subsequent session, and revised as needed.

An important caveat to the above paragraph from Van Audenhove and Vertommen’s (2000) “negotiation approach” to intake and treatment choice involves the imperative need to find a match or fit between the client’s perception of things and the therapist’s perspective; the assessment process and construction of a treatment plan is not driven solely by the therapist. It is imperative that clinicians pay attention to how clients experience and assess themselves—what they consider their primary problems, the duration of their problems and any precipitating events, why they are seeking help at this point in time, how they classify themselves, how they relate to themselves, what they see as their strengths and weaknesses, whether they have had therapy before and what their experience of it was like, their assessments of the likelihood of changing for the better, and how they think they can best achieve their desired outcomes and goals: “the client’s theory of change is often at least as important as the theory believed by the therapist” (Mahoney, 2003, p. 41; further supported by Bohart & Tallman, 1999; Hoyt, 1998). In addition, how clients interact with therapists often sheds light on their characteristic patterns of behavior, which are usually implicated in the problems for which they are seeking help (Yalom, 2002; Garfield, 2003).

To summarize, in addition to the technical knowledge and clinical expertise that counselors and psychotherapists bring to assessment, initial sessions must always:

• Include an exploration of clients’ perspectives regarding both what ails them and their ideas about what might be most helpful
• Involve informing clients of your perspective on them, their problems, and the most appropriate course of treatment
• Involve a negotiation process between the perspectives of client and therapist

Although the primary goal of assessment may be to understand clients in such a way that will ultimately serve their immediate concerns and lifelong development, knowing one’s self (deep self-awareness; therapist as instrument) is intimately related to deeply knowing others (Yalom, 2002; Mahoney, 2003).

Attunement

The initial contact that is established in the first session is absolutely critical to successful client outcomes. Whether described as building rapport, establishing a therapeutic relationship, creating an I-thou relationship, or forming a therapeutic “we,” the early aspects of coming together are of paramount importance. As such, intake interviews (the first session) ideally constitute a form of mutual exploration of compatibility. Not only are therapists evaluating the nature of clients, their problems, and their contexts, but clients are also assessing whether or not they feel a compatibility and faith in the therapist’s capacity to help them. Thus, clients should be given the opportunity to ask any questions they have—either about the process and nature of therapy in general or about how a specific therapist works (including theoretical assumptions and specific interventions used). If therapists do not feel confident that they can be of help to a given client, they should refer that client to others who are more competent with that client’s problems, culture, and so forth. Moreover, if a therapist does not like a client, has difficulty relating to or empathizing with a client and his concerns, or feels negative about some dimension of the client’s self-presentation, that therapist is not likely to be optimally helpful to that client. The skill of referral deserves more attention and research: not only recognizing when it is appropriate to refer a specific client, but also how to optimally communicate that decision (Wachtel, 1993; see also Mahoney, 2003, pp. 52–54).

In the first session, many therapists opt not to work from a clipboard and a standardized intake form, and many will not take notes in session (Fosha, 2000; Mahoney, 2003; Garfield, 2003). Although I inquire into and listen for any cues regarding concerns that could demand immediate attention, my overall intention for the initial session is to be as authentic and present as possible; I hope to provide clients with a (therapeutic) form of human relating that is experientially distinguishable from what they are accustomed to. Although I try to remember as many of the details of the client’s presentation as I can, I am not overly concerned with tracking all of the details; clients will return repeatedly to their central concerns throughout a session or the course of therapy (Fosha, 2000; Wachtel, 1993; Mahoney, 2003).

As the first session approaches its end, I ask clients how they feel about working with me. If we have a sense of mutual optimism, I provide them with the Integral Intake and ask them to complete it before their next session (occasionally I have mailed it to clients prior to their first session if, while speaking on the phone, they express a desire to do anything they can to speed up the process and consent to answering personally sensitive questions prior to establishing a sense of trust with me). I tell clients that we will continually evaluate how our work together is progressing, and I encourage them to engage in as much self-observation and self-monitoring (of thoughts, feelings, actions, interactions, etc.) as possible.

Assessing via Paper-and-Pencil Instruments versus Clinical Interviews

It must also be remembered that “psychological assessment includes the use of clinical skills beyond the mechanical administration of tests and computation of scores … that the measurement instrument of greatest value in the final analysis is the clinician, not the test” (Beutler & Rosner, 1995, p. 6). In fact, the assessment procedure most frequently used by clinicians is informal, not involving an instrument—the clinical interview (Beutler, 1995b). Clinical interviews can be either structured (following a predetermined format, set of questions, and order) or unstructured (depending upon the counselor’s skill, competence, judgment, and creativity) (Vacc & Juhnke, 1997; Beutler, 1995b). Although practitioners more frequently use unstructured interviews, Beutler warned that the unstructured interview is “among the least reliable and potentially least valid measure used in psychological assessment” (1995b, p. 94).

Clinical interviews provide a unique condition for gathering certain types of information that would be difficult to obtain with a paper-and-pencil instrument, such as follow-up questions that search for more detailed descriptions of the client, her circumstances, and her experiences. Interviews also afford the counselor’s observation of interpersonal styles and any discrepancies between verbal content and observed behavior.

With these points in mind, Beutler (1995b, p. 97) proposed what he called the “integrative, semistructured interview,” which

occupies a central role in evaluation but does not carry the burden of being the only or even the primary tool …. This conception of the interview as part of a comprehensive clinical evaluation invites the clinician to incorporate the semistructured interview into an integrative battery of assessment procedures.

In essence, such an interview is what occurs between counselor and client after the counselor has perused the client’s completed biographical inventory. This would also be an appropriate way of assessing an illiterate client.

Initial research into the effectiveness of the Integral Intake also shed some unexpected light upon some of the “shadows” of assessment (Marquis, 2002). Many of the research participants—despite their enthusiasm or fondness for a given inventory...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication Page
• Contents
• Foreword
• Preface
• Acknowledgments
• 1 Some General Assessment Foundations
• 2 Integral Theory: The Metatheory Behind the Integral Intake
• 3 Quadratic Assessment
• 4 The Spectrum of Development, Pathology, and Treatment
• 5 Development Lines and the Integral Psychograph With E. Scott Warren
• 6 States of Consciousness, Personality Types, and the Self
• 7 Putting It All Together: Interpreting Clients’ Responses and Treatment Planning (Case Examples)
• 8 Research: Past and Future Developments
• 9 Conclusion
• Appendix: The Integral Intake
• References
• Index
• About the Author
• CD Contents