The Art and Science of Assessment in Psychotherapy

Chris Mace

• Publisher: Routledge
• Year: 2003
• eBook ISBN:
  9781134846191
• Topic: Psychologie
• Subtopic: Histoire et théorie en psychologie

While professional trainings in psychotherapy and counselling vary considerably in the attention they pay to assessment, courses, conferences and workshops devoted to the subject are attracting an audience eager for more demonstration and discussion. In response, The Art and Science of Assessment in Psychotherapy offers an extended symposium on principles and practice. Guided by a belief that comparative study will spur critical reflection and innovation, its presentations encompass a wide range of therapeutic orientations, settings and interests.
In the book twelve distinguished practitioners of widely used approaches within psychotherapy describe the methods they use in their assessments and how these have developed. They also discuss the uses and limitations of the therapies they offer. The approaches covered include psychoanalytic psychotherapy, in-patient psychotherapy, family therapy, group psychotherapy, psychodrama, cognitive-behaviour therapy, couple therapy and focal therapy. Additional chapters look at assessment in the light of psychotherapy research, question how far assessment can be separated from treatment, and ask whether the use of questionnaires and special tests aids or detracts from interviewing as a method of assessment.
As psychotherapy matures as a profession, both chronologically and in response to public demand, interest in assessment methods is growing, yet to date the published material has been limited and dispersed amongst specialist books and journals. The Art and Science of Assessment in Psychotherapy offer the first comprehensive, practical review of a key professional issue which will be of interest to all practising psychotherapists and counsellors.

Chapter 1
Why assess?

It would be difficult to imagine any new social situation in which assessment did not occur. Its use in psychotherapy is not therefore remarkable, but it is interesting that the more experience that psychotherapists have, the more likely they are to spend time in assessment rather than in treatment. This suggests that assessment in psychotherapy is considered both to be particularly difficult, and particularly useful. In this chapter I shall consider some of these possible uses of assessment, and whether or not they are realised in practice. Wherever possible I have drawn on published evaluations, but the number of these found on a computer search was small and many of the gaps have had to be filled in with clinical impressions. Other psychotherapists, with other clinical impressions, may therefore come to rather different conclusions. The chapter will be oriented particularly, but not exclusively, to individual psychotherapy of adults.

Wolberg (1977) lists eleven primary goals of the first psychotherapeutic interview. These, slightly reorganised and with additions, are the headings for the sections of the chapter (see Table 1.1).

ESTABLISHING RAPPORT WITH THE PATIENT

There is little doubt that the quality of the relationship between the psychotherapist and the patient developed in the first interview is an important influence on whether or not the patient adheres to the treatment plan at least in the early weeks—although the contribution to long-term outcome is weaker (Hentschel et al., 1992; Horvath and Symonds, 1991). The skills involved include attending skills, empathy (Squier, 1990) and acceptance. Rapport is more readily established when patient and therapist share similar values (Kantrowitz et al., 1990). Tracey (1988), for example, studied thirty-three clients and their counsellors at a University Counselling Centre and found that the clients thought themselves less responsible for their problems developing and more responsible for solving them than did their therapists. The more agreement there was between the therapists’ and the clients’ attributions, the more satisfaction there was with the first session and the lower drop-out rate. The determinants of long-term outcome may not be the same as the determinants of short-term satisfaction. Kelly and Strupp (1992) found that a moderate similarity between therapists’ and patients’ values was associated with the greatest improvement.

Table 1.1 Some goals of the first psychotherapeutic interview (1, 2, 7, 10 adapted from Wolberg, 1977)

It seems likely that shared language, culture or religion may be important for some clients, but there has been less research into this. Religiosity itself does not apparently influence therapy decisions (Reed, 1992). Flaskerud and Liu (1990) found that Southeast Asian clients matched with therapists with the same ethnic background and language saw their therapists more times than when therapists did not match clients on these factors, but this was not attributable to a reduced drop-out rate. Martin (1993) found that psychotherapists given scenarios, which were identical except that one purported to describe a black adolescent and another a white adolescent, were more likely to find the behaviour of the white adolescent clinically significant than the behaviour of the black adolescent. The author reviews the literature on therapist-client cultural differences, and concludes that there is an increased risk of treatment failure than when client and therapist come from the same culture. Martin suggests the results of the study indicate that therapists are more likely to make incorrect judgements about patients from a different culture, and the increased drop-out is due to this. Therapists, it is concluded, need more training in cultural sensitivity.

Psychotherapists have paid less attention to formal training in establishing and maintaining rapport than counsellors. Methods of training in attending skills have been described by Ivey and Simek-Downing (1980) and of training in empathy by Kagan (1980). That these methods are not widely used may be because their application is, in practice, more difficult to agree on than would be expected. Gallagher and Hargie (1992) identified eight skill areas and twenty-nine key behaviours which were thought to instantiate empathy, acceptance and genuineness, but raters of video-recordings of ‘naturalistic counselling interactions’ rarely agreed when the skills and behaviours were being manifested. Free et al. (1985) found that ratings of the empathy of thirteen therapists by fifty-three patients that they had in brief focal therapy were significantly correlated with outcome, although only modestly. Supervisors’ and therapists’ ratings neither correlated with patient ratings, nor with outcome.

There has been little evaluation of psychotherapists’ training in rapportbuilding. Training packages in psychotherapy skills for trainee psychiatrists have been shown in controlled studies to produce change in skills related to rapport (Goldberg et al., 1984; Lieberman et al., 1989), but the improvements are more limited than the teachers expect, suggesting that training may be more difficult in practice than theoretical accounts would suggest. These accounts, often written by advocates of training, generally assume that neither client nor therapist may be fully committed to the success of the assessment. This may not be so. Each may have negative feelings towards the other. Frayn (1992) compared twenty early drop-outs from insight-oriented psychotherapy with twenty clients who continued in treatment. Therapists were more likely to have negative feelings at the beginning of therapy towards clients who dropped out later, and the clients who went on to drop out were more likely to have negative feelings towards past caretakers, and about their present circumstances.

Practitioners who work in clinics or as team members often find themselves assessing patients that they do not go on to treat. A close rapport between assessor and patient may have the paradoxical effect of reducing satisfaction about transfer to another therapist, and increase the likelihood of patients dropping out of treatment. Experienced assessors attempt to deal with this problem by making clear to the patient at the beginning of the assessment interview that another clinician will be providing the treatment. A comparable problem may arise if assessments and treatment are performed in different modalities. Oliver et al. (1990) found that families were more likely to continue in therapy, and less likely to miss sessions, if they had originally been assessed as a family than if the child with the presenting problem had been assessed alone.

It is arguable that it is more important that the clinician is assessed by the patient than vice versa. Is the therapist someone who can be relied upon to contain intimate information? Will the patient be made to regret imparting it? Will the therapist help? Is he or she going to be very expensive? These are some of the questions that may go through the patient’s mind at the first interview. The patient’s right to have them answered before making a therapeutic contract is a strong argument for making the first interview rather different from other treatment interviews. Providing this sort of information by means of booklets has been shown to increase both satisfaction and compliance in other settings, and it is likely that discussion with the therapist is even more effective. This is also another argument for the first interview being conducted by the patient’s likely therapist.

Conclusions

Rapport at the first interview with the therapist influences whether or not patients continue in therapy through the early sessions. This effect may not hold if the first interview is with an assessor who does not go on to treat the patient, or if treatment is in a different modality, such as family therapy.

OBTAINING PERTINENT INFORMATION

Making a clinical diagnosis

Diagnoses can not be made reliably unless a systematic interview is undertaken. Physical examination and investigation may also be required. Whether diagnosis should be made by the psychotherapist, or whether by a colleague, will depend on the qualifications of the therapist, the style of the assessment interview and the availability of suitable colleagues.

Most psychotherapists work in a health care context and see people who have what are, broadly speaking, health problems. There is therefore an ethical requirement to consider whether treatments other than psychotherapy would be more expeditious or effective. This may mean ruling out of diagnosis psychiatric conditions for which there are well-established physical treatments and sometimes considering and, if qualified, diagnosing physical conditions such as anaemia or thyroid disease which present with psychological symptoms.

Outcome research, audit and managed care all depend on the accurate determination of the patient’s condition before and after treatment. Diagnoses, although flawed, are still the most important predictors of natural history and the more disturbed or unwell the patients being assessed, the more likely are therapeutic errors unless diagnoses are made. If psychotherapists do not make diagnoses they will be assumed to be seeing patients who are ‘worried well’. This may not trouble private or independent practitioners, but will certainly mean a reduction in the resources available to psychotherapy departments in the public sector.

Cognitive behavioural therapy is effective in treating a number of syndromes, e.g. phobias, compulsions, delusions and hallucinations. These may not be evident in an unstructured assessment interview, but will become apparent during a diagnostic interview.

Assessing the strengths and weaknesses of the patient

Psychotherapy may be a personally demanding procedure which can threaten the peace of mind and stability of vulnerable people. There is the possibility of psychosis being precipitated in people with schizophrenia, and of a worsening of self-esteem in patients with intractable problems for whom psychotherapy is likely to fail. Strong irrational feelings for the therapist can be deliberately encouraged in some therapies, but occasionally, as for example when they are erotic feelings, they can lead to lasting harm to the patient and sometimes the therapist. Anticipating a negative reaction of this sort is an important goal of assessment. If the patient has had previous treatment, it is worth paying careful attention to the outcome since similar reactions are likely to be shown in the new therapy situation. Reactions to school-teachers, parents and other medical practitioners can similarly be useful guides.

Psychological mindedness and borderline personality

Two dimensions of intra-psychic strength which have received a lot of attention are psychological mindedness (Coltart, 1988) and the presence of severe disturbance in interpersonal relationships, or borderline personality disorder. Both of these characteristics have proved to be contentious.

When a psychotherapist is assessing a patient, he or she is, according to Coltart (1988), exercising psychological mindedness. But is this a personality characteristic or a set of values? And is a match of psychological mindedness between patient and therapist anything more than the value matches that have already been discussed? More objective assessment, using a value-free method, might be one way to resolve the question. Conte et al. (1990) developed a forty-five item self-report questionnaire which had high reliability and which correlated with some outcome variables in forty-four consecutive new patients at a psychotherapy clinic. However, few of these patients attended a substantial number of sessions (median fifteen) and, as described previously, value matching between therapist and patient results in increased early satisfaction although it is moderate discrepancy which is likely to be associated with longer-term therapeutic gain. McCallum and Piper (1990) randomly assigned seventy-nine psychiatric out-patients with prolonged or delayed grief reactions to eight short-term psychoanalytically oriented therapy groups or to a waiting list. The non-psychologically minded group members were more likely to drop out of the group, but those that remained had as good an outcome as the psychologically minded group members.

The presence of borderline personality disorder or borderline characteristics has received considerably more research attention than psychological mindedness, including the development of more, and more fully validated, psychological assessments. There are a number of studies which find that borderline personality characteristics at first assessment predict poorer outcome, e.g. Herzog et al.’s (1991) study of bulimia nervosa. However, other studies suggest that clinical diagnoses of borderline personality disorder are not accurate predictors of response to therapy. Stone (1990) in a 10–23-year follow-up of 299 borderline in-patients found that although a half of the patients were selected for expressive psychotherapy, two-thirds of the patients taken on made gains on the Global Assessment Scale. However, two-thirds of the patients receiving only minimal therapy also made GAS gains. The difference between Stone and Herzog et al. may be due to the different time scales of the studies. A recent review has concluded that any personality disorder confers a poorer outcome with any sort of treatment (Reich and Vasile, 1993). Perhaps, therefore, borderline personality disorder may confer no worse outcome to psychotherapy than any other type of personality disorder of equal severity.

It is likely that people with borderline personality traits will produce considerably more anxiety in their therapists than will patients without. Patients who are perceived as not psychologically minded will also require a greater modification of the therapist’s normal therapeutic technique. But the research evidence does not suggest that these characteristics indicate an inability to respond to psychotherapy if the patient sticks with therapy. Research is silent about what the therapist can do to enable this to happen, perhaps because there is a limited tradition of research into matching the treatment to the patient. The response of patients with borderline personality to psychotherapy also needs to be compared with their response to other treatment approaches. Shea et al. (1990) found that patients with personality disorders enrolled in the NIMH Treatment of Depression study did worse in all the treatment groups, whether involving imipramine or psychotherapy, than the study participants withou...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• ILLUSTRATIONS
• CONTRIBUTORS
• ACKNOWLEDGEMENTS
• INTRODUCTION
• CHAPTER 1: WHY ASSESS?
• CHAPTER 2: HOW I ASSESS FOR PSYCHOANALYTIC PSYCHOTHERAPY
• CHAPTER 3: HOW I ASSESS FOR IN-PATIENT PSYCHOTHERAPY
• CHAPTER 4: HOW I ASSESS FOR FAMILY THERAPY
• CHAPTER 5: HOW I ASSESS FOR GROUP PSYCHOTHERAPY
• CHAPTER 6: HOW I ASSESS FOR PSYCHODRAMA GROUPS, OR, ‘WOULD YOU LIKE A CUP OF TEA OR COFFEE?’
• CHAPTER 7: HOW WE ASSESS FOR SHORT-TERM COGNITIVE BEHAVIOUR THERAPY
• CHAPTER 8: HOW I ASSESS IN COUPLE THERAPY
• CHAPTER 9: HOW I ASSESS FOR FOCAL THERAPY
• CHAPTER 10: PSYCHODYNAMIC FORMULATION IN ASSESSMENT FOR PSYCHOANALYTIC PSYCHOTHERAPY
• CHAPTER 11: WHAT IS THE POINT OF A FORMULATION?
• CHAPTER 12: BUILDING A COGNITIVE MODEL OF PSYCHOTHERAPY ASSESSMENT
• CHAPTER 13: WHEN ARE QUESTIONNAIRES HELPFUL?