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The Function of Assessment Within Psychological Therapies

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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.'Our 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.'- From the Preface

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CHAPTER ONE. Definitions

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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.

 

CHAPTER TWO. The referral process

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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.

 

CHAPTER THREE. Pre-specialist opinion

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There is strong empirical evidence for the potential benefit of psychological treatments to individuals with a wide range of mental health problems (DoH, 2001), hence, psychological therapies should always be considered as an option when assessing such individuals.

The commencement of the assessment process sometimes predates the referral letter, because most patients referred to specialist local psychological therapy services will already have undergone a preliminary screening. That is to say, the referrer, whether in primary or secondary care, in making the referral is expressing the opinion that the patient may be helped psychothera-peutically This preliminary phase, involving the formation of a “pre-specialist opinion” on the part of the referrer, as opposed to a “specialist assessment” conducted by psychological therapy specialists, is an important but little studied component of an overall assessment for psychological therapies. The referrer, in formulating an opinion, may already be asking any, or all, of the questions posed below.

 

CHAPTER FOUR. Specialist assessment

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Once a decision has been made to refer the patient for a psychotherapy consultation, the specialist assessment proper begins.

To date, there is still a level of uncertainty as to what are the ingredients of a “good-enough” assessment. There is no clear-cut template for assessment and the format of assessment interviews may vary considerably from assessor to assessor.

Our assessment interview technique may reflect our own particular style and it is tailored to each patient according to his/her presenting problems and the nature of the interaction during the interview. While we tend to use a framework to structure the consultation, we also try to retain a flexible “listening ear” and pay particular attention to the nature and quality of the interaction.

Within our personal, structured framework the following questions are paramount.

(a) What are the patient’s key problems and difficulties?

(b) Is psychological intervention a suitable form of treatment for this particular patient?

(c) Is the patient suitable for psychodynamic psychotherapy?

 

CHAPTER FIVE. Suitability for psychological therapy

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In this chapter we will continue with our structured plan by exploring, thinking, developing, and testing hypotheses with the patient, in order to arrive at an answer to a question raised in the previous chapter.

Is psychological intervention a suitable form of treatment for this particular patient?

Appropriate selection of patients for psychological therapy and, in particular, for psychodynamic psychotherapy, is essential. Poor selection may have deleterious effects on patients, and can also lead to a considerable waste of limited resources. Truant (1998) states that on average some 25% of patients will drop out of therapy prematurely, and about 50% of these do so within the first four weeks.

Two well-known generic suitability factors, which in our opinion underpin any form of talking therapy, will now be considered. These are:

(i) motivation to change;

(ii) capacity to form a working (therapeutic) relationship.

It is important to carry out a detailed and careful assessment of these two factors. Our own clinical experience confirms the general view that lack of motivation and poor therapeutic relationship probably account for the vast majority of drop-out cases.

 

CHAPTER SIX. Psychodynamic assessment

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In the previous chapter we examined the two main generic suitability factors: motivation for change and the capacity to form a working relationship, which in our opinion are prerequisites of any form of talking therapy. In this chapter we will concentrate extensively on additional factors, which as we will see, are pivotal in assessing suitability for psychodynamic psychotherapy.

Psychodynamic assessment is an attempt to collate historical data and to reach a diagnostic formulation with the patient in order to understand the meaning of the presenting complaints. These complaints are now going to be considered in the context of the patient’s emotional and personality development, including his/ her fears, conflicts, and defensive structures elicited within the interaction between the patient and the assessor.

As psychodynamic assessment involves also the understanding of the patient’s earlier relationships, the assessor, by virtue of his/ her training and experience, should focus on aspects of these relationships, which may be unconsciously repeated in the assessment process. An unconscious, albeit distorted, repetition based on past relationships will re-occur (be transferred) within the interaction between patient and assessor. These repetitions, which take place in all relationships to greater or lesser extent, Freud (1893) named “transference”. Some authors (Thomä & Kächele, 1987) would argue that transference may indeed develop even prior to an assessment consultation.

 

CHAPTER SEVEN. Case formulation

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Acase formulation is essentially a hypothesis based on the conceptualization and intelligible translation of the individual’s central problems. The formulation process should lead to an understanding of the patient in the context of his/her difficulties and it informs as to the most suitable treatment modality. The referral letter, relevant case notes, information elicited in the interview, and the quality of the interaction during the assessment process pave the way to a descriptive summary of the case. This summary should include history (developmental, family), predisposing, precipitating and perpetuating factors, and diagnosis and risk factors in the context of socio-cultural influences. The collation of this complex and at times even contradictory information to arrive at the formulation in a meaningful and coherent way is not always an easy task. Nevertheless, we are of the opinion that an assessment is not complete without a case formulation. There is evidence that most assessors attempt to reach a formulation in their mind, but that the actual formulation is seldom documented (Perry et al ., 1987).

 

CHAPTER EIGHT. Post-assessment routes

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In the previous chapters we concentrated on the referral process and the various stages of assessment that led to a comprehensive psychodynamic formulation. The formulation helps to sketch an articulated picture of the unique world of the patient and guides the patient and the assessor to a mutual, appropriate, and agreed plan of action.

In certain circumstances, however, the assessment might provide helpful and important insight into issues that the patient may be able to deal with without further need for psychotherapy. Recommendations for no psychological treatment are just as important as recommendations for treatment.

What treatment modality, where and by whom can the patient best be helped?

Post-assessment options

The assessor, in his/her formulation, needs to reach a decision regarding the most suitable form of management. A number of patients may not benefit from a psychological intervention not just because of their lack of motivation and unwillingness to commit to a working relationship, but also because of florid psychotic episodes, continuous substance-related disorders, and organic mental conditions. The assessor should then discuss and explain the reasons why psychological therapy is not appropriate. He/she should also discuss alternatives that might be more appropriate and helpful. These may include, for example, referral to a psychiatrist, day hospital, CMHTs, specialist services.

 

CHAPTER NINE. Concluding remarks

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The aim of this work is to highlight the role of assessment within psychological therapies with a special reference to the psychodynamic approach.

We have explored how the various nuances of the first encounter may shape attitudes and expectations in both the patient and the assessor/doctor. This initial encounter is a joint enterprise where unrealistic expectations are challenged and concerns are empathically listened to and addressed with sensitivity without undermining the patient’s capacity to make decisions. Mutual thinking about the difficulties, reaching an understanding, and imparting information allows the patient to reflect and make appropriate choices.

We have attempted to examine the subtle interaction between two “strangers” by paying attention to verbal and non-verbal communication cues. With the help of clinical vignettes we examined in detail how the patient’s presentation and narrative may assist the assessor gradually to arrive at a provisional diagnosis and a psychodynamic formulation.

 

APPENDICES

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