Assessment

This section is for questions relating to therapy, assessment, formulation and other aspects of working with people in mental health services.

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StarSky
Posts: 77
Joined: Fri Jan 06, 2012 12:50 pm

Assessment

Post by StarSky » Tue Sep 23, 2014 5:24 pm

Recently I was asked to justify my decision to spend 5 sessions assessing someone and I couldn't think of a compelling reason, much less cite any evidence, beyond my clinical judgement for that person. From experience I know that this is not enough to convince outsiders (read: commissioners) to allow us to continue doing things in the way we might be accustomed. I'm also aware that for some therapies assessment is almost a meaningless distinction; you never stop assessing and that basically is the therapy.

So I've been thinking more widely about assessment and was hoping to get a discussion going. I was surprised to see there is no wiki about it. And in contrast with the useful literature on formulation, there doesn't seem to be any recent or seminal writing about it (I should confess I've spent all of 10 minutes googling so happy to be proven wrong). I'd value hearing people's experiences, thoughts, half-formed ideas...

MTwist
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Re: Assessment

Post by MTwist » Tue Sep 23, 2014 9:28 pm

I can't refer to any literature/guidance etc I'm afraid but I can contribute my half-formed thoughts about it... I agree that assessment and particularly formulation can be a critical part of any person's 'encounter' with a psychologist, and I would certainly agree that the division between 'assessment' and 'intervention' is not often a clear one (at least not in the way that I find my therapy sessions going). Also I would say there's a good argument that intervention starts with the first assessment session. I guess it depends somewhat on the service set-up though as to how that's perceived.

One thing I have thought about though when I have experienced more extended assessments is the establishment and deepening of a therapeutic relationship which might be harder to manage, boundary and end, when it's conceptualised with a client - and with you, as a therapist - as an 'assessment'. I don't know if you found that?!

Butterfly22
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Joined: Wed Oct 26, 2011 8:11 pm

Re: Assessment

Post by Butterfly22 » Tue Sep 23, 2014 9:41 pm

An interesting topic. I have always enjoyed doing assessments, so would also be interested in other people's thoughts on the subject. I suppose a lot of things depend on the purpose of the assessment (e.g. Is there a clear question that you're trying to answer and if so what?), whether the assessment is stand alone or would be followed by an intervention with the assessor, whether use of a particular model is required and many more things I'm sure. My early experience of doing assessments as a trainee felt like getting to grips with asking a sequence of questions that I had in my head from lectures/books/models, to the extent that sometimes I was probably overly focused on the questions than being led by the answers. 6 years down the line and having worked In different contexts, things feel a lot different! I suppose holding a purpose in mind for an assessment is the most important thing for me and then selecting methods/an approach that would best suit this.

Without knowing your context, it's hard to gauge how "atypical" a 5 session assessment would be. For me, it would depend in part on your remit although it's really interesting to think about what took you longer to reach a decision/work through the process on this occasion (which sounds to be the case from your post) and what the difficulty is in making this explicit (both to yourself and to your colleagues!).

My work is mainly with complex families and I reflect often on my approach to assessment. I tend to spend less time gathering lots of thorough background information at the beginning and rather focus on getting a broad picture, defining a very clear focus/set of goals and moving quicker into an action phase, often necessitated by context. The assessment on each area/goal happens as we go along, so we build a bit of an understanding, generate an intervention and refine as we go in response to the effect. I'm always very explicit about my role and my intentions and restate/revisit these throughout if I feel that these might have become unkcear or misunderstood at any point. The idea that some therapies are a continual assessment fits a little bit with my experience, to the extent that discovery and learning continues and deepens throughout, but I would have some wariness about this being a justification for long pieces of directionless therapeutic work (not what you're advocating I know!). Sometimes a longer intervention can serve as an assessment of sorts if it answers a question- for example (from my context) does this type of approach support a family to create the required change in these key areas?

Something in particular that interests me about assessments that I see in my setting is how long the assessment process can sometimes be, when what is required (and sometimes quite urgently) is for an intervention to begin. Whilst of course I firmly believe that any intervention requires the building of a rapport, a clear contract and a working formulation, there seems to be a lot of information being gathered over numerous sessions, worksheets being completed, creative tools being used without a clear purpose (I.e. It's not always clear to me how that information will be useful/used in the upcoming work) and I wonder sometimes whether this is in part due to an avoidance/delaying of the initiation of the change process, which can bring challenge on many levels not only to clients but also potentially to workers as they move out of the (relative safety) of the engagement/rapport building phase.

Just some initial thoughts on the matter- I'm by no means an authority!

CuppaT
Posts: 121
Joined: Wed Oct 05, 2011 5:20 pm

Assessment

Post by CuppaT » Tue Sep 23, 2014 11:38 pm

I can only speak from half formed thoughts here and my experience too...

Interesting topic - and a very wide area. As mentioned, the type of service, purpose of assessment, clinical need, risk, and amount of material to work with guides the process and the time spent on assessment.

Some assessments are for a very specific issue, and as such are funded to be completed within a short amount of time (unless clinical need demands more and then this can be renegotiated or put through the right channels).

The majority of my assessment experience has been of individuals or couples as a part of court proceedings, and those required in-depth interviews that averaged between 2 and 8 hours over several meetings. There were some cases that required even longer due to new information and risk.

The assessment process itself included interviews (taking personal histories; risk assessment; and of the specific concerns/difficulties) and psychometric testing. The process also included time spent on reviewing medical, police and local authority records and discussions with social workers.

In my view those assessments have been events, ongoing processes, and interventions.

In contrast to this, I've been involved in assessments purely for cognitive function and those have usually been carried out in a much much shorter timeframe and are much more like an event.

'Assessment' is such a huge area, some types of assessments that I'm involved in can occur continually I.e. Acute assessment inpatient settings. Community based assessments that I've been involved in have been carried out over weeks with clients as a part of assessing the ongoing work and those assessments have been more like a continual process rather than events.

Personally I really enjoy in-depth assessment work as I really get a sense of the person and their issues, experience of complex formulations, and generally I just find it very interesting. Keeping a clear focus of what the purpose is and how much flexibility I have with the process helps me with staying on the right path, else is be tempted to keep assessing to understand rather than move into clearer, defined intervention work! However I think that might also be a reflection of my experience being more in assessment than intervention, so it is familiar territory to me.

StarSky
Posts: 77
Joined: Fri Jan 06, 2012 12:50 pm

Re: Assessment

Post by StarSky » Wed Sep 24, 2014 11:55 am

Interesting points and clearly much more than half-formed thoughts! Thank you all

To give a little context, the question was a clinical tutor playing devil's advocate (I hope). I was presenting a piece of work I did from adult placement and I spoke about how important the formulation was in guiding my intervention. He questioned whether I would have used the same intervention with someone else who was hearing voices and if so what justified the 5 assessment sessions. A brilliant question as I've thought lots about it since!
Butterfly22 wrote: Something in particular that interests me about assessments that I see in my setting is how long the assessment process can sometimes be, when what is required (and sometimes quite urgently) is for an intervention to begin. Whilst of course I firmly believe that any intervention requires the building of a rapport, a clear contract and a working formulation, there seems to be a lot of information being gathered over numerous sessions, worksheets being completed, creative tools being used without a clear purpose (I.e. It's not always clear to me how that information will be useful/used in the upcoming work) and I wonder sometimes whether this is in part due to an avoidance/delaying of the initiation of the change process, which can bring challenge on many levels not only to clients but also potentially to workers as they move out of the (relative safety) of the engagement/rapport building phase.
This really resonates with me. Although I think the assessment was sufficient and thorough, I don't know if I can honestly say it was necessary to do the work we did. I feel like I was being an agent for my guy, but possibly my own anxieties as a trainee factored into time it took to complete the assessment. Perhaps a more experienced clinician could have worked all the pertinent clinical information into a formulation much earlier?

Interestingly, at the beginning my placement supervisor said something to the effect of: "You know how to assess, go do it". And I didn't question it at the time, or even remember it until recently...

reefflex
Posts: 31
Joined: Fri Dec 14, 2007 12:40 pm

Re: Assessment

Post by reefflex » Wed Sep 24, 2014 3:08 pm

In my service we have a concept of an "extended assessment" which can be from anywhere between 4-12 sessions. The functions of an extended assessment can be one or more of the following:

- clarifying a diagnosis where there have been varied opinions in the past, lots of comorbidities or intersections between axis I and axis II disorders (in the old DSM-IV) - beyond a standard assessment we would therefore adminster structured clinical interviews as well as other multi-axial measures such as the PAI.

- Particularly if you are going to properly assess for personality disorder, you cannot and should not do it over one or two sessions - you need to obtain a detailed history of pervasive patterns of disturbance in a variety of functioning domains, review all previous medical records for relevant info, you should have info from secondary respondents, and you should assess symptoms formally and through other measures besides self report if possible.

- preparing a detailed and definitive report where there is a complex history, and ambiguities and inconsistencies in the notes reflecting a lack of clarity about the individual and their history. This can be to support another process such as a medico-legal issue, or to equip the client with a tool to use to represent themselves in another treatment or medical context, where they might struggle to give a coherent account of themselves.

- to clarify a formulation and treatment objectives where there are diffuse or hard-to pin-down symptoms, through a process of between session recording and guided discovery, eg recording and analysing nightmares and re experiencing symptoms between sessions to try to identify target traumatic memories for treatment, where the patient has an extensive history of trauma and struggles to make the links between specific events and PTSD symptoms.

- to assess engagement issues, by undertaking a very limited piece of therapy work - ie do they attend reliably, what are the in-session dynamics, what other obstacles might there be to safe and effective treatment.

- to assess treatability issues, if for example, there is a particular barrier such as dissociation, affect regulation or agoraphobic panic, we might implement a limited skills based intervention to see if the client is able to engage, utilise and ultimately stablise the problem sufficiently to enagage in a more extensive psychological therapy.

Ruthie
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Re: Assessment

Post by Ruthie » Wed Sep 24, 2014 10:40 pm

I think a lot depends on the individual and the context. If you're seeing someone with a simple phobia (unlikely if you're a trainee) and you spend 5 sessions assessing, then I would suggest you get a move on. I think it is very important to ask ourselves if our time spent "assessing" or "rapport building" is really avoidance of actual interventions.

However, if you don't have enough of a formulation on which to base an intervention then you can't proceed. Sometimes (often) it is worth investing time in a comprehensive assessment and formulation to save wasted time on things that just don't work. This is especially true with more complex cases and where your assessment and formulation is feeding into the whole team's approach. Where I work we have people on the ward for weeks (sometimes months) without a clear diagnosis (or formulation - but I work in a highly medicalised environment). My role in such an assessment might include individual sessions, getting information from family/friends, neuropsych assessment, ward based observations, off-ward observations, getting information from the nursing staff and it can be a lot more than 5 sessions! I recently had a junior doctor quite put out when I said I wanted to prioritise a cognitive assessment over doing CBT as I thought the person may have some cognitive difficulties that would have an impact on the effectiveness of CBT. The junior doctor (and the consultant) didn't want me to waste time and thought I should just do the CBT and see if it worked. Aside from what they meant by "do the CBT" (it's not like you dish it out like medications), I'm glad I stuck to my guns and did the cognitive assessment as a. I was right and b. it was far more useful for planning the individuals long-term treatment than a few sessions of largely ineffective CBT would have been. So don't rush to intervene if there are good reasons to keep assessing.

I don't believe throwing interventions at people in the hope that something will stick is a good way to do therapy. So I'd say extended assessment is warranted if you don't have a sufficient formulation and intervention plan, ESPECIALLY if previous plans have not had a positive effect as you need to slow down and think things through rather than be under pressure to act. The case above is another example of needing to assess factors which are likely to impact on the effectiveness of therapy or how you would do therapy before proceeding with something which may be ineffective.

In terms of rapport building, I work with people with psychosis so it is very emphasised in the way we work with people. I have mixed feelings about it tbh. I think it is vital, particularly with people who are paranoid and distrustful of professionals. However, if it is all very cosy and you have reasonable rapport then it is time to ask questions about avoidance. There have been times were I feel as psychologists we have kept people on with no evidence of therapy being helpful in the name of "rapport building" when it might have been better to work in a more consultative way with the team and have the person referred back at the point at which they are more ready for therapy. But that's a pet soap box!

My own tendancy is to move quite quickly to interventions even with complex clients (sometimes especially so, as it is helpful for people to see some movement rather than becoming more hopeless). You don't need a perfect formulation, just enough to start intervening in a reasoned way and then you continuously evaluate, assess and reformulate throughout your work with someone. It's never as neat in real life as in case reports (well not in my practice anyway)!

Ruthie
If God invented marathons to keep people from doing anything more stupid, the triathlon must have taken Him completely by surprise.

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