Eric, what you say makes perfect sense to me! I think that assessments are rather silly actually, unless a person is entering into a long-term treatment program. Otherwise, they are a waste of time, because if a person is limited to 8 or 12 hours of psychotherapy, even if they do have some deep, underlying disturbance that is revealed through a thorough assessment, it cannot be adequately addressed in such a short time; it can only be placed in a larger context at best. I think that detailed information about people who make it clear that they are interested only in short-term therapy is more of an irritation than anything else because it cuts into time that is already too short. I think if a therapist is skilled, s/he can start where-ever the client is immediately, with no paperwork at all, and if there are recurring threads, they will appear as discussion ensues, then those can be be explained to the client as they come up, that way, the assessment occurs during therapy, not before. That way, it is meaningful and useful for the client, rather than just being some mysterious, secret thing that the therapist does not actually discuss with the client, but only uses in order to assign a diagnosis. I guess as long as it is necessary to assign a diagnosis before therapy can begin, then lengthy assessments will be necessary, even though they irritate the client and interfere with the fragile trust being established in the beginning. I don't think I will ever be willing to deal with insurance companies because of these sorts of things they insist on that I think damage the therapeutic relationship.<div>
<br></div><div>Katherine<br><br><div class="gmail_quote">On Mon, Dec 28, 2009 at 1:39 PM, Eric Rutberg <span dir="ltr"><<a href="mailto:ericrutberg@yahoo.com">ericrutberg@yahoo.com</a>></span> wrote:<br><blockquote class="gmail_quote" style="margin:0 0 0 .8ex;border-left:1px #ccc solid;padding-left:1ex;">
<div><div style="font-family:arial, helvetica, sans-serif;font-size:12pt"><div>Adam and all !</div>
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<div>I appreciate these thoughts around assessment and diagnosis. I was discussing "ethics of assessments" today with a colleague. I'm always working on how to assess clients in a way that clearly identifies presenting and underlying issues (ie: spirituality, support systems etc.) to treatment and leads to an accurate diagnosis. </div>
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<div>At the agency with whom I am affiliated, we are asked to complete an initial "psychosocial assessment" form supplied by the agency. It's like 8 pages long and asks many questions from substance abuse and family history of mental illness to childhood abuse and vocational aspirations. From the assessment, we are then to form a treatment plan. </div>
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<div>Some clinicians feel compelled to interview the client with the hopes of answering all the Q's. I find this method questionable on several levels. 1st, I don't like documenting in writing the details of the lives of clients, especially if such details are not directly related to the subject at hand. I find clients typically arrive to counseling with a problem or issue on their mind. I talk with them about the various aspects/perspectives presenting and document those on the initial assessment and leave the rest as n/a. I also find that if I answer all the Q's on the assessment, the treatment plan becomes unweildy. (We are supposed to address all issues from assessment in the treatment plan.) Insurance constraints, and resources of money and tie in general compel "us" to treat in a most consice, brief way. ALSO, the assessment tool we are asked to use digs into areas that were not brought to the fore by the client, but
by the clinician asking the q's. This does not seem client-centered and feels awkward/intrusive to me, in the sense that I want things to unfold more naturally. </div>
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<div>Am I making sense?</div>
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<div>BTW: I have been working on transferring the differential decision trees from the DSM-IV to an interactive web-based process. Check it out at <a href="http://yourwellbeing.org/DiffDiagTree.htm" target="_blank">http://yourwellbeing.org/DiffDiagTree.htm</a></div>
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<div>Thoughts?</div>
<div>Eric</div>
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<b><span style="font-weight:bold">From:</span></b> Adam Blatner <<a href="mailto:ablatner@verizon.net" target="_blank">ablatner@verizon.net</a>><br><b><span style="font-weight:bold">To:</span></b> <a href="mailto:list@grouptalkweb.org" target="_blank">list@grouptalkweb.org</a><br>
<b><span style="font-weight:bold">Cc:</span></b> <a href="mailto:DRAMATHERAPYLST@LISTSERV.KSU.EDU" target="_blank">DRAMATHERAPYLST@LISTSERV.KSU.EDU</a><br><b><span style="font-weight:bold">Sent:</span></b> Sun, December 27, 2009 4:07:51 PM<br>
<b><span style="font-weight:bold">Subject:</span></b> Assessment in Psychotherapy<br></font><br>
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<div><font size="2" face="Arial">Dear Colleagues, I've been thinking about the general theme of diagnosis---not the finding of labels, but of really understanding. Perhaps "assessment" might be a better term. How to find out what's going on, what formulation might lead to the most rational construction of a general treatment approach; which elements to include in which order, and how to sequence the gradation of complexities?
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<div><font size="2" face="Arial">So, in light of developments in the fields of psychiatry (in its best sense---there's a lot going on in practice that I don't like)--- we need to update our evaluation to include things that weren't taught back in the 1960s when I was in specialty training, and these are the kinds of things that if you don't ask, people won't tell you. </font></div>
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<div><font size="2" face="Arial"> a. Co-morbidity. Whatever the problem, there's a chance that there's an un-reported co-morbid addiction or near-addiction, a distraction, a way of numbing-down, and these can includ not only drugs and alcohol, but sex, food, binging, thin-ness, news, work, clutter, debt (shopping), gambling, television, video games, etc. </font></div>
<div><font size="2" face="Arial"> b.Supportive relationships often primary live-in or spouse may be more abusive or neglectful or exploitative and if you don't ask, the client is so oppressed that it doesn't occur to them to volunteer it... it's just the way life is, isn't it? </font></div>
<div><font size="2" face="Arial"> c Sexuality---often more complex than one might assume</font></div>
<div><font size="2" face="Arial"> d. Spirituality---folks don't expect you to ask about this, and sometimes forget that it's important. If not religious, what is source of grounding? Often nothing, and often this is more of a lack than people know---they just assume that the world is this way. If there is a religion, it may be a source of support and could possibly be worked to serve more in this way; or it could be a source of distress---hell being a bigger theme in some people's lives than they want to admit.</font></div>
<div><font size="2" face="Arial"> e. Sources of talent, strength, optimism, etc.--- the impact of positive psycholog--should be recognized... </font></div>
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<div><font size="2" face="Arial">2. In the current climate of ambivalence towards psychiatry, there are many non-medical therapists who are excessively anti-medication. </font></div>
<div><font size="2" face="Arial"> A measure of wariness is appropriate. Many psychiatrists diagnose too readily and prescribe excessively, with lack of close follow-up. A significant portion of people on meds don't need them at all or don't need as much. Some of the people not on meds should be offered a trial, gradually trying one or another type, working collaboratively among therapists, prescribing psychiatrist, and empowered and informed client. Some folks in medium-term therapy are greatly benefitted by some meds.</font></div>
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<div><font size="2" face="Arial"> About "diagnosis"--- people are right to look at the DSM-4 with suspicious eyes. Many docs use it as a blunt instrument. In many people's cases it hardly describes what's going on. </font></div>
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<div> Any thoughts? Warmly, Adam Blatner</div></font></div></div></div></div></div></div><br>
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<br></blockquote></div><br><br clear="all"><br>-- <br><br>Katherine<br><br><br>"Education is not the filling of a bucket, but the lighting of a fire." -- W.B. Yeats<br>
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