Introduction
First up: assessment. We all know the importance of assessment in the overall scheme of things. If a mechanic doesn’t correctly diagnose the technical fault of a car, it’s highly unlikely that they would have much luck in repairing it. They can have the fanciest workshop and the most expensive tools, but none of that would be useful if they haven’t diagnosed the fault correctly. Our work in therapy is exactly the same. We could have completed hundreds of training courses on all kinds of amazing therapeutic tools, but unless and until we have assessed a client correctly, no therapeutic tool would be useful. If we haven’t diagnosed properly but jump into treatment, what we are doing is similar to throwing darts in a dark room, hoping that one of them would hit the target. I mean, it’s possible to hit the target, but we’re using a terribly ineffective method!
Unfortunately, I find that so often this important step is overlooked or rushed through. There are a few reasons for this:
Often we are unsure of what to unpack - it’s so easy to get lost in the unorganised stories that the client presents to us. Hours of stories, with many branches and so many aspects to consider. What do we unpack? What’s more important and what’s less important? If the client has many complaints, which one do we prioritise when planning treatment?
At times we don’t assess enough because we simply think that we have enough to go by. We know what the client seems to be troubled by, we have heard their complaints. So it’s time to get to work, right? Let’s pick an area and start treating. But let’s go back to our car and mechanic analogy. Just because we know the complaint, it doesn’t mean our diagnosis is complete. For example, just because we know a car won’t start when you turn the ignition, it doesn’t mean your mechanic has all the information they need to go by. A good mechanic would hear that complaint and would know where to go to assess further.
At times we don’t assess enough because our personal anxieties as therapists get in the way. For example, we may have an anxiety around not getting to solutions fast enough. We might worry that the client is paying for the session and they want to see some outcomes quickly. The problem is that by not assessing enough, we don’t speed up the process of recovery. We do the opposite! We slow it down because we are a lot more likely to use ineffective treatments.
A thing to remember is that the period of assessment can also be considered as a period of bonding and building rapport with our clients. As you assess, you are also providing the client with a listening ear. Most clients are delighted to finally have someone in front of them that is so attentive, asking the right questions and is genuinely interested in them and their lives. So view the period of assessment as an important, meaningful part of treatment and don’t feel like you need to rush through it.
I should say that I have come across certain clients that were anxious to quickly get to the treatment part and start hearing the therapist’s input, strategies and so on. So as a blanket rule, I find it helpful to explain to the client the role of the assessment period and that we will definitely get to the treatment phase, but first we need to allow time for assessment to be complete. In my experience, that explanation seems to do the trick!
The 4 Golden Signposts to Good Assessment
So a golden rule to remember is: Stay. With. Assessment. Longer. We need to sit with assessment until it feels like we have what we need to move on to the next stage.
A golden sign to look for: Is the next step clear to me? Do I know where I’m going and what we are trying to achieve?
A golden question to ask: What should I unpack? Which aspect of the client complaint, their story or life situation do I need to explore further and understand?
A golden word: “Why”. We need to ask ourselves and the client: why? If it doesn’t make sense that someone would be thinking, feeling, behaving or believing the way that our client is thinking, feeling, behaving or believing, we need to stop and ask “why?”. We need to try to investigate further anything that doesn’t make sense based on our personal life story, emotions or understanding of how the world works. If we can’t put ourselves in the client’s shoes, we can’t design effective treatments! The question 'why' is designed to help us put ourselves in the clients’ shoes by understanding how they got to the point where they think or feel the way that they do.
Case Example
Let’s look at an example. I had a client, let’s name him N, who presented with a lot of anxiety relating to perfectionism. He needed to be perfect at work, which created a lot of anxiety for him. He was unable to switch off work related anxiety, which peaked when he had performance or presentations.
My first instinct was that his perfectionism was related to his self image. N himself believed he had low self esteem and wanted to please others and always described his anxiety as related to his self image. He needed to do well at work in order to feel good enough and avoid feelings of being a failure. I spent a lot of time in therapy unpacking his self image, and trying to work out where he developed a fear of not being good enough. I also jumped into treatment and began working on his self image and self esteem using CBT, schema therapy, emotion regulation and so on. But treatment wasn’t going too well and progress was slower than I would have liked. His anxiety was persisting.
At some point I did this thing that I often do when I feel that a client isn’t progressing as they should: I held a case conference with myself to review the case! I realised where I had failed to stop and unpack. I had not unpacked the client’s reasons for perfectionism and had just assumed that the reasons were self image and self esteem related. At the next session I explored that a bit more carefully. Turns out, client wasn’t afraid of not being good enough if they did poorly at work! His fear of losing his job related to experiences of hardship in his childhood and fear of poverty, if he was to lose his source of income. I made an assumption about the client’s source of perfectionism and anxiety based on perhaps my own life experiences or the life experiences of others around me that I was most familiar with.