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Depression

There Is No Real Therapy Without Assessment

Therapy is ongoing assessment and assessment is ongoing case formulation.

You often hear practitioners say they don’t like assessment. I have no quibble if what they mean is clinical work whose only goal is to classify people, whether as suitable for hiring, unfit to parent, and so on. That work is not for everyone. But often what they mean is that they don’t like the critical thinking, case formulation, and potential for being flat-out wrong that is often associated with assessment instruments. My complaint is that these things pertain to therapy as much as to assessment.

Many clinicians practice therapy without assessment, but that isn’t real therapy. These include Acceptance and Commitment Therapy (ACT) practitioners who already know, before discussing the situation even, that the problem is psychological inflexibility and the solution is the hexaflex. This is particularly ironic because one feature of the hexaflex is a distrust for verbal rules of the sort, “This client needs ACT.” There are intersubjective therapists who already know that the problem is that the patient’s parents didn’t treat her right and the solution is therapeutic attunement. This is particularly ironic because the central tenet is “making sense together,” but the initial sense of the situation is made without the patient. There are couple’s therapists who already know that the answer is couple’s work, behaviorists who already know that the answer is exposure, and psychiatrists—you get the picture.

The problems with already knowing are that you might be wrong and you’re leaving the patient out of the process of knowing in any event. It enacts “working on” versus “working with.”

Real therapy—as opposed to going through the motions—requires a case formulation, an explanation of the presenting life problem that relies on the client’s own imagery and implies a reason to do therapy. For example, a man is sentenced to therapy by his wife after he had an affair. He has been classically depressed since the affair was discovered. His wife wants to know that he has fixed what’s wrong with him before giving the marriage another try. If you already know what to do, then you are doing therapy without assessment.

An assessment need not include testing—testing is merely a way to get different kinds of evidence for the critical thinking machine. In therapy, there is often more relevant evidence in the patient’s depiction of what happened and in the patient’s in-session behavior. Suppose, for one example, that the man is an ideal patient; he doesn’t push any boundaries, will pay your full fee by check, and honestly tells you his best rendition of what happened. The woman came on to him, and he could not resist, although he should have. He has followed in his father’s footsteps, successfully taking over the family business. You wonder about the moment she came on to him. She represented a supplier, and told him in his office that she had just gotten divorced and could use a boost to her ego. Then she leaned in and kissed him. He remembers worrying at that moment only about whether he had coffee breath.

My assessment at this moment might be that he is overly compliant. Entering the family business, succumbing to the woman’s agenda (which wasn’t even about him), and his reasons for and conduct within the therapy spell compliance. What does he want in a given situation or in his life? This seems to be a question that he rarely asks. You realize your suggestion is putting him in an impossible situation, since he can agree that it fits only by complying. Still, you suggest meeting regularly to allow him to express himself without having to worry about your agenda, so he can explore his own agendas. His job will be to stop suppressing any noncompliant thoughts and your job will be to make sure that therapy doesn’t become an ego boost for you. After you explore the events that led to him taking over the family business, you might develop a sort of code with him whenever he is compliant with you, where either one of you can ask whether there is any ego boosting or joining the family business going on.

To get to this kind of case formulation, you have to be committed to a unique explanation of his situation based on evidence from him rather than ideas from some theorist, comfortable with floating ideas that could be wrong, and committed to justifying therapy rather than generically recommending it for life problems. In other words, you have to do an assessment.

This post was originally published in The Colorado Psychologist.

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