Assessment And Case Formulation In Counselling And Psychotherapy PDF

3 Assessment Structure and Skills Copyright © 2014. SAGE Publications, Limited. All rights reserved. van, Rijn, Biljana. Assessment and Case Formulation in Counselling and Psychot...

3 Assessment Structure and Skills Copyright © 2014. SAGE Publications, Limited. All rights reserved. van, Rijn, Biljana. Assessment and Case Formulation in Counselling and Psychotherapy, SAGE Publications, Limited, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/jcu/detail.action?docID=5164533. Created from jcu on 2024-07-29 09:14:56.  Chapter outline This chapter examines how the assessment context impacts the content and the purpose of an assessment session. It suggests how to approach assessment therapeutically and the skills useful in conducting an assessment. The chapter includes a discussion on structuring and keeping assessment notes and includes the provisional note format. Assessment Settings and Contexts Consideration of the counselling context is often a first point of reflection in deciding how to prepare for an assessment session. Whether the assessment is for a private practice or an organisation impacts the aims and the structure of the session. Organisations often have a proscribed assessment structure in place linked to their aims and type of service. The following are three examples of an assessment setting: Employee Assistance Schemes (EAPs) usually have contracts with businesses and other organisations to offer counselling to their employees. They usually refer clients to their own network of qualified therapists, and the work is short term. The therapists assess the clients referred to them. EAPs usually have their own format for assessment notes, related to their aims and the number of sessions they offer. The assessment format contains questions about work-related issues, how the current difficulties impact the client’s work performance and the list of structured aims for the sessions. Although consideration is given to underlying themes relevant to the current issues, the emphasis is not placed on the client’s past relationships and developmental history. Non-statutory and voluntary counselling agencies often offer low-cost psychotherapy and counselling to the general public. Clients refer themselves and, if accepted, can have psychotherapy or counselling for a specific period. The assessment is done prior to therapy by an assessor and has a dual purpose: a counselling purpose, as defined in the previous chapter, and it is a gateway into the service. The aims of the assessment are reflected in the structure and thoroughness of the assessment process. It is important that clients are referred to therapists who have sufficient skills to work with them and Copyright © 2014. SAGE Publications, Limited. All rights reserved. assessors are mindful about assessing different levels of risk alongside questions related to the client’s current circumstances, personal history and health, and aims for therapy. Private practice. When assessing in private practice the therapist’s task is focused on deciding whether s/he and the client can work together. The therapist can usually be flexible over the number of sessions and the assessment period. The assessment structure could be similar to that of a voluntary agency but with increased flexibility and the choice of emphasis. Therapists usually vary the degree of emphasis on different aspects of enquiry, depending on their theoretical orientations. van, Rijn, Biljana. Assessment and Case Formulation in Counselling and Psychotherapy, SAGE Publications, Limited, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/jcu/detail.action?docID=5164533. Created from jcu on 2024-07-29 09:14:56.  Case study 3.1 Assessment contexts This case study presents the same client in different assessment contexts. EAP: Amanda Amanda contacted the EAP helpline and was referred to a counsellor in her local area. She had been off sick for a couple of weeks with stress, and her manager suggested that counselling could help. She told the counsellor that she had found out that her first husband had died recently in difficult circumstances. She felt distraught about this but also guilty about her distress. Amanda was in her 40s, married and had two teenage children. She didn’t feel she could talk to her husband about her feelings. Amanda worked in a design business, but her distress meant that she felt unable to deal with clients or face the work. She had no history of mental distress and described her background as good, with supportive parents and one older brother. She wanted the counselling to help her to ‘get back to normal’. The counsellor gave Amanda some information about the process of grief to help her to normalise her experience. They agreed to use the sessions to talk about her feelings about her ex-husband’s death. The counsellor told her that feelings of grief could continue beyond their sessions within the scheme. They agreed that the aim of counselling would be to develop a way of supporting herself with her feelings of grief so that they did not intrude so powerfully on her life and work. Voluntary agency: Amanda Amanda contacted the local counselling service on the recommendation by her GP. Her ex-husband had died recently, and she was feeling very distressed. She was crying at night, felt unable to work and couldn’t sleep or eat much. Amanda felt that her feelings of grief were disloyal to her current partner and children. She did not understand why she felt so devastated by Paul’s death. Amanda was very close to her family and didn’t have many friends outside her closest circle. She had a lot of contact with her parents and her brother, who always tried to help. She normally enjoyed her work and got on well with her colleagues, but felt unable to face them or the clients at this time. She never drank much alcohol, did not use drugs and was not on any medication. Amanda was the younger of the two children in her family. She was always very close to her parents, particularly her mother. Her mother was always helping her to make decisions about everything: school, friends, clothes, etc. Her mother was very glamorous and successful, and Amanda thought that she could never be like her. She never wanted to show her mother when she was upset about something, but couldn’t help doing so. As a teenager, she used to cut herself superficially when she was distressed; she had stopped doing so when she left home to go to university. After university she found a job easily and her parents helped her to get a mortgage. Her first husband, Paul, was her first serious relationship. He was exciting and volatile, and her parents disapproved of him. The marriage ended after only a year. Since then, she always looked out for news about him, and he sometimes contacted her asking her to meet. She sometimes daydreamed about him. She was not directly informed about his death in a car accident and had not been invited to his funeral. Copyright © 2014. SAGE Publications, Limited. All rights reserved. In talking about this in the session, the assessor became aware of the importance of the relationship with Paul and the lack of closure in it. The assessor was aware of Amanda’s potential for self-harming and wondered if it was still something she used to self-soothe. However, she did not think Amanda was at immediate risk and thought that it would be appropriate to accept her for counselling at the service. They agreed that Amanda would use the counselling to find a way of emotionally ending this relationship. Private practice: Amanda Amanda came to see the counsellor in private practice on the recommendation from one of her colleagues. The counsellor followed a similar assessment format to that of the voluntary agency. He was aware of the themes of the lack of ending and separation in Amanda’s life. Her relationship with her mother seemed emotionally and practically intertwined. Her first marriage seemed to be her first attempt at separating from her mother. van, Rijn, Biljana. Assessment and Case Formulation in Counselling and Psychotherapy, SAGE Publications, Limited, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/jcu/detail.action?docID=5164533. Created from jcu on 2024-07-29 09:14:56.  The counsellor tentatively offered that reflection to Amanda. She was thoughtful for a moment, and then said she had never thought about it in that way. She then started to talk about how she still found it really difficult to say no to her mother, but felt she needed to be grateful for all the help and support. When she was in the relationship with Paul, her mother even told him that he wasn’t the right person for her. Amanda was very angry about it at the time, but now felt guilty about that. She never felt confident in making her own decisions. The counsellor was aware of the themes of separation and grief and Amanda’s lack of confidence in her decisions. Because of that he thought that it would be important for her to make her own decisions about the counselling process. She agreed with this. To facilitate this, he suggested having six sessions to talk through her feelings of grief and reconnect with her normal life and relationships. At the review session, they would evaluate the work they did and decide whether she wanted more sessions. She said she was relieved by this and wasn’t sure whether she would want to delve any further. For reflection in supervision Think about the contexts in which you work and how they would impact on an assessment you would conduct. What are the limitations of each of the contexts? Conducting an assessment When conducting an assessment session we use our usual active listening and therapeutic skills in addition to other counselling skills and approaches. These have been covered more widely in Bager-Charleson and van Rijn (2011) and include: Creating a balance between listening and probing Working with boundaries prior to, within and after the session and reflecting on the effect of therapeutic boundaries within the session Focusing and selective inattention We create a balance between listening and probing in order to facilitate the therapeutic relationship and find out relevant information about the client. This is a complex assessment skill. The assessor needs to listen attentively to the client, while asking relevant questions and probing into issues which are not immediately obvious. Copyright © 2014. SAGE Publications, Limited. All rights reserved. This is an example of an assessor following up a theme and probing, which helped the client open up about his concerns about his use of alcohol. We work with boundaries prior to, within and after the session and reflect on the effect of therapeutic boundaries within the session. The assessment process, like psychotherapy and counselling, starts even before the actual session, at the point when a client makes the first contact. Boundaries in the assessment session form a therapeutic frame and become an important part of the therapeutic process. They can be related to time, money and roles within the therapeutic relationship. We practice focusing and selective inattention. Case study 3.1 shows how the depth, the level van, Rijn, Biljana. Assessment and Case Formulation in Counselling and Psychotherapy, SAGE Publications, Limited, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/jcu/detail.action?docID=5164533. Created from jcu on 2024-07-29 09:14:56.  of detail and the focus of the client’s narrative varies according to the therapeutic setting and demonstrates that each assessment is limited in scope. Assessors focus on some aspects of the narrative more than others and practise selective inattention to some areas. The aim is to attend to the main tasks of the assessment and avoid delving inappropriately into the therapeutic work within the session. The following are some of the aspects we need to consider as areas of focus in the assessment. Length of time and number of sessions available for therapy The duration of therapy could be limited because of service limitations and the client’s or therapist’s availability. For example, if a client is coming to work-based counselling with clear work-related presenting issues, the assessor might only take a brief personal history, paying attention to any recurring themes that might be significant to the current problem. In case study 3.1, the EAP counsellor focused on the presenting problem (grief) and, apart from the broad-based history, did not delve into further exploration of historical themes. He was aware that in the allocated four sessions his role would be to facilitate the client in developing strategies for dealing with grief rather than opening up longer term themes which might underlie her experience. Case study 3.2 Balancing listening and probing Client: … Mhm … I am not an alcoholic, I mean I don’t drink all the time, but when I go out with my mates it often becomes a bit of night Assessor: So you’re saying alcohol is not a problem as such? But maybe something happens when you go out with your mates? Client: … Yeah. I drink a bit too much then [sighs] Assessor: Is there anything you do at those times that is a concern for you? Client: [quietly] I don’t always remember. I don’t remember how I got home last Saturday or what I did [sighs] Copyright © 2014. SAGE Publications, Limited. All rights reserved. Case study 3.3 Time boundaries in assessment Jane came 30 minutes late to her assessment session. She told the assessor that she hadn’t completed the questionnaires sent to her with the assessment letter and asked whether she could do them in the session. The assessor explained that they had 20 minutes left of their booked appointment and that this meant they couldn’t complete the assessment. She offered another assessment appointment to Jane and asked whether she wanted to use the remaining time to complete the questionnaires. Jane was angry at first. She told the assessor that lateness was not her fault and that she wanted the assessor to conduct the full session. The assessor remained calm, listened to Jane and said that she was unable to extend the session and that this would be the case in any subsequent therapy sessions. She stressed that booking another assessment appointment was not a punishment for lateness, but to ensure that they didn’t have to cut Jane’s time short. After a brief conversation, Jane agreed to this. In the following weeks, Jane phoned the service and rearranged the appointment time for her assessment twice before eventually coming to the session two months after the first appointment. The assessor enquired van, Rijn, Biljana. Assessment and Case Formulation in Counselling and Psychotherapy, SAGE Publications, Limited, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/jcu/detail.action?docID=5164533. Created from jcu on 2024-07-29 09:14:56.  into this and Jane said that, on reflection, she wasn’t ready for counselling at the time of the first appointment. For reflection in supervision How would you have responded to Jane? Reflect on how you deal with boundaries in the assessment session and what the impact of your approach is. Is there anything you might like to develop or change about it? Client protection Client protection is an important reason for choosing the areas of focus and selective inattention, particularly where it is important to avoid retraumatising a client. At the assessment session, the therapeutic alliance has not yet been established. However, the intensity of the confidential, helping setting with an interested stranger could lead the clients to disclose more personal information than they are ready for. In case of a previous trauma, detailed recounting of a traumatic experience can lead to retraumatisation. Retraumatisation is a raw re-experiencing of the traumatic memories, without the healing aspects of integration and reorganisation, which happens in ongoing therapy (Cozolino, 2002). In order to attend to this, assessors need to ask some factual information about the traumatic event (the nature of trauma, when did it happen, how long did it last) and how the client dealt with it, while not inviting detailed recollection. In case study 3.1, none of the assessors asked the client to recount the detail of the accident which led to the death of her ex–husband. Even when the assessment session leads to working with the same therapist, invitation into painful recollections might need to be limited in order to offer the client a safe and contained experience of the session. Attachment and the working alliance Attachment is an important concept in any humanistic, relational psychotherapy and relevant to assessment in each setting (Eagle, 2006; Meyer & Pilkonis, 2002; Mohr, Gelso & Hil, 2005). Copyright © 2014. SAGE Publications, Limited. All rights reserved. The concept was created by Bowlby (1982) and developed further by Ainsworth (1979) and Ainsworth, Blehar, Waters and Wall (1978). It describes a developmental process by which children gain security by seeking proximity to parental figures in unfamiliar or stressful situations. Based on these early experiences children develop lifelong patterns of attachment. People who are securely attached are able to seek reassurance from others at stressful times. People who have developed insecure patterns of attachment might become anxious and preoccupied or dismiss any need for reassurance in stressful situations (Wallin, 2007). Assessment is often a stressful and unfamiliar situation for clients (and sometimes for us too), and this might highlight an attachment pattern, which is important to recognise. In order for an assessment session to progress, the client needs to experience a level of trust in you and have van, Rijn, Biljana. Assessment and Case Formulation in Counselling and Psychotherapy, SAGE Publications, Limited, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/jcu/detail.action?docID=5164533. Created from jcu on 2024-07-29 09:14:56.  an experience of a therapeutic process. However, assessment is not therapy, and the level of engagement between you and the client also depends on whether you will continue to work together or not. Your attachment pattern is also important in this process. If you have an anxious or preoccupied attachment pattern you might feel uneasy about separating from a client and inadvertently invite a prematurely warm and intense experience. Although helpful at the time, this kind of contact can be limiting for the client. In organisations where the assessor refers the client to a different therapist, this kind of experience can limit the level of initial engagement with the therapist, which is essential for good therapeutic outcomes (Miller, Duncan, Brown, Sorrel & Chalk, 2006). On the other hand, a dismissing attachment pattern with an anxious client, or a preoccupied attachment pattern, may lead you to hear the extent of the client’s distress. Mohr, Gelso and Hil (2005) found that such attachment patterns led to the highest levels of unhelpful countertransference in initial sessions and had a negative impact on outcomes. This is the one of the reasons why self-reflection is so important for therapists who need to engage with a client with genuineness and acceptance, form a supportive relationship in a single session, and let go in a way that will facilitate the client. For personal reflection Think about a client you felt particularly moved by in the first session. What did you resonate with in their experience, in how they came across or how they related to you? What was the meaning of this experience for you, for the client and the work you were going to embark on? Now reflect in the same way on the opposite experience, a first session with a client you did not connect with. Relate this to your attachment pattern. Adopting a pluralistic stance A pluralistic stance is defined by Cooper and McLeod (2011: 7) as: Copyright © 2014. SAGE Publications, Limited. All rights reserved. The assumption that different clients are likely to benefit from different therapeutic methods at different points in time and that therapists should work collaboratively with clients to help them identify what they want from therapy and how they might achieve it. The pluralistic stance is particularly important in the assessment process. Clients come to counselling at different stages in their lives having engaged the processes of change to a different extent (Prochaska & DiClemente, 1992). It is important for an assessor to bear this in mind and collaboratively explore what sort of therapist and approach would suit them best. van, Rijn, Biljana. Assessment and Case Formulation in Counselling and Psychotherapy, SAGE Publications, Limited, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/jcu/detail.action?docID=5164533. Created from jcu on 2024-07-29 09:14:56.  Case study 3.4 shows just one example of how a client might wish to work at different times in his life. Clients might not ask for a particular theoretical orientation but frequently have ideas about the ways in which they wish to work. It is important for an assessor to enquire into this and in this way facilitate the development of the early therapeutic alliance. A review of the research evidence by Norcross, Krebs and Prochaska (2011) made recommendations about addressing clients’ preferences prior to the start of therapy. When therapists have concerns that these preferences were not in the client’s best interests they recommended sharing those concerns with the client in order to make a collaborative decision about the way to proceed in therapy. Case study 3.4 A pluralistic stance in assessment When Michael came for an assessment he told the therapist that he had previously had therapy, which finished a year ago. It was a good experience, but he felt he needed more support at this time in his life. His long-term relationship had recently broken down and he had been made redundant at work. He was now living in temporary accommodation. He wanted therapy to help him to regain a sense of direction in his life. The assessor asked him about his experience of his previous therapy and how he wanted to work with a therapist now. He said he had a very good relationship with this previous therapist. She was warm, and he felt safe to say anything and explore anything. She didn’t say much or direct him in any way, but he felt that this gave him a space for exploration. At this time, he wanted to work in a way that would be more focused and challenging. For reflection in supervision Think about how you would describe your approach to a new client. How might you respond to a client who seems to want a different way of working? How flexible can you be in your approach? For example, if you are usually non-directive, how would you meet a client who says that he wants a proactive counsellor? Using Standardised Questionnaires in Assessment Copyright © 2014. SAGE Publications, Limited. All rights reserved. Previously in this chapter we have talked about skills related to individualising an assessment process. Use of standardised measures may seem to be in contrast to this and may present a challenge to a relational therapist. The use of questionnaires in assessment and evaluation of psychological therapies has increased considerably over the years. There has also been a wealth of research into the use of standardised measures in therapy and assessment, particularly in the areas of psychotherapy evaluation and feedback. Within the NHS, standardised questionnaires and evaluation of therapy have become a routine practice, recommended by the Department of Health. This has influenced non-statutory agencies and therapists in private practice. There are several functions questionnaires can fulfil in assessment and ongoing therapy: van, Rijn, Biljana. Assessment and Case Formulation in Counselling and Psychotherapy, SAGE Publications, Limited, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/jcu/detail.action?docID=5164533. Created from jcu on 2024-07-29 09:14:56.  To provide the therapists with additional information To enable an evaluation of therapy, by quantifying the outcomes To enable clients to give feedback to the therapist Mace (1995) conducted a survey in the NHS about the use of standardised questionnaires in assessment. His findings suggested that questionnaires prepared the client for the assessment session, provided information to the assessor and improved the attendance of the first assessment session when sent beforehand. However, his survey also highlighted some difficulties. Some clients struggled to complete the questionnaires due to literacy problems. Clients were also concerned about confidentiality of the questionnaires and afraid of the therapist’s prejudice on the basis of their responses. Assessors expressed concerns that questionnaires could be potentially demanding and discouraging for clients; clients did not share these concerns. Both groups shared concerns about confidentiality. These findings are particularly important in considering the use of standardised questionnaires in assessment and show the potential benefits to the assessment process. They also highlight the importance of the assessor’s clarity about confidentiality, sensitivity about levels of literacy and possible issues of shame in disclosing personal information. When questionnaires are used for evaluation of therapy, the approach to it varies in different agencies. In some, therapists are not involved with evaluation in any way. Questionnaires are completed by the clients and given directly to the researchers. However, this approach misses an opportunity to use the questionnaires to develop the level of clients’ engagement with therapy and help the therapists to adapt their approaches to individual clients. There is now a body of research, spanning a couple of decades, which shows that client feedback during therapy improved outcomes (Howard, Moras, Brill, Martinovich & Lutz, 1996; Lambert & Shimokawa, 2011; Lambert, Whipple, Smart, Vermeersch & Nielsen, 2001; Miller et al., 2006). Both studies by Lambert (2001 and 2011), which replicated the same methodology with an increased number of clients, showed that feedback increased the duration of treatment and improved outcomes for clients. Sripada et al.’s (2010) research evaluated a feedback model Copyright © 2014. SAGE Publications, Limited. All rights reserved. which demonstrated that feedback improved therapists’ accuracy and empathy. Evaluation of therapy is not as relevant for the assessment session as it is for the rest of the therapeutic process. However, it is an opportunity for an assessor to talk to the client about the importance of giving feedback to the therapist and engaging in a dialogue about the progress of therapy. The open communication in the assessment session can then model the open, collaborative attitude in the therapeutic process. Choosing a questionnaire Having decided to use a standardised questionnaire in the assessment, the therapist or the van, Rijn, Biljana. Assessment and Case Formulation in Counselling and Psychotherapy, SAGE Publications, Limited, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/jcu/detail.action?docID=5164533. Created from jcu on 2024-07-29 09:14:56.  agency needs to choose which one to follow and decide the frequency of their use. The frequency, following the assessment session, would depend on whether questionnaires were used only for evaluation or for a more frequent, feedback-oriented approach. Miller et al. (2006) reported that most therapists were not likely to use any feedback instruments if they took more than five minutes to complete, score and interpret. This indicates that shorter questionnaires would be of more benefit than the longer ones. Some questionnaires have been developed in relation to particular clinical diagnoses and symptoms, such as depression and anxiety. These are some examples of commonly used measures: Beck’s Depression Inventory (Beck, 1996): a 21-item questionnaire, measuring depression Patient Health Questionnaire, PHQ-9 (Kroenke et al., 2001): a nine-item questionnaire which distinguishes between clinical and non-clinical populations General Anxiety Measure, GAD-7 (Spitzer et al., 2006): a seven-item questionnaire, which was initially developed for generalised anxiety disorder and found to have sensitivity for other anxiety disorders (Kroenke, Spitzer, Williams, Monahan & Lowe, 2007) Other questionnaires are designed to give more general feedback about a client’s wellbeing as well as give feedback on the sessions. Some examples are: CORE-10 (CORE Information Management Systems, 2007) Helpful Aspects of Therapy (Elliott, 1993) Session Rating Scale (Miller, Duncan & Johnson, 2002) There are also specific questionnaires that evaluate the working alliance, such as: Working Alliance Inventory (Horvath, 1986): a 12-item questionnaire developed to measure working alliance as defined by Bordin (Bordin, 1979) Alliance Negotiation Scale (Doran, Safran, Waizmann, Bolger & Muran, 2012): a 12-item Copyright © 2014. SAGE Publications, Limited. All rights reserved. questionnaire measuring the working alliance The examples listed above are not exclusive and you can find other questionnaires that might better suit your work and your setting. Working with questionnaires Working with questionnaires poses questions about their use in collaborative, relational therapeutic practice. Questionnaires are defined, structured and limited by their aims and design. They offer an opportunity to quantify a human experience. All of that can be seen as van, Rijn, Biljana. Assessment and Case Formulation in Counselling and Psychotherapy, SAGE Publications, Limited, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/jcu/detail.action?docID=5164533. Created from jcu on 2024-07-29 09:14:56.  incompatible with a humanistic, relational practice. However, the ways clients use questionnaires are individual and because of that have a potential to create a dialogue. In my own setting we have been using questionnaires in both assessment and the therapeutic process for the last 15 years. We have found that clients use them in different ways, depending on what they have wanted to communicate to the assessor and the therapist. This means that a therapeutic attention to the content has been essential to good practice. Clients have reported finding it easier to refer to difficult issues in questionnaires, prior to talking about them directly with a therapist. Some examples are thoughts of suicide and self- harm, or difficulties in the relationship with the therapist. It is then left to the therapist to notice this and bring it into the session, demonstrating attentiveness and respect for the client’s experience. In this way, the questionnaires become an additional route in communication and engagement with therapists, not unlike the creative types of communication, such as artwork, or dreams, which clients also bring into sessions. There are some possible pitfalls in using questionnaires. An assessor can be too rigid in interpreting the questionnaire results, without reference to their client, resulting in a premature diagnosis (for example, a score of 20 on PHQ-9 could lead to a diagnosis of a severe depression and outcome of non-acceptance into therapy). This might not take into account the individuality of the client who completed the questionnaire, their subjectivity in relating their own experience and the influences of their culture and context. The other therapeutic error could be in not paying sufficient attention to the client’s responses because of the therapist’s dislike of questionnaires and the view that they were ‘just paperwork’ required by the agency. Completing a questionnaire is a personal process in which clients disclose the information they want to communicate to the assessor. Dismissing this communication can lead to ruptures in the therapeutic relationship and possible mistakes in risk assessment. To summarise the experience in my own setting, we have found that respectful, relational practice with questionnaires involves: Copyright © 2014. SAGE Publications, Limited. All rights reserved. Always looking at the completed questionnaires clients hand in Always checking the risk factors Always asking the client about any areas they wish to highlight and enquiring into areas of particular intensity (for example: ‘I feel down or depressed nearly every day’) or responses which are incongruent with how a client presents in the assessment For reflection in supervision How would you approach working with questionnaires in the assessment session? Role-play introducing the client to the use of questionnaires in giving feedback about therapy. van, Rijn, Biljana. Assessment and Case Formulation in Counselling and Psychotherapy, SAGE Publications, Limited, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/jcu/detail.action?docID=5164533. Created from jcu on 2024-07-29 09:14:56.  Making Notes Clients present in different ways in the assessment session and their ways of recounting their narrative and focus vary. In considering how to approach writing up and structuring an assessment you are also shaping and organising the narrative that emerged in the session. In doing that it is important to consider the purpose of the assessment notes. Like any other clinical notes, they need to represent the client and the session accurately, respectfully and objectively. Depending on the assessment context, they might also be used to pass on the referral information to another therapist or a service and this would inform the structure you needed. Often, writing up assessment notes is a process that enables the assessors to reflect on the session and create their own meaning of the experience. This process is usually supportive to an assessor. Creating a narrative and structuring experiences enable mentalisation (Fonagy, 2002), or a capacity to reflect on experiences, rather than be immersed in them or dissociated from them. There are a number of available templates for structuring assessment information and process, such as Bager-Charleson and van Rijn (2011), Cornell (1986) and McMahon (2009). They usually combine the information about the presenting issues and current circumstances with personal history, context and health issues. The Van Rijn template suggests the following format, which combines factual history taking with a client’s narrative. Presenting issues and current circumstances. A client is invited to talk about reasons and difficulties which bring them to therapy at this stage in their life. The assessor also asks factual information about the client’s support network and work/study in view of assessing their general level of functioning. Personal history. A client is invited to narrate their personal history, such as: who was around in their childhood and adolescence, what the family relationships were like, how they experienced school and friendships and how they left home. This gives a client’s view of their developmental history at the time of the assessment and helps the assessor develop a view of long-standing relationship patterns. Counselling and psychotherapy history. A client is asked about any previous therapy Copyright © 2014. SAGE Publications, Limited. All rights reserved. and their experience of it. This also offers an opportunity to discuss therapist preferences. Health and medication. A client is asked about current health issues and medication. Assessors also ask about alcohol and drug use. Aims for therapy. In the final part of the assessment, the assessor and the client formulate the initial therapeutic aims. For reflection in supervision Consider the context in which you conduct assessments and develop a notes structure that would best suit your circumstances. In doing that consider the following questions: van, Rijn, Biljana. Assessment and Case Formulation in Counselling and Psychotherapy, SAGE Publications, Limited, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/jcu/detail.action?docID=5164533. Created from jcu on 2024-07-29 09:14:56.  What is the purpose of your notes? Who are they aimed for? What is the information you think is important? What is the main focus in the way you work? Copyright © 2014. SAGE Publications, Limited. All rights reserved. van, Rijn, Biljana. Assessment and Case Formulation in Counselling and Psychotherapy, SAGE Publications, Limited, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/jcu/detail.action?docID=5164533. Created from jcu on 2024-07-29 09:14:56.  Chapter summary Structuring an assessment A decision about the structure of an assessment session needs to be related to the context and the aims of an assessment. Conducting an assessment Counselling skills and attitudes are of relevance in conducting an assessment session: Learning to create a balance between listening and probing in order to facilitate the therapeutic relationship and obtain relevant information Working with boundaries prior to, within and after the session Focusing and selective inattention Adopting a pluralistic therapeutic stance (Cooper & McLeod, 2011) Using standardised questionnaires Standardised questionnaires are increasingly used in the evaluation of counselling and psychotherapy. As well as evaluation, they offer an opportunity for client feedback and empowerment, which is particularly important in relational therapeutic practice. Making notes Like any other clinical notes, assessment notes need to represent the client and the session accurately, respectfully and objectively. Depending on the assessment context, they might also be used to pass on the referral information to another therapist or a service and this may inform the structure you choose to use. Copyright © 2014. SAGE Publications, Limited. All rights reserved. van, Rijn, Biljana. Assessment and Case Formulation in Counselling and Psychotherapy, SAGE Publications, Limited, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/jcu/detail.action?docID=5164533. Created from jcu on 2024-07-29 09:14:56.