ASSESSMENT IN

PSYCHOTHERAPY
& PSYCHOTHERAPEUTIC
PROCESS

AP/20004A
UNIT II & III
• What is the purpose of assessment in psychotherapy?
- For comprehensive evaluation of clients; formal and informal techniques
(standardised tests, diagnostic interviews, questionnaires, MSE, checklists,
reports by significant others, etc.)

(Cormier, Nurius, & Osborn, 2009):

1. Obtain information on a client’s presenting problem and other related
problems
2. Identify controlling/contributing variables associated with the problem
3. Determine the client’s goals/expectations for therapy outcomes
4. Gather baseline data to assess and evaluate client progress and the effects
of treatment strategies
5. Educate and motivate the client
6. Plan effective treatment interventions and strategies

“What treatment, by whom, is most effective for this individual with that
specific problem & under which set of circumstances?” (Paul, 1967)
• The essence of assessment is in evaluating a client’s strengths, weaknesses,
desires, and motivation. The skill in carrying out an assessment is in
balancing all of these elements, while considering the best of several
approaches to therapy.

• Halgin and Caron (1991) suggested a set of key questions that

psychotherapists should ask themselves when considering whether to
accept or refer a prospective client:
- Does the person need therapy?
- Do I know the person?
- Am I competent to treat this client?
- What is my personal reaction to the client?
- Am I emotionally capable of treating the client?
- Does the client feel comfortable with me?
- Can the client afford treatment under my care?

There are times when the outcome of an assessment interview will be that
the client is referred to another agency.
 SETTING THE STAGE
• The initial stage of a therapeutic process involves relationship building and
focuses on engaging clients to explore issues that directly affect them.
Some factors that can influence the progress and direction of therapy are
the quality of the relationship established, the physical setting, the
therapist’s skill, and the client’s background.

• The therapist must ensure that the physical environment is conducive to

open and honest communication, free from distractions and interruptions.
The physical environment should feel welcoming and confidential,
providing a sense of privacy and security for the client.
• Regardless of the arrangement within the room, a therapist should not be
interrupted while conducting sessions. Auditory and visual privacy are
mandated by professional codes of ethics and ensure maximum client self-
disclosure.

• Okun & Kantrowitz (2008) listed 5 important characteristics that helping

professionals must possess: self-awareness, honesty, congruence, ability to
communicate, and knowledge.
(Strong, 1968): expertness, attractiveness, and trustworthiness.

• Expertness is the degree to which therapists are perceived as

knowledgeable and informed about their specialty.

• Attractiveness is a function of perceived similarity between clients and

therapists as well as physical features. Therapists can make themselves
attractive by the way they greet clients, speaking clearly, maintaining eye
contact, etc. Clothes should be clean, neat, and professional looking but not
attract undue attention.

• Trustworthiness is related to sincerity and consistency. Those who are

genuinely concerned about their clients show it over time by establishing a
close relationship.
 INTAKE INTERVIEW
• The therapist begins by building rapport with the client, establishing a
warm, empathetic, and nonjudgmental demeanor. This helps create a safe
and trusting atmosphere where the client feels comfortable expressing
themselves and engaging in the therapeutic process.

• The therapist outlines the roles and responsibilities of both the therapist and
the client in the therapeutic relationship. This includes clarifying
confidentiality policies, discussing the purpose and goals of therapy, and
establishing expectations for attendance, participation, and feedback.

• In the first session, both therapists and clients work to decide whether they
want to or can continue the relationship. Therapists should assess whether
they are capable of handling and managing clients’ problems through being
honest, open, and appropriately confrontive (Okun & Kantrowitz, 2015).
Clients must ask themselves whether they feel comfortable with and trust
the counselor before they can enter the relationship wholeheartedly.
• Egan (2014) summarizes five nonverbal skills involved in initial attending.
They are best remembered in the acronym SOLER.

S = face the client squarely. Facing a client squarely can be understood literally or
metaphorically depending on the situation. The important thing is that the therapist
shows involvement and interest in the client.

O = adopt an open posture. Do not cross arms and legs. Be non-defensive.

L = lean toward the client

E = eye contact. Good eye contact with most clients is a sign that the therapist is
attuned to the client. For some other clients, however, less eye contact (or even no
eye contact) is appropriate.

R = relax.

• Some behaviours that therapists must avoid: giving advice, lecturing, excessive
questioning, storytelling, interrupting, blaming, etc.
• Identifying data
- Client’s name, address, or contact information (if required). This information is
important in the event the therapist needs to contact the client between sessions.
The client’s address also gives some hint about the conditions under which the
client lives.
- Age, sex, marital status, occupation (or educational qualification).
- If client has an informant, their relationship with the patient
- Ask referral question

• Presenting problems/History of present illness

• It is best when these are presented in exactly the way the client reported them.
If the problem has behavioral components, these should be recorded as well.

- How much does the problem interfere with the client’s everyday functioning?
- How does the problem manifest itself? What are the thoughts/feelings that are
associated with it? What observable behavior is associated with it?
- How often does the problem arise? How long has the problem existed?
- Can the client identify a pattern of events that surround the problem? When
does it occur? With whom? What happens before and after its occurrence?
• Personal history

- Medical history: any unusual or relevant illness or injury from prenatal period
to present.
- History of mental/psychiatric illness
- Educational history: age at start of schooling, academic progress through
grades, learning difficulties, extracurricular interests, relationships with peers.
- Vocational/occupational history: Where has the client worked, at what types
of jobs, for what duration, and what were the relationships with fellow
workers?
- Sexual and marital history: Where did the client receive sexual information?
What was the client’s dating history? Any engagements and/or marriages?
Other serious emotional involvements prior to the present? Reasons that
previous relationships terminated? What was the courtship like with present
spouse? What were the reasons (spouse’s characteristics, personal thoughts)
that led to marriage? What has been the relationship with spouse since
marriage? Are there any children? (menstrual history in case of women)

- Character traits (introvert/extrovert, aggressive, anxious, etc.); use of leisure

time; habits (food, alcohol, drugs, sleep), interpersonal relationships, etc.
• Past history

• Family history
- parents’ ages, occupations, descriptions of their personalities, relationships
of each to the other and each to the client and other siblings.
- order of brothers and sisters; relationship between client and siblings.
- any medical/psychiatric history in the family?
- family dynamics & relationships (attitude towards client, attitude towards
illness/models of belief)
- living arrangement, social status, etc.

• Risk assessment

• Goal setting
• Mental Status Examination

1. General appearance & behaviour: client’s physical appearance, including

dress (appropriateness, etc.), posture, gestures, facial expressions,
psychomotor activity

2. Mood & affect: client's emotional state (mood) and outward expression of
emotions (affect); includes assessing for signs of depression, anxiety, mania,
or other mood disturbances; objective/subjective affect, type (elated, sad,
angry, anxious, irritable; blunted, labile, incongruent, etc.)

3. Speech: intensity (soft/loud), pitch (monotonous/abnormal changes), tone

(slow/rapid), spontaneity/hesitancy, productivity, relevance, reaction time,
deviation (mutism, stuttering/stammering, slurring, flight of ideas, etc.)

4. Thought: What was the general level of information, vocabulary, judgment,

and abstraction abilities displayed by the client? What was the stream of
thought, regularity, and rate of talking? Were the client’s remarks logical?
Connected to one another?

5. Perception: hallucinations, illusions, depersonalisation, etc.

6. Cognition: consciousness (time, place, person), attention, concentration,

memory, abstract thinking, judgment, insight
• General Principles of Interviewing

1. Consent for the interview

2. Privacy and confidentiality

3. Respect and consideration

4. Empathy/Rapport

5. Patient-Therapist relationship

6. Patient-centered

7. Safety and comfort

• Techniques of Interviewing/History taking

1. Effective Listening: The professionals must not only listen to what has
been said by the patient but also focus on to the non-verbal gestures and
observe the behaviour through different phases of the history.

2. Questioning: the therapist should start with open ended broad questions
and then should gradually narrow down the focus.

3. Expanding the Scope of Information: There are a number of techniques

that can be used to expand the focus of the interview. These techniques are
most successful when a degree of trust has been established in the
interview and the patient feels that the professional is nonjudgmental
about what is being shared. These include clarifying, associations,
probing, etc.
• Techniques which can impede the information collection

While supportive and expanding techniques facilitate the gathering of

information and the development of a positive therapist-client relationship, it is
important to note that certain techniques can actually hamper the interview and
collection of information. Some of these activities are from the same
categories as the more useful interventions but are unclear, unconnected,
poorly timed, and not responsive to the patient's issues or concerns.

These include closed-ended questions, compound questions, “why” questions,

judgmental questions, minimizing patient's concerns, premature advice,
premature interpretations, abrupt transitions, non-verbal communication
 CASE CONCEPTUALISATION
• Case conceptualisation is the process of understanding and interpreting a
client's presenting problems within the context of their individual history,
personality, and current circumstances.

• It is an ongoing process that evolves throughout the course of therapy as new

information emerges and the client's needs change. It serves as a roadmap for
therapy, guiding the therapist's interventions and facilitating collaboration
between the therapist and client towards achieving therapeutic goals.

• It involves gathering and organising information about the client,

identifying patterns and themes, and formulating a comprehensive
understanding of the factors contributing to their difficulties. This
understanding serves as the foundation for developing a treatment plan and
guiding the therapeutic process.

• A comprehensive approach is vital for providing evidence-based, client-

centered therapy, which can lead to profound results, including improved
insight, self-esteem, and motivation to make positive changes in their lives.
• A case conceptualisation consists of four components: diagnostic
formulations, clinical formulations, cultural formulation, and
treatment formulations (Sperry, 2010; Sperry & Sperry, 2012).

• A diagnostic formulation is a descriptive statement about the nature and

severity of the individual’s psychiatric presentation. The diagnostic
formulation helps the clinician in reaching three sets of diagnostic
conclusions:
i) whether the patient’s presentation is primarily psychotic,
characterological, or neurotic;
ii) whether the patient’s presentation is primarily organic or psychogenic in
etiology; and,
iii) whether the patient’s presentation is so acute and severe that it requires
immediate intervention.

The focus is on providing a formal diagnosis or classification of the client's

condition, which informs treatment planning, communication with other
professionals, and reimbursement for services. For all practical purposes the
diagnostic formulation lends itself to being specified with DSM-5 criteria and
classification.
• A clinical formulation, is more explanatory and longitudinal in nature, and
attempts to offer a rationale for the development and maintenance of
symptoms and dysfunctional life patterns. It involves integrating
information from multiple sources to develop a comprehensive
understanding of the client's presenting problems, underlying mechanisms,
and treatment needs within a biopsychosocial framework.

• The focus is on synthesising the client's history, current symptoms,

personality traits, interpersonal dynamics, and environmental context to
guide treatment planning and intervention selection.

• Clinical formulation involves conducting a thorough assessment of the

client's psychological, social, and biological functioning, including their
developmental history, family dynamics, coping strategies, and strengths.

• The purpose is to develop a coherent understanding of the client's

difficulties that informs personalised treatment goals, intervention
strategies, and therapeutic techniques tailored to their unique needs and
preferences.
• A cultural formulation is a systematic review and explanation of cultural
factors and dynamics that are operative in the presenting problems. Cultural
formulation involves exploring the client's cultural background, ethnic
identity, acculturation level, and cultural beliefs about health, illness, and
healing through culturally competent assessment and inquiry.

• It provides a cultural explanation of the client’s condition, as well as the

impact of cultural factors on the client’s personality and level of
functioning. Furthermore, it addresses cultural elements that may impact
the relationship between the individual and the therapist, and whether
cultural or culturally sensitive interventions are indicated.

• The focus is on understanding the cultural context in which the client's

difficulties occur and adapting assessment, diagnosis, and treatment
approaches to be culturally sensitive and responsive.
• A treatment formulation follows from the diagnostic, clinical, and
cultural formulations and involves developing a personalised treatment plan
based on the client's diagnosis, clinical presentation, cultural background,
and treatment goals, informed by evidence-based practices and therapeutic
principles.

• The focus is on identifying the most appropriate interventions, techniques,

and strategies to address the client's specific needs, preferences, and
treatment objectives.

• The purpose is to optimise treatment outcomes, enhance treatment

adherence and engagement, and maximise the effectiveness of therapeutic
interventions by addressing the client's individual strengths, challenges, and
cultural considerations.

The most useful and comprehensive case conceptualisations are integrative

ones that encompass all four components: diagnostic, clinical, cultural, and
treatment formulations.
• What goes on in a case conceptualisation process?

1. Mental Status Examination (MSE)

2. Presenting Problem: What symptoms or life difficulties brought the
client in? How do they view these problems? The presenting problem
refers to the client’s perception of the problem or, in other words, what
brought them to therapy. Describe the client's symptoms, concerns, and
goals. Identify the main issues to address. Consider the duration and
severity of problems.
3. History: This section of the case conceptualisation should include
treatment history, medical history, drug & alcohol history, and relational
history (developmental, family, etc.). It is also essential to examine the
client's natural tendencies, traits, and vulnerabilities that may make
specific problems more likely. This allows the therapist to consider the
contextual factors at play in the client’s presenting problem.
4. Diagnosis: In most cases, therapist starts with a provisional diagnosis.
Once a comprehensive assessment is completed, formal diagnosis may be
done. The DSM provides the criteria for all mental health diagnoses.
5. Theoretical Orientation: Some things to consider when making this
decision include:
- Is your theoretical choice based on the symptoms you see?
- Is it based on your personal preference?
- Do your client’s goals lend themselves to a particular approach?
- Does your agency require you to use a particular therapeutic modality?

6. Treatment Plan: This is the road map to the client’s recovery. The therapist
would collaborate with their client to identify both short and long-term
treatment goals. This is not a one-time deal, the therapist will continually need
to evaluate the goals, objectives, and interventions, and adapt them to the
evolving therapeutic relationship, the client’s response to interventions and
their changing needs.

Identifying any protective factors the client may already have and developing
interventions that build on them is also essential. Discuss specific
interventions, referrals, and approaches. The plan should be comprehensive,
regularly reviewed, and modified to ensure that it effectively reduces the
client's distress, helps them change unhealthy patterns, builds new skills, and
improves overall functioning.
7. Human Diversity Considerations: Human diversity refers to the unique
aspects of a client that makes them different from those around them and affect
their experience in the world. Such differences can include ethnicity, marital
status, gender, age, religion, socioeconomic status, and specific group
affiliations, among others. It is important to consider how the client’s unique
cultural background influences their presenting issue, their engagement in the
therapeutic process, and their relationship with the therapist.

• Patterns: Do they live an active or sedentary lifestyle? Is their personality

naturally more dependent or independent? Identifying predictable patterns
in a person's thinking, feeling, acting, and coping reflects their baseline
tendencies in stressful and non-stressful situations.

• Perpetuating Factors: What factors in their lives maintain their problems?

Avoidance? Unhelpful thoughts? Pinpoint and explore the habits, beliefs, or
dynamics that maintain the problem. This means looking into their
unhealthy coping strategies, cognitive distortions, relationship patterns,
lack of social support, unstable living situations, and any other factors that
may be contributing to the issue.
8. Legal & Ethical Issues: A therapist should always consider their legal and
ethical obligations as they conceptualise the cases.
- Do you have any possible mandates?
- Have you obtained signed releases? Minor consent?
- Are there safety issues that must be managed?
- Are there necessary referrals or health professionals involved in the client’s
treatment?

9. Prognosis: The final part of the case conceptualisation refers to the likely
course and outcome of treatment.
When considering the prognosis, the therapist should assess internal and
external protective factors, the client's strengths, and their readiness for
change. These will be factors to build on and incorporate in the treatment plan.
Conversely, therapist should also consider risk factors, or those that could
impede treatment progress so these can be adequately addressed during
treatment. Therapist should also estimate the number of sessions required for
treatment.
 Framework for Process in Psychotherapy

• A framework for the therapeutic process in psychotherapy provides a

structured approach to understanding and guiding the stages and dynamics
of therapy.

• Psychodynamic Approach: This approach focuses on changing

problematic behaviors, feelings, and thoughts by discovering their
unconscious meanings and motivations. The main goals of psychodynamic
therapy are client self-awareness and understanding of the influence of the
past on present behavior.

• Techniques: Free association; Dream analysis; Analysis of transference;

Identification/analysis of resistances & defences; Interpretation.
• Humanistic Approach: This approach focuses on the potential of
individuals to actively choose and purposefully decide about matters
related to themselves and their environments. It encompasses theories that
are focused on people as decision makers and initiators of their own growth
and development.
• Therapists following humanistic approaches help clients increase self-
understanding through experiencing their feelings. Some important
humanistic therapies include person-centered therapy, existential therapy,
and Gestalt therapy.

• Behavioral Approach: This approach is especially popular in institutional

settings, such as mental hospitals or sheltered workshops. Therapists help
clients learn new, appropriate ways of acting, or help them modify or
eliminate excessive actions (adaptive behaviours replace those that were
maladaptive).
• An assumption that all behaviour is learned, whether it be adaptive or
maladaptive; rejection of the idea that human personality is composed of
traits.
• Cognitive/Cognitive-Behavioural Approach: Cognitive approaches focus
on mental processes and their influence on mental health and behaviour. A
common premise of all cognitive approaches is that how people think
largely determines how they feel and behave.
• Rational Emotive Behavioural Therapy (REBT), Reality Therapy (RT),
Cognitive Therapy (CT), Cognitive-Behavioural Therapy (CBT)

• Three key features of cognitive-behavioural approach:

i) a problem-solving, change-focused approach to working with clients;
ii) a respect for scientific values; and
iii) close attention to the cognitive processes through which people monitor
and control their behaviour.
• Stages of Change Model (Prochaska & DiClemente, 1983): Although originally
proposed in the context of addiction treatment, the model was later adapted for
psychotherapy more broadly. This model outlines five stages of change that clients
typically progress through during the therapeutic process:

1. Pre-contemplation: Client is not yet considering change and may be unaware of

the need for therapy. The focus of therapy is often on building awareness,
motivation, and readiness for change.
2. Contemplation: Client acknowledges the need for change but may feel uncertain
about taking action. Therapy involves exploring the pros and cons of change,
resolving ambivalence, and increasing motivation for change.
3. Preparation: Client begins to actively prepare for change by setting goals,
making plans, and gathering resources. Therapy may focus on developing coping
skills, problem-solving strategies, and a support network to facilitate change.
4. Action: This stage involves implementing specific strategies and behaviors to
achieve the client's goals (skill-building exercises, behavior modification
techniques, cognitive restructuring)
5. Maintenance: Once the client has successfully made changes, the focus shifts to
maintaining and consolidating these changes over time. Therapy in this stage may
involve relapse prevention strategies, ongoing support, and addressing any
remaining challenges or barriers to long-term change.
• Common Factors Model: The notion that all therapies work through
common factors was first introduced by Saul Rosenzweig in 1936. He
observed that all therapies resulted in comparable outcomes, and based on
this observation, he suggested that they probably worked through factors
that were common to them all.
These common factors include the therapeutic alliance, client and therapist
factors, expectations and placebo effects, and extra-therapeutic factors
(i.e., factors outside of therapy). According to this model, therapists can
enhance therapeutic outcomes by focusing on building a strong therapeutic
alliance, fostering hope and expectancy, and tailoring therapy to meet the
individual needs of clients.

• Contextual Model (Wampold & Imel, 2015): According to this model,

there are three pathways through which psychotherapy produces benefits.
That is, psychotherapy does not have a unitary influence on patients, but
rather works through various mechanisms. The three pathways of the
contextual model involve: a) the real relationship, b) the creation of
expectations through explanation of disorder and the treatment involved,
and c) the enactment of health promoting actions.
 Pragmatic Issues related to Psychotherapy
1. Accessibility & Affordability: Access to psychotherapy (mental health
services) can be limited by various factors, including geographical
location, financial constraints, language barriers, cultural stigma, or
discrimination (Mojtabai et al., 2011; Sareen et al., 2019). Therapists and
mental health organisations may need to explore solutions, such as
sliding-scale fees, tele-therapy options, or community-based clinics, to
improve accessibility for underserved populations (Cook et al., 2013).

2. Cultural Competence and Diversity: Clients from diverse cultural

backgrounds may have unique beliefs, values, and communication styles
that influence their experiences and preferences in therapy (Sue & Sue,
2013). Therapists need to demonstrate cultural competence by
understanding and respecting the cultural norms, traditions, and identities
of their clients (APA, 2017). Culturally sensitive assessment and
intervention strategies, such as adapting therapy techniques to align with
the client's cultural background, can enhance therapeutic rapport and
effectiveness (Smith et al., 2011).
3. Stigma and Mental Health Awareness: Stigma surrounding mental health can
deter individuals from seeking therapy. Increasing mental health awareness and
reducing stigma through education, advocacy, and public campaigns can help
normalise the experience of seeking therapy and encourage individuals to prioritise
their mental health.

4. Matching Clients with Appropriate Therapists: Finding the right therapist

who is a good fit for the client's needs, preferences, and cultural background can be
a challenge. Therapists and mental health organisations may need to improve
methods for matching clients with appropriate therapists, such as offering therapist
directories, providing intake assessments to assess client preferences, and offering
a range of therapeutic modalities to accommodate diverse client needs.

5. Ethical and Legal Considerations: Therapists must adhere to ethical guidelines

and professional standards of practice, such as maintaining client confidentiality,
obtaining informed consent, and avoiding conflicts of interest (APA, 2017). Ethical
decision-making frameworks and consultation with colleagues or supervisors can
help therapists navigate complex ethical dilemmas and ensure ethical practice
(Pope & Vasquez, 2016).
Therapists must ensure compliance with relevant regulations and ethical guidelines
when providing tele-therapy/online services (APA, 2013).
 Termination of Psychotherapy
• The successful outcome of therapy depends on a working alliance between
therapist and client. The termination phase—a patient’s transition out of
therapy—is a crucial factor and can play an important role in future growth.

• The challenge for the therapist at the termination phase is to use this phase
to the maximum benefit of the client.

• The goals of this stage include the consolidation and maintenance of what
has been achieved, the generalisation of learning into new situations, and
using the experience of loss and/or disappointment triggered by the ending
as a focus for new insight into how the client has dealt with such feelings in
other situations.

• One special type of ending is referral to another therapist or agency.

Referral can occur after initial assessment, or may take place after several
sessions of therapy.
• Ethically, therapists must terminate treatment if they can’t address a client’s
needs, if the client isn’t benefiting from treatment over time, or in the event
of an inappropriate multiple relationship that may impair objectivity or
judgment or harm the patient.

• Abandonment, or ending therapy without fully addressing client needs or

without making arrangements for other treatment, can cause unnecessary
distress and even worsen clients’ symptoms. However, if a client threatens
or assaults the therapist, they can terminate treatment immediately without
a termination phase.

• No matter the reason for terminating, ensuring a smooth transition can help
clients continue to grow after the last session.
- Discuss termination early on/Avoid abrupt termination.
- Know when to refer/Consult with experts.
- Look back on positive growth/Look forward to potential challenges.
• When to terminate a relationship is a question that has no definite answer.
However, closing should be planned and deliberate. If the relationship is ended
too soon, clients may lose the ground they gained in counseling and regress to
earlier behaviors. However, if closing is never addressed, clients can become
dependent on the counselor and fail to resolve difficulties and grow as persons.
There are several pragmatic considerations in the timing of closing (Cormier,
2015; Young, 2017).

- Have clients achieved behavioral, cognitive, or affective contract goals? When

both clients and therapists have a clear idea about whether particular goals have
been reached, the timing of closing is easier to figure out.

- Can clients concretely show where they have made progress in what they
wanted to accomplish? In this situation, specific progress may be the basis for
making a decision.

- Is the therapeutic relationship helpful? If either the client or the therapist senses
that what is occurring in the sessions is not helpful, closing is appropriate.

- Has the context of the initial therapeutic arrangement changed? In cases where
there is a move or a prolonged illness, closing (as well as a referral) should be
considered.