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Most therapists will have their own version of an assessment but there are some generic questions, which will need to be covered when client and therapist first meet. Some of these include:
- Personal and contact details.
- What the current problem is and how the client perceives it.
- If there are any underlying medical conditions, which may affect therapy, such as medication for anxiety.
- Is the client aware of any underlying factors for their current issue.
- Are any other agencies involved? For example a GP may have referred the client or therapy might be part of a legal agreement.
- Is the issue having a wide-ranging effect on other people? For example those clients with drug or alcohol abuse problems often report that their family is deeply affected by their problems.
Another very important factor when assessing clients as a therapist is to ascertain during an initial assessment, which must be monitored as therapy progresses, is whether or not CBT is actually an appropriate type of therapy for the client. As we saw during the first unit of the course, CBT is not effective for everyone and therefore it would be a waste of time for both client and therapist if therapy were to be undertaken with either of them knowing that a positive outcome was highly unlikely.
Safran et al., (1993) argued that positive outcomes in CBT will be more likely if the client:
- Is aware of their different emotions.
- Accepts responsibility for change.
- Can form a good, collaborative relationship with the therapist.
- Is reasonably optimistic about therapy.
It should also be kept in mind that CBT is much less likely to be successful with clients who have extremely deep rooted issues that are based in childhood or if they have learning difficulties, which mean they are unable to understand their cognitive processes and will not be able to engage in homework tasks. In these instances, it is ethically correct to immediately refer the client on to another therapist who is better equipped to help them deal with their issues. This must be done with the client’s agreement and in a way, which does not lead them to feel as though they have been abandoned.
During a first session, clients will be discussing what has brought them there and it is during this time that the therapist must begin to apply the skills we discussed earlier in this unit. It is very important that they do not judge the client and that they do not let their own beliefs and values intrude on their work with the client. If this is something that is proving difficult for the therapist then they must seek assistance from a supervisor or mentor as to how to continue. This may mean that another person must sit in on a session, something that will need to be agreed with the client. If it emerges that issues are insurmountable then again, the client will need to be referred on to another therapist.
Questioning by the therapist is a key skill during the initial assessment session. The client may only reveal information which they think is relevant and so it will be up to the therapist to unravel the problem and work through what is likely to be a set of ‘layers’ in order to get to the root of a client’s issue. In order to do this, open questioning must be applied so as to avoid the possibility of simple one-word responses, which are not likely to provide enough information. When the client responds to questions, the therapist must engage active listening to pick up on any information, which may need further exploration to reveal more details.
Clients may not want to reveal information because they may have feelings of guilt about it or they know that it will provoke very strong emotions, which they do not feel that they are ready to deal with. The therapist should be able to work with this and form a relationship with the client that is solid enough for the client to feel comfortable to discuss anything that is causing them distress. It is useful for the therapist to remind their client that, initially, bringing problems out into the open may cause them further grief for a short time but this is necessary in order to be able to work through them.
Problems during assessment
Problems can present themselves for both therapist and client during an initial assessment. For example, therapists might find it difficult to sift through what is relevant detail and what is not when trying to work through layers of information. They may also find it difficult to judge what is a ‘wrong’ question, i.e. one that is not going to get the information that they need. Experienced therapists will be able to work out when they have asked an irrelevant question more quickly and move on to ask a question from a different angle – this is something that will come with practice for new therapists.
Clients may experience difficulties in answering questions for two reasons. Firstly they simply may not know the answer to what they are being asked and secondly, they may know but are extremely reluctant to reply. When clients do not know the answer, the therapist should persist with them and help them to respond by the use of homework activities, which may trigger an answer.
If clients are reluctant to answer, this is often through fear of disapproval or that the therapist might think that they are ‘being silly’ and laugh at them. In some situations though, clients may fear that they are going to be diagnosed as being ‘mad’ or ‘mental’ and that they will be locked away or the police and Social Services will become involved and will have their children removed from their household. In cases such as these, frequent reassurances to the client should help them to reveal their thoughts, though this may be a long process and the therapist will have to be very patient when working with clients such as these. Remember that many clients who undertake CBT experience catastrophic thinking on a regular basis so their ideas about being seen as ‘mental’ are part of their condition.