My Stance on Assessment

by Amanda Southwell (nee Croucher)

Introduction

There are a wide variety of issues raised by assessment and the form of its application. Many counselling agencies utilise a range of assessment procedures and techniques, including pre-counselling interviews and diagnostic testing. Individual counsellors approach assessment according to the particular theoretical model to which they adhere and may apply qualitative measuring tools accordingly. Assessment, therefore, is a generic and often confusing term, referring both to the process and content within counselling practice. Throughout this essay I will endeavour to discuss a portion of methods and techniques, placing assessment within the modernist and postmodernist theoretical frameworks, and in doing so present both positive and cautionary aspects. Finally, I will conclude with my own reflection of "assessment", providing reasons for my adopted stance.

Diagnosis as Assessment

Diagnosis is concerned with classifying a problem, matching signs and symptoms of a client with a known category of disorder or dysfunction.

DSM IV (Diagnostic and Statistical Manual of Mental Disorders)

The purpose of the DSM IV is made evident in its introduction: "·to provide clear descriptions of diagnostic categories in order to enable clinicians and investigators to diagnose, communicate about, study, and treat people with various mental disorders." (Diagnostic and Statistical Manual of Mental Disorders IV, p. xxvii).

Certain conditions make counselling difficult, such as counselling someone who is actively hallucinating or suffering from schizophrenia. It is essential, therefore, that counsellors should be aware of the major psychiatric disorders outlined in the DSM IV. However, the proper use of the criteria requires specialised clinical training, thus rendering it difficult to apply in mainstream counselling. Many also believe that using such a means to classify a client may "turn the person into a thing, an object of study rather than a complex changing individual" (Palmer & McMahon, 1997, p. 8). Individual responsibility, disability, determination, and competency are not taken into account, all of which may be relevant in such cases as Pathological Gambling. Certain advances have been made, however. The consistently problematic issue of cross-cultural assessment has now been addressed in a new culture-specific section in the text, the inclusion of a glossary of culture-bound syndromes, and the provision of an outline for cultural formulation designed to enhance the cross-cultural applicability of the DSM IV.

The Mental Status Exam

The MSE differs chiefly from such assessment tests as the DSM IV in that it is essentially a record of the counsellor's observations during the interview, rather than a factual analysis of symptoms, or a report by family, friends, or another professional. By analysing appearance, behaviour, speech, mood, depersonalisation, obsessional traits, delusions, orientation, concentration, memory and insight throughout the session, the counsellor can gain information about the client and their emotional difficulties in the here-and-now as well as in the past. Significant risk factors can be identified, and it is a useful tool for assessing a client over time. Counsellors must, however, guard against the wish to prematurely infer meaning from what the counsellor is actually seeing, and the temptation to "see" things that are really the counsellor's own assumptions.

Multimodal Therapy

Multimodal assessment, developed by Arnold Lazarus, examines each area of a person's BASIC - I.D.: Behaviour, Affect, Sensation, Imagery, Cognition, Interpersonal relationships, and Drugs/Biology. A fundamental premise is that patients are usually troubled by a multitude of specific problems that should be dealt with by a similar multitude of specific treatments. It provides an operational way of answering the constant inquiry: Who or what is best for this individual (or couple, or family, or group)?

The Multimodal approach has an eclectic, integrative perspective, and continual scanning of each modality and its interaction with every other can enhance a counsellor's effectiveness and awareness of the client's chief problems. It can also be adapted for use extending from individuals, couples, families, and groups to broader community and organised settings. However, the average duration of a complete course of Multimodal therapy is approximately 50 hours, clients may become overwhelmed by too many questions, and therapists may ignore presenting problems in favour of the modality assessment.

Individualised Assessment

The application of different forms of diagnosis or testing has the potential to emphasise powerful forces that are mysterious to the client, and give therapists an overly certain sense of explanation. Individualised Assessment makes use of formalised diagnostic assessments, but goes further to describe the client's particular situation, and the way in which he or she influences outcome, both positively and problematically. Tests are only turned to after a collaborative relationship is established between the counsellor and client, and "because [they] are working together to see what new understandings might emerge, clients do not feel they are being objectified or having their privacy invaded" (Fischer, 1985, p. 42). Assessment moves beyond the tester as scientist whose task is to identify the patient's traits, defences and symptoms through measurement, to a concurrent involvement of assessor and client using everyday, shared language.

"Qualitative" Methods of Assessment

In keeping with the need for greater client involvement, humanistic oriented counsellors often employ "qualitative" methods of assessment where the client participates actively in learning/assessment exercises integrated into the counselling sessions themselves. These include the uses of a lifeline to map significant experiences along a life continuum, the Likert scale or those similar, determining the strengths of experiences and feelings using numbered intensities, and the genogram, to name but a few.

The genogram, in particular, is a useful tool used widely in family therapy. A central principle agreed upon by systemic family therapists is that "clients are connected to living systems and that change in one part of the unit reverberates throughout other parts" (Corey, 1996, p. 367). The genogram, originally founded by Bowen in his studies on family systems therapy is a useful tool for "mapping" (McGoldrick & Gerson, 1985, p. 3). By scanning the family system historically and assessing previous life cycle transitions, present issues can be placed within the context of the family's evolutionary patterns. Clients can recognise how their own circumstances may relate to possible destructive patterns that have been maintained throughout the generations before them, therefore enabling family members to alter these patterns. It also allows clinicians to get to know the family, and easily record data which may otherwise be given in an "ad hoc" fashion. While some recommend that the genogram should be constructed in the first session, it is of utmost importance that the counsellor is flexible as to timing, as the cases of each client or group may not warrant the time spent on compilation. In addition there remains the danger of genograms being used inappropriately as an "easy" tool, or as a way of avoiding or intellectualising away very "current" conflicts. It is easy to forget that the purpose of therapy is to bring about changes, not record elegant diagrams.

Involving a client or family in qualitative methods of assessment enables them to be placed in the "expert" position, teaching the therapist. The following theories sustain a similar discourse.

Person-Centred Therapy

A significant shift away from the objectivistic, measurement approach to assessment is indicated in the work of Carl Rogers. As described by Palmer and McMahon (1997): The concepts of assessment, diagnosis and treatment are seen by most person-centred therapists as compromising "genuineness" - a cornerstone of the person-centred framework - as the client is viewed in an objective manner. The major person-centred objection is to expertise: it is anathema to think that an "expert" knows another person better than she knows herself (p. 15).

What mattered to Rogers was not how or by what means the counsellor assessed the client, but how the client assessed him or herself. In his own words, "·the opportunities for new learning are maximised when we approach the individual without a preconceived set of categories which we expect him to fit" (Rogers, 1965, p. 497). The client is seen as having the sole potential of knowing fully the dynamics of his perceptions and behaviour, and the constructive forces bringing about reorganisation of self and relearning reside primarily in him. To Rogers, diagnosis could be unwise and detrimental, as the locus of evaluation shifts so definitively in the expert that dependent tendencies may develop in the client, who may also develop a belief that the measure of his personal worth lies in the hands of another. Considerations of such a nature have led person-centred therapists to minimise the diagnostic process as a basis for therapy. Rogers admitted, however, that tests may have a place, especially if they were used toward the conclusion of counselling and if the client requested them, but recommended caution in using tests or in taking a complete case history at the outset.

Postmodernism and Narratives

The belief in progress, rationality, and scientific theories are now seen as characteristics of modernity. Many believe we are currently moving into a postmodern era. While modernist thinkers tend to be concerned with facts and rules, postmodernists are concerned with meaning, salience of cultural difference and deconstruction of realities. The implication for counselling is a movement away from the "modernist 'grand theories' of those such as Freud·towards a much more fragmented, locally or personally constructed integrationist or eclectic approach to knowledge" (McLeod, 1998, p. 221).

Postmodernism espouses that people live their lives within the dominant narratives or "knowledges" of their culture and family, and the significance of story-telling and narrative are a primary means of making sense of social experience and communication with others. However, the dominant cultures in which people live can construct narratives that impoverish the actual life experience of the person and their own stories. Postmodern narrative therapists believe that when life narratives offer only unpleasant choices or carry hurtful meanings, they can be altered by highlighting different, previously un-storied events or by creating new meaning from already-storied. Thus, new narratives are constructed.

A characteristic of the modernist approach to stories is to explain them through underlying structures or archetypes instead of letting them "tell themselves". Thus, only the "expert" can understand the story. Postmodern therapists believe that there are no prior meanings hiding in stories or texts. A therapist with this view will expect a new, more useful narrative to surface, but the conversation, not the therapist, is its author. In the words of Freedman and Combs (1996): When therapists listen to people's stories with an ear to "making an assessment" or "taking a history of the illness" or "offering an interpretation", they are approaching people's stories from a modernist, "structuralist" worldview. In terms of understanding an individual person's specific plight or joining her in her worldview, this approach risks missing the whole point (p.31).

Postmodernism rejects what Foucault (1980) terms "global unitary knowledges", (as cited in Wood, 1997, p. 24) such as the DSM IV as the only sources of truth when working with people. A postmodernist view of history-taking accepts that this process is always subjective, always coconstructed. Having a knowledge base or attachment to a theory can undermine and devalue the unique experience of the client, as can holding information and opinions on the patient that the latter is unaware of, and might even disagree with.

Conclusion

Palmer and McMahon (1997) reiterate that "assessment must begin with an open mind on behalf of the counsellor, a readiness to enter into another's world" (p. 93). However, they also imply that formalised assessment is an essential component of the therapeutic process, usually beginning at the first point of contact with the client. I would tend to disagree, on the basis that this stance places the counsellor as "expert", and is in danger of diminishing or even nullifying collaboration between the client and counsellor. This is not to suggest that a more structured form of assessment is inappropriate. Certain circumstances certainly call for a more rigid diagnosis, based on perhaps the agency worked for, or the needs of a mentally ill or suicidal client. In other situations, measurement or qualitative tools, such as the lifeline and genogram, may be of use to allow clients to carry out their own explorations. Assessment tools have been created for a purpose, all of which may have merit, some of which, in my view, are more effective than others. The discretion of the counsellor is vital in determining which to employ. On the other hand, to discredit the post-modernist and person-centred view of clients as being the interpreters of their own experience, in favour of assessment as "procedure", is to condone a hierarchy whereby the counsellor knows more about a person's lived experience than the person does.

The dismissal of any of the above without careful consideration would seem to me to be injurious to the counselling process. Each must be weighed in the light of the theoretical framework adopted by the counsellor, the needs of the client, and the specific situation at hand. In my opinion, a simple but fundamental law can encompass all facets of assessment, and is described by Egan (1998): "Assessment, then, is not something helpers do to clients...Rather, it is a kind of learning in which, ideally, both client and helper participate" (p. 116).

References

Corey, G. (1996). Theory and Practice of Counseling and Psychotherapy. California: Brooks/Cole Publishing Company.

Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition). American Psychiatric Association.

Egan, G. (1998). The Skilled Helper: A Problem-Management Approach to Helping. California: Brooks/Cole Publishing Company.

Freedman, J. & Combs, G. (1996). Narrative Therapy: The Social Construction of Preferred Realities. New York: W.W. Norton & Co.

Fischer, C. T. (1985). Individualising Psychological Assessment. California: Brooks/Cole Publishing Company.

McLeod, J. (1998). An Introduction to Counselling. Philadelphia: Open University Press.

Mc.Goldrick, M. & Gerson, R. (1985). Genograms in Family Assessment. New York: W.W. Norton & Co.

Palmer, S. & McMahon, G. (1997). Client Assessment. London: Sage Publications.

Rogers, C. (1965). Client-Centered Therapy. Boston: Houghton Mifflin Company.

Wood, C. (1997). To Know or Not To Know: A Critique of Postmodernism in Social Work Practice. Australian Social Work, 50 (3), 21-27.