The Vicissitudes of Therapeutic Assessment

The following piece was written in preparation for a training day on “First Sessions and Initial Assessments and Dilemmas”.

The tension between (inter)subjective and objective aspects of the assessment encounter

Whether it is an assessment at school, university or at work, or by a medical specialist or other expert, one question - running alongside the necessary factual questions of the assessment - is a subjective, emotional one: “will I get to feel seen as a person?”

The essentials of empathic, therapeutic assessment: "What is WRONG with you?"

It is in the nature of assessment that a supposedly uniform, objective set of criteria, applicable to anybody, gets applied to us as an individual. Yes, we want the assessment to be fair and square, and useful: we want the expert’s expertise and honest opinion. But the other question that gets raised is whether our subjective sense of self is being recognised, taken into account and appreciated within the assessment.

This tension between an objective, universal or generic outer description versus the subjective individual inner reality becomes more charged and obvious in counselling and therapy, whether we are being assessed as clients, students in training or as qualified practitioners.

How does 'unconditional positive regard' and 'acceptance' get sustained in the context of judgement and assessment?

For many, in many situations, it's either acceptance or it's assessment - they are construed as opposites, irreconcilable. And many of us in the therapeutic profession have come to it because we sought refuge in the cosy sphere of 'unconditional positive regard' and 'acceptance', away from judgement and assessment - because we are caught in assuming unconsciously that if any judgment is going to get made, it will have to be a harsh, negative one - therefore: better to avoid all judgment altogether.

But: without discerning judgement, empathy can become flimsy and ungrounded and turn into blind, collusive acceptance, which is not what we want to promise or offer as therapists, and it’s not what we hope for or want as clients.

So we want to be able to hold the crucial recognition: both 'unconditional positive regard' and judicious judgement can fulfil a loving purpose; and ultimately, in order for love, empathy and acceptance to have impact and 'bite' and helpful, developmental impetus, they depend upon a differentiated judgement of what's really needed. So far from being irreconcilable opposites, we want to inhabit the recognition that these apparent opposites depend on each other - judgement is a necessary ingredient in ‘wise’ empathy and acceptance. We, therefore, do not want to maintain any habitual bias against assessment - we want to be able to see and support its fundamental validity, even when it appears in contorted manifestations.

How to deliver objective, uniform, expert assessment?

Indeed, when coming to therapy, many clients demand from us a quasi-medical diagnosis of their ‘condition’ and ‘prognosis’, and some feel relieved when they get it. They do not understand any reluctance on the therapist's part to carry out an examination, formulate a diagnosis and make an assessment - many assume that these are the very tasks they are paying us for. Now with a client like that, who has already handed themselves over to the supposed blessings of objectivity, it is us who get to hold awareness of its problematic aspects. Even when the client has long abandoned it, we identify with and continue to champion the longing to feel deeply seen and met in our unique subjectivity - with all our flaws, wounds and potential - which is just as present, and probably more so, when we come to therapy.

As practitioners, how do we do justice to that tension, which is present especially in a first meeting and initial assessment? How do we establish a working alliance, when the client is both demanding to be judged and assessed as well as afraid of it or resistant to it (maybe unconsciously so)?

The therapeutic professions have not entirely emancipated themselves from the general assumption in education that entirely objective impersonal assessments are both possible and worthwhile. So even whilst our therapeutic principles and understanding tell us that “it is the relationship that matters” and that all assessment is intersubjective and relational, for the purposes of therapy training, we appear to defer to the emotional incompetence of the rest of the educational world and strive for fairness through objectivity.

Intake assessments and school transference in therapy training

For the purposes of therapy, many therapists accept that the heart of our work depends on our subjectivity – recognising that the only tool we have at our disposal is our self; that is all we can work with, for better or for worse. If - in pursuit of exclusive objectivity, academic uniformity and quasi-medical accountability - we try to eradicate the vagaries of our subjectivity from our practice, we destroy the essential foundations upon which our work depends.

But in therapy training (especially through increasing academic influence since the 1990’s) educational norms appear to outweigh the principles of therapy, lending the whole collective space and learning community a school atmosphere. That has the unfortunate and profoundly unhelpful consequence that many students entering counselling or therapy training of some form or another immediately regress back to school, assuming that success in therapy training now depends on similar behaviours as back at school then. They tend to therefore take refuge in similar roles and survival mechanisms (becoming good, cooperative pupils or delinquent, protesting renegades, or anything in between), with the result that usually the first transference which students bring to training and project onto tutors and training organisation is not a parental one – it’s a teacher transference.

In principle, this kind of transference which students bring to their training is, of course, not dissimilar from the kind of transference that occurs in therapy: the same schemas, scripts and adaptations which we developed in school become re-activated in training. And to some extent the success of any therapeutic training depends upon the degree to which the student’s transference to the training, i.e. the student’s ‘habitual position’ (with its characteristic defences, anxieties and underlying impulses) can be addressed and worked through during the training, in therapy, in experiential groups but also in the training groups itself.

It was Carl Rogers who recognised that counselling training is likely to be more effective and productive if it encourages students’ self-directed learning, i.e. if the means and the ends of the training are congruent and coherent: if we are aiming for a profession of practitioners capable of independent reflective practice, then a traditional educational paradigm with its hierarchical and ‘other-directed’, pre-defined and imposed curriculum, format and structures is likely to create more problems than it solves. However, since the early 1990’s most counselling and therapy training has shifted significantly towards standard academic paradigms, even if that does include some experiential process and practice.

Therapeutic authority in defensive linear practice?

What we notice in supervision is that many therapists arrive into their practice as supposedly independent reflective practitioners with ingrained ‘super-ego’ projections onto the profession and its organisations: many supervisees come out of training carrying fairly linear assumptions about ‘correct’ practice, and the supposed ‘rights’ and ‘wrongs’ of how to be a good therapist. These kinds of assumptions and habitual patterns effectively undermine the therapist’s sense of therapeutic authority and therefore the therapeutic space they are able to provide for their clients: in very immediate, nitty-gritty terms, these unresolved transferences (to the supposed authorities of their training and their profession, manifesting in compliant and deferential inhibiting attitudes) interfere with the therapist’s responsiveness, spontaneity and creativity in relation to their client. The therapist does not feel free to follow their intuitions, lest they are in danger of being sued and struck off the register.

This kind of defensive practice in an increasingly litigious culture is well-recognised in medical circles - in the end, it does not serve anybody: it fails the client, and it fails the vocational passion of the practitioner, who resigns themselves to going through the motions.

These kinds of tendencies in ourselves, in our colleagues and in the profession at large are inimical to the depth of relational practice which we want to pursue (and which attracts most of us to the profession in the first place). The more we explore the depths of the relational encounter at the heart of the therapeutic process, the more we recognise that the traditional models of therapy do not do justice to the vicissitudes and dilemmas which the therapist experiences.

Therapeutic authority through relational multiplicity and flexibility

Following Petruska Clarkson (1994), we recognise that the therapeutic space consists of diverse, distinct and mutually contradictory relational modalities, which each have their validity, but are in constant tension with each other. As a therapist, I cannot hope to do justice to the client and to their psychological conflicts if I short-circuit the inherent relational complexity by imposing simplistic, linear instructions upon myself. The psyche is not linear, the therapeutic process cannot be linear, so my relational response must not be linear. So ideally my training and supervision and professional community does not model, uphold or insist upon linear ideals, borrowed from other disciplines and educational paradigms and based upon principles drawn from the objectifying natural sciences (rather than the humanities).

As many of the elders of our profession have expressed: uncertainty, ‘negative capability’ and a capacity for sustaining helplessness are more important qualities and faculties for a therapist than knowledge, skill and competence. We want to be as open as we can to a multitude of relational configurations and relational spaces. Conversely, we want to impose as little dogmatism and habitual fixity on the therapeutic position and how we construct the therapeutic space (in order to maximise our capacities of being sensitive to how the client’s unconscious constructs the space).

Whether we use Martha Stark’s seminal distinction between ‘one-person’, ‘one-and-a-half-person’ and ‘two-person psychology’, or Clarkson’s distinction between working alliance, reparative, authentic and transference/countertransference modalities, ideally the therapeutic space I provide allows for all of these possibilities, unimpeded by linear ideas of the ‘rights’ and ‘wrongs’ of what should happen. This then allows me to notice that these different modalities are in constant dynamic tension with each other, creating transformative rupture-and-repair cycles in the therapeutic relationship which therefore can become as developmental as a ‘good-enough’ early attachment relationship.

"All I want from you is a simple therapeutic diagnosis."

Relational multiplicity in assessment

These ideas become relevant in any kind of assessment we conduct: from the first moment that a client (or a student) makes contact with us, we attend to the particular atmosphere of the relational space we are transported to and co-create. Even when our task includes and requires an explicit assessment and the application of a set of standard criteria, we can notice the particular meaning and function these ideas acquire in this particular relationship, knowing full well that these same ideas can have a completely different relational effect and meaning with somebody else.

The client’s construction of the fix-points of the therapeutic space

One client is convinced that the rudimentary fixed points of the therapeutic framework apparently imposed on her necessarily put her into an inferior, compliant position; the next one is as convinced that therapy is an un-holding, wishy-washy useless environment, which fails to give him direction and security.

One client is convinced that the therapist treats her as one more miserable burden in an assembly line of rote, clinical cases treated according to the same manual; the next one is as convinced that the therapist’s attention to the way the two of them are making contact with each other in the room is a pointless, distracting irrelevance.

One client is convinced that the therapist’s empathic attitude is an invitation into a friendship which is supposedly the only place where this kind of warmth and acceptance can happen as by definition it is impossible in the cold clinical context of a consulting room; the next one is as convinced that the therapist’s boundaried and apparently cold clinical presence is a sign and conclusive evidence of a personal dislike.

In all of these situations, the therapist is the same personal-professional presence, but it gets perceived and experienced and constructed in very diverse and contradictory ways by different clients, who bring their wounds - their woundedness and their protection mechanisms against it - into the room and into the relationship.

In conducting an assessment, we recognise that this process is well under way by the time the client picks up the phone or enters the room. What kind of working alliance is available to be established depends upon how we navigate these pre-existing perceptions and assumptions: how do we engage with the client’s unconscious construction of the therapeutic space and our therapeutic presence?

Inevitably, as the therapist I am floating in a sea of contradictory currents, and it is understandable that I have the impulse to seek refuge in some guideline, some fix point, some standard procedure. As Bion said, there should be two frightened people in every consulting room. However, in attempting to assure my composure and portray a semblance of therapeutic authority by imitating some mould of ‘correct’ procedure, or reaching for some linear policy of how to be a good therapist, I lose access to the rich, paradoxical quicksilver complexity of the relational moment (in Ehrenberg’s felicitous phrase: I lose “the intimate edge”).

Contradictory relational elements in assessment

The client can legitimately expect at least three aspects from an assessment:

• the therapist’s expert judgement as to whether therapy would be feasible, suitable, and productive and whether it would be a good investment, and if so, what kind of therapy - this is the equivalent of a medical examination, diagnosis and proposed treatment
• some negotiation of the business realities of therapy, i.e. mainly the financial deal
• but in order to make an informed, emotional decision about therapy, the client also needs a relational experience of what therapy would actually be like, and how the therapist engages in the relational multi-verse that has already been co-constructed

So in terms of relational modalities, the initial assessment requires the therapist to do justice to just about all of them, in their tensions and contradictoriness. Specifically, an initial assessment …

• needs to establish a working alliance first and foremost (as I have suggested elsewhere, the field is profoundly confused about the working alliance, and its two aspects: the ego-ego alliance and the unconscious, energetic alliance – both are at stake, and not at all straightforward. For example: many therapists assume that a warm, engaging presence and coming towards the client empathically will maximise the chances of building an immediate, positive alliance; however, some clients perceive a too solicitous or willing attitude on the part of the therapist as unprofessional weakness. We want to make sure that we do not operate on assumptions that would apply to ourselves as clients, as to what promotes an optimum alliance.) At some point some kind of explicit working understanding does need to be negotiated, and that includes the contract and the business aspects of the arrangement.
• most clients legitimately expect a quasi-medical assessment and opinion (as I have suggested elsewhere, it makes sense to include ‘medical model’ as an additional modality - which Clarkson a priori excluded from her 5 relational modalities of psychotherapy)
• it is unlikely that a solid working alliance will be formed unless some kind of authentic relating, some human encounter has occurred, if only implicitly
• all of the above modalities are predicated on there being a mutual understanding between client and therapist, on the most basic emotional levels and in terms of the why’s and wherefore’s of therapy. The possibility of such understanding is filtered through the lens of the transference/countertransference modality, and includes the client’s hopes and needs for some reparative function which therapy might fulfil

So, in essence, all relational modalities are involved in an initial assessment.

These above are some of the ideas and dilemmas we want to explore on a training day on “Dilemmas of First Sessions and Initial Assessments”.