ABSTRACT
Developing a clear and thorough picture of the client through assessment is an essential part of the initial stages of any psychotherapy. Ideally, this is best done in a structured intake assessment process. This can be done by asking the client to complete an intake form and a brief initial consultation, or by inviting the client for a longer assessment session (personally, I use the former method). It is important to strike a good balance between letting the client discuss their presenting problems and how they affect them, letting the client ‘offload’ to some extent (for a number of clients, this will be the first time they have discussed many of their issues) and obtaining information that is useful in identifying the client's central concerns/problems, selecting a focus for therapy (or several areas of focus), and establishing the client's goals for therapy. These then inform the overall assessment/diagnosis and treatment plan for the client. I offer here areas of consideration that may help in this process. Another important aspect of assessment is identifying if you are a ‘good match’ for the client, not only in terms of whether you and the client experience a sense of rapport, but also if you feel you have the right set of skills and experience to work with them effectively.
Demographics. Client age, gender, current living situation/relationship, type of job (if relevant). Accounting for the client's intersectional identity here is important in contextualizing the client and identifying whether any potential adjustments need to be made to the therapy (e.g., with neurodiverse clients), or if the impact of minority stress needs to be accounted for (Meyer, 1995; Mirowsky and Ross, 1989). Note: when presenting in supervision, it is advisable to hide some details to preserve the client's anonymity.
Presenting problems and client's theory of problems and theory of change. What are the client's main concerns and problems they are seeking therapy for? How do these problems manifest in their everyday life? How severe does the client feel they are? What is the client's view on the origin of these problems? What do they think will help? If there is more than one problem, which does the client feel is most important to address? Which problems cause them the most difficulty? What, in your view, would be the most rational area of focus for the therapy?
Symptoms. What symptoms does the client experience? How severe are they? How do they affect the client's functioning? Do the symptoms seem to indicate a particular psychological disorder or fit the symptom pattern for a particular diagnostic category from ICD-11 (WHO, 2019) or the DSM-5 (APA, 2013)? I strongly recommend that all therapists routinely use screening tools and outcome measures as part of their assessment process. I personally use CORE-10 (which measures overall levels of functioning and distress), PHQ-9 (which measures depressive symptoms), GAD-7 (which measures anxiety symptoms) and ACE's form (which identifies a number of Adverse Childhood Experiences). All of these measures are freely available online (see also Point 90).
Medical and mental health history/previous therapy. Does the client have any diagnosed physical or mental health problems? Are they taking any medication? When did they last have a general health check-up? Have they had any previous counselling or therapy? What was their experience of previous therapy? What was helpful and what wasn’t? Have they used any self-help methods?
Goals. What are the client's goals for therapy? (I suggest the client identifies between three and five goals.) Are these goals realistic? How motivated is the client to make changes in their life? How will they know when they have achieved their goals?
Lifestyle and psychosocial factors: What is the client's sleeping pattern? What is the client's diet? Do they engage in regular exercise? What is their typical weekly alcohol/recreational drug consumption? What does a typical day look like for the client? Do they have a support network? Do they have long-term friendships or relationships? Are they experiencing any relationship conflict either in their family, with friends, or at work or school?
Life history: How does the client describe their childhood and adolescence? What was school like for them? What are the major life events or significant events or periods of time in their life? Have they ever experienced anything traumatic? Did anything happen in childhood or adolescence which might be considered abuse? Where clients disclose trauma, I also use the PCL-5 measure to identify trauma symptoms and as part of a trauma-informed approach (see Point 58).
Mental state. How did the client tell their story? Over-detailed? Impressionistic? Vague? What were the client's gestures? Was the client smartly dressed? Did the client appear not to be taking care over their appearance? Did the client seem focused or were they easily distracted and confused? Was there any agitation? Is there a slowness or a flight of thought? Is there a flatness of mood, or extreme emotional lability?
Attachment style. What is your impression of the client's attachment style? Secure, avoidant, ambivalent or disorganized? What do you provide as evidence of this? What do you imagine the impact of this will be on the development of the working alliance? How does this impact upon your treatment planning and approach to therapy with this client?
Obstacles to therapy. Ask the client how they might potentially sabotage their therapy. What do you anticipate problems in therapy to be? Are there features of the client's presentation or perspective that may pose problems in the therapy process? Are there external factors that may interfere with the therapy?
Expectations and preferences. What are the client's expectations of therapy and the role of the therapist? What is the client's expectation regarding the length of therapy, and their engagement in the process? Does the client have any specific preferences regarding the type of therapy they want, what they want from the therapist and what they think they need?
Strengths and resources. What strengths does the client have? What resources do they have that will be useful in the change process? This can include friends and family relationships, personal qualities, level of insight, and may also include additional factors, such as a client's economic situation (which can mean greater opportunities for change potentially available to the client). What personal qualities or perspectives does the client have that will be useful in therapy or in effecting change in their life?
Motivation for therapy. Does the client appear to be well motivated for therapy? Is the client being encouraged, coerced or pushed into therapy by someone else?
Prognosis. Taking into account the nature, severity and duration of the client's problems, and the resources they have, their level of motivation, and the level of rapport between the client and the therapist, what conclusion can be drawn regarding the expected length and frequency of therapy? Does this match the client's expectations? What will the client's problem severity be at the end of therapy, as an educated guess?
