Monday, 23 February 2015

The vicissitudes of therapeutic assessment

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

Whether it is an assessment at school, university or at work, or by a medical specialist or other expert, the question always is also: “do I feel seen as a person?”
It is in the nature of assessment that a supposedly uniform, objective set of criteria gets applied to us, raising the question as to whether our subjective sense of self is being recognised, taken into account and appreciated in the assessment.
This tension between an objective, outer description versus the subjective 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.
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. However, the longing to feel deeply seen and met in our unique subjectivity – with all our flaws, wounds and potential – is just as present.
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 as well as afraid of it or resistant to it?

On the level of the words and explicit communication, the client may be asking whether they are indeed a borderline, or a manic-depressive or whatever label they are fishing for, and these are - of course - legitimate questions. But implicitly, there may be other questions which would simultaneously be asked and answered: "am I hopeless case?" "is it all my own fault?' "is my pain real?" "did I bring this upon myself?" "am I just being a bit lazy or stupid, when really I should pull my socks up?" Whose questions are these? Whose opinions and perceptions are we confirming or opposing?
The presupposition of such questions is that the problem rests in one individual (usually presumed to originate in some genetic disposition or biochemical given) - there is very little room for exploration of the possibility that 'the problem' may be co-created, that a family's biochemistry is interwoven with each other and that the symptom may be systemic and not reducable to one pathological individual. These kinds of considerations are already ruled out by the way the questions get asked, creating dilemmas for the therapist who rightly finds it impossible to give straight 'yes' or 'no' answers to them.
Therefore, what is omitted in this assessment set-up is the recognition that the question lies in the eye of the beholder - and not just the therapist, but also the client's internal and external beholders, observers, judges who constitute the intersubjective context in which the client is being pathologised. This intersubjective field exists long before the therapist is asked to step into it and perform the assessment, which can therefore never be 'objective' and 'neutral'. A good therapist doing an assessment perceives, responds to, takes into account this pre-existing field of opinions and judgements and identifies with or against them, creating an intersubjective entanglement which underpins any attempt at 'objectivity'.

The therapeutic professions have not entirely emancipated themselves from the idea that impersonal objective assessments - in and of themselves - are either possible or useful. However, our therapeutic principles and understanding tell us that “it is the relationship that matters”. Therefore, the heart of our work depends on our subjectivity – 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.
Any supposedly 'objective' assessment is situated within and contextualised by the intersubjective relationship in which it occurs - whether the supposedly 'objective' facts or 'truths' are helpful or not does not mainly depend on the information that gets imparted in the assessment: the effect of the assessment depends on the relational dynamic within which it is delivered.

The same thing is true, of course, in our training as practitioners: many students who enter counselling or therapy training of some form or another regress back to school, assuming that success depends on similar principles and therefore take refuge in similar roles and survival mechanisms (becoming good, cooperative pupils or delinquent, protesting renegades, or anything in between).
This kind of transference which a student brings to their training is not dissimilar from the kind of transference that occurs in therapy: the same schemas, scripts and adaptations which we developed in school become reactivated in training. And to some extent the success of any therapeutic training depends upon the degree to which 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 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 a standard academic paradigms, even if that does include some experiential process and practice.
What we notice in supervision is that many therapists arrive in 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, inhibiting and deferential 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 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.
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 and imposed from other scientific disciplines and educational paradigms.
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 capacity to be 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.
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 idea acquire in this particular relationship, knowing full well that these same ideas can have a completely different relational effect and meaning with somebody else.
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: “the intimate edge”).
The client can legitimately expect at least three aspects from an assessment:
– the therapist’s expert judgement as to whether therapy would be suitable, productive and 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

In offering a training day on “First Sessions and Initial Assessments”, these are some of the ideas and dilemmas we want to explore.

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