When meeting potential new patients, one of the most common questions I often receive is “Why do I have to do an assessment? The other therapists never did one, we just got to work.” The other one is “I just did an assessment with a psychiatrist, why do I need another one?” These are fair questions, and here’s how I typically respond:
“Why do I have to have an assessment? The other therapists never did one, we just got to work.”
For some issues like marital distress or job changes, it might make sense to jump right in: it’s clear that my lying to my wife or my worry about fitting in at the new school are issues that can immediately be addressed. However, these are counseling issues, and clinical disorders are treated quite differently from a cognitive behavioral approach. Essentially, I don’t know where to start working if I don’t do the assessment to figure out not only what is, but importantly, what is NOT a problem. Honestly, most good counselors I know will also some sort of interview or gather background information to better understand why I’m lying to my wife, or what my past history has been at schools and fitting in.
Think of it this way: if I went to see my doctor for stomach pains, She (hopefully) won’t say “that sounds bad: let’s do surgery.” She’ll ask questions about when it started, how intense the pain is, what makes it better or worse, often while listening to the sounds my stomach makes with a stethoscope, and even palpating the stomach. She might then suggest a specific blood test to confirm or rule out potential diagnoses and then create a treatment plan specific for me based on what she knows about the issue I’m experiencing. If medication is involved, she’ll have to take in consideration my sensitivity to medication based on my gender, age, weight and other factors.
We do the same thing, but rather than a physical exam and blood test, we use an assessment battery. Our primary tool is the Anxiety Disorder Interview Schedule (ADIS-VL by Brown and Barlow), which allows us to thoroughly examine Anxiety, OCD, Mood, Trauma and Substance Abuse Disorders, while also screen for other commons issues that we see, such as personality issues and pervasive childhood disorders like autism spectrum disorders. We’re also able to utilize disorder-specific tests, and clinical interviewing techniques to suss out other issues.
If we don’t complete a battery of tests to understand what the issue is, we may end up treating something that isn’t the actual issue. We hear “I’ve been diagnosed with OCD” or “I read online and I know I have OCD” However, without a detailed differential diagnosis, OCD can be mistaken for Generalized Anxiety Disorder (worry about many different issues without a compulsion) , a Specific Phobia (fear of vomit rather than contamination), Obsessive Compulsive Personality Disorder (not one area of worry, but a desire to control everything in life), or behavioral issues (acting out when not getting one’s way). We not only need to make sure it’s OCD, but even within that diagnosis, we need to understand when it started, how it’s changed over time, how much insight (or lack thereof) the individual has, and how often he or she can resist engaging in the compulsion. Without this level of detail we cannot develop a treatment plan for the patient. We don’t want to develop a plan along the way: it’s just not efficient, much like starting surgery without knowing exactly what the issue is.
“I just did an assessment with a psychiatrist, why do I need another one?”
A psychiatrist’s role in the treatment of a psychological disorder is different from the psychologist’s, and thus has a different assessment. The psychiatrist typically is trying to determine what medication would be most efficacious, often an SSRI or SNRI if it’s an anxiety, mood or OCD issue. A psychologist needs a more detailed understanding of thinking patterns and behaviors to determine a more detailed plan of treatment that involves challenging irrational cognitions and changing maladaptive behaviors. A parallel could be a school counselor helping a student choose courses to best get into college while a math tutor is interested in specific strengths in weaknesses the student has in trigonometry. Each person has a role that is useful, but they aren’t the same.
While it’s understandable that patients get frustrated at the time and cost involved in yet another assessment, once we begin the assessment process, they quickly understand why it’s necessary. Many patients ask why others don’t do it after we complete it, as they have a better understanding of their issues and how it affects their lives, and most importantly allows us to put together a treatment plan specific to them.