Assessment, treatment plan and therapy contract

The process usually begins with a series of thorough assessment interviews so that the problems causing you distress can be identified. This usually takes from 2 to 6 hours. Here are some of the questions you may be asked:

  • What kind of difficulties are you experiencing: Behavioural? Emotional states? Physical symptoms?
  • When did the problem start? Can you identify a specific event which marked the beginning of the problem?
  • What made you decide to come for therapy?
  • Have you experienced this type of problem before? Have you been treated for the problem before?… Did it help?
  • Do you currently take medication for anxiety or depression or other psychological problems?
  • Do you use substances like drugs or alcohol to alter your mind state or mood? If so, how much and how often?
  • Do you have any physical symptoms that might indicate that they have a physical illness?
  • Have any of family members had psychological problems (depression, anxiety, suicide attempts, breakdown, dependence on alcohol or drugs)?

You are also likely to be asked about your history, education, experiences in the family of origin and at school, work experiences and status and important relationships.

You may also be given some written questions to answer which will provide information about your symptoms and psychological state.

Through all this, the clinician aims to arrive at an understanding of the nature of your problems and why you have the symptoms they are experiencing. This includes an understanding of:

  • Predisposing factors – Aspects of your personality and events in youir personal history which have made you vulnerable to developing this particular problem.
  • Precipitating factors – A particular stressor (such as a job loss or a bereavement or an assault), a change of life circumstances (moving to a new job, having a family), or an accumulation of stressors over many months, can result in the development of severe and distressing symptoms.
  • Maintaining factors – Once symptoms develop, the way we cope with them and adjust to them may maintain them. Depressed people may feel that no-one is interested in them and withdraw from friends. The absence of personal contact and social support makes them more depressed. Socially anxious individuals may think that others will be critical or mocking and avoid or reduce their social contacts. This increases their fear of social situations. The bulimic feels relieved that by vomiting she can get rid of food after a binge and this actually makes her feel safer about binging and therefore more likely to do it.

The therapy contract

At the end of the assessment the therapist will discuss with you his or her understanding of the main problem areas, how the problems developed in the past and how they are being maintained in the present. On this basis the therapist will describe the kinds of intervention that are likely to be of help, what you yourself will be required to do to participate in the interventions and how many sessions of therapy are likely to be needed. If you do not understand or agree with the therapist’s conclusions about what the main problems are, you should discuss this in detail. Similarly, if you they have any questions or concerns about the expected length of the therapy, you should raise these and discuss these carefully.

A commitment to best practice is part of the ethical code of health professionals registered with the Health Professions Council of South Africa. This means that therapists keep themselves informed about the latest research about the kinds of intervention that have been shown in research trials to be most helpful for the kind of problem they are seeking treatment for. On this basis they can recommend the kind of intervention that is likely to be suitable for each client.

Treatment may be based on a shorter term cognitive-behaviour therapy approach where the main focus will probably not be on the past but on what is happening in the present. However it may be important to go into some past events if they are still troubled by painful memories of them, and sometimes an understanding of what went wrong in the past can give they direction towards a better future. For more complex problems and ones that have not responded to briefer forms of intervention, the therapist may recommend schema therapy where there may be more of a focus on memories from childhood and the self-defeating patterns that these give rise to in the present.

Next – Cognitive therapy and CBT