Reassessing ‘assessment’

One of the side effects of having more time than I used to is that I begin to brood over the meaning of the words I once used without a second thought. It particularly happens on long walks without the running commentary of the radio. In a recent bIog I talked about ‘recovery’. Now I’ve started to think about a word I would never have given much more than a second thought too as a working psychiatrist- ‘assessment’.

The problem with many words in mental health is that they can begin to assume alternate meanings. Use of the ‘active’ and ‘passive’ tense can be important too in conveying a sense of who has the power. There is something very passive about being ‘counseled’ and the act of counseling has itself taken on various meanings from receiving counseling as ‘therapy’, wise counsel as ‘advice’ and being ‘counseled’ as a form of disciplinary act.

I don’t remember as a psychiatric trainee being specifically trained to carry out a ‘psychiatric assessment’. I was taught how to master a psychiatric interview, which considered of ‘taking the history’ (which can sound and feel rather like a rather one-sided action on the part of the doctor, removing something from the patient) and carrying out a mental state examination. I soon learned that for the interview to be effective I had to spend as long actively engaging the patient in thinking I was a person with whom they would be willing to share their experiences, as asking all the questions that psychiatrists are (in)famous for. Later on, I began to research how both GPs and psychiatrists approach the ‘consultation’ as the meeting between professional and patient is commonly known in primary care. Indeed actively ‘consulting’ the doctor conveys more power to the patient than being interviewed or assessed by them. I spent hours, days and weeks observing interactions for my research. I remember the patient who, when asked by the psychiatrist whether he knew if he had had a traumatic birth quite reasonably replied ‘well the Battle of Britain was on at the time doctor’.

Somewhere along the line, the psychiatric interview or consultation became the ‘assessment’ with a list of questions to ask the patient. Changes in the examination system of doctors reinforced this, with the shorter structured OSCEs (Observed Structured Clinical Examinations) with role-played patients, that are probably fairer to the candidates, but reward marks for asking the ‘right questions’ when ‘assessing depression’, ‘suicide risk’ or ‘hallucinations’. I’m as guilty of this as anyone. I teach suicide risk assessment skills. The blurb for my latest book on depression mentions assessment too.

So what’s the problem I have with assessment? Well, when a person assesses another they are implicitly making a judgment about their suitability for something or their ability to achieve particular goals. As a patient I have been assessed for therapy. That’s fair enough perhaps when there are indications as to whether or not a person might benefit rom that intervention. Psychologists regularly carry out assessments perfectly reasonably as not everyone will benefit from their specialist expertise. But how often is this mutual assessment? Are you a person I could talk to?

And so often now I see mental health assessment as a tool to exclude rather than seek to help a person find the help they might benefit from. Its more ‘this person isn’t psychotic or actively suicidal so there is nothing we can offer them’ rather than, ‘this person is consulting me. They are extremely distressed. They don’t understand what is happening to them. How can I help them?’ In our increasingly fragmented health care system everyone is carrying out assessment according to their particular ‘criteria’ while the service user understandably feels they have been ‘assessed to death- when is someone going to help me?

Can we move away, in mental health care, from this culture of assessment back to one of a consultation, which David Tuckett and his colleagues first described many years ago as the ‘Meeting Between Experts’?

I am the expert in what I am experiencing. You are the expert in what might be effective. In consulting you and providing you with all this very sensitive information about my inner life, I’m an trusting that you as a professional will be able not only to say if you will be able to help me personally, but also that you will do your best to help me access what I need.

I really need your assistance now to navigate this increasingly hostile system of care. I am asking for your help.

8 thoughts on “Reassessing ‘assessment’

  1. JL says:

    Another good one Linda.
    Have I been assessed to death – oh yes. Few weeks ago saw psychiatrist in medical hospital at 3pm. Section 136 in the evening full m h assessment about midnight. Assessment becomes pointless when someone like me although acutely distressed still knows what not to say or how to duck the question (expert at this). Your italics at the end sum it up perfectly – all I want is to be really listened to (does it really matter about my clothes?) and I want you to help me in the best way you can. If I say I feel suicidal believe me, I’m not attention seeking and I don’t appreciate being shown the door and having to walk 5 miles home at night. When I need help in making a decision it will be obvious and I might even say ‘I’m all over the place please help me’ but it should be a meeting between experts. I like that and shall use it next time!!

  2. elvis jones says:

    I have had many consultations with several psychiatrists in outpatient and inpatient settings. Problems were clinical anxiety, clinical depression and emotionally unstable personality (as they see it!).

    I am puzzled by on the one hand a (supposed?) concrete thing eg. Depression, and how it relates to decisions, events, circumstances, relationships and contexts. I am worried that assessments miss the vicious circles, or poor decisions, taken by me, which maintain or even worsen my problems making further treatment with drugs necessary.
    I am sorry I can’t be more helpful.

  3. shrinking81 says:

    My new favourite phrase to describe clinical meetings, or assessments, is “constructed reconstruction” – I think this nicely conveys that this is an active process of developing meaning and understanding between two people working together.

  4. elvis jones says:

    Treating problems is an intolerance of them, and an intolerance of human life. Exploring problems is an acceptance of what it means to be human, terrible though that may be sometimes. Needless to say, the former approach does not lead to personal reintegration.

  5. tulikajha says:

    Thanks for this thought provoking piece. ‘Assessment’ seems to have become synonymous with triage and onward referral at various points of access to mental health services. It can seem to be focussed upon eliciting exclusion criterion for the service the patient is presenting to …it might as well be a flow chart for eg:
    GP refers on if pt suicidal . SPA ‘assesses’ and refers to CMHT who assess and refer for eg to psychology who assess to refer to a certain type of therapy …then do they get assessed again?
    Within the restraints of austerity, numerous restructuring and renaming of the teams and services , can we ‘engage’ with our service users in a meaningful way during these so called assessment meetings so that this experience ( regardless of what we call it) in itself can become therapeutic ?

    But what about the service users who demand a diagnosis and treatment and would prefer to be assessed and examined ?

    I had chosen psychiatry because it promised an environment of curiosity and a collaborative search for meaning behind each ‘symptom’ rather than performing a tick box exercise of symptom checklists . The electronic patient records have little space for free text…perhaps this is very symbolic of the move away from engaged alliance and towards ‘assessment’.

    It’s all too easy though to adopt a powerless position in the face of poor resources and entrenched culture . Can we start perhaps with being mindful of the dynamics within each of our assessments ? Are we just ticking boxes or do we have a sense of ‘the person ‘ we are sharing the space in our office and in our minds with ? If the other person feels understood , does it matter what we call that meeting ?

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