Academic journal article American Journal of Psychotherapy

Assessment of Suitability for Psychotherapy

Academic journal article American Journal of Psychotherapy

Assessment of Suitability for Psychotherapy

Article excerpt

Part II of this paper presents an outline for the assessment of suitability for psychotherapy based on the patient's ability to participate in the basic tasks of the therapeutic process and provides a coherent approach to this complex and difficult task. Several factors, such as therapeutic interaction and relational history, influencing the patient's ability to form a productive working relationship can be assessed clinically and are well supported by research. Others, such as motivation and supportive life circumstances, although less supported by research, still appear to be clinically important. Influences on the ability to create a model of the patient's psychopathology, such as introspection, circumscribed focus, and some aspects of the model itself, are supported by limited research but important for some therapies. There is little research on trial interventions, though these remain a crucial assessment dimension for short-term therapies, particularly. Countertransference, although traditionally not viewed as part of assessment, is actually an important tool that has been validated by research.

Part I of this paper outlined the value of careful psychotherapy-suitability assessments, and described a process involving the traditional history and diagnosis, the creation of a model of psychopathology, and evaluation of the patient's ability to engage in the therapeutic process. Part II discusses this third component in detail, structuring the discussion around the basic tasks of the therapeutic process (1): productive working relationship, patient-model factors, trial interventions, and countertransference.

PRODUCTIVE WORKING RELATIONSHIP

The patient's capacity to form a stable and viable working therapeutic relationship began to be recognized as an important predictor of outcome in the psychoanalytic literature of the nineteen-sixties and seventies (2). It became a central suitability criterion for brief psychotherapy, where the therapeutic alliance must be established rapidly, there are limited opportunities for it to develop, and the patient must also be able to disengage rapidly (3).

A number of assessable factors will influence the formation of this relationship. Motivation affects the patient's use of the relationship as a vehicle for learning in the treatment (4). Direct assessments of the quality of the therapeutic alliance and evaluation of the underpinnings in the patient's relational history are also valuable. The patient's life circumstances may determine whether they can maintain the therapeutic relationship, so it is also included in this category.

MOTIVATION

Motivation has traditionally been important as a criterion of suitability though the supporting research has not been consistent. It is a complex, multidimensional construct which includes the motivation to change, the capacity for insight, self-understanding, and active participation. Aspects, such as willingness to make sacrifices, the initial level of distress, the desire to relieve suffering, secondary gain from the illness, taking personal responsibility, realistic goals, positive expectations of therapy, and the curiosity to understand oneself, seem conceptually related and are often included. Two additional factors, less clearly conceptually related, are psychological-mindedness and honest communication (2,5). Cognitive therapists use some similar ideas to assess suitability, though they do not categorize these as part of the motivation construct. This includes accepting personal responsibility as an active agent in the change process, using the therapeutic relationship as a vehicle for self-exploration and viewing the goals and tasks of therapy as relevant (6). There is little agreement on the meaning of the term, and many researchers have defined it so broadly that it becomes synonymous with suitability. It seems difficult to rate reliably, particularly in patients with personality disorder who are difficult to assess regarding their motivation to change (7). …

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