Note: This article was originally published in Substack on 05 Apr. 2024
Why I Don’t Do a “Thorough and Structured” Intake.
by Jimeion Muecke.
In my previous post, I spoke a little more about my relationship with trying, as a therapist. More specifically, how do I try to help my clients? The answer: I have put a huge amount of energy into creating systems that strengthen and protect the therapeutic relationship as much as possible, especially in the infancy of a clients therapy.
At a time when the therapeutic relationship is most fragile.
That previous post carried an undertone, I think, that we should be trying. I’m not sure I made clear why I believe that though, which is what I want to share here.
Should vs. Could
At the outset of the client’s therapy journey, there’s a substantial need to enhance our efforts in building the therapeutic relationship. Why? I think it’s too easy to start therapy the way we’re told and taught we ‘should’, which can be at odds with what a client wants and needs.
A prime example is how I hear most therapists treat the initial session as “assessment.” The effort is to gather a broad and thorough picture of the clients present life and history—across many life domains—the more the better. It’s an understandable approach. We want to appear professional, knowledgeable and structured. Plus we don’t want to miss anything important.
Just so you know, I’m talking out of experience here. I previously worked at an NGO, an Australian not-for-profit early intervention service for young people (Albeit a brief stint. I was actually fired). They were (and may still be) the absolute masters of ‘assessment’ sessions. When I was there, we used an assessment template called HEADSS, you can google it if you’re interested. It stands for:
- Home
- Education, employment, eating and exercise
- Activities and peer relationships (inc social media)
- Drug use
- Sexuality
- Self-harm, safety and spirituality
To get through HEADSS with clients, we were given 1.5 hours at the first meeting. I realise now that this was more for the clinician, not the client.
In team catch ups, we spent more time talking about how to get through HEADSS more efficiently, and about interventions, instead of how to better connect with our clients.
There are some obvious benefits with such a thorough and structured interview template. You would clearly hit on some important information in running through it with clients.
In reality, it was a bit of a nightmare. There was heaps of anxiety to get all the information in the allotted time—the damn thing had to be printed on about 6 pages of paper.
Clients also understandably jump around to different topics—how dare they not follow the template? Obviously, a true deep connection with those clients was near impossible; I was half-focused on the paper and half on them. On top of that, I’m having to ask them things that have no significance for them, e.g. why do I have to tell you about my drug history when I’m here to talk about my crippling anxiety and need help.
To me, it’s an example of therapy being done to clients, not with them.
Going further, this will make some of you cringe. I almost never do genograms with clients or explore their family tree. I’ve done something similar only a handful of times in my entire career, times when it was clear to me that understanding those relationships was integral to my client.
Previous Contributions:
At What Cost?
Again, I get it. We don’t want to miss something potentially important, so we use these structures. But at what cost? The cost can be at the very thing that will help clients actually get better, which is a deep therapeutic relationship that attends as closely as possible to an individual’s wants and needs.
We all like to talk about doing it, but how well are we actually achieving it?
We love to talk about building trust with our clients, but how well do assessment sessions do that? At a time when trust is at its weakest, are assessments the best that one can do? I don’t think so. To me, assessment sessions are actually more likely to erode trust.
I know we don’t want to miss anything important, but in being so pre-determined and thorough in what we ask clients we could be saying, “Hey, I’m sorry, but I don’t trust you to tell me what I feel like I need to know, so I’m just going to ask you about everything – is that ok?”
I know we do it with warmth, kindness and genuine care (hopefully), but we can still do better…
Trust Your Clients
How I operate now couldn’t be further from those heavily structured HEADSS assessments. I almost never have anything pre-determined to ask clients. I trust them to tell me what they need me to know. If it’s that important, they will tell me. If they don’t want to tell me, hopefully they will when they are ready. If they want to but can’t tell me, hopefully our conversations will help them ease them into sharing them.
In short, come on people, trust your clients. Don’t do an assessment to ask them everything, just because you were told you should or to play it safe. The client hasn’t played it safe to come and be vulnerable with you – the least you can do is trust them in return.
P/S: I know I really got on my high horse for this one, but this is one of those things I’m really passionate about.
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