| Decisions in mental health treatment are often | | | | Nonetheless, he agreed to meet with me regularly and |
| relatively subjective and clinical judgment is prone to | | | | then as we worked further, and as I became |
| errors. But must it be that way? | | | | concerned that his problems might have a biological |
| There is a solution, but, since this problem | | | | basis, to undertake neuropsychological testing and a full |
| characterizes all of our work, finding it can be | | | | neurological workup. In fact, since he suffered from |
| challenging. To start with, the clinical decision maker | | | | headaches, with the neurological workup he wanted an |
| and the subject are both human beings, their reactions | | | | MRI of his brain done. |
| eluding any "empirically supported" treatment protocol. | | | | Why go to all this trouble and expense in assessing |
| For example, the difficulty in arriving at an effective | | | | this relatively ordinary case? Typically someone like |
| treatment plan is compounded by variations in the way | | | | Owen would be swept into a once weekly treatment, |
| mental health labels are understood by a clinician. | | | | possibly emphasizing CBT. The initial cost of these |
| Consider depression. When clients describe | | | | evaluations, without including the cost of |
| themselves as “depressed,” how do we know | | | | psychotherapy, was to be about $3000. Using the |
| exactly what they mean? For one, “depression” | | | | bare bones approach, minus the testing and |
| may represent momentary discouragement. Another | | | | neurological workup, we could infer that Owen |
| may be suffering from a relatively fixed biologically or | | | | suffered from ADD and executive function problems. |
| personality disorder-based dysthymia. A | | | | But would that be the whole picture? |
| practitioner’s choice of treatment | | | | The initial clinical assessment allowed me to start |
| strategy—psychotherapy, medication, or | | | | Owen on ADD medication while the full evaluation was |
| both—hinges on her or his impression of the etiology | | | | being conducted. The neurological examination showed |
| and character of the client’s depression. | | | | entirely normal results, as did an MRI of his brain. To |
| To reduce this margin of error, together with | | | | further assess the cause of his headaches, he also |
| colleagues at the Center for Collaborative Psychology | | | | had his cervical spine X-rayed. The results, again, were |
| and Psychiatry in Kentfield, California, I have evolved | | | | entirely within normal limits, leaving the source of his |
| an approach that improves accuracy in assessment | | | | headaches obscure, most likely anxiety-induced. |
| and treatment. This method emphasizes methodical | | | | Neuropsychological testing underscored the |
| fact finding, a careful clinical evaluation, the use of test | | | | seriousness of Owen's combined ADD and |
| data whenever possible, and continual feedback | | | | temperamental idiosyncrasy. While irritability is |
| between the therapist, client, and, at times, significant | | | | frequently associated with both childhood and adult |
| others. Clinical progress is carefully monitored and | | | | ADD, further testing was eventually needed to fill in the |
| revisions of the treatment undertaken as needed. We | | | | blanks about Owen's diagnosis. |
| call this model “collaborative” to underscore the | | | | Six months later a supplementary set of psychological |
| centrality of the alliance between therapist and client | | | | (personality) tests were done, in part to track Owen's |
| and, in the case of children and adolescents, between | | | | progress. My colleague, Philip Erdberg, conducted these |
| therapist and parents. Whenever possible there is a | | | | and joined our treatment team as the "third member," |
| third member of the treatment team, a | | | | mentioned above. His unique take on the situation, |
| psychologist-assessor, who performs an initial | | | | building on the neuropsychologist's, emphasized Owen's |
| psychological or neuropsychological evaluation of the | | | | intelligence and creativity. Owen craved constant |
| client. Abbreviated assessments are repeated at | | | | stimulation setting up a vicious cycle: he'd get bored, |
| intervals to follow the client's progress. | | | | seek novel situations, get bored again, and so on, |
| Perhaps you are thinking, “All well and good, but can | | | | becoming progressively more unproductive. Even if I |
| my clients afford these enhancements to | | | | were able to engage Owen in understanding and |
| treatment?” And you may be concerned that | | | | finding alternatives to this habitual pattern, there was |
| incorporating a third person into the treatment team will | | | | every reason to expect that his proclivity for bailing out |
| interfere with the treatment alliance. Further, what if the | | | | of situations would be repeated in our work together. |
| client becomes skeptical about the therapist's clinical | | | | So, I had to be especially creative in strategizing our |
| opinions, preferring the psychologist-assessor’s | | | | work. I also collaborated with Owen's parents, guiding |
| findings to the therapist's? | | | | them on how to manage him. |
| While, of course, these issues arise, at the Center we | | | | As we worked with his ADD and executive function |
| have almost always been able to use them to our | | | | problems, Owen agreed to ten to fifteen sessions of |
| clinical advantage. In the sixty-plus cases we have | | | | behavior training with a psychologist who specialized in |
| completed, this third person, when properly trained in | | | | ADD. Cognitive-behavioral interventions helped him |
| our collaborative technique, has virtually always made | | | | learn to sit still and deal with his impatience. Owen also |
| the treatment stronger. And, we have found that a | | | | needed encouragement, in the form of confirmation |
| third, consultative presence usually helps keep the client | | | | that indeed he was a fish out of water and would |
| in treatment. | | | | have to stretch to comprehend and reach others who |
| Money is an individual issue, but we believe that if | | | | were not as smart and creative as he. Since Owen |
| treatment is supported and focused by good | | | | said he wanted to have friends, he acceded that |
| psychological assessment, it will likely prove less | | | | adjusting his attitudes and behavior should be worth |
| expensive and more successful than one initially guided | | | | the effort. |
| only by subjective clinical impressions. | | | | Of course, we could have done an assessment with |
| Consider the following case: | | | | no bells and whistles, no neurological or |
| Owen, 22, is bright, maybe brilliant, but moody and | | | | neuropsychological assessment, no extension of |
| remarkably stubborn. Awkward and disheveled, picture | | | | testing. But since everyone was exasperated with |
| him in a Parisian garret drinking absinthe and talking | | | | Owen, a diagnosis and a “fix” were needed. I |
| philosophy. Despite enormous potential, Owen wallows | | | | believe the extra expense of the neurological and |
| in a puddle of mediocrity. He falls in love hard, but | | | | psychological workups was more than justified—as |
| relationships don’t last. Owen’s parents, two | | | | a result, we knew exactly what we were treating. |
| straight-arrow accountants, inevitably compare him to | | | | Hence, we could tailor the treatment and its |
| his older brother, a Harvard graduate bound for | | | | interpersonal and behavioral components precisely to |
| medical school. They unremittingly focus on | | | | Owen's needs. No wasted effort, money, or time. |
| Owen’s professional success, finding his unique | | | | There you have it: a procedure that includes careful |
| needs and idiosyncrasies difficult to understand. | | | | assessment and in this case psychological testing, a |
| Owen was referred to me after being expelled from | | | | medical evaluation, ongoing formal evaluation of |
| college for the second time in three years. A year | | | | progress, and structured collaboration between client |
| earlier an incident of drunken rowdiness ended his stay | | | | and practitioner. I believe this assessment and |
| at an excellent California university. He then managed | | | | treatment procedure is more accurate and reliable |
| to transfer to a rigorous private college where he | | | | than the strategy we psychotherapists typically use; it |
| failed to do his schoolwork. By the time of referral, his | | | | is ultimately also likely to be more cost effective. True, |
| parents were so perplexed they were willing to let me | | | | I'm a psychiatrist, but so much of what I do is |
| “do anything" to help. | | | | psychotherapy. I doubt that differences between our |
| I arranged to meet with Owen's parents and then | | | | disciplines should modify the recommendations I have |
| Owen. As his parents had warned, Owen was moody | | | | made. Given the subjective nature of our work, I |
| and reluctant to receive help. “Nothing was | | | | believe that any movement toward therapist accuracy |
| wrong,” he insisted, "outside of my parents' | | | | and accountability for treatment results should be |
| heavy-handedness and excessive worry." | | | | welcome. I hope you come to share that conviction. |