Carvalho-2016-About Assesment

British Journal of Psychotherapy 32, 2 (2016) 237–255 doi: 10.1111/bjp.
12210
Teaching and Learning
ASSESSMENT: A PERSONAL OVERVIEW
RICHARD CARVALHO
The author offers personal rather than scholarly reflections on the

sometimes difficult process of assessment. He discusses aims of
assessment which include risk assessment, and an assessment of the
prospective patient’s ability to engage in the therapeutic process as
indicated by their engagement with the assessor’s interpretive remarks,
albeit oppositionally or defensively, and whether consciously or
unconsciously. Implicit or explicit in this engagement will be the issue of
the patient’s habitual ways of relating, the transference. Consideration is
also given to how we can evaluate the nature of the patient’s motivation,
not only with regard to insight and change, but also to dependency
and malignancy. The issue of treatment choices is discussed, along
with the desirability of any management decisions being offered as
interpretations. The author also addresses the issue of note and record
writing in the light of the scope this gives for countertransference
enactment, as well as the issue of what records are kept for what
purposes and of how and when these are communicated to GPs.
Vignettes illustrate some of the difficulties and pitfalls of the process.
KEY WORDS: ASSESSMENT, ABILITY TO ENGAGE, MOTIVATION,

TREATMENT CHOICES, RECORDS, VIGNETTES
INTRODUCTION
What follows are personal reflections on my experience of nearly 40 years of assess-
ment. The article was written for the introductory seminar in an assessment course set
up by the Society of Analytical Psychology, essentially as a conversation piece;
whence the deliberate informality. I have deliberately not attempted an exhaustive
review of a large and rather variegated literature, so that there are extensive omissions
in what I do quote, including such classics as Coltart’s (1987) and Hinshelwood’s
(1991) helpful papers. Assessment is a fraught subject, about which there is a surpris-
ing lack of agreement. Difficulties start with the word which can feel threatening and
may suggest being weighed in the balance and found wanting, an impression which
may be reinforced where we may be weighing up the likelihood of a person being a
‘suitable’ candidate for trainees whose interests we want to protect, or for a scarce
NHS resource. So how might we get round this?
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238 Richard Carvalho
We need to frame the idea in our own minds by connoting it as the patient’s assess-
ment, with our help, of their own situation, of what it is which has brought them to the
very difficult decision to consult a perfect stranger in the hope of help, with all the
potential social and personal shame that can be elicited by revealing a vulnerable self
which the individual may fear is unedifying. We might hope that an assessment is a
sort of taking stock. We are trying to help the patient to think about themselves. We
also need to help them at some level to be aware, if we are to be their therapist, that
they need to be assessing us. Not every couple works or gets along, and we need to
match our prospective patients’ vulnerabilities and weaknesses with our own and
those, where possible, of our colleagues, junior or senior.
In order to facilitate this, we need to make the event into a genuine meeting of minds,
one in which what Stern and others have called ‘moments of meeting’ are possible
(Boston Change Process Study Group, 2010), so that the prospective patient feels prop-
erly met and understood. This is so that the couple involved can then come to a conclu-
sion together as to what it is the patient feels their difficulties consist of, and what sort
of treatment, if any, might best help them, without prejudice. There may be many pres-
sures upon us to come up with a particular decision: referring GPs or psychiatrists may
communicate an urgency to help a patient whom they are afraid to fail; we may wish
not to let down a colleague, especially one who is senior; the clinic may need patients
for its trainees; or there is the contrary temptation of making the assessment into a hur-
dle to be cleared on behalf of trainees who need ‘suitable patients’ (Crick, 2014); and
then there is the prejudice that one particular modality of treatment is necessarily pref-
erable to another: we need to match the skills and personalities we or our colleagues
have to the specific help our patients need, skills we may not be in a position to offer.
Agreement between assessor and patient is obviously an ideal scenario; there will
inevitably be occasions where we find ourselves in an oppositional interaction in
which ‘moments of meeting’ are very hard to come by; and where there are moments
of meeting, the patient may then be faced with what feels like a wrench where, having
made contact with the interviewer, he or she has to exchange the contact they have
made with the assessor for another individual. This can happen however careful the
assessor is, and however carefully expectations have been managed before the inter-
view. This is not simply a matter of the transference, but of an engagement which it is
painful to break when it has been good.
AIMS OF ASSESSMENT
Assessment is pretty straightforward when it doesn’t matter; but when it really mat-
ters, it can be very difficult. It has essentially three purposes.
Risk Assessment
The first is to reasonably assess any potential risk which might suggest that psycho-
therapy could be dangerous to the patient, his or her family and friends, the public or
even the therapist/analyst. It is important to be aware that occasionally there are
important signs that one should not engage a patient, that there may be risks attached

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British Journal of Psychotherapy 32, 2 (2016) 237–255
Assessment: A Personal Overview 239
to the undertaking of psychotherapy, and that some individuals need either another
modality of treatment altogether or no treatment at all.
To Assess the Capacity to Engage

The second purpose is broadly to evaluate the patient’s capacity to constructively
engage in the process of psychotherapy: can the patient engage creatively and con-
structively with interpretation, including observations about the transference. It is
also important to be aware of the possible motivations for psychotherapy, that not
everyone is motivated either benignly or for change. If there is a reasonable degree of
engagement and motivation, we need to be aware of the sorts of interpersonal and
technical demands the patient makes on us. This has obvious importance when
assessing for a clinic serviced by trainees or inexperienced therapists.
Treatment Options
Finally, in the light of these considerations, we have to make a judgement as to how a
patient might best be helped, whether by psychotherapy of whatever modality, by
some other type of help, or by being encouraged not to seek help.
So assessment has two aims which may sometimes seem conflictual: the first has to
be to ensure there is no reason to suppose that psychotherapy in any of its forms is
contraindicated; the second is to engage the patient in a process which tests his or her
capacity to engage. How these contradictory aims can be reconciled will be an impor-
tant consideration of this paper, though to my knowledge, it has never been satisfacto-
rily resolved.
We need to have in mind all the above considerations at assessment so that on the
rare occasions that they obtrude, we are not completely taken by surprise, without,
however feeling discouraged. Inevitably there is a good deal of muddling through,
and sometimes, especially with disturbed patients, they are already irreversibly estab-
lished before you can decide on the wisdom of taking them on. Other issues to take
into account are (1) the method/format of assessment, (2) the choice of treatment
options, and (3) consideration about the types of notes which might be kept and con-
tact with GPs. As I say, however, the core issues are fairly simple and take up rela-
tively little pace in this presentation in comparison to the space taken up by caveats,
because neglecting them can have serious consequences, albeit relatively rarely.
THE REFERRAL
I will start with considering the referral. This is unlikely to be a formal one in private
practice, but one nonetheless needs to be in the habit of thinking of the motivation
and the dynamics behind any referral. Before we get to the initial interview, we may
have received a formal referral, especially if we work in the NHS. This may impor-
tantly reflect a dynamic between the referrer and the patient which needs to be exam-
ined in case this is one we are being drawn into ourselves. As I suggested in the
introduction, there may be considerable pressure from a GP or a psychiatrist who has
VC 2016 BPF and John Wiley & Sons Ltd

reached an impasse with a patient, so called ‘heart-sink patients’ for instance, to pro-
vide what they have felt unable to provide. This may not in itself matter, but we need
at least to be able to address it, perhaps with the referrer, and certainly with the patient
should we proceed with the assessment.
How we get our referrals will vary. Many may come as self-referrals, some perhaps
from patients who have been sent by ex-patients or supervisees. Sometimes even
referrals which come from colleagues or institutions can turn out to be problematic,
so it is very important to assess referrals wherever possible.
The following sorts of issues should make us pause for thought:
Very isolated individuals; no obvious long-term stable or sustaining relation-
ships; chronicity; unemployment – especially long-term, both of these some-
times suggesting an inability to sustain an enterprise long-term; a chronic
medico-psychiatric career; a history of psychosis; the desperation of an
uncritical referrer. Present or recent drug/alcohol addiction, suggestive of the
likelihood that conflict or pain cannot be stayed with.
None of these – except perhaps unresolved and active substance or alcohol abuse, are
of themselves reasons not to see a patient; but referral is not always a good idea; it
may be more helpful for instance to work with the GPs to help him or her to tell the
patient frankly that while they can offer a patient no other realistic help, they might
nonetheless be able to see the patient supportively on a highly structured, time-
prescribed basis, or in the case of substance abuse, refer the patient to the relevant
services until such time as they have been free of drugs and/or alcohol for long
enough to suggest that pain and conflict can be sustained.
Another pitfall might be a referral for someone already involved in psychotherapy,
though this might not always come to light before assessment: for instance:
A man came to assessment complaining of depression, though he was not
obviously depressed when he came, and was curiously unrelating at
interview. It became clear to me that the focus of the depression was in fact
the patient’s wife who was evidently actively depressed, and that I was
blocked at every intervention. Eventually, I suggested that it was as if the
would-be patient was intent on ensuring that the interview should be an exer-
cise in sterility to prove that there was nothing to be done, and that this was
in order not to disturb the wife’s perception of herself as immutably
depressed. I said that it was as if the intent was to recruit me and any poten-
tial psychotherapist into a system in which it could be established that noth-
ing and no one could be effective in changing it, and I wondered if they
might even have already defeated family therapy. I was then somewhat star-
tled when the patient disclosed that this was exactly what the eminent family
therapist who was currently seeing the family had said very recently at their
last regular ongoing meeting.
This patient had not disclosed the fact that he was already in treatment with his fam-
ily, even though he had filled in a questionnaire for the SAP clinic which explicitly

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enquired about this. But the fact of an ongoing or recently ended or unsatisfactorily
concluded psychotherapy needs to be considered extremely carefully (see for
instance Crick [2014], where she discusses a very destructive patient who was taken
on in the wake of an unresolved therapeutic failure which was then repeated in the
next therapy).
However we receive our referrals, we need to be careful about the way we then
invite the prospective patient to the initial meeting. We need to avoid needless disap-
pointment, and to make it clear that we are meeting to try and understand together
what their needs are and how best these may be met, whether this be with psychother-
apy or some other modality; by us or perhaps by some other agency. But bear in mind
that however explicit you are about not being the person who will ultimately be offer-
ing ongoing therapy, there are patients who will not have taken this in and will wish-
fully assume you are.
THE INTERVIEW
I will start with a checklist of things we need to keep in mind and review at
assessment:
1. A risk assessment. Are there any dangers in engaging with this patient and helping
him/her engage with him/herself?
2. Are there any diagnostic categories of which we might need to beware? There
might be enduring long-term mental illness or certain sorts of personality structure
that might give us pause for thought; or organic illness masquerading as emotional
difficulty.
3. The capacity to engage. Is a dialogue possible? This may not necessarily be an
explicit one predominantly involving spoken content, but it might be one more
involving process. Is this susceptible to interpretation? Is this elaborated consciously
or unconsciously by the patient? Is it possible to explore with the patient the rela-
tionship they are rehearsing with you, the transference?
4. Willing or unwilling engagement might suggest the motivation of the patient.
Allowing for the fact that we know that all of us who enter analysis or psychother-
apy will do so ambivalently and with a view to hanging onto our habitual defensive
modes and attachments rather than relinquishing them, does the predominant moti-
vation seem to be in the direction of understanding in order to effect change; or does
it seem to be more in the direction of reinforcing the habitual defensive style, of
reinforcing what we might understand to be the predominant style of relating
according to the internal working model, which might be dependent or sado-
masochistically malignant for instance?
5. What sort of course of action (‘treatment’) do we think is most appropriate? We
have to be open to every modality of psychotherapy as a possibility (even if we
don’t know much about them), including behaviour therapy; to the idea that no treat-
ment could be the best recommendation; to the idea that a referral to a psychiatrist
or to a physician is to be recommended, in which case the GP is the appropriate
resource.

6. Meanwhile, we need to decide how we conduct the assessment in terms of what sort
of format we use, that is, a structured, semi-structured or an unstructured interview.
7. And how do we communicate our findings with the patient, not only our under-
standing of the dynamics, but also the management issues?
8. Lastly, how do we communicate our findings to the notes, and to which notes? Do
we communicate with the GP, and in what circumstances?
Spelt out as a list, these issues look deceptively neat. In practice, there is likely to be
no particular order in which things crop up, and one has to move flexibly between all
these issues. I will start with number 6 on the list, because the first decision we have
to make is how we actually speak to the patient.
Format/Method of Interview
There is no fixed rule, though I have never found structured interviews to yield infor-
mation helpful in evaluating the suitability of a patient. This is because on the whole,
they mostly deliver information about the patient, and rarely any information about
the patient in relation either to him/herself or the interviewer: there is usually no sense
of dynamic. Psychiatric or medical histories are usually of this type, although a
skilled practitioner will often conduct these in an unstructured manner.
I have tended personally always to start with an unstructured approach, very much as
I might approach any other session. Some practitioners greet the patient silently so as to
invite them tacitly to use the space projectively. Personally, I tend to greet them by
introducing myself and telling them how long we have together. I usually say something
about the difficulty of the challenge of finding some way of telling a perfect stranger
about their very personal difficulties. Some people advocate a more austere approach.
Ogden writes about an unstructured assessment session in one of his papers
(Ogden, 1989). The snag here is that even with questionnaires before the session or
with referrals from trusted sources, you cannot be sure that you might not trigger an
eruption of affect or even psychosis which cannot be managed in the session, or hap-
pen upon information which requires you rapidly to change to a more structured,
investigative tack. An example would be:
A patient who had been referred for private analysis by an experienced and
senior psychologist in the health service who was also a psychoanalytic
psychotherapist. The patient had a history of delusions in the context of a
diagnosis of a schizophrenic illness. It was the referrer’s impression that the
patient was now free of this and of the accompanying delusions. These
included his fear that he could be at risk of abusing his little nieces. At
interview, it became evident to me that this was still a very real fear. I
therefore moved into doing a mental state examination in order to explore
the seriousness of the patient’s residual illness, and abandoned the ‘process’
of an unstructured interview as unhelpful at this juncture, and as potentially
irresponsible. The patient seemed uninterested in exploring the meaning of
his delusions, and too concrete to pursue it. When I reverted to a mental

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state examination, the extent of the patient’s paranoid ideation and of his
delusional thinking became evident, and he gratefully accepted the
interpretation that what he was really seeking was a psychiatric review of his
medication which had been reduced, resulting in a recurrence of his
symptoms. He was not interested in the idea of subsequent psychotherapy.
It is important in the light of this sort of experience to think about the difference here
between an unstructured process interview and a formal one. Process tends to be
interested in content and structured formal enquiry with form. Psychiatry is usually
concerned with form or phenomenology, that is, with the formal attributes of a
patient’s mentation. It is interested, for instance, as to whether hallucinatory voices
are in the second or third person – the form – rather than the content, what the voices
are actually saying, because such differences have important diagnostic and prognos-
tic implications: voices in the third person are likely to be indicative of schizophrenia
while those in the second person of depression. Analysts are more interested in the
content. Whereas content is essential for understanding what a patient is trying to
communicate, an appreciation of form is essential for psychiatric diagnosis and has
important implications for prognosis, such as the likelihood of psychotherapy work-
ing and drug choice.
The advantage of an unstructured interview is that you offer the patient a ‘trial of
analysis’ which gives them a taste of the process – with you as an individual at least,
and your way of working, which also affords enough space for the necessary dynamic
to make itself evident between you. The risk is of inadvertently finding yourself in
something unexpected, as I described above. David Malan, in his book Psychother-
apy and the Science of Psychodynamics (1979), suggests that a way of avoiding the
risk that engaging a patient might precipitate an emergency is to start with a semi-
structured interview in which you determine initially what the current crisis is, how it
arose, and what sort of crises there may have been in the past in response to what cir-
cumstances. This permits the interviewer to enquire about the seriousness of any pre-
vious episode and to cut, if necessary, to a mental state evaluation at the time of
maximum disturbance and now in the present. Whereas the structured nature of the
psychiatric interview is somewhat antithetical to obtaining what is needed from a psy-
chodynamic interview, it is nonetheless important to respect the requisite skills even
where we don’t possess them, and to have a nodding acquaintance with what they are
concerned to find when the need arises. An excellent brief guide to these is to be
found in the Oxford Handbook of Psychiatry (Semple and Smyth, 2005 [2014]) which
also contains diagnostic information about the sorts of common conditions which
might be of concern at interview, however rarely (see below).
This obviously relates to the risk assessment to which I will come next. Such an
approach, however, does not ensure against the unexpected:
A young man was referred by a general psychiatrist who described him as very
vague and schizoid and unable to state clearly what was troubling him; but the
psychiatrist thought he might benefit from psychotherapy. At one stage in the
interview, I was struck by this man referring to his ‘scoring chicks’, in the context
of his having told me earlier about his very vexed relationship with his mother in

the absence of his father whose death from a cerebro-vascular accident he had
witnessed as a little child. Something led me to notice the ambiguity of the word,
‘scoring’, which might be understood as both ‘pulling’ and cutting. Nothing in
this young man’s history could have indicated what happened next which was
that he became frankly manic in the session, and I had a great difficulty talking
him down by interpreting the anxiety which my observing this indication of possi-
ble sadism, without spelling it out, had induced.
I should add here that there is no fixed rule as to how long an assessment session
should be or how many sessions it should take. I personally only offer 50-minute
interviews, though I know some analysts set aside an hour and a half. Often a satisfac-
tory conclusion can be reached at the end of a single 50-minute session, but some-
times it is important to follow this up with one or more sessions, especially where you
are not sure what use, if any, a patient is making of your interventions, or for instance
you want to be surer of your impression that a patient who seemed very disturbed on
arrival really has been as settled as they seemed to be initially by being understood.
The more sessions you offer, however, the more powerful the bond you are likely to
create between you and the patient, an important consideration, particularly if you
know you have to refer your patient on to someone else. It is not fair on the patient or
on your successor.
Risk Assessment
Risk assessment obviously entails diagnosis to the extent that this is possible or rele-
vant for psychotherapy, and at least some sort of formulation; so I shall consider these
under the rubric of risk.
‘Risks’ include: suicide, murder, violence, dangerous acting out, the escalation of
pathology, serious or fatal exacerbation of psychosomatic disease. The victims of all
these risks can be the patient, the patient’s family, their spouse, the general public or
the analyst, who might not be the victim of overt violence etc., but who may become
despairing and ill themselves:
I found myself walking down the street in a cheerful mood and then registered
that I had been subtly ‘down’ and demoralized for some time, even to the point of
feeling a kind of low grade physical illness. I was suddenly aware that my last
patient, who tended to feel a need to be very obstructive had been at last talking
about something which he had evidently been avoiding for several weeks and was
no longer projecting the problem into me.
Special caution should be exercised where therapy has failed in the past, especially
where the ending has not been worked through and/or has been abrupt or bitter. One
should be cautious about the temptation to think that one might succeed where others
have failed. Why have the earlier therapies failed? Have complaints been filed? Are
there indications of malignancy; of vexatiousness (vexatious complaints to regulatory
bodies are becoming more common); of acting out?

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Suicide should be directly enquired about in anyone who is explicitly depressed.
Vague feelings that one might like to be dead are probably not serious. Serious
thought about it is, and enquiry should be directed at well-developed thoughts about
ways and means: has the patient thought about doing it, how they would, where they
would, how or whether to communicate with the outside world – suicide notes etc.?
Have they been actively planning? Have they made provision, like storing medica-
tion, buying hose for the exhaust, etc.? Have they tried in the past?
The most important pointer for all these potential dangers is past form. Has there
been any history of violence to self and others in the past; and if so, under what cir-
cumstances? Are there any factors that might predispose to unpredictability, such as
habitual impulsivity, the use of alcohol or other drugs which lead to disinhibition and
greater unpredictability, the presence or predisposition to psychosis? Are there delu-
sions of a nature that might be acted upon, passivity experiences or hallucinations
which might direct the patient to do their violent bidding, and so on?
In the case of psychosomatic illnesses, how prone is the patient to relapse/exacerba-
tion under what sort of stress, and how dangerously? Again, past form is important. It
is important to have thought about whether an ulcerative colitic is likely to seriously
exsanguinate every time he/she becomes angry in the analysis, or whether separation is
likely to lead, for instance, to the escalation of an epilepsy to status epilepticus. These
are examples which come from my practice and are not exhaustive.
And finally, the possibility of exacerbating the condition you are treating has to be
born in mind: how likely is a malignant regression; a psychotic breakdown; an
unbreakable dependence; stalking of the analyst?
Diagnosis may be of some help here: impulsivity is likely to be a feature of some
borderline conditions; ‘thick skinned’ narcissism is more likely to predispose a patient
to not want to be a ‘patient’, but to be their own therapist and locate the problem in the
person whom they are ostensibly consulting, often with the effect of making them seri-
ously doubt themselves and feel helpless, enraged. They can be left feeling a failure as
a therapist, seriously demoralized, shamed and guilty. Characteristically, such patients
feel the need to be uncomprehending and proof against any invitation, however
empathic, to think about corresponding states in their own development as presumably
containing too much of a threat of destabilizing primitive affect. Similarly, some ‘anti-
social’ disorders may be induced by the feeling that such states are so intolerable that
they must be induced in the other and not taken back at any cost. Borderline pathology
is more likely to seek a malignant regression into impasse. None of this is to suggest
that none of this can be worked with, but we need to evaluate it critically.
Medical Considerations
It needs to be added here that there are certain physical conditions that mimic emo-
tional difficulty or psychiatric disease. These are traps that even experienced doctors
fall into, but the awareness needs to be there so that rats can be smelt. The trick is
often that there is no obvious dynamic present to explain the symptom.

There is a systematic table of several organic causes of mental illness or symptoms
in the Oxford Handbook of Psychiatry (Semple and Smyth, 2005 [2014], pp. 130–1).
I want to stress that no non-medical assessor could be expected to be aware of these
causes, of which I will give only selected examples from Semple and Smyth; but it is
helpful to be aware that there are such causes, and again, to reiterate that the clue to
the presence of an organic disease can often be in the absence of any obvious
dynamic linking the onset or the recurrence of the symptoms. Not necessarily, alas.
But parenthetically, being mindful of the medical serves also to remind us of the fact
that the mind is very much the function of the body in which it is rooted and which
gives rise to it. There is an indissoluble reciprocal interrelation between the two.
Here are some of the conditions cited by Semple and Smyth with their organic
causes:
Psychosis: neurological (epilepsy, brain tumours, dementia, head injury);
endocrine (low thyroid, excess cortisol [Cushing’s disease], low adrenal func-
tion [Addison’s disease]); metabolic, for example, porphyria (which can have
a variety of mental manifestations; see e.g. the depression presenting somati-
cally in the example below); lupus; some medications; drug abuse.
Depression: neurological (epilepsy, Parkinson’s, brain tumour, dementias);
infections (e.g. HIV, glandular fever); cancer (see e.g. below); medica-
tions, for example, blood pressure medications, analgesics; drug abuse.
Mania: neurological (stroke, epilepsy, multiple sclerosis); endocrine, for
example, hyperthyroidism; medication (steroids, antidepressants); drugs
(amphetamines, cocaine, cannabis).
Anxiety: neurological, for example, epilepsy, especially temporal lobe epilepsy
(see e.g. below); some pulmonary disease (chronic obstructive airways dis-
ease); some cardiac conditions; overactive thyroid; some medications (antide-
pressants, blood pressure medication); drug abuse (alcohol, benzos, caffeine,
cocaine, cannabis, ecstasy etc.).
Example 1: Cancer presents as depression
A woman in her 60s became depressed. She returned to her former analyst
and they sought to explain this in terms of ‘life events’ that seemed
significant. Some weeks later, the cause became evident in terms of the
weight loss and lassitude, and her bronchial carcinoma was diagnosed.1
Example 2: Temporal lobe epilepsy presents as panic attacks
A woman was referred by an organic psychiatrist for psychotherapy because of

her anxiety attacks. She struck me as quite a strange young woman, but her
anxiety attacks came on her out of the blue, quite randomly and without any
obvious precipitants. When I enquired about the pattern of her anxiety, she
described the spread of anxiety, upwards from her midriff to her head, which is
the classical description of so called ‘abdominal epilepsy’, a form of temporal
lobe epilepsy; and this was indeed confirmed by her subsequent EEG findings.

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Phaeochromocytoma is incidentally, similarly, another, if rather rarer cause of epi-

sodic anxiety attacks occasioned by the secretion of adrenaline by the tumour.
Example 3: A pubescent 12-year-old porphyriac girl presents with ‘belly ache’

‘Belly ache’ is here a diagnosis in that children presenting emotional distress
somatically with an acute abdomen were unfortunately called ‘little belly
achers’. This girl was admitted to hospital with abdominal pain for which there
was no immediate or obvious physical cause. She was normal on examination,
and all routine tests were within normal limits. Furthermore, she had recently
been uprooted from her home in South Africa where as ‘Cape coloureds’, her
family had suffered considerably, she had just started a new school in London
where she had no friends and felt very foreign. On top of all this, her parents
were splitting up. She seemed a perfect fit for the psychosomatic diagnosis of
‘little belly acher’: that is, somatic symptom; normal examination and tests; an
abundance of stressors. An intuition, however, led to a systematic review of
potential organic causes of belly ache (and of depression), and raised the
suspicion of porphyria which was confirmed by the appropriate tests.
Psychosomatic illnesses can be marked with serious physical manifestations, even
though they may have been triggered emotionally. The tag does not mean ‘imaginary’
but refers to their origin. We need to be mindful of what might have led to them, and
of how prone the patient may be to relapse or exacerbation, under what sort of stress,
and how dangerously? Again, past form is important, and I mentioned above the
examples of ulcerative colitis and epilepsy.
It is important to recognize that psychotherapy can risk the possibility of exacerbat-
ing any condition you are treating, and we need to ask ourselves how likely we are to
induce a recurrence of illness of whatever sort, a malignant regression, a psychotic
breakdown, an unbreakable dependence and/or stalking the analyst and so on.
As I have said, there are no hard and fast exclusion criteria for psychotherapy, but
engagement is in and of itself a powerful agent. Once we allow a vulnerable person to
engage with us, we have a correspondingly grave responsibility towards them, if only
to disengage them with as little damage as possible where psychotherapy is a bad
idea, or if we have to refer them on. There is obviously a debate to be had as to
whether it is desirable for non-medical practitioners to have medical and/or psychiat-
ric cover. As I say, doctors are not immune from missing physical and psychiatric ill-
ness, and the message is to remain vigilant, especially to the lack of a dynamic. There
is also the issue of when it is sensible to insist that therapy/analysis is only possible if
the patient agrees with the practitioner being in contact with the patient’s GP, and if
necessary, the psychiatrist.
The Capacity for Engagement

So it is with all this in mind – something which Malan is at pains to stress – that we
have carefully surveyed the landscape before we risk even the most anodyne of

interpretive sallies: witness my noticing the ambiguity of the word ‘scoring’ with the
young man who became manic in the session.
Once we are in the territory of making interpretations, we are in the territory of a
‘trial of analysis’, and what is crucial here is the response and engagement of the
patient. This is not the place to expatiate on the business of making interpretations,
but it is worth spelling out that we will not necessarily be interpreting explicit verbal
or symbolic material; often we will be confronted by process which might take the
form of enactment:
An example is of a woman who was completely silent for several minutes.
No ‘enabling’ invitation to speak was of any avail, and she simply sat
silently and weeping copiously. Here, my countertransference response was
important. I was intensely moved. We have to be careful about our
countertransference – it may be plumb wrong. But I hazarded that it was as
if she felt quite lost and wanted me to come looking for her and find her.
This enabled her to speak and to start to talk about having felt completely
invisible as a child of parents who felt inappropriate in many ways, and of a
mother who sounded very narcissistic and explosive. She had felt, precisely,
lost, that no one had ever come looking for her. Her behaviour with me
puzzled her because she had been in a previous therapy in which she had
talked easily. We were able in the end to understand that she had only
engaged in this therapy as a ‘false self’, because she had not felt ready at
that time to risk the pain of her dissociated, ‘true self’.
There are various lessons to be learned from this example. First of all, however
skilled we are, patients are not always ready to engage, as in this patient’s previous
therapy; or they may be ready to engage on a particular piece of work and not another.
The second is that there is a measure of luck involved in the process: I might not have
been blessed by that particular countertransference aperçu. But thirdly what is impor-
tant here is the patient’s feedback and engagement which tells us not only whether or
not we might be on the right track, but whether they are working with us. Once I had
‘found’ her, this woman could start to explain the experience she was clearly trying to
communicate in this enactment without words, and go far beyond my tentative assay
to make links with what she had and had not engaged in her previous therapy.
Sometimes a patient may greet our interpretation with flat denial. What matters
then is what happens subsequently in the session. Is it that they are showing us that
they are motivated, at least unconsciously, not to work with us; or is something else
afoot?
Another example is of a young man who seemed oppositional and stroppy. I
wasn’t getting anywhere, and at a point wondered if for some reason, he felt
angry in general and with me in particular. He simply said ‘no’ in a
‘whatever’ sort of manner; then he asked if he could smoke. So I said, ‘So
you mean, “not angry, but fuming”’, at which he laughed in implicit
agreement, and the session proceeded more cooperatively.

V
This is a case of the confirmation of an interpretation with unconscious material,

where despite apparent opposition, the unconscious at least is working with us.
The Transference
It is obvious that both the interpretations2 in these two examples involve the transfer-
ence although not explicitly so. In the first case, the patient used me as the person she
feared would not find her while hoping I would; in the second, I was or was not differ-
entiated from whomever it was with whom he was angry. There has been a lot of dis-
cussion about whether it is possible to have formed a transference in the course of a
session or two, or whether one should only talk about ‘transference readiness’ which
need not detain us; but it seems to me that individuals habitually relate as their internal
working models dictate, and that it would be surprising for this to not be present, if not
accentuated, in the context of an assessment which usually concentrates the attention
of the unconscious, even to the point of precipitating a dream for the occasion. A pro-
pos, some practitioners usually explicitly ask for a dream, with the assumption that this
is likely to reveal the depth of a patient’s disturbance, but it is not my particular prac-
tice. In both these cases, it was clear to the patients that they were relating to me in
these transference ways, but it is sometimes important to explicitly press the enquiry.
Motivation
This is intrinsically complicated by our universal reluctance to surrender what
Bowlby called our internal working models, especially because they are essentially
identifications with our internal attachment objects: and the more we need analysis,
the more insecure we are likely to be and the more likely therefore to cling to what we
have. Being required to modify ourselves entails modifying, or in more drastic terms,
surrendering our attachments which we are unlikely to do willingly. So we all start
fundamentally ambivalent as patients. Another potent cause of resistance is the terror
of what we need to be contained with: this is our unmentalized affects. Containment
seems on paper to be an excellent idea until it comes to the event when we are faced
with what Bion calls ‘turbulence’; and of course, these two sources of ambivalence
come together when being faced with losing our attachments faces us with what
seems like the overwhelming turbulence of our emotions.
A promising sign is vigorous engagement with interpretation, including observa-
tion of the transference. But this should not lull us into a false sense of security,
because the ambivalence is unavoidable. But flat lack of engagement is a baleful sign,
especially if it is unmodifiable with further defence interpretation.
A young psychiatry trainee who had applied for a psychotherapy training
talked about the holiday she had been on recently and her fear of diving in
‘deep blue water’. I noticed how she was at pains to avoid any emotionality
at points where she talked about painful subjects or about incidents which
made her angry. She had experienced her mother as distant and unrelating
and had been displaced very early by another sibling from whom she was

estranged. I noticed that the distance she kept from herself was similar to
that she described her mother keeping emotionally. I wondered if she was
frightened, perhaps understandably, of diving in deep blue water with me for
fear of what she might find. She agreed; but it made no difference to her
ability to relate to herself or to me in the session or the subsequent one. I
suggested that while she wished to train, she was signalling to me her very
real ambivalence about risking contact with herself. She was nonetheless
accepted for the training. Some years later I encountered her when she asked
me to supervise her work with a patient. Analysis had not enabled her to
meet her emotional self, and she was now also keeping her patients at bay as
well as herself by rationalizing their emotions.
Another sort of motivation is essentially an idealizing dependency where it is hoped
that the psychotherapist will become the idealized/idealizing mother to the idealized
infant in order to repair an attunement gone wrong. The very fact that a therapist is
striving to understand their patient naturally lends itself to an idealization. The patient’s
fantasy may be that there should be no breaks or interruptions. (This is the fantasy
which incidentally commonly underlies the tragedy in which the analytic couple ends
up in an ill-starred and tragic sexual affair with the almost inevitable disillusion and
ethical procedure. Here the therapist has not been able to confront the patient’s incipi-
ent rage or resist the allure of the idealization, perhaps because of corresponding and
often dissociated difficulties in their own history.) This sort of motivation is often
marked by a sort of passivity in which the patient ostensibly agrees with the assessor’s
interpretations which they may flatteringly idealize, but with which they do not truly
engage or develop with either conscious or unconscious material.
Perhaps the polar opposite of this is the patient who seems to be motivated by not
only simply rehearsing an internal working model, usually one of abuse, where some-
one is abusing someone else, but one in which the polarity is always that the subject
who does the abusing will remain the prospective ‘patient’, and his or her object the
hapless therapist. I put patient in quotation marks because the interviewee has no
intention of the ‘suffering’ implicit in the word, patient (patior 5 suffer Latin), but on
the contrary, of avoiding suffering by having what may seem to them the best of both
worlds: s/he keeps a malignant attachment, but is not the one who suffers from it.
Where such patients do get taken on, they can make their conscientious analysts’ lives
hell, and often turn into vexatious litigants when they are rumbled and dismissed. The
clue to this is spiteful and sadistic attacks on the analyst and on anything he/she might
say. The idea that such behaviour might arise out of their own suffering is of course to
be kept at bay at all cost, and comes to nothing, only inviting further derision and
abuse. Where the analyst does manage to get heard, it can only be experienced as
sadistic, because the patient no longer feels in control and the polarity of abuser/
abused is now experienced as reversed. The analyst is now perforce the abuser
because there are only two positions, abuser or victim.
Again, there are no absolute exclusion criteria to working with any patient; but it is
wise to have thoroughly explored how negotiable these difficult configurations are

V
and how amenable to interpretation. It is also important that different analysts have
aptitudes for different challenges: some are much more talented with antisocial or
with psychotic patients than others. As I mentioned earlier, it is important to bear in
mind the strengths and weaknesses of prospective patients in relation to our own or
those of whom we might refer them to.
TREATMENT OPTIONS
It is often possible to have arrived at a reasonable conclusion as to what course of
treatment is likely to help a patient over the period of a session. But sometimes it only
becomes apparent over a break between sessions how held a patient who has seemed
very fragile might have been by your interventions, or whether a patient who has
seemed very detached has been able to remain somewhat more open to himself
despite an interval. This is sometimes important in determining the frequency and
intensity of sessions. Some fragile or impulsive patients are unlikely to be able to sus-
tain psychotherapy outside a hospital setting.
As I have indicated, it is important to be open to your assessee needing to not have
treatment of any sort, or to having a medical or psychiatric condition for which they
need to go back to their GP.
Some patients may be socially isolated or have difficulty in relationships which
may suggest that group therapy or analysis would be more helpful than individual
work; or it may become apparent that there is a family system, perhaps with vulnera-
ble children, which requires family intervention. I did not mention under risk assess-
ment the issue of vulnerable marriages, but it is important that marriages are based on
largely unconscious contracts, often involving the implicit agreement to share the
roles of complementary internal working models. One member of a marriage seeking
psychotherapy may in these circumstances be symptomatic of a problem which needs
a marital intervention. Practitioners need to be mindful of the vulnerabilities of mar-
riages and of the relative frequency with which marriages can break up in individual
treatment, sometimes appropriately, sometimes less so.
What is important in sharing your decision with your patient as to what course to
follow – whether it be no treatment, analysis, psychotherapy or whatever other
modality – is that it be shared as an interpretation. After all, it is an interpretation in
the first place, just as medical treatments are based on diagnoses which are interpreta-
tions of the facts as they are understood, and may turn out to be misunderstood. Here
are some self-explanatory examples:
‘My impression is that you find yourself very engaged in what we have been
doing here and are eager to continue the work you have already started’.
‘I am mindful of how painful the emotion you have encountered are, and
how difficult to tolerate, and am wondering if you agree with me that it
would be easier for you to feel looked after were we to have more frequent
sessions than the one session per week which you had originally envisaged’.

‘I notice how quickly you found yourself closing up again between our two
sessions and wonder if it would be easier to keep a sense of emotional
continuity on [however many] sessions a week.’
‘You have told me how addictive you feel yourself to be, and your history
supports this impression: I was wondering about a time-limited contract of
fifteen fortnightly sessions.’3
‘I understand that you come here looking for psychotherapy; but we have
both noticed that it seems to feel too dangerous for you to risk engaging with
anything which opens you up to painful experience, so I wonder if you are
communicating a sense that whereas consciously you think that
psychotherapy would be a good idea, unconsciously at least, it seems too
dangerous to you at this particular point.’
None of these are presented as exemplary interpretations, but the point of presenting
management decisions in this way is to clearly link the interpretation to the material
which has gone before and has been shared, and to do so in a way which also permits
further negotiation (haggling the price/value is after all quintessentially about nego-
tiation/interpretation). The decision you come to needs to be consensual, otherwise
the situation can arise in which a trainee to whom the patient is subsequently referred
for four or five times a week treatment finds him/herself, for instance, with a training
patient who has been looking for once a week psychotherapy, for behavioural ther-
apy, or even a psychiatrist, and who has no wish or motivation to attend for four or
five times a week analysis.
NOTES AND COMMUNICATIONS

What sort of notes you keep in private practice and whether or not you communicate
with GPs will be determined by personal preferences and experience. In the NHS or a
clinic, you will obviously be required to write notes and to communicate with the GP
who may or may not have been the referrer. It is important for anyone who might
have to make a decision as to whether or not to take your patient into therapy/analysis
that the process of your interview be clear enough for them to follow the dynamic and
to have a vivid sense of the quality of your patient’s – now prospectively their – use
of the session, of your interventions/interpretations, of how the patient responded, of
how they related to you in the transference, and of the nature of their engagement.
This is where formatted interviews like a psychiatric one are unhelpful. The dynamics
must be alive in your write up.
I would also recommend that you write as if you know that the patient is going to
read your account, not because these days your patient has a right to demand his notes,
but because it will require you to write empathically rather than judgementally; to write
as it were from within their shoes. Racker (1968) writes about complementary and
concordant countertransference experience: complementary CT is where we find our-
selves feeling (and behaving if we don’t catch ourselves in time) as if we corresponded
to our patient’s fantasy, positive or negative; concordant CT is where we have

V
understood the fantasy which the patient is communicating via our CT and can inter-
pret it empathically accordingly, rather than behaving as an extension of their fantasy.
Writing as if to or at least for our patient makes it less likely that we enact a destructive
complementary CT on paper. But we do also need to remember that anything which
finds its way onto the patient’s NHS record may be seen by them in time.
There is then the issue of what we write for files which anyone can see rather than
for our private use, and what we choose to write to the patient’s GP. These issues will
be governed to a large extent by departmental policy, but need to be thought about.
We need to be governed to some extent by the GP’s need to know: if there is a high
likelihood of self-destructive behaviour or of hospital admission, then they may need
to know what you are embarking on with a patient which may involve their manage-
ment at some point; if someone is embarking on a routine analysis, then it is question-
able whether they need to be informed at all, especially as now having the prefix
‘psycho-’ in any form or anywhere on your records can seriously affect your insur-
ance ratings and your employment prospects. Such considerations make many
patients understandably reluctant that GPs should be informed at all, even where it is
routine departmental policy.
CONCLUDING VIGNETTE
I realize that what I have laid out might seem intimidating. Most assessments, as I
said at the beginning, are pretty straightforward, and in any case, we all have to fum-
ble our way into doing them. As I suggest, the important issue is your patient’s
capacity to engage, and the sorts of caveats I have had to mention usually make them-
selves evident in some intuition that something is not right. It is obviously wise at that
point to seek the opinion of someone in whom you feel confident. But the message is
that you need to trust yourself and get on with it: you only learn if you are prepared to
get it wrong, forget things and generally make mistakes.
I will conclude with a vignette of one of my assessments which illustrates how
wrong one can be:
I was referred a woman who had self-damaged severely with the intention of
killing herself on those occasions when she had achieved something she val-
ued highly and desired, a relationship, a job or a house for instance. She was
extremely oppositional at assessment and told me that she would kill herself
sooner or later, probably sooner with therapy, and every fibre in me told me
not to take her on, especially as she had defeated a long string of psychia-
trists, some of whom had been my distinguished teachers. The truth is I was
both very moved by her desperation – it felt she literally had nowhere to go,
as well as feeling frankly intimidated.
My initial misgivings at assessment seemed well founded when she came to
therapy. She came and essentially sat in hostile silence for several years, apart
from occasionally reiterating her suicidal feelings and intentions. She also
articulated murderous feelings towards me which I took very seriously, telling
her that in telling me about these, she was wanting to ensure that I took the

precaution of having a suitably powerful male nurse outside the door when I
saw her. I felt complete despair and was led to the point where all it felt I could
do was to ‘keep vigil’ until she finally managed to destroy herself. The idea of
vigil came from the old pneumonia vigil which, in the days before antibiotics,
doctors would keep by a patient’s bedside over the crisis at the height of the ill-
ness when a patient would either die or pull through. Experience showed that
the doctor’s presence could make all the difference.
Something in this shift in my way of being present seemed to permit a conver-
sation to happen, and she was able to let me know about the fact that her mother
had been displaced by the birth of her baby sister when she was only 11 months
old. This allowed my patient to make the imaginative jump to an empathic under-
standing as to the anguish and rage this would have caused a very little, preverbal
infant, and to imagine the intensity of her infant mother’s despair, her humiliation,
her rage, her jealousy, envy and vindictiveness. My patient realized that her
mother had only married and then conceived in competition with her sister, mar-
rying only when her sister had married, and conceiving only when her sister had
conceived. During my patient’s childhood, it had been as if there had been an
embargo on anyone in her mother’s immediate family, my patient, her sibs or her
father, having anything, as if the gain of anyone close to her would repeat her ear-
lier, unbearable displacement, shame and humiliation. My patient began to appre-
ciate that her hostility to me had been her mother’s, and to understand that she
was on reflection motivated by a sense of loyalty and empathy towards her
mother: she had felt the need to behave like an extension of his mother’s envy, to
destroy herself whenever she made a gain. The same embargo made having a
therapy and any risk of benefitting from it impossible; whence the threats to kill
herself or me – on her mother’s behalf. One very significant dream early on in the
therapy, and long before we had been in a position to understand it, had been of a
huge eye following her from outside of her house: it followed her from window to
window as she moved between the rooms, gazing in with all-seeing malice at her
every movement. It was only a sympathetic analysis of his mother’s infantile
panic and the pathos behind her malignancy that allowed my patient to separate,
for her mother to be laid to rest and for my patient be permitted a life.4
According to my own criteria, I should never have taken this patient on: she told me
that she was suicidal and potentially homicidal; her past form corroborated her suici-
dality and strongly suggested she could not receive help; she told me that she would
be more likely to get worse than better; she was oppositional and seemed motivated
not to have therapy; she was hard to engage. How wrong we can be.
NOTES
1. Bronchial carcinomas have the curious ability to cause metabolic effects at a distance,
including mood changes, which no one has yet explained.
2. There is the vexed issue of what constitutes an interpretation. This is the topic of a volumi-
nous literature. I use the word in its strict etymological sense: of negotiating value (Latin:

V
inter 5 between; pretium 5 prices); that is, the value of what you are communicating to me via
whatever means in a mathematical-logical sense? So that in terms of our two examples: (1)
[Silent, weeping lost] 5 [wanting to be looked for]? (2) [Silent, oppositional, bolshy] 5 [an-
gry]? Interpretation is in its nature a question: does this 5 that?, not a pronouncement: this
does 5 that, even though I might have to vigorously assert the fact that that is what the evidence
seems to suggest to me in the face of a patient’s resistance or anger. But the fact that it suggests
itself to me does not make it right.
3. This is an actual example of a patient who was sent to me in a health service psychotherapy
department by a GP whose letter read ‘Dear Dr., this pt is an alcoholic who has been drink-free
for 6/52. He has started to dress in his wife’s clothes and is contemplating becoming a male
prostitute. Please see and treat.’ There are obvious hazards in taking on a patient with this sort
of description, in particular their forming a very addictive transference which the 15 fortnightly
session contract of what was a focussed psychotherapy was designed to mitigate. In the event,
the patient who was motivated for change did very well.
4. Henri Rey (1988) talks about the need for internal objects, often several, to be analysed
before the patient can receive the benefit of their own.
REFERENCES
Boston Change Process Study Group (2010) Change in Psychotherapy. New York: Norton.
Coltart, N. (1987) Diagnosis and assessment for suitability for psycho-analytical psychotherapy.
British Journal of Psychotherapy 4: 127–34.
Crick, P. (2014) Selecting a patient or initiating a psychoanalytic process. International
Journal of Psychoanalysis 94: 465–84.
Hinshelwood, R.D. (1991) Psychodynamic formulation in assessment for psychotherapy.
British Journal of Psychotherapy 8: 166–74.
Malan, D. (1979) Psychotherapy and the Science of Psychodynamics. London: Butterworth.
Ogden, T. (1989) The initial analytic meeting. In: The Primitive Edge of Experience. London:
Karnac, pp. 141–61. Reprint 1992.
Racker, H. (1968) Transference and Countertransference. London: Hogarth.
Rey, J.H. (1988) That which patients bring to analysis. International Journal of Psychoanalysis
69: 457–70.
Semple, D. and Smyth, R. (2005) Oxford Handbook of Psychiatry. Oxford: Oxford University
Press. 2014, 3rd edition.
RICHARD CARVALHO is a fellow of the Royal College of Psychiatrists, a member of the

Tavistock Society of Psychotherapists, a training and supervising analyst of the Society of Ana-
lytical Psychology as well as for other bodies. He was consultant psychotherapist at St Mary’s
Hospital in Paddington, London for 16 years. Address for correspondence: [rrncarvalho@btin-
ternet.com]

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British Journal of Psychotherapy 32, 2 (2016) 237–255 doi: 10.1111/bjp.

Teaching and Learning

ASSESSMENT: A PERSONAL OVERVIEW

The author offers personal rather than scholarly reflections on the

KEY WORDS: ASSESSMENT, ABILITY TO ENGAGE, MOTIVATION,

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C 2016 BPF and John Wiley & Sons Ltd

To Assess the Capacity to Engage

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British Journal of Psychotherapy 32, 2 (2016) 237–255

C 2016 BPF and John Wiley & Sons Ltd

VC 2016 BPF and John Wiley & Sons Ltd

British Journal of Psychotherapy 32, 2 (2016) 237–255

C 2016 BPF and John Wiley & Sons Ltd

VC 2016 BPF and John Wiley & Sons Ltd

British Journal of Psychotherapy 32, 2 (2016) 237–255

C 2016 BPF and John Wiley & Sons Ltd

VC 2016 BPF and John Wiley & Sons Ltd

British Journal of Psychotherapy 32, 2 (2016) 237–255

A woman was referred by an organic psychiatrist for psychotherapy because of

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Phaeochromocytoma is incidentally, similarly, another, if rather rarer cause of epi-

Example 3: A pubescent 12-year-old porphyriac girl presents with ‘belly ache’

The Capacity for Engagement

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British Journal of Psychotherapy 32, 2 (2016) 237–255

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This is a case of the confirmation of an interpretation with unconscious material,

VC 2016 BPF and John Wiley & Sons Ltd

British Journal of Psychotherapy 32, 2 (2016) 237–255

C 2016 BPF and John Wiley & Sons Ltd

VC 2016 BPF and John Wiley & Sons Ltd

British Journal of Psychotherapy 32, 2 (2016) 237–255

NOTES AND COMMUNICATIONS

C 2016 BPF and John Wiley & Sons Ltd

VC 2016 BPF and John Wiley & Sons Ltd

British Journal of Psychotherapy 32, 2 (2016) 237–255

C 2016 BPF and John Wiley & Sons Ltd

RICHARD CARVALHO is a fellow of the Royal College of Psychiatrists, a member of the

VC 2016 BPF and John Wiley & Sons Ltd

British Journal of Psychotherapy 32, 2 (2016) 237–255

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