Intake Assessment

The intake assessment process usually involves a series of steps: the potential use of questionnaires or other test instruments, an intake interview, the development of a preliminary case conceptualization, a discussion with the patient about the appropriateness of the approach for him or her, a discussion of treatment goals, and the development of a preliminary contract for therapy.

Therapists and therapy practices vary in their use of assessment instruments. In some private practice settings the case documentation may consist of an information sheet about each patient (e.g., contact information, billing information, next of kin), notes from interviews and therapy sessions, and little else. In some group practices more formal documentation may include basic information about each patient, a standard intake questionnaire related to the presenting problem and any other health concerns the patient may have, consent forms for release of information and for assessment or therapy, and case notes. In hospital or university clinic settings, where databases are more typically used, the above information is commonly obtained from each patient, and this information may be supplemented by standard questionnaires that are used to document the initial state of the patient and treatment progress.

A wide range of questionnaires can be used in intake assessment. Which questionnaire or set of questionnaires will be employed is often a matter of therapist preference, but it may also depend on the type of practice setting. For example, an outpatient clinical service that offers general mental health treatment will likely incorporate assessment of anxiety or depression in an instrument battery, since these problems often present in such a setting.

Almost all therapists use the clinical interview as part of the intake assessment process. The clinical interview is a highly flexible tool for obtaining information from patients. The interview can focus on specific issues or problems and therefore take little time to conduct, or it can be comprehensive and take hours to complete. It can be unstructured and flexible to the needs of the patient or highly structured to obtain standardized and wide-ranging information. The interview can serve as a stand-alone assessment process, or it can be a prelude to psychotherapy. Which form of interview process is the most appropriate for a given setting and patient is a judgment best made by the clinician.

In the context of cognitive therapy, certain domains of information are almost always obtained (D. J. G. Dobson & Dobson, 2009). They include the presenting problem or problems, since a major focus of the treatment will be their reduction or elimination. A problem list can include symptoms, diagnoses, emotional states, cognitive or psychological problems, interpersonal disputes or dysfunction, substance use problems, health concerns, financial worries, legal difficulties, school or occupational difficulties, leisure concerns, problems of other people such as children or intimate partners, problems of daily living such as housing or transportation, problems with mental health treatment, or any combination of the these concerns.

The assessment during the intake interview should include information about the behavioral or interpersonal consequences of each problem rather than a global perception on the part of the patient. The severity of each problem, its frequency, its duration when it occurs, and past attempts to cope with the problem should all be evaluated to the extent possible. On the other hand, the therapist does not want to get bogged down in the early stages of an intake session because considerable additional information needs to be obtained. The assessment of problems should be comprehensive but also quick to allow for the collection of history and other information that is necessary in the early phase of treatment.

Once the problem list has been developed and the therapist and the patient have agreed with respect to the most important problems in the patient’s life, the therapist will shift the focus of the first session to the collection of other important information: the personal history of the patient, his or her social development, schooling and occupational history, important social relationships, health history, and the history of the presenting problem in the context of other developmental issues. The therapist will also evaluate past coping efforts with the presenting problems, any treatments that the patient is involved in or may have attempted in the past, and the resources that the patient has at his or her disposal. In particular, if the past therapy was a model different from cognitive therapy, the therapist may comment about the difference between the current treatment and the past one to offset any negative biases the patient might have toward treatment in general.

One assessment strategy that has been recommended (Dobson & Dobson, 2009) is to ask the patient for a series of self-descriptive adjectives. If this task is done at the end of the assessment interview, the therapist can make some covert conjectures about what the patient will say and then contrast the patient’s actual words with the therapist’s predictions. Agreement between the patient’s self-descriptions and the therapist’s predictions will help to demonstrate that the therapist’s understanding of the patient is accurate. However, considerable discrepancies between the patient’s self-descriptions and the therapist’s predictions may suggest the need for further assessment or questioning by the therapist to better understand the patient’s self-perceptions.

The therapist may need more information at the end of the initial interview. If so, additional testing can be conducted, records can be obtained from other therapists or other settings, conversations with significant other people in the patient’s life can be held, and further interviews with the patient can be conducted. The therapist will want to have sufficient information to ensure that his or her case conceptualization is adequate to initiate treatment. On the other hand, a single intake interview will often yield enough material to generate at least a preliminary case conceptualization and to permit the start of treatment planning.