On the therapeutic value of not offering psychotherapy: an account of an extended asssessment

This paper looks at why the assessment of patients for treatment in a hospital psychotherapy department should be such a source of strain. It is argued that a major cause of this strain is the need to manage a role conflict between acting as a therapist or gatekeeper. This role conflict is often experienced as a sense of guilt in the assessor about depriving the patient of a valuable commodity, psychotherapy. An example of an extended assessment with a particular patient is given to illustrate how this role conflict might manifest itself, in this case in the struggle by both patient and therapist to find value in the decision not to offer long-term treatment. Some of the transference implications of arriving at and communicating a judgement regarding treatment are then discussed. Finally the question is addressed as to whether the decision made was the right or wrong one, and what it means to think of assessments in these terms