Decisions in mental health treatment are often relatively subjective and clinical judgment is prone to errors. But must it be that way?

There is a solution, but, since this problem characterizes all of our work, finding it can be challenging. To start with, the clinical decision maker and the subject are both human beings, their reactions eluding any "empirically supported" treatment protocol. For example, the difficulty in arriving at an effective treatment plan is compounded by variations in the way mental health labels are understood by a clinician. Consider depression. When clients describe themselves as “depressed,” how do we know exactly what they mean? For one, “depression” may represent momentary discouragement. Another may be suffering from a relatively fixed biologically or personality disorder-based dysthymia. A practitioner’s choice of treatment strategy—psychotherapy, medication, or both—hinges on her or his impression of the etiology and character of the client’s depression.

To reduce this margin of error, together with colleagues at the Center for Collaborative Psychology and Psychiatry in Kentfield, California, I have evolved an approach that improves accuracy in assessment and treatment.  This method emphasizes methodical fact finding, a careful clinical evaluation, the use of test data whenever possible, and continual feedback between the therapist, client, and, at times, significant others. Clinical progress is carefully monitored and revisions of the treatment undertaken as needed. We call this model “collaborative” to underscore the centrality of the alliance between therapist and client and, in the case of children and adolescents, between therapist and parents. Whenever possible there is a third member of the treatment team, a psychologist-assessor, who performs an initial psychological or neuropsychological evaluation of the client. Abbreviated assessments are repeated at intervals to follow the client's progress.

Perhaps you are thinking, “All well and good, but can my clients afford these enhancements to treatment?” And you may be concerned that incorporating a third person into the treatment team will interfere with the treatment alliance. Further, what if the client becomes skeptical about the therapist's clinical opinions, preferring the psychologist-assessor’s findings to the therapist's?

While, of course, these issues arise, at the Center we have almost always been able to use them to our clinical advantage. In the sixty-plus cases we have completed, this third person, when properly trained in our collaborative technique, has virtually always made the treatment stronger. And, we have found that a third, consultative presence usually helps keep the client in treatment.

Money is an individual issue, but we believe that if treatment is supported and focused by good psychological assessment, it will likely prove less expensive and more successful than one initially guided only by subjective clinical impressions.

Consider the following case:

Owen, 22, is bright, maybe brilliant, but moody and remarkably stubborn. Awkward and disheveled, picture him in a Parisian garret drinking absinthe and talking philosophy. Despite enormous potential, Owen wallows in a puddle of mediocrity. He falls in love hard, but relationships don’t last. Owen’s parents, two straight-arrow accountants, inevitably compare him to his older brother, a Harvard graduate bound for medical school. They unremittingly focus on Owen’s professional success, finding his unique needs and idiosyncrasies difficult to understand.

Owen was referred to me after being expelled from college for the second time in three years. A year earlier an incident of drunken rowdiness ended his stay at an excellent California university. He then managed to transfer to a rigorous private college where he failed to do his schoolwork. By the time of referral, his parents were so perplexed they were willing to let me “do anything" to help.

I arranged to meet with Owen's parents and then Owen. As his parents had warned, Owen was moody and reluctant to receive help. “Nothing was wrong,” he insisted, "outside of my parents' heavy-handedness and excessive worry." Nonetheless, he agreed to meet with me regularly and then as we worked further, and as I became concerned that his problems might have a biological basis, to undertake neuropsychological testing and a full neurological workup. In fact, since he suffered from headaches, with the neurological workup he wanted an MRI of his brain done.

Why go to all this trouble and expense in assessing this relatively ordinary case? Typically someone like Owen would be swept into a once weekly treatment, possibly emphasizing CBT. The initial cost of these evaluations, without including the cost of psychotherapy, was to be about $3000. Using the bare bones approach, minus the testing and neurological workup, we could infer that Owen suffered from ADD and executive function problems. But would that be the whole picture?

The initial clinical assessment allowed me to start Owen on ADD medication while the full evaluation was being conducted. The neurological examination showed entirely normal results, as did an MRI of his brain. To further assess the cause of his headaches, he also had his cervical spine X-rayed. The results, again, were entirely within normal limits, leaving the source of his headaches obscure, most likely anxiety-induced. Neuropsychological testing underscored the seriousness of Owen's combined ADD and temperamental idiosyncrasy. While irritability is frequently associated with both childhood and adult ADD, further testing was eventually needed to fill in the blanks about Owen's diagnosis.

Six months later a supplementary set of psychological (personality) tests were done, in part to track Owen's progress. My colleague, Philip Erdberg, conducted these and joined our treatment team as the "third member," mentioned above. His unique take on the situation, building on the neuropsychologist's, emphasized Owen's intelligence and creativity. Owen craved constant stimulation setting up a vicious cycle: he'd get bored, seek novel situations, get bored again, and so on, becoming progressively more unproductive. Even if I were able to engage Owen in understanding and finding alternatives to this habitual pattern, there was every reason to expect that his proclivity for bailing out of situations would be repeated in our work together. So, I had to be especially creative in strategizing our work. I also collaborated with Owen's parents, guiding them on how to manage him.

As we worked with his ADD and executive function problems, Owen agreed to ten to fifteen sessions of behavior training with a psychologist who specialized in ADD. Cognitive-behavioral interventions helped him learn to sit still and deal with his impatience. Owen also needed encouragement, in the form of confirmation that indeed he was a fish out of water and would have to stretch to comprehend and reach others who were not as smart and creative as he. Since Owen said he wanted to have friends, he acceded that adjusting his attitudes and behavior should be worth the effort.

Of course, we could have done an assessment with no bells and whistles, no neurological or neuropsychological assessment, no extension of testing. But since everyone was exasperated with Owen, a diagnosis and a “fix” were needed. I believe the extra expense of the neurological and psychological workups was more than justified—as a result, we knew exactly what we were treating. Hence, we could tailor the treatment and its interpersonal and behavioral components precisely to Owen's needs. No wasted effort, money, or time.

There you have it: a procedure that includes careful assessment and in this case  psychological testing, a medical evaluation, ongoing formal evaluation of progress, and structured collaboration between client and practitioner. I believe this assessment and treatment procedure is more accurate and reliable than the strategy we psychotherapists typically use; it is ultimately also likely to be more cost effective. True, I'm a psychiatrist, but so much of what I do is psychotherapy. I doubt that differences between our disciplines should modify the recommendations I have made. Given the subjective nature of our work, I believe that any movement toward therapist accuracy and accountability for treatment results should be welcome. I hope you come to share that conviction.