David Jensen, JD
former Staff Attorney
The Therapist
(January/February 2016)
Reviewed November, 2022 by Sara Jasper, JD, CAE (CAMFT Staff Attorney)

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Oh, the lovely Ariadne fell hard for the handsome Theseus. It was love at first sight, and not only did she see in him a husband, but he was also a way off the island of Crete. There was, however, a significant complication: Ariadne met Theseus during a perilous mission. As the son of King Aegeus of Athens, he had volunteered to enter the labyrinth and fight the fearsome Minotaur.

According to Greek mythology, King Minos of Crete instructed Daedalus, a great architect, to build a labyrinth to house the Minotaur. The labyrinth was infamous for its complexity, causing people to become lost behind its great walls until they were inevitably devoured by the Minotaur King Minos had recently conquered Athens, and he demanded as tribute that every year Athens send seven maidens and seven youths to be sacrificed to the fearsome beast. Theseus joined the group of youths who were to be sacrificed, but he had a different objective in mind. Instead of being devoured by the Minotaur, he was going to slay it. So, he travelled to Crete from Athens, and, upon arriving, Ariadne espied him and fell in love with him. She offered to help Theseus fight the Minotaur so long as he agreed to marry her and take her away from Crete. And help him she did.

Theseus’ mission was risky for two reasons. The first is that he had to slay the Minotaur, which would not be easy because the beast was so fearsome. Then, assuming he did slay the Minotaur, he had to find his way out of the labyrinth, which also would not be easy. It was within the realm of possibility that Theseus could slay the Minotaur, but then get lost and die in the labyrinth.

Should Theseus prevail over the Minotaur, Ariadne came up with an ingenious way for enabling him to find his way out of the labyrinth. She gave him a ball of red thread, which he unfurled as he made his way through. Once the Minotaur had been slain, he simply had to follow “Ariadne’s Thread” out to her waiting arms. For thousands of years, Ariadne’s Thread has been synonymous with finding a way out of a difficult situation.

Human Behavior: The Ultimate Labyrinth
When practicing psychotherapy, some issues can seem labyrinthine in nature. What is going on with this patient? What is going on with this couple or family? What should I do about this patient’s substance abuse problem? What should I write in my notes? Is there an imminent risk of this patient committing suicide, or just suicidal ideation? Is there a credible risk of this patient committing imminent violence against a third party? Or, although the patient uttered a threat to harm, was he merely jesting or talking tough to impress or be histrionic? To be a psychotherapist is to enter the labyrinth of human behavior.

Regardless of the conundrum, the way out is always the same: follow Ariadne’s Thread! Of course, in the Greek myth, Ariadne gave Theseus red thread to unfurl and follow. In the world of psychotherapy, however, the red thread is metaphorical and composed of three core activities of the profession: assessing, evaluating, and managing the case. These three core activities, I believe, are at the heart of the standard of care, and you should follow them because they will lead you out of whatever labyrinth you find yourself in.

Note that the words “assess,” “evaluate,” and “manage” are active verbs. Practicing psychotherapy is an activity, one involving a marked degree of thought, judgment, and action to do well. There is a “thinking” component to the work, and there is a “doing” component to the work. The “doing” concept involves actions like writing concise treatment notes; consulting with a colleague or two about a significant clinical issue; utilizing clinical interventions during a session; contacting the police to do a welfare check; and, reporting suspected child, elder, or dependent adult abuse. The soundest professional judgments evidence a doing of something reasonable to help the patient achieve treatment goals, or to help keep the patient or others safe.

Additionally, in answer to the age-old question of what should be included in one’s treatment records, Ariadne’s Thread is a good place to start. Good treatment records evidence an assessment of the patient, whether that patient is an individual, a group, or a family. Good records evidence an evaluation of the patient, meaning the identification of a significant issue to address in therapy. And, good records evidence a treatment plan for the patient, including monitoring patient progress throughout treatment.

Think of a case you have been working on. If you had to, could you highlight or produce assessment information regarding the patient? If a third party had to take over your case, would that third party be able to tell what you were treating the patient for and how the patient is doing in therapy? If it had to, would your file be able to help you persuade a third party, such as an insurance company or a county mental health agency that continuing services is “medically necessary” for this patient? A good, thorough case file is a powerful piece of persuasive evidence.

Part I: The Assessment of the Case
Ariadne’s Thread consists of three parts: assessing, evaluating, and managing the case. However, the word assess is multi-faceted in the psychotherapy world. Assessing can refer to the initial formal assessment of a patient within the county mental health system. It can also refer to the on-going work of ascertaining whether a patient is making progress in therapy. In this sense, a practitioner is continually assessing as part of good psychotherapeutic practice. And, it can refer to efforts to “triage” a case to determine whether to take the case at all.

The essence of a good assessment is the gathering of information from the patient about the patient’s life. It is not just the patient’s story, but the patient’s story as heard through the uniquely-attuned ears of a mental health professional. It also includes what you see in the patient’s affect and behavior. What are the patient’s “presenting problems”? What events in the patient’s life have precipitated a call to a psychotherapist? What are the patient’s strengths as a human being? Assessing is a honing-in on or an identifying of issues to explore further with the patient. As you listen to a patient, or review information about a patient, what issues resonate with your knowledge and training regarding human behavior?

There are many ways to gather information about a patient. Apply those “clinical interviewing” and “active listening” skills you learned in graduate school. The essence of the legal requirement here is following the procedures you were taught in graduate school for acquiring information about patients.

For individual patients, the Mental Status Examination, with its areas of appearance; manner and approach; orientation, alertness, and thought processes; and, mood and affect is a good way of gathering information about a patient. It is likely the gold standard in the field.

The American Psychiatric Association has posted a number of “assessment measures” at its website (www.dsm5.org) that can be utilized by practitioners. These assessment measures can help a practitioner triage a case as well as focus on a diagnosis. Additionally, insurance companies and county mental health departments typically post a wide variety of assessment devices on their websites, if you are looking for examples.

A thorough assessment also includes gathering information about the patient’s family or support system. If the patient is a minor, is the minor’s primary caregiver for therapy or against therapy? How will third parties likely affect the course of therapy?

Time will always be a salient factor in assessing a patient. To meet the standard of care, a practitioner just needs to be able to show that he or she has done a reasonably good job of gathering information given the amount of time the practitioner had to conduct the assessment. The guiding question will always be whether the information obtained was reasonable under the circumstances.

Part II: The Evaluation of the Case
Evaluating the information gathered is the second part of Ariadne’s Thread. What does the information gathered mean to you as a mental health professional? The goal is to formulate a “diagnostic impression” of the patient. A good evaluation comes down to completing this algorithm: I believe “X” about this patient because of “Y,” with “X” being the judgment made, i.e., “major depression,” and “Y” being the factual information that supports that judgment, i.e., the severity and duration of symptoms.

Evaluating a case means wrestling with these sorts of questions. Based on your education, training, and experience, is the patient depressed? If so, is the depression major or minor? Is the patient suffering from ordinary grief or major depressive disorder? Is the patient suicidal or homicidal? If working with a couple, what is the couple’s “pattern of interaction”? Do you suspect child, elder, or dependent adult abuse? Being a psychotherapist necessitates the making of judgments about patients and the quality, or lack thereof, of their interpersonal relationships and support systems. The soundest judgments arise from good fact gathering and the reasoned application of the practitioner’s education, training, and experience to those facts.

An evaluation of a patient might also indicate the need to refer the patient to a physician for medical care; to refer the patient to a psychiatrist because you have noticed something amiss in the patient’s thought processes or behaviors; to refer the patient for psychological testing because you have noticed something amiss in the patient’s affect, behavior, or cognitive functioning; or, to refer the patient to community agencies for the meeting of temporal needs.

Part III: The Management of the Case
Managing the case is the third part of Ariadne’s Thread. This essentially means formulating a treatment plan that is reasonably calculated to help the patient achieve treatment goals. The formulation of the treatment plan should result from a collaboration with the patient about the work. Treatment plans these days, especially in the public and managed care milieus, are all about establishing patient goals for the course of therapy. Good treatment plans also take into account a patient’s culture and are sensitive to diversity issues.

In creating treatment goals, a good acronym to follow is the word “SMART.” Within this acronym, S stands for a specific goal; M stands for a goal that can be measured; A stands for a goal that is attainable by the patient; R stands for a goal that is relevant to the patient’s treatment; and T stands for a goal that is time-bound or capable of being tracked.

Hence, with a patient with a substance abuse problem, a SMART goal could be as simple as reducing the number of alcoholic drinks consumed in a day from 5 to 3. Such a goal would be specific in the sense that it addresses a behavior. The goal is measurable because a patient can report whether compliance has been met. The goal is attainable because it is a fairly short “walk” from five drinks to three. The goal is relevant to the patient’s overall plan of getting consumption of alcohol under control. Finally, the goal is time-bound because it is limited to 24-hour time periods.

Notice that a good SMART goal itself follows Ariadne’s Thread. Information about the patient’s behavior and progress in treatment is gathered and evaluated. And, such evaluation may reveal a need to modify the treatment plan, including the goals of therapy. SMART goals should definitely be included in the treatment record.

Conclusion
Ariadne’s Thread is also present in more common treatment situations. For instance, to work with a couple, information about the couple must be gathered and the couple’s “pattern of interaction” identified and evaluated, and then managed with interventions reasonably calculated to improve that relationship.

Ariadne’s Thread is also present in administrative aspects of the profession. For example, the essence of mandated reporting laws is gathering information, evaluating it in terms of the categories of suspected abuse, and then reporting it to authorities, if abuse is suspected.

In the end, Ariadne’s Thread is synonymous with finding a way out of a difficult situation. In the psychotherapy profession, few situations are as labyrinthine as the possible suicidal or homicidal patient. A good assessment and evaluation in these cases is critical to the successful management of them. When faced with these types of cases, relax, breathe, and follow Ariadne’s Thread out of the problem! Yes, Ariadne has laid her thread throughout the psychotherapy profession; you just have to follow it to find your way.