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8 assessmenT

Doi: 10.1037/14441-009 Biopsychosocial Practice: A Science-Based Framework for Behavioral Health Care, by T. P. melchert Copyright © 2015 by the american Psychological association. all rights reserved.

The overarching purpose of the science-based biopsychosocial approach to behavioral health care is the application of science and ethics to meet indi- viduals’ behavioral health needs and promote their biopsychosocial function- ing. assessment plays the initiating role in the treatment process for reaching this purpose. assessment occurs continuously throughout treatment—at each patient contact therapists normally engage in some type of assessment of the patient’s functioning and the progress of treatment. Therapists also assess the effectiveness of treatment at termination and often afterwards in terms of follow-up. assessment is therefore important throughout the treat- ment process. it is critical at the outset, however, because the initial assess- ment of a patient’s concerns and situation significantly affects how the parties involved conceptualize the issues. Decisions about how to proceed are based on this initial evaluation; at this point a decision is made whether any further intervention or contact is even needed.

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150 biopsychosocial practice

a wide variety of conceptual frameworks have been applied to under- standing the process of psychological assessment over the history of behavioral health care. The dominant approach in the United states in the past three decades has involved the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the american Psychiatric association. There are many issues beyond psychiatric diagnosis that are important in behavioral health assessment, but this manual has played a leading role in how mental disorders are conceptualized. The first two editions of this manual (1952, 1968) were based on a psychoanalytic understanding of personality and psychopathol- ogy. however, in the 1970s, the field of american psychiatry took a different direction when it employed an atheoretical, descriptive approach that largely excluded considerations of etiology and development. The third edition (DSM–III), published in 1980, reflected this approach and thereby avoided some of the shortcomings of the earlier editions. as a result, the DSM–III became much more influential. its basic conceptualization of psychodiagnosis has also continued through to the latest (fifth) edition, the DSM–5 (american Psychiatric association, 2013). now most psychiatrists primarily prescribe psychotropic medicines based on a biological formulation of assessment and treatment (mojtabai & olfson, 2008). (The basic purposes of science are often stated as going from description to explanation, prediction, and control. The DSM has been focused on the lowest level of these scientific goals.)

Whereas the DSM–III and subsequent editions of the manual have taken an atheoretical, descriptive approach, a wide range of theoretical orienta- tions has emerged within psychology for explaining the nature, etiology, and treatment of psychopathology. Carl rogers (1951), the founder of humanistic psychology, argued that “psychological diagnosis is unnecessary for psycho- therapy, and may actually be detrimental to the therapeutic process” (p. 220). instead of conducting assessment and treatment planning, rogers argued that providing empathy, genuineness, and unconditional positive regard within the therapy relationship were “necessary and sufficient” for successful ther- apy outcome and constructive personality change. Behavior therapists also tended to neglect formal psychological assessment and instead focused on symptoms (hayes & Follette, 1992). Behaviorists often viewed symptoms as the problem and conducted a functional analysis of behavior to identify the environmental contingencies that reinforced behaviors and that would then be used to guide treatment. Cognitive therapists traditionally relied on gen- eral formulations about the causes, precipitants, and maintaining influences of depression (Beck, Freeman, Davis, & associates, 2004), anxiety (Beck, emery, & Greenberg, 1985), and other disorders. These general formulations tended to be applied to everyone within a diagnostic category, though recently more individualized cognitive behavior therapy case formulations are also being advocated (Persons & Tompkins, 2007). like humanistic therapists,

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postmodern constructivist therapists also generally deemphasized assessment and case conceptualization. solution-oriented therapists were largely unin- terested in the nature or causes of a person’s problems (de shazer, 1985), whereas narrative therapists would argue that objective knowledge is not possible and so the client and therapist together need to co-construct an understanding of the client’s life and situation (White & epston, 1990).

These varied approaches to assessment and case conceptualization pres- ent a very complicated picture that is emblematic of the pre-paradigmatic era of the behavioral health field. Therapists could select from an eclectic array of theoretical orientations to guide their clinical work, and the orientation they chose frequently affected the type of information they collected, their understanding of that information, and the type of treatment that would then be recommended and provided. a common question asked by therapists con- cerns the extensive psychosocial history information that often has to be col- lected because it is required, for example, in hospitals and clinics accredited by the Joint Commission. in many cases, much of this information goes unused. When operating on the basis of a traditional theoretical orientation, one’s adopted orientation may determine the type of assessment information that is needed and the treatment provided. Gathering comprehensive psychosocial history information about a case is consequently often not particularly useful.

a science-based biopsychosocial approach to behavioral health care is oriented very differently from these traditional approaches. instead of choos- ing from one of the traditional theoretical orientations in the field, assessment and treatment are based on a unified scientific understanding of development, functioning, and behavior change. This approach recognizes that safe and effective therapies are available for addressing behavioral health needs, and the understanding of which treatment approach is indicated in particular cases is based on a comprehensive biopsychosocial assessment and treatment plan, not on one’s preferred theoretical orientation. This approach to assessment and case conceptualization can be complex, particularly when compared with some traditional approaches that focus on a limited set of issues highlighted by a particular theoretical orientation. This chapter clarifies that complexity by discussing the important components and processes involved and plac- ing them in a logical sequence. The overall goal of this process is to produce comprehensive and thoroughly evaluated assessment results for informing the remaining phases of treatment.

This chapter outlines the general conceptual framework for a unified science-based biopsychosocial approach to behavioral health care assess- ment. The following chapters then show how to use that information to plan and carry out treatment, monitor its progress, and assess its effective- ness at termination and follow-up. extensive knowledge of human develop- ment; psychopathology; the biological, psychological, and sociocultural bases

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of behavior; legal and ethical issues; and measurement must be combined with strong interviewing, relationship building, and other skills to compe- tently conduct behavioral health assessment. This chapter does not address those subject areas but instead focuses on the conceptualization of the basic purposes and processes of behavioral health care assessment. The discussion encompasses behavioral health care in general. it provides the overarching framework that can be applied across all types of general and specialized prac- tice and behavioral health care settings.

raTionale For anD CharaCTerisTiCs oF The sCienCe-BaseD BioPsyChosoCial aPProaCh To

Behavioral healTh Care assessmenT

The conceptual foundations of the science-based biopsychosocial approach to assessment in behavioral health care are based on the scientific understanding of human psychology and on professional ethics, and the over- arching purpose of this approach is to provide health care services that meet individuals’ behavioral health needs and improve their biopsychosocial func- tioning. These foundations and overarching purpose result in several perspec- tives that are different from many traditional approaches to assessment in the field but are essential in a science-based, health care-oriented approach.

A Unified Scientific Approach to Understanding Behavioral Health Care

The most important characteristic of the science-based biopsycho- social approach to understanding human psychology and behavioral health care is its conceptual foundations in professional ethics and scientific knowl- edge regarding human development, functioning, and behavior change. This results in a very different perspective on assessment compared with approaches based on the traditional theoretical orientations. in a traditional approach, one’s theoretical orientation often dominates the assessment findings; a cli- nician’s orientation frequently determines how an individual’s concerns and disorders are diagnosed, conceptualized, and then treated (Garb, 1998). The results of an assessment and treatment plan are often predictable depending on whether one consults a clinician with a biological, psychoanalytic, cognitive, systemic, eye-movement desensitization and reprocessing, or other orienta- tion. This approach developed for logical historical reasons (see Chapter 2), but its assumptions and conceptual foundations are not consistent with a science-based biopsychosocial approach to understanding human psychology and behavioral health care.

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The biopsychosocial approach to behavioral health care assessment uses just one unified scientific framework for understanding development, function- ing, and behavior change. Therapists might use a variety of evidence-based therapies to treat problems and disorders depending on the circumstances of a case, but there is still just one science-based perspective for understanding human psychology and behavioral health problems. The scientific understand- ing of human psychology is extraordinarily complex and much remains to be discovered, but the field has evolved to the point where human development, functioning, and the practice of behavioral health care can all be understood from a single unified scientific perspective.

The biopsychosocial approach to behavioral health care is also oriented around its role as a health care profession, the basic purpose of which is meeting the health needs of the public. it is not oriented around being a service industry that offers a range of behavioral health services and consumers taking primary responsibility for making decisions about which services best fit their needs and preferences. instead, it is oriented around being a health care profession that applies scientific knowledge and health care ethics in an evidence-based manner that integrates the best available research evidence, clinical experience, and information regarding patients’ values and preferences to meet individuals’ health needs (american Psychological association Presidential Task Force on evidence-Based Practice, 2006; institute of medicine, 2001). This overriding purpose guides the knowledge, skills, and dispositions that therapists bring to their clinical work.

Reliable and Valid Assessment

The reliability and validity of behavioral health assessment findings are important from the perspective of both the scientific and ethical foun- dations of behavioral health care. The scientific underpinnings of the field strongly emphasize reliable and valid measurement of human characteristics. measurement reliability and validity are fundamental in psychology and all of science—science simply does not progress without accurate measurement. research into the epidemiology and etiology of psychopathology, the effec- tiveness of treatment for different conditions, and a host of other important behavioral health care questions has limited usefulness without reliable and valid measure of all the predictor and outcome variables. health care likewise loses its scientific credibility without reliable, valid assessment and diagnosis.

The ethical foundations of behavioral health care also require reliable and valid assessment in terms of the safety and effectiveness of intervention. Unreliable and inaccurate assessments carry major risks of not helping and actually causing harm. among the clearest examples of the harm that can result are unreliable suicide or homicide risk assessments. as mentioned in

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Chapter 3, the patient safety movement in american health care over the past decade resulted in part from concerns about the impact of missed and delayed diagnosis, and depression with subsequent suicide attempt may be among the common missed diagnoses that result in death (schiff et al., 2009; Wachter, 2009).

Unreliable and inaccurate behavioral health assessments can be unhelp- ful or harmful in more subtle ways as well. assessment findings have a major impact on how problems, dysfunction, strengths, and resources are understood by the patient, therapist, and other stakeholders and on the services that are provided as a result. if relevant issues are not pursued or insufficient rapport with patients results in important information not being elicited, problems can easily be missed or misidentified. For example, a child’s academic failures in school might be misattributed to a lack of motivation and effort rather than to a learning disability; discrimination the child is facing related to their sex, race, culture, or sexual orientation; or abuse or neglect the child is expe- riencing at home. When this happens, the child’s problems may very well go unresolved, which itself entails a number of negative sequelae. in addition, the child may internalize a negative self-concept and sense of self-efficacy that may remain over his or her lifetime and that is not only inaccurate but also maladaptive. Therapists’ ethical obligations to not cause harm, prevent foreseeable harms, and provide benefit clearly can be violated if their assess- ments are unreliable or invalid.

Incorporation of Biopsychosocial Domains, Strengths, and Weaknesses

a main feature of the biopsychosocial approach is its comprehensive integrative approach to understanding health and functioning. This approach is based on the recognition that psychological outcomes are multifactorially determined from the interaction of the inextricably intertwined psychologi- cal, sociocultural, and biological influences on development and functioning. individuals clearly also have strengths as well as weaknesses across all these domains. Gaining a complete and accurate assessment of an individual’s needs and functioning consequently requires the integration of knowledge regarding strengths and resources in addition to problems, disorders, and vulnerabilities.

Behavioral health care assessment that is based on this approach con- sequently requires a biopsychosocial perspective as well as an assessment of how an individual functions well and poorly across the important areas of their lives. indeed, what individuals do well or possess in terms of a strength often has as much significance in their lives as what they do poorly or what they lack. For example, a person who has had little success with intimate rela- tionships and has highly conflictual relationships with parents and siblings may have very fulfilling friendships, may be a highly competent and valued

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employee, and may enjoy excellent physical health as a result of careful atten- tion to diet and exercise. another individual may suffer from a severe and persistent mental illness but is reliable, caring, and loyal and provides much needed support within the family. These individuals’ lives cannot begin to be understood without a holistic approach that recognizes strengths as well as weaknesses and the full spectrum of biopsychosocial functioning. Focusing only on a person’s maladaptive characteristics or behaviors or only on par- ticular areas from across the biopsychosocial domains can lead to incomplete and even deleterious assessment results.

BasiC PUrPoses oF Behavioral healTh Care assessmenT

Building on the underlying rationale for and characteristics of the bio- psychosocial approach to behavioral health care assessment, a consideration of the overall purposes of assessment helps inform the processes and proce- dures that need to be incorporated into assessment practice. although a wide variety of theoretical orientations historically have been applied to under- standing assessment, current guidelines and resources suggest significant con- sensus regarding the primary purposes of assessment in behavioral health care.

at the most basic level, the treatment process does not proceed without the identification of behavioral health problems that warrant clinical atten- tion. assessment serves several important additional purposes, however. For example, maruish (2004b) noted that psychological assessment is important for treatment planning, the provision of baseline data for monitoring the progress of treatment, and as a therapeutic intervention in itself (as feedback to the patient is provided and discussed and the patient and therapist arrive at mutually agreed upon treatment goals).

an examination of major guidelines and resources for conducting behav- ioral health care assessment reveals significant convergence around its primary purposes (melchert, 2011). although their emphases differ, the guidelines significantly overlap regarding several basic purposes for behavioral health care assessment that extend beyond the initial identification of problems and concerns (e.g., see american Psychiatric association, 2006; Groth-marnat, 2009; lezak, 1995; maruish, 2004b; s. m. Turner, Demers, Fox, & reed, 2001; Wiggins, 2003). a synthesis of these guidelines suggests the following basic purposes of psychological assessment:

1. identify behavioral health problems and concerns that require clinical attention.

2. Gather information regarding a patient’s behavioral health and biopsychosocial functioning in order to develop a comprehen- sive case conceptualization and treatment plan.

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3. engage the patient in the treatment process through a collab- orative approach that includes patient self-assessment and a discussion of objective feedback provided back to the patient.

4. Provide ongoing assessment during the course of treatment in order to monitor progress, refine the treatment plan, and refo- cus interventions as needed.

5. Provide baseline data for an outcomes evaluation and assess- ment of the effectiveness of treatment.

These overarching basic purposes apply even though the specific pur- poses of assessment in particular cases may vary substantially. initial intake assessments with new patients are very different from the reevaluation for ongoing care of chronic issues with patients who are well known to the thera- pist. assessments conducted for consultation to others usually do not lead to one performing subsequent treatment or outcomes assessment at all. For behavioral health care assessment in general, however, there is substantial agreement regarding the general purposes listed above.

The sections that follow discuss the issues that must be addressed in clinical practice in order to achieve the basic purposes of behavioral health assessment. a comprehensive health care–oriented approach to assessment is outlined here. assessment procedures vary significantly depending on the specific purpose and setting (e.g., community mental health center, inde- pendent specialty psychotherapy practice, primary health care, inpatient psychiatry, medical, educational, forensic, industrial, organizational, sport, and correctional). The discussion here, however, focuses on the general conceptualization of behavioral health care assessment that can be adapted and applied across pro fessional practice settings. This discussion begins with a consideration of which areas of patients’ lives need to be considered to develop comprehensive case conceptualizations that meet their behavioral health and biopsychosocial needs.

areas To inClUDe in Behavioral healTh Care assessmenT

Behavioral health assessment has become much more biopsychosocial in orientation over the last half century. This is clearly reflected in the evolu- tion of the DSM. The first two editions, DSM–I and DSM–II, were published by the american Psychiatric association in 1952 and 1968 and relied heavily on psychoanalytic theory. symptoms for specific disorders were not specified in detail, and many were seen as reflections of broad underlying conflicts or reactions to life problems that could be categorized generally as either

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neurosis or psychosis. Alternative theoretical explanations for psychological development grew in popularity during that time (e.g., humanistic, cogni- tive, biological, feminist, and multicultural approaches) and weaknesses in the DSM I and II became obvious. As a result, the third edition of the DSM (DSM–III), published in 1980, presented a thoroughly revised approach to conceptualizing psychiatric diagnosis. That edition used an atheoretical descriptive approach that did not specify or imply etiology for most of the disorders, and it also introduced the multiaxial assessment system that, with modifications, was used for over three decades until the publication of the DSM–5 in 2013. The multiaxial system incorporated what is essentially a biopsychosocial approach to assessment by including clinical disorders and conditions on Axis I, personality disorders and pervasive developmental disorders on Axis II, medical issues on Axis III, environmental stressors on Axis IV, and general overall level of functioning on Axis V. In the DSM–5, Axes I, II, and III have been combined, and separate notations are to be made for important psychosocial and environmental factors (formerly Axis IV) and disability (formerly Axis V). That is, the same biopsychosocial information is to be documented but in a less differentiated manner than before. The DSM–5 also recommends that the Z codes of the International Classification of Diseases (10th ed., Clinical Modification; ICD–10–CM; World Health Organization, 1992) be used instead of the former Axis IV listing of stressors. (Health insurers in the United States are scheduled to begin using ICD–10 codes for payment and reimbursement in October 2014.) These Z codes do not represent mental disorders but do capture many of the problems individuals experience in the social realm (e.g., those noted in Chapter 5).

The five-axial system of the DSM–III greatly expanded the scope of assessment for mental health and biopsychosocial functioning, but it pro- vided little guidance regarding the breadth and specificity of the informa- tion that should be evaluated when conducting an assessment. Because the DSM–III, DSM–IV (American Psychiatric Association, 1994), and DSM–5 are descriptive systems, they provide little guidance on how to understand the etiology and development of patients’ problems. They also leave out level of insight, readiness to change, sense of responsibility, and other factors that greatly affect treatment. Clinical intervention requires much more comprehensive assessment information to identify effective long- term solutions to patients’ problems in individual cases (e.g., American Psychiatric Association, 2006; Beutler, Malik, Talebi, Fleming, & Moleiro, 2004; Goodheart & Carter, 2008).

The controversy surrounding the development and release of the DSM–5 also suggests that more research into the nature and classification of psycho- pathology is badly needed. For example, Allen Frances (2009), who chaired

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the committee that revised the DSM–IV, noted the lack of research connect- ing psychiatric syndromes with any underlying neurobiological mechanisms and strongly questioned the loosening of DSM–5 diagnostic criteria regard- ing several disorders. Because of the lack of a neuroscience-based classifica- tion of mental disorders, the national institute of mental health (2011) announced a major research initiative that shifts away from current DSM diagnoses and replaces them with dimensional categories based on advances in genomics, pathophysiology, and behavioral science. This new framework, called the research Domain Criteria (rDoC), uses a dimensional conceptu- alization ranging from normal to abnormal, and classification is based on basic behavioral neuroscience findings rather than existing DSM disorders. new rDoC-based research will take years to conduct, but future editions of the DSM are likely to evolve considerably as a result.

virtually all contemporary behavioral health assessment systems indi- cate that it is important to incorporate all three of the biopsychosocial domains when conducting behavioral health assessment. many have noted specific areas within these domains to include when conducting assessments. melchert (2011) found substantial overlap when the specific areas included in six influential behavioral health assessment systems were compared. all of the 26 specific components listed in Table 8.1 were included in at least two of the systems, and 18 of the components were included in at least four of the systems. The overlap in these assessment systems suggests that all 26 of these component areas are considered important in behavioral health care assess- ment. To evaluate the content-related validity of this set of assessment areas, l. meyer and melchert (2011) examined the information contained in 163 individual outpatient therapy files from three different clinics and found that these 26 components captured 100% of the intake information found in the patient files. There was no intake information in any of the patient files that could not be categorized into these component areas, and each of them was necessary to capture all of the information.

Because each of these areas of patients’ lives can be important in their development and current functioning, all of them need to be considered when learning to conduct comprehensive biopsychosocial assessment. The depth and detail that one pursues in particular assessments depends on one’s spe- cialization, the setting where one practices, and the specific purpose of the assessment. For example, just a small number of these areas might be included when conducting screens and other brief assessments of patients’ needs in university counseling centers or primary health care clinics. as the general framework for conceptualizing behavioral health care assessment, however, the above categorization is useful for delineating areas of individuals’ lives that can significantly affect their current functioning as well as their growth and development over the life span.

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assessment 159

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160 biopsychosocial practice

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assessment 161

reliaBiliTy, valiDiTy, anD ThoroUGhness oF assessmenT inFormaTion

The reliability and validity of assessment information are major pri- orities in behavioral health care from the perspectives of both science and ethics. The legitimacy and credibility of the field as a science-based health care profession are weakened if scientific principles involving measurement and assessment are compromised. Unreliable, incomplete, or inaccurate assess- ments also have ethical implications: They might be not only unhelpful to patients, their families, and others but also even have negative consequences.

The level of reliability, validity, and thoroughness of assessment informa- tion that is needed can vary significantly, however, depending on the purpose of the assessment. Within the clinical context, assessment needs vary greatly depending on whether they are conducted for emergency purposes (e.g., when patients are suicidal or homicidal), consulting purposes (e.g., to assist other treatment providers with complex cases), reevaluation purposes (e.g., to assess the progress of patients in long-term care for the management of chronic con- ditions), or intake purposes (e.g., to gain an initial assessment of the needs of patients receiving behavioral health care for the first time). many psychotherapy cases involve individuals who self-refer to address mild or moderate problems regarding their emotional functioning, and they often can personally provide most or all of the information needed to complete the assessment. When the therapist plans to provide ongoing treatment in these cases, establishing an effective therapeutic relationship becomes a priority and may take precedence over the timely gathering of comprehensive assessment information.

The referral question also plays an important role in deciding how to approach the assessment of a particular case. one’s assessment approach with psychotherapy patients who self-refer is typically much different from the approach for cases in which parents, spouses, partners, physicians, or educators initiate the referral. in these latter cases, the information provided by third parties is often critical to the reliability and validity of the assessment. other referrals address legal or administrative questions such as child custody, disability status, readiness to return to employment, or the insanity defense. (an interest- ing and controversial referral question that has arisen in states with sexual pred- ator laws involves determining whether a convicted child molester who has completed his or her sentence should then be civilly committed and detained indefinitely.) one’s approach to obtaining reliable, valid, and thorough assess- ment information can vary widely across these types of referral questions.

although the reliability and validity of assessment information are always a priority, limited resources and practicality prevent highly thorough assessments from being conducted in many cases. an overwhelming amount of information from across the biopsychosocial domains can be collected, and using triangulation

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162 biopsychosocial practice

and other methods to evaluate its accuracy is highly time consuming and costly. moreover, such a thorough approach is not needed in many situations. employee assistance programs, crisis hotlines, university counseling centers, and school counseling departments are limited in the services they can provide given the large number of individuals served by a small number of personnel, and so screen- ing and other brief assessment procedures are commonly used to identify cases to refer for more thorough assessment. on the other hand, inpatient psychiatric care routinely requires that medical and psychosocial evaluations be completed in order to thoroughly evaluate the severity and complexity of the issues involved.

The issues addressed in the assessment also play a major role in deciding the type and thoroughness of the information collected. Patient self-report can efficiently provide reliable information regarding some issues; other issues are most reliably and efficiently assessed through the use of questionnaires or psychological tests. For example, one’s level of distress, mood, and other sub- jective states are typically assessed through self-report, which is often the only reliable source of information regarding one’s internal subjective state. variables such as personality characteristics, educational achievement, and intellectual or neuropsychological functioning are often most reliably, validly, and efficiently assessed through the use of test instruments. When an assessment is needed of a patient’s performance of responsibilities at work or at home, on the other hand, work supervisors and family members often provide more reliable and complete information than what patients themselves may be aware of or will- ing to report. Children and cognitively disabled adults are usually unable to provide reliable reports regarding several aspects of their lives. legal, medical, substance abuse, educational, and child protective service issues also may not be reliably reported by patients themselves. Though patient self-report infor- mation is often the most time-efficient to collect, it carries a high risk of being incomplete or inaccurate (sometimes completely inaccurate) for many purposes.

The importance of obtaining reliable assessment information is evident when one considers how often a patient’s perception of his or her behavior or performance varies from that of family members, employers, educators, or vari- ous public officials (r. C. miller & Berman, 1983). For example, a husband entering treatment might ask for help with getting along with a “nagging” wife; the wife might report that the husband’s violence and alcohol abuse are about to result in a divorce and child custody battle. a patient might report that his or her supervisor at work is angry, unfair, and prejudiced, but the supervisor might report that the employee frequently argues with coworkers, repeatedly makes sexually inappropriate comments, has substandard produc- tivity, and is not responding positively to supervision. Children referred for treatment frequently report circumstances and behaviors that conflict with other reports. The minimization or exaggeration of problems is frequently sub- conscious or unintentional, but at other times it is not. in either case, relying

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assessment 163

only on patient self-report can result in inaccurate assessments that might be unhelpful or potentially hurtful for the patient or others.

in general, patients themselves are the primary source for information about their personal distress and other internal states. Therapists often have the most expertise for identifying psychological symptoms and making psychi- atric diagnoses. a patient’s medical status is ordinarily best understood by his or her medical providers, whereas family members often have the most insight regarding the patient’s functioning within the family. employers or educa- tors often have the best perspective on an individual’s functioning at work or school, whereas officials within criminal and legal systems can often provide reliable information regarding a person’s legal involvement. Therapists must be conscientious in their decisions about the most reliable sources of informa- tion for the purpose as well as adept at collecting data using a variety of sources and techniques. This also requires the ability to communicate and collaborate effectively with other human services professionals, family and community members, and others who play important roles in patients’ lives.

a useful model for conceptualizing the reliability of assessment informa- tion was proposed by strupp and hadley (1977). in their tripartite model of mental health and therapeutic outcomes, at least three different stakeholders hold different perspectives and have different interests in a patient’s psycho- logical functioning and treatment. First, the authors argued that the patient is the best judge of his or her own distress and discomfort. second, the patient’s family and particular community members often have the best perspective for judging a patient’s functioning in important life roles within the family, at work, or in the community. Third, therapists are normally the best judges of a patient’s psychological functioning and psychopathology. speer (1998) expanded on this model by specifying the sources that are likely to provide the most reliable and useful information regarding these different perspec- tives. The capitalized bold letters in Table 8.2 indicate those individuals who are likely to provide more reliable information regarding different dimensions of a patient’s health and functioning. in this model, significant others could include employers, neighbors, friends, and landlords in addition to family members. Public gatekeepers are those who have professional responsibili- ties involving the patient but not a social relationship; examples include law enforcement officials, emergency room staff, court officials, and child or adult protective services staff. independent observers are professionals or specialists who can perform medical, psychiatric, or other evaluations of the patient.

The use of standard intake questionnaires and interview protocol forms can help ensure that the collection of assessment information is reasonably thorough. standardized screening instruments are also widely recommended because they can provide psychometrically reliable and valid data, and a patient’s scores can be compared with normative data that are usually

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164 biopsychosocial practice

available. These instruments can also be readministered during and after treatment, providing a useful mechanism for monitoring treatment prog- ress and evaluating outcome (see Chapters 10 and 11).

at a basic level, the adequacy and thoroughness of the assessment infor- mation collected for a given case can vary from completely inadequate (e.g., almost nothing is known about important relevant issues) to fully adequate for the purpose. variation in the purposes of assessment and the uniqueness of each case make it difficult to establish precise guidelines for evaluating the adequacy of assessments, but l. meyer and melchert (2011) developed a five- point rubric to rate the general thoroughness of assessment data with regard to each of the biopsychosocial component areas listed in Table 8.1. The descriptors for the five points on the rating scale are noted in Table 8.3. The

TABLE 8.2 Reliable Sources of Behavioral Health Assessment Information

Source Distress Symptoms,

disorder, diagnosis Functioning, role

performance

Patient A B c Significant others d e F Public gatekeepers g h I Independent observers j K l Therapist/provider m N o

Note. Bold capital letters indicate sources that are more likely to provide reliable information. From Mental Health Outcome Evaluation (p. 50), by D. C. Speer, 1998, San Diego, CA: Academic Press. Copyright 1998 by Elsevier. Adapted with permission.

TABLE 8.3 Detail and Comprehensiveness Scale

for Assessing Biopsychosocial Components

Score Rating description

0 Information regarding component area is not present at all. 1 Only a few details or basic data are mentioned, or a check box for this

component is marked, but no further information is provided. 2 Most or nearly all basic details or data are present; strengths and

weaknesses may be mentioned briefly but are not clearly assessed as a strength or a deficit.

3 Most or nearly all details or data are present, plus one of the following two is also met: (a) strengths associated with this component are described, or (b) deficits associated with this component are described.

4 All of the following criteria are met: (a) most or nearly all details or data are present, (b) strengths associated with this component are described, and (c) deficits associated with this component are described.

Note. From The Use of a Comprehensive Biopsychosocial Framework for Intake Assessment in Mental Health Practice (Doctoral dissertation); Appendix F, by L. Meyer, 2008, Milwaukee, WI: Marquette University. Copyright 2008 by L. Meyer. Adapted with permission.

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assessment 165

TABLE 8.4 Examples of Intake Assessment Notes Documenting

Particular Assessment Issues

Score Substance use example Medication example Religion example

0 [Information regarding this component area is missing.]

[Information regard- ing this component area is missing.]

[Information regard- ing this component area is missing.]

1 “Patient states she drinks alcohol.”

“Patient takes Prozac.” “Patient is Roman Catholic.”

2 “Patient reports drinking alcohol socially, approxi- mately twice per month. She reports not smoking and does not consume caffeine or any illicit drugs.”

“Patient currently takes Prozac, 40 mg, once daily for depression.”

“Patient is Roman Catholic, is active in her faith, attends church regularly, and was raised Catholic.”

3 “Patient reports drinking alcohol socially, approxi- mately twice per month. She reports not smoking and not consuming caffeine or any illicit drugs. Patient reports drinking has a neg- ative impact because when she goes out and drinks with friends, she usually drinks too much and does not want to get out of bed the next day.”

“Patient currently takes Prozac, 40 mg, once daily for depression. He states that the medication is help- ful because he no longer feels depressed and is more active socially.”

“The patient reports that she is Roman Catholic, is active in her faith, goes to church regularly, and was raised Catholic. She states that her religion has helped her by providing a positive support group during her recent difficulties.”

(continues)

application of this approach is illustrated through examples of intake assess- ment notes for each of the five levels on the scale (see Table 8.4). missing important details is typically problematic, with potentially serious conse- quences, and thereby introduces risks of harm. Comprehensive, detailed information, on the other hand, minimizes those risks while maximizing the likelihood of effective treatment over both the short and long term.

assessmenT oF The severiTy oF PaTienT ProBlems anD sTrenGTh oF resoUrCes

The information that is gathered through the methods discussed above must be further evaluated at multiple levels to be useful for developing treat- ment plans that minimize risks of harm and maximize the likelihood of treatment effectiveness. The first of these levels concerns the severity of the patient’s problems and needs that have been identified.

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166 biopsychosocial practice

4 “Patient reports drinking alcohol socially, approxi- mately twice per month. She reports not smoking and not consuming caf- feine or any illicit drugs. Drinking on a social basis has been helpful, accord- ing to the patient, because she gets to go out with friends and feels more comfortable socializing and meeting new people. Patient reports that drink- ing also has a negative effect because when she goes out and drinks with friends, she usually drinks too much and does not want to get out of bed the next day.”

“Patient currently takes Prozac, 40 mg, once daily for depression. He states that the medication is helpful because he no longer feels depressed and is more active socially. He reports the medication has a downside as well—he strongly dislikes the side effects of dry mouth, insomnia, sexual dysfunction, and weight gain, and he is afraid he will have to take the medication ‘forever.’”

“The patient reports that she is Roman Catholic, is active in her faith, goes to church regularly, and was raised Catholic. She states that her religion has helped her by providing a positive support group during her recent difficulties. However, she also states that her religion has had a detrimental effect because she does not always agree with church doc- trine and feels a great deal of inter- nal conflict and guilt as a result.”

Note. From The Use of a Comprehensive Biopsychosocial Framework for Intake Assessment in Mental Health Practice (Doctoral dissertation); Tables 3.3, 3.4, and 3.5, by L. Meyer, 2008, Milwaukee, WI: Marquette University. Copyright 2008 by L. Meyer. Adapted with permission.

TABLE 8.4 Examples of Intake Assessment Notes Documenting

Particular Assessment Issues (Continued)

Score Substance use example Medication example Religion example

The severity of patient problems obviously varies widely and has direct implications for treatment planning. The most severe and urgent prob- lems typically involve emergency issues that must be attended to immediately. emergency behavioral health problems often involve suicidality or homicid- ality, as well as family, medical, legal, and other crises that also require imme- diate attention. other problems may be quite serious and require intensive intervention but not on an emergency basis. at the other end of the con- tinuum are minor problems and needs that can be addressed through psycho- education or a referral to external sources of information or support.

many individuals face a serious problem in just one area of their lives; others face major problems in several areas. Consequently, the severity of the need has to be assessed with regard to particular issues. many models for assess- ing the severity of patient problems range from none to severe. since the publi- cation of DSM–III (american Psychiatric association, 1980), the terms mild, moderate, and severe have been used to indicate the level of severity of mental

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assessment 167

disorders, and many other systems have incorporated these same terms and concepts (e.g., huyse et al., 2001).

in addition to noting the severity of individuals’ problems and dis- orders, the biopsychosocial perspective emphasizes positive functioning and personal resources as well. Behavioral and medical health assessment in the past tended to emphasize deficits and pathology because of their major impact on individuals’ lives. a biopsychosocial perspective to health care, on the other hand, emphasizes the whole person and the full continuum of function- ing across the biopsychosocial domains. Gaining a holistic assessment of an individual’s needs and functioning consequently requires an assessment of strengths and resources as well as problems and vulnerabilities. strengths and resources include both internal resources (e.g., coping skills) and external resources (e.g., social support), and frequently they serve critically impor- tant roles in people’s lives, often as important sources of support when fac- ing serious problems and needs in other areas. The U.s. substance abuse and mental health services administration (2011a) initiated a program to focus more attention on developing strengths and resources among individu- als with mental illness and substance use disorders. They identified eight dimensions for promoting wellness and recovery: physical, emotional, social, occupational, intellectual, financial, environmental, and spiritual well-being.

The full spectrum of functioning within particular areas of individuals’ lives is illustrated in exhibit 8.1. rather than conceptualizing problems using a unipolar scale ranging from no problem to severe problem, a bipolar scale

EXHIBIT 8.1 Assessing the Severity of Problems and Strength of Resources

Within Biopsychosocial Areas

+3 Major strength—A major strength or resource that is an important contributor to the health and well-being of the individual

+2 Moderate strength—A moderate strength or resource that adds significantly to the individual’s health and functioning; could be developed or amplified further

+1 Mild strength—A mild strength or resource for the individual; could be developed or amplified further

0 No problem or need—No evidence of problem or need in this area, though not an area of strength; could be developed into an area of strength

-1 Mild problem—Individual is experiencing mild psychological distress and/or impairment in functioning or faces minor risks for a decline in functioning.

-2 Moderate problem—Individual is functioning significantly less than optimally and/or is facing risks for a significant deterioration in level of functioning.

-3 Severe problem—Individual is functioning far below an optimal level and/or risks a major deterioration in level of functioning, with dangerous or disabling consequences possible.

Note. From Foundations of Professional Psychology: The End of Theoretical Orientations and the Emergence of the Biopsychosocial Approach (p. 131), by T. P. Melchert, 2011, London, England: Elsevier. Copyright 2011 by Elsevier. Adapted with permission.

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168 biopsychosocial practice

incorporates positive functioning as well. This conceptualization, ranging from severe problem at the low end to major strength at the high end, does not apply neatly to all areas of individuals’ lives. For example, if one experienced no significant maltreatment as a child, it is unclear whether that would be best viewed as a strength or simply as having no needs in that area. if a per- son with a history of severe child abuse worked through the consequences of those experiences and conscientiously developed healthy relationships and strong resiliency and parenting skills as a result, these consequences would be viewed as strengths and not vulnerabilities. These issues would require careful analysis if this scale were used as a measurement model. as a concep- tual model, however, which is the main interest here, a bipolar conceptual- ization of problem severity is very useful as a reminder of the importance of assessing both problems and strengths across biopsychosocial areas.

Table 8.5 illustrates how a bipolar conceptualization of patient needs and strengths can be applied to gain a thorough assessment of patient cases. The dots in the table summarize the assessment of needs and strengths across the biopsychosocial areas for the case of a mildly depressed female hospital administrator who is effective at work, managing a large number of important responsibilities with generally positive appraisals by the chief executive. many of her subordinates view her as irritable, arrogant, and difficult, though she is widely regarded as efficient in managing the hospital. This patient has distant and perfunctory relationships with her husband and children, however, as well as distant and conflictual relationships with her parents. her husband has told her that he expects to leave their marriage once their two children graduate from high school. she consumes significant amounts of alcohol when not at work and neglects her physical health. she also privately worries that her life will not be meaningful after retirement because there are few things outside of work that she finds interesting. as another example, the checks in the table refer to the assessment of a homeless man diagnosed with bipolar affective disorder and substance dependence. he has a pleasant and engaging personality, is funny and widely liked, but he has significant needs and problems in most areas of his life. his substance abuse makes him vulnerable to criminal victimization, and he becomes despondent after these incidents. he was severely physically and emotionally abused during child- hood and has had difficulty trusting others since then. he is determined to “make it on my own,” however, and has a long history of rebounding after experiencing thefts and assaults. note that even though these individuals’ lives differ dramatically, they both were rated as having moderately serious problems in terms of their level of psychological functioning.

Comprehensively assessing patients’ problems and strengths is neces- sary for gaining a thorough understanding of their needs, level of function- ing in important areas of their lives, and biopsychosocial circumstances as a

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assessment 169

TA B

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g

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h is

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✓ •

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170 biopsychosocial practice

whole. identifying problems, needs, and vulnerabilities as well as strengths and resources that can be relied on for support or can be developed even fur- ther are important for developing treatment plans that have the maximum likelihood of being effective over the long term. Focusing on strengths along with problems also helps individuals gain a more accurate self-identity and communicates that their therapists are interested in them as whole persons and not just interested in their problems. This in turn helps develop rapport and a stronger therapeutic relationship, both of which are important to posi- tive treatment outcomes as well (see Chapter 10).

overall evalUaTion anD inTeGraTion oF assessmenT inFormaTion

The assessment information collected and evaluated using the guide- lines described in the preceding section should be evaluated at two additional levels in order to develop fully informed treatment plans. The problems and needs identified have to be prioritized, and their overall severity and complex- ity must be evaluated.

Prioritization of Problems and Needs

Patients with emergency needs provide the clearest example of the impor- tance of prioritizing problems and needs. The most common emergencies in behavioral health care involve danger to self or others; in addition, individuals face crises involving family, medical, legal, financial, criminal, or other problems that may require intensive, urgent intervention. in all these cases, failing to address emergency needs as the first priority can have serious consequences. For example, a college student who becomes severely destabilized and suicidal after failing to be admitted into medical school should address the suicidal ideation before exploring educational and career options. addressing the career and edu- cational decisions before the suicidality may not only be unhelpful but may also increase stress and uncertainty and the chances of a suicide attempt.

maslow (1943) presented the best-known approach to conceptualizing the prioritization of human needs. in his hierarchy of needs model (depicted in Figure 8.1), the four lowest levels of needs (physiological, safety, love/ belonging, esteem) are deficiency needs, which, when met, allow one to move up the hierarchy and establish new priorities for personal growth. research has shown that need fulfillment is more fluid than that suggested by a stepped hierarchical model (Wahba & Bridgewell, 1976), but maslow’s model is nonetheless widely considered useful for categorizing different types of needs and arranging their priority. For example, the suicidal college student has to

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assessment 171

address his basic safety and security needs (i.e., as a result of being a danger to himself) before he can address issues related to self-esteem, self-identify, meaning, and purpose. likewise, a homeless person who is worried about basic needs for food, clothing, shelter, and physical safety may find it impos- sible to focus on higher level needs until some level of basic physical stability is achieved. Focusing on self-esteem and existential issues regarding meaning and fulfillment in life can be very difficult and potentially counterproductive if one’s lower level needs have not been met.

Overall Complexity of Problems and Needs

assessing the severity of individuals’ problems and the strength of their resources, along with prioritizing their various needs, allows for another level of evaluation that is critical for planning treatment. This evaluation involves the complexity of patients’ problems and needs in the context of their biopsy- chosocial circumstances as a whole. significant comorbidity within the psycho- logical domain is common, and coexisting problems across the biopsychosocial domains occur frequently as well. Co-occurring substance dependence; person- ality disorders; other clinical syndromes; or serious family, medical, or financial problems are common and greatly complicate an individual’s life and treatment. The complexity of a patient’s situation must be evaluated before a rational and

Basic Physiological Needs

Safety and Security Needs

Love, Belonging

Self-Esteem

Self-Actualization

Figure 8.1. Maslow’s (1943) Hierarchy of Needs Model.

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172 biopsychosocial practice

effective treatment plan can be devised to resolve problems and needs over the short and long term.

as with most aspects of behavioral health, the complexity of biopsycho- social problems and needs can be conceptualized as falling on a continuum. Patients without clinically significant mental health problems or concerns would be assessed as having problems of essentially no complexity; those with one or very few problems of lesser severity would be viewed as having problems of very little or mild complexity. Patients with problems of major complexity would include those with multiple problems at moderate or severe levels of need or risk along with strengths that are insufficient to counterbalance the problems (see Table 8.6). Cases of major complexity often involve severe and persistent mental illness or substance dependence; significant comorbidity; a developmental history involving major abuse, neglect, or other trauma; or major personality pathology. some cases involve a serious problem in just one area, and although the complexity of the problems may be low, the severity of the problems or risks faced may be quite serious nonetheless. For example, a young adult who enjoys strengths and resources in many areas might experi- ence serious destabilization surrounding a humiliating relationship breakup.

more complex and serious behavioral health and biopsychosocial needs often require more comprehensive and detailed evaluation. Patients with seri- ous problems across the biopsychosocial domains may need medical and neuro- psychological evaluations, the findings of which are combined with input from family members, employers, teachers, parole officers, or others. Thorough and detailed assessments are more frequent in inpatient psychiatric and substance abuse treatment programs when patients experience highly complex prob- lems. Because the interaction of problems and resources across the many areas of peoples’ lives results in a very complex array of combinations, evaluating the interaction of developmental, etiological, risk, protective, sociocultural, and medical factors in patients’ functioning can require significant clinical

TABLE 8.6 Overall Complexity of Patient Problems and Needs

Level of complexity General guideline

None or very little Minimal or no clinically significant mental health problems or concerns; significant strengths prevent issues from developing into clinically significant problems

Mild A small number of problems, usually of lesser severity; presence of strengths helps mitigate their effects

Moderate Intermediate number of problems, usually of intermediate severity, and intermediate number of strengths

Major Multiple problems of moderate or higher levels of severity and/or risk; strengths insufficient to counterbalance problems

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assessment 173

experience. Therefore, case consultation with more experienced and expert clinicians typically increases as severity and complexity of problems increase.

There is some evidence that comprehensive, well-integrated assessment such as that described above is not common. Two studies have included ratings of the adequacy of clinicians’ assessment reports from a comprehensive, bio- psychosocial perspective. mcClain, o’sullivan, and Clardy (2004) investigated the adequacy of the case formulations completed by a sample of 79 psychiatric residents according to an integrative biopsychosocial framework. The study found that, on average, none of the groups of residents (first through fourth year, from four different institutions) wrote biopsychosocial case formulations that reached what was identified as the basic level of competency. The reports typically included information regarding a wide range of biological, psycho- logical, and sociocultural factors, but the information was not well integrated and was judged to have the potential to lead to problems in treatment.

l. meyer and melchert (2011) found similar results. Their study exam- ined the treatment records for a sample of 163 psychotherapy outpatients to evaluate the comprehensiveness of the written assessment documentation and the extent to which that information was integrated and formulated in a manner that would maximize treatment effectiveness. Table 8.7 provides the

TABLE 8.7 Levels of Comprehensiveness and Integration of Behavioral

Health Care Assessments

Score Rating description

0 Assessment is missing critical biological, psychological, and sociocultural information in the context of the particular case.

1 The clinician obtained information regarding a variety of components across the biological, psychological, and sociocultural domains, but a lack of focus and attention to important concerns could lead to less effective treatment.

2 Basic competency. The clinician obtained comprehensive biological, psycho- logical, and sociocultural information, and there is some evidence of integra- tion of this information to address the patient’s most important concerns.

3 The clinician obtained comprehensive biological, psychological, and socio- cultural information; obtained information about some of the strengths and weaknesses the patient possesses; and the integration of this information helps to prioritize the patient’s concerns and problems.

4 The clinician addressed the patient’s strengths and weaknesses comprehen- sively across the biopsychosocial domains with attention given to individual and sociocultural differences. This information is integrated so that strengths are reinforced and amplified and weaknesses and problems are addressed. Issues are prioritized to reflect the patient’s needs, circumstances, and preferences and to maximize treatment effectiveness.

Note. Adapted from “Examining the Content of Mental Health Intake Assessments From a Biopsychosocial Perspective,” by L. Meyer and T. P. Melchert, 2011, Journal of Psychotherapy Integration, 21, p. 79. Copyright 2011 by American Psychological Association.

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174 biopsychosocial practice

rubric used to rate the level of comprehensiveness and integration of assess- ment information in that study.

The mean rating of the files in the l. meyer and melchert (2011) study was only 1.17 (SD = .45), and only 14.1% of the files were rated at 2 or higher on the scale, the midpoint indicating basic competency. The find- ings from this and the mcClain et al. (2004) study suggest that assessment information is often reported descriptively, with too little depth and detail, and without an analysis and integration that explains patients’ current problems in the context of their strengths, resources, weaknesses, vulner- abilities, and developmental history. Table 8.8 illustrates what comprehen- sive, integrative assessments look like; it provides examples for each of the five levels of thoroughness in the l. meyer and melchert study for three different types of patient cases.

DisCUssion: assessmenT oF The Whole Person

Conducting behavioral health assessment using the guidelines described in this chapter is a very ambitious undertaking. it requires extensive data col- lection across many areas of biopsychosocial functioning. Clinical interview- ing and relationship buildings skills are necessary to develop good rapport with patients so that more reliable and complete information is shared. strong communication and collaboration skills are needed to work effectively with other parties who can provide information that is important to the assessment. large bodies of knowledge regarding development; personality; psychopathol- ogy; the psychological, sociocultural, and biological bases of behavior; and psychometric measurement need to be learned and applied in order to prop- erly analyze and evaluate the information collected. Professional ethics and legal issues must be handled appropriately throughout the process. Clinical experience is also necessary for the proper evaluation and integration of all the data collected.

The ability to conduct thorough biopsychosocial assessments in this manner represents masterful clinical skill. This type of approach increases the likelihood that individuals’ behavior, health, and biopsychosocial needs are accurately identified, that vulnerabilities and risk factors are not missed, and that strengths and resources that are important in people’s lives are rec- ognized. This approach also meets all of the basic purposes of assessment that were noted at the beginning of this chapter. it identifies problems and concerns that need clinical attention and provides the information needed for developing comprehensive case conceptualizations and treatment plans. it provides baseline data for conducting ongoing assessment over the course

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assessment 175

TA B

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s)

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176 biopsychosocial practice

TA B

L E

8 .8

E xa

m p le

s o f C

o m

p re

h e n si

ve a

n d I n te

g ra

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A ss

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m e n ts

(C

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w ith

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p to

m s

re la

te d t o a

n a

n xi

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d is

o rd

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a n d

in d ic

a te

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e h

a s

b e e n u

n d e r

th e

tr e a tm

e n t o f a p

h ys

ic ia

n fo

r th

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co

n ce

rn s

fo r

3 m

o n th

s. S

h e s

ta te

s h e p

re sc

ri b e d a

n xi

o ly

tic s

fo r

th e se

sy

m p to

m s

b u t sh

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o e s

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th e m

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a tio

n . H

e r

sy m

p to

m s

h a ve

re

ce n tly

g o tt e n w

o rs

e . T

h e t h e ra

p is

t n o te

s th

e m

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a tio

n a

n d d

o sa

g e t h e

p a tie

n t h a s

b e e n t a ki

n g , in

cl u d in

g

im p o rt

a n t co

m p o n e n ts

s u ch

a s

si d e

e ff e ct

s a n d m

e d ic

a tio

n a

d h e re

n ce

. T

h e t h e ra

p is

t n o te

s th

a t th

e se

is su

e s

m a y

b e r

e la

te d t o c

u rr

e n t p ro

b le

m s.

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a tie

n t p re

se n ts

w ith

s ym

p to

m s

o f

d e p re

ss io

n , a n d t h e t h e ra

p is

t o b ta

in s

in fo

rm a tio

n r

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sy ch

ia tr

ic a

n d

p e rs

o n a l h

is to

ry a

n d p

a st

t ra

u m

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h e t h e ra

p is

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h is

to ry

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l s u

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rk , a

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r e

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ip s

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ia l t

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3 T

h e p

a tie

n t p re

se n ts

w ith

s ym

p to

m s

re la

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n a

n xi

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m e n t o f a p

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n .

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sy m

p to

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n tly

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p is

t n o te

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a -

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o sa

g e t h e p

a tie

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b e e n

ta ki

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cl u d in

g im

p o rt

a n t co

m p o -

n e n ts

s u ch

a s

si d e e

ffe ct

s a n d m

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a -

tio n a

d h e re

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. T h e t h e ra

p is

t n o te

s th

a t th

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n h

a s

h e lp

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p to

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a d u

n d e si

ra b le

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s,

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w e ig

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.

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a tie

n t p re

se n ts

w ith

s ym

p to

m s

o f

d e p re

ss io

n , a n d t h e t h e ra

p is

t o b ta

in s

in fo

rm a tio

n r

e la

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e rs

o n a l h

is to

ry .

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p is

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s a li

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e e n

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e n t sy

m p to

m s

a n d h

is to

ry . T

h e

th e ra

p is

t d is

cu ss

e s

w ith

t h e p

a tie

n t

d e tr

im e n ta

l a n d b

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ia l p

a tt

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s to

t h e li

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.

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w ith

a d ju

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e n t

co n ce

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re la

te d t o h

e r

p e n d in

g

d iv

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e , a n d t h e t h e ra

p is

t o b ta

in s

in fo

rm a tio

n r

e g a rd

in g t h e q

u a lit

y o f h e r

so ci

a l s

u p p o rt

n e tw

o rk

. T h e t h e ra

p is

t a ls

o o

b ta

in s

in fo

rm a tio

n r

e g a rd

in g

h o w

m a rr

ia g e a

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iv o rc

e h

a ve

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d e tr

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l t o h

e r

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io n in

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n d

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o si

tiv e im

p a ct

s a s

w e ll.

13647-09-PT3_Ch08-3rdPgs.indd 176 6/6/14 3:33 PM

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assessment 177

4 T

h e p

a tie

n t p re

se n ts

w ith

s ym

p to

m s

re la

te d t o a

n a

n xi

e ty

d is

o rd

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a n d

in d ic

a te

s sh

e h

a s

b e e n u

n d e r

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tr e a tm

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h ys

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n fo

r th

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co

n ce

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fo r

3 m

o n th

s. S

h e s

ta te

s h e p

re sc

ri b e d a

n xi

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tic s

fo r

th e se

sy

m p to

m s

b u t sh

e d

o e s

n o t lik

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th e m

e d ic

a tio

n . H

e r

sy m

p to

m s

h a ve

re

ce n tly

g o tt e n w

o rs

e . T

h e t h e ra

p is

t n o te

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e m

e d ic

a tio

n a

n d d

o sa

g e t h e

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b e e n t a ki

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cl u d in

g

im p o rt

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s u ch

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s, m

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a tio

n a

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, a n d

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t h e m

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a tio

n h

a s

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m e -

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te h

e r

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s ym

p to

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in r

e ce

n t

m o n th

s b u t h a s

a ls

o h

a d u

n p le

a sa

n t

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s, s

u ch

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w e ig

h t g a in

a n d

tir e d n e ss

. T h e t h e ra

p is

t n o te

s th

e

co n ce

rn t h a t tr

e a tm

e n t o f th

e a

n xi

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w

ith m

e d ic

a tio

n o

n ly

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n o t a ct

u -

a lly

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a n a g e t h e e

ff e ct

s o f

h e r

a n xi

e ty

b u t m

e re

ly m

a n a g e d t h e

sy m

p to

m s.

T h e t h e ra

p is

t a ls

o n

o te

s th

a t th

e p

a tie

n t b e lie

ve s

h e r

a n xi

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is

re la

te d t o h

e r

fa m

ily o

f o ri

g in

is su

e s

a n d d

e ve

lo p m

e n ta

l h is

to ry

.

T h e p

a tie

n t p re

se n ts

w ith

s ym

p to

m s

o f

d e p re

ss io

n , a n d t h e t h e ra

p is

t o b ta

in s

in fo

rm a tio

n r

e la

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o n a l h

is to

ry .

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p is

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cu rr

e n t sy

m p to

m s

a n d h

is to

ry . T

h e

th e ra

p is

t d is

cu ss

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w ith

t h e p

a tie

n t

d e tr

im e n ta

l a n d b

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a tt

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s o f re

sp o n se

s to

t h e li

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ve n ts

. T h e

th e ra

p is

t m

a ke

s lin

ks b

e tw

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n t’s

p e rs

o n a l h

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io n in

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h tin

g r

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rr e n t

p a tt

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s th

a t a ls

o a

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d in

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n t’s

p a re

n t’s

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tio n sh

ip .

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e p

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p re

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ts w

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d ju

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re la

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t o

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d in

g

d iv

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a n

d t

h e

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in fo

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tio n

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q u

a lit

y o

f h

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h o w

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rr ia

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im e n ta

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n d h

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p o si

tiv e im

p a ct

s a s

w e ll.

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p is

t p ri o ri tiz

e s

th e p

a tie

n t’s

p ro

b le

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in t h e

co

n te

xt o

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e n

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rc e

s a

n d

ta

ke s

th e p

a tie

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io u s

b e lie

fs a

n d

p

re fe

re n

ce s

in to

a cc

o u

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to

m a

xi m

iz e

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.

N o te

. F

ro m

T h e U

se o

f a C

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p re

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ch o so

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ra m

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o rk

f o r

In ta

ke A

ss e ss

m e n t in

M e n ta

l H e a lth

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ct ic

e (

D o

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rt a

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); T

a b le

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, b y

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0 0

8 ,

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a u ke

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I: M

a rq

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n iv

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178 biopsychosocial practice

of treatment to monitor progress, refine the treatment plan, and refocus interventions as needed. The baseline data also allows for an outcomes assessment that helps measure the effectiveness of treatment. Conducting thorough behavioral health assessments also helps engage patients in the treatment process by helping them gain insight into the nature of their prob- lems. Communicating to patients a thorough understanding of their problems, vulnerabilities, strengths, and resources is important to developing thera- peutic relationships and alliances, and there is consistent evidence that the therapeutic relationship and alliance are among the strongest predictors of treatment outcome (see Chapter 10).

it must be noted that behavioral health assessments in many settings do not require the comprehensive, thorough approach described above. as noted, it is not practical to conduct thorough assessments in all cases, and screens and other brief assessment procedures are sufficient for many purposes. learning a thorough conceptualization of the assessment process is critical, however, for being able to put clinical cases in proper context and appropri- ately evaluate the information obtained. it is difficult to judge the serious- ness and complexity of people’s problems if one does not understand the full spectrum of problem severity, the interaction of strengths and vulnerabilities across the biopsychosocial domains, the role of etiological and developmental factors, and the importance of prioritizing issues to minimize risks and maxi- mize the likelihood of treatment effectiveness.

This comprehensive assessment approach is significantly more com- plex than descriptive approaches that merely gather and report assessment information or approaches conducted on the basis of one of the traditional theoretical orientations that focus primarily on a single domain or area of functioning. The findings of the mcClain et al. (2004) and l. meyer and melchert (2011) studies suggest that many clinicians do not apply high levels of evaluation and integration to the assessment information they gather. Perhaps many of the therapists in these studies were applying a personally adopted theoretical orientation that focused their attention on particular issues, and they judged that a thorough analysis and evaluation of patients’ biopsychosocial circumstances was unnecessary. Clearly, the approach advo- cated here is different.

The importance and usefulness of comprehensive and thoroughly evalu- ated assessment information are evident when considering treatment planning, the next general phase of the treatment process. Well-designed treatment plans that effectively resolve problems and address needs while building resources and resilience over the long term as well as the short term require comprehen- sive, reliable, and valid assessment information that is appropriately evaluated and integrated.

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assessment 179

Case eXamPle: a CoGniTive–Behavioral versUs a BioPsyChosoCial aPProaCh To assessmenT

WiTh a milDly DePresseD PaTienT

This case example illustrates how behavioral health care assessment can differ when using a traditional orientation compared with the science-based biopsychosocial approach.

Cognitive–Behavioral Approach to Assessment

maria is a 44-year-old married latina woman presenting with con- cerns about depressed mood. The patient first consults a psychologist with a cognitive–behavioral theoretical orientation. The psychologist notes that maria wrote on the intake questionnaire that “my husband wants me to see a psychologist for mild depression.” The patient indicated no concerns about her physical health, marriage, work, or finances. she noted that she has two children, 9 and 11 years old. she denied any suicidal ideation or disturbing thoughts or feelings, and she reported drinking alcohol “socially.”

after reviewing the questionnaire and quickly scoring the scales, the psychologist notes that maria scored in the mild-to-moderate range of depression on the intake questionnaire, and he asks her about her depressed mood. she reports that she is “perhaps a little depressed,” but it’s really not a problem for her though her husband is concerned. she reports that she probably has a biological predisposition to depression because her mother seemed depressed as long as she can remember. she again denies any suicidal ideation. she reports being a pharmacist who is well respected at work and that her family is financially stable. she says that she is not arguing or fight- ing more than a normal amount with her husband, children, or coworkers, but she admits that “i am not really enjoying my family life the way i should, or my work, or my friends, or really much of anything except for my kids. i love my kids so much—they’re really wonderful. But everything is kind of a chore. i’m not seeing my friends much anymore. i suppose i’m not that much fun to be around either. That’s probably why my husband asked me to see a therapist. so here i am.”

maria goes on to explain that she has been married for 12 years to a physical therapist who has a good job at a local orthopedic clinic. she reports that she and her husband have a good marriage and family life, though she feels they have drifted apart since their children started school. she says she was “head-over-heels, totally in love on my wedding day. it was the happiest day of my life! he was interesting, and intelligent, and had a good career. he is funny and positive. and he’s incredibly fit and attractive.” she says her

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180 biopsychosocial practice

girlfriends “just love him—they’re really jealous of me.” she reports that their two children, in third and fifth grade, are both doing well. “They like school, they seem to be above average in their classes, they have nice little friends, and they’re well behaved at home.” she reports that the children attend an after-school program until she or her husband can pick them up after work and that she spends most of her nonwork time at home with the children. she says that she loves her husband and children a lot but that she doesn’t have much enjoyment in her life. “To tell you the truth, i feel guilty. i’m not the best wife, and i’m not the best daughter to my own parents either—i actually avoid them. i hope i’m being a good mom to my kids, though i worry about that. i’ve just sort of slacked off on things.”

at this point, the psychologist explains that he thinks maria is showing typical signs of mild depression. The psychologist points out that her com- ments show that she engages in dichotomous thinking, as when she implied that if she isn’t really happy with her social life or leisure activities, then she feels like nothing is enjoyable, or that if she has cut back on some of her activities, she has “slacked off on everything.” The psychologist also notes that she tends to overgeneralize from some of the less satisfying aspects of her social life and marriage and concludes in a blanket fashion that she has slacked off on everything and that nothing is enjoyable anymore.

Biopsychosocial Approach to Assessment

maria consults a second psychologist, who takes a biopsychosocial approach to treatment. she completes a similar intake questionnaire, and the psychologist inquires about the same initial topics. she relates the same general information, though the psychologist asks for more details regard- ing several topics. For example, he asks some follow-up questions about her work, and she reports that she is considered a strong member of the staff and gets very positive evaluations—“i’m a really good worker and i have high standards; i don’t make mistakes and am really good with providers and with customers. i get some of the highest merit raises in the region.” When she reports that she has good physical health, the psychologist asks about her level of physical exercise and activity. she reports that she used to exer- cise regularly, nearly as much as her husband, but she gradually stopped after the children were born. she reports that she eats healthy—“i have to! my husband is a health fanatic and he makes most of the meals. and i don’t snack between meals. i suppose you don’t believe that because i’m kind of heavy now. it’s actually kind of disgusting, compared to the way i used to be.” When asked how she gained weight if she eats well, she says it’s due to alcohol—“i drink a glass of wine or two in the evening to unwind.” The psychologist asks about her marital relationship, and she reports that she and her husband gradually

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assessment 181

stopped going out on dates after their children were born—it was hard find- ing babysitters, and it cost a lot of money. her mother babysits for free, but she also criticizes their parenting, so they stopped asking her to babysit. “my mother is a traditional mexican lady, and she really doesn’t approve of me having a job outside the home. she likes my husband and adores our kids. But she doesn’t like it that i work.” she also notes that her parents are very disappointed that she and her husband do not belong to a church and the kids are not being raised to be religious.

The psychologist asks maria about their social life, and she reports that she and her husband stopped going out with other couples and she stopped seeing her friends, though her husband still goes out with his friends and is active socially. When asked about the quality of their intimate relationship, she reports that she and her husband used to have an active and satisfying sexual relationship, but that dropped off and she doesn’t really enjoy sexual relations a lot anymore. The psychologist asks about her hobbies and interests, and she reports that she used to enjoy reading, music, and film a lot, but now she mostly watches Tv. she said that she’d like to be involved in the parent–teacher orga- nization at school but hasn’t found the time. When asked about her relation- ship with her own family, she reports that she has been avoiding her parents mostly because she doesn’t like criticism from her mother.

The psychologist explains to maria that her lack of involvement in social and other activities is common for young parents who begin raising children. The psychologist notes that she and her husband appear to have been very successful with their careers and children, but they have neglected their relationship. he also notes that she sounded quite disappointed about neglecting her exercise and physical health. he asks her whether she is fol- lowing a pattern similar to her own mother and whether she would like to explore possibilities for improving her relationship with her mother and the rest of the family.

The psychologist explains that there are several different ways to address these issues, but before they decide on the best approach, he would like to hear her husband’s perspective on these issues. she agrees to ask him to come in for their next appointment. at the end of the session, the psychologist completes a form (see Table 8.9) with the patient to help summarize maria’s situation. maria notes that the summary ratings simplify things but give a picture of her life that she never thought about before, and they help her realize that things could be a lot better.

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182 biopsychosocial practice

TA B

L E

8 .9

S u m

m a ry

o f th

e B

io p sy

ch o so

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ss e ss

m e n t fo

r th

e C

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n e e d

0

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st

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d e

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M a

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th

B io

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a l f

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h ys

ic a l h

e a lth

✓ C

h ild

h o o d h

e a lth

h is

to ry

✓ M

e d ic

a tio

n s

✓ H

e a lth

h a b its

a n d b

e h a vi

o rs

✓

P sy

ch o lo

g ic

a l f

u n ct

io n in

g

L e ve

l o f p sy

ch o lo

g ic

a l f

u n ct

io n in

g ✓

H is

to ry

o f p re

se n t p ro

b le

m ✓

In d iv

id u a l p

sy ch

o lo

g ic

a l h

is to

ry ✓

S u b st

a n ce

u se

a n d a

b u se

✓ S

u ic

id a l i

d e a tio

n a

n d r

is k

a ss

e ss

m e n t

✓ E

ff e ct

s o f d e ve

lo p m

e n ta

l h is

to ry

✓ C

h ild

h o o d a

b u se

a n d n

e g le

ct ✓

O th

e r

p sy

ch o lo

g ic

a l t

ra u m

a s

✓ M

e n ta

l s ta

tu s

e xa

m in

a tio

n ✓

P e rs

o n a lit

y st

yl e a

n d c

h a ra

ct e ri

st ic

s ✓

S o ci

o cu

ltu ra

l f u n ct

io n in

g

C u rr

e n t re

la tio

n sh

ip s

a n d s

o ci

a l s

u p p o rt

✓ C

u rr

e n t liv

in g s

itu a tio

n ✓

F a m

ily h

is to

ry ✓

E d u ca

tio n a l h

is to

ry ✓

E m

p lo

ym e n t

✓ F

in a n

ci a l r

e so

u rc

e s

✓ L e g a l i

ss u e s/

cr im

e ✓

M ili

ta ry

h is

to ry

✓ A

ct iv

iti e s

o f in

te re

st /h

o b b ie

s ✓

R e lig

io n

✓ S

p ir

itu a lit

y ✓

M u lti

cu ltu

ra l i

ss u e s

✓

13647-09-PT3_Ch08-3rdPgs.indd 182 6/6/14 3:33 PM

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