Mental Status-WEEK 3

3 Assessment and Diagnosis Pamela Bjorklund

A comprehensive assessment of the patient who presents for psychotherapy is nec- essary to develop an appropriate treatment plan. In some settings, a comprehensive assessment must be conducted during the initial session. This chapter presents the format and tools for such an assessment. The comprehensive psychiatric database and instruments included in this chapter can also be integrated in a setting that allows the therapist to conduct an assessment over several sessions. However, the therapist may bill for an initial, comprehensive assessment only once during the course of the assessment process. In reality, most assessments continue throughout the treatment, and therapists initially use only selected instruments in acquiring a database. The set- ting and population with whom a therapist works determine what is necessary and what is optional. Other screening tools not included in this chapter may be required by an agency or employer or are necessitated later by an evolving understanding of the patient.

INTRODUCTION

Even if the advanced practice psychiatric nurse (APPN) sees a patient only for the assess- ment, a sensitively crafted intake assessment can be a powerful therapeutic tool. It can establish rapport between patient and therapist, further the therapeutic alliance, allevi- ate anxiety, provide reassurance, and facilitate the flow of information necessary for an accurate diagnosis and appropriate treatment plan. For better or for worse, an assess- ment is a relational process. It represents a verbal and nonverbal dialogue between two therapeutic partners, whose behaviors reciprocally influence each other’s style of com- munication and result in a specific pattern of interaction (Shea, 2017). To the degree this pattern of interaction transcends its question-and-answer format to constitute an authentic encounter between the patient and therapist; an assessment can play a signifi- cant role in the change process (Safran & Muran, 2000). At the very least, a sensitively crafted assessment can help ensure that a patient in distress returns for follow-up care.

Shea (2017) identified the broad goals of clinical assessment as follows:

1. To effectively engage the patient in the data-gathering process 2. To collect information and form a valid database 3. To develop an evolving and compassionate understanding of the patient 4. To develop an assessment from which a tentative diagnosis can be made 5. To collaboratively identify problems and therapeutic goals

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6. To collaboratively develop a tentative treatment plan to achieve these goals 7. To effect some decrease in the patient’s anxiety 8. To instill hope and ensure that the patient will return for the next appointment

The goals of engaging the patient in a therapeutic alliance, gathering data, uniquely understanding the patient as a person, and arriving at the most appropriate diagnosis and treatment plan are parallel assessment processes (Shea, 2017). Generally, the more powerfully engaged the patient and therapist are during the assessment process, the more valid are the data on which to base the diagnosis that will guide the choice of treatment plan.

In a clinical sense, validity refers to the accuracy of the database, that is, to whether the clinician actually elicited the information he or she tried to elicit (Shea, 2017). The more valid the database—and by implication, the more valid the diagnosis—the more confidence the therapist can have in the treatment plan and the more reassurance he or she can offer to patients about their probable course or expected outcomes. The success- ful engagement of patients in the assessment process is key to the validity of assessment data. It requires empathy, patience, a willingness to afford patients sufficient time to tell their stories in their own manner, the ability to structure patients when necessary, and careful attention to patients’ needs for comfort, privacy, and security. Consequently, this chapter examines important areas for assessment and provides specific screening tools to aid in the assessment process while attending to the manner in which the therapist also fosters therapeutic engagement. It describes the process of taking a history and the comprehensive assessment of areas of patient functioning that are important to the practice of psychotherapy, including ego functioning, affective development, interper- sonal relationships, and belief systems. The chapter ends with a discussion of diagnosis and case formulation, without which the treatment plan has no rationale.

TAKING A HISTORY

Fundamentally, the comprehensive psychiatric history is a form of life story told to the therapist by a patient in his or her own words and from his or her own point of view (Sadock, Sadock, & Ruiz, 2015). In some situations and with the patient’s consent, excluding only emergency situations, the psychiatric history may include information from other sources, such as a parent, spouse, former therapist, other referral source, or medical record. The therapist must collaborate with a consenting patient in negotiat- ing the details of how and when to obtain collateral information from other sources. A comprehensive history includes information about the current episode of illness with data related to the onset, chronology, and severity of current symptoms and stressors. It also includes past and present psychiatric and medical histories, a psychiatric review of systems, medication and substance use histories, a history of violence or self-destructive behavior, any history of trauma, and developmental, family, social, educational, occupa- tional, and legal histories. Box 3.1 provides an outline of the major sections of the psy- chiatric history/initial psychiatric interview as adapted from The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults (3rd ed.; American Psychiatric Association [APA], 2016; Box 3.2) and Kaplan & Sadock’s Synopsis of Psychiatry (11th ed.; Sadock et al., 2015). Appendix 3.1 outlines the content of a comprehensive psychiatric database developed from multiple sources, including professional experi- ences in various clinical assessment venues (APA, 2016; Gordon & Goroll, 2003; Marken, Schneiderhan, & Munro, 2005; Morrison, 2014; Sadock et al., 2015; Scully & Thornhill, 2012; Shea, 2017). Appendix 3.2 presents a sample intake assessment form adapted from Shea (2017) that includes all sections of the comprehensive psychiatric database.

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Obtaining such a comprehensive history from the patient and, if necessary, from informed sources close to the patient is essential to making an accurate, culturally appro- priate diagnosis and developing a specific, culturally sensitive, and effective treatment plan (Sadock et al., 2015). From this life story, the therapist can begin to paint a picture of the patient’s personality characteristics, strengths and areas for growth, interpersonal style, cultural context, and development from his or her earliest years to the present moment. Taking a history, which also can be seen as a cocreative act of constructing a comprehensive life story, allows the therapist and ultimately the patient to more com- pletely understand who the patient is, where the patient has come from, and how the patient may develop in the future (Sadock et al., 2015). It is an essential first step to reimagining the life story. That people in psychotherapy often come to change their life stories over the course of treatment is a positive development, because a patient’s reflec- tions on past circumstances in light of the changing present heralds the creation of a dif- ferent future (Barker, 2001). The revision of life stories through narrative is the essential work of psychotherapy, which is a unique form of encapsulated experience that focuses on the life experiences of another such that those experiences can be reconsidered, more deeply understood, reframed, and thus reconstructed in healthier ways (Peplau, 1989). It all starts with taking a history.

I. Reason for the evaluation A. Identifying data B. Source and reliability of data C. Chief complaint

II. History of the present illness (HPI) A. Symptoms B. Stressors

III. Past psychiatric history A. Trauma history

IV. Substance use/abuse history V. Past medical history

VI. Family history VII. Developmental and social history

A. Strengths B. Support systems C. Values/belief systems

VIII. Review of systems IX. Mental status examination (MSE) X. Case formulation XI. DSM-5 diagnoses XII. Treatment plan

BoX 3.1 Major Sections of the Psychiatric History

The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults (3rd ed): psychiatryonline.org/doi/book/10.1176/appi.books.9780890426760 psychiatryonline.org/guidelines

BoX 3.2 Websites for American Psychiatric Association (APA) Practice Guidelines

DSM-5, Diagnostic and Statistical Manual of Mental Disorders (5th ed.).

Source: American Psychiatric Association. (2016). The American Psychiatric Association practice guidelines for the psychiatric evaluation of adults (3rd ed.). Arlington, VA: Author; Sadock, B. J., Sadock, V. S., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

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CASE EXAMPLE

opening moves

In settings where a comprehensive history must be completed in one session, the thera- pist must accomplish a number of important alliance-building tasks in the first minutes of the initial assessment. These include an appropriate greeting, introductions (if not already made in an earlier contact), an indication of seating preference, a brief introduc- tion to the assessment process, and an open-ended invitation to the patient to tell the therapist how he or she can be of assistance. In these moments, the therapist should indicate what the interview will be like, how much time it will take, what sort of ques- tions will be asked, and what sort of information the patient is expected to share. The therapist needs to create a comfortable and secure environment that allows the patient as much control as possible (Morrison, 2014). Early in the assessment, a nondirective interview style with open-ended questions yields control to the patient, generally builds rapport, and garners facts that are more reliable (Morrison, 2014; Shea, 2017). Because studies have shown that patients give the most valid information when they are allowed to answer freely, in their own words, and as completely as they wish, it is generally desirable to initially employ open-ended questions that allow the widest possible scope of response (Morrison, 2014). To illustrate how a therapist may begin the data-gathering process, Box 3.3 summarizes the first moments of an initial clinical assessment with a fictive psychotherapy patient, who has indicated in an earlier phone contact her prefer- ence to be called by her first name, Beth.

In the medical model, the patient’s response to the therapist’s opening question is called the chief complaint, but it might better be called the patient-identified problem in a holistic nursing model. It is the patient’s stated reason for seeking help and is

APPN: Hello, Beth. It’s nice to meet you in person. Please, sit down. You can make yourself comfortable here. [Points to a chair.]

Patient: Okay, thanks. APPN: As I mentioned on the phone, I am an advanced practice psychiatric

nurse, and in today’s session, I hope to get a clearer sense of the dif- ficulties you alluded to on the phone. I will be asking questions about important areas of your life, and with your permission, I would like to be able to take a few notes. I don’t want to forget anything. [Smiles, waits for a response.]

Patient: That’s fine. APPN: I would like to get as much history as I can today, but if we aren’t able

to get to everything, we’ll continue next week. I’ll be asking lots of questions about your present circumstances and your past history, so if any of my questions make you uncomfortable, please let me know. I do not want to contribute to your distress, but I do want to hear as much about your thoughts and feelings as you are comfortable telling me.

Patient: That’s fair. I’ll try. APPN: Could you tell me in whatever way you like what brings you in today? Patient: [Takes 5 to 10 minutes to tell her story, with open-ended prompts by

the therapist only as needed, e.g., “What happened then?” “Could you tell me more about that?” “How were you feeling at that time?” “What else was going on?”]

BoX 3.3 Beginning the Clinical Assessment

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recorded verbatim. It often reveals the problem uppermost in the patient’s mind (Morrison, 2014) and can indicate the content region (Shea, 2017) or assessment area (APA, 2016) the therapist should explore first. When the patient’s response to the thera- pist’s opening question is a denial that anything is wrong, it is often helpful to rephrase the question in terms of why others may think the patient should seek help, such as “Can you tell me what went on that your (mother, spouse, friend, employer, primary care provider, court officer) thought you might benefit from coming in?” Another tech- nique is to ally with the patient’s resistance or sidestep it; for example, “Nothing may be wrong, but because you’re already here, perhaps we can try to figure out if there is something else I can help with.” Such denials are the first indication that the therapist may encounter significant resistance from the patient to engaging in psychotherapy, and they are cogent reminders that the first task of data gathering is alliance building.

During the minutes that follow the patient-identified problem, while the patient is freely telling his or her story, much is signaled that the therapist will need to explore in greater depth later in the interview. The therapist needs to mentally note or write down these areas of clinical interest, or content regions, so that specific questions can be asked at the appropriate time. Box 3.4 summarizes the content from Beth’s response to the therapist’s opening question.

APPN: Can you tell me in whatever way you like what brings you in today? Patient: I don’t know. [Long pause.] Donna N. [referral source] sent me. She and

my mom and my advisor thought I had depression. Actually, I’ve been depressed on and off since the 10th grade. [Another long pause.] I have a lot of problems getting along with my parents, especially my mom. I’ve been thinking about dropping out of school until spring semester to get my head together, but my advisor talked me out of it. I am dropping only one class. I’m not really happy about deciding to stay in school. I cried for 3 hours about it. I’m overwhelmed with school. I can’t catch up. I don’t care about anything anymore. I’m happy just to stay in bed. The slightest things make me feel bad. I’m angry all the time. My mother thinks my personality has changed. I don’t know. Maybe it has. I’m more irritable around my boyfriend. The slightest things he does put me on edge. My mother, too. She calls me every night in the middle of studying, and it gets on my nerves. If she didn’t call me, I wouldn’t even think about her.

APPN: Beth, you mentioned you are quite irritable these days and have been crying a lot. Can you tell me more about the depressive symptoms you’ve been having?

Patient: Well, I sleep okay, but I wake up tired, and I have no energy for any- thing. I’m not really sad, just angry and irritable and overwhelmed with everything.

APPN: Anything else? Patient: A few days ago I thought about suicide. It just crossed my mind. I don’t

really want to die. I just want my problems to end. APPN: What did you think about? [Therapist takes this opportunity to thor-

oughly assess current suicide risk and to explore the past history of sui- cidal behavior. She then returns to the “depression” content region to more thoroughly assess the possibility of a diagnosable mood disorder, such as major depression or dysthymia.]

BoX 3.4 Exploring the Patient-Identified Problem

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Expanding the Assessment

Although no rules dictate which content regions to explore first or in what order, it is generally advisable to thoroughly explore one before moving on to another (Shea, 2017). In this example, the therapist chooses to first explore the symptoms of a possible mood disorder and, when the patient (Beth) broaches the subject, to assess her current suicide risk. However, Beth makes a mental note to follow these content regions with the devel- opmental, family, and social histories, focusing on Beth’s strained relationships with her mother and boyfriend and on her academic decline. After a thorough assessment of the current suicide risk and any history of suicidal behavior, the therapist returns to the current mood symptoms and the history of the present illness (HPI) to get a more thorough sense of the onset, extent, severity, and chronology of mood symptoms and whether criteria are met for any particular mood disorder. In doing so, she learns more about Beth’s hostile and enmeshed relationship with her mother. It seems the patient has been dysthymic since the 10th grade, when Beth’s mother put her daughter’s dog to sleep without her knowledge. This occurred on the day Beth got her braces removed from her teeth. A family celebration had been planned: “It was supposed to be a happy day for me. It wasn’t.” Apart from the fact that it is the humane thing to do, an engaged clinician should take this opportunity to further strengthen the therapeutic alliance— which facilitates continued data gathering—by empathizing with the patient’s distress about what appears to have been a significant loss and a rather cruel act of sabotage by the patient’s mother (e.g., “You must have been very hurt by this.”). The therapist then needs to move to the developmental and family history to learn more about this incident and to more thoroughly assess the family dynamics, especially the patient’s relationship with her mother (e.g., “Tell me more about that day, your relationship with your mother, and your family situation.”).

In this way, the therapist proceeds to take a history, thoroughly exploring all the major sections of the comprehensive psychiatric database (see Box 3.1) by opening new content regions as opportunities arise. Open-ended questions invite exploration in new content regions, reveal what is uppermost in a patient’s mind, and may yield important information about the patient’s capacities, defenses, or degree of resistance to engaging in psychotherapy. Closed-ended questions elicit the specific details—such as symptom type, severity, frequency, duration, and the context in which a symptom occurs—that are necessary to thoroughly assess a content region or establish a diagnosis. Table 3.1 provides an outline of open-ended and closed-ended assessment questions along a con- tinuum of openness. Opportunities to open new content regions do not always arise spontaneously; and in those cases, the therapist must guide the assessment into new clinical areas. Occasionally, time constraints may force a therapist to make an abrupt transition to unexplored content regions in order to complete the assessment within the allotted time. Nevertheless, the transition can be made skillfully, sensitively, and in a manner that continues to facilitate the therapeutic alliance. Box 3.5 illustrates the use of open-ended and closed-ended questions to facilitate skillful, even if abrupt, transitions to new content regions.

organizing the History of the Present Illness

Of all the major content regions of the psychiatric history, the most important is the HPI. It represents the heart of the assessment interview. It is the most substantial part of the initial clinical assessment and includes a description of the patient’s key symptoms, their timing and associated problems, and the stressors that account for their exacer- bation. When well organized, the HPI develops much like a short story. It progresses chronologically through the onset and development of the patient’s key symptoms to

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TABLE 3.1 ASSESSMENT QUESTIONS: CONTINUUM OF OPENNESS

Type Example

Open-Ended Types

Open-ended questions What brings you in today?

How can I help you?

How would you describe your relationship with. . .?

Gentle commands Tell me about your family situation.

Try to describe how you felt when. . .

Share with me what you think a good outcome would be.

Intermediate Types

Swing questions (client can say “no” or client can elaborate)

Can you describe the depressive symptoms?

Can you tell me anything more about that?

Can you tell me what you’re thinking right now?

Qualitative questions How have you been sleeping?

How is school going?

How have you been getting along with your mom?

Statements of inquiry So you have never before received any therapy?

Your mother decided to go back to school when you did?

You say you just want to stay in bed all the time?

Empathic statements You must have been so hurt by that.

That is very frustrating.

It is hard to lose someone you love.

Facilitating statements Go on.

I see.

Closed-Ended Types

Closed-ended questions How many drinks did you have?

How often do you feel that way?

Closed-ended statements You can sit down here.

We’ll take about 50 minutes to. . .

Medications can be very effective in these cases.

Source: Adapted from Shea, S. C. (2017). Psychiatric interviewing: The art of understanding (3rd ed.). New York, NY: Elsevier.

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the time of the patient’s presentation for evaluation. By the end of a detailed HPI, an experienced clinician should be able to construct a near complete differential diagnosis. A thorough and well-constructed HPI contains the following components, roughly in the following order:

1. A statement of the patient’s baseline functioning or last period of stability 2. Any previous diagnoses of psychiatric disorder and a brief synopsis of the course

and treatment 3. The onset of the first symptom and its precipitant 4. A chronology of one to three key symptoms, including when they worsened and the

precipitant events that caused them to worsen 5. Associated symptoms related to the one to three key symptoms 6. Documentation of the “why now,” that is, why the patient presents for treatment

now 7. Repetition of components 3, 4, and 5 if there is more than one diagnosable disorder 8. A list of pertinent negative symptoms, that is, symptoms that are not present 9. A list of additional stressors not mentioned

Box 3.6 documents the HPI in the case of Beth, inserting numbers 1 through 9 at appropriate points in the text to mark the essential HPI components as listed above.

APPN: Beth, you’ve told me a great deal of very helpful information about your family situation. I’m beginning to understand the kinds of things you’re dealing with. But I’ve noticed the clock, and we have only 15 minutes left. There are some other things I need to know before we can talk about where to go from here. Can you handle a few more questions? [closed-ended question]

[Note: Using a patient’s name judiciously can comfort, contain, invite closeness, and facilitate the therapeutic alliance. If used artificially or too often, it can seem ingratiating or insincere and can distance the patient and impede the therapeutic alliance.]

APPN: You mentioned that you saw a school counselor when you were in the 10th grade and your dog was put to sleep. Can you tell me more about that treatment? [open-ended, swing question]

Patient: Well, there’s not much to tell. I saw her only once. It wasn’t really a treatment. We talked for about 30 minutes. A teacher was concerned when she saw me crying at school. I didn’t go back. She said I didn’t have to if I didn’t want to.

APPN: Were there any other times that you saw a counselor, therapist, or psychiatrist? [closed-ended question]

Patient: No. APPN: So you’ve never before received any therapy or any psychiatric treat-

ment, either as an inpatient or outpatient? [closed-ended statement of inquiry]

Patient: No. APPN: Okay. What about substance abuse? [open-ended question] Patient: Treatment? No, never. In fact, I don’t use anything. I don’t even drink

coffee. I suppose . . .[long pause; therapist waits] APPN: Go on. [facilitating statement] Patient: Well, I have tried some things, but it was a long time ago. APPN: Tell me. [open-ended, gentle command]

BoX 3.5 Transitioning to New Content Regions

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mental Status Examination

The mental status examination (MSE) has become a standard component of the initial clinical assessment. It is the clinician’s description of the patient’s current mental func- tioning. It is a direct examination of the patient’s behavior and the examiner’s infer- ences from what the patient says and does. In making these inferences, the clinician must carefully consider the patient’s educational and cultural background. Illiteracy and differences in ethnic, cultural, and linguistic backgrounds can distort the results of the MSE (Jacob, 2012). The principles of symptom elicitation during the MSE are com- parable to those employed in interpreting diagnostic laboratory tests, which require both sensitivity and specificity, and are employed to screen, exclude, or confirm abnor- malities (Jacob, 2003, 2012). Although it is beyond the scope of this chapter to discuss

Beth is a 20-year-old college junior majoring in business administration who has felt chronically depressed since approximately the 10th grade, when her mother put her dog to sleep without her knowledge on a day the family planned to celebrate the removal of her braces (1).* She has no previous history of psychiatric treatment (2). In August, she moved away from home for the first time after having an argument with her parents about money and college expenses. The focus of the conflict was Beth’s resentment about their refusal to help her more with college expenses when they had money for new recreational vehicles, house remodeling, and, most significantly, her mother’s sud- den enrollment in the Denton Business University, which coincided with Beth’s change of majors from psychology to business administration. She moved in with her boyfriend of the past year and a half and found herself feeling increasingly irritated with him (3). Despite these stressors and her increasingly low mood, she functioned relatively well in school until approximately 3 weeks ago, when she began to feel more depressed, apa- thetic, and fatigued than usual. She wanted to drop out of school but was talked out of it by her academic advisor and ended up dropping only one course. She states she sleeps well but wakes up tired and has no energy. She “doesn’t care about anything anymore” and is “happy to stay in bed.” The “slightest things make me feel bad,” and she has crying episodes three or four times per week. Beth has lost approximately 8 pounds in the past 3 weeks. She reports that she does not feel sad, hopeless, or helpless, just over- whelmed by school, work, changing majors, having to interact with her parents—her mother calls her every evening during her study time—and having to work harder to get along with her boyfriend in close quarters. All her symptoms have worsened over the past 1 to 2 weeks and are exacerbated by the seemingly daily conflict with her mother and boyfriend (4). Within the past week, she has begun scratching on her wrists with plastic, serrated knives—something she has not done since high school (5). Three days ago, a particularly loud and hostile phone conversation with her mother annoyed Beth’s boyfriend, causing a bitter argument between the two of them. He stomped out of the apartment and did not return that night (6). She felt “abandoned” and “panicky”; thoughts of suicide (no plan or intent) crossed her mind, which scared her enough that she contacted her college vocational counselor, who referred her for psychiatric evalu- ation (7). She denies acute suicide ideation today, as well as any symptoms of mania or hypomania, psychosis, or severe anxiety (8). Additional stressors include 20 to 25 hours per week of work at McDonald’s while carrying 12 semester credits, a substantial tuition bill that comes due very soon, and a growing sense that she needs to move again because she cannot tolerate the increased closeness with her boyfriend (9).

*Parenthetic numbers 1 through 9 mark the essential components of the history of present illness that are listed in the text.

BoX 3.6 Documenting the History of Present Illness

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in detail how to perform a formal MSE, Appendix 3.1 includes a comprehensive out- line of the content and possible organization of a formal MSE. Many of its sources (see Appendix 3.1) describe the performance of the MSE in great detail.

All APPNs must learn to perform a comprehensive, formal MSE, which has value even in the case of psychotherapy patients who present as cognitively intact. A formal MSE may elicit subtle abnormalities not readily apparent earlier in the assessment pro- cess. Although the volume of material to cover can seem daunting, much of the MSE is obtained during the general history-taking interview, requires no special questions or tests, and can be assessed through informal observation that begins the moment the therapist first encounters the patient. The key is to know what elements to look for and to be systematic in looking for them. When comfortable with a format for a complete MSE, the therapist can tactfully transition from informal observation to a direct, sys- tematic examination of the patient’s cognitive status when a suitable opportunity pres- ents itself (Box 3.7). General introductory questions followed by specific confirmatory questions are standard. Open-ended formats and general probes are sensitive screening strategies (e.g., “Have you felt like odd things are happening that you cannot explain?”). More precise confirmatory questions provide specificity (e.g., “Are your thoughts read by other people?”; Jacob, 2003).

Sometimes, opportunities for a smooth transition to the formal MSE do not present themselves. Occasionally, a complete examination is impossible, such as with a very agi- tated or uncommunicative patient; and sometimes, it can seem insulting to ask appar- ently high-functioning people what today’s date is or whether they can remember a “red ball” and “37 Elm Street” for a period of 5 minutes. Nevertheless, when a clini- cian inadvertently fails to perform a formal MSE or makes a deliberate decision not to perform one in a patient who seems unimpaired, the therapist risks missing impor- tant information that may emerge only through a direct, systematic examination of a patient’s cognitive function. Until it becomes second nature, APPNs should choose a format, memorize it, and perform the MSE the same way each time (Morrison, 2014).

Box 3.8 presents one way of organizing data from the MSE. It summarizes the results of Beth’s formal MSE as it might appear in a formal diagnostic report or on a clinical assessment summary. However, therapists must develop their own systematic method of obtaining, organizing, and recording the MSE so that the process becomes second nature. Although the results of Beth’s MSE are essentially within normal limits, the doc- umentation of specific mental status abnormalities can help to substantiate a diagnosis and particular treatment needs.

Time Frames and Closing moves

The patient’s unique circumstances determine how much time the therapist spends on each major section of the psychiatric history. In Beth’s case, the therapist will spend much of her time gathering data for the HPI and the family, developmental, and social histories.

APPN: You mentioned a short while ago that you’re having trouble with your memory, so let’s see exactly what that difficulty is. Can you tell me today’s date?

APPN: You say that you cannot concentrate. Let’s take a closer look at that. I’m going to give you three things to remember and then ask you in a few minutes to recall them: a red ball, 37 Elm Street, and a clock radio. Can you repeat them now?

BoX 3.7 Transitioning to the MSE

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Very little time is needed for the psychiatric history, medical history, substance use his- tory, and MSE because the patient is young, physically healthy, cognitively intact, and has no history of prior psychiatric treatment or significant substance use. Although the needs of the patient determine which content regions are most appropriate for deeper exploration, and taking into consideration time constraints (usually 60 minutes for an initial assessment), Morrison (2014) and Shea (2017) provide guidance on how to carve up the allotted time when the assessment data must be gathered in one session. Morrison (2014) suggests the following:

Shea (2017) suggests at least 5 to 7 minutes for the scouting period, which is what Morrison (2014) calls free speech and what is essentially the time it takes for the patient to narrate his or her story. By the end of the first 30 minutes of the initial assessment, the therapist should be nearing completion of the content regions that seem most pertinent for that patient. Often, during the third 15-minute period, the family history, medical history, social history, and the formal MSE are completed (Shea, 2017). In Beth’s case, exploration of the family, developmental, and social issues would have been explored in depth earlier, because they are uniquely important content regions for her and might have extended into the third 15-minute assessment period.

In any case, Shea (2017) recommends that the therapist monitor, at least every 5 to 10 minutes, the progress of his or her data gathering and adjust the pace as necessary. It is probably a good idea to check with the patient by asking, “Is this okay for you?” During the last 15 minutes of the assessment period, regional content explorations of the major sections of the psychiatric history are completed; final points of clarification

Beth is an attractive, subdued, casually and appropriately dressed, 20-year-old single, White female who appears to be her stated age. She is quite distressed and is fight- ing back tears. However, she makes good eye contact and readily engages with the examiner. Her speech is fluent, soft, and quavering; her affect ranges from flat to sad and angry. Her mood is dysthymic and congruent with her affect. Her movements are graceful and without abnormality. She is alert and fully oriented. She evidences no prob- lems with attention, concentration, or memory. She can recall 6/6 objects at 0 and 5 minutes, can subtract serial sevens without difficulty, repeats five digits forward and backward, can abstract proverbs, and has an adequate fund of general knowledge. Her thought processes are logical, linear, and goal directed with no evidence of a thought disorder. Prominent themes in her thought content include her smoldering resentment toward her parents, particularly her mother, and her feelings of being overwhelmed by her schoolwork. She denies current, active suicide or homicide ideation as well as all signs and symptoms of psychosis. Superficially, her judgment is intact. She appears to be of above-average intelligence; however, her problem-solving abilities are transiently overwhelmed. She is excessively worried about “not being ahead of the game,” as she customarily would be.

15%: Chief complaint and free speech

30%: History of present illness; pursuit of information relevant to the differential diagnosis; histories of suicide, violence, or substance use

15%: Medical history; review of systems; family history

25%: Personal (developmental and social) history

10%: MSE

5%: Discussion of the diagnosis and treatment plan; plan for next visit

BoX 3.8 Documenting the Mental Status Examination (MSE)

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are pursued; and termination occurs. Time can get away from even experienced psy- chotherapists, especially when a patient is particularly distressed, verbose, vague, or disorganized. However, whenever possible, the last 5 to 10 minutes of the assessment period should be devoted to discussing the findings, treatment recommendations, and follow-up plan; answering whatever questions the patient may have about those find- ings; processing the patient’s assessment experience; paving the way for the next visit; and in doing all that, continuing to build the strong therapeutic alliance on which a good psychotherapy outcome depends. Box 3.9 illustrates the closing minutes of Beth’s initial clinical assessment.

Assessing Ego Functioning

The assessment of ego functioning from the perspective of ego strength, as opposed to ego deficit, is a valuable skill for nurse psychotherapists. The identification and assess- ment of ego strength help the therapist locate a patient on a developmental continuum, suggest a place to join with the patient to begin the therapeutic work, provide data to develop therapeutic goals, and create a valid construct for psychotherapy outcome mea- surement (Bjorklund, 2000; Burns, 1991). The person who gains ego strength as a result of his or her work with a therapist has made noteworthy therapeutic progress. Broadly defined, ego strength is the capacity for effective personal functioning (Burns, 1991). It encompasses specific capacities such as adaptability, resourcefulness, self-efficacy, self- esteem, interpersonal effectiveness, life satisfaction, and the many other mental health indicators succinctly encapsulated in Freud’s (1923/1961) well-known phrase “to love and to work.” Like the solid foundation of a well-built house, ego strength supports the

APPN: [Summarizes diagnostic impression and treatment recommendations.] So that’s what I’m thinking right now. What are your thoughts?

Patient: What happens if the medication doesn’t help? APPN: We have lots of options, including trying a different medication, but

it is important to remember that medication is only one tool at our disposal. Even when it works, it doesn’t solve relationship problems, although it can give you more energy to deal with them. That’s why psychotherapy is so important. Do you have thoughts about that?

Patient: Not really, except .  .  . [long pause; therapist waits] I don’t really like talking about my family. It leaves me with a bad feeling.

APPN: Yes, I have a pretty clear sense of how difficult that was for you. Is there anything I could have done differently to make that easier for you?

Patient: No, I don’t think so. APPN: Tell me more about what this [assessment] experience has been like

for you? Patient: Actually, it wasn’t as bad as I was thinking it would be. In a way, I feel

relieved. I’m willing to try anything. APPN: I can hear how distressed you’ve been. On the other hand, that’s a very

positive attitude. I think there is every reason to believe you can feel significantly better very soon. And if not, we will work together to figure out why. How does that sound?

Patient: Good. Sounds good. APPN: Will this time next week work for you? [details of follow-up are

negotiated]

BoX 3.9 Ending the Clinical Assessment

3. ASSESSmENT AND DIAGNoSIS ■ 117

individual in the pursuit of life goals, dreams, and ambitions, especially during times of trouble. It ensures coping abilities, provides an individual with a sense of identity, can be recognized during initial assessment and throughout therapy, and increases as patients grow in maturity (Bjorklund, 2000). To the degree each ego function can be identified and assessed in the clinical situation, ego strength can be acknowledged, rated, rein- forced, supported, built upon, or “loaned” to some degree to lower-functioning patients by their relatively higher-functioning therapists in the process of identifying with the therapist’s own ego strength (Bjorklund, 2000).

Identification occurs through the ongoing corrective emotional experience that con- stitutes therapy and the therapist’s repetitive modeling of the kinds of coping behaviors indicative of ego strength. Table 3.2 identifies 12 ego functions and their definitions (Bellak, 1989). The list can be used as an assessment outline for the purpose of identi- fying patient strengths, or it can serve as the basis for self-reported or observer-rated

TABLE 3.2 EGO FUNCTIONS FOR ASSESSMENT

Reality Testing Differentiating Inner From Outer Stimuli

Judgment Aware of appropriateness and likely consequences of intended behavior

Sense of reality of the world and of the self

Experiences external events as real; differentiates self from others

Affect and impulse control Maintains self-control; can tolerate intense affect and delay of gratification

Interpersonal functioning Sustains relationships over time despite separations or hostility

Thought processes Attention, concentration, memory, language, and other cognitive processes are intact; thinking is realistic and logical

Adaptive regression in the service of the ego

Relaxation of ego controls, allowing creative perceptual or conceptual integrations to increase adaptive potential

Defensive functioning Defenses satisfactorily prevent anxiety, depression, and other unpleasant affects

Stimulus barrier Aware of sensory stimuli without stimulus overload

Autonomous functioning Cognitive and motor functions (i.e., primary autonomy) and routine behavior (i.e., secondary autonomy) are free from disturbance

Synthetic-integrative functioning

Integrates contradictory attitudes, values, affects, behavior, and self-representations

Mastery competence Performance consistent with existing capacity

Object constancy Ability to provide for oneself, caretaking and soothing in the absence of the caretaker

Source: Adapted from Bellak, L. (1989). The broad role of ego function assessment. In S. Wetzler & M. Katz (Eds.), Contemporary approaches to psychological assessment (pp. 270–295). New York, NY: Brunner/Mazel.

118 ■ I. GETTING STARTED

ego strength assessment scales to measure more concretely a patient’s emerging ego strength. Table 3.3 provides an example of an observer-rated ego strength assessment scale constructed in everyday language. The assessment items in Table 3.3 suggest spe- cific questions the therapist may ask to elicit information about the ego functions out- lined in Table 3.2 and Box 3.10.

TABLE 3.3 OBSERVER-RATED EGO FUNCTION ASSESSMENT TOOL*

Assessment Item Ego Function

Always (1) Almost Always (2) Usually (3) Sometimes (4) Hardly Ever (5) Never (6)

1. When dealing with strong feelings, has trouble with getting too upset or losing control with words or actions

Regulation and control of affects and impulses

2. Explains problems as being caused almost entirely by others

Defensive functioning; interpersonal functioning

3. Has trouble sitting back and looking at own behavior in a realistic way

Defensive functioning; interpersonal functioning

4. Believes he or she is basically a good person, worth caring about, but with some problems

Synthetic-integrative functioning

5. Seems to feel good or bad about self, depending mostly on how others are feeling about him or her

Affect regulation and control of affect; synthetic-integrative functioning

6. Seems able to recognize how he or she is feeling

Regulation and control of affect; defensive functioning

7. Seems able to express his or her feelings in an appropriate manner

Regulation and control of affect and impulses

8. Seems really weird, bizarre, or out of touch with reality

Reality testing; sense of reality of the world and of the self; thought processes

9. Able to look at self fairly realistically in terms of good and bad qualities

Sense of reality of the world and of the self; synthetic-integrative functioning

10. Explains his or her problems by means of hallucinations, false beliefs, control by supernatural power

Reality testing; sense of reality of the world and of the self; thought processes

11. Seems as if he or she does not notice other people exist

Interpersonal functioning

12. Seems afraid of being close to others Interpersonal functioning

13. Tends to see others as having both good and bad qualities

Synthetic-integrative functioning

14. Seems to need others to lean on Interpersonal functioning

(continued )

3. ASSESSmENT AND DIAGNoSIS ■ 119

Assessment Item Ego Function

Always (1) Almost Always (2) Usually (3) Sometimes (4) Hardly Ever (5) Never (6)

15. Can structure his or her own time and enjoy it

Autonomous functioning

16. Tends to lump people together and see them as much the same

Interpersonal functioning

17. When left alone, has a hard time taking care of himself or herself

Autonomous functioning

18. Seems to perform up to his or her capabilities

Mastery competence

19. Seems basically to trust other people Interpersonal functioning

20. Seems to use people to get things he or she needs

Interpersonal functioning

21. Sees his or her problems as resulting from being a bad person

Regulation of affect; synthetic-integrative functioning

22. Seems able to recognize and respond to the feelings of others in an appropriate manner

Regulation and control of affect and impulses

23. Is the type of person others want to be friends with

Interpersonal functioning

24. Recovers from significant emotional upset relatively quickly with previous capacities intact or improved

Adaptive regression in the service of the ego

*Not a validated tool.

Source: Adapted from Tulloch, J. D. (1984). Observer-rated ego function assessment tool. (Unpublished handout). Denver: University of Colorado Health Sciences Center.

• How do you deal with strong feelings? (1)* • How would you describe yourself? (9) • What kind of person is your mother? (13) • Describe your most important relationships. (16) • How do you think others view you? (23) • What do you think is the cause of your problems? (2) • What part do you play in these difficulties? (3) • Tell me about your hobbies and interests. (18) • How do you deal with downtime? (15) • What is it like for you to be alone? (17)

*Parenthetic numbers refer to the assessment items in Table 3.3.

BoX 3.10 Sample Questions to Assess Ego Functioning

TABLE 3.3 OBSERVER-RATED EGO FUNCTION ASSESSMENT TOOL* (CONTINUED)

120 ■ I. GETTING STARTED

The assessment of ego functioning yields important information about a patient’s sense of self and the degree to which he or she has consolidated a core identity. Where ego strength is lacking with respect to the ego functions identified in Table 3.2— particularly interpersonal functioning, defensive functioning, synthetic-integrative functioning, affect regulation, and a sense of the reality of the world and the self—identity diffusion can be discerned in the clinical interview, because a close connection exists between ego strength and identity (Bjorklund, 2000). The features of identity diffusion include markedly contradictory personality traits, temporal discontinuity in the self-experience, feelings of emptiness, and subtle body-image disturbances (Akhtar, 1995; Bjorklund, 2000). Even though not all these features can be elicited and explored to an equal degree through formal questioning, Akhtar (1995) believes it is almost always helpful to ask the individual to describe himself or herself. In the resulting description, “one should look for consistency versus contradiction, clarity versus confusion, solidity versus emptiness, well-developed and comfortably experienced masculinity or femininity versus gender confusion with gender dysphoria, and a sense of inner morality and ethnicity versus the lack of any historical or communal anchor” (p. 103). Box 3.11 provides an illustration in Beth’s case, prompting the therapist to flag the possibility of identity diffusion.

Goldstein (1995) provides an alternative mode of assessing ego functioning. She dis- cusses the nature of ego-oriented assessment as a process of data collection focused over several interviews on a patient’s current and past functioning and on his or her inner capacities and external circumstances. The following five questions (Bjorklund, 2000, p. 126) are an important guide to the therapist in the overall assessment of ego strength:

1. To what extent is the patient’s problem a function of stressors imposed by his or her current life roles or developmental tasks?

2. To what extent is the patient’s problem a function of situational stress or of a trau- matic event?

3. To what extent is the patient’s problem a function of impairments in his or her ego capacities or of developmental difficulties or dynamics?

4. To what extent is the patient’s problem a function of the lack of environmental resources or supports or of a lack of fit between his or her inner capacities and exter- nal circumstances?

5. What inner capacities and environmental resources does the patient have that can be mobilized to improve his or her functioning?

APPN: What sort of person are you? Patient: I don’t know. [long pause] I don’t feel like I know who I am. APPN: How would you describe yourself? Patient: It’s funny . . . I hate being alone, but I’m not really very social. I keep

to myself a lot. I want to be around people, but they really irritate me most of the time. I don’t think I’m an irritable person. Not really. [long pause; therapist waits] Sometimes, I hate myself. I’m really bright, but I don’t seem to accomplish much. I have friends, but I don’t fit in any- where. It seems like it doesn’t take much for me to fall apart.

APPN: You look troubled. Patient: [Silence] APPN: How would other people describe you? Patient: Some people think I’m really sweet. My mother thinks I’m very arro-

gant and conceited. I don’t know. A lot of people tell me I look angry all the time, but I don’t feel that way.

BoX 3.11 Assessing Identity Diffusion

3. ASSESSmENT AND DIAGNoSIS ■ 121

These questions are important, but questions 1 through 4 may be difficult to ascer- tain, especially if the person has had frequent or early trauma of which they may not even be aware. For question 5, collaboration with the patient about available resources may be helpful in the initial assessment. Although the assessment of ego functioning is not essential to all forms of giving help, it can assist a psychotherapist in determin- ing whether initial interventions should be directed toward enhancing resources and stabilization, including nurturing, maintaining, enhancing, or modifying inner capaci- ties; mobilizing, improving, or changing environmental conditions; or improving the fit between inner capacities and external circumstances (Bjorklund, 2000; Goldstein, 1995).

Those with impaired ego function most likely have significant early trauma and may not be able to answer some questions that assess ego function because experiences are dissociated from memory. Thus, all patients should be screened with the Dissociative Experiences Scale (DES). See Appendix 3.3 for a copy of this tool. This is a 28-item self- report screening tool that asks the respondent to circle the percent (0%–100%) of time that the experience happens to them. Sample questions include:

1. Some people find that they have no memory for some important events in their lives (for example, a wedding or graduation).

2. Some people have the experience of finding new things among their belongings that they do not remember buying.

3. Some people have the experience of looking in a mirror and not recognizing themselves.

4. Some people have the experience of feeling that other people, objects, and the world around them are not real.

A score of 28% or more indicates that a more thorough evaluation for a dissocia- tive disorder is indicated. Further assessment measures for dissociation are included in Chapter 17. See Appendix 3.3 for the DES.

When a patient is overwhelmed by current stressors but shows good past ego functioning and has some environmental supports, the practitioner may use a brief, supportive, and cognitive approach aimed at stress reduction and more effective prob- lem-solving. If the person is severely and persistently ill, a patient with limited ego strength and developmental deficits that interfere with his or her ability to cope with intimate relationships or current life roles may need interventions targeted toward improving ego function (Bjorklund, 2000; Goldstein, 1995), and a longer psychotherapy treatment with more frequent psychotherapy sessions may be indicated.

In Beth’s case, given what turned out to be a significant lack of object constancy (see Table 3.2), dysregulation of affect and impulse control, an inability to tolerate the close- ness of her most significant interpersonal relationships, and an inability to integrate con- tradictory feelings about those significant others—and about many other things, such as continuing her college career—she and her therapist will need to nurture, maintain, and modify some important inner capacities. Given the severity of current environmental stressors, such as the move away from home, withdrawal of her parents’ financial sup- port, her mother’s hostility and intrusive neediness, significant debt, an unsatisfactory living situation, a stressful job, and a change in college majors, she will also need the therapist’s support to mobilize, improve, or change environmental conditions.

Assessing Affective Development

When affective development has proceeded optimally, people have capacities for affect awareness, affect tolerance, and affect modulation (i.e., affect regulation and control). They are aware of their feelings and can identify and describe those feelings, express

122 ■ I. GETTING STARTED

those feelings in socially appropriate ways, tolerate unpleasant feelings in themselves and others, and find ways to soothe themselves until unpleasant feelings pass. They can maintain their self-esteem and their generally positive outlook and feelings about others even when angry or hurt. They can contain the most intense feelings without losing control and can maintain their equilibrium and their boundaries in the midst of others’ intense emotional expression. They can experience a full range of emotions and have developed an appropriate capacity for empathy, caring, and concern without falling prey to affect contagion (i.e., feeling exactly what another feels). They can orient to internal experience when necessary or desirable and have a capacity for fantasy and imagination.

Significantly, persons whose affective development has proceeded optimally can also realistically interpret the social meaning of emotional experience; it is an individual’s interpretation of an unpleasant affect that leads to the experience of a specific negative emotion and to the intensity of the emotional arousal (Bradley, 2000). In other words, experience and cognition allow the individual to elaborate positive or negative affect throughout the gamut of emotional experience (Bradley, 2000). Compared with those whose affective development is impaired, persons whose affective development is opti- mal can tap into their inner worlds and use experience and cognition to interpret diffuse affective arousal as meaningful emotional experience—as both significant and less than catastrophic. They are simultaneously more affectively aware, less emotionally reactive, and able to achieve therapeutic distance from emotions if necessary. Their interpreted emotional experience is construed as manageable, and they have a repertoire of strate- gies to cope with it. These are the capacities the therapist examines when assessing a patient’s affective development.

Much psychopathology ensues as a consequence of impaired affective development (Bradley, 2000). Conversely, much good therapeutic work has been done when a patient has grown in the capacity to identify, tolerate, regulate, and appropriately express affec- tive experience. All types of psychotherapy promote affect regulation. Some therapies do this with the acquisition of specific behavioral skills to reduce the intensity of affect, such as breathing or distracting techniques to cope with anxiety. Others emphasize adaptive coping strategies, such as mindfulness, positive self-talk, or the correction of cognitive distortions to mitigate distress. Others involve reexperiencing and repro- cessing of painful affects or repeated exposure to previously avoided situations so that desensitization and mastery can occur. Ultimately, they all work to modify the internal mental representations or cognitive–emotional schemas that produce automatic, mal- adaptive emotional responses (Bradley, 2000).

Affective regulation and control is an important ego strength (see Tables 3.2 and 3.3), and all effective therapy promotes it. However, some individuals described as alexithymic have such extreme difficulty experiencing, describing, and seeing connections between feelings and symptoms that they fare poorly in and frequently drop out of expressive psychotherapies, that is, those that discuss and examine affects (Bradley, 2000). These individuals are notably lacking in psychological mindedness, the awareness of internal experience and its relationship to external situations, events, or behaviors that are very important for successful psychotherapy outcomes (Bradley, 2000; Taylor, 1995). Defined as the inability to describe or be aware of emotions or mood (Sadock et al., 2015), alexi- thymia is a multifaceted construct that encompasses several different factors, including difficulty identifying subjective emotional feelings and distinguishing between feelings and the bodily sensations that constitute emotional arousal; difficulty describing feel- ings to other people; an impoverished fantasy life; and an externally oriented cognitive style (Taylor, Bagby, & Parker, 2003).

The most widely used measure of the alexithymia construct is the Toronto Alexithymia Scale (TAS-20; Bagby, Parker, & Taylor, 1994a, 1994b). The TAS-20 is a self-report scale

3. ASSESSmENT AND DIAGNoSIS ■ 123

with a three-factor structure that corresponds to the multifaceted construct described previously. Factor 1 assesses the ability to identify feelings and to distinguish them from the somatic sensations that accompany emotional arousal (i.e., “I am often con- fused about what emotion I am feeling,” and “I have feelings that I can’t quite iden- tify”). Factor 2 assesses the ability to describe feelings to other people (i.e., “I am able to describe my feelings easily,” and “It is difficult for me to reveal my innermost feelings, even to close friends”). Factor 3 assesses externally oriented thinking and, indirectly, reduced fantasy and imaginable activity (i.e., “I prefer to analyze problems rather than just describe them,” and “Looking for hidden meanings in movies or plays distracts from their enjoyment;” Parker, Taylor, & Bagby, 2003; Taylor et al., 2003). A therapist can administer the TAS-20 at the outset of therapy as part of an overall diagnostic evalu- ation or to assess a patient’s psychological mindedness, suitability for an expressive psychotherapy, or capacity for affect awareness and tolerance. Even if not administered directly, the TAS-20 and the observer-rated ego function assessment tool in Table 3.3 (Box 3.12) nevertheless suggest questions the therapist can ask in the context of an initial clinical assessment to assess affective development, that is, capacities for affect aware- ness, tolerance, modulation, regulation, and control.

Assessing Interpersonal Relationships

Identification of a patient’s interpersonal strengths is a necessary first step in affirming and supporting them. It is also important in keeping a balanced view of the potential for adaptation, growth, and successful psychotherapeutic outcome in a patient with other areas of less optimal ego functioning. It is possible to assess the depth of a patient’s interpersonal relationships—one indicator of ego strength—by reviewing the patient’s past and present interpersonal environment to elicit detailed descriptions of significant others, including mothers, fathers, spouses, friends, and pets (Akhtar, 1995; Bjorklund, 2000; Horowitz, Rosenberg, & Bartholomew, 1993; Shea, 2017). The presence of the fol- lowing three features in the patient’s descriptions of significant others suggest some impairment in interpersonal functioning (Akhtar, 1995; Bjorklund, 2000):

1. An insistent emphasis on the patient’s feelings and views about the person described rather than on that person’s independent attributes (Box 3.13)

• Are you generally able to recognize how you feel at any given time? (6)* • How would you describe your feelings right now? (6, 7) • Can you describe how you felt when that happened? (6, 7) • What is your internal experience like? (2) • What do you suppose prompts/are the feelings that prompt your mother to call dur-

ing your study time each evening? (22) • What do you think your mother was feeling when you hung up on her? (22) • How do you deal with especially strong feelings? (1) • How do you think others feel about you? (23) • What happens when you are upset? (1, 7) • How do you calm yourself when you are upset? (1, 7) • How long does it take to calm down? (24) • How do you feel about yourself when you are angry/frustrated/upset? (4, 9) • Are you still able to see yourself as a good person when she gets angry at you?

*Parenthetic numbers refer to the assessment items in Table 3.3.

BoX 3.12 Sample Questions to Assess Affective Development

124 ■ I. GETTING STARTED

2. An extreme and affectively charged verdict rather than a balanced account that permits mixed feelings toward the person described (Box 3.14)

3. An inability to see independent motivations in others (Box 3.15)

As conveyed in the alternative responses detailed earlier, descriptions of important relationships that evidence the ability to see significant others as separate individuals, with independent motivations and reasons of their own, suggest significant ego strength in the area of interpersonal relationships. The same is true for descriptions of significant others that show the patient has the capacity to experience others ambivalently—as whole people with good and bad qualities, who can simultaneously gratify and care for others as well as frustrate and disappoint them. More ominous are descriptions that indicate a patient functions in relationships at the level of need gratification (i.e., people have value only to the degree they can meet his or her needs); descriptions that indicate a patient cannot clearly differentiate people or differentiate self from others (i.e., people

APPN: Can you tell me what sort of person your mother is? Patient: I hate her. I think she’s a witch. It’s always all about her, not me. I’ve

tried and tried to get along with her, but it’s impossible. If she didn’t call me every night, I wouldn’t even think about her. [As opposed to this: She’s prickly. She’s bright and beautiful, but she makes a lot of demands on people and likes to be the center of attention.]

BoX 3.13 Insistent Emphasis on Own Feelings

APPN: How would you describe your mother? Patient: She’s a horrible mother. She is completely selfish. She has never done

anything for anybody her entire life. She has never once told me she’s proud of me or that she wants me to do well in school. [As opposed to this: She tries to be a decent mother. I imagine she loves me and my brother in her own way, but she competes with me. It’s like she’s jealous of me. When I changed my major to Business Administration, she enrolled in Denton (Business University). What does that tell you? I guess she’s got some problems of her own to deal with.]

BoX 3.14 Extreme Accounts of Others

APPN: What do you suppose prompts your mother to call you and interrupt your studying every night?

Patient: She wants me to fail. It makes her look good. Sometimes, I think she just likes upsetting me. She gets something out of it. I think she hates me as much as I hate her. [As opposed to this: I’m sure she has her reasons. I just can’t figure out what they are. Like I said before, she’s got problems of her own to deal with. Sometimes, I think she is having as hard a time with my moving away from home as I am. Other times, I think she really is jealous of my success. It’s painful to realize, but I think she has mixed feelings about me, and I certainly have mixed feel- ings about her.]

BoX 3.15 Inability to See Independent Motivations

3. ASSESSmENT AND DIAGNoSIS ■ 125

are always “just like me” or “pretty much all the same”); or worse, descriptions that indicate a patient functions more or less autistically (i.e., other people seem not to exist or are experienced as aversive stimuli). Table 3.3 includes several assessment items that indirectly measure interpersonal functioning and suggest questions the therapist can ask to explore the quality of a patient’s interpersonal relationships (Box 3.16).

One cannot overstate the importance of understanding the nature of a patient’s inter- personal problems and the quality of his or her interpersonal functioning. Interpersonal problems are among the most common complaints reported in clinical interviews (Horowitz et al., 1993). Interpersonal relationships often are the focus of psychotherapy, and the work of psychotherapy occurs in an interpersonal environment through rela- tional processes. The therapist can learn much about the patient’s interpersonal func- tioning in the context of the therapeutic relationship, that is, through the manner of the patient’s relating to the therapist and through the therapist’s reactions to and feel- ings about the patient. From the way the patient relates to the therapist, particularly in the anxiety-provoking circumstance of crossing the boundary from everyday social discourse to interaction in the consulting room, the therapist can see firsthand the devel- opmental phase that predominates in the patient’s personality and interpersonal func- tioning (Scharff & Scharff, 2005). Ultimately, this firsthand experience may provide the best assessment data.

If, however, the therapist desires a more structured approach to assessing interper- sonal functioning, perhaps for purposes of measuring psychotherapy outcomes, he or she can administer an instrument such as the Inventory of Interpersonal Problems (IIP; Horowitz, Rosenberg, Baer, Ureno, & Villasenor, 1988), which is a self-report inventory that has been used to identity dysfunctional patterns in interpersonal interactions. It describes different types of interpersonal problems and has been used to measure the level of distress associated with them before, during, and after psychotherapy (Horowitz et al., 1993). Each of its eight subscales describes a different interpersonal style (Box 3.17). This instrument can also be useful in clinic settings where the clinician complet- ing the initial assessment is different from the eventual therapist. Although the IIP is not included in this chapter, Table 3.4 provides a fragment of it.

ASSESSING ADULT ATTACHMENT

The quality of the patient’s earliest interpersonal relationships with caregivers may influence the adult personality. In particular, attachment insecurity in infancy and early childhood has been shown to predict various forms of psychopathology in adolescence

• WHAT IS YoUR PART/THEIR PART IN THAT RELATIoNSHIP PRoBLEm? (2, 3, 21)* • Can you trust people? (19) • What is it like to have to trust or depend on someone else? (12, 19) • What type of friend to others are you? (23) • What makes a relationship a close one? (20) • Do you have any close relationships? (12) • How do you do with intimacy in relationships? (12) • What do relationships mean to you? (20) • What happens if there is no one around to lean on? (14, 17) • How would you feel about the person if he or sher could no longer provide or could

no longer meet your needs?

*Parenthetic numbers refer to the assessment items in Table 3.3.

BoX 3.16 Sample Questions to Assess Interpersonal Functioning

126 ■ I. GETTING STARTED

TABLE 3.4 A FRAGMENT OF THE INVENTORY OF INTERPERSONAL PROBLEMS

It is hard for me to: How much have you been distressed by this problem?

Not At All (0) A Little Bit (1) Moderately (2) Quite a Bit (3) Extremely (4)

Example

1. Get along with my relatives

0 1 2 3 4

Part I. The following are things you find hard to do with other people:

1. Trust other people 0 1 2 3 4

2. Say “no” to other people

0 1 2 3 4

3. Join in on groups 0 1 2 3 4

4. Keep things private from other people

0 1 2 3 4

5. Let other people know what I want

0 1 2 3 4

6. Tell a person to stop bothering me

0 1 2 3 4

Source: Adapted from Horowitz, L. M., Rosenberg, S. E., & Bartholomew, K. (1993). Interpersonal problems, attachment styles, and outcome in brief dynamic psychotherapy. Journal of Consulting and Clinical Psychology, 61(4), 549–560. doi:10.1037/0022-006X.61.4.549. Copyright 1993, with permission from the American Psychological Association.

Domineering I try to change other people too much.

Intrusive It is hard for me to stay out of other people’s business.

Overly nurturing I put other people’s needs before my own too much.

Exploitable I let other people take advantage of me too much.

Nonassertive It is hard for me to be assertive with another person.

Socially avoidant It is hard for me to socialize with other people.

Cold I keep other people at a distance too much.

Vindictive I fight with other people too much.

BoX 3.17 Interpersonal Styles

and adulthood (Shmueli-Goetz, Target, Fonagy, & Datta, 2008). When the therapist sus- pects that attachment issues may be complicating the patient’s interpersonal function- ing, he or she may want to assess the patient’s attachment system in a more structured way (Box 3.18). Provided that he or she has obtained training in administration proce- dure, the therapist may choose to utilize the Adult Attachment Interview (AAI) for the assessment. Numerous studies have established the reliability and validity of the AAI

3. ASSESSmENT AND DIAGNoSIS ■ 127

(Shmueli-Goetz et al., 2008). Although the AAI protocol is readily available online (see Box 3.19), the scoring manual is available only in conjunction with training courses; and the published protocol, too lengthy to append in full, is not considered a substitute for AAI training (George, Kaplan, & Main, 1985; Main & Goldwyn, 1998). In general, the AAI focuses on the adult patient’s childhood relationships with parents, thus facilitat- ing an overall assessment of the quality of the attachment to parents, starting with child- hood experiences that may have affected the patient’s adult personality, and moving through adolescence to present-day, adult experiences.

• How would you describe your relationship with your parents? As a child? Now? • What words would you use to describe your mother/father? As a child? Now? • With whom did you/do you now feel the closest? • What did you/do you now do when you feel upset about something? • Did your parents ever threaten or hurt you, even jokingly or to discipline you? Anyone

else? • What did you/do you now do with feelings of loss? Rejection? Threat? • Were you ever separated from your parents as a child? Suffered a loss? • How do you cope with losses/separations from significant others now? • How do you think your overall experiences with your parents have affected your

adult personality? • What do you wish for your own children?

BoX 3.18 Sample Questions to Assess Attachment

• Toronto Alexithymia Scale (TAS-20)* • Beck Depression Inventory (BDI; copyright Psychological Corporation) • Dissociative Experiences Scale (DES; see Appendix 3.3) • Impact of Events Scale (IES; see Appendix 3.4); Zung Self-Rating Depression Scale

(ZSRDS) (see Appendix 3.5) • Geriatric Depression Scale (GDS; see Appendix 3.6) • Patient Health Questionnaire (PHQ-9; see Appendix 3.7) • Young Mania Rating Scale (YMRS; see Appendix 3.8); Hamilton Anxiety Rating Scale

(HAM-A) (see Appendix 3.9) • Generalized Anxiety Disorder Questionnaire (GAD-7; see Appendix 3.10) • Yale-Brown Obsessive–Compulsive Scale (Y-BOCS; see Appendix 3.11) • Mini-Mental State Examination (MMSE; www.dhs.state.or.us/spd/tools/cm/aps/

assessment/mini_mental.pdf) • Global Assessment of Functioning (GAF) • Quality of Life Scale (QOL; see Appendix 3.12) • CAGE Questionnaire (see Appendix 3.13) • Alcohol Use Disorders Identification Test (AUDIT; see Appendix 3.14) • Adult Attachment Interview (AAI; www.psychology.sunysb.edu/attachment/

measures/content/aai_interview.pdf) • Child Attachment Interview (CAI; see Appendix 3.15) • Strange Situation Procedure (SSP; www.psychology.sunysb.edu/attachment/ measures/

content/ss_scoring.pdf) • Adverse Childhood Experiences (ACE) Scale (see Appendix 3.16)

*The TAS-20 can be purchased directly from its developer, Dr. Graham J. Taylor, Department of Psychiatry, Mount Sinai Hospital, Toronto, Ontario, Canada.

BoX 3.19 Screening/Assessment Tools

128 ■ I. GETTING STARTED

More specifically, in a series of 20 assessment questions, with suggestions for fol- low-up probes, the AAI orients the interviewer to the patient’s family constellation. It encourages the patient to remember and describe his or her earliest memories of rela- tionships with parents and asks for descriptors of each parent that reflect the childhood relationships with them (George et al., 1985). The interview protocol covers areas with attachment implications, including the patient’s childhood (and adult) experiences of separation, the person(s) to whom the patient as a child felt most close, what the patient did as a child when upset, how he or she coped with feelings of loss and/or rejection, whether or not the patient as a child ever felt threatened by parents, and how the patient understood and responded to such threats. The AAI protocol also explores other poten- tially traumatic experiences in both childhood and adulthood. It assesses the patient’s experience of the impact of these events and explores the patient’s wishes and hopes for his or her own children as well as the patient’s present-day, adult relationships with living parents (George et al., 1985).

ASSESSING CHILD ATTACHMENT

The Child Attachment Interview (CAI; see Appendix 3.15) is similar in content to the AAI but focuses on the child-as-patient’s current attachment relationships rather than the adult patient’s memory of relationships in childhood (Shmueli-Goetz et al., 2008). Like the AAI, the CAI protocol elicits information about the family constellation but focuses on current and/or recent attachment-related events, including times of fam- ily conflict, distress, illness, hurt, separation, and loss (Shmueli-Goetz et al., 2008). It includes interview items that elicit self-descriptions and caretaker descriptions, which may illuminate the child’s self-representations and representations of his or her pri- mary caregivers as well as potentiate exploration of meaningful links between self- descriptions and attachment representations (Shmueli-Goetz et al., 2008). Because the CAI is a narrative-based assessment that relies on a level of linguistic competence (i.e., verbal ability), it requires a developmentally appropriate interviewer stance with age- specific cues, or follow-up probes to help children remember and express attachment experiences (Shmueli-Goetz et al., 2008). Throughout the CAI, such probes are used to assist the child to tell his or her story. Verbal and nonverbal behavior is coded and scored. Although the CAI is a systematic, valid, and reliable assessment of the school- age child’s experience of parental availability (i.e., parent–child attachment), it cannot replace parental and teacher reports, nor is it appropriate for infants and toddlers for whom attachment is defined not by parental availability but rather by behavioral strate- gies to maintain proximity to attachment figures (Shmueli-Goetz et al., 2008).

For attachment assessment during very early childhood, a separation–reunion pro- cedure such as the Strange Situation Procedure (SSP; Ainsworth, Blehar, Waters, & Wall, 1978) may be appropriate (Box 3.19). The SSP is conducted in an unfamiliar, or strange environment by an unfamiliar person (a “stranger”) over a series of eight, brief, separation–reunion episodes that are designed to generate just enough stress to acti- vate the infant’s or toddler’s behavioral attachment system. Separations are designed to be stressful but sufficiently manageable so that reunions become a reflection of the quality of the child–parent relationship (Ainsworth et al., 1978). Typically, the strange situation is videotaped and coded based on the child’s observed behaviors. Categories of observed behavior include proximity- and contact-seeking behavior, contact-main- taining behavior, resistant behavior, and avoidant behavior. Based on SSP scoring, attachment security is classified as secure, insecure avoidant, insecure resistant, or inse- cure disorganized. Scoring methods for the SSP are detailed and include considerable commentary to facilitate valid and reliable scoring; thus, training in coding the SSP is advised (Ainsworth et al., 1978).

3. ASSESSmENT AND DIAGNoSIS ■ 129

Assessing Belief Systems

The disorders for which patients seek out psychotherapists lie on the boundary between the natural world and the constructed social world (Wakefield, 1992). Whether a patient construes a particular symptom as harmful or a particular constellation of symptoms as a disorder or an illness for which help is required has a lot to do with his or her values and beliefs. A disorder exists when a person’s internal psychological or physi- ological mechanisms fail to perform their functions as designed by nature but only if this impinges on the person’s sense of well-being as defined by social values and meanings (Wakefield, 1992). Ultimately, the whole point of diagnosing a psychiatric disorder is to help a patient regain the ability to function effectively in social, occupational, and family roles. Most of the behaviors and feelings categorized as symptoms of mental illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM) can be construed as what many people do or feel at various times without having a psychiatric disorder or suffer- ing from a mental illness.

Belief systems, spiritual practices, religious affiliation, and other frameworks for meaning and purpose can have a profound impact on a person’s well-being, resilience, or ability to adaptively cope with adversity. An inventory of the person’s strengths is important to plan where to intervene in the treatment hierarchy see Chapter 1. At other times, a patient’s symptoms may result from unrest in the person’s belief systems or from conflict in his or her religious, spiritual, philosophical, ethical, or existential frameworks (Shea, 2017). It is therefore crucial that a therapist assess a patient’s val- ues, beliefs, and framework for meaning to identify problems and support important strengths. The information gleaned may suggest the utility of individual psychother- apy slanted toward existential concerns (Shea, 2017); or it may remind the therapist that patients sometimes find meaning and purpose in everyday, well-known activities, such as caring for their families, engaging in community service, or staying close to nature.

Although an understanding of the stages or processes of faith (Fowler, 1981) or spiri- tual development (Wink & Dillon, 2002) is not absolutely necessary to an understanding of how to assess belief systems (and is beyond the scope of this chapter), the therapist should consider that how people construct meaning in life is subject to developmental shifts (Fowler, 1981) and is the product of maturational processes that continue over the course of adult life (Wink & Dillon, 2002). Spiritual development is linked to other processes of development. It requires capacities for abstraction, ambiguity, and ambiva- lence (i.e., the ability to integrate paradox and disparate notions of self, other, and the world), which are some of the same capacities that constitute ego strength as earlier described. It involves going beyond the linear and strictly logical modes of apprehend- ing reality described by Piaget’s model of cognitive development to an integrated cogni- tive–emotional view of the world that embraces paradox and incorporates feelings and context as well as logic and reason in making judgments about the nature, meaning, and purpose of self, other, and the world (Wink & Dillon, 2002). Changes in or consolidation of belief systems, meaning frameworks, and other processes of making sense of life’s meaning and purpose, occur more frequently during periods of adversity and crisis than during times of stability (Stokes, 1990). Such changes are more salient for women and older adults (Wink & Dillon, 2002), both of whom tend to experience more stress than other social groups (Mirowsky & Ross, 1992, 1995). The therapist assessing the quality, salience, and influence of his or her patients’ belief systems should keep these findings in mind and use the energy existing in crisis to promote positive change.

Practically speaking, assessing the values and beliefs of patients is a standard part of taking a history (see Box 3.1). As a matter of course, the therapist should inquire about the patient’s belief systems and values, both social and moral, including values about

130 ■ I. GETTING STARTED

work, money, play, children, parents, friends, sex, community concerns, and cultural issues (Sadock et al., 2015). Much of this information is gleaned in the process of obtain- ing a patient’s developmental, family, and social history. Specific assessment questions are illustrated in Box 3.20 and in Table 3.5, which is an adapted portion of the World Health Organization’s (WHO) Quality of Life–Spirituality, Religiousness, and Personal Beliefs (WHOQOL–SRPB) field-test instrument. The WHOQOL–SRPB has been devel- oped from an extensive pilot test of 105 questions in 18 centers around the world. The resulting 32-item instrument represents the finalized version currently in use in field trials (WHO, 2002).

TABLE 3.5 A PORTION OF THE WORLD HEALTH ORGANIZATION’S SPIRITUALITY, RELIGIOUSNESS, AND PERSONAL BELIEFS FIELD-TEST INSTRUMENT

1 = Not at all 2 = A little 3 = A moderate amount 4 = Very much 5 = An extreme amount

To what extent does any connection to a spiritual being help you to get through hard times?

1 2 3 4 5

To what extent does any connection to a spiritual being help you to understand others?

1 2 3 4 5

To what extent does any connection to a spiritual being provide you with comfort/reassurance?

1 2 3 4 5

To what extent do you find meaning in life? 1 2 3 4 5

To what extent do you feel your life has a purpose? 1 2 3 4 5

To what extent does faith contribute to your well-being? 1 2 3 4 5

To what extent does faith give you comfort in daily life? 1 2 3 4 5

To what extent does faith give you strength in daily life? 1 2 3 4 5

To what extent do you feel spiritually touched by beauty? 1 2 3 4 5

To what extent are you grateful for the things in nature that you can enjoy?

1 2 3 4 5

• What helps you cope with adversity? • What gives you a sense of meaning and purpose in life? • What matters most to you in life? • What are your beliefs about health/illness/therapy/seeking help? • To what extent do your spiritual/religious beliefs comfort you? • What enables you to stay healthy/get better/find comfort/continue living? • What do those spiritual/religious practices bring to your life?

BoX 3.20 Sample Questions to Assess Belief Systems

(continued )

3. ASSESSmENT AND DIAGNoSIS ■ 131

To what extent are you able to experience awe from your surroundings, for example, nature, art, music?

1 2 3 4 5

To what extent do you feel any connection between your mind, body, and soul?

1 2 3 4 5

To what extent do you feel the way you live is consistent with what you feel and think?

1 2 3 4 5

How much do your beliefs help you to create coherence between what you do, think, and feel?

1 2 3 4 5

How much does spiritual strength help you to live better?

1 2 3 4 5

To what extent does your spiritual strength help you to feel happy in life?

1 2 3 4 5

To what extent do you feel peaceful within yourself? 1 2 3 4 5

To what extent do you feel a sense of harmony in your life?

1 2 3 4 5

To what extent does faith help you enjoy life? 1 2 3 4 5

How satisfied are you that you have a balance between body, mind, and soul?

1 2 3 4 5

To what extent do you consider yourself to be a religious person?

1 2 3 4 5

To what extent do you consider yourself to be a part of a religious community?

1 2 3 4 5

To what extent do you have spiritual beliefs? 1 2 3 4 5

Source: Adapted from the World Health Organization. (2002). WHOQOL-SRPB field-test instrument. Retrieved from https://www.who.int/mental_health/media/en/622.pdf

TABLE 3.5 A PORTION OF THE WORLD HEALTH ORGANIZATION’S SPIRITUALITY, RELIGIOUSNESS, AND PERSONAL BELIEFS FIELD-TEST INSTRUMENT (CONTINUED)

ASSESSING FUNCTIONAL STATUS

For several important reasons, the APPN must be able to competently assess a patient’s functional status and degree of functional impairment. First, for most psychiatric disor- ders to meet diagnostic criteria, the most commonly used diagnostic system (the DSM) requires that individuals meet a clinical significance criterion, which is that symptoms result in either clinically significant distress or impairment in social, occupational, or other important areas of functioning (McQuaid et al., 2012). Second, improved func- tioning in one or more domains is often a goal of psychotherapy. Thus, the means and methods by which the APPN assesses functional status are important to outcomes evaluation, that is, the process of determining the extent to which psychotherapy has been effective in targeting symptoms and improving the patient’s health status and/or quality of life. Third, measures of functional status are important to patient for various

132 ■ I. GETTING STARTED

reasons, including that degree of functional impairment has implications for compen- sation and pension procedures as well as decisions around the extent to which a psy- chiatric disorder is judged to have a military service connection (McQuaid et al., 2012). Fourth, functional status is often a better indicator of service needs and treatment out- comes than diagnosis alone (McQuaid et al., 2012). Thus, the APPN must be prepared to perform and document diagnostic evaluations that include competent functional assessments across the relevant domains of functioning.

Although this chapter addresses the assessment of mental health functioning broadly, its scope does not include detailed discussion of the many types, domains, and processes of assessing functional status. In some cases, the APPN may recommend a more com- prehensive assessment of functional status from an occupational therapist or disability specialist. However, a number of screening instruments and rating scales are available to assess, measure, document, or monitor functioning in social, occupational, psychologi- cal, interpersonal, and other domains (Table 3.6). One of the most common and better known measures of functioning, included in Table 3.6 but no longer utilized in the DSM-5 diagnostic system, is the Global Assessment of Functioning (GAF; APA, 2000), which is

TABLE 3.6 COMMONLY USED CLINICAL RATING SCALES

Scale Reference*

Quality of Life Scales

Quality of Life Enjoyment and Satisfaction Questionnaire Q-LES-Q

Endicott, Nee, Harrison, and Blumenthal (1993)

Quality of Well-Being Scale (QWB) Kaplan and Anderson (1988)

Quality of Life in Depression Scale (QLDS) Hunt and McKenna (1992)

Medical Outcome Survey (MOS) Ware and Sherbourne (1992)

Mental Health Status and Functioning Scales

Clinical Global Impression (CGI) National Institute of Mental Health [NIMH] (1970)

Endicott Work Productivity Scale Endicott and Nee (1997)

Global Assessment of Functioning (GAF) American Psychiatric Association (APA), 2000: DSM-IV-TR

Sheehan Disability Scale Leon, Shear, Portera, and Klerman (1992)

Social and Occupational Functioning Assessment Scale (SOFAS)

APA, 2000: DSM-IV-TR

Work and Social Adjustment Scale Mundt, Marks, Shear, and Greist (2002)

Adverse Effects Scales

Abnormal Involuntary Movement Scale (AIMS) Guy (1976)

Simpson–Angus Extrapyramidal Symptom Rating Scale Simpson and Angus (1970)

Cognitive Disorders Scales

(continued )

3. ASSESSmENT AND DIAGNoSIS ■ 133

Scale Reference*

Delirium Rating Scale Revised—98 (DRS—R98) Trzepacz et al. (2001)

Mini-Mental State Examination (MMSE) Folstein, Folstein, & McHugh (1975)

Alcohol Use Disorders Scales

Alcohol Use Disorders Identification Test (AUDIT) CAGE Questionnaire

Saunders, Aasland, Babor, De La Fuente, and Grant (1993)

Ewing (1984)

Michigan Alcoholism Screening Test (MAST) Selzer (1971)

Mood Disorders Scales

Beck Depression Inventory, 2nd Revision (BDI-II) Beck, Ward, Mendelson, Mock, and Erbaugh (1961)

Hamilton Depression Rating Scale (HAM-D) Hamilton (1960)

Inventory of Depressive Symptomatology (IDS) Rush, Gullion, Basco, Jarrett, and Triveldi (1996)

Quick Inventory of Depressive Symptomatology (QIDS) Rush et al. (2003)

Patient Health Questionnaire (PHQ-9) www.pfizer.com

Geriatric Depression Scale (GDS) Yesavage et al. (1983)

Montgomery–Asberg Depression Rating Scale (MADRS) Montgomery and Asberg (1979)

Zung Self-Rating Depression Scale (ZSRDS) Zung (1965)

Young Mania Rating Scale (YMRS) Young, Biggs, Ziegler, and Meger (1978)

Anxiety Disorders Scales

Hamilton Anxiety Rating Scale (HAM-A) Hamilton (1959)

Yale-Brown Obsessive–Compulsive Scale (Y-BOCS) Goodman et al. (1989)

Psychotic Disorders Scales

Brief Psychiatric Rating Scale (BPRS) Overall and Gorham (1962)

Positive and Negative Symptom Scale (PANSS) Kay, Fiszbein, and Opler (1987)

Aggression and Agitation Scale

Overt Aggression Scale—Modified (OAS-M) Coccaro, Harvey, Kupsaw-Lawrence, Herbert, and Bernstein (1991)

*References in this table are listed at the end of the chapter.

DSM-IV-TR, Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.).

Source: American Psychiatric Association. (2016). The American Psychiatric Association practice guidelines for the psychiatric evaluation of adults (3rd ed.). Arlington, VA: Author; Bresee, C., Gotto, J., & Rapaport, M. H. (2009). Treatment of depression. In A. F. Schatzberg & C. B. Nemeroff (Eds.), The American Psychiatric Association Publishing textbook of psychopharmacology (4th ed., chap. 53). Arlington, VA: American Psychiatric Publishing.

TABLE 3.6 COMMONLY USED CLINICAL RATING SCALES (CONTINUED)

134 ■ I. GETTING STARTED

a clinician-rated, global measure of illness severity. Scores range from 0 to 100, with a higher score indicating better functioning. A GAF score is typically based on a patient’s worst functioning within occupational, social, or psychological domains. It combines psychiatric symptomatology and social–occupational functioning into a single score even though they are distinct constructs, and even though research has found that GAF scores are most significantly associated with symptom ratings rather than social or occupational functioning (McQuaid et al., 2012). Table 3.6 lists several alternatives to the GAF. In addi- tion, as an alternative to the GAF, McQuaid et al. (2012) offer a detailed description of the Inventory of Psychosocial Functioning (IPF), which is a newly developed, 80-item, self- report measure designed to assess functional impairment experienced by veterans and active-duty service personnel across multiple domains.

GENOGRAMS

The family genogram is a useful tool for the assessment of individuals, couples, and families; and it should be a routine part of any comprehensive patient or family assess- ment (Glick, Berman, Clarkin, & Rait, 2000). Encouraging or assigning a patient the task of drawing his or her family genogram is an effective assessment and intervention strat- egy at different points in the therapy. It can yield significant assessment data and lead to important, new patient understandings and insights as multigenerational patterns take shape and assume new meaning. In essence, the genogram is a graphic sketch of the patient and several generations of his or her family. Occupational and social roles, major life events, significant illnesses, and important dates—for example, births, deaths, marriages, and separations—are mapped. The quality and longevity of significant rela- tionships are noted. The graphic presentation of family events and relationships facili- tates the linkage of current issues, concerns, or circumstances to the multigenerational family’s structure and evolving patterns of relationship (Glick et al., 2000). The family genogram has several purposes:

1. It provides the identified patient, family, and therapist with a graphic structure to explore past and present difficulties.

2. It provides the therapist with background information to put current patient difficul- ties in context.

3. It uses the assessment process as an opportunity for patient intervention, for exam- ple, as the patient begins to see patterns emerge (Glick et al., 2000).

In addition, based on genomics research findings, emerging standards of care for psychiatric assessment and treatment now include a more detailed family history or pedigree (genogram), assessment of environmental risk factors, genetic screening and testing if indicated, and application of individualized therapies based on assessment data (Pestka et al., 2010). While genetics is the examination of specific genes and their effects, genomics considers all the genes in a human genome and their interactions with each other, which has relevance for psychiatric practice along pathways of prevention, screening, diagnostics, prognostics, treatment selection, and monitoring of treatment effectiveness (Pestka et al., 2010). Nationally endorsed genomics competencies include the following nursing genomic assessments:

1. Gathering and/or clarifying family history information 2. Updating or constructing a family genogram 3. Assessing environmental factors 4. Assessing genomic physical findings

3. ASSESSmENT AND DIAGNoSIS ■ 135

5. Assessing genetics/genomics learning needs (Consensus Panel on Genetic/ Genomic Nursing Competencies, 2006, 2009; Greco, Tinley, & Seibert, 2012; Pestka, Meisheid, & O’Neil, 2008; Pestka et al., 2010)

Figure 3.1 shows a genogram with the inclusion of demographic, occupational, and major life event information (Varcarolis, Carson, & Shoemaker, 2006). In Beth’s case, a

Polish/Jewish Irish/Catholic

d. Heart attack Suicide

BS

BA William

Did not complete HS ETOH

BSN Nurse

m. 2004

Key:

Male Female

Death Miscarriage

Divorce

Identi�ed patient

Relationship lines:

Close

Close/con�ictual

Con�ictual

Distant

Stockbroker Jewish

No job ETOH 5/04 Suicide attempt 11/06 Psychotic episode DX schizophrenia

BA

Retired engineer

Schoolteacher Smoker DepressionDepression

d. Emphysema Smoker

d. in childbirth

Hank

55

Catherine Mike

Ethan Jackson

55 35 75 28

Keith Jennifer

54 50

35 31

4 2

31

FIGURE 3.1 An elaborated genogram with demographic, occupational, and major life event information. d., died; DX, diagnosis; ETOH, alcohol; HS, high school; m., married.

Source: Adapted from Varcarolis, E. M., Carson, V. B., & Shoemaker, N. C. (Eds.). (2006). Foundations of psychiatric mental health nursing (5th ed.). Philadelphia, PA: W. B. Saunders.

136 ■ I. GETTING STARTED

family genogram was not done because of her limited knowledge of family history and her refusal to participate in a family session. Had it been done, the family genogram would have revealed a multigenerational pattern of affective disorder, substance abuse, and early parent loss. Beth might have seen in graphic form some of the factors relevant to her strained relationship with her mother including her birth only 15 months after the birth of her older brother; a lengthy separation from her mother before age 3, pre- cipitated by her mother’s psychiatric hospitalization; and the death of Beth’s maternal grandmother very early in Beth’s mother’s life, followed by a series of unstable living arrangements.

ASSESSING SPECIAL POPULATIONS

The initial psychiatric assessment follows an established, comprehensive format but also hones in on the specific content domains most relevant to the patient-identified problem and presentation. Some patient populations, if not most patients, will require ongoing assessment of missed or emerging symptoms as the patient becomes more com- fortable disclosing them and/or the therapist better comprehends the clinical situation. For example, the patient who presented initially as depressed and anxious might later disclose the full extent of his or her bulimia, substance use, suicide ideation, violent fan- tasy, confusion, cognitive impairment, disability, personality disorder, or any of dozens of other symptoms, syndromes, or conditions. The literature is replete with specialized information, which is beyond the scope of this chapter, about focal assessments within given clinical domains; and the APPN should be comfortable turning to the scholarly literature whenever he or she experiences a knowledge gap. The literature includes, for example, information on psychiatric violence risk assessment (Buchanan, Binder, Norko, & Swartz, 2012); suicide risk assessment (Sadek, 2019); disability and occupa- tional assessment (Williams, 2010); assessment of personality disorders (Widiger & Samuel, 2009); psychiatric evaluation of the agitated patient (Stowell, Florence, Harman, & Glick, 2012); specialized assessment of eating disorders (Berg, Peterson, & Frazier, 2012); and specialized assessment of cognitive function in older populations (Milisen, Braes, & Foreman, 2012).

SCREENING TOOLS

Screening tools can provide useful assessment data to supplement data obtained from the clinical interview. They can identify problem areas for psychotherapeutic focus and contribute to case formulation or to the determination of the differential diagnosis. For example, psychiatric rating scales can generate baseline measures of symptom sever- ity, social and occupational functioning, or quality of life for purposes of monitoring changes over time or measuring psychotherapeutic outcomes. Although a single rating scale score at best provides only a snapshot of a complex clinical situation, repeated rat- ings can objectively describe longitudinal change over a defined treatment period and therefore provide some justification for the choice of treatment plan and some measure of its efficacy. Such ends are secondary to their overall purpose, which is to contribute to a deeper, more holistic, more empathic understanding of the person who presents for help and, in doing so, often risks so much.

Psychotherapists have long been challenged to quantify the impact on patients’ lives of both psychiatric illness and the therapies employed to treat psychiatric illness (Bresee, Gotto, & Rapaport, 2009). Early on, Barrell and colleagues (Barrell, Merwin, & Poster,

3. ASSESSmENT AND DIAGNoSIS ■ 137

1997) encouraged APPNs to use assessment tools to measure patient outcomes and to evaluate the efficacy of practice. Currently, with the arrival of “pay for performance” standards, a more rigorous approach to assessment and treatment is no longer optional (Bresee et al., 2009). The concept of measurement-based care, which refers to the use of rat- ing scales to measure the outcome of psychiatric treatment, has arrived (Zimmerman, Young, Chelminski, Dalrymple, & Galione, 2012). The practice of assessing psychiatric vital signs also has arrived. Based on the prevalence of anxiety and depressive symp- toms across diagnostic categories, Zimmerman et al. (2012) have recommended that anxiety and depression be regularly assessed and monitored as psychiatric vital signs in all patients regardless of diagnosis.

In addition, given the prevalence of childhood trauma and the long-term conse- quences, every adult should be screened with the Adverse Childhood Experiences (ACE) Scale. This is a 10-item scale that asks the person about disturbing events that occurred during childhood. A score of 4 or more indicates a highly significant increase in the development of chronic disease and mental illness (Felitti et al., 1998). See Appendix 3.16 for the ACE Scale. A more extensive instrument that evaluates specific traumatic experiences is the Traumatic Experience Checklist (TEC) which has 39 items (Nijenhuis, Van der Hart, & Kruger, 2002). This is a self-report measure that lists 29 traumatic events in the first column, the age when it happened in the second column, and how much impact the event had on the respondent on a 1 to 5 Likert-type scale in the third column. This tool is available in many languages and can be downloaded from www.enijenhuis.nl/tec.

The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults (3rd ed.; APA, 2016) and the American Psychiatric Publishing Textbook of Psychopharmacology (5th ed.; Schatzberg & Nemeroff, 2017) both emphasize the utility of structured instruments for patient assessment and outcomes evaluation; and both list commonly used clinical rating scales, screening tools, and structured instruments (Table 3.6). Fifteen screening tools commonly used by APPNs to assess psychotherapy patients and measure treatment outcomes are included in this chapter as appendices or are proprietary and can be purchased from their publishers (Box 3.19). They include several of the rating scales listed in Table 3.6.

DIAGNOSIS AND CASE FORMULATION

For any patient, the last steps in the assessment process are to formulate the case and determine the diagnosis. It is important to understand the relationship between a screening tool, along with the data it generates, and a diagnosis. Screening instruments are commonly used in many areas of healthcare and are well accepted by the general public and healthcare professionals. They are helpful in that they suggest the presence or absence of one or more diagnoses. In essence, screening tools identify the presence and severity of symptoms and therefore the likelihood of a diagnosis, but their results do not produce a diagnosis. The results of screening instruments have to be interpreted and put in the context of the broader assessment.

An important distinction exists between the presence of symptoms and the diagno- sis of psychiatric disorder. Symptoms do not generate a diagnosis unless their nature, number, duration, and context (e.g., impaired social and occupational functioning) meet the established criteria of a diagnostic taxonomy such as the DSM for the suspected diagnosis. The distinction between symptoms and diagnoses underscores the impor- tance of using systematic criteria to make a formal diagnosis. The data generated by screening tools can contribute to the systematic process of determining a diagnosis, but no one can assume that a score of 38 on a Beck Depression Inventory (BDI), for example,

138 ■ I. GETTING STARTED

determines a diagnosis of major depression. What it indicates is the likelihood of a major depression. Further investigation, including the rest of the assessment process, which continues throughout treatment as the therapist observes how the patient responds to interventions, and the integration of findings across assessment areas are required to make that determination.

Diagnosis

Although a comprehensive assessment is essential to understanding a patient’s con- cerns and capacities and to developing an appropriate treatment plan, a diagnosis is not central to psychotherapy. It is possible to help a person regain the ability to function effectively in social, occupational, and family roles without one. Nevertheless, skills in differential diagnosis are useful. They are among the specified competencies for APPNs, and a DSM diagnosis is required for purposes of insurance reimbursement. Some prac- tice guidelines do specify the forms of psychotherapy to which research evidence points as most effective for certain diagnoses. Although it is beyond the scope of this chap- ter to address the development of skills in differential diagnosis, or to fully describe the historical development of the DSM, some discussion of the concept of diagnosis is warranted.

Psychiatric diagnosis is facilitated by psychiatric nosology, or classification. Attempts to classify mental illness began in ancient times and accelerated in the 19th century, first with the French physician, Philippe Pinel, who developed the first modern classifica- tion of psychiatric illness, and later in the 19th century with the German psychiatrists Wilhelm Griesinger, Richard von Krafft-Ebing, Karl Kahlbaum, and most important, Emil Kraepelin, whose classification system dominated European and (to a lesser degree) American psychiatry for the next 100 years (Brown, DePetro, & Whitaker, 2014; Shorter, 2015). Kraepelin’s classification system was based upon close, systematic obser- vation of psychopathology and data collected from large groups of patients, whose per- sonal circumstances and individual characteristics were factored out. Kraepelin focused instead on the general characteristics patients held in common (Brown et al., 2014). His descriptive approach did not find expression in American psychiatry until DSM-III was published in 1980 with a new feature, that is, specific diagnostic criteria for clinically relevant categories of illness. Among other reasons for this change, by this time more effective psychotropic medications had emerged and explicit diagnostic criteria were needed to ensure homogeneity and validity of participant sampling for clinical trials of psychiatric drugs (Brown et al., 2014).

Influential as Kraepelin was in Europe, the immediate origins of the DSM lay in a psy- chiatric nosology developed in the United States by the psychoanalyst Karl Menninger, who had been a brigadier-general and head of psychiatry in the Office of the Surgeon General during World War II (Shorter, 2015). Thousands of war veterans were return- ing to civilian life with nonpsychotic, nonphysical disorders that seemed to have been environmentally triggered (e.g., by the war; Brown et al., 2014). Thus, Menninger pub- lished his psychiatric nosology in October 1945 as the Technical Medical Bulletin number 203 of the U.S. Army, which thereafter was known simply as Medical 203. Influenced by psychoanalysis, with its primary diagnosis of psychoneurosis, Medical 203 became the basis of psychiatric classification in the postwar United States (Shorter, 2015). By 1948, however, the APA had become increasingly dissatisfied with the diagnostic system. It charged its Committee on Statistics to prepare an official taxonomy that was eventually published in 1952 as DSM-I, which was substantially a rehash of Medical 203 (Shorter, 2015). Given the prestige of psychoanalysis, DSM-I went through 15 printings by 1962, with each successive edition less moored to psychoanalysis but only marginally more acceptable to the APA as a psychiatric taxonomy (Shorter, 2015).

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By the late 1960s, the shift from psychoanalysis to biology was in full swing, and DSM-II was published to align American diagnosis with the 8th edition of the World Health Organization’s International Classification of Diseases (Shorter, 2015). However, the structure of DSM-II was still very similar to DSM-I in terms of the main categories of disorder, including a Freudian section with what were called psychoneurotic disorders in DSM-I and neuroses in DSM-II. In 1973, the APA commissioned DSM-III, which was published in 1980 with a couple of major changes, including consensus-based diagnosis and the concept of diagnostic criteria (Shorter, 2015). DSM-IV, released in 1994, continued the multiaxial, empirically based, descriptive tradition of DSM-III but added a collec- tion of culture-bound syndromes and a new criterion to roughly half of the disorders in the manual, namely, that symptoms must cause a clinically significant level of distress or impairment in the functioning of the patient (Brown et al., 2014).

The DSM-IV-TR described psychiatric disorders in terms of clusters of symptoms and relied heavily (and necessarily) on phenomenological description, that is, the sub- jective interpretation of experience as opposed to objective, physiological markers—of which there are very few in psychiatric illness. This edition attempted to reconcile mul- tiple, competing theoretical notions about the cause of psychiatric illness in essence by avoiding the question of causality altogether, focusing only on symptom presentation. The DSM constitutes a consensus effort to achieve uniformity among mental health pro- fessionals with radically disparate theoretical orientations, ranging from the behavioral to the psychoanalytic (Mechanic, 2007). In sum, the DSM is a political document with clinical utility. It allows for greater precision in the use of psychiatric labels, which can facilitate clearer communication among mental health professionals with different dis- ciplinary backgrounds; and it can define more clearly samples of patients for psychiatric research. Because the DSM is a tool for clustering symptoms and syndromes, a DSM diagnosis implies various therapeutic interventions. For clinicians, diagnosis serves one overriding purpose—to suggest an appropriate treatment plan that will further guide the discovery of information that will lead to the most effective methods of helping people regain optimal functioning in social and occupational roles (Shea, 2017).

In 2013, DSM-5 was published with new categories of disorder, recognition of the dimensional nature of mental illness, a lifespan approach to the organization of con- tents, ever-increasing length (the DSM is now up to 947 pages), and some significant changes in the diagnostic understanding of selected categories of illness (e.g., eating disorders and autism spectrum disorders).

From its inception, the DSM has engendered controversy (Frances, 2013). A diagno- sis is an extraordinarily complex concept. Few biological markers exist to substantiate a psychiatric diagnosis. The socially constructed aspects of diagnosis stem from the reality that the DSM is a sociopolitical document drafted by committee, that is, by consensus panels of experts who nevertheless are bound to their historical, cultural, social, politi- cal, moral, and professional contexts. Because most psychiatric disorders do not yet have known physiological correlates, a diagnosis is made by matching data from clini- cal interview, observations of behavior and mood, and patient self-report of symptoms to lists of diagnostic criteria. We cannot yet order imaging or laboratory studies to diag- nose most psychiatric disorders. Moreover, what we see as constituting a psychiatric disorder shifts as cultural conditions change, knowledge grows, and time passes. Social conditions in particular historical eras create “niches” for psychiatric disorders such that new, sometimes gendered behavioral expressions of emotional distress and psychic suffering emerge, flourish for a time, and then disappear (Elliott, 2000). With each new version of the DSM, some diagnostic labels are discarded and new ones are added. In light of their complicated and controversial nature, perhaps diagnoses are best made, when they must be made at all, as a necessary evil and with an attitude of humility and profound respect for the complexity of human beings. Given the importance of DSM

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diagnoses for research purposes, their prominence within clinics and other medicalized practice sites, and their role in obtaining insurance reimbursement, diagnoses must also be made with a thorough understanding of the DSM, which is the most commonly used taxonomy of mental disorders in the United States and is now in its fifth edition.

The DSM-5 significantly changes current processes of assessment and diagnosis with the addition of dimensional and cross-cutting assessments to the DSM’s categorical diag- noses (Jones, 2012). A categorical diagnosis is either present or absent, and a categorical diagnostic system like the DSM assumes that psychiatric disorders are discrete entities with homogeneous populations that all display similar symptoms of a disorder (Jones, 2012). In reality, patient populations are widely heterogeneous and do not fall neatly into diagnostic categories, just as psychiatric disorders are neither homogeneous nor divided by distinct boundaries (Jones, 2012). This reality has highlighted some of the significant shortcomings of the current diagnostic system including excessive comor- bidity (i.e., the need for multiple diagnoses); irresolvable boundary disputes with their corresponding conflicts among clinicians with differing diagnostic views; and exces- sive use of the unspecified, formerly known as not otherwise specified (NOS) diagnostic category (Jones, 2012).

To address these shortcomings, the DSM-5 Task Force has proposed adding dimen- sional assessments to every diagnosis in the DSM. Dimensional assessments are rating scales with multiple (three or more) ordered values that measure the frequency, dura- tion, severity, or other characteristics of a psychiatric disorder (Jones, 2012). A symptom cannot be either present or absent. Rather, it exists along a continuum of severity rang- ing from, for example, 0 = not at all, 1 = for several days, 2 = more than half the days, and 3 = nearly every day (Jones, 2012). In addition to including dimensional assessments for individual disorders, the DSM may also soon include cross-cutting assessments to mea- sure symptoms such as depression and anxiety that commonly occur across patients regardless of the presenting problem or eventual diagnosis (Jones, 2012). Such symp- toms have been conceptualized as psychiatric vital signs, given the evidence for their occurrence across diagnostic categories (Zimmerman et al., 2012).

In sum, a diagnosis is probably best understood as a descriptive tool, subject to change over time, which can assist in the identification of a current clinical syndrome for which a particular treatment is indicated. A diagnosis is a descriptive label that catego- rizes persons who evidence clusters of symptoms and behaviors considered clinically meaningful in terms of their course, outcome, and response to treatment—although no one fully agrees on the nature, significance, or utility of these designations (Mechanic, 2007). In some cases, a diagnostic label denotes an underlying condition with genetic and physiological antecedents (e.g., schizophrenia). In other cases, it refers to a pattern of response to various forms of stress not clearly connected to underlying physiologi- cal phenomena (e.g., adjustment disorder). The diagnosis is not itself the thing it con- notes, that is, a disorder. However systematically or carefully it is crafted, a diagnosis represents a snapshot in time. Diagnostic error is common, and diagnoses tend to be fluid—that is, subject to the irresolvable boundary disputes identified by Jones (2012)— which is what accounts for the reality that, for example, what looks like attention deficit hyperactivity disorder at age 5 years might become oppositional defiant disorder at age 9 years, conduct disorder at age 12 years, antisocial personality disorder at age 18 years, and bipolar disorder at age 21 years. Here lies the need for diagnostic skill as well as humility and a lack of narcissistic investment in being “right” about the “correct” diagnosis.

Although DSM-5 has eliminated multiaxial diagnoses, it has retained diagnostic cate- gories and supplemented them with the addition of one or more dimensional assessments. In Beth’s case, the diagnosis of major depression was determined from the fact she had the requisite number of designated DSM symptoms for the diagnostic category, including

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depressed mood and loss of interest or pleasure, in the 2-week period before her assess- ment. This represented a change from previous functioning, caused clinically significant distress and impairment in social and occupational functioning, and was not caused by the direct physiological effects of a substance or a general medical condition (APA, 2013). The dimensional assessment for the categorical diagnosis of major depression used the Patient Health Questionnaire-9 (PHQ-9; see Appendix 3.7), which assesses the severity of nine possible depressive symptoms over a 2-week period using a 4-point scale: 0 = not at all, 1 = for several days, 2 = more than half the days, 3 = nearly every day. Beth scored 16 out of a possible 27 points on the dimensional assessment, indicating a moderate level of major depression. Because she reported that some of these depressive symptoms had been pres- ent for longer than 2 years, a possibility emerged that this major depressive episode was superimposed on a dysthymic disorder, so dysthymia was provisionally included in the differential diagnosis. However, more information will be needed to make that diagnosis, including perhaps some collateral information from people who know Beth.

Beth’s therapist also had concerns about a possible diagnosis of personality disorder given her history of intense and unstable relationships with her most significant others, the predominance of anger in her affective presentation, the apparent identity diffu- sion, her difficulty being alone, self-injurious behavior (wrist scratching), her inability to modulate interpersonal distance, and her apparent lack of object constancy (e.g., “If she [my mother] doesn’t call me every night, I get extremely anxious.”). Nevertheless, a diagnosis of personality disorder was deferred because it was not clear on the basis of a single interview, especially in the middle of a major depressive episode, that the impair- ments in personality functioning (self and interpersonal) were relatively stable across time and consistent across situations (APA, 2013; Good, 2012). In addition, it was not yet clear that Beth’s individual personality trait expression, which seemed at first glance to include at least one pathological trait domain (negative affectivity), could not be better understood as normative for her developmental stage (APA, 2013; Good, 2012). Finally, it should be noted that Beth had no medical diagnoses to report and that the clinician’s assessment of her overall level of functioning employed the GAF scale. Beth’s GAF was scored at 41 due to suicide ideation, self-injurious behavior, and serious impairment in academic and social functioning.

A psychiatric assessment is not the completion of a symptom checklist; and a diag- nosis cannot express the clinician’s empathic understanding of the patient, even though accurate, empathic understanding of the patient may be essential to the diagnostic pro- cess (Silberman, 2010). Despite the comprehensiveness of the DSM diagnostic system, much is missing from this diagnostic picture. It has a flat, two-dimensional quality and does not really encapsulate the essence of Beth’s case. It does not tell us enough. It does not clarify the boundaries between normality and illness in her case, establish an etiol- ogy for the diagnostic entities, or convey any understanding of the psychological or neurophysiological factors that might be contributing to her presentation (Silberman, 2010). It does not put Beth’s case into a theoretical perspective, prioritize her problems, predict any sort of outcome, or most important, paint a rounded picture of her unique- ness and humanity. For that, we need a case formulation.

CASE FORMULATION

Case formulation lies “at the intersection of etiology and description, theory and prac- tice, and science and art” (Sim, Gwee, & Bateman, 2005, p. 289). Case formulation fills the gap between the purely descriptive, atheoretical DSM criteria, which say nothing about the cause of a person’s problems, and the practical art of prescribing a particu- lar treatment approach for a given patient. Accurate diagnoses and effective treatment

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plans are essential to helping people; but in the gap that lies between, we need a process to link the patient’s various complaints to one another, explain why these problems have emerged, and provide predictions about the person’s probable course (Sim et al., 2005). We need a process to capture the essence of a case. Case formulation does so by succinctly describing the essential features of a case—by encapsulating the complaints, problems, diagnosis, etiology, treatment options, and prognosis with enough sensitivity and specificity so that the uniqueness of the individual appears and a more complete picture emerges of what is required in the way of help. Box 3.21 illustrates a formulation of Beth’s case.

Sim and associates (2005) identify clear benefits to the therapist in having a case for- mulation. These are related to the following five aspects of any given case: integrative, explanatory, prescriptive, predictive, and therapist elements. Box 3.21 illustrates how a case formulation can attempt to integrate clinical data, including biological, psychologi- cal, and sociocultural data; summarize the salient features of a case; identify important issues quickly in the context of an explanatory framework that provides insight into the intraindividual and interindividual aspects of the case; prioritize the patient’s prob- lems and the interventions that will address them; and identify the target symptoms by which interventions will be evaluated (Sim et al., 2005). At the prescriptive level, it dem- onstrates how the case formulation guides the therapy in choice of goals, including the point at which intervention will begin. It demonstrates how a case formulation sheds light on the prognosis of the case and makes predictions about the probable course of treatment. It illustrates how a case formulation helps the therapist recognize and organize the complex issues that lie beyond the presenting problems such that greater empathy with the patient is possible (Sim et al., 2005).

In sum, a case formulation provides the context for an evolving therapeutic rela- tionship. It allows the therapist to better understand the nature of the therapeutic relationship and to anticipate how to manage therapy-interfering events and resis- tance to change, including in Beth’s case the possibility of self-injurious behavior or the impulse to flee from any further closeness with the therapist. Case formulation begins a process of actualizing in practice the holistic model of healing discussed in Chapter 1. More than integrating the physiological, emotional, spiritual, cogni- tive, and sociocultural data obtained through a comprehensive assessment process, it attempts to do so such that the person seeking help is more comprehensible as a complex, multidimensional being within specific cultural contexts. A particularly successful case formulation begins to actualize the practice treatment hierarchy dis- cussed in Chapter 1, Figure 1.6. A good case formulation identifies, or begins a pro- cess of identifying in an ongoing way, a hierarchy of treatment interventions that can promote the patient’s healing over time.

In Beth’s case, a treatment hierarchy would move from a period of stabilization, through processing of past and present feelings and events, and on to future visioning and an integration of past, present, and future. It would move from a focus on increasing external resources to a focus on developing internal resources see Chapter 1, Figure 1.6. Beth’s treatment may start with concrete, supportive, case-management interventions designed to promote safety and stabilization in physiological, emotional, and social spheres, such as medication to target her depressive symptoms, laboratory work to rule out complicating physiological conditions, a schedule of psychotherapy sessions and academic support services, a plan to seek financial and emotional support from her father, a new living situation, and a concrete plan to limit destabilizing phone calls with her mother. As therapy progresses, interventions would move up the treatment

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hierarchy to focus on building healthier relationships, improving communication and interpersonal effectiveness, processing thoughts and feelings, and developing internal resources, such as insightfulness; the ability to tolerate distress, unpleasant affect, and ambiguity; or the ability to integrate disparate feelings about her mother, herself, or other significant persons. Ultimately, integration is the goal, as defined by Beth within her own cultural context.

Beth is a 20-year-old college junior with no previously diagnosed psychiatric problems. She presents with symptoms that meet criteria for a diagnosis of major depression, sin- gle episode, moderate severity, no psychosis, possibly superimposed on an underlying dysthymic disorder. Diagnostic criteria are met in the context of a 4- to 5-year history of family conflict, particularly with her mother, and a hostile-enmeshed family system that is not supportive of separation or individuation. The current episode is largely pre- cipitated by Beth’s moving away from home for the first time. Beth and her mother are both having a difficult time with the separation, but that is largely unacknowledged. Instead, they stay close with angry, conflict-ridden phone conversations initiated each evening by her mother and from which Beth does not or cannot separate herself.

Beth has considerable strengths: she has stayed in school despite her intense distress, has continued to work at a stressful fast-food job, and has not escalated her wrist- scratching behaviors. However, she might not be doing as well as she is but for the fact she has been living with a significant other since moving away from home. Of concern, that relationship is unstable, marked by some of the same intense conflict and abandon- ment anxiety that characterizes her relationship with her mother, and may not last much longer. In that case, I would expect to see an exacerbation of the self-injurious behaviors used previously to cope with stress. It is possible a low-level, chronic risk of passive sui- cide ideation may become transiently active and acute. An intense argument with her boyfriend, followed by his abandonment of her for an entire night, is the acute precipi- tant for the current therapy contact and evaluation. The vicissitudes of the therapeutic relationship are likely to precipitate similar responses.

To treat the major depression, I will start a selective serotonin reuptake inhibitor and order a thyroid-stimulating hormone test to rule out hypothyroidism. Because she gives a reliable history of birth control, I will not order a test for beta-human chorionic gonadotropin. Individual psychotherapy with a relational focus, starting at one session per week, begins next week. Ongoing assessment for a diagnosis of personality disorder will occur in the context of the therapeutic relationship. Given Beth’s successful engage- ment in the assessment process, I expect she will be able to form a therapeutic alliance despite some difficulties modulating distance in close relationships. Family therapy with a colleague has been recommended and refused, but Beth may be more open to this option as individual gains are made. Beth will continue to receive academic support services at the college, and I will suggest that she investigate options for student hous- ing on campus. She may be able to maintain her relationship with her boyfriend for a time if she gets a reprieve from the increased intimacy demanded by their close living quarters. I will also suggest she open a dialogue with her father about financial sup- port, as she has an appropriately close and relatively conflict-free relationship with him. I will encourage her to continue to use her current support system and will work with her to expand and strengthen it as more pressing problems are addressed (e.g., as her depressed mood begins to lift, she is better able to modulate and tolerate contact with her mother, she achieves some stability in her living situation, and she is more able to negotiate the demands of work and school).

BoX 3.21 Sample Case Formulation

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CONCLUDING COMMENTS

A comprehensive assessment of the patient who presents for psychotherapy is neces- sary to develop an appropriate treatment plan. In some practice settings, a comprehen- sive assessment is required in the initial session, and many tools are available to help the therapist. This assessment is a relational process that sets the tone for subsequent sessions. If sensitively crafted, an intake assessment can be a powerful therapeutic tool with the potential to further the therapeutic alliance, on which all good psychotherapy outcomes depend. Far from being a rote process with a simple question-and-answer format, a comprehensive intake assessment is a creative act (Havens, 1998). It begins the ongoing, essentially creative activity of two reciprocally influencing therapeutic part- ners in constructing the patient’s life story. The more powerfully engaged the patient and therapist are in the assessment process, the more valid are the data on which to base the diagnosis that will guide the choice of treatment plan.

In addition to taking a comprehensive biopsychosocial history of the patient who pres- ents for psychotherapy, the therapist must assess the patient’s ego functioning, affective development, interpersonal relationships, and cultural belief systems. Genograms play an important role in the assessment process, as do the screening tools, diagnosis, and case formulation in the therapeutic process. Several rating scales, psychiatric databases, and other screening tools are commonly used to facilitate assessment and diagnosis or to measure psychotherapy outcomes. Although nothing substitutes for experience, the assessment format and rating scales presented in this chapter provide a foundation that equips the novice nurse psychotherapist for the creative collaboration that lies ahead.

DISCUSSION QUESTIONS

1. Discuss the ways in which a comprehensive clinical assessment presents a unique opportunity for intervention in the psychotherapeutic context.

2. How may an assessment interview in the psychotherapeutic context differ from conventional medical history taking?

3. Discuss the relationship between the therapeutic alliance and the validity of clinical assessment data.

4. Describe the major goals and tasks of assessment. 5. Describe the ways in which a psychotherapist facilitates and strengthens the thera-

peutic alliance in the process of completing an assessment. 6. How would you describe the connections among ego functioning, affective devel-

opment, sense of self, and interpersonal functioning? 7. Think of a patient in your practice context with whom you have had a therapeutic

relationship. What specific questions would you ask to assess that patient’s ego functioning, affective development, and interpersonal functioning?

8. How does the therapeutic relationship with a psychotherapy patient serve as an assessment tool? Can you assess the areas of patient functioning mentioned in Question 7 without asking specific questions? If so, how?

9. What are the similarities and differences among screening, that is, employing a screening tool, diagnosing a disorder, and formulating a case?

10. Given what you have learned about Beth in this chapter, can you construct an alternative case formulation? Can there be multiple formulations of the same case? How so?

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LIST OF VIDEOLINKS

1. Clinical interviewing: intake, assessment, and therapeutic alliance www.psychotherapy.net/video/clinical-interview-intake-assessment-training

2. The DSM-5 and psychodiagnostic interviewing (4-video series) www.psychotherapy.net/video/dsm5-series

3. Conducting an MSE www.psychotherapy.net/video/mental-health-hospitals-mental-status-exam

4. Motivational interviewing step by step (4-video series) www.psychotherapy.net/video/motivational-interviewing-series

5. Advanced motivational interviewing: depression www.youtube.com/watch?v=3rSt4KIaN8I

6. Psychiatric interviews for teaching: depression www.youtube.com/watch?v=4YhpWZCdiZc

7. Psychiatric interviews for teaching: anxiety www.youtube.com/watch?v=Ii2FHbtVJzc

8. Psychiatric interviews for teaching: mania www.youtube.com/watch?v=zA-fqvC02oM

9. Psychiatric interviews for teaching: psychosis www.youtube.com/watch?v=ZB28gfSmz1Y

10. Psychiatric interviews for teaching: somatization www.youtube.com/watch?v=4-bH55MCa1U

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Bellak, L. (1989). The broad role of ego function assessment. In S. Wetzler & M. Katz (Eds.), Contemporary approaches to psychological assessment (pp. 270–295). New York, NY: Brunner/ Mazel.