The information that is obtained by mental health professionals in an initial psychological assessment is the cornerstone from which a comprehensive treatment plan can be developed. The effectiveness of the treatment plan relies heavily on the information gathered such as issues, disorders, obstacles, strengths, willingness, and abilities of the client.
There are several types of assessments including, mental health and addiction assessments for status, treatment, as well as professional assessments on individuals who have very emotionally challenging careers such as police officers or professionals who have crossed the professional boundaries and have been sanctioned by professional licensing boards, law enforcement or their employer. During this course, we will focus primarily on mental health and dually diagnosed mental health and addiction assessments.
While it is gratifying to focus on the end result of positive client changes that occur through treatment, it is crucial to have a functional baseline or clinical yardstick from which to begin. Not only does this give the foundation for the treatment plan, but it also highlights the improvements made as treatment moves along. You must know where you came from to see how far you’ve come, so to speak.
Assessments are client-centered by their very nature and specifically relate to the distress and difficulties that each client must endure. The assessment usually consists of:
-A description of the current problem
-A complete medication history
-Mental status exam
-Alcohol and drug history
-Current living arrangements
Usually, a specific form is utilized. This form is not universal but usually created by the facility or professional. It is the counselor’s responsibility to gain sufficient information regarding the client and the client’s presenting concerns to establish an effective treatment strategy.
Many times objective diagnostic measurements are administered as a means of gaining more information about the clinical needs of the client so as to provide strong recommendations to the referral sources. Assessments are best done face to face and in person. This enables body language, tone, and affect to be considered.
The Counselor and the Process
Performing an evaluation, assessment, and/or mental status exam involves observation, conversation, and exploration. As a professional conducting the assessment, it is important to immediately start to perceive signals and make first impressions. When listening to the client avoid stereotypes and consider the context.
The assessment should be geared to the age of the client. There would be different questions and tools used for children, adults, or seniors.
A brief introduction with an explanation of what will be happening during the process can improve cooperation and reduce anxiety. The professional can talk about how the assessment will be conducted, through questions, inventories, verbally, written, or both.
After the assessment is complete the professional reviews all of the data that they have obtained from the assessment process, including any tests or inventories, if administered, to make a preliminary psychological diagnosis. Frequently, the clinician will refer to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) for clarification of mental health disorder symptoms and criteria.
Mental health assessments and neuropsychological tests should always be conducted by a trained professional, such as a psychologist or other mental health practitioner. Many tests and inventories have specific requirements and cannot be performed even by credentialed, licensed professionals.
Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V)
Getting the right treatment always depends on having the right diagnosis. If symptoms are caught early it makes them easier to treat and less likely to come back in other areas of a client’s life.
During the assessment process, the clinician is attempting to put together a preliminary diagnosis when symptoms are present.
The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) could require a course in itself, however, this course will provide a brief overview.
The DSM V was published in May of 2013 by the American Psychiatric Association. The DSM, through many revisions since its first publication in 1952, has been referred to as the “bible” of psychiatric diagnosis because it provides definitions, symptoms, and characteristics for mental disorders that are recognized by clinicians from around the world. The DSM V contains no information regarding treatment or cause. The DSM IV called for clinicians to evaluate individuals on five levels or axes.
Axis I identifies mental disorders
Axis II identifies personality disorders and mental retardation
Axis III identifies relevant physical diseases and conditions
Axis IV identifies the individuals psychosocial and environmental issues
Axis V is used by the clinician to assess an individual’s overall functioning based on the 100-point scale called the Global Assessment of Functioning (GAF).
This multi-axial system was the way in which the DSM-IV tried to address “the whole person.” It grew out of the professional conviction that, in order to intervene successfully in an emotional or psychiatric disorder, we need to consider the affected person from a variety of perspectives. Only the first three axes were used for coding diagnosis.
The DSM V combines the first three DSM-IV axes into one list that contains all mental disorders, including personality disorders and intellectual disability, as well as other medical diagnoses. Other conditions that are a focus of the current visit or help to explain the need for a treatment or test may also be coded, usually ICD-9-CM V codes or starting in October of 2014 the ICD-10-CM Z codes.
The Mental Status Exam
The mental status exam is an important part of the clinical assessment process. It is a structured way of observing and describing a client’s current state of mind, under the domains of appearance, attitude, behavior, mood and affects, speech, thought process, thought content, perception, cognition, insight, and judgment. There are some minor variations in the subdivision of the Mental Status Exam and the sequence and names of Mental Status Exam domains.
The purpose of the Mental Status Exam is to obtain a comprehensive cross-sectional description of the client’s mental state, which, when combined with the biographical and historical information of the psychiatric history, allows the counselor to make an accurate diagnosis and begin treatment planning.
The data is collected through a combination of direct and indirect means: unstructured observation while obtaining the biographical and social information and focused questions about current symptoms, situation, and history. Overall, the mental status exam contains more information observed by the professional, rather than symptoms reported by the client, with some exceptions.
-The clients presenting appearance includes their sex, chronological and apparent age, ethnicity, apparent height and weight (average, stocky, healthy, petite), any physical deformities (hearing impaired, injured
-Basic Grooming and Hygiene are noted.
-Attire, the type, and appropriateness of their dress and grooming. For example, have they dressed appropriately for the weather? Do they have accessories like glasses or a cane?
-Gait and Motor Coordination are also noted (awkward, staggering, shuffling, rigid, trembling with intentional movement or at rest), posture (slouched, erect), work speed, any noteworthy mannerisms or gestures are included in the notes.
Manner and Approach:
Important factors to consider and note include:
-Interpersonal characteristics and approach to the evaluation
-friendly and open
-normal rate and volume
-Recall and Memory
-able to explain recent and past events
-recalls three words immediately after two rehearsals
and then again after five minutes
-able to recall your name after 30 minutes
Orientation, Alertness, and Thought Processes:
-Orientation refers to their awareness of person, who they are; place, where they are; time, what year is it; presidents, who is the president of the United States; and your name. This serves as a reference for their cognitive functioning.
-Alertness describes whether the client is for example, sleepy, alert, tired, dull, or highly distracted. It indicates their focus and awareness.
-Overall coherence and concentration are important factors to note. Thought process issues can include whether the client is difficult to understand regarding their line of reasoning.
-It is important to explore if the client is experiencing any hallucinations or delusions. Most assessment forms will list these out in the form of checklists. Some examples include auditory hallucinations, visual hallucinations, and delusional parasitosis. When lists such as this are presented it is vital to give examples such as, Do you ever experience voices that other people can’t hear? (Auditory Hallucination) Do you ever see people or things that others don’t see? (Visual Hallucinations) Do you have the feeling that bugs are crawling on you? (Delusional Parasitosis, sometimes referred to as Morgellons and/or Formication).
-Other important factors to assess with regard to thought processes include judgment and insight. How did the client make some of the decisions they have made? How do they feel about the outcome? These are crucial when moving forward with the treatment. Also, intellectual ability and abstraction skills, such as What would I mean if I said I was feeling blue? or how are dogs and cats similar? need to be addressed.
Mood and Affect:
-The mood can be explored by asking about how they feel most days, for example, happy, sad, despondent, or euphoric. Does this match how they are presenting?
-The clients affect refers to how they feel at any given moment. If a client’s affect is flat, but they are describing their favorite childhood memory that shows the effect that is inconsistent with the content of the conversation. Affect can be expressed by words such as restricted, blunted, inappropriate.
-To differentiate mood from affect think in terms of mood as the overall feeling most days and the effect as more of the in the moment presentation.
-Building rapport is one of the most fundamental dynamics between a counselor and a client. Rapport refers to establishing the ability to relate to others. In a mental status, exam rapport is frequently described by terms such as, easy to establish, initially difficult but easier over time, difficult to establish, tenuous, and easily upset.
-Facial and Emotional Expressions, described by terms such as relaxed, tense, smiled, laughed, became insulting, yelled, happy, sad, alert, day-dreamy, angry, smiling, distrustful/suspicious, tearful when discussing such and such are important factors in this area.
-No assessment would be complete without addressing any history of or current suicidal and/or homicidal Ideation. Again using terms such as ideation, are for the report only. When talking with a client you would ask, have you ever thought about hurting yourself? If the client reports ideation the next step would be to explore if they have a clear plan and intent, no clear plan, but intent, or no plan and no intent. More simply put, You have told me that you have thought about hurting yourself within the last week. Have you thought about how you would do this and do plan carry these thoughts out?
The client’s risk for violence, responses to failure, impulsivity, and anxiety are also important mood and affect areas.
Scales and Instruments Used in Assessments
There are hundreds of instruments created to streamline the assessment process. Some are for mental health, some for addictions, many for dual diagnosis of both mental health and addictions, some for geriatric clients, some for adults, and others for children. The following are samples of popular instruments.
The Functional Assessment of Mental Health and Addiction Scale (FAMHA)
The Functional Assessment of Mental Health and Addiction scale (FAMHA) was specifically designed to meet the criteria for both mental health issues and addictions.
Dually diagnosed clients have multiple service needs in mental health, addiction treatment, and medical interventions. Thus, functional assessments like the FAMHA are the key to not only measuring the outcomes of treatments on a broad scale but crucial to the clinician’s full understanding of a patient’s individual needs.
The FAMHA is not the only scale of this type but will give the learner an overview of information gathered for the dually diagnosed individual.
Description of the FAMHA:
The scale describes the population types as:
-Mentally Ill Substance Users (MISU)
-Substance Using Mentally Ill (SUMI)
-Medically Compromised – Substance Using Patients (MCSU)
The scale assesses these individuals across a broad range of symptoms and functional domains. The 46 items of the scale document functional deficits across all bio-psychosocial functional domains in such a way as to capture the current state of overall functioning, whilst demonstrating specific areas of need. The 46 items subdivided into 6 bio-psychosocial dimensions:
2. SocialCommunity Living
3. SocialInterpersonal Skills
5. Psychological Functioning
6. Physical Functioning.
In addition to the dimensional scales, data as to the patient’s primary and secondary drug of choice, alcohol consumption, prior mental health, and addiction treatment episodes, demographics, and current medical, mental health and addiction diagnoses are also collected to add to the clarity of the diagnostic profile. It is expected that continued statistical analysis, including factor analyses of further trials, will yield more refined, discrete scale dimensions and add to the overall utility of the instrument.
It can be used as both an indicator of current functioning for diagnostic assessment and as a repeated measure to demonstrate the changes that occur to patients throughout the clinical cycle.
Because the term dual diagnosis is somewhat broad and misleading (for example; mental illness and learning disabilities are dual diagnoses). The distinction between MISU, SUMI, and MCMU patients has a significant impact on the selection and use of a variety of intervention techniques and strategies.
Development of the Scale
The FAMHA was developed with a variety of criteria in mind. It was felt that the FAMHA should not only assess the obvious symptom categories of major mental illness and addiction but should also:
1. include functional domains that are deemed important for community-based treatment clinics;
2. demonstrate reliability and validity;
3. possess sensitivity to treatment-related change;
4. be appropriate and relevant to the dually diagnosed population that it functionally assesses;
5. be a useful tool for treatment planning and clinical governance;
6. have low administration costs;
7. be relatively easy to use by all levels of clinical staff.
The current version of the FAMHA meets all of these criteria and can be administered in as little as 8 minutes by a trained, experienced rater.
The FAMHA uses a seven-point, three-way anchored Likert-like scale, ranging from extremely dysfunctional symptoms or behaviors (Score 1) to normative levels of these behaviors and symptoms (Score 7).
The scale was designed to quantify patient functional levels more systematically than the Global Assessment of Functioning (GAF)(APA, 1994) and provides for the systematic rating of functional deficits in critical areas that could not otherwise be assessed in this population. In addition, FAMHA overall scores are designed with a coefficient that readily converts the total score to overall GAF scores. Thus, it refines the diagnostic profile for individual patients that is necessary for appropriate diagnosis within both ICD-10 (WHO-1996) and DSM-IV (APA 1994) diagnostic systems.
The Addiction Severity Index (ASI)
The ASI is possibly the most widely used measure of substance abuse in the field. This is a semi-structured interview designed to provide important information about aspects of the life of patients that may contribute to their substance-abuse problems. The Addiction Severity Index (ASI) provides a general overview of substance-abuse problems rather than a focus on one particular area (200 questions on 7 subscales).
The interview is based on the idea that addiction to drugs or alcohol is best considered in terms of the life events that preceded, occurred at the same time as, or resulted from the substance-abuse problem. The ASI focuses on seven functional areas, or subscales, that have been widely shown to be affected by the substance abuse: medical status, employment and support, drug use, alcohol use, legal status, family and social status, and psychiatric status. Each of these areas is examined individually by collecting information regarding the frequency, duration, and severity of symptoms of problems both historically over the course of the patient’s lifetime and more recently during the thirty days prior to the interview. Within each of the problem areas, the ASI provides both a 10-point, interviewer-determined severity rating of life problems as well as a multi-item composite score (computer-calculated) that indicates the severity of the problems in the past thirty days.
The ASI is widely used clinically for assessing substance-abuse patients at the time of their admission for treatment. It takes about an hour to gather the basic information that forms the first step in the development of a patient profile for subsequent use by the staff in planning treatment.
The ASI also examines psychosocial functioning (medical, legal, employment, psychological, and social/family), which is crucial to understanding alcohol dependency.
Millon Clinical Multi-axial Inventory
The Millon Clinical Multi-axial Inventory is a true/false questionnaire that takes less than 30 minutes for an average person to complete. It is designed to reveal personality traits or characteristics of a person and is considered to be very useful in that it can reveal aspects of a person to assist in making a diagnosis more quickly than a traditional clinical interview. Like the DSM, there are several versions of this test, and only the most recent is considered valid.
Beck Depression Inventory
The Beck Depression Inventory is a test that is designed to be used alongside the DSM in order to clarify a diagnosis of depression. While this is possible use, this test is mainly used to evaluate the effectiveness of treatments for depression. This test uses weighted ratings and asks questions regarding the typical symptoms of depression such as depressed mood, poor self-image, and withdrawing socially. This test is updated to match the current DSM.
Minnesota Multiphasic Personality Inventory
The Minnesota Multiphasic Personality Inventory is a very common test that is used by clinicians to differentiate between potential diagnoses as well as to plan and evaluate treatment. However, this is a very popular test and is commonly used outside of clinical settings as well, such as penal institutions and human resources departments. This test is found to be remarkably accurate at predicting treatment outcomes. Like most psychiatric tests, there are several versions of the MMPI.
Again, different tools have different requirements per what type of professional can administer it. There are a vast number of tools available.
A mental health assessment is done to explore alcohol and drug issues mental health problems, such as anxiety, depression, schizophrenia, as well as to help distinguish between mental and physical health problems. An assessment should be done by a qualified, trained professional. The information obtained is crucial to the correct diagnosis and effective treatment planning.
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