PSA6669 - SECTION 2: UNDERSTANDING THE ASSESSMENT PROCESS
Assessment Scenario 1
James P. is a thirty-nine year-old white male who presents in recovery from multi-substance abuse, and with a history of serious depression, low self-esteem and self-worth, and a serious binge eating disorder. He has very few friends and has not been able to maintain any romantic relationships, spending a lot of time alone. He reports that he grew up the youngest child in a very abusive family, with a distant ineffective father and a non-nurturing mother with serious psychological difficulties, as well as two older siblings who bullied, humiliated and controlled him virtually all of his childhood. From a very early age, he was overweight and a compulsive eater, reporting that he was the subject of a great deal of teasing at school. He was not allowed to engage in any after school activities when growing up, as his mother forced him to perform menial janitorial work at a local parochial school to make extra money for the family.
When client came into his teenage years, he discovered some real talent as an athlete, and become a star on his high school football teams, getting in touch with stored reserves of anger that fueled his very aggressive play. Client also reports getting in a number of fights during his high school years, enjoying the release from this but reporting that his anger scared him as well. He reports that the only two states he seemed to be capable of were complete surrender/submission or explosive anger.
Although his sports abilities provided a sense of status, client reports he was unable to receive much pleasure from it, as he always had the feeling of being a fake or phony and still remained extremely unhappy. Nevertheless, he was able to leverage his sports success and good grades into a scholarship to a good college away from home. During his freshman year at college, he developed serious problems with social anxiety, accompanied by an acute sense of depersonalization and a collapse of any sense of self-confidence. During this period he first began to abuse alcohol, then got heavily into club drugs and cocaine. Client had one semi-serious suicide attempt during this time, which he never told his family about.
After college, client was able to be accepted into a prestigious graduate program, during which time he began to attend 12-step programs and was able to stop using alcohol and drugs. However, with the cessation of drug use, client began to have increasing difficulties controlling his binge eating, and his weight began to increase steadily except for a couple of occasions when he forced himself to adhere to a strict diet. A difficult career transition precipitated a major drop in client’s sense of identity and a final crisis of confidence, at which point his binge eating began to spiral completely out of control, at which point he entered counseling.
A thorough assessment process revealed the presence of a fairly serious attachment disorder, dysthymia, anhedonia, significant self-loathing, extreme hopelessness and pessimism, and very poor skills at relationships and interpersonal effectiveness. Client presented with enormous difficulties in sorting out his affective life, as all of his emotional responses to his childhood problems felt like a great mass of undifferentiated feelings that had nowhere to go. Additionally, client has serious distortions in how much weight he has gained and what his body looks like.
What areas do you feel might warrant deeper examination in the course of a thorough assessment process? Where would you begin to explore the various signs and symptoms presented by the client, what diagnoses might you consider in light of the problems presented, and how would you begin to create a viable treatment plan?
These are the essential questions for any clinician attempting to engage in a comprehensive psychosocial assessment process.
A psychosocial assessment has no specifically defined parameters (Jordan & Franklin, 2003). However, before the problem identification, before the goal setting, before the intervention, there needs to be some organized process or system of gathering information related to the person’s history, strengths, problems and challenges, resources, and future plans. This process is termed Psychosocial Assessment.
Psychosocial refers to the personal, biological, cultural, psychological, social, cognitive, functional and spiritual aspects of an individual.
Assessment is a systematic process of collecting information and monitoring progress. [Levine, ER (2002). Glossary. In AR Roberts & GJ Greene (Eds), Social Workers desk reference(pg. 830).New York: Oxford University Press].
This course will help you become familiar with the purpose of assessment and the various methods of assessment, as well the ethical obligations of the practitioner.
This is an introductory course designed to give the student an overview of assessment methods. It is not designed to enable the student to practice a specific method without more specific training and supervision from an expert clinician.
The interaction that happens naturally in an interview - either in person or by telephone - is a resource for information that can’t be underestimated. However, in the information age, why can’t someone just fill out a form on a computer and then have the computer come up with the activities that will fix the problem?
Researchers have found that written self reports are fallible because minor changes in wording, question format or order can influence the responses. [Schwarz N (1999a) Self reports: How the questions shape the answers. American Psychologist, 54, 93-105].
In addition, there may be age related differences in self reports that can result in misleading conclusions. [Schwartz N, Park D, Knauper B (2005) Cognition, Aging and Self Reports. Grant AG 14111 from the National Institute of Aging. To appear in D. Park & N Schwartz, (eds) Cognitive Aging—A primer. 2nd Edition, Philadelphia, PA: Psychology Press].
Moreover, the presence of cross-cultural material often creates great challenges for the gathering of information through a general questionnaire. Words, ideas and concepts can have subtle differences in connotation based upon the culture in which they are presented.
Conducting face to face interviews eliminates the collection of erroneous responses due to: 1) a failure in understanding the question, 2) confusion about the time frame being addressed, and 3) cultural barriers to communication such as age and language. The interview also allows an evaluation of mood and affect, presentation of self, and communication style.
The assessment process is more than collecting information. It is more than analyzing the responses. It is a dynamic interaction between the practitioner and the individual or family unit being assessed.
The completeness and accuracy of the content will ultimately be largely dependent on how comfortable the individual is with the practitioner. The person being assessed needs to have confidence in the skill and experience of the practitioner. There needs to be a level of trust that the information being shared will result in the resolution of the current problem and/or the eventual attainment of identified personal goals.
This trust is created by a number of core features contained in the method of conducting the assessment process:
- The practitioner needs to listen and observe
- The practitioner needs to be respectful of the individual being assessed.
- The practitioner needs to be sympathetic.
- The practitioner needs to communicate clearly without being judgmental.
Finally, the practitioner needs to be able to utilize theoretical knowledge, clinical judgment and the construction of the information into a written psychosocial study or report. [Jordan C & Franklin C (2003) Clinical Assessment for Social Workers. 2nd Ed Chicago: Lycem Books pg 2].
In order to make sense out of information that is non-sequential, inconsistent, and often incomplete, it is important to have a process that effectively applies sound theoretical models of human development and behavior, as well as both cognitive and emotional intelligence. This requires that the practitioner be comfortable with analytic thinking, pattern recognition and creativity.
There will be two kinds of thinking processes that get used in assessments: inductive and deductive modes of thinking. Clinicians should understand each, know the differences between the two, and be able to apply them both in appropriate ways.
Deduction is moving from a general theory to a specific case. An example would be applying object relations theory to the assessment of a person who presents with signs and symptoms of borderline personality disorder. The clinician conducting the assessment would be on the lookout for signs of all or nothing thinking, splitting, and confused boundaries, in line with what object relations theory would predict.
This type of thinking is dependent on the validity of the theory from which the hypothesis was developed, the appropriateness of the application to the specific case and the usefulness it has to the construction of a specific intervention plan.
Case example: An individual presents with symptoms of depression. Is the depression a result of biological factors and social isolation? If the answer to either question is “no”, then it is neither logical nor consistent to treat the depression with medication and social supports. (Adapted from Bisman, CD (1999) Social work assessment: case theory construction. Families in Society, 80(3), 240-246.)
Induction is using observations of patterns of behaviors / symptoms out of which a theory is developed. To use the example just given, this would involve using observation of a representative sample of socially isolated persons who also have a history of depression to determine if medication and social supports result in any improvement in the symptoms. If actual improvement is documented, then the hypothesis is that medication and social supports will reduce depression.
By using inductive and deductive thinking processes, information obtained in the assessment interview and from other sources like documents, records, and information from family members can be put together into one of the key purposes of the assessment – developing a logical hypothesis of what elements are key to the client's challenges and potential improvements - from which an intervention plan can be developed.
In fact, it is always better to generate multiple hypotheses and to examine how the information can be interpreted in different ways. For example, borderline personality disorder can be conceptualized as a problem with object relations, but also viewed through the perspective of difficulties in developing certain affective and behavioral skills, such as emotional control and modulation, interpersonal effectiveness skills, etc.
Related to the hypothesis development is a second and connected purpose of the psychosocial assessment: to formulate a diagnosis and an intervention plan in order to improve outcomes for the individual or family system.
The practitioner needs to be cautious about their own biases and cognitive errors in developing the hypothesis and intervention plan. The practitioner should always keep the individual/family system goals at the center of any intervention plan. The assessment process is about the person being assessed - not about the practitioner.
Of particular risk for a clinician is an over-reliance on any single theory of practice. There is no one single theory of human development or human behavior. Depending on your practice setting, some theories will be more relevant than others. Practitioners need to have a broad working knowledge of a variety of theories in order to offer the individual options for interventions that are significant and pertinent. Just as “one size does NOT fit all”, no one theory or approach meets the intervention needs for all clients.
Theories mark the difference between a professionally educated practitioner and a technician. Professional practitioners with a knowledge base in theoretical models can apply this knowledge to changing circumstances and complex cases. No matter how theories are categorized, they guide practice, explain and predict, direct research and provide a basis for policy.
Theories have two functions - to explain and to predict. Theories influence the choice of interventions that would be most likely to succeed. Professionals value theory as a guide to practice. Clinical interventions should have a theoretical model that is specific to the individual being assessed, and relevant for the problems and challenges that have been identified.
Practitioners need to guard against errors of interpretation related to personal bias and lack of professional knowledge. Even though theories cannot explain all behavior, the professional who has a depth of understanding about a variety of theories does have an advantage in interpreting information obtained in the assessment process.
Practitioners need to know what theory is a good “fit” for the mission of your agency, the population served and the problems that need to be addressed. [Bennett, S (2004) ppt presentation, “Helping Students Apply Theory to Practice”, NCAAA Orientation for Field Instruction.
To illustrate the relationship between theoretical models and practice interventions, it is only necessary to explore the needs of disaster survivors. There are a variety of disasters - natural, accidental or intentional. Some are predictable like hurricanes; some are not, like mechanical failures or criminal acts.
The victims of disasters come from every educational and socio-economic level. The very young and the very old are especially vulnerable in a disaster situations because they are the least likely to be able to take care of their own needs.
All disaster survivors have one thing in common - they are no longer able to provide for themselves. The theoretical model that works best as a starting point for this population is Abraham Maslow’s Hierarchy of Needs. [Maslow A (1943) A theory of human motivation. Psychological Review, 50, 370-396].
Physiological needs are the most basic and necessary of needs. These include oxygen, water, food, shelter, clothing and a means of excreting bodily waste products. After the physiological needs, come the needs for safety and security. Stable and predictable circumstances, protection from further harm are sought by victims of disaster. Once these needs are satisfied, then the social needs become more prominent. Reconnection with family, friends and community surface and there is a need to know how others survived the disaster. Self-esteem needs come into play last.
Using this model, interventions would begin with the basic physiological needs with special attention to the very young and the very old. Providing food, shelter, clothing, medication and supplies would be the first step in helping this population. The next step would be to ensure the safety, predictability and security. This would entail setting up a system that continues to provide for the uninterrupted delivery of goods and services to ensure that the basic needs are met.
Contacting family and friends and identifying resources for rebuilding the community would be the next priority. The last intervention would be addressing the emotional reactions to the disaster. This is how a theoretical model informs decision making within an actual clinical situation.
Examination of the Biological First
This is a course on psychosocial assessment. However, there is an entire aspect of effective assessment that will not be covered in detail that is entirely relevant for any discussion of assessment. This is concerned with the role of the mental health clinician in having the capacity to understand the difference between signs and symptoms that are the result of a mental health problem versus another cause.
The relevance for mental health clinicians lies in understanding that there is a population of patients who seek help from a mental health practitioner for anxiety, depression or other emotional problems when the underlying problem is actually a medical or physical illness. These patients will then be dependent upon the skill and knowledge of the mental health clinician in looking below the surface of the presenting problems in order to discern the presence of an ailment that will require more extensive interventions than counseling.
Physicians who are general practitioners have at their disposal numerous articles and guidelines to help heighten their awareness of mental health symptoms and diagnoses - even when their patients identify their problems as medical complaints. In this regard, generalists have a broader based perspective where patients seek help for physical complaints when the true problem is psychological or emotional in nature, or vice versa.
Mental health clinicians are well advised to keep their own reminders in this area. If mental health clinicians encounter deepening signs of depressive illness, a diagnosis made too quickly or too facilely may miss potential physical causes for the depression.
Depressive symptoms are often the initial symptoms of some physical diseases, the aftermath of trauma, or side effects from prescribed medications. When the medical illness goes untreated, psychiatric treatment only addresses the symptoms – leaving untreated potentially severe and life-threatening medical problems.
For instance, research has found that biologic relationships exist between malignancies (cancers) and depressive syndromes. Depressive symptoms are associated with cancer in up to 50% of cases. On many occasions the onset of depression is the first indication of undetected carcinoma (cancer). The depressions exhibited by the patient range from adjustment disorder with depressed mood to major depression.
The responsibility here lies in conducting a thorough enough assessment to direct the patient to the kind and level of resources that will best target the real problems. Whereas all physicians receive at least a rudimentary introduction to mental health problems, most mental health clinicians are largely untrained and unskilled in looking for the signs and symptoms that could be indicative of underlying physical illnesses.
This is a period in history when millions of Americans are without insurance and forego necessary preventive medical care. Clients can present for a counseling session through their Employee Assistance Program or at a low-cost mental health center as their first point of entry into the medical system. This means that even a beginning mental health clinician can be placed in the position of needing to be attuned to signs that suggest a more serious medical problem.
There are numerous examples of lifesaving referrals from mental health professionals to medical specialists. Some particularly powerful examples were:
- A severely depressed woman admitted to a psychiatric unit in a medical hospital for severe headaches that her primary care physician ruled to be psychosomatic. Fortunately, the team quickly sought another opinion and her malignant brain tumor was treated surgically with success.
- A successful differential medical diagnosis of an older depressed gentleman who had decreased appetite and fatigue, which turned out to be the result of stomach cancer.
- A Nurse Clinical Specialist in Psych/Mental Health cautioned a friend to seek medical help rather than an antidepressant for the hopelessness she was feeling in her pain management treatment. Her back pain had persisted and she had a cracked rib. As the nurse suspected, her diagnosis was Multiple Myeloma, a malignant cancer of the plasma cells and bone marrow which ultimately took her life.
In some cases, the depressive symptoms are caused by the frustration, discomfort and hopelessness these patients experience secondary to their physical symptoms. There may be reluctance - a kind of denial process - among some practitioners to diagnosis severe and terminal illnesses. It is, therefore, the role of all healthcare professionals to be cognizant of such possibilities.
Moreover, many illnesses exist together. When two or more medical conditions present simultaneously, they are said to be co-morbid.
What often prevents adequate diagnosis from either medical or mental health practitioners is incomplete information. Depression - and medical or other psychiatric illnesses - may be linked biologically, psychologically - or may appear to be entirely unrelated. For this reason, a thorough assessment is one that considers the presence of physical illness or other physiological factors, in addition to the presence of a mental or emotional disorder.
While this subject area is of tremendous importance for any clinician who wishes to provide a thorough assessment of a client's problems, it is outside the scope of this training. For clinicians who require further training in this area, it is recommended that yourceus.com's course on this topic be considered: DIFFERENTIAL DIAGNOSIS: IDENTIFYING COMMON MEDICAL CONDITIONS FREQUENTLY MISDIAGNOSED AS MENTAL HEALTH PROBLEMS.
Before moving to a discussion of the development of a clinical impression, there is one other area that warrant some examination: the use of measures in assessment.