“About fifteen pounds.”
“Do you feel like a bad person?”
“Yes.”
“Tell me about it.”
“Nothing to tell. I’m just a piece of shit.”
“Are you thinking of hurting yourself?”
I waited a moment before answering, “Yes.”
From The Center Cannot Hold: My Journey Through Madness by Elyn Saks. © 2007 by Elyn Saks. By permissions of Hachette Book Group, Inc. All rights reserved.
After a number of other questions, Elyn Saks was referred to a mental health professional to diagnose her distress and formulate a treatment plan. In this chapter, I will introduce you to the ways in which mental health professionals clarify the type of problems a person is describing. This will include methods of assessment that have been developed to maximize reliability and validity. I will then discuss the major classification systems used throughout the world.
Elyn Saks
Initial Assessment and the Mental Status Exam
As a clinician, people come to see you in a variety of ways. Some people set up an appointment and tell you about how they are feeling distressed. They may tell you about feeling anxious or sad. If you work in a hospital, people may be brought to you by others who are concerned by the behaviors they display or the experiences they describe. As a clinician, it is your job to make sense of the information you are given. The first task is that of assessment.
During the clinical interview, mental health professionals gather information about the status of an individual they are working with.
© iStockphoto.com/Izabela Habur
Psychological assessment is simply the process of gathering information about a person so that you can make a clinical decision about that person’s symptoms. In the process, you may create a variety of hypotheses about the possible causes of the symptoms. Had the person taken drugs that were causing the behavior? Did the person suffer a negative experience such as being robbed or raped? Is the behavior part of an underlying physical or mental disorder? Part of the task of the clinical assessment is to gather data necessary to rule out or support the possible causes of the symptoms.
The Clinical Interview
Most mental health professionals use a clinical interview to initially gather information concerning the status of an individual with whom they are working. Since the interview is also an interaction between two people, it is a chance for the professional to establish rapport, which will lead to more complete information. The information gained from this interview includes not only the individual’s present symptoms but also the social and cultural context in which these symptoms appear. This context includes the individual’s social support, family relationships, and connections within his or her community. It is also important to assess the individual’s attitudes, emotions, and experiences of others in his or her world. The clinical interview further offers the opportunity to assess the current ability of the individual to care for him- or herself.
psychological assessment: the process of gathering information about a person so that you can make a clinical decision about that person’s symptoms
Overall, the major areas of consideration in a clinical interview are (1) the current areas of distress and their history; (2) any past mental health problems; (3) social history including social support; (4) the manner in which cultural factors may influence the current condition; and (5) any way in which previous family, medical, or psychological factors may influence the current situation.
The Mental Status Exam
Throughout the world, the clinical interview has been organized into major categories and referred to as the mental status exam. This exam is often given quickly to gain initial information.
mental status exam: clinical interview organized into major categories designed to determine a person’s cognitive processes
The first major category of the exam is the individual’s appearance and behavior. In the report, the mental health professional would note such factors as the individual’s clothing, grooming, and posture. Motor activity, such as slow movements, may be part of a later diagnosis of depression, whereas quick, abrupt movements may be associated with mania.
The second major category of the exam is mood and affect. Affect refers to the emotions that the individual is expressing during the interview. The person might seem happy or sad. The professional might note that the person laughs or cries in describing situations, where other individuals would not laugh or cry. Such affect would be described as inappropriate. It should also be noted if the individual shows no affect when describing situations such as receiving a large raise in pay or losing a friend, where others would be happy or sad. Such affect is said to be flat. Mood, as compared with present affect, is more long term. To assess this, the professional notes how the individual reports he or she has been feeling recently. Has the individual been feeling blue or angry?
The next category is speech quality. Here, the professional notes the manner in which an individual speaks. Is the person speaking quickly or very slowly? Does the person’s manner of speaking feel pressured? Does the person speak very quietly or with great volume? These are the types of speech characteristics the professional can observe and record.
The next major category is thought processes. In describing thought processes, the professional can note if the individual answers the questions that are asked and adds more information when appropriate. On the other hand, some individuals will produce responses that are not related to the question asked or tell a narrative in which each sentence is not related to the one that came before it. This is referred to as a flight of ideas. The content of the individual’s thought is also important. Is there a theme to the thoughts, such as that the CIA is out to get the individual? This would be referred to as delusional thinking. Does the individual keep repeating a certain theme? For example, some individuals express constant concern that they will have a heart attack or that their spouse is cheating on them. This is referred to as obsessional thinking. The professional should also take particular note if the person is talking about suicide or homicide. This may require an intervention.
flight of ideas: spoken expression in which comments are not related to a question asked or jump abruptly from one topic to another unrelated topic
delusional thinking: an unrealistic pattern of thoughts forming a theme
obsessional thinking: a pattern of repeated thoughts beyond the control of the person
Another major category is perceptions and a general awareness of the surroundings. Distortions of perceptions can include hallucinations in which the individual perceives experiences without external stimulation. Individuals with a psychotic disorder may hear a radio program talking to them directly or respond to voices in their head. General awareness of the surroundings includes the question of whether the person knows who and where he or she is and the present date and time.
The final categories describe intellectual functioning and insight. Intellectual functioning is generally noted in terms of current vocabulary used in the interview as well as previous academic achievement. The professional can also note if the person has an abstract understanding of the information he or she is reporting. Insight refers to the individual’s awareness of his or her own self and the factors related to his or her current situation and distress.
Structured Interviews and