Based on the work of John Bowlby and Mary Ainsworth, Attachment Theory states that early experiences with primary caretakers during infancy provide a “working model [of oneself] and others” (Broderick & Blewitt, 2006). It is also worth noting that the concept of attachment, as described here does not pertain to a specific set of observable behaviors. Instead attachment is a system of beliefs that sure the purpose of an emotional bond known as “proximity maintenance…[in addition to a] safe haven…
[and]…secure base” (Broderick & Blewitt, 2006, p125) with which to interact with one’s world Instead have profound effects throughout one’s lifetime. It is for this reason, an individual’s early attachment experiences have profound affects that last a lifetime. It is in the early social interactions with primary caregivers during infancy that we first learn trust others and develops a capacity for emotional regulation. Mary Ainsworth’s research utilized a measure called the “strange situation test” (Broderick & Blewitt, 2006, p126). Based on her observations four types of attachment styles have been observed. Babies with secure attachments show distressed when separated with a caregiver and are easily comforted upon her return so they are able to return to their play activities (Broderick & Blewit, 2006; Ingram, 2012). Anxious-Ambivalent attachments, like securely attached babies are distressed when their caregiver leaves. However, when they return, they are more anger and resistant to their caregivers attempts to provide comfort (Broderick & Blewit, 2006; Ingram, 2012). Infants with Avoidant Attachments do not cry when separated from their caregiver and ignore them when they return in the room (Broderick & Blewit, 2006; Ingram, 2012). Finally Disorganized Attachments are seen in an infant’s tendency to avoid a caregiver when they approach while seeking them out if stressed (Broderick & Blewit, 2006; Ingram, 2012).
Goals for Attachment Interventions
A primary goal of attachment theories, regardless of one’s developmental stage is the consistent availability and access to an attachment figure (Cassidy & Shaver 1999). However it is important to note that an individual’s “assessment of availability” (Cassidy & Shaver, 1999, p39). changes throughout life. For example, during infancy availability is equated to physical proximity and consistent responsiveness from a primary caregiver. As we mature, the perception of availability pertains to communication and the cognitive appraisal of responsibility to relationship and emotional needs (Cassidy & Shaver, 1999).
For purposes of intervention in order to address disruptions in attachments it is important to assess the individual’s “current appraisal (Cassidy & Shafer, 1999, p39) of their attachment. As a current working model that influence’s one’s relationships, this construct varies and changes in response to relationship experiences throughout life (Cassidy & Shafer, 1999, p39). Intervention goals vary in accordance with: (1) an individual’s current relationship experiences and (2) their developmentally relevant methods of assessment of an attachment figures availability and inherent trustworthiness. Overall, goals center around the disruptions in present attachments and their long-term consequences for a relationship (Cassidy & Shafer, 1999).
Attachment Theory Interventions
One example of a Parent-Child Attachment Intervention is the “Steps Toward Effective Enjoyable (STEEP) Program” (Cassidy & Shafer, 1999, p565). The primary interventional goal for this program is to address a mother’s “working model of attachment by focusing on her feelings, attitudes and representations of the mother-child relationship” (Cassidy & Shafer, 1999, p565). Involving regular home visits staring around the later trimesters of a woman’s pregnancy and into early infancy. It takes a proactive approach. Participants include those who are at greater risk for parenting issues based on prior history. Individual and group sessions allow the individual to alter their beliefs about self and relation to others in order to prevent repeat experiences of old family history.
Attachment Interventions for adults in individual psychotherapy can include, for example the work of Mary Main who describes three types of parental attachments towards children: “autonomous, dismissing and preoccupied” (Cassidy & Shafer, 1999, p565). Interventions utilized in Mary Main’s approach include metacognitive exercises that ask individuals to consider the working models and belief systems guiding their parental efforts. “Reflective functioning” (Cassidy & Shafer, 1999, p581), is an example of another intervention that involves reviewing life events and evaluating it from everyone’s perspective. Finally, interventions can also be aimed at allowing mothers to develop an understanding of their mental state and a child’s needs (Cassidy & Shafer, 1999).
One convenient example of attachment assessments in early infancy, includes the work of Mary Ainsworth, as described earlier. With this in mind, they involve analysis of child-parent interactions and the stability of observable behaviors over time. As individual’s progress assessments such as “The Cassidy-Marvin System” (Cassidy & Shafer, 1999, p297), are useful. This assessment involves categories of attachment styles similar to Ainsworth’s but for individuals in early child and more diverse display of behavioral responses (Cassidy & Shafer, 1999). Attachment assessments for adolescents and adults, according to the Handbook of Attachment (Cassidy & Shafer, 1999), include a series of narrative interviews. The main goal in this respect is to examine the mental constructs they utilize in current relationships and behavioral responses to these preconceptions (Cassidy & Shafer, 1999).
FINAL QUESTION: “Would a goal of therapy be to increase healthy forms of attachment? Is this possible?” In a nutshell, based on this book review and overview of interventions/assessments/goals I believe it is possible to work on attachments. An overview of my own attachment history and my husband, shows how fundamentally important this personal construct is in all relationships throughout one’s lifetime. I also believe, in this respect, that addressing it is a worthwhile and fruitful endeavor. One ideal example of the possibility of change is my own husband. His mother was an alcoholic, who died in her forties. Married 8 times in her life, she wasn’t a source of stability for him. Additionally, my husband’s father was never around. Despite this history, and after taking time to address these issues in his own life, he is an amazing husband and wonderful father. He is motivated to create the family he never had. Therefore, I would love to address this issue in my future practice.
Broderick, P. C., & Blewitt, P. (2006). The life span: Human development for helping professionals. Boston MA: Pearson.
Cassidy, J & Shaver P.R. (1999). Handbook of Attachment. New York: The Guilford Press.
Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.
“The treatment plan is the road map that a patient will follow on his or her journey through treatment….Treatment planning begins as soon as the initial assessments are completed…[and] is a never-ending stream of therapeutic plans and interventions, (Perkinson, et al, 2009, p. 75).” Each agency requires will require atreatment plan for clients and have a specified deadline for completion. It is eventually included as a part of the client’s permanent record and becomes a map for the services provided.
How to Define Problems.
Ingram (2012) defines clinical case formulation as “a conceptual scheme that organizes, explains, or makes sense of large amounts of data and influences the treatment decisions, (p. 3).” The first step to defining the problem is gathering data from the client, significant others, clinical records, and one’s own clinical judgment. This information can allow us to develop a problem list, which we can utilzie to develop diagnoses that can indicate potential treatment targets (Ingram. 2012).
Ingram (2012) describes the problem identification process as involving two key tasks: defining “the presenting problem…[and developing a] comprehensive problem list” (p43). The BASIC SID comprehensive problem framework involves assessing the following areas: “behavior, affect, sensation, imagery, cognitive, spiritual, interpersonal, [and medical]” (p43). Developed by Arnold Lazarus in the 1980’s, this assessment method allows a holistic assessment of clients, without the influence of theoretical conceptualization in the process (Ingram, 2012).
Standards for Defining Problems
Problems are define solvable goals for treatment.
Problem titles define to the client’s real-world problems & current functioning.
Problems are written clearly and tailored to the client’s specific situation.
Problems do not pertain to theoretical concepts & clinical hypothesis.
Problem’s reflect the client’s value system & not therapist’s.
The problem list is complete & comprehensive
How to Define goals
Every problem listed requires a treatment goal to resolve the issue. Success of therapy is measured in terms of evidence of progress toward the goal. They also provide a guideline for treatment planning and criteria for when to terminate therapy. There are four standards for defining goals:
There should be a logical connection between the outcome goal and the problem title.
The goals should be theoretically neutral.
The goals should be realistic, measurable, and attainable.
Standards for Writing a Treatment Plan
Focused on resolving problems and achieving goals.
The plan is logically related to the clinical hypotheses & data gathered.
The plan pertains to knowledge of clinical research.
It is strategically clear problem -> evidence -> goal -> objective -> intervention.
The plan pertains to the client’s specific situation
The plan is appropriate given situational constraints, (insurance, treatment setting, etc).
The plan addresses legal & ethical issues.
The plan utilizes referrals and community resources.
Essential Elements of a Treatment Plan
The Problem List
The problem list reflects problems that need to be addressed during the treatment process. “The problems must be specific, [and provide] a brief clinical statement of a condition of the patient that needs treatment, (Perkinson, 2009, p. 76).” Since the problems are abstract concepts by themselves, treatment plans list evidence of signs and symptoms for every problem listed.
“Once you have generated a problem list, you need to ask yourself what the patient needs to do to restore normal functioning, (Perkinson, 2009, p. 77).”
Difference between goals and objectives
GOALS define what you hope to achieve in therapy with the client.
OBJECTIVE: Define what the client will do to achieve this outcome
GOAL = TREATMENT
OBJECTIVES = STRATEGY
How to write them…
“A goal is a brief clinical statement of the condition you expect to change in the client…You must state state what you intend to accomplish in general terms, and then specify the condition of the patient that will result from treatment. All goals will label a set of behaviors that you want to elicity in the patient, Goals should be more than the elimination of pathology. They should be directed toward learning…(Perkinson, 2009, p. 77).”
After listing problems and goals, you list objectives. Objectives are list specific skills that the patient will exercise in order to achieve a goal. “It is a concrete behavior that you can see, hear, smeel, taste or feel…[and] must be stated clearly so that anyone would know when he or she saw it.
Interventions follow objectives. “Interventions are what you do to help the patient complete the objective…they are also measurable and objectives…There should be at least one intervention for every objective. The person responsible for the intervention should be listed.
For successful case formulation to occur, it is essential that the resulting treatment plan matches the client’s specific needs (Ingram, 2012). Our textbook also lists three common errors associated with matching a treatment plan with the client’s specific needs. The first of these errors involves developing a case formulation without adequate data to support underlying hypotheses (Ingram, 2012). In order to avoid this error, I believe it will help to complete the “three-column worksheet” (Ingram, 2012, p88), described in our text. Another useful preventative for this mistake is to make sure your data is complete. The second error mentioned in our textbook involves the presence of data that contradicts a case hypothesis (Ingram, 2012). As Ingram, (2012), mentions it is essential that a therapist enter the data-gathering process without a predefined orientation (p89). I would surmise, that doing so would color a therapist’s understanding of the client’s situation. The final case formulation error mentioned in our textbook involves failing to address a key issue in the client’s case. If a wealth of data exists in support of a specific case hypothesis, it would be a disservice on the part of our client’s to overlook this issue. One step therapists can take to prevent this might involve carefully reviewing information from the database after the initial interview process. A second step a therapist can take, might involve a consultation with a co-worker or supervisor.
Sample Treatment Plan
Attached is a copy of a treatment plan I created for a class. It doesn’t refer to an actual client and is purely a hypothetical and acdemic exercise. Keep in mind, it is my first attempt… 🙂
Ingram, B.L. (2012). Clinical Case Foundations: Matching the Integrate Treatment Plan to the Client. (2nd. Ed.). Hoboken, NJ: Wiley.
Progress notes provide an “organized method of planning, giving, evaluating, and recording rendered client services. A viable method of record keeping is SOAP noting. SOAP is an acronym for subjective (S), objective (O), assessment (A), Plan (P), with each letter representing one of the sections of the case notes, (Cameron, et al, 2002, p. 286).” Most agencies also have a deadline regarding when documents must be completed and entered into the client’s file. Progress notes are usually required within 24-48 hours after as session. Widely utilized in medical settings, it is also common within the counseling field.
Problem Solving Process
A textbook of mine describes the process of clinical case formulation defining it as: “a conceptual scheme that organizes, explains, or makes sense of large amounts of data and influences the treatment decisions, (Ingram, 2012, p. 3).” Essentially, this process involves four basic steps: (1) identifying the problem, (2) seeing explanations for them, (3) plan implementations, (4), defining goals, (Ingram, 2012).
GATHERING DATA: includes subjective and objective data, it is free of assumption, interpretation and/or diagnosis (Ingram, 2012).
DEFINING THE PROBLEM: stated in simple terms, the problem should be defined as solvable targets for treatment. It should be comprehensive and complete, reflecting client’s values & not the counselors (Ingram, 2012).
GOALS & OUTCOMES: There should be a logical relationship between the problems and goals. They should be realistic, attainable, and testable. Ingram, (2012) describes core clinical hypotheses as useful in these cases and defines them as follows: “a single explanatory idea that helps to structure data about a given client in a way that leads to be better understanding, decision making, and treatment choice, (p. 11).”
TREATMENT PLAN: includes a description of interventions used to address the client’s problems. Includes process goals and outcome goals.
Components of the SOAP NOTE
Subjective vs. Objective
Ingram (2012), provides a clear differentiation between subjective and objective data in the folloiwng statement: “What the client ells you goes in [SUBJECTIVE DATA}…how the client tells it goes in [OBJECTIVE DATA], (p. 83).” In other words, the subjective section provides the client’s story in their own words. The objective data contains observations on how the client tells the story.
The purpose of subjective data is to provide a place where the client’ own story can be told. For this reason, it contains information from the client and the client’s family. “Without losing accuracy, the entry should be as brief and concise as possible; the client’s perceptions of the problem(s) should be immediately clear to an outside reader, (Cameron, 2002, p. 287).” Quotations should be kept to a minimum, however important statements pertaining to thoughts such as SI and/or HI, for example should be included.
What client tells you.
What significant others tell you.
The objective data includes clinical observations, medical records, and the therapist’s impressions. It excludes case formulation and information pertaining to either the client or family members’ verbal reports. Objective information should be factual, “written in quantifiable terms – that which can be seen heard smelled, counted, or measured.” Objective information included can come either from outsider records or the counselor’s observations. Include information which is precise and descriptive, (i.e. “As evidenced by”). Words with negative judgments that are open to interpretation should be excluded. During my practicum class, the instructor required us to include the following: (1) general, (2) speech, (30 psychomotor, (4) mood, (5) affect, (6) thought, (7) insight & judgment, (8) impulse control.
Information from outside records
This section provides an overview of the client’s clinical judgment. It draws on information from the subjective and objective sections. It often lists client’s symptoms, diagnoses, and clinical impression. Cameron, et al, (2002) notes: “the assessment portion of the SOAP notes is the most likely section to be read by others, such as outside reviewers auditing records, (p. 289).”
Summary of counselor’s clinical judgment.
Synthesis of information from subjective & objective sections.
Consisting of the plan and prognosis, information here can include a list of future interventions, appointments, treatment progress, and/or psychoeducation. “the prognosis is a forecast of the probable gains to be made by the client given the diagnosis, the client’s personal resources, and motivation to change, (Cameron, et al, 2002, p. 289).”
Plans for therapy
Overview of treatment plan
Description of client’s prognosis.
An Example of a SOAP NOTE…
This example comes from my practicum class in which I recorded a series of sessions with an individual who was “playing the part” of a character. Therefore, it does not pertain to an actual client, and is a byproduct of a hypothetical exercise. Additionally, since it is important to keep in mind, this was my “first” effort at every doing a progress note, (therefore its far from perfect)… 🙂
POMR – An Alternative to SOAP
Cameron, et al, (2002) also discuss an alternative to the SOAP Format. POMR is an acronym which stands for “Problem-Oriented Medical Record. It begins with a review of the clinical assessment and continues with a list of problems derived from this history. It concludes with a treatment plan and progress note. To read more about this document click here. It is utilized commonly within the health care field it contains four components:
Ingram (2012) describes the problem identification process as involving two key tasks: defining “the presenting problem…[and developing a] comprehensive problem list” (p43). The BASIC SID comprehensive problem framework involves assessing the following areas: “behavior, affect, sensation, imagery, cognitive, spiritual, interpersonal, [and medical]” (p43). Developed by Arnold Lazarus in the 1980’s, this assessment method allows a holistic assessment of clients, without the influence of theoretical conceptualization in the process (Ingram, 2012).
At my internship, the biopsychosocial assessment occurred during my first meeting with the client over a two hour period. This document includes the following key components, ensuring all relevant information is addressed adequately.
This includes the obvious identifying information for the client including name, DOB, identification number, address, & method of payment. Other information can include: race, sex, marriage status, and employment.
What is the client’s stated reason for entering therapy? Obtaining information on the presenting problem includes not only the nature and history of their current complaints, but their goals for therapy. In other words, what does successful resolution of this issue look like? Sometimes intake forms include a current symptom checklist . This can be a point of discussion, to further define the presenting problem.
The Therapist’s interpretation of the problem:
What is the history, nature, extent, and severity of the problem?
What are the client’s personal treatment goals as it pertains to this problem?
What barriers exist to the achievement of these goals?
What are your observations and feelings overall about the presenting problem.
The Client’s Interpretation of the problem:
What does the client say the reason for coming to therapy?
ASK: Why were you referred? or What are some things you might need to work on or would like to see get better?
Family’s Interpretation of the problem.
What does the family say about the client? If no family is present than just say no collateral obtained.
ASK: What does SUZY need to work on or what things can improve?
Others to ask: referral source, caseworker, school, etc…
PSYCHOLOGICAL: Mental Health History…
Biopsychosocial exams also include a psychiatric history section. What is the client’s past history with psychiatric treatment, (i.e. outpatient, inpatient, medication list)? Has the client been diagnosed with a mental illness previously? My internship site also includes a substance abuse history, spiritual assessment here. Sometimes these forms include a mental status exam section and functional assessment.
Psychiatric History (hx treatments, diagnoses, medications, etc).
Current Mental Health Symptoms:What symptoms are they currently displaying? How long have they been occurring? symptoms should correlate to the diagnostic criteria
Past Diagnoses: (List any diagnosis from previous providers. If unknown, write “unknown”)
Previous Mental Health Treatment: Any past providers? Who and how long? What worked and did not work? Any medications in the past?
Current level of mental and physical functioning (describe impairments and skills within to justify)
Mental:Your interpretation of the client and how you feel their symptoms are affecting their life. I also include justification for diagnosis..
Physical:How is their physical health impacting their functioning? Do they need to follow up with a PCP?
Co-Occurring disabilities, disorders and medical conditions: Are there two diagnosis occurring at the same time? Are you ruling out diagnosis? IS there substance use or medical issues along with mental health?
Self harming ideations– any cutting, burning, scratching etc?
Imminent risk of harm:Are they at risk currently
Urgent needs (Describe any high risk situations, including suicide risk, personal safety and risk to others):
Mental:Are they currently putting themselves at risk behaviorally or with their choices?
Physical:Any urgent physical symptoms that need to be addressed?
SOCIAL: Family History….
The biopsychosocial assessment also includes information pertain to the client’s family background, social history, and culture. The following information is obtained: family of origin, current family, marital status, educational background, career history. Finally, while not included on the form for my internship, other resources suggest a review of the client’s legal history as well as any offender/victim issues. While not included on my internship’s form, other resources I’ve found include information on the client’s developmental history physically and educationally.
Family of Origin & Current Family
Demographic and historical information:
Who are their parents and what are their ages.
Any siblings and ages? What is the relationship with these people.
Marriages and divorces of parents.
If in foster care you may also include the dynamics of the foster family as well.
Rules of the house and the consequences if not followed.
Parent’s names and ages (or death dates).
Siblings and ages.
Current relationships with family and how it was like growing up.
Any husbands, boyfriends children and their ages.
What their relationships with them are like.
Divorces, separations, deaths and incarceration of parents and significant others (include reasons):Are there any deaths or incarcerations or divorces that are significant?
Current Significant Relationships
families, friends, community members
Marital Status & Sexual History
Abuse & Trauma History
Witnessed or Experienced
Physical / Sexual / Emotional
Any Neglect or Abuse…
(Describe if there is a need for supports)
Who do they go to when they have problems or need help
Career & educational background
What grade and school are they in?
How are their grades?
What is their behavior like? I
typically go back 2-3 years to establish patterns.
Did they need IEP, special education? Is it working?
did they graduate HS? GED?
Any IEP or special education while in school?
Literacy Level:Where is their reading level?
Need for Assistive Technology
Vocational history: Employer/Wage/Position/etc…
Living Situation & Finances.
Who lives in the home?
Whom do they live with?
Source of Income.
Any current charges pending or waiting?
Legal history and results.
BIOLOGICAL: Medical History…
Since medical issues frequently influence one’s mental health it is also important to obtain the client’s medical history. Information obtained includes a list of the client’s medical issues, prescribed medications, history of hospitalizations and surgeries, as well as their primary physician’s contact information.
Significant Medical history
Urgent physicial symptoms?
Date of Initial Prescription
Primary care physicians contact information:Name of doctor and contact information
Did you request a release to speak with the primary care physician? Yes
Did you make contact with the primary care physician after initial assessment? Yes, the appropriate form was mailed/faxed.
to include developmental age factors, motor development and functioning
Have they been (or did they meet) their developmental milestones on time?
How is their hearing?
Have they ever been tested?
You can also assess auditory hallucinations here.
How is their vision?
Do they wear corrective lenses?
When was their last eye exam?
(for children/adolescents –
Are they up to date with immunizations?
Prenatal exposure to alcohol, tobacco, or other substances
PERSONAL ASSETS AND LIABILITIES
Strengths as described by the client:What does the client state are their strengths?
Limitations:What needs to be worked on?
Individual needs and Client-identified areas for improvement and desired outcomes:
What does the client stated they want to improve in therapy?
Diagnosis & Diagnostic Impression
Diagnosis – simply the DSM-5 diagnoses listed
This is where you will list out the criteria the client meets for the diagnosis above.
You need to make sure that the symptoms reported earlier match the criteria.
In reading an IDI a clinician should already see how you came up with this diagnosis
INTERPRETIVE SUMMARY AND TREATMENT RECOMMENDATIONS
Treatment needs and recommended interventions for client and family:What do you recommend? Individual, Family, Psychological eval, CD eval, psychiatric eval etc.
What are the issues that need to be addressed? Justify why? Due to the nature of John’s symptoms, cognitive behavioral therapy is recommended.
Identification of who needs to be involved in the client’s treatment:Who needs to be involved?
Plan to meet needs:What is the plan to meet the needs? Frequency of sessions?
Evaluation of progress:Progress will be evaluated at intake, quarterly, and discharge using the WHODAS 2.0 12-item interview-administered version.
The Mental Status Exam (MSE) provides a cross-sectional snapshot of a client’s mental state at a particular point in time (Morrison, 2014; Robinson, 2002). Conducted informally, the MSE is routinely conducted as part of an intake interview (Hays, 2013). This tool provides an organized set of observations made during an interview that pertain to “sensorium, perception, thinking, feeling and behavior” (Robinson, 2002, p6). Since the MSE is designed to provide accurate snapshot of an individual’s mental state at one point in time, its diagnostic utility is limited (Hays, 2013; Morrison, 2014; Robison, 2002). Nonetheless, this tool can help describe abnormalities in an individual’s mental state and present it in an organize manner (Robinson, 2002). It can shed light on “red flags” that require further assessment (Morrison, 2014). As a key component of the intake interview, the MSE, is used frequently during admission to a facility or program. It is also useful when a client first enters therapy to provide an overview of a client’s current condition. When taken alongside collateral information and other assessments this tool can also can aid in treatment planning. In this respect, the MSE is also useful to determine an individual’s response to treatment. Finally, MSE’s are used to monitor a client’s well being in response to serious diagnoses such as schizophrenia (American Psychiatric Association, 2013).
It is a cross-sectional assessment tool.
It is not a substitute for diagnosis.
A primary goal is to note abnormalities that require further analysis.
Provides set of standardized observations to guide evaluation.
Information Gathered in a MSE
As stated earlier, the MSE is designed to gather information on: (1) sensorium and cognitive functioning, (2) perception, (3) thinking, (4) feeling, and (5) behavior (Robinson, 2002). This information is divided and organized into the following areas (Hays, 2013; Morrison, 2014; Robison, 2002):
Information gathered regarding an individual’s appearance can include observed physical traits; grooming habits, and attire. Additionally, it often reveals demographic information on an individual’s age, gender, and cultural background. How does the patient look? My textbooks describe three areas of observation to note here, (Hays, 2013; Morrison, 2014).
GENERAL APPEARANCE: “information concerning general appearance should be evidence [available to] the unpracticed eye, (Morrison, 2014, p. 119).”
LEVEL OF ATTENTION: How alert is the patient? Are they hypervigilant? Are they drowsy & inattentive?
LEVEL OF ACTIVITY: The patient’s level of activity can be an indicator of diagnosis. Observations can include level of motor activity, tarditive diskinesia, purposefulness of movement, tremor, etc.
BEHAVIOR: Is the client pleasant, cooperative, agitated? Is their behavior appropriate given the current situation? Observe mannerisms, expression, eye contact, ability to follow commands.
Morrison, (2014), describes “mood as how we feel, and affect as how we appear to feel” (p122). Observations on affect can include variations in quality, range, appropriateness and degree of reactivity (Robinson, 2002). Notable factors regarding a client’s mood can include reports of feeling states that predominate most often. Finally, the level of congruency between affect and mood is also notable symptom.
MOOD: “The client’s self-reported feeling, (Hays, 2013, p. 124).” Assessed via inquiry: how are you feeling?
AFFECT: “External expression of emotional state, (Hays, 2013, p. 124).”
QUALITIES OF MOOD & AFFECT:
TYPE: exactly what is the client feeling: Sad, Happy, etc??
LABILITY: How uncontrollable are their emotional displays??
APPROPRIATENESS: Is there a congruency between thoughts and emotions???
Speech & Language
Speech reflects an individual’s verbal expression and can vary greatly in fluency, quality, rate and flow (Morrison, 2014; Robinson, 2002). Language refers to the communication of ideas and can be described in terms of the meaning it contains and quality of articulation (Morrison, 2014; Robinson, 2002).
QUALITIES OF SPEECH:
“FLUENCY: initiation & flow of speech (Hays, 2014, p. 124).”
“REPETITION: repeating words or phrases (Hays, 2014, p. 124).”
“COMPREHENSION: Understanding of spoken/written commands (Hays, 3014, p. 124).”
“PROSODY: Attention to tone, rate, rhythm, (Hays, 2014, p. 124).”
QUANTITY, RATE, VOLUME, FLUENCY, & RHYTHM.
DIAGNOSTIC EXAMPLES FROM MORRISON (2013).
CIRCUMSTANTIAL SPEECH: indicates nonlinear thought pattern.
DERAILMENT: speech incoherent where ideas are loosely associated or unrelated.
NEOLOGISM, ECHOLALIA, & INCOHERENCE.
Sensorium & Cognition
Sensorium refers to the brains ability to intake and process information from the senses. Sensorium also refers to an individual’s level of consciousness overall. In contrast, cognition refers to the processes of logic, reason, memory, abstract reasoning and intellect (Hays, 2013). Robinson, (2002) adds that cognitive function assessments also assess for level of alertness and orientation in addition the one’s degree of attention and concentration. While these factors frequently reflect one’s level of education d native intelligence, they can also indicate the presence of a functional deficit (Morrison, 2014).
LEVEL OF CONSCIOUSNESS: LOC refers to the level of wakefulness. Is the patient conscious, if not can you arouse them? Are they able to maintain focus on the conversation?
ORIENTATION: Is the client oriented to time, place and person?
ATTENTION & CONCENTRATION: Is inquired & observed. How distractable are they? Assessments involve evaluating how well clients attend and concentrate during an assigned task.
MEMORY: How effective is the client’s ability to recall short term and long term information?
INTELLIGENCE: Intelligence is the ability to acquire and apply knowledge. It includes both observed and inquired information.
ABSTRACT THINKING: this refers to an ability to grasp facts that are not concrete and removed from the “here and now”.
Thought & Perception
An assessment of thought and perception is garnered through inquiry via the intake interview. Perception is a reflection of how the brain interprets sensory input (Robinson, 2002). Hallucinations and illusions are just two examples of perceptive symptoms. In contrast, thought content and process assess what garners the focus of an individual’s mind (Robinson, 2002). For example, thought content focuses on what an individual is thinking about, and can include symptoms of obsession, phobia, and delusion (Hays, 2013; Morrison, 2014; Robison, 2002). In contrast, thought process refers to the clarity and organization of our thinking (Robinson, 2002).
THOUGHT CONTENT: Thought content refers to what the client is actually thinking about. Examples include the following:
SUICIDAL &/OR HOMICIDAL IDEATION
DELUSIONS: (i.e. paranoia, etc).
THOUGHT PROCESS: Thought process refers to the clients manner of thinking…observations include “clarity of communication, association, & connectedness between topics (Hays, 2014, p. 124).” Examples include the following:
highly irrelevant comments (loose associations or derailment)
frequent changes of topic (flight of ideas or tangential thinking)
excessive vagueness (circumstantial thinking)
nonsense words (or word salad)
pressured or halted speech (thought racing or blocking)
PERCEPTION: An assessment of perception examines abnormalities in how a person interprets sensory information, (Hays, 2014). Disorders of perception can include the following:
HALLUCINATION: Perception of sensory input when no stimuli present (Robinson, 2002).
ILLUSION: Misperception of stimuli, (Robinson, 2002).
Insight & Judgment
Insight refers not only to an awareness of reality, but also to the degree of self-knowledge we possess regarding how we influence our world (Hays, 2013; Robinson, 2002). Judgment is defined in one’s decision-making abilities and how this is reflected in our actions (Morrison, 2014).
INSIGHT: An assessment of insight can include the clients level of acknowledgement regarding issues they currently struggle with and willingness to comply with treatment
JUDGMENT: Assessing a client’s problem solving ability can include utilizing a hypothetical scenarios and asking what they might do.
ABC STAMP LICKER
Robinson (2002) provides the following as a way of remembering the main areas to assess during a mental status exam, “ABC STAMP LICKER”
Appearance Behaviour Cooperation
Speech Thought content & form Affect Mood Perceptions
LOC / Orientation Insight & Judgement Cognitive function & Sensorium Knowledge Ends (suicide/homicide) Reliability
Junke, et al, (2007) state that suicide is the 11th leading cause of death amongst Americans. Hays, (2013) also mentions that approximately 40% of the general population have “had periods of suicidal thinking at some point in their lives” (p130). With this in mind, an understanding of common suicide assessment tools is vital for the student therapist. Establishing a rapport is essential in order to begin discussing an individual’s suicidal thoughts in an honest manner (Hays, 2013). This also ensures greater accuracy in suicidal risk assessments (Hays, 2013). A direct and calm approach provides the client an opportunity to discuss this behavior in a safe environment. Hays, (2013) states that a thorough suicidal risk assessment should consider all of the following elements:
Self-Reported Risk Level – In clients who acknowledge suicidal ideation, it is important to obtain the client’s self-reported level of risk. As stated earlier, in order to ensure the accuracy of a suicidal risk assessment, it is important to first establish a rapport with the client. The client needs to feel they are in a safe and empathetic environment when discussing this issue.
Suicide Plan – Hays (2013) states, “the best indicators of suicidal risk are ideation, plan, intent and means” (p.131). With this in mind, counselors need to ask the client if they have developed a suicidal plan. Risk increases when clients have plans ironed out in detail, and are able to access their preferred means of suicide (Hays, 2013).
Suicidal History – Counselors should assess for a personal and familial history of suicide attempts and/or threats (Hays, 2013).
Psychological Symptoms – Hays, (2013) states that suicidal ideation correlates with long-standing symptoms of distress, depression, hopelessness, and difficulty sleeping (p132). Additionally, mental disorder diagnoses and substance use history greatly increases a persons’ risk for suicide. Hays (2013) states that 90% of those who commit suicide have a mental diagnosis, and alcohol abuse increases an individual’s risk for suicide by 50-70% (p.132) .
Environmental Stressors – Stressful situations such as an impending divorce and the loss of a loved one, can increase an individual’s suicide risk (Hays, 2013).
Support System – A suicide risk assessment should include a review of an individual’s social network, and support system (Hays, 2013).
With this information in mind, it is now possible to begin comparing five suicide assessment tools for this assignment. The key elements of a suicide assessment described above, will be used as a point of comparison while discussing these tools.
Military Suicide Risk Assessment Guide (DHCC Clinicians, 2003)
Risk Factors. This tool begins with a review of factors that increase an individual’s suicide risk (DHCC Clinicians, 2003). In addition to listing common socio-demographic risk factors, this tool provides an overview of common life stressors and mental health diagnoses associated with suicide (DHCC Clinicians, 2003).
Assessment Questions. In an effort to guide the assessment process, this tool states: “suicide risk increases with a specific plan, positive means, strong intent, low likelihood of rescue…[and] a positive history of previous attempts” (DHCC Clinicians, 2003). In light of this fact, this tool provides a list of question that assesses an individual’s suicidal plan, previous history, as well as protective factors (DHCC Clinicians, 2003).
Treatment Recommendations. This tool very briefly provides a list of suggestions depending on whether the patient meets high suicide risk criteria. For example, this tool encourages the counselor to remain with the patient who meet high-risk criteria and make arrangements for transfer into hospital setting for further evaluation (DHCC Clinician2003).
“SAD PERSONS” Mnemonic Overview. The final page of this tool provides a brief overview of suicide risk factors in an easy-to-remember mnemonic “SAD PERSONS”. While this information is duplicative, it provides as an easy-to-remember review of key suicide risk factors discussed previously.
No information is missing in accordance with Hay’s list of suicide risk assessment factors (Hays, 2013). However, this tool only provides a brief overview of the suicide risk assessment process. In this respect, it is most useful as a quick guide rather than an in-depth reference source.
The next suicide risk assessment tool reviewed for this assignment is an article published by the American Counseling Association. After providing an overview of statistics on various suicide rates, this article discusses a new suicide risk factor mnemonic: “IS PATH WARM?” (Junke, et al, 2007). “Each letter corresponds with a risk factor noted as frequently experienced and reported within the last few months before suicide” (Junke, et al, 2007). The specific risk factors listed in this mnemonic include: (1) suicidal ideation, (2) substance abuse, (3) anger, (4) trapped feelings, (5) hopelessness, (6) anxiety, (7) recklessness, & (8) mood (Junke, et al, 2007).
Junke, et al (2007), note that the presence of these factors signifies a warning that more thorough suicide assessments are necessary. In this respect, this tool is simply a means of augmenting a therapist’s clinical judgment by shedding light on key risk factors associated with suicide ideation.
This suicide risk factor mnemonic serves the purpose of indicating key suicide risk factors in an individual’s history. It is not intended for use as a thorough suicide assessment guide and includes no information on an individual’s suicide plans, environmental stressors, psychological symptoms, suicide history, or protective symptoms (Junke, et al, 2007).
The next assessment tool reviewed for this assignment is an article that discusses another suicide risk factor mnemonic: “SAD PERSONS” (Unknown, 2015a). As with the previously mentioned mnemonic, this tool is useful in assessing suicidal risk factors that indicate the need of more in depth assessments. The risk factors associated with this “SAD PERSONS” mnemonic include the following:
Sex & Age – Males are more likely to commit suicide and individuals ranging from 15-24 years of age are at elevated risk (Unknown, 2015a).
Depression – Clinically depressed individuals are 20 times more likely to commit suicide (Unknown, 2015a).
Prior History of Suicide & Alcohol Abuse – Substance use increases an individual’s risk for suicide and 80% of completed suicide occur in individuals with a previous history of suicide (Unknown, 2015a).
Rational Thinking Loss – Symptoms of psychosis are associated with a higher risk of suicide (Unknown, 2015a).
Inadequate Support System – The loss of a valuable support system is associated with a higher risk of suicide. Death and divorce are common examples of this sort of loss.
Illness – Terminal illness is associated with a “20 fold increase risk of suicide” (Unknown, 2015a).
Organized Suicide Plan – A detailed plan, that encompasses access to a means of killing oneself, greatly increases risk for suicide in the individual (Unknown, 2015a).
As noted earlier, the purpose of this tool is assessing for key risk factors associated with a heightened risk for suicide. Unlike the previous mnemonic tool, this one provides a scoring system with treatment suggestions to guide therapist’s clinical judgments. This tool does not address the elements of a suicide risk assessment listed in our Hays (2013) textbook. Instead it exists as a precursor to this process and helps indicate if more thorough assessments are required.
Suicide Risk Assessment Interview Form (Unknown, 2015b)
The next suicide assessment tool reviewed for this assignment is an interview form (Unknown, 2015b). It includes all information essential in a suicide risk assessment indicated in our Hays, (2013) textbook. Additionally, this tool provides guidance throughout the process by outlining the steps in assessing suicidal risk (Unknown, 2015b).
Self-Reported Risk Level – The Suicide Risk Assessment Interview (Unknown, 2015b) begins with an assessment of the patient’s safety. This involves determining if the client has access to a weapon and if they are able to remain safe throughout the assessment. The form also asks individuals to describe the circumstances and relevant details associated with their suicidal thoughts.
Suicidal Plan – Hays (2013) states that “the best indicators of suicidal risk are ideation, plan, intent and means” (p.131). With this fact in mind, this tool includes questions to thoroughly addresses all of these elements in an individual’s suicide plan (Unknown, 2015b).
Protective Symptoms – This Suicide Risk Assessment Interview Form asks about an individual’s coping skills and support system (Unknown, 2015b). These questions are indicative of protective factors that reduce one’s risk for suicide
Complete History – This tool includes information on an individuals past suicidal history (Unknown, 2015b). It also addresses an individual’s medical background and past history of substance use (Unknown, 2015b).
Environmental Stressors – This tool also assesses an individual’s cultural background and the presence of relevant life stressors (Unknown, 2015b).
Psychological Symptoms – An array of psychological symptoms associated with suicide risk are assessed in this tool. (Unknown, 2015b). For example, in addition to assessing symptoms of psychosis, and depression, it provides information behavioral cues indicative of heighted suicide risk (Unknown, 2015b).
Recommended Assessment Steps
STEP ONE: “Conduct a thorough assessment” (Unknown, 2015b). Information should be gathered on the client’s past medical and psychiatric history. In addition to assessing the patients current symptoms, other information should be gathered such as the patient’s sociocultural background and coping skills (Unknown, 2015b).
STEP TWO: “Specifically inquire about suicide” (Unknown, 2015b). – While not all individuals are ready to discuss their suicidal thoughts, an open and honest discussion about any suicidal ideations is vital (Unknown, 2015b).
STEP THREE: “Determine the extent of suicidal ideation” (Unknown, 2015b). The next step in the suicidal risk assessment process includes a determination of the extent and pervasiveness of any suicidal intentions (Unknown, 2015b).
STEP FOUR: “Assess lethality and determine risk level” (Unknown, 2015b). Step four involves assessing an individual’s suicide plan. This includes a determining the plan’s level of lethality as well as the extent of an individual’s access to means of suicide (Unknown, 2015b).
STEP 5 & 6 : The final two steps of a suicidal risk assessment include determining if a safety plan exists and developing one as necessary to ensure a patient’s safety (Unknown, 2015b).
APA Practice Guidelines for Assessing Suicidal Behavior (Jacobs & Brewer, 2004)
The last suicide assessment tool reviewed for this assignment includes an article published by the American Psychiatric Association. This article provides an overview of the APA “Guidelines for Assessment & Treatment of Patients with Suicidal Behaviors” (Jacobs & Brewer, 2004, p373). This resource doesn’t include the specific steps listed in the above Suicide Risk Assessment Interview (Unknown, 2015b). Nonetheless, it is still the most comprehensive tool on assessing suicidal patients. While much of the information in this tool is a reiteration of information discussed previously, it is addressed in a much more thorough manner (Jacobs & Brewer, 2004). This tool provides guidance for therapists throughout the suicide risk assessment process (Jacobs & Brewer, 2004). For example, this article discusses in greater depth, characteristics to evaluate in a suicide assessment including: (1) current suicidality, (2) Past Suicide History, (3) Psychiatric Illnesses, (4) Psychosocial Factors, and (5) coping skills (Jacobs & Brewer, 2004). It also provides guidelines to determine the appropriate safety measures and treatment setting relevant to a specific case (Jacobs & Brewer, 2004). In this respect, it goes well beyond the other tools. Not only does it discuss what information one needs to gather, it provides detailed insight on what to do with this information. This insight is critical for beginning therapists who are working to develop their own clinical judgment.
The Military Suicide Risk Assessment Tool is useful in providing an overview of the Suicide Assessment Process (DHCC Clinicians, 2003). The Mnemonic Risk Assessment Tools are used to indicate if key suicide risk factors are present in an individual’s history (Junke, et al, 2007; Unknown, 2015a). This is useful in determining if a more thorough suicide risk assessment is necessary history (Junke, et al, 2007; Unknown, 2015a). In contrast, the Interview Form (Unknown, 2015b) and APA Practice Guidelines, (Jacobs & Brewer, 2004), provide a thorough review of the suicide risk assessment process. The Interview Form provides a set of topics to address with steps to guide the assessment process (Unknown, 2015b). The APA Practice Guidelines provide insight on how to utilize the information once it has been gathered. This tool can guide clinical judgment in determining the level of care and safety measures required for a particular case (Jacobs & Brewer, 2004).
“Robert Kegan is a psychologist who teaches, researches, writes, and consults about adult development, adult learning, and professional development. His work explores the possibility and necessity of ongoing psychological transformation in adulthood; the fit between adult capacities and the hidden demands of modern life; and the evolution of consciousness in adulthood and its implications for supporting adult learning, professional development, and adult education. In addition to his faculty appointment at HGSE, Kegan serves as educational chair of the Institute for Management and Leadership in Education; as codirector of a joint program with the Harvard Medical School to bring principles of adult learning to the reform of medical education; and as codirector of the Change Leadership Group, a program for the training of change leadership coaches for school and district leaders. Kegan, a licensed clinical psychologist and practicing therapist, lectures widely to professional and lay audiences, and consults in the area of professional development. ‘I have been told,’ he says, ‘t may help to know that I am also a husband and a father; influenced by Hasidism; an airplane pilot; a poker player; and the unheralded inventor of the ‘Base Average,’ a more comprehensive way of gauging a baseball player’s offensive contributions,’ (Harvard.edu, 2016).”
((FYI – what follows is a ‘quick and dirty’ overview of Kegan’s Theory of Development in an attempt to prepare for the NCE licensure exam))
A “Constructive Developmental Theory”
“Kegan is a constructive-developmental psychologist….Constructivists believe that the world isn’t out there to be discovered, but that we create our world by our discovery of it…. Developmentalists believe that humans grow and change over time and enter qualitatively different phases as they grow….Constructive-developmentalists believe that the systems by which people make meaning grow and change over time (Shiftingthinking.org, n.d.).”
Inspired by Piaget…
Kegan’s theory of development is inspired by Piaget who described human development as a byproduct of our interaction with the world and desire to make “some sense” of it. Piaget defines schemas as building block of knowledge that allow children to interact with their environment & exist as mental representations of our world. As mature, we encounter information that challenges our previous understanding of things. This cognitive disruption goads us forward to incorporate the new information through the processes of assimilation and accomodation.
In his book,”The Evolving Self,” Kegan, (1983) describes unique insights from Piaget’s theory. Piaget provides a window into how how humans make sense of their world by interacting continually with their environment and creating a new systems of meaning in their adaptation to it. When we interact with our world as children, a unique relationship develops between oneself and the environment. Our interactions with the social world define us as we in turn define it. In other words, subject and object cannot exist independent of one another. Instead, they interact in an ongoing “process of evolution as a meaning-constitutive activity, (Kegan, 1983, p. 42), the end result of which is a constructed reality, that reflects our schematic understanding.
“Piaget’s vision derives from a model of open-systems evolutionary biology. Rather than locating the life force in the closed individual or environmental press, it locates a prior context which continually elaborates the distinction between the individual and the environment…primary attention..is not to…changes in an internal equiblirium, but to an equilibrium in the world between the progressively individuated self and the bigger life field…an interaction sculpted by and consitutive of reality itself, (Kegan, 1983, p. 43).”
FIRSTLY, regarding Piaget’s developmental theory is very Hegelian in nature. The word dialectice comes to mind as a key descriptor. Growth comes by merging opposing ideas and new concepts into one’s thinking:
SECONDLY, regarding Piaget’s develomental theory reminds me of Thomas Kuhn’s book “The Structure of Scientific Revolutions.”
In this book, Kuhn, ( 2012) describes how academic fields tend to operate on an implicit set of beliefs and assumptions or “paradigm”. These paradigms exist explanatory models of belief systems that guide the progression of knowledge within a scientific field. Functioning much like a schema, new insights are utilized to expand the prevailing paradigmatic explanatory model – until something unique is encountered. This anomaly produces a crisis – and eventually a new paradigm. Likewise, when one’s current schema no longer fulfill developmental needs, new ones develop in their place.
FINALLY, with all this in mind, Kegan (1983) makes the following comment about Piaget’s developmental stage theory:
“[development]…is marked by periods of dynamic stability or balalnce followed by periods of instability…These periods fo dynamic balance amount to a kind of evolutionary trunce: furhter assimilation and accomodation will go on inthe context of the relationship struck between the organism and the world…Seen ‘psychologically,’ this process is about the development of ‘knowing’ but at the same time we experience this activity…the…tension between self preservation and self-transformation is descriptive of the very activity of hope itself…a dialectic of limit and possibility. (Kegan, 1983, p. 45)”
Subject & Object
If human development is an ongoing process of reality construction as Kegan’s theory asserts, then change is definitely a risky propositon. It requires us to re-examine our own system of meaning and current perception of reality. Albertson, (2014) notes: “change is a dangerous enterprise, for it entails balancing a tension between self-preservation and self-transformation..this process of psychological is…’messy’, (p. 76).” This process of change, seems to entail a deconstruction of previous ways of knowing in order to develop an entirely new system of meaning. Kegan (1983) utilizes a neo-Piagetian objections relations theory to describe how this change occurs:
“subject-object relations [is] not…[going] out i the “space” between a worldless person and a personless world…Subject-object relationsh emerge out of a lifelong process of development…a succession of qualitative differentiations of the self from the world, (Kegan, 1983, p. 77).”
With this in mind, the SUBJECT can be thought of as a “things…experienced as…simply a part of the self…things that are Subject to you can’t be seen because they are a part of you. Because they can’t be seen, they are taken for granted, taken as true—or not even taken at all. You generally can’t name things that are “Subject,” and you certainly can’t reflect upon them—that would require the ability to stand back and take a look at them. You don’t have something that’s Subject; something that’s Subject has you. Kegan (1994) describes Subject as ‘those elements of our knowing or organizing that we are identified with, tied to, fused with or embedded in’ (p. 32). (shiftingthinking.org).” In contrast, OBJECTS include anything or anyone we encounter in the world on a daily basis. “Things that are Object in our lives are ‘those elements of our knowing or organizing that we can reflect on, handle, look at, be responsible for, relate to each other, take control of, internalize, assimilate, or otherwise operate upon’ (Kegan, 1994, p. 32). (shiftingthinking.org).”
Stages of Social Maturity
In his NCE review CD’s, Rosenthal, (2005) describes Kegan’s constructive-developmental theory as a theory of social maturity. “More complex appreciations of the social world evolve into existence as a person becomes able to appreciate stuf abstractly that they used to appreciate only in concrete forms…as babies grow into adults, they develop progressively more objective and accurate apprecations of the social world….they do this by progressing throughf five…periods…(incorportive, impulsive, imperial, impersonal, institutional, interindividual), (Rosenthal, 2005)”
“If you want to understand another person in some fundamental way you must know where the person is in his or her evolution….a lifelong process….[this is because] the state of a person’s revolution defines the underlying logic of [their] meanings…what the experience means to him or her….what is the subject-object relationship the person has become in the world. (Kegan, 1983, p. 113-114).”
Incorporative Stage (infancy – two years)
R/T Piaget’s Sensiorimotor Stage
R/T Maslow’s Physiological Survival Orientation
FOCUS – the child is focused in sensorimotor information and reflexive action (i.e. sucking, etc). No sense of self exists.
CULTURE OF EMBEDDEDNESS – Primary Caretakers
FUNCTION ONE “Holding on”– Maintaining close presence with caregiver for comfort & protection.
FUNCTION TWO “Letting Go”– Do not meet every need for child encouraging independence.
FUNCTION THREE “Continuity” – Permit self to become a bigger part of family culture, allowing prolonged separation
“Robert Havighurst was born in 1900 in Depere, Wisconsin, a small town in the midwestern United States. His family was German in origin. His grandfather immigrated to the United States in 1847. As the oldest of five children, Robert Havighurst attended public schools in Wisconsin and Illinois. He then attended Ohio Wesleyan University, Ohio State University (Ph.D. in physical chemistry), and Harvard University as a post-doctoral fellow. During 1924-1927, he worked on the structure of the atom and published a number of papers in journals of physics and chemistry. In 1928, he made a significant career shift with a decision to work in the field of experimental education…(International Adult Education Hall of Fame,2015)”
According to Havinghurst human growth & development is a byproduct of successful fulfillment of psychosocial tasks we encounter throughout the course of our lives. In this respect, Havinghurst conceives human beings as active learners and development as a matter of his interaction with the environment. “According to R. Harvighurst a developmental-task is a task which an individual has to and wants to solve in a particular life-period…it is the midway between an individual need and a social demand…The developmental-tasks concept assumes that social and educational arrangements impede or support the corresponding tasks (Uhlendorff, 2004, p. 55).” Specific developmental tasks arise at critical times in our lives as a result of the combined effects of cultural pressure and physical maturation. Mastery of these tasks is critical for successful development. Havinghurst (1961) made the following remarks on successful aging:
A theory of successful aging should be a statement of the conditions of individual and social life under which the individual person gets a maximum of satisfaction and happiness and society maintains an appropriate balance among satisfactions for the various groups which make it up – old, middle aged, and young, men and women, (Havighurst, 1961).”
“I went to the woods because I wanted to live deliberately, I wanted to live deep and suck out all the marrow of life.” Henry David Thoreau
“A life spent making mistakes is not only more honorable but more useful than a life spent doing nothing” George Bernard Shaw
“Finish each day and be done with it. You have done what you could. Some blunders & absurdities have crept in; forget them as soon as you can. Tomorrow is a new day. You shall begin it serenely & with too high a spirit to be encumbered with your old nonsense” Ralph Waldo Emerson
“Rules for Happiness: Something to do, Someone to Love, Something to hope for” Immanuel Kant
“We ate well and cheaply & drank well and cheaply & slept well and warm & loved each other” Ernest Hemingway
The price of anything is the amount of life you exchange for it.” Henry David Thoreau