Major Depressive Disorder involves a depressed mood, loss of pleasure, and changes in overall functioning (American Psychiatric Association, 2013). Other symptoms associated with this diagnosis include weight loss, psychomotor changes, fatigue, feelings of worthlessness, and difficulty concentrating (American Psychiatric Association, 2013). Hays, (2013), states that “the lifetime prevalence of major depressive disorder [is] estimated to be 17% in the general population” (p151). Max Hamilton originally published The Hamilton Rating Scale in 1960 (Hamilton, 1960). This scale was initially intended as a tool to guide interview assessments for individuals diagnosed with either depression or affective disorders (Hamilton, 1960). Its main purpose is to assess the intensity and frequency of depressive symptoms (Hays, 2013). This assessment is “highly effective in differentiating individuals diagnosed with clinical depression from non-depressed individuals” (Hays, 2013, p153). A free online version of this tool has been provided for this assignment and will be reviewed next. (Hamilton Rating Scale for Depression, n.d.).
My First Impression
In order to form a good overall impression of this tool’s usefulness, I utilized insights from the DSM-5 manual on Major Depressive Disorder (MDD). The questions within this assessment appeared to correlate directly with diagnostic criterion for MDD (Hamilton Rating Scale for Depression, n.d.). Additionally, a resource titled “Structured Interview Guide for The Hamilton Depression Rating Scale”, showed me how these issues could be reviewed in a therapy session (Williams, 1988). Below, I discuss my impressions of this tool by referring to the criteria for MDD while utilizing insights from the interview guide mentioned above (American Psychiatric Association, 2013, p161; Williams, 1988).
Criterion A1: Depressed Mood: The Hamilton Rating Scale uses two questions to assess mood. The first question asks respondents to rate the presence of a depressed mood (Hamilton Rating Scale for Depression, n.d.). Question eighteen indirectly addresses the issue of mood, by asking about symptomatic variations occurring throughout a day (Hamilton Rating Scale for Depression, n.d.). Williams (1988), suggests that the quality and variation of mood symptoms are key indicators of MDD.
Criterion A2: Diminished Loss of Pleasure: The DSM-5 lists the loss of pleasure as a symptom of depression (American Psychiatric Association, 2013). Question seven, of the Hamilton Assessment asks respondents to rate changes in their level of participation and involvement (Hamilton Rating Scale for Depression, n.d.). This question manages to address criterion A2 only indirectly. Therefore, a therapist would need to assess for a loss of pleasure in activities previously experienced as enjoyable, in a follow-up interview (Williams, 1988).
Criterion A3: Significant Weight Loss The DSM-5 describes significant changes in weight without dieting as another symptom of MDD (American Psychiatric Association, 2013). The Hamilton Inventory addresses this in question sixteen (Hamilton Rating Scale for Depression, n.d.).
Criterion A4: Insomnia or Hypersomnia – A relatively significant portion of the Hamilton Depression Inventory addresses the issue of sleep problems associated with MDD (Hamilton Rating Scale for Depression, n.d.). Three out of twenty-one questions in the Hamilton Rating Scale are devoted to assessing sleep patterns (Hamilton Rating Scale for Depression, n.d.). I find this fact perplexing.
Criterion A5: Psychomotor Changes: The Hamilton Rating Scale addresses this criterion in questions eight and nine (Hamilton Rating Scale for Depression, n.d.). Additionally, the questions appear to correlate very well with DSM-5 Criteria.
Criterion A6: Loss of Energy – The DSM-5 manual addresses somatic symptoms associated with MDD briefly in Criterion A6 which refers to a loss of energy (American Psychiatric Association, 2013). Nonetheless, the Hamilton Rating Scale devotes questions twelve through sixteen to assessing a diversity somatic symptoms (Hamilton Rating Scale for Depression, n.d.). I surmise this can indicate potential medical causes underlying depressive episodes.
Criterion A7: Guilt & Feeling of Worthlessness – The DSM-5 manual describes “feelings of worthlessness and excessive or inappropriate guilt” (American Psychiatric Association, 2013, p161) as a symptom of MDD. The Hamilton Depression Inventory assesses this issue briefly in question two, which asks respondents to rate feelings of guilt (Hamilton Rating Scale for Depression, n.d.). Williams (1988) suggests asking clients: “Have you been putting yourself down this past week, feeling you’ve done things wrong, or let others down” (p5). This may be a nice follow up question upon completion of the assessment.
Criterion A8: Concentration & Decision Making – The DSM-5 lists deficiencies in concentration and decision making as key symptoms of MDD (American Psychiatric Association, 2013). Nonetheless the Hamilton Rating Scale, fails to address this issue altogether (Hamilton Rating Scale for Depression, n.d.). Williams (1988) suggests asking questions such as: “Were you able to focus on what you were doing?…Did you notice that minor decisions were more difficult to make than usual?” (p8). These questions might be helpful to assess for this factor in a post-assessment interview.
Criterion A9: Suicidal ideation – The DSM-5 lists “recurrent thoughts of…suicidal ideation” (American Psychiatric Association, 2013, p161) as a symptom of MDD. Question three of the Hamilton Rating Scale briefly assesses the presence of suicidal thoughts (Hamilton Rating Scale for Depression, n.d.). In my opinion, a more thorough assessment of this issue should be included after completion of this assessment. For example, Williams (1988) suggests asking: “This past week, have you had thoughts that life is not worth living? What about thinking you’d be better off dead or wishing you were dead? Have you had thoughts of hurting or killing yourself?” (p4)
Questions Related to Specifiers & Comorbidities: Several questions remain in the Hamilton Rating Scale, do not pertain to diagnostic criterion for MDD (Hamilton Rating Scale for Depression, n.d.). These questions assess for symptoms of anxiety, insight, paranoia, OCD, alongside Depersonalization and Derealization (Hamilton Rating Scale for Depression, n.d.). These symptoms correlate with MDD diagnostic specifiers and comorbid diagnoses (American Psychiatric Association, 2013).
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, 23(1), 56-62.
NERD ALERT!!! This is an old paper I’ve posted because I am studying for a licensure exam 🙂
After administering a psychological assessment, it is necessary to compare raw scores against a predetermined criterion in order to attain a derived score. Hays, (2013) points out that this is essential since raw scores are meaningless by themselves. The derived score provides a meaningful interpretation of the raw score against a defined standard. Three main types of derived scores exist based on the type of standard utilized. Norm-referenced scores compare an individual’s results against group scores in order to determine a person’s standing along a bell curve (Hays, 2013, Norm-Referenced Scoring, 2009). I.Q. tests provide just one example of a norm-referenced score. Criterion-referenced scores compare an individual’s performance on an assessment test to an established criterion (Hays, 2013, Smith & Stoval, 2002). This scoring method is often utilized in the educational system to assess a student’s academic achievement (Hays, 2013, Smith & Stoval, 2002). Finally, self-referenced scores utilize an individual’s previous scores on the same test in order to assess change over time. Self-referenced scores are frequently utilized in personality tests and interest inventories.
Description & Interpretation
Tests utilizing norm-referenced scores allow the comparison of an individual’s results with a normative sample (Hays, 2013). In order to interpret norm-referenced tests, an individual’s raw score is converted into a derived score. This allows test users to compare an individual’s score to establish norms for the test (Cohen, 1996). In order to create these norms, a version of the test is administered to a representative sample that reflects its target population. The characteristics that comprise this sample are carefully considered since this greatly influences the generalizability of results (Cohen, 1996).
Norm referenced scores have various formats (Mertler, 2007) “A percentile rank…indicates the percentage of the norm group that scored below a given raw score” (Mertler, 2007, p114). A developmental scaled score allows educators to compare a student’s performance with children in his age group and/or grade level (Hays, 2013). Finally, standardized scores “have a mean at 100 and a deviations that occur in equal intervals” (Norm referenced scoring, 2009, p645). IQ tests utilize a standardized norm-referenced scoring system (Hays, 2013). In order to create a standardized test, raw scores of a normative sample are transformed so that they reflect a bell shaped curve (Mertler, 2007). The standard deviations are all equal, and measures of central tendency are in the exact center (Mertler, 2007).
Examples of normative tests include the Graduate Record Exam (GRE), the WISC intelligence tests, and Terranova testing. These tests represent three unique scenarios in which this scoring method is utilized. They are each briefly reviewed below.
Graduate Record Examination (GRE).
The GRE, is “the most widely accepted graduate admissions test worldwide” (Hays, 2013, p192). GRE scores are utilized as admission criteria for entry into graduate school. The standards utilized to assess an individual’s results vary in accordance with the needs of a program, (Hays, 2013). The GRE General Test contains a verbal, quantitative and written portion. The verbal portion of the test examines an individual’s ability to understand and use written material. The quantitative portion examines an individual’s quantitative reasoning and understanding of mathematical concepts. The quantitative and verbal subtests are combined and scored on a 130-170 point scale, with a mean around 150 and 10 point standard deviations (Dulan, et al, 2013). The written section of the GRE General Test is scored separately on a scale of 0-6 with a mean at about 3 and standard deviations at just under 1 (Dulan, et al, 2013) Scores are reported in one point increments and converted into percentages in comparison to a norm-referenced sample (Dulan, et al, 2013). This newly revised scoring system, developed in August, 2011, replaces a 40-year-old norm-referenced sample (Cohen, et al 1996). According to ETS, the revised GRE scoring system provides greater precision in assessing variations in performance between test takers (Dulan, et al, 2013).
Wecshler Intellgence Tests (WISC).
David Weschler defines intelligence as “the aggregate or global capacity of the individual to act purposefully, to think rationally and to deal effectively with his environment.” (Weschler, 1944, p3). The adult version of the Weschler intelligence test was originally developed in 1939. It has undergone several revisions with the latest version coming out in 2008 (Hays, 2013) The Adult WISC contains 15 subsets that are combined into a verbal score alongside a performance score (Hays, 2013). The WISC for children assesses four main areas, including: “Verbal comprehension, perceptual reasoning, working memory, and processing speed” (Hays, 2013, p173). The adult and child versions of the WISC tests are based on samples of about 2000. Individuals (Hays, 2013). It has a standardized norm-referenced scoring system with a mean at 100 and standard deviations of 15 (Hays, 2013).
The Terranova test assesses language, reading, math, science and social studies for students from kindergarten through grade school (Hays, 2013). The Terranova test is a byproduct of the NCLB “No Child Left Behind Act” (Hays, 2013). It is used to monitor student progress and assess the quality of curriculum and instruction provided. According to McGraw hill, the Terranova test norms are based on a sample of 200,000 children who were administered the test in 2011 (McGraw Hill, 2013). Both criterion referenced and norm referenced standards are utilized to assess Terranova scores. The norm-referenced scores are provided in the form of a national percentile score in the above-mentioned subject areas (McGraw Hill, 2013). An objective performance index compares a student’s scores against predetermined criterion (McGraw Hill, 2013).
Description & Interpretation
Criterion-referenced tests use established criteria as a means of assessing an individual’s score (Hays, 2013). Criterion-referenced scores describe a person’s level of knowledge and skill mastery (Cohen, et al, 1996). In comparison, norm-referenced scores show how a person has done in comparison to others (Cohen, et al, 1996). Types of scores provided by these tests can include measures of speed, quality, or precision of performance (Mertler, 2007). Scores such as pass/fail, or below average/average/above-average are not uncommon in these scoring methods(Mertler, 2007).
In order to assess an individual’s level of knowledge against a predetermined standard, criteria are utilized as a reference point. These criteria provide cutoff scores along a continuum as a means of interpretation of an individual’s raw score (Mertler, 2007). The process of determining these criteria is known as “standard setting” (Mertler, 2007, p101). The criteria can vary greatly from a continuum-based model to a dichotomous perspective (Cohen, et al, 1996). Nonetheless, it is important to note that the criteria are based on expert judgment. Therefore, it is difficult to understand exactly what goes into the process without interviewing the experts.
Much controversy exists regarding the criteria setting process, as it relates to high-stakes testing (Hays, 2013; Mertler, 2007). High stakes testing is a practice that involves assessing students regularly to evaluate the curriculum and instruction they receive (Hays, 2013). While a well-intentioned endeavor, critics state it limits teacher creativity, and ignores critical components of a student’s achievements (Mertler, 2007).
A key benefit of criterion-referenced tests, is their ability to assess an individual against a predetermined standard. The utility of this form of measure can be found within a wide diversity of contexts which are discussed below.
Substance Abuse Assessment.
Alcohol Abuse can be thought of as the consumption of alcohol despite negative consequences (Hays, 2013). Alcohol dependence includes symptoms alcohol abuse alongside the presence of tolerance and withdrawal (Hays 2013). The Michigan Alcoholism Screening Test (MAST) is a 24-item screening inventory comprised of yes or no questions (Mclellan, 2001). It can be completed in less than 15 minutes, and assesses for symptoms of alcoholism (Mclellan, 2001). “Scores of 5 or more indicate alcoholism, scores of 4 suggest the possibility of alcoholism, and scores of 3 or less indicate the absence of alcoholism” (Hays, 2013, p145).
Assessment of Early Reading Difficulty.
The “Dynamic Indicators of Basic Early Literacy Skills” (DIBELS) test, assesses early reading development in students from kindergarten through six grade (Mertler, 2007). It assesses phoenomic awareness, reading comprehension, fluency, and basic phonics (Mertler, 2007). The criterion-referenced scores provide a benchmark assessment that identifies students with an early learning disability, who are in need of additional instruction (Mertler, 2007). It is also utilized to monitor progress of students of student’s reading skills against grade level standards (Mertler, 2007). On the scoring reports of a DIBEL assessment are a criteria levels that show on a table how an individual’s results compare against this benchmark level (Mertler, 2007).
College Entrance Exams
The Scholastic Aptitude Test (SAT), utilizes criterion scoring to assess an individual in three areas: (1) critical reading ability, (2) mathematics, and (3) writing. (Hays, 2013). The scores in each section can range from 200-800 with a combined possible score from 600-2400. The purpose of this test is to assess a college applicant’s “academic ability and intellectual skills” (Hays, 2013, p185). It is useful as a predictor of future academic in college applicants and is useful for higher education institutions in this context.
Description & Interpretation
Self-referenced scores utilize a test-taker’s previous performance as a point of comparison (Hays, 2013). Without testing norms or pre-established criteria, the results of self-referenced tests provide intra-individual comparisons in order to assess growth or change (Brown, 1996; McDermott et al, (1992). Another term for self-referenced scores is IPSATIVE testing. (Ipsative, 2009).
A key criticism of this form of assessment, is that it fails to adhere to the principles of psychometrics (Brown, 1996). McDermott, et al (1992) define this form of scoring as a “personal-relative metric” (p505). Brown (1996) describes self-referenced tests as ordinal measures. Hays (2013), defines ordinal scales as “rank or nominal categories…in which the relative size among intervals are difficult to know” (p88). From a mathematical perspective, this means self-referenced tests soring methods do not have equal intervals, or an absolute zero point (Hays, 2013). It is therefore, impossible to subtract, multiply, or divide these scores. Additionally, statistical concepts such as measures of central tendency and standard deviation, are meaningless (McDermott et al, 1992)
As a result of these unique characteristics there is little agreement on how to best treat self-referenced scores statistically (Martinussen, et al, 2001). While some individuals remain highly critical of IPSATIVE measures (McDermott, et al, 1992), others remain optimistic and state the distortion in IPSATIVE testing is minimal (Hughes, 2011; Martinussen, et al, 2001). In my research for this paper I found three examples of situations in which this scoring method are useful, despite these limitations.
Strong Interest Inventory.
The strong interest inventory is a self-referenced assessment utilized for purposes of educational and career planning. E.K. Strong first developed it in 1927 and its latest version was published in 2004 (Hays, 2013). “This widely researched test contains six sections: occupations, subject areas, activities, leisure activities, people and your characteristics” (Hays, 2013, p.228). Individual’s respond to questions based on answers similar to a Likert scale. The Personal Style Scale is a measure that can indicate elements of your personality that you desire to express in your career (Prince, 1998). Other scales such as the Occupational Scale helps determine if your interests match up with a particular career or field (Prince, 1998)
Myers Brigs Type Indicator.
The Myers Briggs Type Indicator (MBTI) was developed in the 1920’s by Katherine Briggs and her daughter Isabel Myers (Hays, 2013). It utilizes IPSATIVE measures and is comprised of a series of forced choice questions based Jungian theory (Hays, 2013). Four personality dimensions are measured in order to determined an individual’s personality type based on Jungian theory: (1) introversion versus extroversion, (2) intuition versus sensing, (3) feeling versus thinking, and (4) perceiving versus judging (Hays, 2013). The MBTI has received criticism due to a lack of research that supports its theoretical foundations (Hays, 2013). Additionally, there are others who question the validity and reliability of IPSATIVE personality assessments that utilize forced choices questionnaires (Martinussen, et al, 2001). Nonetheless, this established personality assessment is used frequently in the context of vocational and relationship counseling.
Ipsative Assessment in Higher Education.
An interesting article I found for this assignment discusses the potential benefits of IPSATIVE assessment in education (Hughes, 2011). Assessment plays a central role in education, primarily as means to maintain standards (Hays, 2013; Hughes, 2011). Since educational assessment utilizes criterion and norm referenced scoring methods, the feedback it provides has an externalized focus (Hughes, 2011). These methods exclude a valuable opportunity to use assessment as an integral part of the learning process (Hughes, 2011). IPSATIVE measures can provide a unique counterbalance to externalized criterion measures, and would a learner’s performance to personal goals. The assessments provided would be highly motivating as a measure of one’s own progress. Despite these benefits, Hughes (2011) does admit it is unrealistic for these forms of assessment to be utilized alone. However, they can be a valuable component when taken alongside norm-referenced and criterion-referenced assessment methods (Hughes, 2011).
Brown, H. (1996). Strength and limitations of ipsative measurement. Journal of Occupational and Organizational Psychology. 69, (pp. 49-56).
Cohen, R., Swertdlik, M., & Phllips, S. (1996). Psychological testing and assessment: An introduction to tests and measurement. Mountain View, CA: Mayfield Publishing Company.
Dulan, S. W., & Advantage Education (Firm). (2013). McGraw-hill’s GRE: Graduate recordexamination general test. New York: McGraw-Hill.
Hays, D.G. (2013). Assessment in counseling a guide to the use of psychologicalassessment procedures (5th Ed.). Belmont, CA: Brooks/Cole, Sengage Learning.
Hughes, G. (2011) Towards a personal best: A case for introducing ipsative assessment in higher education. Studies in Higher Education 36(3) 353-367.
Ipsative (2009). Oxford University Press.
Johnson, C., Wood, R, Blinkhorn, S. (1988). Spuriouser and suprioser: The use of ipsative personality tests. Journal of Occupational Psychology. 61 153-162.
Martinussen, M., Richardsen, A. M., & Vårum, H. W. (2001). Validation of an ipsative personality measure (DISCUS). Scandinavian Journal of Psychology, 42(5), 411-416. doi:10.1111/1467-9450.00253
McDermott, P. A., Fantuzzo, J. W., Glutting, J. J., Watkins, M. W., & Baggaley, A. R. (1992). Illusions of meaning in the ipsative assessment of children’s ability. The Journal of Special Education, 25(4), 504-526. doi:10.1177/002246699202500407
McGraw Hill (2013) TerraNova common core. Retrieved from: file:///Users/kathleenjohnson/Downloads/wpTerraNovaCommonCore.pdf
Mclellan, A. T. (2001). Michigan Alcoholism Screening Test (Mast). In R. Carson-DeWitt (Ed.), Encyclopedia of Drugs, Alcohol & Addictive Behavior (2nd ed., Vol. 2, pp. 728- 729). New York: Macmillan Reference USA.
Mertler, C. (2007). Interpreting standardized testing scores: Strategies for data-driven instructional decision making.. Thousand Oaks, CA: SAGE Publications, Inc. doi:10.4135/9781452232317.n6
Prince, J. R. (1998). Interpreting the strong interest inventory: A case study. The Career Development Quarterly, 46(4), 339.
Smith, D. K., & Stovall, D. L. (2002). Individual norm-referenced ability testing. In R. B. Ekstrom, & D. K. Smith (Eds.),Assessing individuals with disabilities in educational, employment, and counseling settings. (pp. 147-171) American Psychological Association. Weschler, D. (1944). The measurement of adult intelligence (3rd ed.). Baltmore MD: Williams &Wilkins
“In this assignment, students will demonstrate knowledge of prevention, education and/or advocacy activities which can assist their clients. Students will develop measurable outcomes, and analyze collected data with the goal of increasing the effectiveness of prevention, education, and advocacy activities at their current Internship site.
Students will work their site supervisor to identify a prevention, education, or advocacy component of services which could benefit from some analysis. This project (like all research) begins with good questions.”
For this assignment I focus on two survey’s: (1) The Adverse Childhood Experiences Questionnaire & (2) A Resiliency Scoring Survey.
The ACE’S Questionnaire
Overview of The CDC-Kaiser Permanente (ACE) Study
“The CDC-Kaiser Permanente Adverse Childhood Experiences (ACE) Study is one of the largest investigations of childhood abuse and neglect and later-life health and well-being…The original ACE Study was conducted at Kaiser Permanente from 1995 to 1997 with two waves of data collection. Over 17,000 Health Maintenance Organization members from Southern California receiving physical exams completed confidential surveys regarding their childhood experiences and current health status and behaviors.” CDC.gov, 2011).The purpose of this study was to discover if a correlation existed between early childhood experiences and overall well-being later in life. The results of this study illustrate that wide-ranging social, psychological, and health-related consequences exist as a result of early childhood traumatic experiences. Over 70 research papers have been published since 1998 (acestoohigh.com, n.d.). All of these studies show a correlation between early child adverse experiences and deficits in well-being later in life.
A Definition of “Adverse Childhood Experiences”
So what exactly are Adverse Childhood Experiences anyway? “ACEs are adverse childhood experiences that harm children’s developing brains so profoundly that the effects show up decades later; they cause much of chronic disease, most mental illness, and are at the root of most violence,” (acestoohigh.com, n.d.). Adverse Childhood Experiences fall into three general categories: childhood abuse, neglect, and household experience (Felitti, et al, 1998). The CDC.gov (2016) website provides a definition of these three categories of Adverse Childhood Experiences:
How does ACE’s survey define abuse?
(1) EMOTIONAL ABUSE: “A parent, stepparent, or adult living in your home swore at you, insulted you, put you down, or acted in a way that made you afraid that you might be physically hurt,” (CDC.gov, 2016).
(2) PHYSICAL ABUSE: “A parent, stepparent, or adult living in your home pushed, grabbed, slapped, threw something at you, or hit you so hard that you had marks or were injured,” (CDC.gov, 2016).
(3) SEXUAL ABUSE: “An adult, relative, family friend, or stranger who was at least 5 years older than you ever touched or fondled your body in a sexual way, made you touch his/her body in a sexual way, attempted to have any type of sexual intercourse with you,” (CDC.gov, 2016).
How does the ACE’s survey define neglect?
(1) EMOTIONAL NEGLECT: Someone in your family helped you feel important or special, you felt loved, people in your family looked out for each other and felt close to each other, and your family was a source of strength and support.
(2) PHYSICAL NEGLECT: There was someone to take care of you, protect you, and take you to the doctor if you needed it2, you didn’t have enough to eat, your parents were too drunk or too high to take care of you, and you had to wear dirty clothes.
How does the ACE’s survey define household dysfunction?
(1) MOTHER TREATED VIOLENTLY: Your mother or stepmother was pushed, grabbed, slapped, had something thrown at her, kicked, bitten, hit with a fist, hit with something hard, repeatedly hit for over at least a few minutes, or ever threatened or hurt by a knife or gun by your father (or stepfather) or mother’s boyfriend.
(2) HOUSEHOLD SUBSTANCE USE: A household member was a problem drinker or alcoholic or a household member used street drugs.
(3) MENTAL ILLNESS IN HOUSEHOLD: A household member was depressed or mentally ill or a household member attempted suicide.
(4) PARENTAL SEPARATION OR DIVORCE: Your parents were ever separated or divorced.
(5) CRIMINAL HOUSEHOLD MEMBER: A household member went to prison.
Overview of Survey Questionnaire
For my data research project, I decided to utilize a shortened version of the ACE’s study questionnaire provided by the National Council of Juvenile & Family Court Judges, (n.d). While the CDC’s original ACE’s study was much more comprehensive, it was quite lengthy and provided information well-beyond the scope of this project (CDC.gov, 2016). Additionally, it was felt that the number of willing participants I could garner for this project would be turned off by the 20-pages survey that over 100 questions. Instead, the National Council of Juvenile & Family Court Judges (NCJFCJ.org) survey is just one page and includes ten questions. This ACE’s survey includes just 10 questions with ten “yes or no” responses. Additionally, the scoring system of this test is quite simple. Respondents are to count the number off “yes” responses, and this gives them their “ACE Score”. This score can then be compared against the results of the original CDC research. Each of these question touch upon one above-described areas of Adverse Childhood Experiences:
(1) Did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
(2) Did a parent or other adult in the household often push, grab, slap, or throw something at you? or
Ever hit you so hard that you had marks or were injured?
(3) Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way? or try to or actually have oral, anal, or vaginal sex with you?
Question #4-5: Neglect
(4) Did you often feel that no one in your family loved you or thought you were important or special? or your family didn’t look out for each other, feel close to each other, or support each other?
(5) Did you often feel that you didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Question’s #6 – 10: Household Dysfunction.
(6) Were your parents ever separated or divorced?
(7) Was your mother or stepmother: Often pushed, grabbed, slapped, or had something thrown at her? or Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
(8) Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
(9) Was a household member depressed or mentally ill or did a household member attempt suicide?
“This questionnaire was developed by the early childhood service providers, pediatricians, psychologists, and health advocates of Southern Kennebec Healthy Start, Augusta, Maine, in 2006, and updated in February 2013. Two psychologists in the group, Mark Rains and Kate McClinn, came up with the 14 statements with editing suggestions by the other members of the group. The scoring system was modeled after the ACE Study questions,” (Alaska Center for Resource Families, n.d.). This survey focuses on protective factors rather than risk factors. Additionally, it provides a causal explanation as opposed to a etiological one. Rather than examining adverse childhood experiences as a cause for long-term deficits in well-being, this survey focuses on factors contributing to resilience in life. In other words, what factors exist as a protective factor associated with someone’s long-term well-being.
What is Resilience?
“The Oxford English Dictionary defines resilience in two ways. On the one hand it stands for ‘the ability of a substance or object to spring back into shape; elasticity’. This is a more scientific oriented definition that refers to the elasticity of raw materials. On the other hand, resilience is de ned as “the capacity to recover quickly from difficulties; toughness’. Hereafter resilience will be understood in the ability of technical and/or social systems to be tough when facing disturbances, regardless of their kind. This highly general definition, with the commonly known keyword of ‘toughness’, (Mauer, 2016).” In other words, the notion resilience is a toughness an individual presents to handle life’s challenges. Many factors play a role in an individuals resiliency.
(1) Individual protective factors can include temperament-based characteristics that are reinforced within one’s environment that result in positive adaptive learned responses to daily challenges (Werner, 2005).
(2) Familial protective factorspromote resiliency through the establishment of positive bonds with a caregiver who is reliable and able to provide a structured environment (Werner, 2005).
(3) Community protective factors promote resiliency “through elders and peers in their community for emotional support and sought them out for counsel in times of crisis”, (Werner, 2005, p. 12).
The survey I utilized for my data project comes from the Alaska Center for Resource Families, which aims to provide resources to assist families who wish to either adopt or participate in the foster care system (acre.org, n.d.). This Resiliency survey includes 14 questions based on the above-described factors (individual, familial, and community). For example, question 14 asks “I believed that life is what you make it” (Alaska Center for Resource Families, (n.d.). This is an individual temperament-factor contributing to one’s overall resiliency score. In contrast question #1 asks: “I believe that my mother loved me when I was little” (Alaska Center for Resource Families, n.d.). This question is a familial factor that contributes to one’s resiliency score. Finally questions such as #7 reflect a community factor that contributes to one’s overall resiliency score: “When I was a child, teachers, coachers, youth leaders or ministers were there to help” (Alaska Center for Resource Families, n.d.).
The survey provides a likert-type scale with responses ranging from “Definitely true; Probably true; Not sure; Probably not true; and Definitely not true.” All “Definitely true & Probably True” responses are count as one point. The maximum score a person is able to obtain from this test is 14. The high the score the more protective factors they had in childhood contributing to their overall resiliency to adverse life events.
Filetti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., … & Marks, J. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. American Journal of Preventive Medicine, 14(4), 245-258.
Maurer, A. (2016). In Search of the Golden Factor: Conceptualizing Resilience in the Framework of New Economic Sociology by Focusing ‘Loyalty’. In New Perspectives on Resilience in Socio-Economic Spheres (pp. 83-109). Springer Fachmedien Wiesbaden.
“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.
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).
As a student therapist, I am spending about 20+ hours a week at a substance abuse treatment center. The biggest lessons I’ve learned thus far, pertains to the nature of resistant as it appears within addiction. Since understanding this concept is critical to my effectiveness, I’m stopping to reflect upon what I’ve learned thus far….
As I see it, a perplexing dualism exists within the counselor’s mind while providing therapy. On the one hand, you have a Rogerian unconditional positive regard as an essential element in the therapeutic relationship. On the other hand, you have the sort of confrontational style found with addiction counseling’s history. Where is there a middle ground between these extremes? In today’s medically-based climate, objective analysis of presenting symptoms is emphasized. Adding to this is is the attitude of individualism prevalent in Westernized medicine. As an INFP, I gravitate toward empathy, understanding, & validation. As a biracial individual, multicultural sensitivity is a priority. Is the pendulum swinging away from these things as it pertains to the practice of therapy?
From clinical perspective resistance to recovery is as infuriating as it is perplexing. Effective solutions to escape the miseries of addiction are available What is preventing them from utilizing these tools?!?!
…So how can one begin to step outside the empathist’s hat, and begin to develop a discerning clinical judgment on the matter of this perplexing resistance, that allows you to prolong & magnify misery when healing solutions exist within one’s reach? My first answer to this question came in the form of insights from the “SASSI-3”
Measuring Resistance – SASSI3
“SASSI” stands for “Substance Abuse Subtle Screening Inventory”. It is utilized in intake evaluations at the inpatient substance abuse facility I’m interning at currently. This brief self-reporting instrument helps identify those who are likely to have a substance abuse problem (sassi.com, n.d.). Of relevance to this post, are a few “subtle scales” which don’t have a direct bearing on substance abuse behaviors, but are useful for making”inferences” (sassi.com, n.d). I describe a few interesting subtle scales below:
“OAT” Obvious Attributes
“OAT Scale scores measure the extent to which an individual endorses statements of personal limitation…low scorerers are likely to be reluctant to acknowledge personal shortcomings. (Miller, Renn & Lawzowski, 2001, p. 3)”. As I understand it, this score reflects characteristics of our temperament that can either function as strengths or areas of growth. Low scorers are more prone to deny their shortcomings. Miller, Renn, & Lazowski, (2001) suggest that “it is not useful to agree or disagree with clients’ self-appraisals” (p. 3).. When encountering individual’s with low OAT scores, it is important to avoid being too critical since this can cause clients to become defensive. Instead motivational interviewing is useful to build discrepancy and reduce resistance.
“SAT” Subtle Attributes
The SAT score is useful in identifying “characteristics of substance misuse that are not easily recognized as such (Miller, Renn & Lawzowski, 2001, p. 3).” The utility of this measure, is in its ability to help reveal information clients deny to themselves or become deluded about. In other words, it is a measure of an individual’s degree of self-deceptiveness regarding the consequences of one’s behavior. Miller, Renn, & Lazowski, (2001) note the “sincerely deluded” (p. 3) nature of an addict’s tendency to avoid acknowledging the consequences of continued use. So how does one begin discussing such subjects?
“There is no point in giving people messages that are too strong and too discrepant from their points of view. On the other hand, there is also no point giving a message unless it promotes positive change. Successful feedback depends on starting from a point that clients can accept and then increasing the breadth of their understanding.(Miller, Renn & Lawzowski, 2001, p. 4).”
“The primary purpose of the DEF scale is to identify defensive clients who are trying to conceal evidence of personal problems and limitations (Miller, Renn & Lawzowski, 2001, p. 3).” In other words, it assesses an individuals tendency to conceal of an personal or situational problems in their lives. This is ego-driven activity, reveals how they feel about themselves in relation to others. For example, low DEF scores indicate low self esteem & feelings of hopelessness about one’s situation. In contrast, elevated DEF scores indicate individuals are concealing their problems in order to “fake good” (Miller, Renn, Lazowski, 2001, p.4). Concealing problems in this way serves to protect people from something painful they wish to avoid dealing with.
So to conclude, the SASSI-3 characterizes resistance as a: (1) a refusal to acknowledge personal shortcomings, (2) a tendency to remain deluded about the consequences of one’s actions and (3) a general desire to conceal personal problems from oneself.
So How Do You Address this Resistance????
Earlier this week, in a supervisory meeting, the interns sat down to discuss the cases they were assigned. As the “newbie” of the group, I stepped back and listen throughout most of the session. At one point, an intriguing debate ensued between the supervisory therapist and an experienced intern who is close to graduation. From their discussion, I noted two divergent attitudes on the utility of confrontation and direction. Underying these divergent attitudes were two very different approaches to therapy. What follows are two different therapeutic approaches that appear as opposite ends on a continuum. What follows is a description of the two extremes along this continuum of variance in therapy approaches:
A Rogerian Nondirective Stance
Non-directive therapy, considers the client to be his/her own expert. In other words, the direction that therapy takes depends on a client’s own personal judgment and not the therapist’s. Rogers describes non-directive therapy as client-centered in the sense that they have a capacity for self-understanding and self-direction. It is a mirror opposite of authoritarian confrontation common in addiction counseling. This empathetic approach involves the establishment of “a collaborative partnership that respects the client’s capacity for and right to self-determination (Policin, 2003, p. 20)”
From this perspective a therapist’s job is unconditional positive regard and an acceptance of their feelings. It excludes a need to explain, challenge, or direct (Raskin, 1948). The client’s subjective stance, takes presidence over the therapist’s clinical judgment:
“the nondirective point-of-view on this issue is that to the extent that some other frame of reference than the client’s is introduced into the therapeutic situation, the therapy is not client-centered” (Raskin, 1948, p. 106).
Confrontation in Counseling…
Defined as “process by which a therapist provides direct, reality-oriented feedback to a client regarding the client’s own thoughts, feelings or behavior” (White & Miller, 2007, p. 2), therapeutic confrontation has a long history in the field of addiction counseling. Historically, this counseling style was utilized in chemical dependency treatment to overcome denial & resistance (Policin, 2003). Aggressive confrontational styles like “Synanon’s attack therapy” Pokin, (2003), were utilized to break down the defense mechanisms underlying an addict’s utilized to deny their problems. White & MIller (2007) described this confrontation as a highly varied form of confrontation ranging from “frank feedback to profanity-laden indictments, screamed denunciations of character, challenges and ultimatums. (p. 2)”. This description resonates with a story my own therapist told me of her own internship experience at a substance abuse treatment facility in the 70’s.
A Comparison of Non-direction & Confrontation
Understanding of the client?
According to White & Miller (2007) the prevalent view of addicts changed somewhere between the 1920’s – 1950’s from an individual who was struggling with side effects of medications to a “‘vicious’ addict who sought narcotics as a source of pleasure” (p. 4). Implicit in this confrontational perspective is a view of the client the cause of these problems. This perspective focuses on an addict’s “defective, psychopathic personality (White & Miller, 2007, p. 4)”. In contrast, a Rogerian non-directed approach, focuses on the client not as a cause of the problems, but as the solution to them. Finally, modern perspectives point toward alterations in brain function.
A Confrontational Perspective holds the client as the cause of his/her problems and attributes their issues to a personal defect of some sort (White & Miller, 2007; Policin, 2003). In contrast, a modern view of addiction holds a medically based-perspective which dictates that addiction is a disease. The cause of addictive behavior are neurological alterations in the brains reward system. These alterations in the reward and control circuits of the brain (Inaba & Chen, 2014) are associated with addiction since they are responsible for encouraging us to engage in those behaviors that are beneficial for our survival. Our textbook calls this reward pathway the “go switch” (Inaba & Chen, 2014, p. 2.13), since it is the brain’s motivator and reinforces beneficial behaviors. In an addict’s brain, alterations can be found in this area. Personally, I believe an epigenetic & biopsychosocial perspective best describes the complex causal factors underlying addiction.
Understanding the solutions?
Underlying the confrontational stance common in counseling’s history, is the fact that – if left to their own devices – addicts would continue to engage in self-destructive behavior. “…addicts avoid dysphoric affective states, anxiety, and genuine intimacy by using substances and engaging in antisocial behaviors, such as manipulation of others for their own needs” (White & Miller, 2007, p. 5).” This observation, appears to underlie the extreme forms of confrontation described earlier.
In contrast, modern treatment approaches involve symptom management during detox alongside some form of therapy (inpatient,outpatient, group and/or individual). Motivational interviewing is useful in helping the client attain self-awareness. This can involve helping clients gain insight into their addiction while uncovering behavior patterns and attitudes underlying their habit. Personally, I haven’t seen a pure non-directive stance in the addiction counseling field. However, I believe an empathetic stance and collaborative approach are critical factors of successful counseling.
In the next section, I’d like to return to that internship supervisory meeting I mentioned earlier. Here’s an overview of the two sides of the debate I listened to on that day….
Can There Be a Middle Ground Between Extremes???
Side one – Sugar Coating Truth.
The intern in this conversation made a comment on the pointlessness of sugar-coating the truth & asked the supervisor what the point was if we never confronted them on anything. “Isn’t there a case in therapy when it is warranted to give our opinion on matters pertaining to the client’s well-being?” After all, “to sugarcoat the truth is to do a disservice for the person who is on the receiving end. You don’t do anyone favors by avoiding blunt truth (Nguyen, 2015).”
Side Two – Raising Concerns on Confrontation & Coercion….
“It is time to accept that the harsh confrontational practices of the past are generally ineffective, potentially harmful, and professionally inappropriate. (White & Miller, 2007).”
“Confrontation continues to play a strong role in many treatment programs (White & Miller, 2007, p. 176).” Obviously, it isn’t utilize in the extreme forms common in counseling’s history. However, despite its continued research has shown this method as often less effective than supportive approaches (White & Miller, 2007). Additionally Policin (2003) notes that confrontational styles, are shown to produce “harmful effects including increased drop-out, elevated and more rapid relapse, and higher DWI recidivism (p. 20).” My own impression of this approach is it has the potential to be harmful, shame-inducing. It focuses on change through emotional coercion over insight or conscious choice.
My thoughts thus far? Somewhere between these extremes lies a healthy balance.
Miller, F.G, Renn, W.R. & Lawzowski, L.E. (2001). Sassi Scales: Clinical Feedback. Springville, IN: The Sassi Institute.
Polcin, D. L. (2003). Rethinking Confrontation in Alcohol and Drug Treatment: Consideration of the Clinical Context. SUBSTANCE USE & MISUSE, 38(2), 165-184.
Raskin, N. J. (1948). The development of nondirective therapy. Journal of Consulting Psychology, 12(2), 92.