Topic: Psychological Assessment
1. Textbook read Chapter 4
2. Fernandez’s pgs. 51-68
3. From additional readings: Sims’s Chapter 1 (pgs. 3-23)
I recommend before you post your response, you read the chapter so this posting would make sense to you, and you will be better prepared to respond. We are starting now with clinical material, and from this moment on, it will be all about Psychopathology. Keep in mind each week will be a different topic, so please my dear students, do not fall behind
Assessment is the first and crucial step in trying to figure out what’s wrong with the patient and how to best help him/her. It is a skill that is perfected through constant practice, and this is your first step in this process. When patients come to you, they are not nicely “packed” into clearly delineated problems so you can arrive to the diagnosis. No, most likely they come with a confusing clinical picture, and it is your job to make sense of that confusion. It is important, because at times, the consequences could be serious (see below). You need to know your stuff, be a disciplined observer of human nature, keep the big-picture in mind at all times, and always know how you are supporting your diagnosis; that is the bases for your judgment. You are not going to “shoot from the hip”, and this is not done just because “you have a feeling about it”. When I do clinical supervision, I always ask, how do you know what you think you know? Assessment is not a cookbook approach, in which you go through the DSM5 hoping to hit with the diagnosis that fits, nor a “hunch” or “feeling” about what you think your patient has. No, it is the disciplined process of understanding what is in front of you, gathering all the data (Interviews, Tests data, observation, mental status, etc) and analyzing it to arrive to a preliminary diagnosis, then, you will further test your assumptions, and the process continues. But above all you need to understand that in Psychopathology is not just about knowing the illness, but knowing what kind of patient has that illness; in other words, you need to understand your patient.
Here is an excerpt from my book:
“ A good assessment is crucial. At times, it is useful to utilize standardize tests or projective techniques to get a formal understanding of the patient’s psychological functioning. But this is only a minor part. We need to pay attention to the patient’s presentation, the manner in which he/she speaks, the mannerisms, and the language. The patient will be telling you a story, but the narrative is only part of the message, and you need to be aware of these factors if you want to understand. You have to pay attention to what is said and how it is said as well as what is not said. And as you move forward you begin to elucidate the nature of the patient’s conflict.
Andrew Sims, in his landmark book on Psychopathology writes: “Phenomenology, the empathic method for eliciting of symptoms, can never be learned from books. Patients are the best teachers, but it does help to know what one is looking for, the practical clinical aspects in which the patient describes himself, his feelings and his world. The doctor tries to unravel the nature of sufferer’s experience –to understand it well enough and to feel it so poignantly that the account of his findings evokes recognition from the patient” (Sims, 1988). Of course the patient is bothered by the symptoms, but they are not merely the expression of underlying physiological or even psychological dysfunction; they themselves are meaningful units that express a message of this particular existential dilemma he/she suffers. So a patient who is suffering from a serious difficulties swallowing food is experiencing a significant dilemma in which desire and duty collides, and in which he is self-punishing by depriving himself from food and expressing his anguish as “I can’t swallow” this situation and “I’m choking” with ambivalence ( see My Brother’s Keeper” story). Prior to seeing me, he had months of interminable and intrusive medical tests, which couldn’t explain his symptoms and at the end he was told he had “anxiety”.
Class Participation Topic for this week.
In regards to the Psychological assessment, I have a couple of examples that highlight the need for a good assessment. I want to add this little vignette to get you thinking about this subject. A few years ago, I had a case of a man who was sent to me to treat his “psychological condition”. He was an officer in the Navy and he was acting “weird” and was difficult to understand sometimes and to follow what he was trying to say. It is a long story, but when I did the assessment, again using Psychological Tests and a very careful Clinical History, I found significant problems with left temporal functioning (he had a mild expressive aphasia) , in addition to inconsistencies to what “appear” to be a Psychological “Problem”. This guy was not “neurotic” and his symptoms just did not make any sense. I spend a good deal of time listening to him, although this listening was difficult; I spoke to his wife, I learned of their history together, in other words, I
aimed at understanding my patient.
Given my assessment of his psychological functioning, my interviews with the patient and his family and the results of the Testing, I asked the referring physician to take a second look and she did an MRI and found a huge tumor in his left temporal lobe.
Again, perhaps this is a more dramatic case, but I want to emphasize the importance of a good assessment, with sound Clinical History, knowledge of Psychopathology (what this course is about!), the development of good listening and perceptive skills and proper Psychological Testing. On the other hand, a few years ago, I was asked to evaluate a man who had lost consciousness, had frequent syncope episodes with loss of memory for the event and he was thought to have a “neurological condition”. His is also a long story that I will not repeat here, but essentially, he was a true case of “Conversion Disorder” (Hysteria), which was resolved, first via hypnosis and later with ongoing psychotherapy. He had been tested with all kinds of technology without arriving to a definitive diagnosis; but it was his particular life-situation, together with a very careful history that pointed in the direction of hysteria (I will talk about him later in the course). In this case, contrary to the one above, the assumption was an “underlying physical condition” which, under careful assessment (and treatment) demonstrated the opposite.
When it comes to children, the assessment takes on a particularly different emphasis, as you need to consider developmental stages, cognitive-emotional development, cultural and family factors and, very important, situational factors. Several years ago, I was asked to evaluate this young 8-year-old boy for ADHD whose behavior appeared to me inconsistent in various settings. I decided to do school observation in a couple of different classes, and I found out his behavior was highly depended on the class and teacher present; yes sometimes he acted-out in ways that appeared as ADHD, but it wasn’t ADHD, it was the “situation”, not the child. This is a theme that repeats often and that it takes effort for me to convey to parents and teachers. A child behavior, at any given point in his/her life is ALWAYS the interaction of individual factors AND the environment. Frequently we need to intervene on both areas to bring a change in behaviors. Now, when I talk about the environment, I do not only refer to physical or social environment, but also family dynamics. When I do an intake for a new kiddo I always have the parent or parents present, not just to get historical information from them, but also to observe how they interact with each other. I use this information later when I present to the parents my observations, and very often they admit they were never aware of this or that until I pointed it out to them. As we go along, I will describe some of those cases.
Well I hope you have enjoyed reading these cases and get a sense of the importance of conduction good clinical assessment.
What I would like for you to do is to comment on anything you found interesting in this posting. Remember that:
1. You have to respond to this posting
2. keep a copy of your posting in WORD
3. This posting will be unavailable after two weeks, so you can’t delay.
4. At the end of the semester you will take ALL of your class Participations and turn them in for grading.
OK, now we are starting and this course will be moving “fast and furious”. Do your readings and ENGAGE!
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