PSYCHIATRIC EVALUATIONS According to the National Guideline Clearinghouse, the following are practice guidelines for the psychiatric evaluation of adults.
Methods of obtaining information include: patient interviews, use of collateral sources, use of structured interviews and rating scales including functional assessments, use of diagnostic nests, physical examination, and work with multidisciplinary teams.
The process of an assessment usually involves developing initial impressions and hypotheses during the interview and then the continual testing and refinement of the hypotheses based on information obtained thereafter. After a clinical formulation is made (taking into account a cultural formulation and risk assessment), a diagnosis is made if appropriate and an initial treatment plan is developed.
Sometimes as social workers we will only complete part of this process. For example, an evaluation in an ER could include the first part, but since the patient is admitted you would not complete the initial treatment plan.
We also might not have access to all of the information listed above. We could evaluate a person who refuses to share pertinent information, or who cannot remember pertinent information. (These two things would then contribute to our findings.) The evaluation will be longer or shorter depending on what information and resources we have available to us (for example, blood tests or medical history.)
Some places have a "psychiatric evaluation" template or form to follow and some don't so it is important to know how to do one of these without a template.
As with psychiatric evaluations, some places have a "suicide assessment" template or form to follow. The last place I worked used a simple template for assessing suicidality in child clients: -Has the client ever attempted suicide before? -Does the client have (biological or not) relatives who have attempted or completed suicide? -Does the child have a means to complete or attempt suicide? -Is the child making gestures of self-harm?
TO ASK THE CLIENT: -Are you thinking about killing yourself? -Why did you (insert self-harm gesture here if applicable, for example ... cut your arm) -I am concerned about your safety. Will you sign a safety contract, promising that you will not hurt yourself anymore today? We can talk more tomorrow if you are still thinking about this.
For me, this assessment was a good place to start but it was not utilized correctly by many of the staff.
In general terms, a suicide assessment should include the following components: -A thorough psychiatric examination that identifies risk and protective factors (and which of the risk factors can be modified). -Asking the client directly about suicide. -Determining the client's level of suicide risk. -Determine treatment setting and plan. -Document.
There are many different sets of guidelines for suicide assessments, and also many templates. Since most of the templates are copyrighted they are not easily accessible on the internet. I printed two of the most helpful sets of guidelines and will bring them to the next group, as I don't think I can attach files here.
The best book that I have ever read about suicide and suicide prevention is Night Falls Fast: Understanding Suicide by Kay Redfield Jamison.
It talks about the history of suicide and people's attitudes towards suicide, addresses psychology and psychopathology, methods and places, biology, neurobiology and neuropsychology, and prevention. Very informative.
Emma, this is an excellent post? I am curious to hear others experiences with psychiatric evals and more importantly what are some of the discomforts or barriers you have run across when asking these very difficult questions?
When I worked with children who were high utilizers of places like where Emma used to work, I used assessments all the time, esp as I had a group of 15 y.o. girls w/that sort of history. The children were used to being asked questions like that, and knew the answers we professionals were looking for. That's not to say that those tools weren't helpful, however- Also I worked in the UK for Children's Protective Services there; we were encouraged to use assessment tools during our first visit or two to assess various things such as general safety, depression and parenting, among others. The thing that struck me the most is that there weren't very many multicultural tools out there (even though London, England is one of the most diverse cities), and so in that way, it felt awkward to ask some questions on the assessments around marital issues. Last year, I worked in tandem with a psychiatrist in downtown Seattle; I asked him if there was a good way to evaluate people from different cultures for mental health issues-he saidthat there hasn't been a good tool developed. Not sure if I should ask this here, but how would you assess suicidality or depression in, let's say, a man from Sudan, or a woman from Iran? I'm sure you all have come across this before. I will write more later-Felicia
Your Post is excellent and it is exactly this dialogue that I envision this discussion going.
I want to give this some thoughtful feedback as you a pose a wonderful question. So, I will respond at a later time when I can give it all of my energy. Thanks team for getting it going.
To address Derek's question about discomfort and barriers:
I have tried to conduct such assessments on people with language barriers, and on people who were from other cultures. In regards to the language barrier, it was a child's father I was having difficulty getting information from. I did what I could with him, attempted to find a translator, and also interviewed the child's mother and elder sister. (Lack of available translators is another serious issue...)
Right after I started a previous job, the following happened. When interviewing a mother of a client (both of whom were of the Salish nation) the mother frequently became offended by what I asked. In addition to seeking information about the child, I was also looking for signs of personality disorders in the mother. I quickly became very aware that I was uncomfortable and wanted to only ask questions that I thought the mother would respond favorably to. I also was aware that another clinician had already interviewed the mother, so I chose to not ask her all of the questions because I assumed the other clinician had. In this case I compromised the validity of the child's assessment due to my own discomfort.
Since then I have learned to recognize my own discomfort and push through it. When I do that I am much more able to complete a valid assessment.
What a great question! I have been in at least one situation like that before as well and I sought supervision. My supervisor told me to do the best I could with the tools I had, but afterwords I felt that I did not complete a comprehensive assessment on the client. My supervisor was of the opinion that it was fine and that I couldn't have done anything differently, which to me felt like perpetuating the idea that people from the U.S. are entitled to better treatment than other people. Needless to say I was not happy with how that situation turned out. I think this is a great point for us to discuss further!
I have had the opportunity to do psychiatric evals and suicide assessments a few times, although I wouldn’t say I have extensive experience. One barrier to a good assessment I’ve noticed in the outpatient setting is that the idea that a patient might be suicidal tends to alarm other staff members, and their anxiety can definitely influence your viewpoint before you even meet the patient. I’ve learned that although I need to take in the perspective of other team members, it’s important to talk to the patient and ask direct questions to find out what’s really going on. It also can be fairly uncomfortable for me to ask direct intrusive questions, especially with someone I’ve just met and haven’t had the chance to establish good rapport with yet. Nevertheless since this assessment may be my only chance to talk to this person, it’s definitely essential to ask directly about self-harm and suicidal thoughts/plans. I think the more experience I have the more confident I feel in doing that. I think Emma is right about having to push through your discomfort, because it's necessary to do a thorough assessment. I do find it especially uncomfortable though when the person is not willing to answer your questions.
Emma, I appreciate you role modeling a good discussion thread. I also appreciate you sharing your experiences with counter-transference to the team because it can only make others feel more comfortable in their sharing and learning.
I want to get back to the idea of integrating cultural components in our psychiatric assessments. There isn't any universal or standard way of doing of implementing cultural factors into our assessments. However, I am biased as i think that social workers are poised to highly value cultural factors in our evaluations as we often draw from a strengths based and PIE, Person in the Environment Perspective. Thus, I think it keeps we as clinicians humble in a sense that we do our homework each and every time we work with someone who isn't part of a privileged majority.
Throughout my experience as a clinicians, I have really learned to embrace this flexibility and learned patience that I am not going to have all the answers at that particular time intersection. One of the many examples that i have learned from has been my experience working with several different Somolian Women in the ER and Hospital settings. It is very typical in the hospital settings to get mental health evaluation requests from physicians. However, with somolian women it hasn't been the case. It is very common for somolian women with depression to admit to the hospital with GI symptoms, Gastrointestinal problems. In fact, many times these particular patients will get a ton of GI work up done with everything coming up negative as the real problem is untreated depression
Felicia’s comment brought some additional thoughts to mind regarding cultural competence. Although not necessarily a suicide assessment, my workplace uses a postpartum depression screening tool. This is administered by computer and then I follow-up with people who have a high enough score to warrant concern. This assessment includes a self-harm question as well, which has allowed me to gain additional experience asking about suicidal ideation. One major problem with this tool that I’ve observed is that women from Asian countries often end up with a positive score on the question about suicidal ideation, but then when you talk to them they state that they’ve misunderstood the question. I believe the phrasing of the question is kind of weird, and we do not have the ability to translate the assessment tool in to multiple languages at this point. It makes it difficult to know how effective we are when assessment tools are not necessarily valid for other cultures and ethnicities.
So, if the real problem is depression, why aren't they coming in with this complaint. This is where you get into the semantics of depression and what is the cultural belief system around depression in the patient's country of orgin. Because in many cultures, including many asian, middle eastern and african cultures mental health problems aren't socially acceptable like they are here in the states. I think many of the axis 1 disorders have a negative connotation in these cultures. The other variable that was very important in the somolian women cases was their discomfort to bring the issues to surface on their own. In each of these cases I worked on, I found out to issues with mental health peripherally, typically from a nursing staff member who often found out peripherally from a trusted friend. It sort of forced me to always think about the cultural family structure with these clients. For example, does this patient coming from a paternalistic society where men are the primary heads of house holds and decision makers and did this intensify any shame or inhibition these women felt in bringing these issues to the surface. In many asian cultures, men are the family spokespersons and decision makers and much of their focus can be on lifting the burden from their sick family member. This can be very delicate in palliative care type situations and the reason why I mention it is that it isn't any less difficult in mental health situations.
Emma, I am so glad that you brought up your experience with countertransference with this issue because I think too often clinicians get caught in the fixed agenda trap where we would like to complete our assessment , come up with a solution and put a bow on the whole thing and be finished. However, I challenge you all to work on your clinical patience and work on your skills of allowing time to garner the variables you need to advocate your clients. It isn't easy, particular in a medical model where we want solutions yesterday. Trust the process of each individuals problem and resist from the temptation to impose our eurocentric value system them even if the process may not seem like the most optimal solution because by trusting the process you are empowering that family to empower their client and gaining their trust which in turn will help them be more receptive in the future to your ideas.
Christy great Post! Lets talk about some of that discomfort that we all have tomorrow night. I also liked your point about some major problems to standardized assessments with multicultural componenets
Very timely post Felicia. Acknowledgement of our Client’s customs and cultural background is imperative for assessments. Ensuring this goal of cultural recognition can at times be a struggle especially when language is a barrier for the worker/client relationship. Recently I needed to assess a woman who had just moved to Bellingham for Dialysis from Vietnam. She moved here with her Spouse and 2 of her 6 children. She had never been far from her place of birth so not only was she attempting to navigate the medical community gauntlet, she also has to deal with the unfamiliar environment of Bellingham. Her initial assessments were with a translator who worked well with the health care team. A plan of care was determined inclusive of basic mental health but I still had a nagging feeling it wasn't as complete as it should be. What struck me was how is it for her to be describing to me through an interrupter how this Dialysis journey is impacting her. The systemic problems I see are Clinic settings with open treatment modules, time factor (many Patients are on their machines for 3 to 4 hours) and most of all the process is very fatiguing. So maybe really effective mental health should be incorporated in a different setting for privacy and a time where the Patient may focus on counseling with 1:1 support in her primary language. My thoughts had been to connect this woman with a phone type support to help alleviate her going out to yet another appointment. Derek recommended through one of his sources, ReWA in Seattle. I am still in the process of coordinating this support and truly do not know if it will work but back to Felicia's original thought, "How do we really attend to cultural aspects of our clients especially language barriers?" Assessing suicide is such an imperative timely situation, what I have done is way too cumbersome and slow to address suicide. I thought of skyping/computer use but I think how impersonal and of course the cost. I basically am without answers but love the fact I have a space to brainstorm with some peers.
Thanks Emma for getting us started and Christy just saw you posted too. Got to run so I'll catch up with your thoughts later.
PSYCHIATRIC EVALUATIONS
ReplyDeleteAccording to the National Guideline Clearinghouse, the following are practice guidelines for the psychiatric evaluation of adults.
Methods of obtaining information include: patient interviews, use of collateral sources, use of structured interviews and rating scales including functional assessments, use of diagnostic nests, physical examination, and work with multidisciplinary teams.
The process of an assessment usually involves developing initial impressions and hypotheses during the interview and then the continual testing and refinement of the hypotheses based on information obtained thereafter. After a clinical formulation is made (taking into account a cultural formulation and risk assessment), a diagnosis is made if appropriate and an initial treatment plan is developed.
Sometimes as social workers we will only complete part of this process. For example, an evaluation in an ER could include the first part, but since the patient is admitted you would not complete the initial treatment plan.
We also might not have access to all of the information listed above. We could evaluate a person who refuses to share pertinent information, or who cannot remember pertinent information. (These two things would then contribute to our findings.) The evaluation will be longer or shorter depending on what information and resources we have available to us (for example, blood tests or medical history.)
Some places have a "psychiatric evaluation" template or form to follow and some don't so it is important to know how to do one of these without a template.
SUICIDE ASSESSMENTS - AN EXAMPLE
ReplyDeleteAs with psychiatric evaluations, some places have a "suicide assessment" template or form to follow. The last place I worked used a simple template for assessing suicidality in child clients:
-Has the client ever attempted suicide before?
-Does the client have (biological or not) relatives who have attempted or completed suicide?
-Does the child have a means to complete or attempt suicide?
-Is the child making gestures of self-harm?
TO ASK THE CLIENT:
-Are you thinking about killing yourself?
-Why did you (insert self-harm gesture here if applicable, for example ... cut your arm)
-I am concerned about your safety. Will you sign a safety contract, promising that you will not hurt yourself anymore today? We can talk more tomorrow if you are still thinking about this.
For me, this assessment was a good place to start but it was not utilized correctly by many of the staff.
SUICIDE ASSESSMENTS - MORE INFORMATION
ReplyDeleteIn general terms, a suicide assessment should include the following components:
-A thorough psychiatric examination that identifies risk and protective factors (and which of the risk factors can be modified).
-Asking the client directly about suicide.
-Determining the client's level of suicide risk.
-Determine treatment setting and plan.
-Document.
There are many different sets of guidelines for suicide assessments, and also many templates. Since most of the templates are copyrighted they are not easily accessible on the internet. I printed two of the most helpful sets of guidelines and will bring them to the next group, as I don't think I can attach files here.
The best book that I have ever read about suicide and suicide prevention is Night Falls Fast: Understanding Suicide by Kay Redfield Jamison.
ReplyDeleteIt talks about the history of suicide and people's attitudes towards suicide, addresses psychology and psychopathology, methods and places, biology, neurobiology and neuropsychology, and prevention. Very informative.
Emma, this is an excellent post? I am curious to hear others experiences with psychiatric evals and more importantly what are some of the discomforts or barriers you have run across when asking these very difficult questions?
ReplyDeleteMost excellent post!!! Sorry, didn't mean to put the ?
ReplyDeleteWhen I worked with children who were high utilizers of places like where Emma used to work, I used assessments all the time, esp as I had a group of 15 y.o. girls w/that sort of history. The children were used to being asked questions like that, and knew the answers we professionals were looking for. That's not to say that those tools weren't helpful, however-
ReplyDeleteAlso I worked in the UK for Children's Protective Services there; we were encouraged to use assessment tools during our first visit or two to assess various things such as general safety, depression and parenting, among others. The thing that struck me the most is that there weren't very many multicultural tools out there (even though London, England is one of the most diverse cities), and so in that way, it felt awkward to ask some questions on the assessments around marital issues.
Last year, I worked in tandem with a psychiatrist in downtown Seattle; I asked him if there was a good way to evaluate people from different cultures for mental health issues-he saidthat there hasn't been a good tool developed. Not sure if I should ask this here, but how would you assess suicidality or depression in, let's say, a man from Sudan, or a woman from Iran? I'm sure you all have come across this before. I will write more later-Felicia
Felicia,
ReplyDeleteYour Post is excellent and it is exactly this dialogue that I envision this discussion going.
I want to give this some thoughtful feedback as you a pose a wonderful question. So, I will respond at a later time when I can give it all of my energy. Thanks team for getting it going.
To address Derek's question about discomfort and barriers:
ReplyDeleteI have tried to conduct such assessments on people with language barriers, and on people who were from other cultures. In regards to the language barrier, it was a child's father I was having difficulty getting information from. I did what I could with him, attempted to find a translator, and also interviewed the child's mother and elder sister. (Lack of available translators is another serious issue...)
Right after I started a previous job, the following happened. When interviewing a mother of a client (both of whom were of the Salish nation) the mother frequently became offended by what I asked. In addition to seeking information about the child, I was also looking for signs of personality disorders in the mother. I quickly became very aware that I was uncomfortable and wanted to only ask questions that I thought the mother would respond favorably to. I also was aware that another clinician had already interviewed the mother, so I chose to not ask her all of the questions because I assumed the other clinician had. In this case I compromised the validity of the child's assessment due to my own discomfort.
Since then I have learned to recognize my own discomfort and push through it. When I do that I am much more able to complete a valid assessment.
In response to Felicia's post:
ReplyDeleteWhat a great question! I have been in at least one situation like that before as well and I sought supervision. My supervisor told me to do the best I could with the tools I had, but afterwords I felt that I did not complete a comprehensive assessment on the client. My supervisor was of the opinion that it was fine and that I couldn't have done anything differently, which to me felt like perpetuating the idea that people from the U.S. are entitled to better treatment than other people. Needless to say I was not happy with how that situation turned out. I think this is a great point for us to discuss further!
I have had the opportunity to do psychiatric evals and suicide assessments a few times, although I wouldn’t say I have extensive experience. One barrier to a good assessment I’ve noticed in the outpatient setting is that the idea that a patient might be suicidal tends to alarm other staff members, and their anxiety can definitely influence your viewpoint before you even meet the patient. I’ve learned that although I need to take in the perspective of other team members, it’s important to talk to the patient and ask direct questions to find out what’s really going on. It also can be fairly uncomfortable for me to ask direct intrusive questions, especially with someone I’ve just met and haven’t had the chance to establish good rapport with yet. Nevertheless since this assessment may be my only chance to talk to this person, it’s definitely essential to ask directly about self-harm and suicidal thoughts/plans. I think the more experience I have the more confident I feel in doing that. I think Emma is right about having to push through your discomfort, because it's necessary to do a thorough assessment. I do find it especially uncomfortable though when the person is not willing to answer your questions.
ReplyDeleteEmma, I appreciate you role modeling a good discussion thread. I also appreciate you sharing your experiences with counter-transference to the team because it can only make others feel more comfortable in their sharing and learning.
ReplyDeleteI want to get back to the idea of integrating cultural components in our psychiatric assessments. There isn't any universal or standard way of doing of implementing cultural factors into our assessments. However, I am biased as i think that social workers are poised to highly value cultural factors in our evaluations as we often draw from a strengths based and PIE, Person in the Environment Perspective. Thus, I think it keeps we as clinicians humble in a sense that we do our homework each and every time we work with someone who isn't part of a privileged majority.
Throughout my experience as a clinicians, I have really learned to embrace this flexibility and learned patience that I am not going to have all the answers at that particular time intersection. One of the many examples that i have learned from has been my experience working with several different Somolian Women in the ER and Hospital settings. It is very typical in the hospital settings to get mental health evaluation requests from physicians. However, with somolian women it hasn't been the case. It is very common for somolian women with depression to admit to the hospital with GI symptoms, Gastrointestinal problems. In fact, many times these particular patients will get a ton of GI work up done with everything coming up negative as the real problem is untreated depression
Felicia’s comment brought some additional thoughts to mind regarding cultural competence. Although not necessarily a suicide assessment, my workplace uses a postpartum depression screening tool. This is administered by computer and then I follow-up with people who have a high enough score to warrant concern. This assessment includes a self-harm question as well, which has allowed me to gain additional experience asking about suicidal ideation. One major problem with this tool that I’ve observed is that women from Asian countries often end up with a positive score on the question about suicidal ideation, but then when you talk to them they state that they’ve misunderstood the question. I believe the phrasing of the question is kind of weird, and we do not have the ability to translate the assessment tool in to multiple languages at this point. It makes it difficult to know how effective we are when assessment tools are not necessarily valid for other cultures and ethnicities.
ReplyDeleteSo, if the real problem is depression, why aren't they coming in with this complaint. This is where you get into the semantics of depression and what is the cultural belief system around depression in the patient's country of orgin. Because in many cultures, including many asian, middle eastern and african cultures mental health problems aren't socially acceptable like they are here in the states. I think many of the axis 1 disorders have a negative connotation in these cultures. The other variable that was very important in the somolian women cases was their discomfort to bring the issues to surface on their own. In each of these cases I worked on, I found out to issues with mental health peripherally, typically from a nursing staff member who often found out peripherally from a trusted friend. It sort of forced me to always think about the cultural family structure with these clients. For example, does this patient coming from a paternalistic society where men are the primary heads of house holds and decision makers and did this intensify any shame or inhibition these women felt in bringing these issues to the surface. In many asian cultures, men are the family spokespersons and decision makers and much of their focus can be on lifting the burden from their sick family member. This can be very delicate in palliative care type situations and the reason why I mention it is that it isn't any less difficult in mental health situations.
ReplyDeleteEmma, I am so glad that you brought up your experience with countertransference with this issue because I think too often clinicians get caught in the fixed agenda trap where we would like to complete our assessment , come up with a solution and put a bow on the whole thing and be finished. However, I challenge you all to work on your clinical patience and work on your skills of allowing time to garner the variables you need to advocate your clients. It isn't easy, particular in a medical model where we want solutions yesterday. Trust the process of each individuals problem and resist from the temptation to impose our eurocentric value system them even if the process may not seem like the most optimal solution because by trusting the process you are empowering that family to empower their client and gaining their trust which in turn will help them be more receptive in the future to your ideas.
Christy great Post! Lets talk about some of that discomfort that we all have tomorrow night. I also liked your point about some major problems to standardized assessments with multicultural componenets
ReplyDeleteVery timely post Felicia. Acknowledgement of our Client’s customs and cultural background is imperative for assessments. Ensuring this goal of cultural recognition can at times be a struggle especially when language is a barrier for the worker/client relationship. Recently I needed to assess a woman who had just moved to Bellingham for Dialysis from Vietnam. She moved here with her Spouse and 2 of her 6 children. She had never been far from her place of birth so not only was she attempting to navigate the medical community gauntlet, she also has to deal with the unfamiliar environment of Bellingham. Her initial assessments were with a translator who worked well with the health care team. A plan of care was determined inclusive of basic mental health but I still had a nagging feeling it wasn't as complete as it should be. What struck me was how is it for her to be describing to me through an interrupter how this Dialysis journey is impacting her. The systemic problems I see are Clinic settings with open treatment modules, time factor (many Patients are on their machines for 3 to 4 hours) and most of all the process is very fatiguing. So maybe really effective mental health should be incorporated in a different setting for privacy and a time where the Patient
ReplyDeletemay focus on counseling with 1:1 support in her primary language. My thoughts had been to connect this woman with a phone type support to help alleviate her going out to yet another appointment. Derek recommended through one of his sources, ReWA in Seattle. I am still in the process of coordinating this support and truly do not know if it will work but back to Felicia's original thought, "How do we really attend to cultural aspects of our clients especially language barriers?" Assessing suicide is such an imperative timely situation, what I have done is way too cumbersome and slow to address suicide. I thought of skyping/computer use but I think how impersonal and of course the cost. I basically am without answers but love the fact I have a space to brainstorm with some peers.
Thanks Emma for getting us started and Christy just saw you posted too. Got to run so I'll catch up with your thoughts later.