Psychology for Dummies (70 page)
Read Psychology for Dummies Online
Authors: Adam Cash
Tags: #Psychology, #General, #Body; Mind & Spirit, #Spirituality
The first step in any problem-solving endeavor is to recognize and clearly define the problem. Psychologists have specific tools and techniques at their disposal for that very purpose. Typically, a visit to the psychologist begins with an exploration of the patient’s
presenting complaint
(the complaint or problem that led the patient to seek therapy) followed by a more thorough information-gathering process.
Psychologist:
Tell me Mr. Smith: What seems to be the problem?
Mr. Smith:
How am I supposed to know? You’re the doctor.
This question sometimes annoys patients because they often don’t know what’s going on and expect the psychologist to have all the answers. However, without a thorough investigation of the patient’s situation, any mental health professional would be engaging only in expensive guesswork. The two most common approaches to clinical assessment are formal interviews and psychological testing.
There may be as many interview techniques in the psychological world as there are individual psychologists out there. Everyone has a different way of getting at the relevant information. So what is the relevant information? As I state in the previous section, most encounters begin with a discussion of the presenting problem. Very few people who come to a psychologist describe their problem according to
Diagnostic and Statistical Manual,
4th Edition,
(DSM-IV)
criteria. Complaints are often vague or convoluted. Early communication problems between the psychologist and the patient are not necessarily because people don’t understand themselves. They’re often due to the fact that the doctor and patient have different vocabularies to describe the same problem. You say
toMAYto,
and I say
toMAHto.
You say you can’t sleep, eat, or stop crying, and I say you’re depressed.
One of the first areas in which psychological problems become evident is social functioning. During the history phase of the interview, the psychologist gathers information about the patient’s family, friends, coworkers, and other major relationships. In addition to social functioning, educational and occupational functioning are assessed as well. Did the patient graduate from high school? Has she been able to stay gainfully employed?
Patients often come to therapy with a lot to say and get off their chests. They’re overwhelmed and sometimes have a hard time knowing exactly how to describe their experience. Although not always so cut and dry, psychologists typically try to structure the first interview with the following steps:
1. The presenting problem is clarified.
2. A history of the patient’s life is gathered.
Is it an autobiography? In a way it is, except that only specific areas are covered. The most relevant aspect in a psychological interview is the history of the presenting problem. When did it all begin . . . ?
3. The patient’s physical health is explored.
An assessment of the patient’s physical health and history is always important in the history-taking process. Many psychiatric or psychological problems can be the result of an underlying physical illness or condition. When was his first physical? Does she have any major medical problems? Is he taking any medications? Does she or has she abused drugs or alcohol? Does he have an altered state of consciousness that requires medical assessment or treatment?
4. A thorough history of any psychological problems is conducted.
Has she ever suffered from depression in the past? Has he ever been treated for a mental disorder? Do any of her family members have a history of mental illness? Has he ever been in a psychiatric hospital or has he ever attempted suicide? Certain pieces of information are extremely important because the patient’s safety could be at issue. A prudent professional always takes the time to assess the most serious aspects of a case first, and no issue is more serious to a psychologist than suicide.
Throughout the interview, the psychologist looks for specific behavioral, cognitive, and emotional indicators of psychological disturbance. This is called a
mental status examination (MSE).
Typically, the psychologist observes 11 mental status areas:
Appearance:
Grooming, hygiene, physical characteristics, and unusual features are observed. Grooming may be bizarre or inappropriate. He or she may be unkempt, disheveled, or unclean. A patient’s weight may be a related issue, specifically being obese or severely underweight. If someone has an unusual appearance, outside of cultural or subcultural norms, it may be worth discussing.
Behavior:
Some of the most striking signs of disturbance come from the way people act.
•
Body movement:
Body movements such as fidgeting, fast movements, slowed movements, or strange gestures may be relevant. Nervous individuals may fidget a lot. Depressed patients may sit slumped in their chairs. Someone with a paranoid delusion that the CIA is following him may get up and peek out the curtains every five minutes.
•
Facial expressions:
Facial expressions are important (sad, mad, immobile, or frozen expressions, for example).
Speech:
Two disorders in particular include disturbances in speech:
•
Schizophrenia:
A patient’s speech may be disordered, jumbled, or difficult to understand. He or she may seem to be speaking a foreign language, using words and phrases that don’t seem to make sense. I once received an anonymous phone call while volunteering at a homeless shelter. When I asked the caller if I could help him, he replied, “Stick the pin in the cushion. You called me. What do you want? The letters make me crazy . . . light bulb . . . beat the drum . . . stick the pin in the cushion . . . what do you want?” This is an excellent example of disordered speech.
•
Bipolar disorder:
The rate and pace of speech can also be abnormal. Patients currently in a manic episode can speak very fast and act as if they have to keep talking. They may jump from one topic to another.
Mood and affect:
Mood describes the predominant emotions being expressed by the patient. Is she sad, happy, angry, euphoric, or anxious? Affect refers to the range, intensity, and appropriateness of a patient’s emotional behavior. Is she mildly sad or intensely sad? Does she feel anything other than sadness, or does she seem to have a full range of emotions? Another common observation of affect is called
mood liability.
How often and easily does her mood change? Is she hot one second and cold the next?
Thought content:
What people think about is relevant to any clinical evaluation. Bizarre thought content, such as delusions, can be telltale signs of the presence of a mental disorder. Less bizarre but sometimes equally disturbing thoughts, such as obsessive preoccupations and intrusive ideas, can also be signs of severe anxiety. Thoughts of death and violence are relevant to assessing suicidality and violence potential.
Thought process:
Different ways of thinking can sometimes be clues to a disorder.
•
Tangential thinking:
Often a sign of thought disorder, tangential thinking is characterized by a wondering focus and the tendency to go off on tangents that are only minimally related to the topic currently being discussed.
•
Clang associations:
These signs are serious indicators of thought disorder. A clang association is when someone ends a sentence with a word, and the sound of that word triggers another thought, related to the conversation only by the sound of the last word uttered. “I came home from work the other day, and the car was in the driveway . . . highway’s are crowded. Loud noises bother me . . . tree.” This type of disordered thought is disorganized and hard to follow and doesn’t make much sense.
Perception:
Perceptual problems consist of hallucinations. Patients can experience auditory hallucinations (voices), visual hallucinations, olfactory hallucinations (smells or odors), gustatory hallucinations (tastes), or somatic hallucinations (strange bodily sensations, such as feeling like bugs are crawling under one’s skin). A very serious auditory hallucination is when patients hear a voice or voices telling them to hurt themselves or someone else. These are sometimes called command hallucinations.
Intellectual functioning:
This status can be casually observed by paying attention to the patient’s vocabulary, general quantity of knowledge and information, and abstract thinking ability. However, trying to figure out someone’s intellectual functioning based on observation alone is highly subjective and should only be used as a starting point for further assessment.
Attention/concentration and memory:
It’s important to observe whether patients are distracted during the interview and have a difficult time concentrating on the task at hand. Their short-term memory can be observed by asking them to remember a few things and checking with them a few minutes later. How well they recall their history and provide historical information provides a measure of their long-term memory. Many disorders present attention problems and memory deficits.
Orientation:
Does the patient know where he or she is? The season? The time? Ascertaining whether a patient knows where he or she is in time and space is an important part of the MSE. Many serious medical conditions and neuropsychological disorders manifest signs of disorientation.