Competency-Based Assessments in Mental Health Practice

Cases and Practical Applications

Susan W. Gray

• Publisher: Wiley
• Year: 2011
• Print ISBN: 9780470505281
• eBook ISBN: 9781118044223
• Edition: 1
• Topic: Politics & International Relations
• Subtopic: Social Policy
• Index: Politics & International Relations

" Competency-Based Assessments in Mental Health Practice should be required reading for all clinical practitioners and students. Author Susan W. Gray provides a competency-based assessment model that moves away from looking at mental illness as a 'disease' to capturing people's strengths and the uniqueness of their experience with mental illness."
—Alex Gitterma
Zachs Professor and Director of PhD Program
" Competency-Based Assessment in Mental Health Practice not only describes the rather cumbersome DSM-IV-TR ® in a manner that graduate students and clinicians can easily understand and apply, but it also presents a competency-based type of clinical assessment that most effectively integrates the social work practice orientation that acknowledges, appreciates, and nurtures client strengths, resilience, and client ability for empowerment."
—Agathi Glezakos, PhD, LCSW
School of Social Work
California State University, Long Beach A competency-based assessment model integrating
DSM classifications for a complete, strengths-based diagnosis C ompetency-Based Assessments in Mental Health Practice introduces a unique, competency-based assessment that presents a brief overview of the major mental disorders that practitioners will likely encounter in their work with clients, followed by a series of case studies and practical applications. This book provides valuable guidance for clinicians to make assessments grounded in client strengths and possibilities for a more therapeutically complete picture of every client's "story." Organized around selected diagnostic categories from the DSM-IV-TR, this hands-on guide offers a multidimensional look at the many factors that play a role in a client's life. Its holistic approach to the assessment process considers each client's unique experience with mental illness, through a concurrent evaluation of strengths and pathology, in order to set the stage for realistic optimism about the potential for change.

CHAPTER 1

An Introduction to the Competency-Based Assessment

Imagine for a moment that a former client of yours, we’ll call her Ellen King, calls you about her daughter, Carol. You had seen Ellen a few years ago for supportive counseling after her divorce from her husband, Gerald. She now asks if you could see Carol because, “She’s driving me crazy.” You schedule an appointment for the next afternoon.

Carol is currently enrolled in the 11th grade and wants to go to college after she graduates. However, her grades could be much better. Carol admits that she’s “only failing a couple of classes.” After introductions, Carol settles comfortably in your office and you ask, “What do you think has happened that your mother made an appointment for you to come here to see me?” Carol has a puzzled look on her face at this point. She confides that she does not know what the problem could be and adds with almost too much intensity, “I feel just fine.” Carol thought that since her parents’ divorce her mother had nothing better to do than to worry about her. “She thinks I’m a mental case. Just because I don’t sleep as much as she does she gets all bent out of shape. Heck! Sleeping is for old people like her. I’m young and I have a lot to do. I can catch up on my sleep later,” adds Carol.

You notice that Carol’s speech is pressured as she goes on to describe those times when she’s “on top of the world” and then a few days later when “I’m totally down.” Carol denies any history of drugs or alcohol and this is corroborated by her mother.

What do you think is going on with Carol?

PERSPECTIVES ON THE ASSESSMENT

The assessment is an ongoing process of data collection that sets the stage for learning more about our clients. There are a number of methods to collect and evaluate information from a range of sources, including, for example, face-to-face interviews, direct observations of behavior, talking with those close to the client, a review of written documents or prior evaluations, and the use of measurement instruments. In the field of mental health, the most widely used categorical system to consider behavioral patterns is the Diagnostic and Statistical Manual of Mental Disorders or DSM (American Psychiatric Association, 2000). The diagnostic categories are supported by field investigations and the manual describes symptoms and related characteristics such as age at onset, predisposing factors, and prevalence. Specific criteria are also provided and include key symptoms, the duration of dysfunction, social and occupational impairment, and considerations for differentiating the diagnosis from other closely related syndromes. The DSM is organized around a multiaxial system geared to take into account the presenting problem as well as related issues, but it does not promote a specific theoretical orientation.

This book introduces the competency-based assessment that expands the DSM’s focus by incorporating a parallel assessment of strengths and resilience. The competency-based assessment provides a framework for clarifying the client’s competence, the “goodness of fit” between the client and his or her environment, and a consideration of the impact of mental illness. This approach to the assessment encompasses finding ways to support the client’s coping and adaptation (Saleebey, 2008). “In this perspective, clients are regarded as active, striving human beings who are capable of organizing their lives and realizing their potentialities, as long as they have appropriate family, community, social, and environmental resources” (Compton & Galaway, 1999, pp. 354–355).

We need to be knowledgeable about many factors related to the client’s presenting issues. This includes familiarity with the diagnoses spelled out in the DSM and the ability to apply them correctly. However, an assessment that is grounded in strengths and possibilities provides a more comprehensive picture of the person’s “story.” In this way, the diagnosis does not define the individual but becomes but one aspect of the multiple dimensions of a person’s life. The dual focus of the competency-based assessment on problems and competencies helps to understand a client’s diagnosis and to consider the experience of what it’s like to live with mental illness (Gray, 2006, 2008). This approach to the assessment extends the understanding of the multiple contributors to mental illness; for example, the stressors in a person’s life, the family’s well-being, housing, income security, and community or the sense of belonging somewhere.

It has become increasingly common to encounter clients whose backgrounds differ from our own. Many times when our clients come to see us they are not at their best. In order to be effective, it is helpful to know about the many dimensions of a client’s life including diversity and difference and how the client can potentially influence the assessment process. Sometimes differences can be interpreted as barriers. Integral to the competency-based assessment is an exploration of the multiple influences of diversity, which are an integral part of one’s identity and their interplay with mental illness (Voss, Douville, Little Soldier, & Twiss, 1999). By exploring the full range of the client’s experiences with mental illness these events can be transformed into opportunities for growth and change. For the remainder of this book, the competency-based assessment sets the stage for the evaluation of mental illness. Many of the client stories in this book include examples of diversity in order to highlight the ways in which the various dimensions of diversity affect a person’s explanations of illness, help-seeking behaviors, and healing practices.

This chapter begins with an overview of the essential components of how the DSM is organized followed by an exploration of the theoretical foundations and perspectives that support the competency-based assessment; in particular, the biopsychosocial framework, systems theory, and the ecological perspective. Client competence is a major theme of the competency-based orientation to the assessment and contributions from the strengths perspective, empowerment, and resilience are accentuated. Integrating the DSM with the competency-based assessment provides a framework to focus on diagnosing mental illness balanced by simultaneous attention to the many ways that people cope when living with a diagnosis. This paradigm shift moves the assessment process from a perspective of helplessness to one characterized by hopefulness.

We now turn to an overview of the DSM.

OVERVIEW OF THE DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS

The DSM is regarded as the standard for classifying mental disorders in the United States and in varying degrees internationally. Beginning in the mid-19th century with various systems to collect census and mental health statistics and from a manual used by the U.S. Army, the DSM evolved over time to its current format that embodies an extensive scope of psychiatric or psychological issues and conditions. There have been numerous revisions and the DSM is currently in consultation, planning, and preparation for yet another edition. This section of our discussion begins with an introduction to the role of the American Psychiatric Association’s (APA) role in the DSM followed by a review of the numerous subsequent editions highlighting how the manual has changed over time. The challenges and contributions facing the DSM are noted and the section ends with a look at the major features.

Introduction

The APA is considered the major professional organization for psychiatrists in the United States. The association publishes various journals, informational pamphlets, and the DSM. The DSM (APA, 2000) is used by psychiatrists and other professionals such as social workers, psychologists, counselors, and marriage and family therapists who can be found working in a range of settings. The DSM is widely recognized as the accepted diagnostic language in the field of mental health, insurance companies, and the pharmaceutical industry (Kutchins & Kirk, 1997). It is universally understood and facilitates the ability to understand the client’s symptom picture. From the client’s perspective, the extent to which he or she is heard and understood helps to reduce their anxiety (Bentley, 2002). The classification system of the DSM helps to sort through what may seem like a confusing array of problems and symptoms.

It is equally important to remember that not every client who comes to see you has a mental disorder. Many times clients who need help are struggling with difficult life circumstances and events and a DSM diagnosis may be unnecessary. In this case, the DSM provides a classification system for conditions that are not the focus of clinical attention, commonly referred to as V codes. These codes refer to the problems that people encounter in life that might prompt them to seek assistance but are not considered mental illness. For example, you might be working in a hospice setting and encounter someone who is grieving the loss of a loved one but the associated sadness is not to the extent where a diagnosis of major depression is warranted.

We now turn to an overview of some of the outstanding historical events that have contributed to the development of the current DSM and conclude with a summary of its major features.

The Evolution of the DSM

Starting with the thinking passed down by the Greeks that mental illness was the result of an imbalance of humors or body fluids, ideas about mental health in the United States were primarily influenced by concepts that had evolved in Europe (Katz, 1985). Up until the seventeenth century, physicians used a person’s horoscope to diagnose mental disorders (Labruzza, 1994). Medieval doctors looked to four humors to explain differences in the person’s personality. More specifically, blood accounted for a happy temperament, choler explained a fiery and competitive temperament, phlegm resulted in a cold, delicate disposition, and bile appeared to cause melancholy.

During the American colonial era, most people with a mental disorder were kept at home and cared for by family. Those suffering from mental illness were referred to as lunatics—a term derived from the root word lunar referring to the influence of the moon. The prevailing belief at the time was that a mental illness was caused by a full moon when a baby was born or by the infant sleeping under the light of a full moon. The lunatic was considered to be possessed by the devil. More often than not, the family member with a mental illness was confined to the attic or cellar and kept locked up in chains. Alternative arrangements included placement in settings referred to as madhouses that were run by physicians in their homes (Leiby, 1978). People who could not afford this type of care and had no relatives to look after them were confined to workhouses or almshouses where harsh treatment tended to prevail. Those who were homeless were most likely to end up in jail. Some led a solitary existence by camping out in the woods.

Beginning with the 19th century Dorothea Dix, an avid social work reformer, led the efforts to improve the treatment of the insane (Kreisler & Lieberman, 1986; Marshall, 1937). She advocated for placing those with a mental illness in what was called asylums where a more humane approach to care was provided. Unfortunately this backfired when the a...

Table of contents

• Cover
• Contents
• Title
• Copyright
• Dedication
• Preface
• Acknowledgments
• About the Author
• Chapter 1 : An Introduction to the Competency-Based Assessment
• Chapter 2 : Formulating the Competency-Based Assessment: Some Basics
• Chapter 3 : Disorders in Infancy, Childhood, or Adolescence
• Chapter 4 : The Cognitive Disorders: Delirium and Dementia
• Chapter 5 : The Substance-Related Disorders
• Chapter 6 : Schizophrenia and Other Psychotic Disorders
• Chapter 7 : The Mood Disorders
• Chapter 8 : Anxiety Disorders
• Chapter 9 : Somatoform, Factitious, and Malingering Disorders
• Chapter 10 : The Dissociative Disorders
• Chapter 11 : Eating Disorders
• Chapter 12 : The Personality Disorders
• References
• Author Index
• Subject Index