Professional Assessments

Depending on what we discover during our assessment process, it may be necessary to bring in experts to help. This section will provide a basic understanding of where to begin working with specific professionals using additional assessments which they provide.

The short descriptions below are based on what the profession offers and how they begin an assessment process. This is not a description of treatment or training they provide, but an overview of how the first few sessions establish your needs and then suggest a course of action.

These experts have much to offer and working with them will help establish and maintain an integrated approach to care. Not all disciplines are required for each individual. Creating a team that works for you is the most important criteria.

Psychiatry

by Peter Forster, MD

Much of psychiatric assessment is based on a very careful and methodical history-gathering process. The goal in the assessments of for depression and bipolar is to have a clear sense of several things: how people's symptoms have changed over time, the transitional process from one mood state to another, how quickly those transitions take place, and if there were any patterns that can be recognized. The influence treatment has had on the course of symptoms is also noted. This very careful and thoughtful analysis not only takes time, but also requires a fair amount of help from the patient.

Another part of the psychiatric evaluation is the mental status examination. This is a structured way of evaluating the important dimensions of mental functioning: mood, attention, memory, patterns of thinking, et cetera. The psychiatrist compares what he finds through the mental status examination with information that he has about typical patterns of thought and emotions found in different conditions. The psychiatrist may request psychological tests to more precisely define the nature of the psychological processes. The psychiatrist may well order some screening laboratory studies, and perhaps neuroimaging, electrocardiogram, or electroencephalogram (EEG).

All of this information is used to identify a diagnosis from which the psychiatrist is able to make suggestions for treatment. The recommendations are based on scientific literature which looks at how others with similar problems respond to treatment.

The focus leans toward symptoms and diagnosis, more so than functioning, although both are important. It's a frequent criticism of psychiatric assessment that psychiatrists focus more on problems than on creative adaptation. People are not just a sum of their problems, they also have come up with creative solutions to these problems. For instance, one person with a severe depression may be unable to leave their bed, whereas another person may have found a way to continue to function normally.

One thing that is important is to find a way of keeping track of mood states and transitions. This is especially true because of a phenomenon called State Dependent Learning. This phenomenon is based on how the brain stores memory. The hippocampus, which is part of the limbic or emotional part of the brain, is where memory is stored. The result is that memory is inevitably stored along with emotions surrounding that memory. In fact, emotions serve as kind of a way of classifying and finding memories. In other words, when you're in a certain mood, it may be very difficult to recall times when you were in a different mood, thus making it very important to keep track of mood changes over time. Otherwise, decisions may get made based on what your mood is at the moment, rather than a more comprehensive sense of how things have been over a period of time.

Psychotherapy

by Rochelle I. Frank, PhD

Standard practice among psychologists begins with a comprehensive assessment of the patient's needs and strengths. Depending on the type of therapy practiced (e.g., cognitive-behavioral, dialectical behavioral, interpersonal social rhythm, psychodynamic), assessment may focus on underlying thoughts and behaviors, coping strategies, former and current relationships, daily schedules, and so forth. Identification of key problem areas (e.g., loss of income, social isolation, insomnia), and specific emotional (e.g., low or expansive mood) and behavioral (e.g., suicidal thoughts) difficulties, leads to clarification of treatment goals and decisions about interventions. Regardless of whether a DSM-IV diagnosis or a narrative description is established, it is important to get a clear and agreed-upon understanding of the issues that will be targeted for treatment.

Assessment often starts during the first telephone conversation, with a brief discussion of the reasons for seeking treatment, impact on current functioning, and identification of resources, supports, and existing services. This conversation provides both therapist and patient with a sense of "goodness of fit" based on personality characteristics, theoretical orientation and professional skills, and offers an opportunity to decide whether or not to schedule an office-based consultation.

Many clinicians, especially those implementing evidence-based treatment (i.e., treatment protocols developed through empirical research, producing consistent positive outcomes), utilize a variety of assessment tools. These range from questionnaires describing personal, family, academic, work, and psychiatric histories, to depression and other symptom inventories. Though important, these instruments do not replace a good face-to-face "clinical interview." The interview includes: discussing information provided on the forms; assessing mental status (e.g., mood, nature and quality of one's thinking and judgment) and current level of functioning (e.g., self-care, school/work performance); and discussing the individual's view of the problems and assessing his/her ability and willingness to participate in treatment. It also is important to identify personal strengths and other resources that bolster treatment outcomes, such as family/social supports, stable income, structured routines, etc. Since many people with bipolar conditions may not have accurate perceptions of their own lives, input from others who know them in various capacities and roles is helpful in providing a context for past and present functioning. Lastly, a discussion of previous treatment efforts and problem solving strategies facilitates informed decisions about current and new interventions.

Primary Care Physician

by Will Meecham, MD

The medical assessment is tailored to the client, but emphasizes identification of illnesses known to be common in those with psychiatric disorders. In particular, attention is paid to detecting medical conditions that might cause symptoms of mental illness. In addition, any limitations on exercise capability are identified, so that the regimen of vigorous physical activity that is part of the Advantage Program can be tailored to the client's strengths and limitations.

The medical provider obtains a detailed medical history, keeping in mind the presence of a psychiatric condition. A thorough history documents prior medical disorders, and sometimes unearths symptoms suggestive of illnesses that might explain or result from psychiatric problems, or that necessitate adjustments to the Advantage Program. A thorough physical examination identifies problems that need further assessment. Comprehensive laboratory studies are ordered to identify metabolic, endocrine, hematologic, infectious, inflammatory, neoplastic, and other diseases. An EKG is obtained to help rule out occult cardiac disorders. Diagnostic imaging is arranged as indicated. Most clients benefit from a brain MRI to eliminate concern that structural brain abnormalities might be causing their symptoms.

Additional studies may be required, depending on the client's age and prior history, the results of the physical examination, and initial diagnostic investigations. Some clients require an EEG to further evaluate neurologic and/or psychiatric symptoms. In other cases, sleep studies or exercise stress tests may be indicated. Obviously, the list of possible diagnostic studies is long and depends on findings in each case. The goal, however, is always to maximize the client's general health and his or her ability to safely achieve Results Worth Striving For.

Relationship Counseling

by Maureen Duffy, PhD

Assessment is a way of helping people figure out where they are at now--what their baseline positions are--so that it will be clearer and easier to get to where they want to be in the future. During the assessment process, you and your family members' hopes for improved relationships will be the foundation. Assessment is only useful when it can help in the process of problem-solving and change.

Relationship assessment is a tool to help you and your family members identify areas of strength as well as areas with room for growth and development. This process is conducted by a licensed mental health professional specifically trained in relationship, marriage, and family issues.

The relationships assessment is a collaborative process between you and your therapist. What this means is that your relationship therapist is not going to assume the stance of expert and tell you what you need to do. You and your family will be fully involved in the process. Your input and that of your family members is critical to successful relationship assessment.

You and your relationship therapist will work together to assess the quality of your relationships and to identify relationship goals along the following dimensions:

• Communication
• Openness, trust, and honesty
• Anger management, conflict management, conflict resolution, and problem-solving
• Expressions of affection
• Intimacy
• Handling emotion and emotional intensity
• Emotional self-regulation
• Supportiveness and caring within the relationship
• Appreciation for self and others in the family
• Family-centered approach to living and thriving with bipolar

The initial formal assessment process culminates with the development of a specific relationship improvement plan for you and your family. Your personalized plan will help you to map out the necessary changes that will result in more satisfying, deeper, richer, less conflicted relationships that will be a source of nourishment and support for you all. Throughout the treatment phase, assessment will be a continuous process, drawing from the initial formal assessment and adjusted, as needed.

Spiritual Counseling

by Scott Sullender, PhD

The assessment process begins by helping the client review his or her spiritual journey--its ups and downs, the moments of power, surrender and transformation, and times of death and rebirth. The assessment will include both the content of one's spirituality and the degree of active practice of one's faith tradition. Your spirituality is your spirituality! The role of the spiritual counselor is not to impose or challenge the client's faith tradition. The counselor's role is to help the counselee examine and/or renew his or her own spiritual walk. Depression or any kind of so called mental illness often does create a "crisis of faith," calling forth from us a re-examination and then a revitalization of our faith tradition.

In addition to conversation, there are several written assessment tools that can be helpful, including "Forgiveness Survey" and the "Spiritual Assessment Scale." Some of the topics or themes assessed in these scales include: meaningfulness of life, purpose of suffering, mindfulness attitude, self-forgiveness and forgiveness of others, gratitude and thanksgiving, presence of the Divine, connection to a spiritual community, strength of hope, inner peace or serenity, personal worth or significance, perfectionism and grace, and a sense of calling or purpose in life. Along the way, a spiritual counselor or spiritual director will teach the counselee a variety of spiritual practices designed, if employed regularly, to strengthen the individual's battle against depression.

Addictions Counseling

by Michael R. Edelstein, PhD

The first step in the assessment process involves understanding the client's perspective on the problem. This includes appreciating the circumstances and context of the problem and evaluating the client's long- and short-term goals. Some clients are clear that they drink or get high excessively, for example, and wish to quit for good. Others are unclear about whether they're overdoing it. Those who are convinced they're addicted, may ask whether abstinence or moderation makes sense for them. Some clients may have a mix of addiction and emotional disturbance and may not know how these are related. Others may have their addiction as a factor in the larger context of relationship difficulties.

The next step involves assessing which problem to address first. Although some clients show impatience and wish to address all their problems immediately, this is not possible. Do we address their addiction problem, emotional problem, or relationship problem initially? It's probably best to have the client decide. Simply and directly state the question: "which problem would you like to start with?" If the client is indifferent, then the therapist can determine which seems most pressing, and start with that. For example, if the client's partner has delivered an ultimatum, e.g., "If you get high again, I'm leaving," then under most circumstances it's prudent to focus immediately on helping the client to abstain.

The next step involves the education process: explaining how addiction is defined, where addictions come from, and how the fundamentals of the change process operate. REBT involves the backbone of our treatment. This approach is explained along with recommending further reading including Three Minute Therapy by this author and When AA Doesn't Work for You by Albert Ellis and Emmett Velten.

Nutrition Counseling

by Ruth Leyse-Wallace, PhD, RD

Findings during the initial interview are evaluated by the nutritionist, discussed with the client, and shared with the team members. Assessment of initial nutritional status includes an interview by the nutritionist to gather information concerning:

• usual food, beverage, and supplement intake
• current weight and recent weight changes
• physical problems with eating (dental health for example)
• the need for a nutrition-focused physical examination (and performance of the exam if needed)
• biochemical laboratory testing to validate observations and findings
• presence of diarrhea or constipation
• possible interactions between medications and nutritional status or individual nutrients
• medical issues that may affect or be affected by nutrition
• presence of nutritional risk factors related to family history (bipolar disorder, diabetes, etc)
• subjective symptoms felt by the client to be affecting intake or nutritional status (frequent nausea or extreme fatigue, among others)

Results of laboratory tests will be evaluated and discussed when they are complete. They will then be integrated into goal-setting and determining a treatment plan. The client's priorities and preferences will be an integral part of goals and treatment planning.

Reassessment and follow-up will occur at appropriate intervals for discovering if nutritional status has changed in the desired direction. For example, it may take one to several weeks for a supplement to promote a change in an enzyme level.

Fitness Coaching

by Mark Jenkins

Assessments are an important step before taking on any new exercise routine. Knowledge of your current condition can help avoid injury and make sure the program will be one that can be followed. Assessments can be as complex as body composition analysis and VO2 Max testing, or as simple as testing for ability to lift weights and touch your toes. It is important to set the baseline condition as well as periodically test for changes. Periodic assessments can help in analyzing the effectiveness of specific exercises and be used in making changes to the program.

A typical thorough assessment may include:

• Health History & Medical Screening
• Vital Sign Measurements
• Body Composition
• Cardiovascular Endurance
• Strength and Muscular Endurance
• Flexibility Testing

Physical Rehabilitation Therapy

Justin Liu, MD

Before a physical activity program is started, a PM&R Physician should perform a thorough pre-exercise assessment. As part of this process, a comprehensive History & Physical examination should be done. Key elements that should be detailed during this exam will include an in-depth look at the individual's prior medical history and uncovering the acute physical issues as well as the subacute chronic issues that are impacting the patient. Family medical history and assessment of the patient's substance use history (i.e. nicotine, alcohol, prescription/non-prescription drugs) are also important variables to consider. A thorough physical examination with focus on musculoskeletal and neurological testing must be completed. A baseline set of blood tests and an electrocardiogram may also be obtained to ensure that the patient does not have other underlying medical conditions that could limit activity. Such conditions like anemia, electrolyte disturbances, dehydration, or arrhythmias must be adequately addressed before an individual can safely embark on a program of regimented physical activity.

Another essential part of the assessment process will be the functional evaluation. The PM&R Physician should accurately determine what the patient's current functional status is. The individual's physical endurance and ability to perform basic activities of daily living should be looked at in detail. In tailoring a program for a patient, it is imperative to see how much function a patient has lost over a recent interim of time. This information will be useful in deciding how to set appropriate and useful goals for the patient.

Career Management Counseling

Maria Chang-Calderon, PhD(c), MSHR

The assessment process requires the client to create an inventory list of strengths and weaknesses with the help of a career management professional. This paves the way to build on strengths as a foundation for enhanced performance.

There are several assessment tools that identify strengths and increase self-awareness. Three recommended assessment tools include the Myers Briggs Type Indicator (MBTI) personality test, 360 Degree Review, and the Big Five Personality Test. The Myers Briggs Type Indicator (MBTI) allows clients to learn more about themselves and career options. The 360 Degree Review allows the client to obtain input from fellow employees from all hierarchical levels. The Big Five Personality Test is another assessment that is not strictly career-oriented, but provides insight that can be applied to careers, such as how one ranks in the following scales: close-minded vs. open to new experiences, disorganized vs. conscientious, introverted vs. extraverted, disagreeable vs. agreeable, and calm vs. high strung. A career management counselor will help to identify which assessment tool would be best for each individual from the many that are available and discuss the meaning of the results.

Financial Coaching

Denise K. Hughes, M.A.

Part I of the assessment process pertains to money mastery skills that help clients reach their full potential. These skills include cash flow management; strategies to fully fund emergency, savings, and investment accounts; as well as strategies to eliminate any unsecured debt. This step also includes an appraisal of mechanisms of asset protection one may need to have in place, such as various insurances and a living trust.

Part II of the assessment will focus on the attitudes and behaviors one brings to their relationship with money. Behaviors consist of one's thoughts, feelings, and actions which are motivated by underlying beliefs. The assessment process will identify both healthy and un-healthy behaviors one has with money and the consequences of each behavior.