How to Write a Mental Health Assessment
From 1986 - 2005 and occasionally thereafter, I performed Mental Health Assessments or Evaluations for a number of clients dealing with disability claims connected with Workers Compensation, the Veteran's Administration, Social Security, the Public Employees Retirement System, unions, large employers, schools systems, and attorneys. While the evaluations for each type of entity were slightly different in nature, all included similar elements described in this Hub.
Diability Insurance and Welfare Reform
A very interesting period in American History is disability judgements occurred under the Bill Clinton Administration, 1992 - 2000. Welfare Reform under President Clinton created large changes in the disability insurance and claims industry particularly within Social Security Disability and Supplemental Security Income payments. One such change was the reducing of required IQ levels for the scale of determinations of Mental Retardation, placing a far greater number of people at the Mild or Borderline levels and thus, capable of living outside of an institution and even independently. This was particularly, since I had worked in MR/DD group homes in the late 1980s under different definitions of Mental Retardation levels. See Atkins v. Virginia for those changes from before the Clinton Administration and in 1994.
During the first year of Welfare Reform in which families were to be removed from the public assistance roles, 400 families in Central Ohio were slated for removal. However, the mental status of the heads of household would not allow it. Unfortunately, these individuals were caught in a place where they were not well enough to work, but also were not ill enough to receive disability incomes. Therefore, these 400 families remained on the public assistance roles.
By the beginning of 2011, at least 1/3 of the families in my County received or were eligible for Food Stamps under the Snap Program, without a Mental Health Assessment required. In early 2012, this increased to 50% of families for a few months, because of the Recession under Presidents Bush 43 and Barack Obama.
That is how IQ determination affected Mental Health Assessments in a significant manner under President Clinton, forward.
Cutting Corners, Opposed to the Brief MHA
One non-profit company in Ohio hired a social worker to perform Mental Health Assessments (MHAs) of Welfare to Work Clients under a federal grant earmarked for assessment, education, training, and job placement. When I was called upon to help at the end of the program, I found that the MHAs had taken only 15 minutes each, a much shorter time and content than I was trained to perform.
Below, I've presented the steps and materials used in the MHAs I performed. Please feel free to leave questions in the Comments section at the end of this Hub.
NOTE: The disability insurance Mental Health Assessments or Evaluations that I performed used roughly three hours of time. Scoring the appropriate testing and making the final evaluation required another hour or more. I take exception to the 15-minute evaluation and determination, although some of these can yield a nugget of valuable information when performed by experienced social workers and nurses. In fact, a nurse, nurse practitioner, medical assistant, physician assistant, or a doctor will often do a short MHA during a regular checkup as part of the complete examination. If mental health issues reveal themselves, then a referral to an appropriate practitioner is often made.
Among the public, I am dismayed to see untrained individuals decreeing that someone is "___________" condition as a source of entertainment, gossip, or of feeling power. Whatever mental health diagnosis they proclaim, it really could be a brain tumor or caused by poor nutrition, for example. If a condition is suspected, then the interested party should guide their friend or relative to a doctor or counselor, if possible, and relate their suspicions to the professional and work together. Families and friends do, indeed, sometimes see conditions in others (or themselves) that need attending and the important part of this is to get help that works -- Kudos to those that do so!
Steps In a Mental Health Assessment for Disability Claims
- Client Information Form - Not only do we gain the usual client information, but also look for signs important to Mental Status that include the ability to read the form and complete the blanks. Erratic handwriting might suggest a mental impairment or condition as well. A form returned essentially blank might suggest some problems and a client may need help filling out the blanks, which is also significant.
- Interview: Medical and Psychological History - The client's medical and psychological history might be included on the information form above, or it might be a separate form that an interviewer uses to ask the client about past and present medical and psychological conditions and examinations, allergies, medications, therapies, etc. It is helpful when medical records arrive with the client, including Workers Compensation and Social Security examinations and transcripts of disability findings by the court system. In addition, the client is asked about symptoms or other events that are causing concern, along with information about their duration and intensity. Incarcerations and hospitalizations would be important. Note: If the client is seeing a medical practitioner, then a physical examination will usually be performed as well and include physical tests like the EEG, blood tests, or any of several others.
- Interview: Family History - In this element, we target heritable and non-heritable illnesses and conditions and look at family interactions. For instance, a history of domestic violence calls to the police would be important. Substance Use among the family members could be significant. The occurrence of Autism Spectrum Disorder (ASD) or ADD/ADHD in one or more family members would be important, as would be a number of psychiatric conditions, treatments, and medications. Living arrangements of the client might be important, along with the facts about visiting and/or residing with family members. If family members accompany the client to the assessment, we can observe their interactions as well.
- Interview: Mental Status - This element of the assessment helps to determine whether the client is well oriented by person, place, thing, and time - who he is, why he is in the practitioner's office, the time and date, and similar understanding. We observe whether the client's facial and hand expressions fit his/her emotional presentation and look for signs of stress, tics, unusual body movements and vocalizations, unusual gait, and similar. The interviewer notes the client's overall appearance, including grooming, cleanliness, posture, weight proportionate to height, and clothing.
- Testing Instruments - A psychologist can choose from a range of tests with which to examine personality (behavior) factors, intelligence, easting disorders, learning disabilities, neurological involvement, ASD, ADD/ADHD, and several others. Test results can be extremely important and in some cases are a key determination factor -- For example, Ohio was the first state in which children and youth could receive Social Security payments for ADD/ADHD, but we found a small group of parents and guardians that coached the young people into exhibiting the behaviors and question answers that would best yield disability payments.
What Tests To Administer
The following are tests that we always administered to disability clients:
- WAIS-IV : Wechsler Adult Intelligence Scale -- This yielded an IQ score and part of this is memory, which is a useful piece of information. Memory problems are important in several psychological and medical conditions. For children, the related WISC-IV is given.
- WRAT-IV: Wide Range Achievement Test -- Tests math and reading skills.
- Draw-a-Person or House-Tree-Person -- A drawing task that is a projective test.
- Sentence Completion Test - Projective test in which the client completes a thought, e.g. "My favorite color is ______________."
- Rorschach -- The ink blot projective test.
- Thematic Apperception Test (TAT) - In this test, a picture on a card is presented to the client, who relates what is happening in the picture.
- Minnesota Multiphasic Personality Inventory (MMPI) - This test examines behavior clusters or patterns and is easy to take via computer or online. This and some other tests can be scored by the company distributing the test and the results snailmailed or submitted to the practitioner online. In any event, results are available to the client through the practitioner within a few days, but not the same day as the test is administered.
Other tests were used if certain conditions were suspected:
- Beck Depression Inventory
- Geriatric Depression Scale
- Luria-Nebraska neuropsychological battery
- IPAT-16 Personality Factor Test
- Child Behavior Checklist - Parent, Teacher, and Youth Self Report checklists.
- Dementia Rating Scale
Test Examples: Projective Testing
- History of Projective Testing
Created by: Joshua Sproul, Emily Bond, and Emily Southers.
Writing the Report: Format
The final document resulting from the assessment will often include include:
- Introduction - Client contact information, time and place of meeting,purpose of assessment.
- Mental Status - Summary of the interviewer observations of client and family and a discussion of the client's reported symptoms and/or those observed by family members.
- Medical History - Summary of client and family medical/psychological histories.
- Testing -- A listing of Psychological and/or Medical Tests administered, along with their scores and other results.
- Interpretation - Interpretation of test results in light of Mental Status and Medical History, with reference to the DSM-IV (DSM-V in 2013), the diagnostic manual of the American Psychiatric Association.
- Diagnosis or Diagnoses - This is a listing and discussion of possible diagnoses for the client, based on the Mental Health Assessment protocol used. In Social Security disability claims, five Axes are used to express diagnoses for an individual:
- Axis I: Clinical disorders that include major mental disorders (Severe Mental Disorders - SMD), learning disorders, and substance use conditions. This Axis now includes Autism Spectrum Disorder.
- Axis II: Personality disorders and intellectual disabilities.
- Axis III: Acute medical conditions and physical disorders.
- Axis IV: Psychosocial and environmental factors contributing to a client's disorder.
- Axis V: Global Assessment of Functioning or Children's Global Assessment Scale for children and teens under the age of 18. (This is the newest Axis to be added).
7. Treatment and Prognosis - The practitioner performing the MHA may state his or her opinion on the prognosis of the client's disorder and suggest treatment(s) and/or referrals to other medical/healthcare professionals. The prognosis may include estimates of the percentage of physical and mental incapacity experienced by the client, along with an estimated capacity to work in gainful employment the future. for example, a practitioner may state that the client is permanently and totally disabled for an insurance claim.
These reports may be used by insurance and government entities, attorneys, judges, and subsequently seen medical and psychology practitioners.
New Diagnoses Added in the DSM-V for 2013
Please note that a former DSM psychiatrist that helped write the various revisions of the diagnostic manual, Allen Frances, has spoken of his concern about the "commercialism and heavy handed censorship" in the DSM-V process. This is despite the fact that the APA elicited public reaction to proposed changes for DSM-V. Further, Brent Robbins, PHD wrote an open letter to the DSM-V writers about his concerns that the new diagnostic criteria make it easier to find individuals as pathological (see links below).
DSM-V New Diagnoses:
- Binge Eating - Binging at least twice a week for 6 months. For bulimia, the criteria is only 3 months.
- Complex post-traumatic stress disorder - This is a severe disorder that includes captivity, psychological fragmentation, loss of feelings of safety, trust, and self-worth; re-victimization, attachment disorder, and destruction of the sense of self. This would include torture, domestic abuse, sexual abuse, etc.
- Depressive personality disorder - Controversial: formerly included in DSM-II, removed from DSM-III and DSM III-R, included in an appendix in DSM-IV-TR, added back into DSM-V.
- Negativistic (passive-aggressive) personality disorder - Rather depressed and passive-aggressive.
- Relational disorder - A relationship itself is disordered, rather than one person in it.
- Sluggish cognitive tempo - Controversial: related to ADD/ADHD, but not related to ADD/ADHD.
A dozen other disorders were proposed, including the archaic Melancholia, more suitable to a great Edgar Alan Poe poem or a Bram Stoker novel. Parental alienation syndrome represents a parent that is bullied consistently belittled in conversations to others by a child. Developmental trauma disorder represents children that undergo multiple complex traumas - this may include child abuse and neglect on a continuing basis. Several others are in the consideration stages as well.
The trend in evaluation and diagnosis seems to be toward finding more disorders, not fewer disorders. The results of this trend in the future may include the labeling of a greater number of people with pathologies and perhaps with additional successful disability claims filed by these individuals and their families. Mental Health Assessment may become more complex and diagnoses more difficult to pinpoint among similar possibilities.
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