Components and Format of a Mental Health Assessment
Common Types of Mental Health Assessments
Mental health assessments (MHAs) are used for a number of situations, including criminal and family court cases; disability claims (workers compensation, veterans benefits, Social Security, the Public Employees' Retirement System), accident claims for companies, and evaluations in school settings. In over two decades, I have found many of these assessments to contain similar elements. Today, recent updates have not changed that status.
Content of a Mental Health Assessment
- 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.
Tests Often Administered by the Evaluator
The following are tests that we always administered to disability clients:
- WAIS-IV/Wechsler Adult Intelligence Scale: This yields an IQ score and part of this score 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: This instrument measures math and reading skills.
- Minnesota Multiphasic Personality Inventory (MMPI) or the newer MMPI 2RF: 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 snail-mailed 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.
- PAI: The Personality Assessment Inventory is a newer instrument that requires a client to answer fewer questions (344) than does the MMPI (600+), but a few more than the MMPI 2RF (338). The PAI is accepted by the American Psychological Association, as are the MMPI and MMP 2.
Projective Personality Tests
- Draw-a-Person or House-Tree-Person: A drawing task that is a projective test in that the client projects personality traits into the drawings.
- Sentence Completion Test: A test in which the client completes a thought, e.g. "My favorite color is ______________."
- Rorschach Ink Blot Test: The inkblot 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.
Test Examples: Projective Testing
Additional Tests for Suspected Conditions
- Beck Anxiety Inventory
- Beck Depression Inventory
- Geriatric Depression Scale (for senior citizens)
- Luria-Nebraska Neuro-psychological Battery
- IPAT-16 Personality Factor Test
- Child Behavior Checklist: This packet includes appropriate Parent-, Teacher-, and Youth Self-Report Checklists.
- Dementia Rating Scale
- Other, as chosen by the evaluating professional.
Format of the Written Report
The final document resulting from the assessment will often 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 and psychological histories.
- Testing: A listing of any psychological and 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-5, the diagnostic manual of the American Psychiatric Association. This manual is used by psychologists and other qualified mental heath professionals as well as psychiatrists.
- Diagnosis or Diagnoses: This is a listing and discussion of possible diagnoses for the client, based on the MHA protocol used and information in the DSM-5.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM - 5) published in 2013 changed the diagnostic write-up from a system of five "axes" for listing five categories of conditions to a single axis for describing the overall mental condition. The 2013 result became a paragraph that replaced five bullet points.
The paragraph first combines the former Axes I, Ii and III into just one statement that contains all of the mental and other medical diagnoses, but this might require more than one sentence. The former Axis IV was eliminated altogether and replaced by a statement that contains an expanded and selected set of medical ICD-9-CM V codes and ICD-10-CM Z codes. Axis V was eliminated as well, but the World Health Organization’s Disability Assessment Schedule may be used and the subsequent findings added in another sentence or more.
Treatment and Prognosis Statement, Optional
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.
Use of Assessment Reports
These reports may be used by insurance and government entities, attorneys, judges, and subsequently seen medical and psychology practitioners.
New Diagnoses in the DSM-5
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-5 process. This is despite the fact that the APA elicited public reaction to proposed changes for DSM-5. Further, Brent Robbins, Ph.D. wrote an open letter to the DSM-5 writers about his concerns that the new diagnostic criteria make it easier to find individuals as pathological.
DSM-5 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: This is controversial and formerly included in DSM-II, removed from DSM-III and DSM III-R, included in an appendix in DSM-IV-TR, and added back into the main text of DSM-5.
- Negativistic (passive-aggressive) personality disorder: Rather depressed and passive-aggressive.
- Relational disorder: A relationship itself is disordered, rather than one person in the relationship.
- Sluggish cognitive tempo: This is controversial and not associated specifically with ADD/ADHD, but is an attention-related cluster of symptoms. It includes "brain fog" and slow work speed.
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 rather than fewer, considering that the SDM-5 includes several newly added conditions. The future results of this may include the labeling of a greater number of people with pathology and may result in additional successful disability claims that increase the financial burden national healthcare.
Additional Changes in Mental Health Assessment
President Bill Clinton's (1992 - 2000) welfare reform created significant changes in disability insurance and claims, particularly Social Security Disability and Supplemental Security Income.
One change was the reduction of IQ levels required for the standard levels of mental retardation, placing a greater number of people at Mild or Borderline levels, capable of living outside of an institution and some with less or even without subsidized income. Such changes illustrate not only reasons for concern in the well being of MR/DD populations, but also concern about untrained individuals diagnosing medical and psychological conditions.
In order to be legally legitimate, MHAs must include a complete and official protocol and can be lengthy. Some legitimate psychometric testing can be completed online, but the availability of online pop personality tests is discouraging and often leads to inaccurate diagnoses.
Among the public and in the press, we see increasing numbers of untrained and un-credentialed individuals decreeing that someone is "___________" condition as a source of entertainment, gossip, or power over. Whatever mental health diagnosis they proclaim - if it actually exits - could be the effects of a brain tumor or poor nutrition, for example. MHAs are serious business and need to be done by qualified health professionals licensed and registered with appropriate agencies.
Be safe. If you suspect a mental health issue in yourself or others, contact a healthcare provider for advice. If danger is imminent, as in self-harm, harm to others, or suicide, call 911.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM–5) www.psychiatry.org/psychiatrists/practice/dsm Retrieved April 1, 2018.
- American Psychiatric Association. DSM History. www.psychiatry.org/psychiatrists/practice/dsm/history-of-the-dsm Retrieved April 2, 2018.
- Inglish, P.: Practical work experience in performing Mental Health Assessments in private practice, for the Social Security Administration, for Ohio Workers Compensation, and for Welfare2Work. 1983 - 2005.
- Sproul, J.; Bond, E.; Southers, E. History of Projective Testing (video). projectivetests.umwblogs.org/ Retrieved August 7, 2012.
Questions & Answers
© 2012 Patty Inglish MS