Lecture Four

Questions to be answered in this lecture:

So how does all of this information regarding the diagnosis of mental disorders effect the work I am doing with clients?

What should I be looking for in when assessing a client with a diagnosis of severe, long term mental illness?

As a wrap up to our previous discussion on the process for diagnosing severe, long term mental illness, let's look at the following thoughts:

We have spent some time talking about different approaches to viewing mental illness. We have noted biological, psychological, and social/cultural viewpoints are all important in understanding the causes, diagnoses, and treatment of the individual.

We have explored each of these viewpoints separately.

We have discussed the biopsychosocial approach and understand that it is the most effective method for understanding and treating severe, long term mental illness.

We have also discussed the classification system used to diagnose mental disorders and understand that this system provides a way of understanding something about the biopsychosocial situation of the individual.

What does this diagnostic information have to do with my job?

If you have an interest in working more intensely with people with psychiatric disabilities or even individuals with mental health concerns, you will frequently deal with diagnostic issues. It is true that an individual is NOT his or her diagnosis. In fact, a diagnosis is only important to the degree that it provides information which can help others understand the experience of the individual and devise a rehabilitation plan which realistically addresses the need of the individual.

Let's look at a couple of case studies.

Roberta is a thirty-five year old female with a history of bipolar disorder. The diagnostic information provided to you by the staff at the Mental Health Center looks like this.

Name: Roberta DOB: 6/14/64

Axis I: 296.44 Bipolar I Disorder Severe with Psychotic Features

Most Recent Episode Manic

With Rapid Cycling

Axis II: 301.83 Borderline Personality Disorder

317.00 Mild Mental Retardation

Axis III: None known

Axis IV: Problems with primary support group

Housing problem

Educational problems

Axis V: Current GAF: 50

GAF at admission to hospital: 30

GAF at Discharge: 61

Roberta presented well at her initial interview. She seemed alert and interested in getting her life back in order after her recent hospitalization. She spoke in an animated fashion, loudly, and with her eyes darting about the room. She chuckles as she tells you the following story.

"I had to go to the hospital because I did some really crazy things. The folks is really angry with me. You know, they built an apartment above the garage for me last year so's I could have some privacy. I had a good job at the dry cleaners ironing clothes and puttin' em up on hangers for the peoples. But a week ago last Friday, I calls my man and tells him I want to get outta this place. So I packs up my clothes and radio and puts 'em out on the porch. But I thinks that my dad's gonna be real sad when he sees me gone. So I went back inside and started tearing things up, you know like some peoples broke in? Then me and Marshall took Mama's car and took off outta there. I was drivin'. That made Mama real mad 'cause I ain't got a license. Next thing I know, we done run the car up on the sidewalk and scared them folks half to death. Me and Marshall thought it was funny. The cops talked to me for a while and then they took me to the hospital. The Docs made sure I got back on my medication and soon I was feelin' right as rain again. Except I'm pretty sorry 'bout all I done. I really tore up that apartment and now Mama and Daddy say I can't go back there. So I been staying with Marshall but his landlord say I gotta move out or Marshall will get kicked outta there. I'd like to see if I can get my job back at the dry cleaners. Now they say I can't come back 'cause I was gone for a couple of weeks and never called. The boss say he needs somebody more 'liable than me."

It's likely that Roberta is doing better on her medication and that she genuinely feels badly about what has happened. It is obvious though that she has some learning problems and may not bew able to fully comprehend the implications of what she has done. It is also likely that Roberta's moods may change rapidly and that being reliable may be very difficult for her even with the regular use of medication. Some of Roberta's flightiness and rapid changes may not be effected by her medication. The behaviors that Roberta currently presents may not be consistent.

It is easy to see why knowing some things about her diagnoses can assist you in developing a plan for her that is realistically based on the expected long term course of her condition. You may not need to be the individual who diagnoses to be able to benefit from understanding the diagnoses.

Food for Thought:

You have a new case. Mannie has never been involved with your agency before. Before you meet him, you look at his records finding the following DSM-IV Diagnosis.

Name: Mannie DOB: 12/23/53

Diagnosis: Axis I: 295.30 Schizophrenia Paranoid Type

Episodic with no Interepisode Residual Symptoms

Axis II: 79.90 Diagnosis Deferred

Axis III: Diabetes Mellitus

Axis IV. Occupational Problems-threat of job loss

Problems with access to health care services

Problems related to the interaction with the legal system/crime:

litigation pending.

Axis V: Current GAF: 44

Highest GAF past year: 78

What conclusions can you draw about Mannie based on this diagnosis alone?

What should I look for when dealing with a client with a diagnosis of severe, long term mental illness?

The ability of an individual to benefit from psychological or social interventions is often effected by the ability of the individual to be able to perceive and think clearly. This is not to say that individuals who can be expected to experience some level of impairment in reality testing most all of the time cannot benefit from rehabilitation. It does suggest, however, that additional medical evaluation may be necessary or other rehabilitation activities may need to be undertaken before dealing with such issues as job training or placement.

One way to evaluate an individual is through the use of a Mental Examination. This sounds like a highly technical process and may certainly be depending on the purposes for which the examination is done. However, most mental status examinations are based on an interview and initial observation of the behavior of the client and remain somewhat subjective. Any professional working with an individual with a severe. long term mental illness undertakes a less formal mental status examination nearly everytime the client is seen. Let's look at the kinds of factors evaluated when looking at an individual's mental status.

If you read through the Glossary in the Reference Room, you will note a number of terms which describe various characteristics of thought and speech which are diagnostically important. But these characteristics also describe the ability of an individual to grasp and process information and concepts.

The form below provides a quick way of evaluating the Mental Status of an individual:

Appearance:

Does the client appear to be: actual age? Older? Younger?

Gender and Race:

Build: thin? medium? heavy? athletic? very obese?

Pupils: equal? constricted? dilated?

Hygienic state: clean? disheveled? unshaven? odorous?

Clothing: neat? untidy? peculiar?

Posture: normal? slumped? rigid?

Facial expression: amiable? happy? worried? tense? angry? suspicious sad? immobile?

Attitude and Behavior: alert? confused? drowsy? hypervigilant? stuporous?

Attention span: satisfactory? poor? distractable?

Eye contact: good stares into space? avoidant?

Muscular movement: normal? fidgety? excited? hyperactive? hypoactive?

Mannerisms: none pacing? handwringing? echopraxia? stereotypy? tics?

Physiological signs: none? tearful? tremorous? crying? blushing? sweating?

Demeanor: friendly? worried? boastful? trustful? demanding? evasive? dramatic? covertly seductive? self-deprecatory? arrogant? cold? irritable? apathetic? reserved? resistive? hostile? cooperative?

uncooperative?

Mood: anxious? fearful? suspicious? depressed? euphoric? relaxed? angry? guilty? ashamed? indifferent? mild? moderate? severe?

Affect: appropriate to content? labile? inappropriate? blunted? flat?

Speech: soft? normal? loud? screaming?

Mother tongue: English? Spanish? Other?

Quantity: normal? mute? verbose? answers only questions?

Speed: slow? normal? rapid? pressured?

Impediments: none? stutter? lisp? slur?

Quality: unremarkable? flight of ideas? concrete? circumstantial? joking? overinclusive? verbigeration? neologistic? echolalic precise? senseless repetition? tangential? confabulating? monotone? obscenities?

Thought and Association: logical? blocking? loose? incoherent? clang (rhyming)?

Somatic Functioning:

Appetite: good poor unable to eat weight loss or gain

in last ______months

Current weight:________

Sleep: 7-8 hours? 9+ hours ? 5-7 hours? 4-5 hours? less than 4 hours?

nightmares? trouble going to sleep? early morning wakefulness?

Substance use: amphetamines? sedatives? alcohol? heroin? speed? caffeine? nicotine? marijuana? cocaine? PCP?

other:

mild? moderate? severe?

Current medications:

Medical Problems:

Rehabilitation Plans often focus primarily on interventions which are seen as directly leading to employment or vocational readiness. It is important to understand. however, that information pertaining to the individual's mental illness is equally important in gauging both the individual strengths and limitations of the client. Diagnostic information coupled with an understanding of the course of a particular mental disorder, factors which impact the course of the disorder such as psychosocial stressors, and the course of treatment for the particular disorder can greatly assist the rehabilitation counselor in developing an individualized rehabilitation plan which addresses the WHOLE individual.

The following schema developed by Seligman (1990) describes a method of treatment (rehabilitation) planning which allows the counselor to easily address those areas which need to be taken into consideration when working with a client with a mental disorder. We will be discussing how this schema applies to the development of a rehabilitation plan.

DO A CLIENT MAP (Seligman, 1990)

Diagnosis

Objectives of Treatment

Assessments as Needed

Clinician Characteristics viewed as thera peutic

Location of treatment

Interventions to be used

Emphasis of Treatment

Nature of Treatment

Timing

Medications needed

Adjunct services

Prognosis

Now, let's consider each of these as it pertains to effective rehabilitation planning for an individual with a severe, long term mental illness.

Diagnosis: We have discussed the importance of understanding the characterisitcs of the disorder experienced by the individual. This is not to say that every individual with the same diagnosis has the same capabilities or limitations. The diagnosis helps the rehabilitation counselor to understand what types of factors may be influencing the ability of the individual to perfomr a specific job (i.e. if the individual experiences disruption in normal thought content, then tasks which require complex thinking and organization may be both difficult and frustrating to the individual.

Objectives of Treatment: Rehabilitation Counselors need to be clear on what they can reasonable accomplish in their setting. While clients with severe, long term mental illness can benefit from the cognitive re-training which occurs when an individual learns a new vocational task, the agency itself may not see re-education as one of their functions. Rehabilitation objectives need to be clearly defined in part so the consumer is not mislead, but also in order to make certain that appropriate adjunct services are being provided and referrals are being made.

Assessments as Needed: Individuals with severe, long term mental illness are best assessed situationally and frequently. Because the individual's performance can be expected to vary, it is important that the door for additional assessment is always kept open. Remember also that individuals with severe mental illness may lack the capacity ot generalize, and therefore assessments done in real-life situations tend to be more reflective of the actual ability of the individual.

Clinicians Characteristics Viewed as Therapeutic: Not every rehabilitation counselor is going to have either the training or the interest in working with this specific population. In any type of counseling situation, the relationship between counselor and client is very important. But for individuals with severe mental illness, the ability to handle personal relationships of any type may be difficult. In many cases, the effectiveness of the rehabilitation strategy may be only as good as the relationship between the client and the counselor.

Location of Treatment: As mentioned before, real-life expectations can only be experienced in real -life. For most individuals, assessment, training, adjustment, and placement are usually most effective when done in the actual milieu where an individual is ultimately expected to perform. It is unrealistic, however, the expect that all organizations have the ability to work with individuals in their own habitat. But counselors need to be flexible in allowing individuals to have more than one location in which to do their work. For instance, the noise on the work floor may at times be highly disturbing to an individual with a severe mental illness (or even people like us). Are there alternative places for individuals to work on those days when they are experiencing difficulty?

Interventions to Be Used: If you decide to take "Vocational Implications of Psychiatric Disability", you will be introduced to those interventions which are most appropriate and effective with individuals with severe, long term mental illness. When selecting interventions, however, one must consider all of the relevant information available including the client's own preferences.

Emphasis of Treatment: As mentioned before, the identification of treatment objectives is extremely important. The emphasis of the interventions selected may be assessment, job readiness, work adjustment, or job placement. But beyond those broad categories, there may be other emphses which address specific needs of a particular individual. For instance, one of the barriers to employment could be problems with interpersonal relationships. So the emphasis may be one developing interpersonal skills which lead to job readiness.

Nature of the Treatment: This area allows the counselor to get very specific about the type of intervention selected. For instance, the counselor may determine that the best way to help the individual develop good interpersonal skills for the workplace might be by actually having a job. But the individual's current interpersonal skills may be problematic. So it is determined that the individual will participate in Supported Employment with a Job Coach present until a level of interpersonal competency is achieved.

Timing: If an individual is experiencing and acute phase of their disorder, it may not be the appropriate time to begin vocational rehabilitation. Further, many individual's are simply afraid to step back into the work place. It is important that the counselor allow the individual to pursue his re-entry process at this own pace. Some individuals may participate in vocational rehabilitation and not have a successful closure for the first few times. Each time, however, the individual makes some gains. The next time may be the right time.

Medications needed: We will be reviewing some of the medications which are beneficial to people with severe long term mental illness. The counselor should be familiar with the signs that an individual is not taking medications appropriately or may need a change. A return to a more active lifestyle can mean that dosages need to be adjusted or other medications need to be prescribed to help control the side effects the client may be experiencing. The input of someone who sees the individual frequently may be invaluable to the physician.

Adjunct services: Psychiatric rehabilitation is a comprehensive process in which a variety of things happen simultaneously and lead to the eventual reintegration of the individual into a full and productive life. It is a team process involving physicians, counselors, psychologists, social workers, rehabilitation counselors, case managers, family members, and the consumer himself. Each of these individuals offers his/her specialty as one part of the whole effort. Referrals are important, but beyond that, ongoing communication between all the individuals working with the individual raises the chances of achieving the desired outcome.

Prognosis: There is no factor related to diagnosis, number of hospitalizations, or course of illness which has been shown to be predictive of the individual's ability to successfully return to work. There are a variety of techniques and programmatic approaches which seem to be more effective than others in working with individuals with severe, long term mental illness. There are also factors related to the nature of the service provided, the ability of a team to work together, and the characteristics of the counselor which seem to impact the overall outcome of rehabilitation. However, even though the prognosis for a complete cure for a particular condition may be poor, this does not mean that the individual's potential for working successfully is also poor.

Food for Thought:

Using the Mental Status Exam and the DO A CLIENT MAP format, develop a rehabilitation plan for Dottie, Class Case Study. We will focus on this plan in our next Class discussion.