image

Contents

Preface

Acknowledgments

About the Author

Chapter 1 : An Introduction to the Competency-Based Assessment

Perspectives on the Assessment

Overview of the Diagnostic and Statistical Manual of Mental Disorders

Setting the Stage for Competency-Based Assessments

The Competency-Based Assessment

The Partnership With Strengths, Empowerment, and Resilience

Summary

Chapter 2 : Formulating the Competency-Based Assessment: Some Basics

Introduction

Understanding the Case Studies

The Competency-Based Assessment

Formulating the Competency-Based Assessment

The Competency-Based Assessment for Agnes Absinthe

Assessment Guidelines

Summary

Chapter 3 : Disorders in Infancy, Childhood, or Adolescence

Introduction

Overview of the Major Characteristics of the Diagnostic Classifications

Incidence and Prevalence

The Pervasive Developmental Disorders

Beginning With Autistic Disorder

Autistic Disorder

Beginning With Asperger’s Disorder

Asperger’s Disorder

The Attention Deficit and Disruptive Behavior Disorders

Attention Deficit/Hyperactivity Disorder

Tic Disorders

The Elimination Disorders

Other Disorders

Beginning With Selective Mutism

Separation Anxiety

Final Thoughts

Practicing the Competency-Based Assessment

Practical Applications

Appendix : Competency-Based Assessments for Chapter 3 Case Examples: Listing of Case Diagnoses

Case Review for Anthony Moretti

Case Review for Paulie Merkel

Chapter 4 : The Cognitive Disorders: Delirium and Dementia

Introduction

Incidence and Prevalence

Overview of the Major Characteristics of the Diagnostic Classifications

Delirium

Beginning With Dementia

Dementia

Beginning With Amnestic Disorder (Amnesia)

Amnestic Disorder

Final Thoughts

Practicing the Competency-Based Assessment

Practical Applications

Appendix : Competency-Based Assessments for Chapter 4 Case Examples: Listing of Case Diagnoses

Case Review for Myrna Joy Bilbus

Case Review for Mary James

Chapter 5 : The Substance-Related Disorders

Introduction

Incidence and Prevalence

Overview of the Major Characteristics of the Diagnostic Classifications

Adding Diagnostic Specificity

Looking at the Specific Substances

Final Thoughts

Practicing the Competency-Based Assessment

Practical Applications

Appendix : Competency-Based Assessments for Chapter 5 Case Examples: Listing of Case Diagnoses

Case Rewiew for Georgette Turnbull

Case Review for Frankie Singer

Chapter 6 : Schizophrenia and Other Psychotic Disorders

Introduction

Incidence and Prevalence

Overview of Major Symptoms

The Path of Schizophrenia

Paranoid-Type Schizophrenia

Disorganized-Type Schizophrenia

Catatonic-Type Schizophrenia

Undifferentiated-Type Schizophrenia

Residual-Type Schizophrenia

The Other Psychotic Disorders

Final Thoughts

Practicing the Competency-Based Assessment

Practical Applications

Appendix: Competency-Based Assessments for Chapter 6 Case Examples: Listing of Case Diagnoses

Case Review for John Potter

Case Review for Hubert Estevez

Chapter 7 : The Mood Disorders

Introduction

Incidence and Prevalence

Building Blocks for the Mood Disorders

The Depressive Disorders

The Bipolar Disorders

The Other Mood Disorders

Final Thoughts

Practicing the Competency-Based Assessment

Practical Applications

Appendix : Competency-Based Assessments for Chapter 7 Case Examples: Listing of Case Diagnoses

Case Review for L. C. Jones

Case Review for Marilyn Greene

Chapter 8 : Anxiety Disorders

Introduction

Incidence and Prevalence

Overview of the Major Characteristics of the Diagnostic Classifications

Generalized Anxiety Disorder

Panic Disorder

The Phobias

Obsessive-Compulsive Disorder

Posttraumatic Stress Disorder

Final Thoughts

Practicing the Competency-Based Assessment

Practical Applications

Appendix : Competency-Based Assessments for Chapter 8 Case Examples: Listing of Case Diagnoses

Case Review for Marybeth McKenna

Case Review for Tom Donohue

Chapter 9 : Somatoform, Factitious, and Malingering Disorders

Introduction

Incidence and Prevalence

Overview of the Major Characteristics of the Diagnostic Classifications

Somatization Disorder

Conversion Disorder

Pain Disorder

Hypochondriasis

Body Dysmorphic Disorder

Somatoform Disorder Not Otherwise Specified (NOS)

Related Disorders Causing Somatic Complaints: Malingering and Factitious Disorder

Final Thoughts

Practicing the Competency-Based Assessment

Practical Applications

Appendix : Competency-Based Assessments for Chapter 9 Case Examples: Listing of Case Diagnoses

Case Review for James LaDuke

Case Review for June Dwyer

Chapter 10 : The Dissociative Disorders

Introduction

Incidence and Prevalence

Overview of the Major Characteristics of the Dissociative Disorders

The Dissociative Disorders

Final Thoughts

Practicing the Competency-Based Assessment

Practical Applications

Appendix : Competency-Based Assessments for Chapter 10 Case Examples: Listing of Case Diagnoses

Case Review for Christopher Columbo

Case Review for Illeana Rodriquez

Chapter 11 : Eating Disorders

Introduction

Incidence and Prevalence

Overview of Major Symptoms

Anorexia Nervosa

Bulimia Nervosa

Binge-Eating Disorder

Final Thoughts

Practicing the Competency-Based Assessment

Practical Applications

Appendix : Competency-Based Assessments for Chapter 11 Case Examples: Listing of Case Diagnoses

Case Review for Nell Jordan

Case Review for Carlie Walker

Chapter 12 : The Personality Disorders

Introduction

Incidence and Prevalence

Overview of the Major Characteristics of the Personality Disorders

The Cluster A Disorders—Odd and Eccentric

The Cluster B Disorders—Emotional, Dramatic, or Erratic

The Cluster C Disorders—Anxious and Fearful

Final Thoughts

Practicing the Competency-Based Assessment

Practical Applications

Appendix : Competency-Based Assessments for Chapter 12 Case Examples: Listing of Case Diagnoses

Case Review for Melvin Myers

Case Review for Denise McMinville

References

Author Index

Subject Index

image

To my beloved husband,

Kenneth E. Gray, JD

. . . again, again, and now once again.

Preface

INTRODUCTION

An estimated 26.2% of Americans ages 18 and older or about one in four adults will experience a diagnosable mental disorder in a given year making it the most common problem you can expect to encounter in practice (Kessler, Chiu, Demler, & Walters, 2005). For quite some time now, practitioners such as social workers, mental health counselors, marriage and family therapists, and psychologists have been recognized as being primarily responsible for assisting with the provision of mental health services in the United States, including assessment, and this trend is expected to continue (Gray, 2008; Miller, 2002; Newhill & Korr, 2004; Pace, 2008; Thyer & Wodarski, 2007). Beginning with the advent of managed care during the early 1980s and up to the recent health-care legislative initiatives, the different disciplines within the health- and mental health-care fields have been rapidly changing to keep up with the demands of providing effective services to those with major mental illnesses. Efficiency and cost containment dominate the contemporary service delivery landscape and exert a strong influence on the way that care is provided. The effects of this direction are viewed with mixed emotions. For instance, practitioners are now facing the challenges of budget cuts and increased costs while continuing efforts to provide quality care to clients (Cohen, 2003). The exigencies of providing mental health care also influence core professional activities, including how mental health problems are articulated. As the mental health field of practice moves toward more efficient and cost-effective delivery of services, quality care dictates that formal mental health diagnoses be provided (Thyer & Wodarski, 2007). The Diagnostic and Statistical Manual of Mental Disorders or DSM is the primary tool used to make this diagnosis. It contains a language that is universally understood across the professions. This book is about helping the diverse yet similar mental health practitioners become more proficient in formulating a differential diagnosis using the classification system delineated in the DSM while maintaining the century-old practice of acknowledging client strengths and resilience.

Assessment in the field of mental health practice is an ongoing process intended to collect data aimed at fostering the understanding of the individual who requires help in the context of his or her environment (Jordan & Franklin, 2003). Seen as a competency-based assessment, this book offers a constructional approach to the systematic exploration of the multiple factors that play a role in a client’s life. Each person’s unique experience with mental illness is considered and the assessment process focuses on a parallel evaluation of assets and pathology in order to set the stage for realistic optimism about the possibilities for change.

The Diagnostic and Statistical Manual and the Competency-Based Assessment

The Diagnostic and Statistical Manual of Mental Disorders is a publication of the American Psychiatric Association (2000) and commonly referred to as the DSM. Until the next major revision is published, a text revision of the manual, known as the DSM-IV-TR®, was issued in 2000 (American Psychiatric Association, 2000). The DSM lists all mental disorders and includes a detailed description of each diagnostic category along with specific criteria in order to help the practitioner make reliable assessments of mental disorders.

Despite its popularity and consistent use as a resource within the mental health field, there have been a number of long-standing criticisms of the DSM that essentially call for more of an emphasis on the client’s social, situational, and environmental factors (see, for example, Bentall, 2006; Honos-Webb & Lietner, 2001; Widger & Sankes, 2000). A common misconception associated with the DSM is that its classification system tends to classify people and less attention is given to the individual’s unique experience with a particular disorder (APA, 2000).

Although the DSM does pose some problems for professionals, nevertheless it remains as the major format by which the mental disorders are organized. The DSM comes from the medical model; that is, individuals are labeled with an illness. Based on this perspective alone, you might lose sight of the fact that clients have strengths and successes despite a serious mental illness. Although a diagnosis is useful, it can have the effect of diminishing the client as a whole person. Each person’s experience with mental illness is different. Certainly those individuals that we work with have a right to expect and receive services consistent with prevailing practices in the mental health field and related ethical standards (Reamer, 2006). This level of professional accountability includes the need to know how to make an accurate assessment. To remain consistent with this time-honored orientation to practice, this book puts the competency-based assessment together with the DSM to provide a framework for an individualized assessment of human behavior within an ecosystems perspective; one that includes the biological, psychological, and social and environmental including cultural variables in the client’s life (Gray, 2006; 2008). By including the competency-based assessment, the client focus includes a simultaneous understanding of both problems and resources. Obstacles are often in the “eye of the beholder.” What may initially be perceived as an obstacle may actually be a positive feature if reframed. The competency-based assessment shifts the assessment away from a dysfunctional conceptualization of problems to include the more helpful instrumental aspects of the person’s life.

Mental health practitioners have a unique role in the assessment and diagnostic process (Pace, 2008). Each profession maintains a distinctive philosophical orientation to practice, but they come together around how to use the diagnostic assessment system found in the DSM (Dziegielewski, 1998; 2002). By offering a common language, communication among practitioners in the mental health field is facilitated by using the diagnostic classification system outlined in the DSM. The DSM is considered as the gold standard for assessments and offers the most comprehensive explanation of diagnostic categories. It is also the language of insurance companies and other funding sources. In order to be effective in today’s current practice environment, you need to know and be able to appropriately utilize this assessment tool.

The competency-based assessment offers a number of advantages to the assessment process. As many of us already know, most clients typically pursue a variety of other options before seeking professional help. They may try to solve problems on their own or look to family and friends for help. Without a doubt the decision about receiving assistance is not always an easy one. In fact, some individuals are mandated to accept our services; for example, state legislation that requires intervention when someone is severely depressed and thinking about suicide. We do not always have the opportunity to see people at their best. In these instances, the person’s expectations about what will happen to them and how they will be evaluated will influence the assessment process. In addition, the extent to which the goals, expectations, and values of the practitioner match those of his or her client will also play a role in the assessment process. The competency-based assessment provides the foundation for a clear description of presenting concerns and related factors along with the identification of personal assets that will more than likely make the assessment process of value to clients (and their families) and ultimately enhance participation and involvement.

A unique feature of the DSM is its multiaxial system for evaluation. This fits well with the competency-based assessment where the multiple factors in the client’s life are examined. By merging the competency-based assessment with the DSM, the diagnostic assessment becomes a process that focuses on client strengths, coping capacities, and those environmental stressors that can exert an influence over the debilitated patterns of relating and behaving. This broad-based approach to assessment is not intended to replace the DSM but to help balance the tensions inherent in formulating a diagnosis. The competency-based assessment complements the DSM’s classification system and offers a structure that incorporates a strengths-based perspective. Alex Gitterman, a noted social work educator, observes that the competency-based perspective “views mental illness through theoretical lenses that attempt to move away from treating a ‘disease’ to capturing people’s unique experiences with mental illness . . . a person is much more than her or his diagnosis” (Gray, 2006, pp. vii–viii).

THE BOOK’S ORGANIZATION

This book presents a brief overview of the major mental disorders that you will likely encounter in your work with clients followed by a series of case studies and practical applications. This is intended to set the stage for connecting the competency-based assessment with the diagnostic classification system outlined in the DSM and provide opportunities to practice your assessment skills. To help you to ascertain the accuracy of your skills, the specific competency-based assessment and the DSM multiaxial classification for each case study are included at the end of each chapter.

You may not always agree with my assessments and the proposed diagnoses should not be seen as infallible. Instead, I hope that the cases will familiarize you with the terminology found in the DSM and stimulate your critical thinking around the assessment process. The cases are drawn from my clinical practice experience and from working with supervisors, students, and fellow colleagues in the field. These experiences bring to life the reality that diverse populations can be affected by mental illness and this shows up in the book’s discussion. The identities of the clients presented have been disguised to protect confidentiality. Details such as the client’s name, occupation, locale, and/or age have also been altered. You will find the case studies, along with the practical applications, to be educational and also fun to read.

The first chapter introduces the competency-based assessment and the major features of the multiaxial classification system found in the DSM. The competency-based perspective provides a strengths-based lens for assessment in the field of mental health and is not driven by any one particular theoretical orientation. This integrative approach complements the practice orientations of various mental health professionals.

The second chapter discusses strategies for reading the case studies. Included is a pictorial representation featuring the biological, psychological, and social factors in the client’s life. This visual summary is intended to serve as a pedagogical tool to help you practice integrating the competency-based assessment with the DSM when diagnosing mental illness in the subsequent chapters.

Chapters 3 through 12 are organized around selected diagnostic categories found in the DSM-IV-TR but there are some omissions. This was done to provide a more extensive review of the mental disorders that you will typically encounter in your clinical practice. Each chapter begins with an overview of a specific disorder followed by a conceptual map that serves as a way to systematically outline the diagnostic features of a specific classification. This map provides a reference point for formulating your differential assessment for each of the case studies. These cases are not listed in any particular order so you will have the opportunity to practice sorting through diagnostic criteria in order to arrive at an accurate assessment.

At the end of each chapter, you will also find a series of practical applications intended to sensitize you to the practicalities of formulating a differential diagnosis. Following Bloom’s (1956) cognitive taxonomy, some of the activities will tap into beginning levels of knowledge about the different disorders. Others will speak to the advanced levels of synthesis and evaluation. That is, they will provide a series of activities ranging from knowing the signs and symptoms of a particular disorder to the more advanced levels of being able to think critically about the specific diagnostic categories. To illustrate knowledge of a specific diagnostic category, for example, you might be asked to determine when the symptoms supporting the presence of a specific disorder become evident in one of the case studies. You might also be asked to consider if there are behaviors that may warrant another diagnosis or if there is enough evidence to support a provisional diagnosis.

To use the book effectively, you need to be familiar with the knowledge and values that guide professionally accountable practices, be attuned to the information in the DSM, and be willing to critique your work. The intent of this book is to provide opportunities to think about and practice formulating an assessment. A key advantage is that this takes place with case illustrations of actual situations rather than experimenting on a real client. Hopefully you will be more comfortable making mistakes and then applying this new learning to actual practice situations. Each chapter focusing on a particular diagnostic classification is designed to be freestanding and autonomous. When using this book, it is helpful to keep in mind that it is organized to be practical and hands on. The conceptual map provided for each clinical disorder helps you to formulate a differential diagnosis and also to prepare for tests in courses related to psychopathology or human growth and development. In addition, the map is a useful tool as you study for credentialing tests after graduation such as licensure exams or certification.

LOOKING TO OUR OWN COMPETENCIES

The book’s organization supports a competency orientation to education. Many professions have generated a list of competencies or measurable practice behaviors that encompass the essential knowledge, values, and skills that define that profession. Although this has been the norm in medicine, dentistry, and nursing, it can now be seen in the counseling professions. For example, the Council on Social Work Education revised its Educational Policy and Accreditation Standards (EPAS) in 2008 to move away from content-based curriculum requirements to a competency-focused curriculum (Council on Social Work Education, 2008). Another example can be found in the work of the American Association for Marriage and Family Therapy (AAMFT) that established a set of core competencies where practitioners can now clearly define what marriage and family therapists should be able to accomplish in their work with clients (Nelson et al., 2007).

The emphasis on competencies has changed how we teach professional skills by shifting the curricular focus to what we do in practice or an outcomes performance orientation. Educators are challenged to answer the question, “What do our students need to be able to do or to know at the end of their educational program?” Sternberg et al. (2000) described competencies in the language of tacit knowledge where they are distinguished as action-oriented, have a value base made up of beliefs and ideas, are cognitive and technical with both know-how and skill, and have a social dimension, which is comprised of working with others. This perspective makes a case for educational practices that link theory and action (Saleebey & Scanlon, 2005). Learning is no longer considered to be a passive activity where students memorize or analyze information but involves applying ideas to real-life situations. Academic coursework becomes the foundation for real-world skills. This book, with its emphasis on practicing the assessment situated in real-life case examples, supports this orientation.

PROPOSED MARKET

It is anticipated that this book will be a resource for practitioners with different levels of professional development ranging from students in graduate social work, mental health counseling, marriage and family therapy, or psychology programs to experienced practitioners and clinical supervisors. It is hoped that the case studies and practical applications will stimulate thinking whether they are assigned as a part of specific course work or to foster discussion between supervisors and their supervisees. The case examples are drawn from actual practice so they provide realistic opportunities to prepare for the realities of the assessment process. Through the drama found in a real client’s story, the cases are intended to make the content come alive and hold your interest in what can be seen as boring and abstract material. You will find the diversity that characterizes contemporary mental health practice illustrated in a number of these case studies. Additionally, instructors and supervisors may ask you to complete the book’s practice applications as part of a homework assignment, to supplement lectures, or to provide evidence of your understanding of the assessment process in practice. Some of the professional jargon will be demystified through the book’s straightforward and readable style.

This book can be used as a primary or supplementary text in a range of courses such as psychopathology, direct practice methods, and human growth and development. The practice applications can be used to stimulate discussion in related courses about counseling theories and methods, ethics, or social policy. The book can also be used by educators in the field practicum experience who prepare student interns for working with clients. Professionals who want to refresh their diagnostic skills or have moved into the field of mental health from another practice specialty may also find the book a useful resource tool.

Acknowledgments

As the work on this book comes to a close and I look back on what has been accomplished, I realize that none of this could have been possible without the encouragement of so many who have been behind the scenes throughout this process. I take this opportunity to thank each and every one of you for your help over the past year and a half. The idea for this book came from listening to my students’ struggles to apply abstract and complicated concepts about psychopathology to their work with real clients. Thank you for this inspiration. You have reminded me that learning the basic information necessary to assess clients is no easy task and assigning a diagnosis to someone can be intimidating. You kept me in the real world of practice when you brought your tough cases to our forum discussions in the classroom. I hope that I heard all of your concerns and translated them into this book. The successes and challenges that you uncovered in your work with clients led me to the competency-based assessment.

I will miss my first editor, Lisa Gebo, who took a medical leave shortly after I came on board with John Wiley & Sons, Inc. Regretfully, she died after a long struggle with cancer. Rachel Livsey gracefully stepped into the picture as my new senior editor. Her commitment to this project was clearly evident by her excellent suggestions and attention to detail. She was easy to work with, extremely supportive, and always available. In addition, her wry sense of humor added a lighthearted touch to our work. I still smile when I remember our conversations at length about the length of the manuscript. I would also like to acknowledge Peggy Alexander’s hands-on efforts to keep the work moving forward until Rachel came aboard. I would like to thank Kara Borbely, senior editorial assistant, for managing the myriad details of the manuscript and seeing it through the publication process. I know there are a number of people who worked behind the scenes with her to make this book a reality such as Kate Lindsay, senior production editor, Rose Sullivan, senior production manager, and Marilyn Matos, production assistant. I hope you all know how much I appreciate your efforts.

I value the comments of the reviewers who took the time to look over the preliminary manuscript. You offered extremely helpful feedback and suggestions. I would especially like to acknowledge Agathi Glezakos, PhD, full-time lecturer, California State University, Long Beach, in the Department of Social Work who provided detailed and comprehensive feedback. I would also like to recognize the contributions from the remaining reviewers from the other universities around the country whose keen observations clearly reflected their interest in this book: Jeffrey S. Bedwell, PhD, University of Central Florida; Robin Bonifas, PhD, Arizona State University; Kurt Organista, PhD, University of California, Berkeley.

I would like to acknowledge my former dean, Debra McPhee, and the current interim acting dean, Phyllis Scott. Both promote the kind of organizational climate where efforts like this can be accomplished. I appreciate the assistance of my former doctoral student and now colleague Janet Courtney, and master’s graduate student Tamika Strachan. Both helped in the early stages of the manuscript. Robert Nolan, a recognized agency director who specializes in working with children, contributed valuable remarks on the chapter devoted to the disorders in infancy, childhood, and adolescence.

Ultimately, I would like to tell my husband, Kenneth, how much I appreciate him. His confidence in me is very special. He has seen me through the writing of several books and still does not seem to mind when we turn down an invitation to socialize with friends because I have work to do. Nor does he mind when we have dinner at late hours or grab some fast food instead of a delicious home-cooked dinner. Although he claims to know nothing about my profession as a social worker, he always manages to find the right thing to say when I’m stuck and somehow manages to find words of encouragement when I find myself having so much to do and in so little time. Once again, I want him to know how grateful I am for his continuing love, patience, and support. His faith in me is a constant.

About the Author

Dr. Susan W. Gray is a professor in the School of Social Work at Barry University, Miami Shores, Florida. She has doctoral degrees in social work and education. Having taught and supervised students for 30 years, she is known as an energetic, fun, and yet challenging instructor. In addition to her current text, she co-authored Psychopathology: A Competency-Based Assessment Model for Social Workers, now in its second edition, and co-authored Psychopathology: A Competency-Based Treatment Model for Social Workers. Her most recent contribution includes Advanced Social Work Practice in Clinical Social Work for the Council on Social Work Education, delineating advanced practice level standards for the 2008 Educational Policy and Accreditation Standards. She has also written extensively on clinical supervision, professional regulation and licensure, rural practice, bereavement groups, intergenerational family assessment tools, the brief solution-focused model of practice, methods of classroom teaching, and aspects of cultural diversity. She is an active leader in state and national professional organizations. Additionally, she is involved in the professional community and continues her work with a community mental health center, hospice, nursing association, senior citizens foundation, marine institute, and the Florida Keys Area Health Education Center. Recognized as an engaging and informative speaker, she has presented numerous papers and workshops at the local, state, national, and international levels.