Mental health counselling or clinical counselling is a practice in psychology that helps relieve psychological disorders or distress by promoting personal development. It also practices psychotherapy, consultation, forensic investigation specifically forensic testimony, formulation, implementation and evaluation of plans and programs for the treatment of psychological dysfunction and research. Because of the nature of this field, it is usually monitored as a mental health profession.
Mental health counselling has its roots from the later part of 19th century. And as the field of psychology grew, branches began to develop, among them is counselling psychology and clinical counselling- both are useful in mental health assessment and counselling.
While closely associated with clinical psychology, there are still marked differences between the two practices.
For one, counselling psychology is used by psychotherapist and counsellors to help patients with milder psychopathological concerns. On the other hand, clinical counselling deals with more severe and advanced forms of psychological disorders such as schizophrenia and psychosomatic disorders. Examples of disorders that could be treated by counselling psychology are the stress-related disorders. In essence, these are just minor mental health illness that requires very little (if there is any) medical interventions.
This method tries to address minor psychological concerns and make use of counselling techniques. This is possible since patients subjected under this method are still in control of their mind. For example, people who are distressed due to problematic circumstances could seek the professionals who could render counselling psychology.
Counselling psychology focuses more on the personal problems of the person that hamper his mental health. It helps him resolve problems by using non-directive methods, therefore a counselling psychologist would only open options that will help resolve the problem without being suggestive or authoritative. Also, counselling psychology is more focused on rational thinking instead of unconscious functioning.
The second difference is that counselling psychology adheres to a humanistic or person-centred approach. Third, it has a different view on the developmental problems associated with mental disorders.
On the other hand, clinical psychology deals more on severe psychological disorders such as clinical manic depression like unipolar and bipolar disorders, sexual dysfunctions such as exhibitionism, fetishism and sadism, phobias, traumas and substance-abuse or dependency.
Because of a more comprehensive and intensive nature of this field, clinical counselling makes use of psychological assessment tools that further confirm the symptoms of disorders among people with disrupted mental health. The mental health assessment is a medium for evaluating symptoms that a person presents. This gives insights to mental health professionals that will guide them in the preparation, administration and evaluation of treatment methods that are apt to the mental health needs of a patient. The process of assessment requires the use of interviews, physical examinations and clinical observations. Also, assessment tools such as intelligence, symptoms questionnaires, personality and neuropsychological tests are widely used. All these contribute significantly to the diagnostic impressions that will be formulated after all data are collected and studied.
Despite these differences, counselling psychology and clinical counselling are proven to be very effective as mental health counselling methods. Both advocates the use of talk treatment that could either help resolve the problem for the mental health patient or open up indications that may be pointed out as causes of the development of the disorder. In effect, both types of counselling make mental health therapy and recovery feasible.
We all know that exercise promotes healthier body and better sense of well-being. It boosts confidence for people who need newer self image while it prevents the aggravation of physical illnesses for some. While nearly all of the research on exercise is focused on demonstrating positive effects on the physical body, there is a growing mass of research that seeks to prove that exercise is good for mental health as well.
A study conducted by the researchers from the Duke University along with other similar studies proved that exercise could help treat depression for 60% of all the participants. This result is similar with the total number of participants who are using medications for their treatment from depression.
However, you don’t have to be a sufferer of a mental illness before you benefit from exercise. You can boost your sense of well-being while walking on the treadmill or by combining yoga and meditation. In a way, exercise could be used as a potential medium for preventing the development of psychological and emotional conditions.
There are three dimensions at which we could look at when examining the benefits of exercise in the mental wellness of a person. Among the less well known is the biological aspect.
One theory suggests that physical workout or exercise could stimulate a part of the brain to release endorphins. Activities that are more likely to trigger the release of endorphins are swimming, cross-country skiing, running, bicycling, aerobics and sports like soccer, football and basketball.
Endorphins are comparable to opiates in a way that they resemble morphine. Endorphins could work in two ways- as a pain reliever (which is produced in response to the stresses brought about by physical work or stress) and as an enhancer of well-being. There are, however, no definite data that could support this claim.
On the other hand, exercise is also found to trigger the release of hormones norepinephrine, dopamine and serotonin. All these are known to help improve mood and is actually the main effect of Prozac, a known antidepressant.
Increase in these hormones could be best observed in a condition known as “runner’s high”. This feeling during after an acute exercise is directly linked to the increased number of the said hormones. However, there are still no conclusive studies proving that improvements on mood could be facilitated for a longer period of time.
Another is the physiological aspect. Nearly all of the feelings we associate with mental wellness come from our personal evaluation of the way our body feels. Say for instance, if you perceive a stomach pain as a form of stress then you will feel stressed (and sometimes even depression) every time your stomach aches. Likewise, exercise could render feelings such as muscle relaxation and easier breathing which we associate with “feeling better”. While this correlation is yet to have a better scientific grounding, we still could not deny the fact that muscle tension and increased blood flow go together with physical fitness.
No one knows yet how exactly exercise affects mental health. But it is common among patients to view exercise as a good medium to elevate their moods. In fact, according to a survey conducted by the Charity Mind nearly two-thirds of all people who said that they use exercise to relieve symptoms of stress and depression believe that exercise actually works for them. The scientific community is yet to understand how this happens though and for now, it remains a truth that people benefit from exercise for mental health.
With extreme emotional issues, we often have no problem deciding whether we need to see a counsellor or not; however, with a slight discomfort, a few bad days, we can’t always make that decision. Ask yourself the following questions and truthfully answer yes or no.
*Do you get honest satisfaction from simple pleasures?
*Do you have respect for yourself?
*Can you laugh at your own errors?
*Do you feel capable of dealing with situations as they come your way?
* Can you accept displays of your own emotions – fear, anger, jealousy, guilt, worry?
* Do you have personal relationships that are satisfying and lasting?
* Do you trust others and assume that others will trust you?
* Do you respect people who differ from you?
* Do you refuse to be pushed around and refuse satisfaction from it?
* Can you feel you are a part of a group?
* Are you able to love somebody?
* Do you accept as much responsibility as comes your way?
* Do you make your own decisions?
* Do you deal with your problems as they arise?
* Do you shape your environment whenever possible and adjust to it whenever necessary?
Count up the number of no answers. If you don’t have any, you are exceptional. A couple of no answers is normal and is absolutely nothing to be concerned about. If, however, you answered no to more than five questions, there is a good chance you could benefit from some type of counselling to help get you back on track.
The fact you are able to take this test is a good indicator that, with the proper counselling, you will be fine. Just don’t let it go until more answers turn to no. You deserve enjoying the best mental health possible. Don’t neglect it.
Elderly people respond to mental health differently than younger people. They are prone to developing more psychological disorders and can cope less effectively with triggering factors of mental impairments.
Retiring could be one of the most enjoyable but dreaded years in the life of a person. Anybody who no longer has definite roles to take apart from being an older member of the society begins to question their own importance, sometimes even existence. Since a retired person no longer holds a job, he is free to use his time on any activity he chooses. The problem though is that he cannot establish a certain activity that would make a life for him enjoyable for the rest of his life. He also feels that he is no longer important since his children who used to depend on him have already taken up their own lives, sometimes living him without company.
In most cases, people who are old are alone. They sulk into life without purpose, without direction, without the sense of worth. Slowly, they will have experiences that would negatively affect their mental health. They then become depressed, lonely and more prone to developing psychological disorders. Since society gives too little importance to elderly people, it tends to disregard them. Until they become debilitated enough due to sickness, disorders and old age that the society begins to notice them. But then, by that time, it is already too late.
The usual life of the elderly is marked by the lack of support that will introduce them to activities that will revitalize their lives. They can no longer put up with their old activities since their bodies, by nature, are deteriorated enough to hinder them from moving and performing as they did before. However, old age should not always be like this. Old people should try to look for newer activities in their lives that would make the rest of their days enjoyable and worthwhile.
They say “you cannot teach old dog new tricks”. This is a myth. An old person who is willing to learn will learn by all means regardless if his body or his mind limits him. Here are some of the hobbies that an elderly could do to increase his mental health:
For some people, the mere fact that they are thinking and can still conceptualize thoughts drive them to be crazy about life. It is never too late to learn to write and for people who used to enjoy writing during their younger years, it is never too late to bring back their attitude towards literature.
Reading could also be a fun activity that would easily let the time pass. Old people who enjoy reading are apparently happier than those who sat idly on their couches throughout the day.
Your fingers may not have the same dexterity they had when you were younger but this doesn’t mean that you can no longer enjoy music. You can learn to play music instruments. The piano, for example, requires too little energy output but the internal satisfaction it provides is high. Also, listening to music could make you think of familiar thoughts that would drive you through the memory lane. This would allow you to meditate on your life. For most people, knowing the fact that they have lived their life will make them satisfied and at peace with themselves. Internal peace is central to achieving the right balance in life.
Did you enjoy gardening as a kid or collecting things as a teenager? You can bring back those old hobbies. After all, you already have enough investments in the past that it would no longer be hard for you to start again.
It is often the case of losing the zest for life when one gets old. But through regaining your appetite for life through hobbies for elderly, you might find again that life is worth living for.
Alzheimers affects that part of brain that control thought, memory, and language, it is one of the most common form of Dementia (destruction of brain cells to cause decline in mental functions)but later it spreads to all regions of brain rendering it ineffective. The onset of Alzheimer slowly progresses and alters personality and behaviour.
In most cases anxiety, suspiciousness or agitation, as well as delusions or hallucinations are observed to be the few changes that is caused by the disease. Memory and thinking process are marred in the initial stages of Alzheimer. It is one of the rising causes of death in elderlies, as patients diagnosed for this disease barely survive more than six years. But the duration of the disease vary between three to twenty years.
There is no permanent cure for the disease so far but effective care and support can help improve condition in the tenure of diagnosis to death. However, the condition can be avoided if healthy ageing takes place in an individual. It also helps to reduce the risk of Alzheimer. The few best measure to ensure healthy ageing involves constant check on cholesterol, blood pressure, weight, stress reduction, socially active lifestyle and regular exercise for body and mind.
Unfortunately it takes longer to diagnose the disease as the brain damage starts much before the symptoms appear. By the time symptoms are visible nerve cells are already degenerated and extinct. The symptoms of disease vary but the first thing one notices is the loss of memory that starts interfering and affecting the regular life of an individual. Apart from this other noticeable changes are confusion and disassociation with the language and fumbling in familiar surroundings.
The first sign noticed should be communicated to family or physician so that it can be identified early and the treatment is started without any further delay. Though there are no particular medical examination to conclude the disease but various tests (including physical and mental) and reviews from family and friend can benefit in diagnosis of the condition. Depression, hormonal changes such as thyroid and side effect of medication act catalyst for those who suffer from the disease and also makes prone to those who don’t. Excessive drinking, unhealthy lifestyle and improper diet can also propel Dementia.
There are medication available to delay the process of brain cell degeneration but they are not known to curb or stop the process altogether. Thus it just slows down the process rather than eliminating the danger of the disease. However, improving quality of life by subtle understanding, care and altering the surrounding can tremendously help the patients suffering from Alzheimer.
The ongoing research in the field of Alzheimer is concentrated on reversal of nerve and brain cell damage. And also to further stop and reduce the degenerative condition in an individual. They are also working on the strategy to optimise the delay of disease and the role of cardiovascular and other health condition to affect the condition.
Those having a family history are more prone to the disease as the genetic makeup makes them more pronounced to be at the risk. More researches have brought forth the theory of plaques and tangles in brain tissue this considered to be more definitive way to diagnose the disease other than this brain scan is followed by tests of urine, blood and spinal fluid. It has also come to light that non-steroidal drugs can help slow the progression of Alzheimer. Vitamin E acts as an antioxidant and is known to slow the progress. The hormone estrogen is also known to ease the condition.
The Alzheimer’s Association has been formed with the intention to share, educate and strengthen the caregiver and family members of Alzheimer patients.
The fear of traveling is the common definition of agoraphobia. This can be a serious condition in which a person isn’t able to leave the home at all or it can be a mild disorder in which a person can’t travel more than a few hours away from home. When a person attempts to go beyond what is considered their “safe” boundaries then they go into an agoraphobia panic attack.
Starting by taking baby steps is the best way a person can slow their agoraphobia panic attacks. In order to finally master their fears the individual must set specific goals to overcome their panic attacks. Family and friends are the best people to help a person through this process.
To the sufferers themselves an agoraphobia panic attack is very frustrating. This is because an agoraphobic attack is often less rational than the typical panic attacks.
A fear of public places, especially those where there is a large gathering of people such as a grocery store can develop from a social anxiety. An individual who suffers from general panic disorders can become embarrassed of their disorder, which can then cause a fear of traveling and suffering a panic attack in public.
The only way for a person to overcome these attacks is to push their limits, which makes treatment of agoraphobia panic attack difficult. Before getting better many agoraphobics tend to get worse for this reason. Since all an individual has to do is stay within their “safe” zone they tend to ignore their agoraphobic problem. However, while the problem can be easy to ignore it is a stifling symptom that comes from a chronic panic disorder.
Little by little, agoraphobia can be overcome. It takes time and a lot of patience. This is one time the person with this disorder must learn to turn to someone trusted to help them through.
The advantage of using your phone as part of your kit is that it’s the one item you’re likely to have with you wherever you are. Create a folder of meditation apps, such as Calm, Insight, Buddhify and Headspace, so if you need to take a few minutes to calm your mind or nerves you can listen to a guided meditation. There are also apps that prompt you to think about what you’re thankful for, such as What’s Good.
Why not put together a comfort playlist of favourite tunes that lift your spirits, improve your mood and energise you? It doesn’t matter how uncool your selection is, no one else need listen to it. Or compile a selection that feels soothing and restful, in case that’s what helps at a particular moment.
Most phones have a voice memo app where you can record yourself talking. Perhaps record a message to play to yourself when you’re feeling particularly anxious, upset or low.
Most people’s phones are filled with photos (which they rarely get round to printing) so put together a digital album that makes you smile. It could include photos of your family, friends and beloved pets, occasions that remind you of happy memories or scenes that uplift you.
Essential oils can be a speedy solution because when you inhale the scent it goes straight to your limbic system, which affects your emotion and memory. That’s why sometimes all it takes is a whiff of a smell instantly to change your mood and bring back memories. It’s well known that chamomile and lavender are calming and soothing (although it’s worth remembering that more lavender than you need can have the opposite effect), grapefruit is uplifting and peppermint refreshing. Keep a little bottle handy to inhale when required or choose a roll-on such as Tisserand’s Head Clear or De-Stress, or Neal’s Yard Remedies’ Energy or Relaxation. These blends can be rubbed on to your pulse points and they’re small enough to fit in a pocket.
When you’re struggling mentally, a list of actions that you can choose from to help yourself can be useful. Write them down and keep them somewhere handy, like your desk drawer or bag. Or save them as a note on your phone so you can access them anywhere, any time.
What you write on the list is personal to you – what would make you feel better when you’re having a tough day? Maybe going for a walk, listening to your comfort playlist or phoning a friend, or more restful suggestions like taking a nap, reading a chapter of your book or meditating.
It’s worth noting down some basic ideas too – drinking a glass of water, making a cup of tea, eating something nourishing or taking a few deep breaths in and out may seem obvious, but it’s easy to forget the importance of such simple actions to wellbeing.
There could be any number of reasons why you feel the need to dive into your mental health first aid kit, but whatever’s going on inside your head, taking it out of your brain and putting it down on a piece of paper can help. Whether that’s as a stream of consciousness, a to-do list of everything you’re trying to remember or reasons for and against an argument, writing it in a notebook can ease the burden.
Focusing on the good things around you can also be useful. Take a few minutes to jot down what you appreciate in your life, what you feel grateful for and what makes you smile. This enables your brain to think of the positives rather than the negatives (it can’t do both at once), giving you a break from stress. And having them written down means that on another occasion you can flick back and recall positive moments.
Whatever else you choose to add to your kit – a quotation you find inspiring, a nourishing snack, something to read or even a puzzle – remember you can add to it or swap things in and out depending on how you feel and what you need at the time. What matters is now you have something to make those stressful situations that little bit easier.
The relationship between narcissism and evil is often on the table for discussion in my field of work. We all have our own vision of what “evil” looks like; it is often imagined as a dark, scary looking, demonic looking individual or “non-person” who has the power to take human life, torture and hurt people without a conscience.
According to Scott Peck, author of “People of the Lie,” there is no psychological term for what he considers the “disease” of “evil.” Peck asks the question “ is evil a disease?” His only purpose for wanting to put “evil” in a disease category is so that science would study it. Peck talks about how “evil” is more the department of the church then psychology. The best psychological term Peck could come up with for “evil” was “Malignant Narcissism.”
Keep in mind the word “Narcissism” in itself includes a personality trait that we all have to some degree, and this includes children who typically pass through a narcissistic stage on their way to maturity. People can be narcissistic without being a malignant narcissist. Some of us need to develop more “narcissism,” which would include healthy self-love and confidence.
Malignant Narcissism is in a category of its own. It has nothing to do with healthy self-love or confidence. It is pure selfishness, complete lack of compassion and empathy, and deriving pleasure in seeing others suffer. These are qualities that cause an individual with malignant narcissism to be a destructive force in the lives of those who love them.
Peck concludes that evil is a destructive force in the Universe, where the opposite force, “love,” is a creative force. Evil spelled backwards is “live.” It lacks “liveliness.” There is death and destruction, if not actually, at least symbolically with the force of “evil.”
People who are close to those who are “evil” usually experience a depletion of their life force. It is as if the malignant narcissistic force is also a highly vampiric force and plugs into the energy of others to sustain them. They also easily sacrifice others to maintain their own narcissistic self-image. Peck gives several examples in “People of the Lie” of clients who were either “Evil” or had “evil” parents or partners, or were bordering becoming evil as a way to avoid their own pain. It is a very enlightening book and a recommended read.
Evil is a strong term and many people are uncomfortable using it as a way of referring to a loved one. It can be very difficult to see someone close to us as being evil. It is difficult to realise we have been living with evil or have had our life force hijacked by it. We often have images of a red horned devil or white eyed monster who want to kill us.
The majority of “evil” people don’t literally kill the physical body. They work to kill the soul, the essence of a person. Many of my clients who have been in relationships with narcissists describe themselves as a shell of the person they used to be. They have lost their energy, their soul, their creativity and passion for life. They even lose their will to live. It is not uncommon that people who commit suicide are victims of malignant narcissists. Not only do they lose their will to live, but there just isn’t enough knowledge in the Psychology profession of the depth of damage that is done by someone who has malignant narcissism. Psychology learns the definition of narcissistic personality disorder and even how to diagnose it in others, but they don’t learn the connection between narcissistic personality disorder and evil.
There is a psychological/spiritual connection that is not often studied or understood. We often think that the person who is “suffering” a disorder is the one who is “suffering.” People with NPD don’t themselves suffer. They inflict suffering upon others and often gain a great deal of pleasure doing so. Now this is evil.
Your garden variety narcissist may be a little full of himself. Have a big ego, be on the selfish side and overly concerned with the image presented to others. He may do damage through his ignorance and through being oblivious, but he doesn’t gain any pleasure from inflicting pain on others. These kinds of people can do damage however, because there can still be a lack of empathy and ability to walk a mile in another’s shoes. Would I define a milder form of narcissism as evil? Well it depends.
One needs to evaluate evil in terms of the qualities of destructiveness, lack of ability to feel and give authentic love, and the damage a person does to the psyche of another.
Peck tells us that the primary quality behind evil is deception. Evil people present a false front to the world and hide behind the image they present. Often the image is of a hardworking, good looking, well dressed, clean, successful and even caring individual. We don’t often glimpse behind the façade to see the vacancy of the soul within the person. It is all smoke and mirrors, lies and false fronts. As I said earlier, a malignant narcissist will easily sacrifice a “loved one” in order to preserve the false front they are so vested in holding up. If that “front” is threatened to be exposed, they will throw the threat under a bus and walk away without conscience.
Peck tells us, from his research, that evil can be hard to spot, even by the person who is being affected by it. When evil walks around looking “normal” we never see it for what it is. If evil was easy to spot in others, it would have no power in the world. It is through the deception that evil has power.
If evil itself has an intention, what would it be? I imagine it would be to get loving hearts to hate, to be angry, to be confused, and to get sidetracked from any kind of positive mission they may have previously been aligned with.
In my experience with narcissistic abuse, most people who are forced to go “no contact” or “limited contact” with a narcissist are very angry, hateful, confused and lost. Not only have they lost most of their life force energy, they have separated from their own “goodness.” This is done when the victim of evil becomes lost in darkness as a result of the vampirism and deception. I help my clients to come to terms with their feelings, because suppressing our “dark emotions” prevents us from healing. We have to find healthy ways to express our pain, our rage, our anger and feelings of injustice and eventually get back to the “love.”
When we love someone who is “evil” we often put our hearts in the hands of someone who will not only break them, but continue to trample on them over and over again. The more “evil” can torture a once loving heart, the less its ability to love. Mission accomplished.
In some ways, I suppose my mission in life is to be a warrior for the heart, to help people remember their own ability to love, beginning with loving the Self. If we can start with offering ourselves kindness, compassion, care and support, we can rebuild our life force and our hearts. We don’t want to let evil “win” by separating us from our own ability to love and be kind to others.
As a counsellor for narcissistic abuse victims, I have seen some pretty angry and hostile victims who, because they are hurting, feel justified in hurting others. They often avoid responsibility and because they see themselves as “victims” they feel justified in their careless behaviour.
We have to ask ourselves, at what point does a victim of evil begin to cross the line to becoming evil themselves? At what point do victims of malignant narcissism become narcissistic themselves? It is entirely possible. Children of narcissists will usually become either Co-dependent or narcissistic. One child may model their parent’s narcissism where another sibling will oppose it and Co-dependently try to extract love where there is none. The sibling who becomes narcissistic, gives up on ever getting love and settles for power instead.
If you were to evaluate the war of good versus evil happening on our planet, wouldn’t it make sense that if evil people were successful at creating more evil people, evil would grow in the world and the mission of evil would gain power?
What if evil was actually a force that possessed people who were vulnerable in some way? What if evil were a force that separated people from their own goodness?
If we truly wanted to heal, and bring more love to the world, we have to start by not only bringing more love to ourselves, but learn how to approach the abuse we have suffered with love rather than fear.
It is fear that takes root in the hearts and minds of man, that gives the evil force an “in.” Fear of annihilation may cause one to try and annihilate others. Fear of not being “good enough” may cause a person to try and make others feel inferior. Fear of being hurt may cause a person to hurt others. Fear of being exposed may cause one to paint others in a bad light. Fear of losing control over one’s environment may cause him/her to manipulate and control others.
The opposite of love is not hate, it is fear! So when you have two choices, love or fear, make the conscious choice to align with love rather than fear. It is a lot of work to bring love to a dark situation.
Peck tells us that the antidote for evil is not hatred, or war, but love. We need to learn to love thy enemy. That doesn’t mean to live with or have that person in our lives, but to cut the psychic cords of attachment to the evil doer by loving oneself enough to break away, and find a way to love the other, from a distance. Instead of wishing for the demise of our enemy, we could pray for their healing; that they see the light. We don’t have to be attached to what actually happens with this person. We are not praying for their healing so that we can have a great partner, or great parents. We pray as a way of releasing ourselves from our own hatred and anger towards that person. When we hold on to hatred and anger towards another person, it becomes a psychic cord, keeping us tied to that person.
Loving in the face of the worse cruelty and carelessness at the hands of our enemy is to set us free, not the enemy. Our enemies must suffer the karmic consequences of their own behaviour. What we put out into the world will come back to us tenfold. This is why we don’t want to put more hatred into the world. It doesn’t mean that initially we won’t feel hatred. We very well may, and this is okay. It is not the feeling itself that is the problem. It is the holding on of the feeling that causes long term issues. Suppressing our feelings is even worse because we end up acting out subconsciously that which we are harbouring within. We must be willing to allow those painful emotions to come to the surface, deal with them, and release them. The ultimate goal is to return to love.
“Uninvited Guest” is a short poem by Vicky from Family Friend Poems that captures the depths of depression and the helplessness one may feel when consumed by mental illness. Yet, through the darkness, the writer holds onto a glimmer of hope at the end of the piece. The author explains that “anyone who has suffered from depression will understand… I urge you to fight. There IS a light at the end of the tunnel”.
Feel broken down, my body aches
My heart it bleeds from past mistakes
Can’t stop the tears, they fall like rain
The words are spinning ’round my brain
So scared and feeling so alone
The coldness fills my every bone
No food, no sleep, can’t think at all
Each way I turn, another wall
This darkness haunts my very soul
My world seems dead I’ve lost control
The only weapon is my pen
Depression has moved in again
As I have discussed in previous blogs on this website, the practice of Psychiatry is challenging. Unlike other medical specialties there are a paucity of laboratory testing or radiologic imaging that will reveal the true nature of the problems being presented at the time of our appointment.
Instead of relying on objective data I must process a wealth of subjective information; that is, the words that you use in describing your current emotional state. I view this challenge much like a good detective would tackle a mystery. To help you better understand the complexities of the evaluation I will try to outline the key components.
Firstly, I certainly recognise that a new patient coming into my office will be uneasy and not sure of what to expect. So it is important to reassure the individual that he evaluation process is straightforward and geared to better understanding what brings the individual to my office.
This brings us to what I call the “Chief Complaint”, best expressed by asking “How can I help you?” Quite commonly people present with concerns about being depressed or suffering from anxiety. The problem with the chief complaint is that what people mean by words like depression or anxiety differ tremendously among individuals. So the chief complaint must be clarified with more specific descriptions of what the person means by the words they are using. Often a perceived problem with anxiety represents a symptom of a depressive disorder. I commonly hear individuals come in concerned about “mood swings” with a fear that they could have bipolar disorder (manic depressive illness). However, after clarifying their concerns by getting a more comprehensive description, I often discover that what they are describing I a swing between feeling fine and feeling depressed, a symptom complex that can be part of a core depressive disorder.
Once the chief complaint is determined, the next step is to obtain a “History of Present Illness”. Specifically, this entails finding out how long the difficulties have been present, what does the development of emotional symptoms look like and what was the context in which the difficulties presented themselves. Since a major goal of assessment is to discover if there are underlying biological (that is, brain related) factors causing symptoms, it is just as important to determine if there are situational factors present during symptom development. Then the challenge is to try to better understand whether there are psychological factors (coping style, attitude and belief systems) influencing or even responsible for producing the current problems bringing the person to my office.
Current problems and symptoms must be understood in the context of any “Past Psychiatric History”. Have these problems and/or symptoms been present in the past? If so, has there been a pattern of episodes? Has there been previous psychiatric treatment and what was the outcome of such treatment? It is always helpful to know if an individual had previous depressive episodes and responded to a particular antidepressant. If there is a history of prior courses of psychotherapy, what type of therapy was it and what was the outcome?
The presence of “Substance Abuse” (another section of the comprehensive evaluation) must be discovered because of the complicating role it may play in the presentation of the individual’s symptoms and concerns. The drugs, amount used and duration of use must be clarified. When substance abuse has been extensive and long term, all bets are off in determining a non-substance abuse primary psychiatric disorder. It is only after months of a brain free of the substance(s) abused can one adequately determine the presence or absence of a core mood or anxiety disorder.
A most important section of this initial assessment consists of the “Family Psychiatric History”. Knowing what the individual’s genetic pedigree is can be very telling. If mood and/or anxiety disorders are prevalent in nuclear and extended family members the possibility of an underlying biological problem must be considered when treatment planning occurs. This does not mean that biological dysfunction is the sole problem. It is quite common to discover that there has been a stress-diathesis interaction; that is, the external situational stressors are interacting with an underlying biological predisposition.
A “Childhood History” is another critical component. To discover that there is a past history of traumatic life experiences raises questions about both the nature of the present problem and aspects of treatment planning. Bullying has unfortunately become recognised as a major factor in the development of future suffering and trauma syndromes. Determining if there was any birth injury, delay in developmental milestones or school related anxiety and avoidance or academic learning difficulties is part of this section. Although a very sensitive area of investigation, learning about a history of abuse, whether it be emotional, physical or sexual, represents important albeit painful information to gather.
The person’s “Past Medical History” cannot be ignored. This section includes the presence or absence of medical system problems (involving heart/vascular, lungs, kidney. Liver, thyroid, gastrointestinal, other hormonal, and brain) that may be impacting on the individual’s current complaints. An accurate and detailed list of current medications and dosages taken is essential for treatment planning due to the varied effects of medication on mental state as well as the risk of drug to drug interactions when psychiatric medications need to be prescribed. Obtaining a history of medication-related or other allergies, surgeries, head injuries or concussions rounds out this section.
The “Psychosocial History” explores childhood specifics, religious background, educational level, job history, marital status and special interests or hobbies. It helps to fill in the context of the present illness.
The “Mental Status Examination” is the psychiatrist’s equivalent of the internist’s physical examination. This examination evaluates the behaviour and demeanour of the individual. Emotional experience and expression is assessed. Thinking content and process along with speech characteristics are components as well. A formal assessment of memory, attention/concentration, abstract language use, fund of knowledge and perceptual/sensory disturbances are an integral part of mental status.
Because severe mental disorders can lead to self or other destructive thoughts and urges, an evaluation of dangerousness risks is an important aspect of a comprehensive evaluation.
After all this information is obtained, a preliminary psychiatric assessment is provided. This diagnostic section utilises the American Psychiatric Association Diagnostic and Statistical Manual, Edition V to aid in evidence-based diagnostic consistency.
The initial plan of treatment may include medication, lifestyle recommendations and psychotherapy. It is important to recognise that both diagnostic impressions and treatment recommendations need to be flexible because as the therapeutic relationship unfolds additional information becomes available which may alter treatment planning.