The Perspectives, Psychiatric History, and Mental Status Examination
The perspectives methodology requires a certain body of information and data about an individual before it can be fully used. This basic level of knowledge is usually obtained in the initial evaluation, together with psychological assessment and interviews with available patient informants (e.g., family members). The evaluation of the patient consists of a full psychiatric history and mental status examination. These two procedures, in particular, provide information about possible familial predispositions for disorders, key developmental data, personal psychiatric history, history of substance use, and a behavioral assessment of present mental and emotional functioning.
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The history and mental status examination have traditionally been the domain of psychiatry, although more and more social workers and psychologists, especially those associated with mental health facilities, now take initial histories and conduct mental status examinations. Indeed, it is the responsibility of the mental health evaluator, regardless of professional group, to provide the information garnered in the history and mental status examination. If the clinician does not obtain a full history and mental status examination in the initial stage of therapy, but rather proceeds without this knowledge to “let the history unfold,” it is nearly impossible to see how the full perspectives methodology could be employed. The clinician seems to have opted for the life story perspective, while information vital for the other perspectives depends on a fortuitous unfolding of the history.
The Perspectives, Clinical Formulation, and DSM-IV-TR Diagnoses
A psychological or psychiatric evaluation consists of the history, mental status examination, and data provided by psychological assessment and informants. The goal of the evaluation is to construct a formulation of the case—the clinician’s summary of the complex interaction of factors that may have influenced the form, content, and function of the disorder that brings the individual into treatment. It is the product, clearly, of the skill and clinical wisdom of the evaluating mental health professional.
The diagnosis is one element of the formulation that relates the clinical presentation of the particular patient to the larger world of clinical syndromes, disorders, and problematic behaviors. The Diagnostic and Statistical Manual of Mental Disorders-IV-TR and the entire DSM series have been an effort to provide empirically valid and reliable criteria for psychiatric diagnostic categories.
One of the most remarkable achievements of North American psychiatry, the DSM has facilitated research and reliable communication in the mental health field by organizing symptoms and behaviors into psychiatric diagnoses.
– Two extremes are found among mental health practitioners’ attitudes toward DSM-IV-TRdiagnoses. In one camp are those who believe their sole evaluation task is to assign the proper diagnosis according to DSMIV- TR criteria. For these clinicians, determining the proper diagnosis is the goal of the evaluation. Following the intention of the DSM-IV-TR, in reaching a diagnosis they are driven not by theory but by their empirical findings in the patient’s history and mental status examination. Clinical research protocols often are concerned only with diagnosis, because of their interest in study participants that meet the symptominclusion profile.
– In the other camp are mental health clinicians who are quite indifferent to DSM diagnoses and avoid them at all possible costs—excluding requests from third-party payers, of course. This group is more interested in letting the patient’s history unfold in the course of therapy. They tend to see diagnostic categories as unfortunate limitations to the complexity of the person’s psychological history and status. For these clinicians, the formulation of the case is a process constantly open to revision based on new information provided in the course of psychotherapy.
The perspectives methodology assists in both the diagnosis and the formulation of the individual case. After obtaining a full history and mental status examination from the patient, the clinician who employs the perspectives methodology will be able to provide the objective and empirical data required by the DSM-IV-TR while also having garnered sufficient information to develop a rich formulation of the person and the disorder. Diagnosis is not sufficient for clinical treatment in psychiatric disorders or in sexual disorders. More must be said about a case than diagnosis, and this “more” is information that is organized with the perspectives methodology.