haL7069X_ch02_036-067.

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Case R
Peter D
ep o
T O T H E C A S E

rt
R E T U R N

ickins
relief that he was
re po int he expressed ck to
use I was no t su and “getting ba ral
too difficult, beca ould respond to now calmer fi rs t tim e in se ve
Treatment Planf interaction with how quickl
y he w normal.” For the le to ge t some
he w as ab
After only a br
ie treatment. tions weeks, to normal

on
du rin g ou r fi rs t encounter, I M y tre at m ent recommenda r- sound sleep and return
Peter ho sp ita l- lativ el y st ra ig ht fo
eded to be for Peter were re ed medication to eating habits
.
knew that he ne he n dealing with ne ed se ssions with me, ild-
Peter
co m m on w ar d. Fir st , he In hi s
ized. As is e w as w anic sy m pt om s. of a tro ub le d ch
anic state, ther lp control his m lithium made told the story
individuals in a m of re sis tance to he te r on vin g be en raised by a mot e
her
am ou nt nn in g Pe od , ha
a tremendous ize d Be gi ic at io n ha s ho un pr ed ic ta bl
n, however. I real - sense, because this med e treat- with extreme and
such a suggestio re co m e in th . M ak in g m at ters
balk at my be effectiv mood variations
that Peter would as prepared to proven to . Se co nd, Peter needed worse, his mother saw Peter, n
the
so I w t of m an ia
mendation, ou s m en ho th er ap y ys , as th e so
int as unambigu a course of psyc compo- younger of the two bo
make my viewpo oughts, I realized to begin l nfide. By doing
m y th w ou ld have severa w hom she could co mfortable al-
as possible. In ld th at y, Pe te r in
way that I wou individual therap ng an so, she set up an unco
that there was no nding Peter back nents. In pi felt unduly
co m fo rta bl e se co ul d w or k with me in develo and liance with him, and he ng.
feel lar ture ell-bei
reets. Of particu nding of the na l distur- responsible for her w fr om hi gh
out onto the st in te ns ity of his understa s ps yc ho lo gi ca gr ad ua tin g
e
concern was th nie. Might he causes of
hi Af te r
M ar e w ou ld al so discuss ol , Pe te r di dn ’t choose the col-
anger toward W
? It bance. duce the scho ute taken by most of his
her in some way could make to re ro
threaten to harm t possible. What choices he ress in his life and to lege es; instead, he el at a lo-
oped with
ed un lik el y, bu am ou nt of st lo n- cl as sm at
seem at the a job
however, was th s symptoms over vidual his girlfriend and took Peter and
did seem likely, able to take ade- manage hi ad di tio n to in di en ie nc e st or e.
be . In nv
Peter would not r- ger course ggested that Peter’s cal co fought almost constantly—
re of hi mself in this diso ap y, I su hi s w ife e
qu at e ca th er in Peter fo r a ey issues—for th
dered state of m
ind.
w as m ot he r and brother jo ions to be mostly about mon riage, but they
ter that I erapy sess of their mar
I explained to Pe out his psy- few family th v Mullins, the treat- 4 years nal depen-
er ne d ab uc te d by Be ha d de ve loped an emotio e
deeply conc e- co nd
worker. Fa m ily other at mad th
and that I was pr t unit’s social dence on each o difficult. When
chological state ly di d m en es ta bl ish in g to
it him. Not on erapy would focu
s on separation seem w him out of the
pared to comm a po ss ible dan- th so ur ce of emotional fi na lly th re
m to be e st ab le hi s w ife
I consider hi I fe ar ed fo r hi s a mor tw ee n Pe te r and his he w as devastated an
d
ot he rs , bu t co nn ec tio n be ho us e, el in gs
ger to l- fits of by fe
ychological wel family. The bene himself burdened
physical and ps ticipated, Peter immediate oved alliance would be found ession and rage. In the
an pr pr
being. As I had d raving in re- such an im ose most concerned of de e breakup,
n ra nt in g an m ul tip le . Th fo r w ee ks that followed th couldn’t
bega he ailable He
. At one point, I about Peter could be av distur- he “b
ottomed out.”
sponse to this n ye lli ng th at ev en t th at hi s sl ee p, or th in k clearly. At
jumped up and
bega
ou nd . su pport in the er m or e, hi s work, eat, cl os e to making
ity to push him ar re ap peared. Fu rth e po int, he cam e
ha d no au th or me ba nc e nce w ith on e night while
as important for personal experie e as an a suicide attempt on
I knew that it w at I was not in- mother’s rder could se rv one in his r. ca Instead of
kn ow th m e di so dr iv in g al
to le t hi m r- th e sa ht into th e e, he pulled
gentle but dete le source of insig g on his impuls
timidated. In a te r in va lu ab
t of this co nd i- ac tin
of the road an
d
explained to Pe re and treatmen as the third over to the side Eventually, over
mined voice, I is ac - na tu
ed to take th p therapy w cried until daw
n.
that I was prepar ite clear was in tion. Grou y I recommended to subsequent weeks, the depres l-
sion
I w as qu of th er ap
tion, which r- fo rm th e tre at - pe rio d of re
. Even I was su g his stay on ed. Following a
his best interest Peter’s sudden Peter. Durin would participate in subsid renity, however, he found
prised, however
, by ment unit, he ative se d and
nd . Ap pa re nt ly, on some e gr ou ps a w eek, during which himself unbelievably energize .
turnarou ou t th re pe rie nc es e pa th to m an ia
ized that he was - he would share his ex traveling down th ay in the hospital,
level, he recogn le to ac er e al so st ru g- r’s st
as then ab rs who w During Pete
of control. He w ing his stability. with othe werful experienc
es these sessions,
in re ga in w ith th e po w e met six times. In
cept he lp e di s- gl in g ho lo gi ca l di s- e ho w stressors in
m itt ed to me that th so ci at ed with a psyc he w as able to se to
Pe te r ad
of his brother, Do
n, as ons of re lu c- a mood disorder
turbed reaction ha d or de r. With expressi al on g w ith his life brought on ogically predis-
ish behavior r agreed to go which he was
biol
to his outland that “something tance, Pete s on go in g interpersonal an
d
al ize . se d. Hi
helped him re my plan po
es plac ed hi m at in-
was seriously w
rong.”
ar ily financial difficulti hen his marriage
mself volu nt
Peter admitted hi me to “prom- Outcome of Peter’s stay in the creased
the Case risk, and, w
cal turmoil
ita l, as kin g tu rn ed ou t, br ok e up , the psychologi
to the hosp ed As it da ys . He ns e for him to
ld be discharg sted precisely 14 ement reached a level too inte
ise” that he wou plained that a hospital la ic im pr ov
within 2 weeks
. I ex d shown dramat tolerate.
e fra m e se em ed reason- ha r only 4 days on lithium, at which
2-week tim as afte
g a guarantee w
able, but providin
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Case R
Peter D
ep o rt
ickins
a job as a bank
to He had applied for ed-
l he was try in g had enrolled in an ch
io ns Be v th at on some leve out his need to teller, and he pr og ra m in w hi
ily sess t ab pport
In the three fam make a statemen cause he was so ucational su e col-
co nd uc te d, Pe ter’s mother
au to no m ou s. Be th e ba nk su bsidized part-tim ade
Mullins be an d d m

on
y re - r w ay , he ha
e remarkabl in every othe urses. Once
and brother wer unicating their cooperative about the administra- lege co Peter communicated that
mm lk e,
sponsive in co ort. For the first he did not ba nces of his choice, I this mov eeling OK” and that he
an d su pp co ns eq ue he w as “f
concer n rs. tiv e quency of
e th at Pe te r co uld remember, M de ci de d to le t the issue rest. t of w an te d to reduce the fre . I con-
tim l ed the poin ce a month
ledged the turmoi As we approach ter what his sessions to on
Dickinson acknow rder must have ke d Pe th is plan. What I w
as
di so scharge, I as curred w ith
that her mood th e pr es - di re ga rd in g af - w ith , ho w ev er,
created for Peter,
as well as
n pr ef er en ce would be
ld be le ss comfortable op ta king
on her young so if I wou n to st
sures she placed m s. In te rc ar e. He asked me hi m fo r “a w as Peter’s decisio he was over
e her proble eing that
to help her solv ng to continue se believe that lithium. He felt d that he didn’t
lly ch ar ge d se ssion, all willi m or e w ee ks .” I “s ic kn es s” an
an emotiona t couple on war- hi s he no lon-
bers were brough d that his conditi take medication
three family mem e of the hurt and Peter realize er term of follow-up want to . I reviewed the risks with
ok ng ed
to tears as they sp past. They also ranted a lo ted out to Peter that ger need respected his right to
of ye ar s y. I po in m , bu t I
confusio n ther ap ith a hi months
clos er to ea ch other, as they he had been through a bout w m ak e hi s ow n decision. Five
beca m e
ey would try to m
ake
hological disord
er. Even as doing very
spoke of ways th e m aj or ps yc w as w en t by, and Peter w found him-
th feeling fine, he he
ps different in though he was l, when suddenly
their relationshi co m e. , an d on go ing treat- wel eling energized and “high.”
s to ab le
months and year individual and
still vulner
nse. I remembe
r the self fe
me with a tone
of eupho-
As successful as be for Peter, ment made se m as he asked me, He called r ses-
oved to ne of his sarcas ice to canc ou ight
el
family therapy pr fo r gr ou p to of th er ap y do I ria in his vo ed th at he m
not true “So how many w
eeks I sens
the same was e gr ou p w as ” I re sp on de d that sion, and become manic. He re-
gh th bin? ain
therapy. Althou three times each need, Dr. To gular follow-up ses- once ag quest that
du le d to m ee t 6 m on th s of re r sp on de d to my urgent re at day.
sche e ot he n th
sed to attend th aps one every that he come in for a sessio
week, Peter refu second week of sions, perh m os t he lp fu l. At t am bi va le nc e, he fol-
the eek, would be With grea
meetings during as se rte d w va lu at e an d en da tio n to re-
s st ay in th e ho spital. He po in t, w e would re-e ue nt lo w ed my recomm
hi ne eq
mptoms had go sion about subs s medication.
that, since his sy ing in common make a deci went along with my sume hi monthly for another year,
th We met
away, he had no in the therapy treatment. He ded quite positively me, usually
with the “p sy ch os
l pl an an d re sp on
k, fo r an d no w Peter contacts ce every
ia e call on
had the potent every other wee with a brief phon r his birthday, to
group.” This issue sis of a power in our work, onths. He co nt in ue d afte
of becoming th
e ba the following 6 m year, on the day
be tw ee n Pe ter and the lit hi um , an d th ere was no evi- t m e kn ow th at “all’s well.”
struggle te r re al ize d th at to take d sy m pt om s th rough- le
Pe oo
treatment staff. it dence of m
rfeiting some un d. bin, PhD
he would be fo as firm in his in- out that perio 6 months, Peter had Sarah To
s, bu t he w At th e en d of
privilege pre- anges.
gh I would have important life ch
sistence. Althou cipate, I realized made some
rti
ferred that he pa

SUMMARY
■ Nearly half the population is afflicted with a diagnosable
psychological disorder at some point in their lives. Approxi-
mately 25 percent of these people seek professional help
from clinicians, 15 percent from other professional sources;
the remainder rely on informal sources of support or go
without help. Clinicians are found within several professions,
such as psychiatry, psychology, social work, nursing, and
family counseling. They are professionals who are trained to
be objective observers of behavior, facilitators of growth,
and resources for people facing difficult situations.
■ Clinicians and researchers use the Diagnostic and Statistical
Manual of Mental Disorders, fourth edition (DSM-IV-TR),
which contains descriptions of all psychological disorders.
In recent editions, the authors of the DSM have strived to
meet the criterion of reliability, so that a given diagnosis will
be consistently applied to anyone showing a particular set
of symptoms. At the same time, researchers have worked to
ensure the validity of the classification system, so that the
various diagnoses represent real and distinct clinical phe-
nomena. The development of the most recent edition, the

65
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66 Chapter 2 Classification and Treatment Plans
DSM-IV-TR, involved a three-stage process, including a
comprehensive review of published research, thorough anal-
yses of the research data, and field trials. The authors of the
DSM consider a phenomenon a mental disorder if it is
clinically significant; if it is reflected in a behavioral or psy-
chological syndrome; if it is associated with distress, impair-
ment, or risk; and if it is not expectable or culturally
sanctioned. The DSM-IV-TR is based on a medical model
orientation, in which disorders, whether physical or psycho-
logical, are viewed as diseases. The classification system is
descriptive rather than explanatory, and it is categorical
rather than dimensional. Diagnoses are categorized in terms
of relevant areas of functioning, called axes: Axis I (Clinical
Disorders), Axis II (Personality Disorders and Mental
Retardation), Axis III (General Medical Conditions), Axis
IV (Psychosocial and Environmental Problems), and Axis V
(Global Assessment of Functioning).
■ The diagnostic process involves using all relevant informa-
tion to arrive at a label that characterizes a client’s disorder.
Clinicians first attend to a client’s reported and observable
symptoms. The diagnostic criteria in DSM-IV-TR are then
considered, and alternative diagnoses are ruled out by
means of a differential diagnostic process. Going beyond
KEY TERMS
See Glossary for definitions
Axis 45 Differential diagnosis 52
Base rate 41 Evidence-based practice in
Case formulation 53 psychology 62
Client 38 Family therapy 61
Clinical psychologist 40 Global Assessment of Functioning
Community mental health center (GAF) scale 50
(CMHC) 60 Group therapy 61
Comorbid 39 Halfway house 60
Culture-bound syndromes 59 Individual psychotherapy 61
Day treatment program 60 Milieu therapy 61
Decision tree 51 Modality 61
Diagnostic and Statistical Manual of Multiaxial system 45
Mental Disorders (DSM) 40 Neurosis 44
ANSWERS TO REVIEW QUESTIONS
Psychological Disorder (p. 40)
1. Patient is used to refer to someone who is ill and, consis-
tent with the medical model, who waits to be treated.
Client refers to a person seeking psychological treatment,
and this term reflects the fact that psychotherapy is a
collaborative endeavor.
2. Comorbid
3. 21
/broker/MH-SANFRAN/MHSF107/MHSF107-02/upload/MHSF107-02
the diagnostic label, clinicians develop a case formulation,
an analysis of the client’s development and the factors that
might have influenced his or her current psychological sta-
tus. Clinicians also attend to ethnic and cultural contribu-
tions to a psychological problem.
■ Once a diagnosis is determined, a treatment plan is devel-
oped. The treatment plan includes issues pertaining to
immediate management, short-term goals, and long-term
goals. A treatment site is recommended, such as a psychiat-
ric hospital, an outpatient service, a halfway house, a day
treatment program, or another appropriate setting. The mo-
dality of treatment is specified and may involve individual
psychotherapy, couple or family therapy, group therapy, or
milieu therapy. The clinician will also approach the treat-
ment within the context of a given theoretical perspective or
a combination of several perspectives. After a plan is devel-
oped, clinicians implement treatment, with particular atten-
tion to the fact that the quality of the relationship between
the client and the clinician is a crucial determinant of
whether therapy will succeed. Although many interventions
are effective, some are not. Mental health professionals
know that change is difficult and that many obstacles may
stand in the way of attaining a positive outcome.
Patient 38
Principal diagnosis 52
Prognosis 50
Psychiatrist 40
Psychological testing 40
Psychosis 44
Reliability 41
Syndrome 43
Validity 41
The Diagnostic and Statistical Manual
of Mental Disorders (p. 50)
1. Reliability refers to the extent to which a given diagnosis
is consistently applied to anyone showing a particular set
of symptoms. Validity refers to whether the diagnosis
represents a real and distinct clinical phenomenon.
2. Axis
3. Axis III
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Internet Resource 67

The Diagnostic Process (p. 57) Treatment Planning (p. 62)

1. Decision tree
2. Case formulation
3. The clinician would begin by consulting the culture-bound
syndromes in the DSM-IV-TR in order to determine
whether the client’s symptoms might best be understood
in this context.
1. CMHCs are outpatient clinics that provide psychological
services on a sliding scale for individuals living within a
certain geographic area.
2. Efficacy; effectiveness
3. Best available research evidence; clinical expertise; and con-
text of the cultural background, preferences, and charac-
teristics of clients

INTERNET RESOURCE

To get more information on the material covered in this chapter, visit our website at www.mhhe.com/halgin6e.
There you will find more information, resources, and links to topics of interest.
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C H A P T E R 3

OUTLINE Assessment
Case Report: Ben Robsham 69
What Is a Psychological
Assessment? 70
Clinical Interview 70
Unstructured Interview 70
Structured and Semistructured
Interviews 71
Mental Status Examination 74
Appearance and Behavior 74
Orientation 75
Content of Thought 75
Thinking Style and Language 76
Affect and Mood 77
Perceptual Experiences 78
Sense of Self 79
Motivation 79
Cognitive Functioning 79
Insight and Judgment 79
Psychological Testing 79
What Makes a Good
Psychological Test? 80
Intelligence Testing 81
Personality and Diagnostic Testing 84
Behavioral Assessment 89
Behavioral Self-Report 90
Behavioral Observation 91
Multicultural Assessment 91
Real Stories: Frederick Frese:
Psychosis 92
Environmental Assessment 93
Physiological Assessment 94
Psychophysiological Assessment 94
Brain Imaging Techniques 95
Neuropsychological Assessment 97
Putting It All Together 98
Return to the Case 99
Summary 100
Key Terms 101
Answers to Review Questions 101
Internet Resource 101