From "Geropsychiatric and mental health nursing / edited by Karen Devereaux Melillo, Susan Crocker Houde",

2nd ed., Pt. 1, Chapter 3, 2011, pp. 53-71

il
.I.

II
iI•l
lr'I
Comprehensive Mental Health 'i
II
,' III
Assessment: An Integrated Approach 111

Lisa A. Brown i
;
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I'

Lee Ann Hoff I lr

Assessment, the first step in the nursing process,
lays the foundation for making a diagnosis, plan-
ning crisis intervention and treatment, imple-
menting the plan, and evaluating results through
follow-up strategies. Lack of progress in meeting
treatment goals, unanticipated complications, and
provider ordering laboratory tests for diagnos-
ing a physical problem does not affect the objec-
tive laboratory results, although it may exacerbate
I' I'I'I
a client's distress, whereas an indifferent attitude
of a provider aiming to ascertain a depressed per-
I'
I
son's risk of suicide may result in denial of suicidal li

provider frustration or burnout can often be traced plans and failure to obtain other data for assess- I.
'1.;
to inadequate or incomplete assessment. Such bar-
riers to effective service delivery are compounded
ing suicide risk. This means that, in addition to
structured assessment guides, the nurse-patient '~I'
in the psychiatric and mental health practice relationship and the provider's communication :'·II
1 i

arena by a key factor in one's exper~ence of emo-
tional distress or mental illness: subjectivity. As
discussed in Chapter 2, the meaning "that people
attach to life events and their emotional, physical,
and social sequelae often constitute a major influ-
ence on one's healthy or unhealthy response to
life's hardships, challenges of role transition, and
recovery from traumatic experiences.
In the physical realm, providers can rely on a
skills constitute the most essential «tools" in the il
psychiatric and mental health assessment process '1;1
!I
I
I
(Peplau, 1993).
This chapter begins with an overview and cri-
tique of assessment methods and published instru-
ments available to the geropsychiatric nurse: nursing
diagnosis, Mini-Mental State Examination (MMSE),
Diagnostic and Statistical Manual of Mental Dis-
orders (DSM), International Classification of Dis- I

variety of technological and other objective assess-
ment and diagnostic tools. In the emotional and
cognitive spheres, however, although structured
assessment tools exist, they are never as accurate
as those available for diagnosing physical phenom-
ena precisely because of the subjectivity of people's
emotional, cognitive, and spiritual response to life
events. To illustrate, the indifferent attitude of a
eases (lCD), and the Comprehensive Mental Health
Assessment tool (CMHA). The use of these tools I!
I
is then illustrated with a case example, with "
the major focus on the CMHA. This tool (Hoff,
Hallisey, & Hoff, 2009) is highlighted for its
close correspondence to the emphasis on func-
tional assessment of older persons, whose welfare
and treatment outcomes can be compromised

53
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 54 • Chapter 3: Comprehensive Mental Health Assessment: An Integrated Approach
by concentrating on pathology and psychiatric
diagnostic labels at this stage of the life cycle.
Also discussed is the CMHA's complementarity
with psychiatrist McHugh's (2001) "essentials"
approach to psychiatric diagnosis.
A service contract form illustrates a client and
provider intervention framework that comple-
ments the CMHA tool. It lists the CMHA assess-
ment items as a structured guide for a data-based
crisis intervention and mental health service
plan that emphasizes a collaborative nurse-
patient relationship as a key factor in treatment
outcomes. Continuing the client-empowerment
focus of the CMHA, it spells out specific strat-
egies that the client and provider will use to
address the items identified.
~il--~O~V~E~RV~I~EW----::O~F~A-,-SS,--E--,S-,-S~M~EN~T~M~E~T~H~O~OS-
The multifaceted process of aging complicates
mental health assessment of older people. As with
any age group, it is essential to rule out an organic
cause for any mental status change before assign-
ing a psychiatric diagnosis. Subsequent to ruling
out all organic causes of changed mental status,
a thorough psychiatric and mental health assess-
ment is warranted.
Nursing Oiagn.osis
Nursing diagnosis addresses areas of life affected
by an alteration in health status. Nursing diag-
noses of mental health are grouped under the
following categories of Gordon's functional
health patterns: cognitive-perceptual pattern, self-
perception-self-concept pattern, role-relationship
pattern, sexuality-reproductive pattern, coping-
stress tolerance pattern, value-belief pattern, and
sleep-rest pattern. An example is "alteration in
mental status related to postoperative procedure
as evidenced by short-term memory loss, disori-
entation to time and place." The nursing diagno-
sis illustrates what the problem is and how it is
manifesting itself. Registered nurses are educated
to provide comprehensive, holistic assessments.
I"
Because they practice in a multidisciplinary sys-
tem, nurses should be familiar with medical diag-
nosis and treatment.
Diagnostic and Statistical Manual of Mental
Disorders and International Classification
of Diseases
The DSM is currently published in its fourth edi-
tion with revisions (DSM-IV-TR). The fifth edi-
tion (DSM-V) is expected to be released in the year
2012. Physicians, advanced practice psychiatric
nurses, social workers, and psychologists use the
DSM-IV-TR as a guide for diagnosing mental dis-
orders. It is important for geropsychiatric nurses
to be familiar with this tool, its benefits, and its
limitations in practice.
The first DSM, published in 1952, was a com-
pilation and description of diagnostic categories.
Reflecting the influence of Adolf Meyer's psycho-
biologic approach, the word "reaction" was used
to depict his belief that each disorder was a reac-
tion .to psychological, social, or biological factors,
or a combination of these factors. The DSM-II
was very similar to the first edition except that it
eliminated the term "reaction," thereby removing
discussion of "cause" and ultimately the mind-
body connection.
The DSM-III, published in 1980, included
explicit diagnostic criteria, a multiaxial system,
and a "descriptive approach that attempted to
be neutral with respect to theories of etiology"
(American Psychiatric Association [APA], 2000,
p. 26). One of the primary goals of creating the
DSM-III was to provide a medical nomencla-
ture for clinical providers and researchers. The
DSM-IV was published in 1994, and the fourth
edition with text revision in 2000.
The DSM-IV has been widely accepted in clini-
cal and research settings. Significant controversy
surrounded the development of the DSM-III and
the revised text (Caplan, 1995; Cooksey & Brown,
1998; Luhrmann, 2000). This controversy seems
to have abated with publication of the fourth edi-
tion with text revision (APA, 2000). Although there

is dialog in the medical literature regarding the
upcoming DSM-V, there is little thought-provoking
discourse. The DSM-V is scarcely discussed in the
nursing and social science literature.
The broad acceptance of the DSM-IV, often
referred to as the "bible" of psychiatry, is evident
in the lack of literature discussing its use, ben-
efits, and limitations. This is most obvious in the
area of nursing and the social sciences, including
social work and clinical psychology. Dialogue is
also limited in the medical arena; however, this is
where most of the literature can be found.
Yet, new voices internationally and across
disciplines raise questions about the validity and
widespread acceptance of the DSM zeitgeist and
its prominence in psychiatrk and mental health
assessment. For example, Marie Crowe (2006,
p. 125), a senior lecturer in mental health nursing
in New Zealand, cautions nurses: "... because psy-
chiatric diagnosis often fails to describe the indi-
vidual's experience of mental distress ... while not
necessarily intentionally, [it] serves to maintain
oppressive power relations within society. It does
this by establishing and maintaining the param-
eters of normality and abnormality in a manner
that reflects particular gender, culture, and class
biases." She goes on to discuss the societal impli-
cations of having a psychiatric diagnqsis and the
biases in the diagnostic process as Outlined in
the DSM-IV. She calls on nursing to stay true to
the discipline with holistic assessments based on
the patient's lived experiences versus their "diag-
nosis." Crowe's analysis resonates with research
findings by Cooksey and Brown (1998), in which
nurses criticized the DSM for its failure to provide
adequate information about the client's individual
experience. This is in direct contrast to a nursing
diagnosis outlining an alteration in mental health.
It is important for registered nurses to be familiar
with the criteria for diagnosis and simultaneously
complete a thorough biopsychosocial assessment
of each client.
Clinical psychologist Gerald Rosen (2008) and
his colleagues have questioned the DSM diagno-
sis of posttraumatic stress disorder, ridiculing the
Overview of Assessment Methods • 55
elaboration of this diagnosis to include "post trau-
matic embitterment disorder as a result of being
insulted or humiliated." He challenges the DSM
for "the cross-cultural medicalization of normal
human emotions" (p. 4).
Psychiatrist Paul McHugh, a long-time oppo-
nent of the DSM, also speaks out about the diag-
nosis of posttraumatic stress disorder. McHugh
and Treisman (2007) propose that this diagnosis
moves the mental health field away from, rather
than toward, a better understanding of the natu-
ral psychological responses to trauma. McHugh's
work (1999, 2001) supports key concepts of crisis
theory, rooted as it is in results of treating trau-
matized combat soldiers at the front lines with
the aim of their rapid return to work, minus the
disadvantage of a psychiatric "disorder" label as a
precondition for receiving necessary services for
the predictable psychosomatic symptoms resulting
from extraordinary war trauma. Applied to gero-
psychiatric health care, the following geriatrician's
request to primary care providers at a Harvard
Medical School conference is apt: Would you
please do a functional assessment and let 80-year-
olds go to their grave without a DSM diagnosis?
Darrel Reiger (2007), vice-chair of the task
force to develop the DSM-V, describes the DSM
as "a dictionary of mental disorder diagnoses that
describes the characteristic's of each mental disor-
der diagnosis" and notes that the DSM-V will pay
greater attention to "measurement based care."
He emphasizes the need for this tool for research,
reminding us that although the DSM is used in
clinical practice, the DSM-III, -IV, and -IV-TR
were all designed primarily with research in mind.
This point resonates with the research findings of
Cooksey and Brown (1998), revealing that many
clinicians find the several hundred page DSM
tome cumbersome in everyday mental health
practice. Another important goal of the DSM-V is
to be more congruent with the lCD.
The lCD is currently in its 9th edition, with the
lOth edition due for publication in 2014. The lCD
is published by the World Health Organization
(WHO) and used worldwide for morbidity and
1[:·:
II!I.
 56 • Chapter 3: Comprehensive Mental Health Assessment: An Integrated Approach
,j mortality statistics, reimbursement systems, and
automated decision support in medicine. This sys-
tem is designed to promote international compa-
rability in the collection, processing, classification,
and public presentation of these statistics.
The !CD includes a section classifying mental
and behavioral phenomena. This has been devel-
oped alongside the DSM, and the two manuals
seek to use the same codes. There are significant
differences, however, such as the !CD including
personality disorders on the same axis as other
mental disorders, unlike the DSM. The WHO is
revising its classifications in these sections as part
of the development of the tenth edition.
Since the 1990s, the APA and WHO have
worked to bring the DSM and the relevant sections
of ICD into concordance, but some differences
remain. An international survey of psychiatrists
in 66 countries comparing use of the !CD and
DSM-IV found that the !CD was more often used
for clinical diagnosis, whereas the DSM was more
valued for research (Mezzich, 2002).
The five axes of the multiaxis systems of the
DSM-IV-TR are as follows (APA, 2000, p. 27;
O'Brien, Kennedy, & Ballard, 1999, pp. 64-65):
Axis I Clinical disorders, such as major depres-
sion or schizophrenia, and other condi-
tionS> such as alcohol dependence, that
may be' a focus of clinical attention
Axis II Personality disorders and mental re-
I I
I tardation
Axis III General medical conditions (e.g., HIV
infection may cause dementia [Axis
I], or alcohol dependence [Axis I] may
cause cirrhosis [Axis Ill])
Axis IV Psychosocial and environmental prob-
lems; includes events and stressors that
may precipitate, result from, or affect
mental status and treatment outcomes
Axis V Global assessment of functioning; indi-
cates the client's overall functional
level, including psychologic, social, and
occupational well-being on a scale of
1 to 100 (low numbers designating low-
level functioning, and higher numbers
revealing a higher functioning level)
Axis V of the DSM corresponds most closely to the
CMHA for use in charting a client's progress from
admission to discharge. However, although the
Axis V assessment is "global" in its inclusion of
psychological and social dimensions for scoring,
it does not identify particular areas of functioning
according to the urgency of a client's need for pro-
vider attention and intervention.
Despite its name, the growing critique of the
DSM underscores the questionable clinical appli-
cation of a tool designed primarily for research. In
this respect, busy clinicians have long recognized
the limitations of lengthy tools for use in clinical
settings. This does not abrogate the importance
of evaluating clinical tools for their validity and
reliability. Rather, it is simply unrealistic to trans-
fer into clinical protocols a tool like the DSM
intended for research versus practice. Besides its
limitation for clinical diagnosis, the DSM also fails
to outline recommended treatment. Neither the
DSM diagnosis nor the !CD code provides a for-
mat to obtain information regarding a particular
individual's functioning in daily life.
Overall, mental health assessment tools are
varied and usually are specific to certain elements
of mental health. For example, there are mania
scales, depression scales, suicide risk assessment
scales, and so forth. Many of these were originally
designed as research tools and may not be suitable
for easy use in clinical practice, particularly in
high-risk situations where time is of the essence.
The average clinician, not to mention the client,
cannot be expected to administer several scales
(each requiring 5 to 10 minutes) with little time left
in a typical 20-minute person-to-person session
that should not shortchange attention to high-risk
issues, such as suicide, violence, job loss, or simi-
lar items illustrated in the CMHA assessment tool
discussed later in this chapter.
Further, let us suppose a client reluctantly
discloses (or fails to disclose altogether) in a
.I

paper-and-pencil checklist a high-risk item, such
as domestic violence, while in the waiting area,
with limited time to discuss such a topic face-to-
face with an empathic provider. Such a "mechani-
cal" approach to The Joint Commission-required
victimization screening in routine health history
checklists might be counterproductive for a vul-
nerable client's readiness to disclose current risk,
which is sometimes implied by presenting physi-
cal symptoms. The CMHA Initial Contact sheet
and Assessment Worksheet offers an alternative in
its Likert-like scale assessing for degree of urgency
in contrast to the DSM approach to diagnosis, as
in identifying "5 out of 7" or "7 out of 10" criteria
for particular diagnoses with no rating of serious-
ness or its effect on a person's functioning. Clearly,
although providing an outline of criteria for each
diagnosis, the DSM-IV-TR does not offer a format
for ascertaining disturbances or deficiencies in a
person's psychosocial functioning in everyday life.
To summarize, mental health assessment tools
are varied and generally are specific to certain ele-
ments of mental health. For example, there are
mania scales, depression: scales, suicide risk assess-
ment scales, and so forth. Many of these were origi-
nally designed as research tools and are not always
suitable for clinical assessment, particularly in
high-risk situations where time is of t~e essence.
r!
'q:--------------------------~r--------
COGNITIVE ASSESSMENT TOOLS
Cognitive impairment is an important issue in
aging patients. Early detection is imperative for
safety and may also allow a person the time and
opportunity to make important financial and
health-related decisions before disease progression
makes it impossible.
There are many tools available for brief cogni-
tive assessment including the General Practitioner
Assessment of Cognition, developed by Brodaty et
al. (2002); Memory Impairment Screen, developed
at the Albert Einstein College of Medicine, Bronx,
NY (Buschke et al., 1999); the Mini-Cog designed at
the University of Washington, Seattle, WA (Borson,
Scanlon, Brush, Vitaliano, & Dokmak, 2000); and
Comprehensive Mental Health Assessment Tool • 57
the MMSE developed by Folstein, Folstein, and
McHugh (1975).
The MMSE remains the most commonly used
instrument (Brodaty, Low, Gibson, & Burns, 2006).
The MMSE provides a brief assessment of an indi-
vidual's cognitive function. It is simple, brief, and
can be administered by a variety of disciplines
with minimal training. The MMSE's use may be
limited by the patient's individual presentation. To
administer the examination correctly, the patient
must possess the ability to interact verbally and
read and write. Its use in assessing patients who
may be blind or have limited education, for exam-
ple, is tentative. The MMSE has been shown to be a
reliable and valid tool for swift assessment of cog-
nition. It has been translated into many languages
and adapted to meet specific cultural needs with-
out affecting validity and reliability.
As with any assessment tool, if the MMSE is
administered in a mechanical way that contra-
dicts the importance of interpersonal rapport and
empathy as prerequisites for a thorough holistic
assessment of a distressed human being, its find-
ings will be limited. For example, item number
eight in the CMHA refers explicitly to the cogni-
tive function of decision making. Depending on
a client's or family member's response regarding
this question, the MMSE might be administered in
the CMHA holistic assessment context. It is pru-
dent never to lose sight of the cultural, social, edu-
cational, and medical-physical factors that may I
• I
affect one's "mental status" (Peplau, 1993) (see Box
3-1 for sample questions from the MMSE tool).
*!------------------------------------
:3 COMPREHENSIVE MENTAL HEALTH
ASSESSMENT TOOL
The CMHA was developed and tested in the 1970s
in the Erie County Mental Health System, Buffalo,
NY (Hoff & Rosenbaum, 1994). The description of
this record system (Boxes 3-2 through 3-7; Table
3-1) is excerpted and adapted from Hoff et al.
(2009, pp. 97-104 and p. 121) and reprinted here
with permission of the authors. A major impe-
tus for this tool came from the New York State
58 • Chapter 3: Comprehensive Mentull-lealth Assessment: An Integrated Approach

I. BOX 3-1 MMSE SAMPLE ITEMS

Orientation time: "What is the date?"

Registration: "Listen carefully. I am going to say three words. You say them back after
I stop. Ready? Here they are ... HOUSE [pause], CAR [pause], LAKE [pause]. Now
repeat those words back to me." [Repeat up' to 5 ti'mcs, but score only the first trial.]

Naming: "What is this?" [Point to a pencil or pen.]

Reading: "Please read this and do what it says. [Show examinee the words on the
stimulus form.] CLOSE YOUR EYES.

Source: Reproduced by special permission of the Publisher, Psychological Assessment

Resources, Inc., 16201 North florida Avenue, Lutz, Florida 33549, from the Mini-Mental State
Examination, by Marshal Folstein and Susan Fohtcin. Copyright ]975, 1998, 2001 by Mini
Mental LLC, Inc. Published 2001 by Psychological Assessment Resources,- Inc. Further repro-
duction is prohibited without permission of PAR, Inc. The MMSE can be purchased frnrn
PAR, Inc. by calling (800) 331-8378 or (813) 968-3003.

government's need for a record system to track the 3. Significant other assessment worksheet
incidence of mental disorders, and the effective- 4. Comprehensive mental health assessment (sum-
ness of community-based services for a range or mary of interview and worksheet data)
people in ac:ute distress or with serious and per- 5. Termination summary
sistent mental illness. 1l1e tool's origin coincided 6. Interagency referral form
with a nationwide development of the community 7. Consultation fOrm
mental health system following Congressional leg- 8. follow-up assessment
islation in 1963 and 1965. The entire CMHA record 9. Child screening checklist
system consists of these forms 1: 10. Service contract

1. Initial contact sheet (includes crisis rating)
2. Client assessment worksheet
1
The complete set ofCMHA forms, including operational
dell nit ions of the 21 assessment items, is available by con-
tacting author Lee Ann Hoff at lceann.hoff@comcast.
net. 'lhose interested in further research on the CMHA
assessment tool can learn more from the Web site of
Hoffet al., 2009: http://www.routledgementalhealth.com/
people-in-crisis/ in the item "Crisis Research."
'the CMHA forms provide a structured guide to
the interview, assessment, and service planning
process with clients. 1-hcir intended usc is within
a health service system that recognizes the intrin-
sic relationship between physical, emotional, and
sociocultural factors affecting the mental health
status of individuals. The underlying philoso-
phy of this record system emphasizes three key
assumptions: (l) the person in distress or crisis is
a member of a social network; (2) the stability of

a person's social attachments and gratification of
basic human needs strongly influences his or her
physical, emotional, and mental health and one's
related ability to function within the community;
and (3) the provision of crisis prevention, early
intervention, and social support services con-
serves costly health care dollars by restoring and
maintaining people in noninstitutional settings
and preventing readmission to psychiatric facili-
ties whenever possible.
The original record system was designed spe-
cifically for clinical use by a psychiatric and men-
tal health interdisciplinary team. It was tested
in the 1970s with crisis and mental health work-
ers and people receiving services in community
mental health agencies in New York's six Erie
County catchment areas that adopted the system.
Included were most publicly funded programs
serving urban, suburban, and rural communities
in a metropolitan area with a population of 1.25
million. A client was considered an active part-
ner in developing the record and had full access
to the record. Examples of client feedback include
the following:
"''m not so bad off as I thought."
"This takes some of the mystery out of mental
health." '
1 vice during acute crisis states and the longer-
"Getting help with a problem isn't so magical
after all."
"Now I have a diary of how I worked out my
problems and got better."
The current CMHA version builds on Hoff's
(1990) research with abused women, in which the
tool was used to assess mental health sequelae of
violence and victimization (Hoff & Rosenbaum,
!994). Its updated edition was developed and pilot-
tested for validity and interrater reliability in six
comparable agencies in Massachusetts and in
Ontario, Canada, by Lee Ann Hoff and psychiat-
ric nursing graduate students at the University of
Massachusetts Lowell (Hoff et al., 2009).
Comprehensive Mental Health Assessment Tool • 59
I...J
,,
The CMHA assessment and planning tool
emphasizes client-centered, goal-oriented treat- Ii,.1i
ment. It uses a five-point Likert-like scale (I= excel- .;:,j
lent/very high functioning, 3 = fair; 5 = very poor/ i!J.
!,Jj
very low functioning) to ascertain client stress
,-)
levels in 21 areas of biopsychosocial functioning :,;
through active collaboration with the client and sig- I'
!
nificant others. It also allows for systematic evalua- ,!i
tion of treatment outcomes and follow-up planning.
,,
I
The forms are designed to assist in the achievement '
of several objectives: l.ii'
j
il
I. To provide health and mental health pro- :I
11
viders, clients, and collaborating agencies a i
standardized framework for gathering data, :\
while including subjective, narrative-style
information from the client and significant
others that is relevant to mental health across
the life cycle.
2. To organize this information in a way that
sharply defines the client's level of function-
ing (emotional, cognitive, and behavioral)
and life-threatening risk, and outlines com-
plementary treatment goals and methods to
evaluate progress toward desired outcomes in
specified functional areas.
3. To assist in fostering continuity between ser-
term mental health treatment needed by some
clients (this objective is especially relevant
vis-it-vis the issue of"socially constructed sui-
cidality" that is sometimes used as the only
"ticket" to psychiatric inpatient admission
when health system economic factors super-
sede client need in clinical decision making).
4. To provide supervisory staff with the informa-
tion necessary to mOnitor service and ensure
quality and continuity of client care.
5. To provide administrative staff with informa-
tion for monitoring and evaluating achieve-
ment of crisis intervention, counseling or
psychotherapy, and related services for individ-
ual clients, and cumulative data revealing ser-
vice outcomes in relation to agency objectives.
 II
60 • Chapter 3: Comprehensive Mental Health Assessment: An Integrated Approach
In an era of providing cost-effective health care
without compromising the quality of care, this
assessment and planning tool is especially rel-
evant in its focus on client-centered, goal-oriented
treatment and systematic evaluation of service
outcomes. Its design depicting a person's func-
tional level also avoids the negative effects of
p·sychiatric labeling. Data concerning a client's
"basic life attachments" and "signals of distress"
(Hansell, 1976) offer a structured, holistic, human-
istic framework for addressing a range of human
experience and functioning affected by various life
events and traumas and the emotional and mental
illness or disabilities that may follow.
The 21 assessment items in the CMHA, with
ratings from high to low functioning, can serve as
a checklist to ensure that a thorough evaluation
has been done. The scaled items evaluate a person's
physical, mental, emotional, behavioral, spiri-
tual, and social concerns allowing for prioritizing
issues for action. The tool can facilitate meeting
the demands of cost-effective service delivery,
emphasis on community-based treatment, client
empowerment, and evaluation of observable treat-
ment outcomes as manifested by the functional
level of the client and his or her quality of life.
The CMHA allows for varying techniques
in collecting data and exemplifies the impor-
tance of obtaining collateral information from
other healthcare providers and significant others.
Depending on the clinical situation, the Client
Self-Assessment Worksheet can be given to and
completed by the client before formal interview or
used as an interview guide. Either way it serves to
reinforce the idea of the client's active involvement
in the assessment process. The complete assess-
ment protocol includes data collection from sig-
nificant others on the same 21 items.
The structured five-point Likert-like scale allows
for formal comparative assessment at (1) initial,
(2) interim, and (3) termination phases of coun-
seling or treatment. Besides prioritizing problems,
immediate risks, and goals, it presents visu-
ally the potential progress in a client's strengths,
rl
functional level, and stress reduction. The scales
and descriptive comments also assist both client
and mental health provider to remain focused and
to chart progress toward meeting treatment goals.
Finally, the tool is a guide for additional interven-
tions or referrals that might follow from the crisis
intervention or counseling process (see Boxes 3-2
through 3-7).
~:1,.-----------------------------------
:~ CMHAAND MCHUGH'S "ESSENTIALS":
DESCRIPTION AND COMMONALITIES
Elements of the CMHA are complementary to
the work of Dr. Paul McHugh of johns Hopkins
University. In his critique of psychiatric assess-
ment tools, McHugh states: "At johns Hopkins
Department of Psychiatry we have long held that
psychiatry needs a new conceptual structure that
ties the mental disorders we treat to mental life as
psychological science understands it today. Such a
structure would insist on defining mental disor-
ders by their essential natures rather than by their
appearances alone" (McHugh, 2001, p. 2).
McHugh divides the 20th century of psy-
chiatry into three segments, the first being
Meyerian, based on the teachings of Adolf Meyer,
who emphasized psychobiology. Psychobiology
differs from biologic psychiatry by studying life
from the psychologic perspective. Next, the psy-
choanalytic period emerged. The discovery of
psychotropic medication in the 1950s put an end
to this period, giving way to emphasis on the
empirical The focus of the empirical period is on
the importance of reliability in diagnosis, revisit-
ing comprehensive assessments as emphasized by
Meyer; this led to the development of the current
DSM. McHugh acknowledges advancements in
the area of research while pointing out that the
emphasis on reliability has neglected the validity
of psychiatry.
McHugh takes issue with certain diagnoses,
such as multiple personality disorder and chronic
posttraumatic stress disorder. He requests psy-
chiatry to give up "appearance driven" diagnosis,
I
I
 CMHA and McHugh's "Essentials": Description and Commonalities •
as did internal medicine many years ago. McHugh
(1999) refers to the "weaknesses inherent in a sys-
tem of classification based on appearances-and
contaminated by self-interest advocacy." He calls
for a new method that can "comprehend several
interactive sources of disorder and sustain a com-
plex program of treatment and rehabilitation"
(McHugh, p. 38).
McHugh (2001) illustrates an alternative
approach to categorizing and treatment plan-
ning for mental disorder. In a structure consist-
ing of interactive perspectives of psychiatry, he
reunites psychosocial components with biology.
These interactive sources of disorder include
four perspectives for asses,sment and diagnosis in
psychiatric practice: (1) the disease perspective,
encompassing pathophysiology and pathogenesis;
(2) the dimensional perspective, including person-
ality, life circumstances, and neurotic symptoms;
(3) the behavioral perspective, including physi-
ological drive, conditioned learning, and choice;
and (4) the life story perspective, encompassing
setting, sequence, and outcome.
Frank Kelly, first introduced in Chapter 2,
is a 72-year-old widowed white man. He
presented to the emergency department
of a community hospital complaining of
chest pain. The cardiac workup was nega-
tive and evaluation revealed that Frank
had been depressed and having thoughts
of suicide. A psychiatric evaluation was
ordered. The crisis team was called and a
clinician proceeded with assessment. The
clinician asked to speak with Frank and then
61
McHugh (2001) and colleagues at johns
Hopkins hold that these four distinct but interre-
lated levels of expression constitute the hierarchi-
cal organization of human psychological life from
the most basic neurological to the most highly
developed psychological functioning. Assessment
skill demands ascertaining the particular way a
person's psychological functioning can go awry as
defined by the four perspectives.
The dynamic interactive sources of disorder
McHugh proposes for assessing psychological
functioning are highly complementary to assess-
ment factors depicted in the CMHA. In particu-
lar, McHugh's four perspectives underscore two
key concepts framing the CMHA tool: basic life
attachments and signals of distress, which are con-
cepts from ego psychology, sociocultural theory,
crisis theory, and preventive psychiatry (Caplan,
1964; Hansell, 1976; Hoff et a!., 2009). i'
The complementarity of McHugh's perspec- ·'
tive and the CMHA become more apparent in the
following case example with application of the
MMSE, nursing diagnosis, and DSM-JV-TR.
i,·.,
his daughter. Unfortunately, his daughter
needed to leave to care for her children and
would return as soon as possible; therefore,
the CMHA was conducted only with Frank.
Comprehensive Mental Health
Assessment for Case Example
Boxes 3-2 through 3-4 illustrate the compre-
hensive mental health assessment for the
case example.
(continues)
 . il. I 1
'· 62 • Chapter 3: Comprehensive Mental Health Assessment: An Integrated Approach

BOX 3·2 INITIAL CONTACT SHEET

Today's date: __S_e;p_,_t-~

___ 2:_,_20_0_9_ !D#: _9_9_9_9_

Name: _ _K_~_c__,_f_v;_1M'llv
_ _ _~

72 __
Age: _ _ Relationship status: 0 Married 0 Single !!!'Widowed

Address: -'--7-'-A'--VlY-""---'S:..:tic_veet;c__-'-''--A-'-Yl)lti~ow-"''--''-U'--'--SA_ __
555-1111
Telephone: _ _ _ _ _ _ _ _ _ __

Have you talked with anyone about this? 0 No BYes

Date oflast contact: _ _ __

__5_5_5_-_2_2_2_2_(_~
Significant other (name and phone): _ _ _K_Ottl_.v_S_I'f'littv_' _ _o__ev_)

Are you taking any medication now? 0 No BYes

If yes, what?

CRISIS RATING: I 2 3 5
Not urgent Very urgent

Probability of engaging for counseling treatment contract (I = high; 5 =low)

i.
I 3 4 5

Summary of presenting situation or problem and help-seeking goal:

Frank Kelly, a 72-year-old Caucasian, widowed male was brought to the emergency
department by his daughter secondary to complaints of chest pain. The cardiac workup
was negative. During his evaluation, a depressed mood and sad affect were observed and
suicidal ideations were reported. Frank was cooperative with the mental health assess-
ment but seemed surprised when the issue of counseling/mental health care was raised.

Date of next contact/appointment:~------------------

Signature (intake/triage person): ~------------ Date: _ _ _ __

I, i
 CMHA and McHugh's "Essentials": Description and Commonalities • 63

CASE STUDY

To be used as initial interview guide with client.

NOTE: Comments by client are italicized; comments by provider are [in brackets].

I. Physical health: How do you judge your physical health in general?

CD 3 4 5
Excellent Good Fair Poor Very poor
Comments: Sometimes I have a lot ofpain with the arthritis but most days it is tolerable.

2. Self-acceptance/self-esteem: How do you feel about yourself as a person?

2 3 CD 5
Excellent Good Fair Poor Very poor
Comments: I am proud of my marriage and we raised three good kids. I had a decent
career as a pipe fitter. I am just not sure what to do with myself now.

3. Vocational/occupational (includes student, homemaker, volunteer): How would

you judge your work/school situation?

Very good
CD
Good
3
Fair
4
Poor
5
Very poor
Comments: Retired, I guess I co.uld use something to do.

4. Immediate family: How would you describe your relationship with your family?
I
Very good
CD
Good
3
Fair
4
Poor
5
Very poor
Comments: The kids come by to see me at least once a week. They have their own lives to lead
now. [Considerable low self-esteem and depression, be may feel unworthy of more attention.]

5. Intimacy/significant other relationship(s): Is there anyone you feel really close to

and can rely on if you're very upset or in a life-threatening situation?
1 2 4 5
Always Usually Sometimes Rarely Never
Comments: I could call my kids if I needed them in an emergency. I don't want to call
them up crying, though. I have no interest in meeting women.
(continues)
64 • Chapter 3: Comprehensive Mental Health Assessment: An Integrated Approach

6. Residential/housing: How do you judge your housing situation?

CD 2 3 4 5
Excellent Good Fair Poor Very poor
Comments: We sold our house five years ago and bought a condo unit in a complex for seniors.

7. Financial: How would you describe your financial situation?

1 CD 3 4 5
Very good Good Fair Poor Very poor
Comments: I don't have any problems paying my bills and I have enough money so it
won't cost the kids to bury me.

8. Decision-making ability: How satisfied are you with your ability to make life decisions?

CD 2 3 4 5
Always very satisfied Somewhat dissatisfied Always very dissatisfied
Comments: I wish I had my w•fe to talk to like I used to but I can make decisions just fine.
[Correlate with MMSE.]

9. Problem-solving ability: How would you judge your ability to solve everyday
problems?

'CD 2 3 4 5
Very good Good Fair Poor Very poor
Comments: Same thing-wish the wife was here but I can do it myself.
[Although he prides himself on problem solving, suicidal ideation suggests desperation
and unhealthy problem solving.]

10. Life goals/spiritual values: How satisfied are you with how your life goals (and
things you value most) are working for you?
1 2 3 4 CD
Always very satisfied Somewhat dissatisfied Always very dissatisfied
Comments: My only goal now is to die and be with my wife. The problem is, if I kill myself
I will go to hell and I will never be with her. I don't go to church as much as I used to with
my wife. I still try to go. I do find it helpful; I feel better when I go.
 CMHA and McHugh's "Essentials": Description and Commonalities • 65

11. Leisure time/community involvement: How satisfied are you with the availability of
leisure time and ability to relax and take part in activities beyond everyday duties?
I 2 3 5
Always very satisfied Somewhat dissatisfied Always very dissatisfied
Comments: I am bored; I watch TV, eat, and sleep. Crying-! don't know what to do with-
out her [wife].
[Needs help in finding social support and involvement beyond immediate family.]

12. Feelings: How comfortable are you with your feelings? (For example, do you often
feel anxious or fearful?)
I 2 3 4 G::::> li'
Always comfortable Sometimes uncomfortable Always uncomfortable
Comments: I cry all the time. I
I
[High correlation with low self-esteem and suicidality.]

13. Violence/abuse experienced: To what extent have you been injured or troubled by
I'
physical, sexual, and/or emotional abuse? I!
I
:.:
CD
Never
2 3
Several times recently
4 5
Routinely
''
(every day or so)
Comment/describe:
Note: If rating of Item 13 is 2 ot_above, answer items 19, 20, and 21 below.

14. Injury to self: Do you have any thoughts of suicide or a plan to hurt yourself in any way?
I 2 3 5
No risk whatsoever Moderate risk Very serious risk
Comments/describe: [Openly admits to suicidal ideations, has access to guns and drinks
alcohol regularly; however, he does not have an explicit, immediate plan to hurt himself.]

15. Danger to other(s): Do you have any thoughts about violence or a plan to physi-
cally harm someone?

G::=> 2 3 4 5
No risk whatsoever Moderate risk Very serious risk
Comments/describe: I would never hurt anyone else.
(continues)
II
66 • Chapter 3: Comprehensive Mental Health Assessment: An Integrated Approach

16. Substance use (alcohol and/or other drugs): Does the use of alcohol and/or other
drugs concern you or interfere with your life in any way (work, family)?
I 2 3 G:::) 5
Never Rarely Sometimes Frequently Constantly
Comments/describe: My wife hated me drinking so I quit about 20 years ago. I started
drinking again six months after she died. I don't have a problem. I only drink at home.
I don't drive after I have been drinking. [Reports consuming 6-8 beers 3-4x/week.
Denies other drug use. Blood alcohol 0 today and drug screen negative.]

17. Legal: What is your tendency to get into trouble with the law?

CD 2 3 4 5
None Slight Moderate Great Very great
Comments/describe: I haven't been in any trouble since I was 17 and even then it was
drinking in public.

18. Agency use: How satisfied are you with getting the help you need from doctors or
other health providers?
2 3 4 5
Always very satisfied Somewhat dissatisfied Always very dissatisfied
Comments: I have no complaints.

19. Relationship with abuser: How would you describe your relationship with the per-
son who has abused you?
I 2 3 4 5

No contact or conflict now Occasional conflict Great conflict and turmoil

Comments: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

20. Safety-self: How safe do you feel now?

2 3 4 5
Very safe Somewhat safe Very unsafe
Comments: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
 CMHA and McHugh's "Essentials": Description and Commonalities • 67

CASE STUDY

21. Safety-children (if there are children): How safe do you think your children are?
2 3 4 5
Very safe Somewhat safe Very unsafe
Comments: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Additional items: Do you have any other issues, concerns, or problems that you wish to
discuss with a counselor?
No, I told you everything.
Urgency/importance: Among the items noted, which do you consider the most urgent
and/or in need of immediate attention?
I want to feel better.

Among the 18 functional items applicable to Mr. Kelly, the following should receive the
most immediate attention and action, based on ratings between 3 and 5 (moderate to
high stress). The number in parentheses ( ) indicates the rating for these priority items.

12: Feelings (5)

10: Life goals/spiritual values (5)

14: Injury to self (4)

16: Substance use (4)

11: Leisure time/community involvement (4)

2: Self-acceptance/self-esteem (4)

5: Intimacy/significant other relationships (3)

Of particular note among these priority rat-
ings is their interrelationship; for example,
Mr. Kelly does not know what to do with him-
self, he just wants to die and be with his wife,
his risk for suicide, feeling reluctant to reach
out to family, and coping with excessive use
of alcohol. Planned actions (by provider and
client) around these "basic life attachments"
and "signals of distress" are illustrated in
Table 3-1, the Service Contract.
(continues)
68 • Chapter 3: Comprehensive Mental Health Assessment: An Integrated Approach

CASE STUDY

Score 24; poor concentration noted; difficulty with recall. Note: See Appendix B for a
sample of MMSE questions and information for obtaining the complete form.

BOX 3-6 NURSING DIAGNOSES

1. Risk for violence toward self as evidenced by suicidal ideations, access to guns, and
frequent use of alcohol.

2. Dysfunctional grieving related to loss of wife and career as evidenced by inability to

establish new relationships, activities, and goals.

3. Knowledge deficit related to signs and symptoms of depression as evidenced by his

difficulty in accepting the recommendation for counseling and mental health care.

4. Situational low self-esteem related to loss of marriage and career and evidenced by
self-report, "I don't know what to do with myself now."

5. Family coping, potential for growth as evidenced by concern by children, regular

visits, and opportunity to open up dialogue regarding increased needs of the family
patriarch.

6. SoCi~l isolation as evidenced by lack of peers, time spent home alone drinking
alcohol.

BOX 3-7 DIAGNOSTIC AND STATISTICAL MANUAL DIAGNOSIS

Axis I Major depressive disorder, single episode, alcohol dependence

Axis II Not applicable

Axis III Hypertension, gout, arthritis

Axis IV Death of wife, retirement, lack of peer support

Axis V Global assessment of functioning (GAP)~ 50

 Data-based Service Planning • 69

~-~---------,------==c:---­ harm himself or herself between sessions. Although

~1 DATA-BASED SERVICE PLANNING
Table 3-1 illustrates a service contract developed
with Frank Kelly from assessment data. Problems
and issues identified for counseling and treatment
correspond to the numbered items in the CMHA
assessment tool. Numbers in parentheses indicate
the stress rating for particular items. Note that of
the 21 CMHA items, the seven functional areas
with ratings of 3, 4, or 5 (indicating high stress or
low functioning) included here illustrate priority
areas for crisis intervention and treatment.
This service contract example suggests a cau-
tionary note regarding suicide prevention. The
"no-suicide contract" is a technique used by some
health providers in which the client promises not to
IN:Jiill;.;_;nu-
Service Contract: Frank Kelly
widely practiced (especially by providers without
specialty training in crisis intervention), such con-
tracts offer no special protection against suicide, or
legal protection for the therapist or other provider.
Any value the contract may have is only as good as
the quality of the therapeutic relationship in which
caring and concern for the client are conveyed.
A no-suicide contract should never be used as a
convenient substitute for time spent in empathic lis-
tening to and planning nonlethal alternatives with
a suicidal person (Clark & Kerkhof, 1993; Hoff et al.,
I
2009, pp. 343-345). The service contract with Frank
Kelly highlights such alternatives, and attention to
Mr. Kelly's losses, his unhealthy coping with alco-
hol, and other issues fueling his despair. I;
I:
'i

Date:--------

Code
1. Physical health
2. Self-acceptance/self-esteem
3. Vocational/occupational
4. Immediate family
5. Intimacy/significant
other relationship(s)
6. Residential/housing
7. Financial security
8. Decision-making ability 15. Danger to other(s)
9. Problem-solving ability 16. Substance use/abuse
10. Life goals/spiritual values 17. Legal
11. Leisure time/community involvement 18. Agency use
12. Feelings 19. Relationship with abuser
13. Violence/abuse experienced 20. Safety-self
14. Injury to self 21. Safety-children

Stress rating code: 1 = low stress/very high functioning 5 =high stress/very low functioning

Strategies/techniques (planned actions

Item/stress rating Problem/issue specification of client and health provider)
12. Feelings (5) "I cry all the time." 1. Provide supportive environment, allow-
ing patient to express feelings freely
2. Provide education on depression
3. Explore role of unresolved grief of mul-
tiple losses (wife, career, health)
(continues)
r
I

70 • Chapter 3: Comprehensive Mental Health Assessment: An Integrated Approach

Service Contract: Frank Kelly (continued)

Strategies/techniques (planned actions

Item/stress rating Problem/issue specification
10. Life goals/spiritual "My only goal now is to die and
values (5) be with my wife." He believes he
will "go to hell" and therefore
not be with his wife if he takes
his own life.
14. Injury to self (4) Suicidal ideation, possesses
guns, consumes alcohol on
regular basis
16. Substance use (4) Drinks 6-8 beers, 3-4x/wk
11. Leisure time/ "I am bored, I watch TV, eat,
community and sleep."
involvement (4)
I
2. Self-acceptance/ Was proud of marriage and
self-esteem (4) career and both are now gone;
"not sure what to do with
myself now."
5. Intimacy/ Has ongoing, reliable
significant other relationship with children
relationships (3) but does not want to burden
them. No peer support.
Signatures:
Client _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
of client and health provider)
1. Explore openness to including
pastoral counseling
2. Discuss opportunities to become active
in his church
1. Recommend immediate removal of
firearms from home
2. Assess risk for suicide every visit
3. Confer with family and discuss
suicide risk
I. Assess if patient believes alcohol to be
a problem
2. Provide education regarding alcohol
and depression
3. Reevaluate frequently
1. Integrate above strategies to increase
activity, decrease isolation therefore
increasing self-esteem/acceptance,
increase possibility of peer relation-
ships and explore options to set goals
and achieve them.
1. Explore areas of interest
2. Set small attainable goals to foster
feeling of worth and accomplishment
I. Discuss attending a grief support group
2. Explore social options available in
his community
3. Explore having joint session with
family as additional suicide
prevention measure

Crisis w o r k e r - - - - - - - - - - - - - - - - - - - - -

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