Mental health articles

Assessment and Psychoeducation
Good treatment is predicated on accurate assessment. Some clinicians favor
formal depression and anxiety assessment instruments such as the
Beck Depression Inventory (BDI) (Beck, Rial, & Rickets, 1974)
Beck Anxiety Inventory (BAI) (Beck, Epstein, Brown, & Steer, 1988)
Hamilton Depression Rating Scale (U.S. DHHS, 1976)
Public Health Questionnaire–9 (PHQ-9) (Spitzer, Kroenke, &
Williams, 1999), a quick self-report assessing major depression
Zung Self-Rating Depression Scale (Zung, 1965).

Assessment measures have the advantages of informing a clinician’s
impressions and objectively measuring a student’s progress over time. Th ese
measures can also open the eyes of students who aren’t sure whether to believe
a therapist’s feedback, and may draw out honest answers from those who
aren’t ready to open up to a therapist but will tell all on a paper-and-pencil or
computer inventory.
But even without formal tests, clinicians can still readily identify mood or
anxiety problems simply by listening closely to students’ presenting concerns
and following up by asking: “What has your mood been like recently?” and/or
“How have you felt emotionally in the last few weeks?” When students don’t
clearly answer these questions—perhaps they are psychologically uncomfortable
or culturally unfamiliar with verbalizing feelings—the information can
usually be elicited by prompting: “Would you say you’ve mostly felt happy?
Sad? Worried?” “Have you been feeling more happy or sad?” “Have you been
feeling more sad or more worried?”
Once mood or anxiety problems are suspected, clinicians should follow up
with questions regarding sleep, appetite, loss of interest in activities, hopelessness,
and physical or other symptoms, to home in on a diagnosis. Knowing
the DSM is obviously desirable, but there’s nothing wrong with trotting out
a copy of the DSM-IV to aid memory and lend authority to the conclusions:
“Let’s go through the symptoms of panic disorder to see if your problems fi t
that diagnosis.” If the student is depressed, clinicians should also assess for
possible bipolar disorder; and in all cases of depression and anxiety, they
should assess for suicidal potential (Chapter 16 in this volume) and substance
abuse (Chapter 11). A thorough assessment also covers precipitants and duration
of the problem, prior episodes (“Have you gone through something similar
in the past?”), and family history of emotional problems. With serious
cases therapists should routinely ask about medical conditions and possibly
recommend a medical checkup.
All these questions are part of a thorough initial evaluation for mood or
anxiety problems. But we must take care not to grill our new patients, since
their motivation for treatment is unknown and presumably they came in to talk
rather than be bombarded with questions. It helps to explain: “I want to ask
about your symptoms so we can understand together what you’re struggling
with emotionally.” It helps too to weave questions into the interview so the conversation
is two-way and students have time to express what they want to say.
Some young therapists are so intent on gathering information that they
lose sight of the purpose of doing so. One reason for assessment, of course, is
to guide treatment choices. Unless we recognize the signs of bipolar disorder,
for example, we may fail to arrange a necessary medication evaluation. But an
equally important reason for assessment is to educate students. Patients have
a right to know what they’re facing, and need this information to be informed
collaborators in treatment.

For many students, just being given a label for their distress, even the general
term “depression” or “anxiety,” proves reassuring, validating, and therapeutic.
Panic suff erers learn that they’re not going crazy or dying or losing
control; OCD suff erers and the depressed learn that they’re not insane; and
anxiety suff erers learn that they’re not worthless or to blame for their condition.
Labeling also can serve as a wake-up call to take problems seriously:
“No, your symptoms aren’t trivial. Th ey’re consistent with a major depressive
episode. It’s good you came here today to get help with this.”

Most students welcome having their problems identifi ed, but not everyone
does. Some students view labels as insulting, damning, simplistic, or plain
wrong. And so, when therapists assign a label, they should follow up by asking
what that means to the student.

Once therapists share their clinical impressions, further psychoeducation
is possible. Anxiety suff erers benefi t from learning that anxiety is a normal reaction to a perceived threat, so common that some star athletes and entertainers
are nervous wrecks before every performance, and that a racing heart,
palpitations, and other bodily manifestations, though unpleasant, are not
physically dangerous. Th erapists can explain further that the goal of treatment
is not to eliminate anxiety, since this impossible aim is likely to instill
anxiety about anxiety—and so elicit it. Rather, a healthy approach is to carry
on in spite of it, to cope with anxiety through letting it be. For depressed students,
the encouragement is similar: Carry on and make constructive decisions
even while caught in depression’s grip. We shall have more to say later
about this strategy.
Depending on the individual, other educational messages can be helpful.
Students who are curious as to why they’re depressed or anxious may profi t
from learning that various factors—genetic vulnerability, biochemical processes,
family history, current stressors, maladaptive coping styles, and patterns
of thinking—can play a part, and that emotional disorders are not solely
matters of “biochemical imbalances” (as noted in Chapter 6 in this volume).
Some students need reassurance that treatment can indeed help, just as others
need reminding that there are no immediate or magical cures. Students new to
therapy, especially if from communities or countries where it is unusual, need
explanations about how therapy works and the importance of their active collaboration
in getting better.