Opening Moves

Practically speaking, how does the therapist take a comprehensive history in one session? In the first moments of an initial assessment in those settings where this is necessary, the therapist must accomplish a number of important alliance-building tasks, including an appropriate greeting, introductions (if not already made in an earlier contact), an indication of seating preference, a brief introduction to the assessment process, and an open-ended invitation to the patient to tell the therapist how s/he can be of assistance. In these moments, the therapist should indicate what the interview will be like, how much time it will take, what sort of questions will be asked, and what sort of information the patient is expected to share. The therapist needs to create a comfortable and secure environment that allows the patient as much control as possible (Morrison, 1995). Early in the assessment, a nondirective interview style with open-ended questions yields control to the patient, generally builds rapport, and garners facts that are more reliable (Morrison, 1995; Shea, 1998). As Morrison (1995) states, “Studies have shown that [clients] give the most valid information when they are allowed to answer freely, in their own words, and as completely as they wish. So, whenever possible, phrase … questions in an open-ended way that allows the widest possible scope of response” (p. 49). To illustrate how a therapist may begin the data-gathering process, Box 4-3 summarizes the first moments of an initial clinical assessment with a fictive psychotherapy patient, who has indicated in an earlier phone contact her preference to be called by her first name.

In the medical model, the patient’s response to the therapist’s opening question is called the chief complaint, but it might better be called the patient-identified problem in a holistic nursing model. It is the patient’s stated reason for seeking help and is recorded verbatim. It often reveals the problem uppermost in the patient’s mind (Morrison, 1995) and can indicate the content region (Shea, 1998) or clinical domain (APA, 1995) the therapist should explore first. When the patient’s response to the therapist’s opening question is a denial that anything is wrong, it is often helpful to rephrase the question in terms of why others may think the patient should seek help, such as “Can you tell me what went on that your _____ (e.g., mother, spouse, employer, primary care provider, court officer) thought you might benefit from coming in?” Another technique is to ally with the patient’s resistance or side-step it (e.g., “It may be that nothing is wrong, but because you’re already here, maybe we can try to figure out if there is something else I can help with.”). Such denials are the first indication that the therapist may encounter significant resistance by the patient to engaging in psychotherapy, and they are cogent reminders that the first task of data gathering is alliance building.

During the minutes that follow the patient-identified problem, while the patient is freely telling her/his story, much is signaled that the therapist will need to explore in greater depth later in the interview. The therapist needs to mentally note or write down these areas of clinical interest (i.e., clinical domains or content regions) so that specific questions can be asked at the appropriate time. Box 4-4 summarizes the content from Beth’s response to the therapist’s opening question.

Expanding the Assessment

Although there are no rules about which content region to explore first or in what order to address them, it is generally advisable to thoroughly explore one before moving on to another (Shea, 1998). In this example, the therapist chooses to first explore the symptoms of a possible mood disorder and, when the patient broaches the subject, to assess Beth’s current suicide risk. However, she makes a mental note to follow these content regions with the developmental, family, and social histories, focusing on Beth’s strained relationships with her mother and boyfriend and on her academic decline. After a thorough assessment of the current suicide risk and any history of suicidal behavior, the therapist returns to the depression content region (i.e., history of the present illness [HPI]) to get a more thorough sense of the onset, extent, and chronology of mood symptoms. In so doing, she learns more about Beth’s hostile and enmeshed relationship with her mother. It seems the patient has been dysthymic since the 10th grade, when Beth’s mother put her daughter’s dog to sleep without her knowledge. This occurred on the day Beth got her braces removed from her teeth. A family celebration had been planned: “It was supposed to be a happy day for me. It wasn’t.” Apart from the fact it is the humane thing to do, an engaged clinician should take this opportunity to further strengthen the therapeutic alliance—which facilitates continued data gathering—by empathizing with the patient’s distress about what appears to have been a significant loss and a rather cruel act of sabotage by the patient’s mother (e.g., “You must have been very hurt by this.”). The therapist then needs to move to the developmental and family history to learn more about this incident and to more thoroughly assess the family dynamics, especially the patient’s relationship with her mother (e.g., “Tell me more about that day, your relationship with your mother, and your family situation.”).

In this way, the therapist proceeds to take a history, thoroughly exploring all the major sections of the comprehensive psychiatric database (see Box 4-1) by opening new content regions as opportunities arise. Open-ended questions invite exploration in new content regions, reveal what is uppermost in a patient’s mind, and may yield important information about the patient’s capacities, defenses, or degree of resistance to engaging in psychotherapy. Closed-ended questions elicit the specific details, such as symptom type, severity, frequency, and duration and the context in which a symptom occurs, that are necessary to assess a new clinical area. Table 4-1 provides an outline of open-ended and closed-ended assessment questions along a continuum of openness. Opportunities to open new content regions do not always arise spontaneously, and in those cases, the therapist must guide the assessment into new clinical areas. Occasionally, time constraints may dictate that the therapist makes an abrupt transition to unexplored content regions to obtain a thorough assessment within the allotted timeframe. However, it can be done skillfully, sensitively, and in a manner that continues to facilitate the therapeutic alliance. Box 4-5 illustrates the use of open-ended and closed-ended questions to facilitate skillful, even if abrupt, transitions to new content regions.

Table 4-1 Assessment Questions: Continuum of Openness

Adapted from Shea, S. C. (1998). Psychiatric interviewing: The art of understanding (2nd ed.). Philadelphia: W. B. Saunders.

Organizing the History of the Present Illness

Of all the major content regions of the psychiatric history, the most important is the HPI. It represents the heart of the assessment interview. It is the most substantial part of the initial clinical assessment and includes a description of the patient’s key symptoms, their timing and associated problems, and the stressors that account for their exacerbation. When well organized, the HPI develops much like a mystery short story (Kluck, n.d.). It outlines the onset of the patient’s key symptoms and progresses chronologically until the time of the patient’s presentation for evaluation. By the end of the HPI, an experienced clinician should be able to read the written assessment and construct a near-complete differential diagnosis. A thorough and well-constructed HPI contains the following components, roughly in the following order:

Box 4-6 documents the HPI in the case of Beth, inserting numbers 1 through 9 at appropriate points in the text to mark the essential HPI components listed previously.

Mental Status Examination: To Do or Not To Do

The mental status examination (MSE) has become a standard component of the initial clinical assessment. It is the clinician’s description of the patient’s mental functioning. It is a direct examination of the patient’s behavior and the examiner’s inferences from what the patient says and does. In making these inferences, the clinician must carefully consider the patient’s educational and cultural background (Giese, n.d.). Although it is beyond the scope of this chapter to discuss in detail how to perform a formal MSE, Appendix I-11 includes a comprehensive outline of the content and possible organization of a formal MSE. Many of its sources (see Appendix I-11, p. 150) describe the performance of the MSE in great detail.

All APPNs must learn to perform a comprehensive, formal MSE, and there is value in performing one even in the case of psychotherapy patients who present as cognitively intact. Although the volume of material to cover can seem daunting, much of the MSE is obtained during the general history-taking interview, requires no special questions or tests, and can be assessed through informal observation that begins the moment the therapist first encounters the patient. The key is to know what elements to look for and to be systematic in looking for them. When comfortable with a format for a complete MSE, the therapist can tactfully transition from informal observation to a direct, systematic examination of the patient’s cognitive status when a suitable opportunity presents itself (Box 4-7).

Sometimes, opportunities for a smooth transition to the formal MSE do not present themselves. Occasionally, a complete examination is impossible, such as with a very agitated or uncommunicative patient, and sometimes, it can seem insulting to ask apparently high-functioning people what today’s date is or whether they can remember a “red ball” and “37 Elm Street.” Nevertheless, when a clinician inadvertently fails to perform a formal MSE or makes a deliberate decision not to perform an MSE in a patient who seems unimpaired, the therapist risks missing important information that may emerge only through a direct, systematic examination of a patient’s cognitive function. “Your best bet is to choose a format, memorize it, and perform your mental status exam the same way every time until it has become second nature” (Morrison, 1995, p. 105).

Box 4-8 presents one way of organizing the data from a MSE. It summarizes the results of Beth’s formal MSE as it might appear in a formal diagnostic report or on a clinical assessment summary. However, therapists must develop their own systematic method of obtaining, organizing, and recording the MSE, so the process becomes second nature. Although Beth’s MSE result is essentially within normal limits, there is value in recording specific examples of mental status abnormalities.

Timeframes and Closing Moves

The patient’s unique circumstances determine how much time the therapist spends on each major section of the psychiatric history. In Beth’s case, the therapist will spend much of her time gathering data for the HPI and the family, developmental, and social histories. Very little time is needed for the psychiatric history, medical history, substance use history, and MSE, because the patient is young, physically healthy, cognitively intact, and has no history of prior psychiatric treatment or significant substance use. Although the needs of the patient determine which content regions are most appropriate for deeper exploration (taking into consideration time constraints, usually 50 to 60 minutes for an initial assessment), Morrison (1995) and Shea (1998) provide guidance on how to carve up the allotted time if the assessment data must be gathered in one session. Morrison (1995, p. 9) suggests the following:

Shea (1998) suggests at least 7 to 8 minutes for the “scouting” period, which is what Morrison (1995) calls free speech and what is essentially the time it takes for the patient to narrate his/her story. By the end of the first 30 minutes of the initial assessment, the therapist should be nearing the completion of the content regions that seem most pertinent for that patient. Often, during the third 15-minute period, the family history, medical history, social history, and the formal MSE are completed (Shea, 1998). In Beth’s case, exploration of the family, developmental, and social issues would have been explored in depth earlier, because they are uniquely important content regions for her and might have extended into the third 15-minute assessment period. In any case, Shea (1998) recommends that the therapist monitor, at least every 5 to 10 minutes, the progress of his/her data gathering and adjust the pace as necessary. It is probably a good idea to check with the patient by asking, “Is this okay for you?” During the last 15 minutes of the assessment period, regional content explorations of the major sections of the psychiatric history are completed; final points of clarification are pursued; and termination occurs. Time can get away from even experienced psychotherapists, especially when a patient is particularly distressed, verbose, or disorganized. However, whenever possible, the last 5 to 10 minutes of the assessment period should be devoted to discussing the diagnosis, treatment recommendations, and follow-up plan; answering whatever questions the patient may have about those findings; processing the patient’s assessment experience; paving the way for the next visit; and in doing all that, continuing to build the strong therapeutic alliance on which a good psychotherapy outcome depends. Box 4-9 illustrates the closing minutes of Beth’s initial clinical assessment.

Assessing Ego Functioning

The assessment of ego functioning from the perspective of ego strength (as opposed to ego deficit) is a valuable skill for nurse psychotherapists. The identification and assessment of ego strength helps the therapist locate a patient on a developmental continuum, suggests a place to join with the patient to begin the therapeutic work, provides data to develop therapeutic goals, and creates a valid construct for psychotherapy outcome measurement (Bjorklund, 2000; Burns, 1991). The person who gains ego strength as a result of his/her work with a therapist has made noteworthy therapeutic progress. Broadly defined, ego strength is the capacity for effective personal functioning (Burns, 1991). It encompasses specific capacities such as adaptability, resourcefulness, self-efficacy, self-esteem, interpersonal effectiveness, life satisfaction, and the many other mental health indicators succinctly encapsulated in Freud’s (1961) well-known phrase “to love and to work.” Like the solid foundation of a well-built house, ego strength supports the individual in the pursuit of life goals, dreams, and ambitions, especially during times of trouble. It ensures coping abilities, provides an individual with a sense of identity, can be recognized during initial assessment and throughout therapy, and increases as patients grow in maturity (Bjorklund, 2000). To the degree each ego function can be identified and assessed in the clinical situation, ego strength can be acknowledged, rated, reinforced, supported, built on, or “loaned” to some degree to lower-functioning patients by their relatively higher-functioning therapists in the process of identifying with the therapist’s own ego strength (Bjorklund, 2000).

Identification occurs through the ongoing corrective emotional experience that constitutes therapy and the therapist’s repetitive modeling of the kinds of coping behaviors indicative of ego strength. Table 4-2 identifies 12 ego functions and their definitions (Bellak, 1989). The list can be used as an assessment outline for the purpose of identifying patient strengths, or it can serve as the basis for self-reported or observer-rated ego strength assessment scales to measure more concretely a patient’s emerging ego strength. Table 4-3 provides an example of an observer-rated ego strength assessment scale constructed in everyday language. The assessment items in Table 4-3 suggest specific questions the therapist may ask to elicit information about the ego functions outlined in Table 4-2 and Box 4-10.

Table 4-2 Ego Functions for Assessment

Adapted from Bellak, L. (1989). The broad role of ego function assessment. In S. Wetzler & M. Katz (Eds.), Contemporary approaches to psychological assessment (pp. 270–295). New York: Brunner/Mazel.

Table 4-3 Observer-Rated Ego Function Assessment Tool*

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