Publications
Buy Dr. Smith's book at LuLu.com
Buy Dr. Smith's book at Amazon.com
This excerpt from Dr. Smith's book gives details of his interview format during a Psychological Evaluation. If Dr. Smith sees you for counseling/psychotherapy, your interview will follow a pattern or protocol mostly generated by what you want and need to say, rather than by the more rigid format described below.
Excerpt from The Mental Status Exam and Brief Social History in Clinical Psychology
By Harwell F. Smith, III
The next question is “How many hours of sleep do you get in a typical twenty-four hour period, counting daytime and nighttime sleep?” If the person gets five or fewer hours on average, then I ask, “What sort of problem do you have with your sleep?” If they get more than five hours, then in my view, they do not have a problem with sleep, and I do not inquire any further. If they are getting more than ten hours, then that is almost always a sign of depression. If there is some suspicion that the person has posttraumatic stress disorder, I want to inquire specifically as to whether they are having nightmares. A lot of people have excess worry when they are trying to fall asleep. I try to find out whether they have initial insomnia, frequent mid-sleep awakening, or early morning awakening. If you wake up at four o’clock in the morning, but you went to bed at ten o’clock, I don’t regard this as the sleep problem of early morning awakening. You are simply getting six hours of sleep at night. The same is true if you wake up at three having gone to bed at nine. You have gotten a full night’s sleep. You may have some anxiety problem, but you do not have a sleep problem. If the subject is tired all day, that suggests that maybe he is not getting enough sleep.
If there has been no reference in the preceding exam to suicide, I start this section by asking, “Have you been having any suicidal thoughts recently?” Regardless of the person’s reply, I say, “Have you ever tried to kill yourself,” because there is literature that indicates that if the person has ever attempted suicide before, they are more likely to actually kill themselves this time than if they have not ever previously attempted. If the person answers that they are having suicidal thoughts, I want to know, “Have you made any plan to kill yourself?” I also want to know, if they are having suicidal thoughts, “What keeps you from it?” Most people, in reply to these questions, will cite their children’s sense of their loss of the claimant, or will cite their belief that they will go to hell if they kill themselves. It is important to state in your report your own clinical conclusion about the risk that the person will kill himself. It is not enough to establish that the person has not made any plan to kill himself, though he has suicidal ideas. An actual clinical judgment is required as to whether you, the clinician, think that the person is suicidal, and so what I will say in this circumstance is something like, “The imminent risk of suicide today is regarded to be small,” or “The imminent risk of suicide is small, but the intermediate to long term risk is large.” Obviously, if you make the determination that the person is likely to go out of your office and kill himself, then you have to do more than just let him leave your office today. In almost every occasion where this has occurred to me, I have been able to convince the person to go over to the state psychiatric hospital that day. I will also get the patient’s permission to let me tell the person who brought him to the exam that the patient is suicidal and has agreed to go to the hospital, and then I will go out and talk to the person and get that person to agree to take the claimant to the psychiatric hospital that day. I will sometimes call the hospital admitting office and alert them to the fact that the patient is coming. I will do this with the patient in the room, as I think that may sometimes cement the patient’s resolve to go to the hospital if they know the doctor is expecting them.
Sometimes there is a significant intermediate or long term risk of suicide that does not require that the patient go to the hospital today. In this case, if the patient will not go to the hospital today, I again talk with the person that came with the patient. I will sometimes call someone on the phone if the patient has come alone, the relative of the patient that the patient specifies, to tell that relative that the patient is having some significant suicidal ideation and needs to receive treatment with antidepressant medicine or evaluation by a psychiatrist immediately. If you let the patient leave your office with imminent suicidal intent, you have to be satisfied that he is going to go seek immediate treatment for this. So you not only have to get an affirmative confirmation from him, you have to be satisfied in your own mind that the patient has the mental capacity to follow through with his affirmation that he will follow through. You need to document that in your report.
I had a patient leave my office one time after a disability exam and go out and ask the lobby attendant where he could go to climb a telephone pole and electrocute himself. This person was obviously in need of immediate further psychiatric attention, and I failed to satisfactorily cotton to that. If he had successfully killed himself, I don’t think I would have been liable, but I would have been troubled.
Social Security would like me to ask every person whether they have homicidal ideas or not, but I hardly ever ask this question. I only ask the question in the case where the person has endorsed problems with anger, has previously in the exam expressed anger, resentment, bitterness, etc. at a particular person, in the case where the person has previous criminal conviction for violent behavior, and the like. I ask, “Have you been having any thoughts of wanting to hurt or kill anybody else?” This allows you to work into further questioning slowly, rather than just asking outright about homicidal impulses. Obviously, there are duty to warn issues and duty to protect issues raised here with the question of homicide, and your notes and report need to reflect that all these considerations have been attended to.
“Have you ever had a head injury where you were knocked out from being hit in the head?” If the person answers in the affirmative, then, “How long were you knocked out for?” I also want to know at what age the period of unconsciousness occurred. If it was just last week, the person could still have a post concussive syndrome. If the person was hit by a car when they were 5 years old and in a coma for six months, then they might have sustained brain damage before they ever went to school; so there would not be any way of knowing whether they were born with the cognitive limitations, or had the limitations imposed on them.
I also ask, “Have you ever had a seizure?” If the person answers yes, then I want to know the details of the seizure: when did they last have one? Why, if they have a history of seizures, are they no longer taking anticonvulsants? Was the seizure perhaps only related to alcohol poisoning? Does the person have grand mal or petit mal seizures; has the seizure disorder ever been diagnosed by a physician?
At this point in the typical interview, I skip to the family history, but if there has been any indication that makes me wonder about dissociative episodes, I will instead ask, “Have you been having any incidents of passing out or unconsciousness?” and then I will ask, “Have you ever had what they call a blackout where you would go on doing things or somebody would tell you they had seen you somewhere, but you wouldn't have any memory of it?” Sometimes a person with an alcoholic history will endorse this as a symptom of being quite drunk. It is very rare, even in a person with Posttraumatic Stress Disorder, that they have had these periods of lost time which are diagnostic of Dissociative Identity Disorder. If the person does endorse them, of course one wants to ask a variety of questions to ascertain whether DID is, in fact, being seen.
I ask the questions about family and childhood history at the end of the interview, because I do not want to traumatize the person early in the interview. I start out this section by saying, “Were you raised in the home by both parents?” If the person answers no, then I find out who raised the person. I always want to know the direct line of the family history. So if a person says, “My grandmother,” I say, “Your mother’s mother?” I record exactly who it was who raised the person. It is at this point that one often finds out about a parent who died when the child was young. This is an area where, as one begins to inquire, one will hear about the child having been raised in foster homes or group homes or having been taken away from the parents by the State.
“Did either of your parents have a drug or alcohol problem?” I want to know which parent did. Sometimes it is both. If both your parents were alcoholic your chance of being one yourself is 50%, so you want to be sure you have scrupulously researched the possibility of chemical dependency in this claimant. I also want to know whether the parental problem was an alcohol problem or a drug problem.
“Did either of your parents have any other kind of mental problem?” If the person answers 'yes,' then I want to know, “Did that person ever have to be in a mental hospital?” The fact the your mother was depressed or that your father was treated for anxiety does not really tell me what problems you might have, but if one of your parents has been psychiatrically hospitalized, then the chances that you have a mental illness are substantially increased. In cases of severe psychiatric disturbance, like Bipolar Disorder I or Schizophrenia, I will ask not only about the psychiatric history of the patient’s parents, I will ask a number of follow-up questions, including whether any of the patient’s siblings has ever been psychiatrically hospitalized, whether any of the parent’s siblings have been, and then I will say, “And now I want the ask you about your grandparent’s generation.” “Did either your grandparents themselves or any of you great aunts or uncles ever have to be in a psychiatric hospital?” I have formed a bias over the years that Bipolar Disorder I and Schizophrenia are inherited illnesses. One occasionally sees a true Bipolar I or Schizophrenia diagnosis with no family history, but in almost every case, one will find that if one inquires into all three generations, one will find the family history of the illness.
The final area of inquiry is the one that is the most disturbing for people. I ask, “Were you sexually abused as a child?” Since you want to know about both sexual and physical abuse, you have to ask the sexual abuse question first. Otherwise, if you ask the physical abuse question first, the person who was sexually abused might answer yes to the question about physical abuse, and you still would not know what they meant by that. Sometimes people will tear up when they answer the question about sexual abuse. If the person says something other than ‘no’, for example,” not that I know of,” or “not that I remember,” then I record that and note it in the report. Why would you say, “Not that I know of,” unless there was a good chance that you had been sexually abused and you were hiding it from yourself?
If the person is unsure whether he has been physically abused or not, I ask the second question, “Did you ever have blood or bruises raised on you?” If he did, then he was physically abused. If somebody has previously endorsed a history or parental alcohol use or abuse as a child, then at this point I ask the person, “Did you witness violence between adults as a child?” There is considerable evidence that witnessing abuse as a child contributes to adult psychiatric problems. If the person is a woman, I will ask, “Have you been physically abused as an adult?” I will also ask this question of vulnerable male populations, for example, men of diminutive stature or men with HIV.
Buy Dr. Smith's book at LuLu.com
Buy Dr. Smith's book at Amazon.com