At Bridge House, we specialize in the assessment of people with highly complex psychiatric and behavioral presentations who have been labeled as treatment-resistant.
In the mental health field, assessment has been conflated with diagnosis, meaning our current approach for determining what an individual is struggling with and what to do about it starts with clearly defining a list of psychiatric diagnoses. This approach is problematic for several reasons:
1. Psychiatric diagnoses are imperfect constructs that are still evolving as our understanding of them deepens.
2. Our current diagnostic system(s) does not account for co-morbidity, which is more common than a collection of otherwise completely isolated conditions.
3. A simple list misses the complex interplay between multiple factors in an individual’s life and does not provide a foundation for understanding the functions of behavior.
Instead of beginning with a list, we begin with a story. We take the time to get to know the person, their experience, and what life has been like for them. A narrative example is the best way to demonstrate how we approach this process. The following is a fictional case that includes many of the elements we often see with our clients and delineates how we approach assessment:
Our imaginary client Barry is a 23-year-old male who was struggling in college and unable to return after a prolonged leave of absence. He has moved back home and feels stuck and trapped. His family is frustrated with his pattern of sleeping in late and avoiding interacting with anyone, and are particularly bothered by his habit of texting them from his bedroom rather than coming downstairs and talking in person. During the pandemic, he had struggled with online classes and felt like he had lost momentum since then. He used to think of himself as a good student and didn’t know what happened or how to get back to his old self. He is experiencing several symptoms of depression: poor concentration, lack of interest, irritability, increased appetite, dysregulated sleep, and, more recently, the development of suicidal thoughts. His biggest complaints currently are feeling like he can’t focus on the most basic things or do anything right, and he feels too exhausted to do any of the things he’d need to do to help himself. He is irritated by the suggestion that he is “just depressed” and is worried something worse is wrong.
Barry is the middle child with an older brother and a younger sister. His early childhood was generally happy but notable for frequent ear infections. In early elementary school, there was concern about inattention and a speech delay, which was later determined to be due to conductive hearing loss. He was treated with bilateral tympanostomy tubes, and his speech improved, but he often still appeared to be disinterested or not paying attention. His father passed away suddenly from brain cancer when he was 11. His mother has a history of depression. Barry’s older brother began struggling with behavior and left the home to attend boarding school after his father died. Barry first saw a therapist and psychiatrist in 6th grade and was tried on several antidepressants but was reluctant to engage. He had been diagnosed with major depressive disorder when he was 12, and more recently, he was diagnosed with adjustment disorder in college. Because of his excessive daytime sleepiness, he had completed a sleep study but was not aware of the results or any recommendations. Barry saw a neurologist for his headaches, who reassured him he did not have a brain tumor like he feared and recommended therapy for stress. Barry tried to attend talk therapy but felt like nothing they talked about “stuck”, and then missed appointments because they were too early in the day, leading to increased frustration from his family members who felt like he wasn’t trying to change his situation and just didn’t seem to care about anything.
After learning about Barry’s story, we begin by writing down all the symptoms reported in a cloud-like formation. We use a wall-sized whiteboard in our weekly treatment team meetings to capture and organize diagnostic information. We are careful to separate out symptoms from behaviors, which we list below. We add to the diagram what we know about the family system and developmental dynamics and assess how these may have influenced the patient’s development, values, and defense patterns. Some symptoms may require additional workup to rule out medical causes. Barry had previously had a sleep study demonstrating mild obstructive sleep apnea. A CPAP machine was obtained for Barry, and he began using it nightly while at Bridge House, and he noticed feeling more alert and less irritable. Barry was also started on an antidepressant in a different category than those he’d tried in the past. When medications and other treatments are indicated, we include them in the diagram and indicate which symptom(s) we are targeting.
Through our informal and formalized measures that we use for assessment, the symptom cloud is divided up, designating discrete symptom complexes (diagnoses) while demonstrating areas of comorbidity. The final diagram resembles a series of overlapping bubbles, with arrows extending outward when describing how these symptoms lead to behaviors and arrows pointing inward, indicating areas of intervention. After completion of the psychological evaluation, which demonstrated relatively lower verbal than non-verbal scores, and processing delay, which was more evident in verbal versus visual tasks, we are able to make more connections between the factors that influenced the presentation of the client’s symptoms, behaviors, and most importantly to determine the function of those behaviors so that effective interventions can be crafted.
Using the diagnostic diagram as a reference tool, we generate a diagnostic formulation that answers these questions:
1. What is occurring?
Barry has major depressive disorder, a previously untreated sleep disorder, and an auditory processing disorder. Yet, the combination of all of these conditions layered on top of his personal history, viewed through the lens of his unique cognitive profile, has created his current presentation. This constellation of symptoms specifically amplified his physical symptoms of constant exhaustion and frequent headaches leading him to worry more about a medical problem rather than a psychiatric one. His beliefs about the utility of therapy were colored by his prior experiences with treatment after the loss of his father because, at the time, his symptoms were more consistent with grief than depression.
2. Why is it occurring?
Barry’s depression arose from his genetic predisposition and due to life events. Barry has always had chronic congestion and gained weight during his depressive episode, leading to him developing obstructive sleep apnea, which quickly becomes a feedback loop that generates increased weight gain and worsening symptom severity. This prevents him from getting restful sleep and contributes to difficulties concentrating, remembering important things, and maintaining consistent energy. Barry also has auditory processing disorder, a condition where a person can hear, but their brain doesn’t know what to do with the information. This may have occurred because he had conductive hearing loss as a child during periods important for language acquisition. As a result, he struggles to pay attention to auditory input in certain settings, like when too many people are talking at once or he cannot see the person who is talking. This made college extra challenging, both in large classes and when lectures were online. He used to be able to compensate for some of these challenges, but his fatigue and increased difficulty concentrating due to untreated sleep apnea and evolving depression made it impossible. When he’s overwhelmed, he appears disinterested or like he is not listening, damaging relationships. He has learned to retreat and withdraw rather than risk negative feedback. He focuses more on physical complaints because they are easier to describe than more complex emotions, and he has learned that keeping his emotions to himself is safer. Lastly, he appears to be “help rejecting” because his early experiences with treatment were invalidating, and his more recent experiences occurred in a format that was hard for his brain to process. Hence, he developed the belief that treatment doesn’t work for him.
3. What is the least restrictive level of care that can meet Barry’s needs?
For Barry, living at home makes him feel acutely aware of his lack of progression in life and sets him up to compare himself unfavorably to his siblings – the environment is not conducive to avoiding unhelpful thought patterns that keep him stuck; however, he still needs support. Barry would benefit from a transitional living level of care – a model of treatment that begins in a more supported environment, facilitating skill-building and progressing toward greater independence through meeting small goals. The ideal program for Barry’s next steps would include a period of living in a small group of similar peers, participating in therapy using other methods besides talking which can be hard for him to process, meeting regularly with a psychiatrist to manage his medications, seeing a sleep specialist to maintain and optimize his CPAP use, and then transitioning to living independently with those same wraparound supports. Since Barry has consistently expressed wanting to return to college, it would be recommended that he start by taking one class while in transitional care. He will most likely be successful if he uses this opportunity to request accommodations for auditory processing disorder and then practices multiple strategies to determine what works best for him in a college setting.
After transitional care that has been informed by an in-depth and accurate assessment, Barry will have his medical and psychiatric conditions managed and will feel more energetic, engaged, and open to positive experiences. He will have gained a greater understanding that not all bad feelings are bad: grief and sadness are normal responses to bad situations, AND when they are prolonged and interfere with the ability to live a normal life, it is possible and necessary to treat them. He will have learned that there is a reason for his difficulty understanding things in some settings but not others. He will have stopped being frustrated with himself because he has tools to navigate perceiving sounds differently – he knows that online zoom presentations with a narrating voice but no visual of a person talking do not work well for him, so he seeks out other formats for school and work, and asks for accommodations when necessary without embarrassment.
By beginning with the client’s story and lived history and utilizing a visual aid for our understanding of complex interactions between genetics, emotions, behavior patterns, beliefs, and environment, we can establish a comprehensive view of a client’s challenges. Our assessment does eventually include a list of diagnoses. Still, the path we take to arrive at those conclusions involves a more nuanced understanding, resulting in more accurate recommendations for the right support for our clients.