Why Test?
Keeping the overall philosophy of why we test patients will help inform how you analyze/interpret findings and how you write the Report. Lets start with the purpose of why we test; e.g. to find deficits so we can diagnose them and then cure them? That sounds right for medical practices, but most mental health folks would be uncomfortable with this approach.
Medical Model
We are pushed from all sides to apply the medical model in mental health service – to get paid you must have a diagnosis severe enough to be reimbursable; i.e., there must be “Medical Necessity” to the problems you are testing for to get reimbursed by Medicare and insurances. BC/BS won’t pay for an assessment that yields a Z code like Z62.820 Parent-Child Relational Problem, or Z63.4 Uncomplicated Bereavement. You need to diagnose a “real” medical condition, your testing must be For the purpose of evaluating, diagnosing, or treating an illness, injury, disease, or its symptoms as summarized by Wikipedia.*
This is improving a bit, as Medical Necessity can be proved through documentation of specific limitations or functional deficits in a patient due to dementia. A big problem is when you, happily, rule out a neurocognitive disorder in someone who turns out to be just overly worried, say after caring for a parent with dementia. Diagnosing Age-related Memory Impairment/Loss will not be insurance reimbursable. This is because, medicine is based on a disease model. In psychology and education the disease model works rather poorly.
By now, it is likely you are feeling a little uncomfortable with this model, which implies mental disorders need to be diseases – something we intuitively know is not true – to warrant recognition in the medical/insurance world. Still, this concept is gaining ground in many places; e.g., note the increase in “Behavioral Health” attached to the name of mental health service providers. Let’s use a typical Emergency Room (ER) as an example setting:
Diagnoses Drive Treatment
The medical model seeks to find and confirm signs and symptoms that fit a specific disease so as to indicate a treatment. This makes sense in an ER. Using physical exam, imaging and lab procedures a doctor can reliably “diagnose” a broken arm after a fall, which leads directly to a specific treatment. The doctor spends a bit of time ruling out other contributory causes or factors (e.g., was there prior osteoporosis playing a role?) and then offers a diagnosis and treatment plan, to guide the ER staff in a standard treatment supporting a standard reimbursement to the hospital.
When the doctor explains the diagnosis of an ulner fracture to the mother of a ten year old complaining of arm pain after falling out of a tree, she will sigh with relief as she knows that now with a diagnosis, a restorative treatment is available. Such a treatment is well known, and is exactly the same in every ER in the world; i.e., reset the bone, and stabilize the arm with a cast so it can heal correctly. This same medical model works well in all medical and dental offices, but in mental health we rarely can repair damage or restore decay.
Try applying this same diagnosis–>to–>treatment model in mental health. A ten-year-old boy who can’t read is tested by a psychologist who diagnoses “a specific learning disability”; the mother sighs with relief because she trusts the medical model knowing that, now, with a diagnosis a treatment can be started to restore her son’s reading. Not so! There is no such specific treatment for a reading disability for which there are a dozen accepted different intervention strategies, making it treated differently in almost ever classroom in every school in the country. There is no clear path to “recovery” to restore reading ability. You can’t write something like “fractured ulna realigned and stabilized with casting” in your Treatment Plan (TP). By definition, the medical model first focuses on determining as specifically as possible damage or deficits, so as to yield a TP.
Deficit vs Strength Assessment
The medical model fails in education and psychological treatment settings. Cognitive and emotional problems don’t conform to physical difficulties where an observable defect can be found, and then repaired or replaced. This is why your supervisor complains when you write “depression” on the problem statement of a mental health TP. Depression is not a disease diagnosis that implies a specific treatment. People are not automobiles where broken parts are diagnosed and replaced. Your supervisor expects to see a TP for a depressed person listing specific behaviors that suggest depression in an observable and measurable way; e.g. Problem #1: Client is sleeping 12 hours per day, four more than usual. Now we have a problem statement that can be addressed, treated and measured as it improves or worsens; e.g., Plan #1: Re-establish use of client’s CPAP machine at least 5/7 nights per wife’s report, and note time of awakening in a daily diary for the next week. This could fall under a measurable TP objective; Goal #1: Client will awaken and rise after ≤8 hours, five night out of seven after treatment has occurred for a set period, like two weeks. If the objective is not met, then the Plan needs to be revised and tried again.
The take-away here is to be thoughtful as to why you test a person. In this writer’s decades of experience with LD kids, he has found it useful to look for strengths rather than deficits or weaknesses, to design a Treatment Plan. Explain to the football coach that his low reading grades are due to a learning difference (sadly, often called a learning “disability”) and as it is not due to poor effort, he shouldn’t be thrown of the team due to getting “D’s” on his report card.
If the objective is to improve reading comprehension to grade level, offer him reading subject matter of high interest – low readability, to get him to practice and enjoy reading for content rather than phonics. Play to his interests (strengths) by giving him reading regard his interests (e.g., football). Set him up as a volunteer with younger kids, helping them learn the alphabet to enhance his confidence. We have no “cures” in psychology, but we can enhance the natural learning capacity in people through motivation, exposure to practice and encouragement. Write your treatment plan (recommendations in a report) focusing on the strengths you find, rather than attempting to treat deficits. Acknowledge the deficits/weaknesses for diagnosing medical sign, symptoms and problems, as you must, to get paid via medical insurance which requires a medical model. But, use a motivational model based on strengths and interests, not a medical model, to guide your recommendations.
__________________
*We have a disease care, not a health care, system in the US. Consider the definition of “patient” vs. “client.” The archaic meaning of “patient” refers to a sufferer or victim. It implies a person who suffers while showing fortitude (patience) as they undergo medical care. Now consider the definition of a “client” who is a person who seeks advice and guidance from a professional. Which would you rather have – patients or clients – in your practice? The attempt to apply a medical model in mental health creates the perception that patients seek to repair their mental health in treatment; i.e. regain happiness. However, mental health clinicians don’t treat/repair people, instead they help their clients develop better, realistic coping strategies to manage problems in their lives.
