The Mental Health Clinician's Workbook Locking In Your
Professional Skills
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The Mental Health
Clinician’s Workbook
Locking In Your Professional Skills
JAMES MORRISON
THE GUILFORD PRESS
New York London
Copyright © 2018 The Guilford Press
A Division of Guilford Publications, Inc.
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All rights reserved
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Last digit is print number: 9 8 7 6 5 4 3 2 1
The author has checked with sources believed to be reliable in his efforts to provide information
that is complete and generally in accord with the standards of practice that are accepted at the
time of publication. However, in view of the possibility of human error or changes in behavioral,
mental health, or medical sciences, neither the author, nor the editor and publisher, nor any
other party who has been involved in the preparation or publication of this work warrants that
the information contained herein is in every respect accurate or complete, and they are not
responsible for any errors or omissions or the results obtained from the use of such information.
Readers are encouraged to confirm the information contained in this book with other sources.
Library of Congress Cataloging-in-Publication Data
Names: Morrison, James R., author.
Title: The mental health clinician’s workbook : locking in your professional skills /
James Morrison.
Description: New York, NY : The Guilford Press, [2018] | Includes bibliographical references
and index.
Identifiers: LCCN 2017055918| ISBN 9781462534852 (hardcover : alk. paper) |
ISBN 9781462534845 (paperback : alk. paper)
Subjects: | MESH: Mental Disorders—diagnosis | Interview, Psychological—methods |
Diagnosis, Differential | Problems and Exercises
Classification: LCC RC469 | NLM WM 18.2 | DDC 616.89/075—dc23
LC record available at https://lccn.loc.gov/2017055918
To the memory of Alan Carl Morrison, 1987–2014
About the Author
James Morrison, MD, is Affiliate Professor of Psychiatry at Oregon Health and Science
University in Portland. He has extensive experience in both the private and public sec-
tors. With his acclaimed practical books—i ncluding Diagnosis Made Easier, Second Edi-
tion; DSM-5 Made Easy; The First Interview, Fourth Edition; Interviewing Children and
Adolescents, Second Edition; and When Psychological Problems Mask Medical Disorders,
Second Edition—Dr. Morrison has guided hundreds of thousands of mental health profes-
sionals and students through the complexities of clinical evaluation and diagnosis.
vii
Contents
Introduction 1
1 Good Beginnings—Abby 5
2 Complaint Department—Brad 18
3 Past Is Prologue—Candice 32
4 Decision Tree—Douglas 43
5 Transitions—Elinor 55
6 Safety First—Fritz 68
7 Central Casting—Gloria 77
8 Self-Defense—Hank 87
9 A Mystery and an Enigma—Inez 98
10 Now and Then—Julio 109
11 Small Bites—Kylie 117
12 Swan Song—Liam 128
13 Age-Old Questions—Melissa 142
ix
x Contents
14 Family Secrets—Norman 154
15 Rejections—Olivia 163
16 To Tell the Truth—Pierce 177
17 Encore—Quinn 194
18 Nil by Mouth—Randolph 203
19 Ghost in the Machine—Siobhán 214
20 Compelling Evidence—Tyler 225
21 Character Reference—Uma 234
22 Motion Sickness—Vincent 244
23 Role of the Dice—Whitney 255
24 Fill in the Blanks—X 268
25 In Other Words—Yasmin 280
26 Goodbye and Good Luck—Zander 290
Appendix—Tables 303
References and Suggested Reading 315
Index 323
Introduction
I have chosen the title of this book with some care, rejecting the alternative Casebook as
not quite conveying what I’ve tried to do. Of course, I hope the many case histories you’ll
encounter here will help you along the road to a better understanding of how a mental
health clinician evaluates a patient. But mostly, because we all learn better by doing, I ask
you at many, many points in the course of these discussions to lean in and work through the
material. There are lots of boxes to check off, and lots of stuff to write down.
Each of these fictionalized histories is constructed to encourage you to think about the
processes of obtaining information from and concerning patients, and about the process of
making a diagnosis. To a degree, each discussion builds on what has come before; that is, I
intend these cases to be read serially. Each of the 26 cases in my “alphabet” of patients (note
that, in naming them, I’ve started with A and marched right through to Z) features a differ-
ent individual with different problems, and each comprises a series of Steps and Notes, as
well as some additional features.
•• Steps (which are numbered) contain the life stories of the patients, and ask for your
input about their evaluation. At the end of each Step, I pose a question about the material.
Usually I try to provide a number of choices for your response. That’s because I don’t want
to put you in the position of having to guess from the universe of possible responses what
I’m thinking. OK, once in a while, multiple choices may not be possible, or may even prove
counterproductive. But I’ll try to keep those instances to a minimum.
•• Notes (which are given capital letters) discuss the answers to the questions I’ve asked
throughout the Steps in each case.
•• The Takeaway briefly summarizes what I’ve hoped to accomplish in each case, espe-
cially which principles, rules, and diagnoses have been covered.
•• In a number of Rants, you’ll find special issues—overdiagnosis of some disorders, for
example—that ruffle (or sometimes smooth) my feathers. I have attempted to resurrect and
1
2 The Mental Health Clinician’s Workbook
address every one of these enemies of good diagnostic practice, so that perhaps they will
begin to bother you, too—enough that you will avoid them.
•• And in a series of Break Time discussions, I’ve indulged some of my other interests.
Mostly, though these brief discussions are all related to mental health issues, I’ve tried not
to involve actual interview techniques and diagnostic criteria. OK, sometimes I’ve failed
utterly. You can indulge me or ignore me as you wish; obviously, what you do on your break
is your business!
•• Supporting literature for each chapter is included in the “References and Suggested
Reading” section at the end of the book. I’ve included each reference specifically mentioned
in the text, plus others that I think are just plain interesting. As often as possible, I’ve fea-
tured those that offer free full text—either through a specific website that I’ve listed, or
through the U.S. National Library of Medicine’s PubMed database. For the latter, just enter
the full title of the article into the PubMed search box and press the button.
•• Finally, anyone who wants to look up to see where I’ve deployed a particular inter-
viewing issue, diagnostic principle, or main diagnosis can refer to the three (rather boring)
tables in the Appendix. There I’ve listed them by case, with page references to three of my
other books.
However, you’ll find little in these pages about treatment options. That’s because I’ve
intended this book as an introduction to the science and art of interacting with patients, in
the service of two goals: forming a relationship, and obtaining the information needed to
make a diagnosis. For treatment issues, many texts and monographs are available. I’ve men-
tioned a couple of my favorites in the References.
How might you use this book? Let me count the ways.
• You could use it as an exercise book when learning to do mental health interviews or
reviewing the basics of diagnosis. This might take place either in a classroom or as a
self-study effort.
• You could instead put it to use as a self-study guide to the mental health issues and
principles I’ve talked about in my other books.
• You might employ it as a review guide in preparing for various qualifying exams.
• Or you might use it as a stand-alone book, without reference to some of the other
materials cited. But I think that would be passing up a good opportunity.
• Finally, you could treat it as a storybook and just read right through without trying
to complete the exercises. I suspect some readers will be tempted to do just that. But
I predict that they will take less away from their experience than will those who put
in the effort to do the exercises as they engage with the material.
Whatever your needs, I do hope that before reading each Note, you will take time to
think about the possible answer(s) you could give to the question posed in the preceding
Step, and to write down your choice(s). Only then should you compare your choice(s) with
what I’ve written. I believe that through this active learning mode, you’ll get the very most
out of the time you spend with this workbook. Of course, you could just read the stories and
Introduction 3
questions in the Steps, and then read my answers in the Notes, without ever really engaging
with the active learning process. You could get through the text a lot faster that way, but I
think you’d take much less away from your experience.
One more caution: When I get a new book, I’m sometimes tempted to tear right through
it in just a few marathon sessions. But in this case, please don’t follow my lead. Rather, do as
I say and practice moderation; I think you’ll get more out of this book if you take it in small
bits. For one thing, you’ll fall into the habit of thinking in terms of a differential diagnosis;
for another, you’ll remember the steps to a diagnosis better if you repeat them on many dif-
ferent days, rather than doing it all at once.
Finally, let me confess that many of the ideas expressed herein are issues I would have
liked to set forth right at the beginning. But if I had, the case of Abby would have taken up
more than half the book, and the rest would be review. This is another way of saying that
some of what you read in later chapters might have been good to know earlier. That’s just the
way with workbooks: They’re a lot of work, for both the reader and the writer.
I am indebted to Hans J. Markowitsch at Bielefeld University in Germany, and to David
Barnard at Oregon Health and Science University, for their assistance in the preparation of
the material in this book. I am also indebted to the many people at The Guilford Press who
have labored, sometimes under duress (caused by me!) to bring this and my other books to
fruition. I especially have in mind Kitty Moore, Marie Sprayberry, Anna Brackett, Judith
Grauman, Carolyn Graham, Katherine Lieber, Martin Coleman, David Mitchell, and Sey-
mour Weingarten.
I want to express gratitude to my first readers, Mary Morrison and Kitty Moore, for
their careful reading and many excellent suggestions. And I especially thank my friend and
colleague JoAnne Renz for reading and commenting on every chapter of the penultimate
draft. Her many valuable suggestions have improved the text remarkably. In the end, of
course, any errors of fact or infelicities of expression are entirely my own responsibility.
1
Good Beginnings—Abby
Step 1
“This school’s right for me. I know it in my heart.” That’s how Abby begins her story.
Indeed, Abby’s first few weeks at college seemed to go swimmingly. She enjoyed
her classes—she even excelled in the challenging humanities course all freshmen had
to take—and she’d begun a relationship with a fellow biology major, now in his second
year at the school. She’d telephoned her mother a couple of times, but so far hadn’t
shared any of her anxieties.
Abby’s high school grades and extracurricular work had earned her a full scholar-
ship. Indeed, as she elaborates now on her successes (even “blessings,” she calls them,
though she later acknowledges that she doesn’t think she is a believer), you might be
tempted to ask, “What are you even doing here in my office?”
Or would that be a mistake? Just what should you say at this point?
As suggested above, ask frankly, “Why are you here?”
Suggest that you’d like Abby to focus on her recent experiences (in other words,
what’s happened to her since she came to college).
Or just keep quiet and let her talk.
Note A
Wouldn’t you just know—the first question in the book, and it’s a trick! I’d feel ashamed,
if it weren’t that I want to drive home the importance of listening to what patients have
5
6 The Mental Health Clinician’s Workbook
to say. It’s a point I’ll make time and again, so be prepared for a little parentalistic*
redundancy.
In my view, asking anything would be a mistake when you have a patient who is intel-
ligent, motivated (Abby has appeared at the office more or less under her own steam), and
is pouring forth a stream of information without prompts from you. OK, maybe she’s telling
more than you want to know right now, but it’s all stuff you’ll need eventually. Consequently,
I’d let her come around to the point in her own time.
From every patient you encounter, you want a fair sample of what I call free speech.
That’s the uninterrupted production of thoughts, ideas, feelings, and fears—whatever men-
tal or emotional content that has impelled the patient to your door. Free speech gives you
the opportunity to hear what’s important to your patient, and it provides you the opportu-
nity to listen for two sorts of speech characteristics.
1. The first is the person’s speech cadences and tonal variations (termed prosody). For
instance, do you detect the slow, hesitant beat of the depressive voice? Or a flat-
tened, devoid-of-emotion tone that may also signal depression, but can even indi-
cate psychosis?
2. The second is flow of thought. Does one idea emerge naturally from the one before?
Do you note any irrelevancies in the speech—perhaps a skipping from one concept
to the next, so that the two ideas appear unconnected? Whatever you hear, even a
few moments of free speech can provide a good start for most mental health inter-
views.
So for now, to encourage a longer run of free speech, if you need to say anything at all, it
should be something wonderfully open-ended and encouraging, such as the clinician’s clas-
sic comment “Tell me more.”
Stay tuned: We’ll talk more about these issues later on in the book. And for the rest of
this case presentation, I’ll stay out of the way. I’m not setting a precedent for future discus-
sions (far from it; mostly, I’ll interrupt until you may wish otherwise), but I’d like to start
out with something a little simple, something clean and clear—in short, a good beginning.
Step 2
In the following narrative (as in similar case material in several later chapters of this book),
some of the material is underlined and given superscript numbers (1). We’ll use those bits to
answer the questions in Note D.
As Abby’s story unfolds, you can see how things began to go awry. Some issues were
minor—just before the Thanksgiving break, she’d gotten back a test paper that bore
*Yes, I know the word is “paternalistic.” Each of my half-dozen or so dictionaries lists it that way; even Gail
Collins used it in one of her New York Times columns, for Pete’s sake. But I prefer my own almost-neologism
(and perfect anagram), partly for its stick-in-the-eye challenge to maintain vigilance for fairness in communi-
cation.
