Chapter 5
ORGANIZING AND PRESENTING THE DATABASE

This chapter begins with tools for organizing the data you have gathered (see Chapter 2) and gives guidelines for presenting data, with emphasis on the importance of keeping data separate from conceptualization. (Table 1.1 in Chapter 1 illustrates the SOHP format, the basis for this and the next two chapters.)

PROCESSES FOR ORGANIZING DATA

There are three topics in this section: timelines, organization of the written client history, and content of clinical observations.

Timelines

There are two timelines that should be created for every client: one for the recent history, leading up to the initial contact with a mental health practitioner; and one for the complete life history.

Writing information on timelines immediately after the initial session, when your head is flooded with facts, will give you confidence that you have a good memory and do not need to take notes continuously during the session. The timelines engage your creativity in developing good formulations and recognizing important gaps in the database. If you need to write a formal report, the narrative of the database is already outlined, and you can organize the flow of the story in chronological order.

Recent History Timeline

A recent history timeline is a horizontal line with the right end representing the present moment and the left end representing the point in the past that marks the beginning of events or experiences that led to the need for mental health services. In inpatient settings, using the acronym PTA (prior to admission) is convenient shorthand for reporting time sequences. Figure 5.1 shows a recent history timeline for Maria, the client whose problems you addressed in Activity 3.1 and 3.3.

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Figure 5.1 Recent history timeline for Maria (see Appendix III for case history)

In your exploration of the problem (see Table 2.1), you will have gathered data to indicate what should be the starting place—a major event, change in functioning, or onset of acute symptoms.

Life History Timeline

With a timeline that covers the entire life of the client, you have a visual aid to understanding the stages, transitions, and key events in the client’s life, both as the client sees them, and through the lens of your psychological knowledge of developmental stages.

It is important to know what stage the person is currently dealing with (e.g., “leaving home,” or “empty nest”), as well as the relative success with which the tasks of prior developmental stages were accomplished. In childhood and adolescence, the developmental tasks follow a predictable course, depending on age, but during adulthood, there can be great variation in the sequence of developmental tasks. For certain cultures, there are strict norms about the developmental stages of adulthood; with others, there is flexibility. It is important to know the cultural norms because people commonly use them to evaluate where they are in life, and can be harshly self-critical (or barraged by criticism of family) if they are “behind schedule” in achieving milestones such as being self-supporting, or having children. Gender is also an important factor; for instance, the challenges of balancing parenthood and career are different for women than for men.

Constructing a timeline simply requires a blank piece of paper and a horizontal line. Once you know the client’s current age, you can mark that number on the right end of the line. Indicate zero for the year of birth near the left end, allowing space prior to birth for genealogical information, data about pregnancy, and the parents’ situation prior to birth. When permitted to tell their stories freely, clients will often present haphazardly: knowing you have the timeline as a tool, you will not feel compelled to interrupt the client’s flow.

The timeline is most useful when all of the information is anchored by the age of the client. The following example from an intake performed in 2011 for a 38-year-old woman shows how to figure out the client’s age for the timeline, assuming the intake was conducted in 2012.

Once that information is put on a timeline, the life history is easier to grasp; additional facts can be added as the therapist learns them. Figure 5.2 provides a life history timeline for Maria.

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Figure 5.2 Life history timeline for Maria (see Appendix III for case history)

The events that you put on a timeline will depend on the client’s life story. You definitely want to include information about past psychological problems, psychiatric treatment, medications, and so forth (remember that the recent history timeline has data about the onset and development of current symptoms). Here are some ideas about significant life history events:

  • Childhood and adolescence: Births of siblings, deaths of grandparents, separations from parents, transitions in schooling, relocation to new neighborhoods, changes in school, changes in family composition from divorces and remarriages, special achievements, hobbies, activities, significant friendships, onset of puberty, first romantic relationship, driver’s license, child-care responsibilities, beginning of sexual activity, first job.
  • Adulthood: Moving out of family home, post–high school education, employment milestones (e.g., change of jobs, promotion, periods of unemployment, retirement), marriage, living arrangements, separation, divorce, changes in family composition (e.g., birth of first child, birth of other children, last child leaves home), death of parents, tragic events or traumatic experiences, special achievements, hobbies, activities, creative pursuits, geographic relocation, health problems, accidents, operations, chronic illnesses.

During case conferences and supervision groups, each person can draw a timeline and jot down notes as the speaker presents information. I regularly do this and find interesting connections or important gaps.

Most commonly, the therapist will draw the timeline after the first session, and new information is added as therapy progresses. Timelines can also be drawn sitting side by side with the client, as you would do a genogram (see Chapter 2). A creative homework assignment, based on Progoff’s (1992) approach to journaling, is to instruct the client: “Make a list of 10 to 12 turning points (or stepping stones) in your life. These should be events that were significant because they were the start of a new phase for you. They could be traditional milestones, like starting high school, but there should also be events that have personal meaning for you.”

Cohort refers to a group of people born at the same time. When you know a person’s age, you also know the year of birth, and this gives you information about the person’s life history in a specific historical context. An example of a cohort difference is age norms for marriage in the United States: In the 1950s, a woman who got married at the age of 23 was older than expected—practically an “old maid,” whereas in the present decade, 23 is considered young to be a bride. Different cohorts are given nicknames. The term baby boomers is applied to the cohort of people born after World War II, and who are now beginning to inflate the ranks of the senior population. Generation X (Gen X) was born in the 1960s and 1970s; Gen Y, also called Millenials, are the subsequent cohort.

When you know the cohort, you know the social, political, and economic factors that influenced life experience, including wars, the Depression, cultural movements (e.g., the civil rights movement), and so on. Different cohorts encounter different developmental challenges as they leave adolescence. You can speculate about the significance of entering the job market during the era of the Depression (or in 2010, when employment was at 13.5% in certain states), and the impact of feminism on women entering early adulthood during the late 1960s. Increased longevity and economic factors have radically changed the nature of development after the age of 50. Years ago, age 70 was viewed as close to the end of life, whereas now it is often the beginning of a phase of at least 15 years, which can involve new friends and interests. The following example shows the kinds of hunches you can form, based on knowledge of the client’s age and cultural data.

If your client is of the same age and culture as you are, you can make assumptions that you are familiar with the historical and cultural events in this person’s past history, but you cannot assume that you understand how the client interprets those events. For clients from other backgrounds, you need to ask questions and do research on significant cultural and historical events. For instance, if someone from Iran talks about geographic relocation in the late 1970s, you should know that the cause was the Islamic revolution. When working with Jewish clients, the Holocaust may be a significant factor in their personal histories and identities, even if they were born after World War II. It is useful to consult a timeline of historical events for the client’s country of origin as well as for the country where you live, obtainable online at many websites (e.g., www.infoplease.com/yearbyyear.xhtml).

Client History

In a traditional report format, the data gleaned from the client (often called the patient history) is presented in a narrative under specific topics: Identifying information, presenting problem (and reason for referral), current situation, prior psychiatric or psychological treatment, family history, educational and occupational history, social and sexual history, and other topics, when relevant, such as military history.

When you are using the problem-oriented method and SOHPing each problem, the database is presented in two different parts of the report:

  1. Background section prior to the problem list: This section includes some of the categories of the traditional case history—identifying information, presenting problem (reason for seeking help), and some life history details, which may be subdivided as needed, along with a section for clinical observations. Use the background section for (a) general information about the client’s history and (b) data that would be repeated under different problem titles.
  2. After each problem title: After the problem title and its accompanying outcome goal, data that are relevant to the problem are presented in the subjective (S) and objective (O) categories.

Clinical Observations

In the background section, you will typically have a “Clinical Observation” section to describe the mental status of the client and to evaluate the type of relationship the client forms with you, a stranger and a helping professional. In the mental status exam (MSE), the clinician uses a specific vocabulary and set categories of information to describe a client in the following categories: appearance, level of consciousness, orientation (to person, place, and time), motor behavior, interpersonal behavior, speech, mood and affect, perception, thought content, thought processes, intellectual functioning, memory, impulse control, insight, and judgment. Zuckerman (2010) provides a guide to report writing with numerous examples of terminology for putting clinical observations into words. The MSE contains descriptive terms applied by a professional expert (you) without conceptualizing or diagnosing. It is therefore part of the database, not the formulation. Because the MSE is usually taught for use with patients with severe pathology, it is generally more difficult to describe a “normal” client than to describe one with pathology.

The clinical observations that you place in the O section must be relevant to the problem title. Your own personal reactions to the client are important data. Sometimes labeled as countertransference, these reactions are only an obstacle to good treatment if you act on them without reflection. When you reflect on your reactions and describe them objectively, they may be very useful in advancing your understanding of the client.

STANDARDS FOR DATABASE

There are four standards that apply to the presentation of data in your case formulation.

Mingling formulation ideas with the database is very common in your first draft. By doing so, you show that you are thinking creatively and interpretively about the data rather than summarizing it in a mechanical, unimaginative way. When you review your first draft, you can cut and paste the formulation ideas, moving them to the hypotheses section. When the client states his or her thoughts in a way that sounds like a formulation (perhaps by using psychological jargon), it is essential to use quotations to show the reader that it is the client who is formulating, not you. Here are examples of two ways that the standard can be violated and how to correct those violations.

Error 1: Formulation Ideas Appearing in the Subjective Data Section

  1. Original wording of Section: The client has been the primary caretaker in her family since she was a child. Her mother was emotionally unavailable. As a result, she tends to meet her own needs and does not seek assistance from others.
  2. Revision, when the formulation ideas came from the client: The client described herself as “the primary caretaker” since she was a child. She explains her difficulty seeking help from others in these words: “Since my mother was emotionally unavailable, I tend to meet my own needs and I don’t seek assistance from others.”
  3. Revision, when the formulation idea is yours (rewriting subjective data section, and moving your formulation idea to the hypotheses section):
    1. S: As a child, the client prepared meals for her family, felt responsible for cheering her mother up when she was unhappy, and took care of getting her younger sister to school and helping her with homework.
    2. H: The client has been the primary caretaker in her family since she was a child. It appears that her mother was emotionally unavailable and never attended to her needs. As a result, she tends to meet her own needs and does not seek assistance from others (Recurrent Pattern [P2] hypothesis).

Error 2: Formulation Ideas Appearing in the Objective Data Section

  1. Problem: Dissatisfaction with current job and unrealized ambitions for material success
  2. Original wording of O section: It was clear to me in our first session that John is expecting more out of life than what he is putting into it. Because he is smoking marijuana on a daily basis, he is unable to gain the motivation to think clearly about his work. (This lacks data and is pure formulation.)
  3. Revision:
  4. O: John’s description of his work was confusing and disorganized. There were times when he would forget what he was saying, and I would have to remind him. He seemed apathetic at times, and did not take initiative but waited for me to direct the session. His explanations for lack of success focused on shortcomings of others.
  5. H: John is expecting more out of life than what he is putting into it. Smoking marijuana on a daily basis may affect his motivation and prevent him from thinking clearly about his work.

When therapists work from a single orientation, they are interested only in data relevant to their theoretical framework. Practitioners who work from other orientations, or who have chosen to be integrative, will judge their databases to be incomplete and biased. In medicine, the database has to be “complete” for the purposes of making a diagnosis, but when dealing with psychological and social problems, the range of relevant data is so broad that it is impossible for it to be complete. Instead the word sufficient is better—sufficient for selecting appropriate hypotheses and designing individualized, effective treatment plans. When those tasks can be accomplished, there are diminishing returns for amassing more information.

The term comprehensive embraces the following criteria:

  • There are specific details and examples; the tone is particular, not general; and the information is concrete, rather than abstract or vague.
  • The information covers a wide scope and is not limited to one narrow aspect.
  • Nothing essential is lacking. When you read the formulation, you find evidence that supports the conceptualization.

If a case formulation report is based on only one session, the database will naturally have gaps. There are several reasons for concluding that the database is not sufficiently thorough:

  • You discover that new data are introduced in the hypotheses or plan sections.

    It is acceptable for data to appear in those sections of the report only when you are repeating data that have been presented previously in the database sections (background, S and O). When the therapist remembers data during the creative process of writing the formulation, then he or she must go back and revise the data section, often just by copying and pasting the missing data.

  • The hypotheses section does not have substantiating evidence in the prior database.

    For example, the following sentence appears in the formulation: His problem stems from the difficulty he experienced in trying to get his needs met by his mother. However, the database lacked anecdotes from childhood or descriptions of his mother’s style of relating. This deficiency in the report can be rectified only by learning to use hypotheses during the session to guide the gathering of data. If there are no substantiating data, then the hypothesis should be discarded from the formulation.

  • Supervisory sessions or tapes of sessions reveal important data that were not included in the database.

    A benefit of using tapes or written transcripts is that someone else can recognize important omissions. Group supervision, where people from many different perspectives ask questions, also is invaluable for helping the therapist recall facts that never made it to the stage of designing the formulation.

A comprehensive database should selectively include direct quotations from the client: Quotations help the reader see the client as a real person, not just a case, and give a sense of the client’s way of speaking, level of insight, and patterns of thinking. Well-chosen quotations provide evidence to support specific hypotheses, and are especially valuable when using cognitive hypotheses. When sessions are not taped, the therapist has to take time immediately after the session to capture good quotations from memory.

Feature films can be useful for case formulation practice; one student used When Harry Met Sally, treating Harry as a client with this problem: Difficulty maintaining an intimate, committed relationship with a woman who both attracts him and can be a good friend. Here is an excerpt from the subjective section that shows the appropriate integration of quotations:

Harry feels he has a “dark side” and he spends “hours and days thinking about death.” He believes that “men and women can’t be friends because the sex part always gets in the way.” When he was single, he would have sex with a woman and afterward think, “How long do I have to lie here and hold her before I can go home?”

Good quotations are necessary for cognitive hypotheses because you need to document exactly how the client thinks.

  • Elisa says she cannot go shopping at an upscale store without feeling like everyone is staring at her because she is “so out of place.” She imagines people are thinking, “She doesn’t belong in here” (data supporting the Dysfunctional Self-talk [C4] hypothesis).
  • Robin notes that she places high expectations on herself and strives “for perfection in everything.” Growing up, she received appreciation from her father only for straight As or a school achievement that earned mention in the local newspaper. Now in graduate school, if she doesn’t get the highest score in the class, she winds up “feeling like a failure.” She described an interaction with her teacher when she went to argue about her grade, and admitted that her anger was out of proportion. “I felt that nothing I do could ever be good enough” (data supporting the Limitations of Cognitive Map [C2] hypothesis).

Quotations give the therapist a chance to independently evaluate the validity of the client’s interpretation of experience. Table 2.3 presented the use of metamodel questions to move from the client’s abstract labeling to sensory-specific descriptions of experience. Here are two examples for a description of verbal abuse—the first one fails to provide data supporting that label.

  1. Nicole complained that her boyfriend “continually verbally abused” her by calling her “too sensitive” and “messy.”
  2. Tanya complained that her boyfriend “continually verbally abused” her, describing how, after she got a rejection letter from graduate school, he told her she was “a worthless loser who is too stupid to succeed at anything.”

It takes experience and judgment to determine what facts and quotations must be included and what can be summarized. It is better to include too much, and then have the challenge of condensing, rather than writing too little, and risk omitting important information. The quality of the database contributes directly to the quality of the formulation. Furthermore, the quality of the supervision and consultation you receive will depend on the database. When you want guidance, your consultant, who will not be meeting directly with the client, must have access to a database that is complete and reliable.

The distinction between subjective and objective data is based on the source of the data. In SOHPing problems, if data come from the client or the client’s family, they go in the S section; if they come from a professional expert or objective tests or records (e.g., results of blood or urine tests, school or legal records, prior hospital charts, and psychological test results), they go in the O section.

In writing the S section, you need to remove all phrases that describe the “when” of the client’s revelation or the “how” of the storytelling. Very often those details are not important and interfere with a smooth, well-organized narrative of the data. If that information is important, it goes in the O section. There are two types of errors: (1) Objective data appears in the subjective section, and (2) subjective data appears in the objective section.

Error 1: Objective Data Appears in the S Section

For the following examples, the italicized words do not belong in the subjective section.

  1. The client’s voice was raised in anger as she described a phone conversation in which her mother blamed her for her brother’s behavioral problems. (Observation of nonverbal behavior goes in the O section.)
  2. With absolutely no compassion or empathy, the client described her husband’s depressed mood and impaired functioning since he lost his job. (Your observation of the client’s process goes in the O section.)

Here is an example of how to revise the report when you detect this error:

  1. Original wording:
  2. S: In the first session, the client was reluctant to talk about her family of origin. However, in the third session, she described her early experiences with a distant father and an alcoholic mother.
  3. Revised:
  4. S: Her father was “distant,” and she describes her mother as an alcoholic.
  5. O: It was not until the third session that the client was willing to talk about her family of origin.

Error 2: Subjective Data Appears in the O Section

These are examples of data that were incorrectly included in O instead of in S:

  1. Jay’s former therapist told him that he was “dysthymic and overly sensitive.” (Data came from the client’s verbal report, not from the professional’s formal report, so they go in S.)
  2. She is in a breast cancer survivor group. (The writer incorrectly thought this was objective because it could have been observed; however, the source of the information was the client’s words.)
  3. Her mother described her as very sullen, uncooperative, and hostile. (A family member is not an unbiased professional, so the source is considered subjective.)

The O section is the briefest section in the SOHP. The details you select are related to the problem title or will be useful in selecting a treatment approach that is a good match for the client. The following example illustrates appropriate objective data for a specific client problem.

  1. Problem: Frustration over repeatedly taking caretaker role in relationships.
  2. O: Amanda was clearly nervous coming into the sessions. She seemed tense, but there was a sense of hope that began to grow as time passed. She expressed strong feelings of frustration as well as sadness through her words and body language. When she told stories or described moments of importance, she primarily used the visual modality. When she recognized connections between her current relationships and her family of origin, she showed satisfaction with herself and me. I think she gained some new insights, and she seemed highly motivated to continue in some form of therapy.

The objective data is useful for treatment planning. The client would be a good candidate for insight-oriented psychodynamic therapy and visual imagery techniques. If there had been any signs that the client took on the role of caretaker with the therapist, it would be important to include them: they would be data of a type of transference directly related to her problem title.

The term subjective database refers to both the S section after the problem title and the background data section that precedes the problem list (see Chart I.C in Appendix I for the outline of a complete report). The database is organized by topics in a logical sequence, not by the order in which the therapist acquired the information. Paragraphs have good topic sentences, thoughts flow logically, and transitions are clear. When writing the subjective data narrative, remind yourself of Standard 12 and: be careful not to slip into writing your formulation ideas.

Writing Style

The key to success on this standard is good writing skills: organize, pare down, and aim for clarity. It is helpful to have a good stylebook handy, and my preference is The Elements of Style (Strunk & White, 2008). This concise book is organized into brief rules with examples. One of the rules of style most frequently violated is this one: Omit needless words. The authors show a comparison between two summaries of Macbeth:

  1. Version 1
  2. Macbeth was very ambitious. This led him to wish to become king of Scotland. The witches told him that this wish of his would come true. The king of Scotland at this time was Duncan. Encouraged by his wife, Macbeth murdered Duncan. He was thus enabled to succeed Duncan as king. (6 sentences, 51 words)
  3. Version 2
  4. Encouraged by his wife, Macbeth achieved his ambition and realized the prediction of the witches by murdering Duncan and becoming king of Scotland in his place. (p. 24; 1 sentence, 26 words)

Notice that the two versions contain the same amount of information. By using a concise style with complex sentences, you can pack a great deal into a limited length. Often the subjective section gets very long, not from too much data, but from repetition, excessive detail, and verbosity. It is absolutely essential to plan to revise your first draft of a report and to put effort into writing skills.

Use of an Outline

An outline is an invaluable tool to assure good organization, yet most of us forget to use it. When you state what the topic of a paragraph is supposed to be, it is easy to recognize when some content does not fit. There is no single correct outline for presenting subjective data that would fit for all clients; there are many different ways to organize your information. Table 5.1 presents the outlines for three different clients’ S (subjective data) sections.

Table 5.1 Organizing the Subjective Section

Method 1: Chronological order over the entire life span, ending with the current time
Problem: Anxiety while communicating at work, school, and in casual social settings.
A. Description of life history relevant to experiences with anxiety and socializing, including first recollections, experiences with parents, and a highlight from each level of school
B. Description of current problems, using data from all categories of BASIC SID, and providing relevant quotations
C. Description of current situations (contexts/people) in which he communicates with comfort
Method 2: Current situation first, followed by chronological order up to the current situation
Problem: Inability to decide if she wants to continue relationship with boyfriend.
A. Description of the client’s current dilemma, including quotations to illustrate different voices in her inner conflict and to provide details of pros and cons
B. Summary of this current relationship from when they first met until the present, using quotations to illustrate both positive experiences and description of problems
C. Chronological presentation of her relationship with her parents, describing their stormy marriage, use of alcohol, and ultimate divorce
D. History of her romantic relationships up to her current boyfriend
Method 3: By topic, without regard to chronology
Problem: Anxiety over husband’s impending retirement and proposed geographic move.
A. Description of her husband’s unilateral announcement two months ago, her reaction, and details of how this decision and the proposed move will impact her and the children
B. Summary of history of marriage and four prior moves, including quotations illustrating frustration at the decision-making process
C. Summary of the core issues that she identifies: complaint that husband is “domineering, controlling, and opinionated” and that he is “violating their contract” that she will have control over the home
D. Description of her concerns about the children, including the negative effects of moving as well as having their “overcontrolling” father become more involved in their lives
E. Illustrate how the client connected her current feelings to her family of origin—“being dominated all the time”
F. Summary of the positive aspects of the change and comments the client made, illustrating empathy for husband’s desire for freedom