Clinical Diagnosis and Assessment

Andrzej Wojcicki/Science Photo Library/age fotostock. Photo for illustrative purposes only; any individual depicted is a model.

Jeannette Walls had an unusual childhood. She and her three siblings—Lori, Brian, and Maureen—had smart, engaging parents who taught them each to read by the time they were 3, explained and demonstrated scientific principles to them, instilled a love of reading and appreciation for the arts, and made their children each feel that they were special. As Jeannette Walls recounts in her memoir, The Glass Castle (2005), her father, Rex, was an intelligent man who was a skilled electrical engineer. Her mother, Rose Mary, was an artist and had trained to be a teacher. Yet Rex had difficulty holding onto jobs, and most of the time Rose Mary didn’t have a paying job. Both parents gave their children enormous freedom to explore and experiment; they also often left the children to fend for themselves.

Rex and Rose Mary would uproot and move the family in the middle of the night, sometimes giving the kids 15 minutes to pack their things and pile into the car. They’d leave town in order to avoid bill collectors or child welfare officials, moving to whatever small town caught Rose Mary’s and Rex’s fancy. Neither parent spent much time fulfilling the many daily responsibilities of parenting, such as preparing meals. For instance, even at the age of 3, if Jeannette was hungry, she knew not to ask her parents for something to eat but to make it herself. She figured out how to make hot dogs: put water in a pot and boil the dogs, standing on a chair by the gas stove in order to do it. During one stint of hot dog making when she was 3, her dress caught on fire. She was so severely burned that she was hospitalized for 6 weeks and had skin grafts. Her hospital stay ended when her father had a fight with her doctor about whether her bandages should remain on; her father carried Jeannette from her hospital room in the middle of the night and out to the car, where her family was waiting for her. They headed out of town to wherever the road took them; Jeannette’s scars never properly healed.

The family referred to this and other late night moves from one dusty town to another as doing “the skedaddle.” A few months after taking Jeannette out of the hospital, the family did the skedaddle again. During Jeannette’s early childhood, Rex would get a job as an electrician or an engineer (often making up stories about previous jobs he’d had or degrees he’d earned). When they left a town, Rex would explain to the family that they were running from federal investigators who were chasing him for some unnamed episode in the past; Rose Mary admitted to the children that frequently they were running from bill collectors. Sometimes they moved simply because Rex was bored.

Rex and Rose Mary tried to make their tumbleweed life into an adventure for their children, and they succeeded to some extent when the children were young. However, the parents’ own problems got in the way of their responsibilities. During most of Jeannette’s school years, her family was so poor that the children ended up eating only one meal a day—the lunch leftovers at school that they were able to scavenge from the trash. When Rex would lose his job, sometimes he’d stay home. He drew up blueprints for a solar-powered “glass castle” or worked on his design for a tool that would find gold in rocks. And increasingly during Jeannette’s childhood, he’d gamble and drink. In what Jeannette describes as his “beer phase,” Rex would drive fast and sing loudly. When he began to drink the “hard stuff,” Rose Mary would get frantic because Rex would become angry: He’d beat his wife, throw furniture around, and yell. Then he’d collapse.

Jeannette Walls

Jeff Newman/Globe Photos/ZUMAPRESS.com

Rose Mary, under duress from her children and the threat of visits from child welfare officials, tried two different stints of working as a teacher, but she hated it so much that she had a hard time getting out of bed to get ready for work, and she had difficulty doing the paperwork required by the job. After a year, Rose Mary refused to work anymore; she claimed that she needed to put herself first—to paint, sculpt, and write novels and short stories—even though Rex still was not working and there was no other regular income.

Did Rex and Rose Mary have psychological disorders? To answer that question, we must return to the criteria for a psychological disorder that we discussed in Chapter 1: a pattern of thoughts, feelings, or behavior that lead to distress, impairment in daily life, and risk of harm, within the context of the culture. Did Rose Mary or Rex experience significant distress? Remarkably, Jeannette’s account of her family conveys little sense that her parents were distressed by their situation. What about impaired functioning? The fact that neither parent was able to hold a job consistently certainly indicates impairment in daily life.

With regard to risk of harm, Rose Mary and Rex put themselves and their children at risk countless times in various ways: They—and their children—regularly went without food (and neither parent was sufficiently motivated to earn money in order to buy food). Rex repeatedly drove while intoxicated, sometimes at 90 miles an hour or more. The family members’ physical safety was put at risk in other ways. One night when Jeannette was 10 years old, she woke up to find a vagrant sexually groping her. When the children asked their parents to close the front and back doors at night, their parents refused: “They wouldn’t consider it. We needed the fresh air, they said, and it was essential that we refuse to surrender to fear” (Walls, 2005. The parents put themselves at risk of harm in other ways, including intense fighting. For example, during one fight, Rex and Rose Mary went at each other with knives—and then their fighting suddenly switched off, and the couple ended up laughing and hugging. Rose Mary admitted to her children that she was an “excitement addict,” and her quest for excitement and Rex’s drinking and related behavior often led the family into dangerous situations.

According to Jeannette’s descriptions, then, both Rex and Rose Mary Walls would seem to have had some type of psychopathology. On what basis should you evaluate and classify their behavior? How would a mental health professional go about identifying their specific psychological problems? How should you go about determining whether a specific diagnosis is warranted? For mental health professionals, a diagnosis is the identification of the nature of a disorder (American Psychiatric Association, 2013). A diagnosis is made by assigning a patient’s symptoms to a specific classification. Classifying a set of symptoms as a disorder allows you to know more than was initially apparent. Depending on how much is known about a given disorder, a diagnosis may suggest the disorder’s possible causes, its course over time, and its possible treatments. In Rex’s case, for example, a diagnosis for his pattern of drinking and related behavior would be what mental health clinicians call alcohol use disorder (which we discuss in more detail in Chapter 9). Having a diagnosis might allow one to infer why he—and other people with the same set of symptoms—may have developed the disorder and whether the symptoms would be likely to shift in frequency or intensity over time. Moreover, the diagnosis might indicate that certain types of treatment, such as those based on behavioral principles (see Chapter 2), might be more effective than other types of treatment.

A diagnosis is based on information about the patient obtained through interviews, observations, and tests. Such information is part of a clinical assessment—the process of obtaining relevant information and making a judgment about mental illness based on the information. Clinical assessments often go further than providing information needed to make a diagnosis. They also can provide information about the specific ways in which and the degree to which an individual is impaired, as well as about areas of functioning that are not impaired. When we discuss the mental health—or mental illness—of Rex and Rose Mary Walls, we are trying to approximate a clinical assessment based on the words—and judgments—of their daughter, Jeannette—someone who knew them intimately. Rex died at the age of 59. Were he alive today and it were possible to make a clinical assessment of him and Rose Mary, we would be in a position to determine with greater confidence whether either of them could be diagnosed with a psychological disorder.