People in Crisis Clinical and Diversity Perspectives

Crisis Research

Validity and Reliability studies of mental health assessment tools comprise a vast and complex field, including that of crisis care. Most mental health assessment tools, including the DSM, are symptom-based, while many were initially designed as research instruments, with limited practicality in busy clinical settings—a disadvantage of particular note in life-threatening crisis situations. One writer, K. Kulic (2005, p. 153) notes that the crisis field is "largely atheoretical" and cites the need for tools validated with actual clients.

Kulic, K. (2005). The crisis intervention semi-structured interview. Brief Treatment and Crisis Intervention. 5, 143-157.

Readers are invited to inquire about and consider collaboration with author Lee Ann Hoff in research using the following two instruments:

  1. The Comprehensive Mental Health Assessment (CMHA) tool (excerpts illustrated in Chapter 3, 9, 11, and 12 of People in Crisis.
  2. A survey tool: Student Stress and Crisis, including impact on academic performance.

The Comprehensive Mental Health Assessment Tool - CMHA

Extending the description and use of this tool in Chapter 3 is an Abstract of the 2002 Pilot Study done on the revised edition of the tool since its development and testing in the 1970s. Significantly, this tool was developed and tested— not as a research instrument, but for its clinical usefulness—during the era when crisis care emerged as an essential facet of comprehensive mental health service, and thousands of institutionalized psychiatric patients were discharged with the expectation of community-based care.

These national developments formed the rationale for developing a tool that integrated crisis assessment with other facets of life affecting mental health status and social functioning.

The result was the CMHA tool, facilitating functional assessment on a 5-point Likert-like scale, not merely numerical symptom identification (as in the DSM) with no indication of severity.

A key aim of this tool was to assess the greater crisis vulnerability of already diagnosed mental patients no longer in institutional protection, as well to identify persons in impending or full-blown crisis with a view to preventing psychiatric hospitalization whenever possible.

Other key facets are the built-in mechanism for systematic follow-up assessment that also support clinical outcome research. The tool was tested with real clients served in six 200,000-population catchment areas of the Erie County mental health system in Buffalo, New York. Following is a summary of revision and further development of this tool.

Abstract

Title: Pilot Study: Face Validity & Inter-rater Reliability: A Comprehensive Mental Health Assessment Tool

Authors: L. A. Hoff, PhD; E. Campbell, BSN; H. Kelleher, RSN; E. Mulholland, BSN

Purpose: To pilot test a revised edition of the 21-item Comprehensive Mental Health Assessment (CMHA) tool (Hoff, 2001) and refine the methods devised for a face validity and interrater reliability study in interdisciplinary mental health settings.

Description: The original 16-item CMHA tool was developed by an interdisciplinary mental health team in the early 1970s and tested for face validity and interrater reliability in a large county mental health system. While psychopathology is assessed, this tool's emphasis is on holism and ascertaining a client's biophysical, emotional, cognitive and behavioral functioning in sociocultural context. Revision of the tool was spearheaded by Hoff's (1990) research with abused women and reinforced by current emphasis on the inclusion of victimization and safety issues as a routine facet of health assessment.

Method and Sample: Pilot testing was done with an interdisciplinary sample of 13 professional staff of a community mental health center in Ontario, Canada (face validity: N = 4; interrater reliability: N - 9). Training in the tool's purpose, directions for rating, and the rating itself was planned for a 5-hour period.

Results: Descriptive statistics revealed highly positive outcomes in both the Face Validity and Interrater Reliability facets of the pilot. Ratings were based on 8 cases compiled by the researchers. These cases illustrate the broad range of mental health problems or disorders. On a Likert-like scale of 1 (excellent) to 5 (very poor)--including space for "comments"--analysis revealed most validity and inter-rater reliability ratings in the 1 and 2 categories. Lower ratings generally corresponded with raters' comments about the standardized case illustrations, some of which lacked sufficient information. Lower ratings and comments signified a need for further editing of the cases and the operational definitions of the 1 through 5 scales of the tool's 21 items.

Raters' evaluation of the pilot study's research process revealed a significant underestimation of the time needed to explain the tool itself and to complete the ratings. This information proved to be the most valuable outcome of the pilot study as a basis for the next phase of this project, for which funding support will be sought.

A Survey Tool: Student Stress and Crisis

This survey tool was developed with an internal university grant supporting original founding of the Life Crisis Institute at Northeastern University in Boston, MA (subsequently an independent entity—see Links, Life Crisis Institute).

The following Poster presentation content of survey results using this tool two decades ago is shared with acute attention to its continuing relevance to student stress and crisis among American college students today.

The tool was also used to survey students at a public university in the state of Maine, with comparable results.

In 2000, the tool was revised at the University of Massachusetts Lowell with a view to its use with that student body. The only major revision was with "Situations Experienced" in which respondents rated the situations on "seriousness" (Scale I), and in a parallel Scale II, in which they rated the degree to which a stressful situation interfered with academic performance.

The revised survey tool was critiqued in student focus groups, with special attention to diversity issues, but has not been implemented as planned with the U-Mass Lowell student body due to budget constraints.

The 1988 APHA Poster presentation of first survey results using this tool follows.

Poster Presentation: American Public Health Association Annual Meeting, Boston, Massachusetts, November 1988

Lee Ann Hoff, PhD - Evaluation of & Response to Undergraduates' Needs during Life Crises

Purpose: To ascertain undergraduatesÂ’ perception of needs and resources during crisis

Sample & Design:

Major Results:

Implications

Recommended Action Based on Survey Results

Readers and researchers in this topical area are invited to collaborate with the author, Lee Ann Hoff, the University of Massachusetts Lowell, and the Life Crisis Institute in obtaining external funding. The funding will support surveying not only the 5-campus University of Massachusetts student body, but potentially other collaborating universities and/or colleges around the continuing issue of student stress and crisis among college and university students. Although findings from this survey are two decades old, the widespread implementation of recommendations from this research (and published literature on crisis service standards) might have prevented tragedies such as the Virginia Tech massacre and other preventable life-threatening actions of students in crisis.