Self worth and relationships

My late 30’s turned out to be a lot more challenging than I ever expected. Not that I was soon to be turning 40. The number makes no matter.

Anyhow. I reflect back on myself and recognize that I look for the approval of others’ as a gauge to my value. My most successful relationships are the ones where I have been invited into the persons’ life to share their passions, their hardships and their road. Sometimes I am muse, nurse or space holder. In the end if I am helpful in anyway towards inspiring or empowering someone. Then, I am of value. It is then that I can take up space. Even just a little bit, over here, in the shadows.  Oh am I in your way? Sorry.

I go to dinners and I do the dishes or comfort the sketchy dog. Is it because I need to be useful to be valued. Yes, I think so. When those relationships break down it’s usually because I have noticed my productivity levels to be down. When I go to festivals, I have a job, when I go to an event I have a purpose. When I am in need, I retreat. My ego does a number on my thought patterns.

In the past year I was dating a beautiful person. Someone who has so much on the go, who continually tries to maintain a number of projects, ideas and visions meanwhile balancing self care. I fell in love with that person. In order to give myself permission to take up space in that persons’ life is to be useful. Well, I wasn’t. I was broken, stubborn and low in self worth and confidence. Basic labor activities became my reason for existing. If I put the box in the wrong place, I failed. Needless to say, the role of muse, helper, nurse etc. is particularly challenging when the best one can do is see past the tears.

You see, it’s not okay for me to be the weak one in a relationship. Just by saying that, I judge you. If it’s okay for you, why is it not okay for me? It’s hypocrisy when the act of helping you during your vulnerability is ok yet I cannot be vulnerable with you and take up space and feel that it’s ok.




I really suck at intimate relationships.

I have come to realize that I really suck at intimate relationships. I’m not sure it’s always been like this. In retrospect, it must have been but I thought it was everyone else. I mean, for me I considered that their actions were at fault or they weren’t what I needed. I’ve dated lots, been married twice and have had a few longer term relationships of a year or more. Generally I cant seem to stand someone after three. Also the same amount of time that I can work at one specific job.

Maybe I’m a runner, when things get hard I run. I noticed this trait about ten years ago and have been attempting to force myself not to quit or run. Not really sure if this serves me. The last several people that I have attempted a committed relationship with have reflected  that I expect too much and become emotionally overwhelmed with feelings of inadequacy, self doubt and blame when those expectations aren’t met.

Thing is, I don’t think this is new for me. Maybe I hid it better with my compulsion to absorb myself in my work or various activities. Not dealing with it has been my distraction, until these people go away. This is usually where I start my process of; it’s them. When they go away, they usually find another. Sometimes they tell me, sometimes they don’t. I guess it depends on their notion of my capacity to have a rational conversation.

The ironic aspect of this is, I have always believed myself to have stellar communication and interpersonal skills. Maybe its only effective if I can disassociate the situation from my emotions, self concept and self worth. By working in the field of mental health, it was expected that I have very strong boundaries, give out no personal information and disassociate any personal feelings, ideas or sense of self from the situation at hand. It seems that this may have carried over into my personal life.

You see, I could never stop being that nurse. I was on-call 24/7 to my friends, family, the lady at the checkout, my job, strangers. People now called me with their latest health issue, traumatic event or crisis. Often strangers would divulge stories and experiences to me and later tell me that they had never told anyone and they don’t know why it came out. When it came time to have conversations with my friends, family, job and strangers about my emotions, stories and needs. I didn’t bother. I would often think that they didn’t need to be bothered and I would be more helpful if I dealt with it myself. So I did. Or I didn’t.

I’m trying to process. In doing that I also am deciding to be transparent. This is my real name. This is my story. You probably are a stranger, maybe you aren’t and it’s the first time you have heard my heart. Maybe you are one of the few that have had the opportunity to hear the whispers of my heart.

The recollection of my childhood is vague. Only just recently, have details from those times started coming back.

Brené Brown on Vulnerability

Compassion Fatigue and processing.

Over the past few years there has been more media attention given to different marginalized populations in poverty and the issues that are now considered an epidemic across Canada with overdoses on drugs like fentanyl. I’ve seen the calls for help, the education on stigmas, the different social, governmental and health care agencies and their perspectives. I’ve also read a lot of opinions from people who have read a newspaper article and have become an expert in the field.

While I am no expert, for some reason my occupational journey has lead me towards experiences that few others have seen to such intensities. I started this journal with the attempt to make sense of my unique perspectives, to share some thoughts and to explore my journey.

The journey has brought me to watching the internet from a cabin in a mountain valley away from as many people as I can. There is a huge sense of guilt associated with the fact that I once did everything I could to help and have the skills and knowledge necessary to make an impact on those issues and I have chosen to run away from the expectations I have put on myself. While attempting to nurture my heart I recognize a need to gain self worth from attempting or actually helping others. Through that I’ve tried to distract myself from the reality that I have compassion fatigue. There has been no medical, psychiatric or professional diagnosis in this regard due to the many struggles I encountered in my transparency with my employer and the overt stigma in mental health that continues to exist.

What is Compassion Fatigue?

 CF is a serious but natural negative consequence of working with people who are suffering or traumatized. It is a trauma response that causes symptoms of post traumatic stress culminating in a helper’s loss of capacity for, or interest in, being empathic or compassionate with others’ suffering. It almost always coexists with burnout. Put differently, CF occurs when the trauma we’ve experienced directly in our own lives (primary traumatic stress) converges with the trauma we’ve experienced indirectly through hearing stories of others’ suffering (secondary traumatic stress) in the presence of pre-existing burnout. Baranowsky & Gentry, 2008)
The short of it, I cared too much.
Compassion Fatigue symptoms are normal displays of chronic stress resulting from the care giving work we choose to do. Leading traumatologist Eric Gentry suggests that people who are attracted to care giving often enter the field already compassion fatigued. A strong identification with helpless, suffering, or traumatized people or animals is possibly the motive. It is common for such people to hail from a tradition of what Gentry labels: other-directed care giving. Simply put, these are people who were taught at an early age to care for the needs of others before caring for their own needs. Authentic, ongoing self-care practices are absent from their lives.
At the age of 7, our family had recently moved to a small town away from extended family and a few supports. My mom was a graphic designer in her mid-twenties, my brother two years old. My father a helicopter mechanic for the oil industry up north, travelled away from home for periods of time. One day a car pulled up to our house and announced my father had been involved in a boating accident. His boat and life jacket were found, he was not. It was determined that the temperature of the water in which he would have ended would have likely given him hypothermia and he likely did not survive. Needless to say, my mother didn’t take it very well and soon I put myself in the role of caregiver out of a need for survival. Not one seven year old has these types of skills and the capacity to learn self care.
While I am proud of the journey that my mother and I have survived, I wonder if my emotional capacity would be different had I learnt the self care skills that a young girl would have at that age. My self care skills were different, I learnt how to cook, clean, care for children, manage household duties, transport my siblings to their activities as well as the additional expectations of a child at that age; my education, extra- curricular activities and various different aspects of my church. I learnt at a young age that I was rewarded for thriving and that I was put on this earth to help people. My belief was that I had a spiritual gift of healing and the reason I was put on this earth was to heal. The thought never crossed my mind that I was to heal myself and instead absorbed the emotions and struggles of others in order to pursue my purpose in the world. This is an expectation I put on myself and there was never an ‘enough’ point.
At 11, after watching  commercials about sick and dying children, reading countless books on WW2 and National geographic magazines as well as the teachings of my church. I decided that I would become a missionary nurse in developing countries and save the world physically, emotionally and spiritually. This concept and expectation has stayed with me everyday since.  I never did go to missionary school, and instead my missionary nurse exploration took a different path.
At the age of 17, young and naive small town girl was accepted to the nursing program at the nearest city college. Within my first year of nursing school an instructor failed me in one of my practicums and told me that I would never be a good nurse and that it wasn’t suited for me. What she didn’t know is that the naive little nursing student wasn’t so naive and incapable but instead had been struggling with the loss of her virginity through a sexual assault. That she did not seek help nor tell those that could support her for many years later. I feel so heartbroken for that self, I told my friend who had been with me on that night and we didn’t speak again. Instead of feeling like I had the capacity for self care, I chose to continue to distract myself and dive further in my need to find self-worth in a helping role. I was determined to show my teacher wrong, I would be a nurse, a good nurse and not just any nurse but I would work in the most challenging of places. One day I would go back and show her my CV to tell her that she was wrong. Well, in reflection, she was probably right. I chose nursing and helping people through traumatic events because it was the only thing I knew. I learned it out of survival not because it was natural to me. It was my destiny to be that nurse for the people that others’ had a hard time loving. Or at least that’s what I have been telling myself.
 So that brings me again to the reflection that despite my best attempts, my decades of caring so much has presented me with no other option but to figure out how to care for myself. As I look down the list of symptoms related to compassion fatigue I see myself reflected back to me in every line.

Normal symptoms present in an individual include:

• Excessive blaming

• Bottled up emotions

• Isolation from others

• Receives unusual amount of complaints from others

• Voices excessive complaints about administrative functions

• Substance abuse used to mask feelings

• Compulsive behaviors such as overspending, overeating, gambling, sexual addictions

• Poor self-care (i.e., hygiene, appearance)

• Legal problems, indebtedness

• Reoccurrence of nightmares and flashbacks to traumatic event

• Chronic physical ailments such as gastrointestinal problems and recurrent colds

• Apathy, sad, no longer finds activities pleasurable

• Difficulty concentrating

• Mentally and physically tired

• Preoccupied

• In denial about problems

I plan to explore my journey in attempts to find that self worth and purpose through the self proclaimed identity of that of a healer, helper and nurse. Sure, I can go back and tell that nursing instructor I did it, but did I? and what was it all for and where do I go from here?
My mom recently asked me about the last time that I can remember I was optimistic and happy. I remember it clearly, what I don’t remember is where it all went wrong. Or maybe it was wrong right from the start. Hmm….
Anyhow, my two thoughts for today…..
Kerry Rae

Mental health assessment for Nurses. Part two of a workshop by Kerry Rae

If you’re reading this you probably already read part one. In part one I broke down the types of things that nurses would assess when in mental health on an interview or observational basis. In our society the next step would be to compile all the information and match the symptoms to the frame work of an accepted diagnosis. When I say accepted diagnosis, I refer to Western Medicine’s use of the Diagnostic and Statistical Manual (DSM) to categorize, medicate and treat symptoms. This tool was developed as a framework to decide whether an institution or insurance agency will provide coverage for treatment. Not as a means of learning more about an individual and deciding the best care given.

This being said, I fully believe in the science of assessment and the  art and science of supporting those who struggle with adapting to norms. I feel that the symptomatology, stories, and dreams of those can be a tool in learning how to support our community and find support for ourselves. The challenges remain in the categorization of these individuals into ‘mentally ill’ and further more into subcategories of ‘psychotic,’ etc. With increased education on decreasing mental health stigmas, we all have become experts in deciding what is best for those who never asked our opinion. Our system needs to become desystemized (I don’t know if that’s a word, you get my drift) and more community based. Art events, community gardens, a helping hand.

Below is an outline of some of the general categories accepted in our Western medical model and the framework of the DSM in applying and regulating the services that one is provided. I may or may not add my perspectives to the categories.

Mood disorders

Also known as affective disorders, affect how people feel about themselves, other people and life in general. They include:

  • depression; important to assess an increase/decrease in sleep, diminished interest, guilt/low self esteem, energy (poor/low), concentration, increase or decrease in appetite, psychomotor agitation or retardation
  • bipolar disorder (manic depression)
  • suicidal behaviour
  • postpartum depression

Anxiety disorders

Involve an unusual degree of fearfulness, worry and even terror. Types include:

  • general anxiety disorder
  • panic disorder
  • phobias (overwhelming feelings of terror in response to a specific object, situation or activity)
  • obsessive-compulsive disorder (repetitive actions are used to cope with recurring, unwanted thoughts)
  • post-traumatic stress disorder (a sense of re-experiencing a traumatic event for months and sometimes years after the incident)

There are four levels of anxiety:

  1. Mild: anxiety that motivates someone positively to perform at a high level. It helps to focus on situation at hand.
  2. Moderate: anxiety narrows perceptual field, person has trouble attending to their surrounding, although they can follow commands or direction.
  3. Severe: increasing anxiety brings someone to another level, inability to attend to surroundings, except maybe a detail. Sometimes develops as physical symptoms like sweating, pounding heart. Anxiety relief can be the only goal.
  4. Panic anxiety: the level reached is terror, where the only concern is to escape. Communication impossible at this point.

It is important to determine what level of anxiety they are experiencing to determine intervention.  At the moderate level hopefully intervention can happen in order to manage before anxiety escalates. Firm, short, direct commands are needed.

Schizophrenia and psychotic disorders

Involve changes in the chemistry and structure of the brain, which may cause lethargy, hallucinations (e.g. hearing “voices”) and delusions (e.g. having supernatural powers):

  • schizophrenia
  • schizoaffective disorder
  • delusional disorder
  • psychosis NOS

Psychosis; a medical condition that affects the brain, so that there is a loss of contact with reality. When someone becomes ill in this way, it is called a psychotic episode. A psychotic episode is characterized by extreme impairment of a person’s ability to think clearly, respond emotionally, communicate effectively, understand reality, and behave appropriately. An individual experiencing a psychotic episode may have delusions or hallucinations. This may be brought on by physical conditions, poor nutrition, overwhelming stress, chemicals, medications or street drugs. It may occur for a brief time or stay permanently.

Substance Use/Abuse Disorders

Refer to excess use of alcohol and/or legal and illegal drugs, leading to significant social, occupational and medical problems:

  • alcohol addiction
  • drug use (illicit drugs or prescription medication)
  • co-existing mental illness and addiction

Personally, having worked over a decade in harm reduction, I believe that substance abuse disorders are in direct correlation to individual/societies attempt at self medicating as a means of coping with traumas. Unless, we figure out a way to support one another as neighbours, community members and family from a place of compassion and support, we will continue to explore self medication. In western medicine we have developed a power hierarchy in that those who have been categorized as a substance user or ‘addict’ suddenly needs someone of higher class to decide what is best for them, that their choices in their own life are wrong. Simply by working with individuals as an equal, diminishing the power dynamics and remembering that one can choose something for themselves. They can chose to drink to oblivion. Every day. By comparing your habits to that person and recognizing that you do a better job in managing your drinking, does not mean you have authority over that person. I can rant all day on this subject. Empower, instead of control.

Personality disorders

Involve patterns of thinking, mood, social interaction and impulsiveness that cause distress to those experiencing them and to their friends and family. Some examples include:

  • borderline personality disorder
  • paranoid personality disorder
  • antisocial personality disorder

This category can be a whole seperate blog entry. Having one of these or the other types of personality disorder basically means you have been type-casted as hard to get along with. Health professionals often will make judgements of these people, their behaviors and their capacity to have the privelege of support and assistance.

Medications: prescription, bought on the street, over the counter, herbal.

When assessing an individual’s mental health, simply finding out what medication they are taking or have recently taken, can be a valuable tool in understanding the current situation. It’s been a couple of years since I have worked directly with psychiatrists so some of the more recent types of medication will not be on this list. However, it is still common for most individuals to be prescribed by psychiatrists or physicians that still utilize the classic list as follows.

  1. Antidepressants: used to treat and control depression.


amitriptyline (Elavil)

clomipramine (Anafranil)

desipramine (Norpramin)

nortryptyline (Aventyl)


citalopram (Celexa)

fluoxetine (Prozac)

fluvoxamine (Luvox)

paroxetine (Paxil)

sertraline (Zoloft)


venlafaxine (Effexor)


buproprion (Wellbutrin)

mirtazapine (Remeron)

trazadone (Desyrel)

Common side effects: headache and stomach upset at onset of medication. Less common: dry mouth, blurred vision, difficulty urinating, constipation, sedation, dizziness.

Comments: Medications take several weeks to reach full effect. Not addictive but should never be stopped abruptly. There are worse side effects when medications are stopped without a tapering schedule.

2. Antipsychotics: also known as neuroleptics, major tranquilizers. Used to treat psychotic illness (schizophrenia and mania). These medications are also used in resistant depression and with behavioral management.


chlorpromazine (Thorazine)

fluphenazine (Modecate)

flupenthixol (Fluanxol)

haloperidol (Haldol)

loxapine (Loxpac)

methotrimeprazine (Nozinan)

pimozide (Orap)

zuclopenthizol (Clopixol)


risperidone (Risperdal)

long acting risperidone (risperidal consta)

olanzapine (Zyprexa)

quetiapine (Seroquel)

Common side effects: drowsiness, dizziness, dry mouth, movement problems, stiff muscles, weight gain.

Comments: tardive dyskinesia TD or involuntary movements may occur when used for longer periods of time. Managing side effects may be achieved by changing dosage, or adding medication (benztropine, procyclidine) for movement side effects.

3. Mood stabilizers: used to treat people in a state of great excitement, emotional stress, and/or depression.

carbamazepine (Tegretol)

divalproex (Elavil)

lithium carbonate (Carbolith)

valproic acid (Divalproex Sodium)

Common side effects: lethargy, trembling, nausea, diarrhea, frequent urination, mental functioning problems.

Comments: medication takes several weeks to take effect. Regular blood tests are required for measuring medication levels and monitoring physical side effects.

4. Anxiolytics: also known as tranquilizers, sedatives. Used to relieve the distress of anxiety.

alprazolam (Xanax)

bromazepam (Lectopam)

buspirone (Buspar)

clonazepam (Rivitril)

chloradiazepoxide (CPZ)

diazepam (Valium)


lorazepam (Ativan)

nitrazepam (Mogadon)

oxazepam (Serax)

temazepam (Restoril)

zoplicone (Imovane)

Common side effects: sedation, lethargy, depression, difficulty concentrating, memory problems.

Comments: dependency can occur with these medications at any time.

Physical concerns

History of head injuries, headaches, dizziness, tremors, pain control (severity, treatment)

Allergies: food, medication, environmental

Substance Assessment/ Risk of withdrawal or psychosocial challenges during assessment.

Prescribed drugs, street drugs, alcohol, tobacco (amount, frequency and reason)What was the longest period did you abstain, how old were you when you started using? What was it? History of treatment.

Nutrition, eating patterns, blood work, infections, sleep, stress, etc etc etc. So yeah, I think this is basically the end of the overview workshop. I had planned to go into further detail in additional workshops but life brought me different plans.

Hope the ramblings of my brain is helpful in what ever you are doing.

Caregiver burnout and Emotional Intelligence

So, I’ve been having some challenges in my personal life. I’m currently living in a little house in a small mountain valley town. Having some time to reflect on my past I have began to accept the reality that I have some type of caregiver burnout, or cumulative PTSD. There isn’t much for official diagnosis’ out there in this realm but I imagine with the challenges in today’s health and social sectors, this issue will not be avoidable.

Having found a useful resource on increasing ones’ emotional intelligence through a program called Emotional Intelligence (EQ) toolkit. I find it really useful and with helpful points. Excerpts from the website;

“The ability to remain emotionally aware and to keep your nervous system in its comfort zone also ensures that your immune system, and other parts of your body that preserve and repair it, remain online doing their job.

There are two things that you can do to quickly reassure your nervous system and bring it into its comfort zone. The quickest and most efficient thing you can do is to turn to another person for reassurance. If that person’s face conveys safety and reassurance, your nervous system will immediately relax and go back into balance. In order to do this, you must be able to send and receive nonverbal emotional cues.

The other thing that you can do is to connect with positive sensory experiences. The toolkit teaches you both of those core skills.”

Website:  Jan 2017

Mental health assessment for nurses. Part one of a workshop conducted by Kerry Rae.

Hey lovelies, I found this document from a workshop I taught to a few LPNs who work in the DTES. It’s a quick blurb on mental health assessment. The information regarding the assessment tools was taken right from the original source. Otherwise, it’s mostly my brain spitting out information. Thought it might be interesting to some folk.
During assessment; information is obtained from the individual in a direct and structured manner through observation, interviews and examination. Initial interview includes an evaluation of mental status. In such cases, where the individual is unable to participate in or complete the interview, the behaviour they exhibit is to be recorded and reports from family members, colleagues and other support if possible, can obtained.
Even when the initial assessment is complete, each encounter with the individual involves a continuing assessment. The ongoing assessment involves what patient is saying or doing at that moment. Environment is often a factor in the ability to conduct an accurate and thorough assessment. While offices are often used alternate types of locations are helpful. I’d often take people into the garden to plant seeds or one can go outside and sit at a park bench while having these types of conversations.
Subjective Data
● Name and general information about the patient
● Client’s perception of current stressor or problem
● Current occupational or work situation
● Any recent difficulty in relationships
● Any somatic complaints
● Current or past substance use
● Interests or activities performed
● Sexual activity or difficulty
Objective Data
  • Physical exam
  • Behavior
  • Mood and affect
  • Awareness
  • Thought process
  • Appearance
  • Activity
  • Judgement
  • Response to environment
  • Perceptual ability
When one investigates a behavior for assessment it is valuable to examine the following:
  • Situation that exhibited the behaviour
  • What the individual was thinking at that moment. You actually have to ask.
  • Whether the behaviour makes any sense in that context. It is important to identify whether you are analyzing the individuals, yours or another persons’ perspective.
  • Whether the behaviour was adaptive, reactionary, inappropriate or dysfunctional.
  • Is a change needed?
Remember, you are not the authority over the person’s life that you are assessing. They know their mind, body and situation better than you. It is important to check your judgements and clarify your assumptions.
One of the common tools in behavior assessment models is the GAIN-SS. Information regarding same was taken from the website
Version [GVER]: GSS 2.0.1
What is your name? _______________________ (First Name)(M.I.)(Last Name)
The following questions are about common psychological, behavioral or personal problems.
These problems are considered significant when you have them for two or more weeks, when they keep coming back, when they keep you from meeting your responsibilities, or when they make you feel like you can’t go on. After each of the following statements, please explain the last time you had this problem, if ever, by responding in the past month (3), 2-12 months ago (2), 1 or more years ago.
What is today’s date (MM/DD/YYYY): ____/____/________
1. When was the last time you had significant problems…
a. with feeling very trapped, lonely, sad, blue, depressed, or hopeless about the future?
b. with sleeping, such as bad dreams, sleeping restlessly or falling asleep during the day?
c. with feeling very anxious, nervous, tense, fearful, scared, panicked or like something bad was going to happen?
d. when something reminded you of the past, and you became very distressed and upset?
e. with thinking about ending your life or committing suicide?
2. When was the last time you did the following things two or more times?
a. Lied or conned to get things you wanted or to avoid having to do something?
b. Had a hard time paying attention at school, work or home?
c. Had a hard time listening to instructions at school, work or home?
d. Were a bully or threatened other people?
e. Started fights with other people?
3. When was the last time…
a. you used alcohol or drugs weekly?
b. you spent a lot of time either getting alcohol or drugs, using alcohol or drugs, or feeling the effects of alcohol or drugs (high, sick)?
c. you kept using alcohol or drugs even though it was causing social problems, leading to fights, or getting you into trouble with other people?
d. your use of alcohol or drugs caused you to give up, reduce or have problems at important activities at work, school, home or social events?
e. you had withdrawal problems from alcohol or drugs like shaking hands, throwing up, having trouble sitting still or sleeping, or that you used any alcohol or drugs to stop being sick or avoid withdrawal problems?
4. When was the last time you…
a. had a disagreement in which you pushed, grabbed, or shoved someone?
b. took something from a store without paying for it?
c. sold, distributed or helped to make illegal drugs?
d. drove a vehicle while under the influence of alcohol or illegal drugs?
e. purposely damaged or destroyed property that did not belong to you?
5. Do you want treatment for or help with? (if yes, please describe below) ……………..
Do you have other significant psychological, behavioral or personal problems
v1._____________________________________________________________ v2._____________________________________________________________ v3._____________________________________________________________
6. What is your gender? Please describe.
7. How old are you today?
The Purpose of the GAIN-SS
The 5-minute GAIN Short Screener (GAIN-SS) is designed primarily to accomplish three purposes:
1. It serves as a short screen for general populations to quickly and accurately identify clients who have one or more behavioral health disorders (e.g., internalizing or externalizing psychiatric disorders, substance use disorders, or crime/violence problems), and would benefit from further assessment or referral for these issues. It also rules out those who would not be identified as having behavioral health disorders.
2. it serves as an easy-to-use quality assurance tool across diverse field-assessment systems for staff with minimal training or direct supervision.
3. It serves as a periodic measure of behavioral health change over time.
We also recommend using scores in the moderate/high range (1 to 5) on the four sub screeners to identify the specific kinds of behavioral health services (e.g., mental health, substance use, work or school programs, welfare programs, justice programs) that are needed:
o Moderate/high scores on the Internalizing Disorder Screener (1+ on IDScr) suggest the need for mental health treatment related to somatic complaints, depression, anxiety, trauma, suicide, and, at extreme levels, more serious mental illness (e.g., bipolar, schizoaffective, schizophrenia). If confirmed by a clinician, typical treatments often include a combination of counseling (e.g., cognitive behavioral therapy [CBT], desensitization) and medication.
o Moderate/high scores on the Externalizing Disorder Screener (1+ on EDScr) suggest the need for mental health treatment related to attention deficits, hyperactivity,
The Purpose of the GAIN-SS
The 5-minute GAIN Short Screener (GAIN-SS) is designed primarily to accomplish three purposes:
1. It serves as a short screen for general populations to quickly and accurately identify clients who have one or more behavioral health disorders (e.g., internalizing or externalizing psychiatric disorders, substance use disorders, or crime/violence problems), and would benefit from further assessment or referral for these issues. It also rules out those who would not be identified as having behavioral health disorders.
2. it serves as an easy-to-use quality assurance tool across diverse field-assessment systems for staff with minimal training or direct supervision.
3. It serves as a periodic measure of behavioral health change over time.
We also recommend using scores in the moderate/high range (1 to 5) on the four sub screeners to identify the specific kinds of behavioral health services (e.g., mental health, substance use, work or school programs, welfare programs, justice programs) that are needed:
o Moderate/high scores on the Internalizing Disorder Screener (1+ on IDScr) suggest the need for mental health treatment related to somatic complaints, depression, anxiety, trauma, suicide, and, at extreme levels, more serious mental illness (e.g., bipolar, schizoaffective, schizophrenia). If confirmed by a clinician, typical treatments often include a combination of counseling (e.g., cognitive behavioral therapy [CBT], desensitization) and medication.
o Moderate/high scores on the Externalizing Disorder Screener (1+ on EDScr) suggest the need for mental health treatment related to attention deficits, hyperactivity, impulsivity, conduct problems, and, in rarer cases, for gambling or other impulse control disorders. These rates are highest among adolescents but still common in about one in five adults in substance abuse treatment. If confirmed by a clinician, typical treatments often include a combination of counseling (e.g., CBT, contingency management [CM], dialectical behavior therapy [DBT], multisystemic therapy [MST]), increased structure in the environment, contingency management, and medications.
o Moderate/high scores on the Substance Disorder Screener (1+ on SDScr) suggest the need for substance abuse, dependence, and substance use disorder treatment and, in more extreme cases, the need for detoxification or maintenance services. If confirmed by a clinician, typical treatments often include a combination of counseling (e.g., CBT, CM, motivational interviewing [MI], community reinforcement approach [CRA], functional family therapy [FFT]) and medications for the management of withdrawal, maintenance, and craving reduction.
o Moderate/high scores on the Crime/Violence Screener (1+ CVScr) suggest the need for help with interpersonal violence, drug-related crimes, property crimes, and, in more extreme cases, interpersonal/violent crimes. If confirmed by a clinician, typical treatments include a combination of counseling (e.g., anger replacement therapy [APT], cognitive restructuring [CR], CBT, MI, CM, MST,) and medications to control impulsive violence and co-occurring problems.
Again, the above information is taken from the Gain SS screening tool from their own website. I have spent some of my time working as a psychiatric assessment nurse for an emergency department as well as the admitting department for provincial correctional institutions. The following is a format of writing outlining a mental health assessment from my training in both areas.
Mental Status Examination
Chief concerns/open ended questions in patient’s own words.
Previous psychiatric hospitalizations: length of time, where, previous or current DSM IV diagnosis.


  • Dress, grooming, hygiene, cosmetics, apparent age, posture, facial expression, eye contact.
  • Hyperactivity/hypoactivity/rigidity, relaxed/restless/agitated motor movements, gait and coordination, facial grimacing, gestures, mannerisms, passive, combative, bizarre, calm, tremors, tics, catatonia, akathisia.
  • Interactions with interviewer: – Cooperative, resistive, friendly, hostile, guarded, aggressive, hopeless, labile.
  • Speech-Quantity: – poverty of speech, poverty of content, volume, slow, rapid, pressured, tone, clanging ( Sounds, rather than meaningful relationships, appear to govern words or topics. Excessive rhyming, and/or alliteration. e.g. “Many moldy mushrooms merge out of the mildewy mud on Mondays.”)
  • Quality: – articulate, congruent, monotonous, talkative, repetitious, spontaneous, circumstantial, confabulation, tangential and pressured
  • Rate: slowed, rapid
Mood and affect
  • Mood (Intensity depth duration): sad, fearful, depressed, angry, anxious, ambivalent, happy, ecstatic, grandiose, anhedonia.
  • Affect (Intensity depth duration) :- appropriate, apathetic, constricted, blunted, flat, labile, euphoric.
  • Hallucinations; visual, auditory(commenting, discussing, commanding, loud, soft, known, unknown, comforting, disturbing), tactile, olfactory distortions.
  • Illusions; Refers to a specific form of sensory distortion. Unlike a hallucination, which is a distortion in the absence of a stimulus, an illusion describes a misinterpretation of a true sensation. For example, hearing voices regardless of the environment would be a hallucination, whereas hearing voices in the sound of running water (or other auditory source) would be an illusion.
  • Depersonalization: feel seperate from their own personal physicality by sensing their body sensations, feelings, emotions and behaviors as not belonging to the same person or identity. Often a person who has experienced depersonalization claims that things seem unreal or hazy. Also, a recognition of self breaks down. Depersonalization can result in very high anxiety levels, which further increase these perceptions. Individuals with depersonalization often find it hard to remember anything they saw or experienced while in third person. Common in PTSD, dissociative disorders, depression and anxiety.
  • Derealization: is unreality of the outside world.
  • Delusions; there are a few different categories including,
Grandiose: exaggerated/unrealistic sense of importance, power, identity.
Persecutory: others are out to harm in some way, ie. food is being poisoned.
Reference: everything in the environment is related to the person, ie. the tv has a special message.
Somatic: an unrealistic belief about the body, ie. the brain is rotting away.
Control: someone or something is controlling the person, ie. radio towers are transmitting thoughts and telling the person what to do.
  • Form and content-logical vs. illogical
  • Loose associations: a loose connection between thoughts that are often unrelated. ie. the bed was unmade. She went down the hill and rolled over to her good side. The flowers were pretty.
  • Flight of ideas: A sequence of loose associations or extreme tangentiality where the speaker goes quickly from one idea to another seemingly unrelated idea. To the listener, the ideas seem unrelated and do not seem to repeat. Often pressured speech is also present. e.g. “I own five cigars. I’ve been to Havana. She rose out of the water, in a bikini.” Typical in mania.
  • Blocking: Interruption of train of speech before completion, ie. “Am I early?” “No, you’re just about on…”(silence) At an extreme degree, after blocking occurs, the speaker does not recall the topic he or she was discussing. True blocking is a common sign of schizophrenia.
  • Neologisms: creation of a new word meaningful only to that person.
  • Word salad: combination of words that have no meaning or connection. ie inside outside blue cat market scream
  • Obsessions: Is the client repeatedly talking about one subject? Or using one term repeatedly? Is the client performing repeated actions, such as “shutting windows” or “thread picking”?
  • Ruminations: focuses on bad feelings and experiences from the past. It’s a way of responding to distress that involves repetitively focusing on the symptoms of distress, and on its possible causes and consequences.
  • Abstract vs. concrete: ie. a rolling stone gathers no moss would be interpreted literally.
  • Circumstantiality: excessive and irrelevant detail in descriptions with the person eventually making their point, ie. We went to the restaurant, the waitress had earrings, yes I like the food.
  • Tangential: digressions in conversation from topic to topic and the person never makes his/her point. Used primarily in response to answering questions in an oblique or irrelevant manner, ie. What city are you from? Well that’s a hard question. I’m from Calgary. I don’t know where my relatives came from. Went to spain once, but i don’t know if I’m Irish or French. * Also called derailment
  • Phobias: fears
  • Magical thinking: is a condition that causes the patient to experience irrational fear of performing certain acts or having certain thoughts because they assume a correlation with their acts and threatening calamities.
  • Poverty of thoughts: reduction in the quantity of thoughts. Typical in psychosis, depression or dementia.
  • Echolalia: Echoing of one’s or other people’s speech that may only be committed once, or may be continuous in repetition. This may involve repeating only the last few words or last word of the examiner’s sentences. This can be a symptom of Tourette’s Syndrome. e.g. “What would you like for dinner?”, “That’s a good question. That’s a good question. That’s a good question. That’s a good question.”
  • Distortions in thinking: catastrophizing (an uncomfortable event is turned into a catastrophe), dichotomous thinking (either/or I am good or bad), selective abstraction (focusing on one aspect, like the negative rather than considering the 5 positive aspects), fortune telling (anticipates a future negative event without facts or outcome), overgeneralization (one event is now representative of the entire situation, a missed anniversary represents a complete failed marriage)
  • Suicidal/homicidal (if homicidal, towards whom)
Sensory and Cognition
  • Level of consciousness, orientation, attention span, recent and remote memory, concentration, ability to comprehend and process information, intelligence, orientation (time/place/person), level of alertness
  • Ability to assess and evaluate situations makes rational decisions, understand consequence of behaviour, and take responsibly for actions, ie. “what would you do if you saw a fire in a movie theatre.”
  • Ability to perceive and understand the cause and nature of own and others’ situation. Awareness of the nature of the illness.
  • Interviewer’s impression that individual reported information accurately and completely
Psychosocial Criteria
  • Internal: Psychiatric or medical illness, perceived loss such as loss of self concept/self-esteem
  • External: Actual loss, ie. death of loved ones, diverse, lack of support systems, job or financial loss, retirement of dysfunctional family system
Coping skills
  • Adaptation to internal and external stressors, use of functional, adaptive coping mechanisms, and techniques, management of activities of daily living
  • Attainment and maintenance of satisfying, interpersonal relationships congruent with developmental stages, including sexual relationship as appropriate for age and status
  • How do you deal with visitors/family members/do you have any friendships or support systems?
  • Ability to adapt and conform to present norms, rules, ethics.
Spiritual (Value-belief)
  • Presence of self-satisfying value-belief system that the individual regards as right, desirable, worthwhile, and comforting
  • Engagement is useful, rewarding activity, congruent with developmental stages and societal standards (work, school and recreation).
There are many different tools in assessing suicidal thoughts and risk. Here’s a pretty easy one;
SAFE-T Suicide Assessment 5 step evaluation and triage.
1) Identify risk factors, evaluate those that can be modified to reduce risk.
2) Identify protective factors, note those that can be enhanced.
3) Conduct suicide inquiry: suicidal thoughts, plans, behavior and intent.
4) Determine risk level/intervention: determine risk. Choose appropriate intervention to address and reduce risk.
5) Document: assessment of risk, rationale, intervention and follow up.
Suicide assessments should be conducted at first contact, with any subsequent suicidal behavior, increased ideation, or pertinent clinical change; for inpatients, prior to increasing privileges and at discharge.
current/past psychiatric diagnoses:especially mood disorders, psychotic disorders, alcohol/substance abuse, Cluster B personality disorders. Co-morbidity and recent onset of illness increase risk.
Age: Suicide risk increases with age. Prior to puberty, suicide attempts or deaths by suicide are rare although suicide ideation is not (Jacobs, 1999). Suicide rates increase after puberty, and older adults (over the age of 65) have consistently shown higher rates of suicide compared to other age groups (Gallagher-Thompson & Osgood, 1997).
Sex: Risk is greater for males than females. Females are more likely to attempt suicide than are males, while males are up to four times more likely to die by suicide (Moscicki, 1999).
History of Psychiatric Disorders: A history of psychiatric disorders can signal an elevated risk for suicide.
Current Axis I Diagnosis: Mood disorders, particularly depression, as well as previous suicide attempts, are among the strongest risk factors for suicide. Anxiety disorders have been associated with an increased risk for suicide and suicidal behaviour, particularly as they co-occur with mood disorders and substance use disorders. Schizophrenia can also contribute to an elevated risk for suicide, particularly during the early years of the illness. Over 90% of all suicides have been associated with the presence of a psychiatric disorder.
Current Axis II Diagnosis: Individuals with a personality disorder, for example borderline personality disorder, are at increased risk for suicidal behaviour.
Social Relationships: Social isolation is a common risk factor for depression and suicide. Individuals’ perceptions of the quality of friendships and family relationships are a relevant factor in assessing risk for suicidal behaviour.
Living Alone: Living alone is associated with increased risk of suicide for men.
Key symptoms: anhedonia, impulsivity, anxiety/panic, global insomnia, command hallucinations, Hopelessness is highly predictive of suicide risk. Hope is a protective factor. Without a sense of hope, suicide is often viewed as an acceptable escape. Anger, depression, guilt, anxiety/panic, insomnia, and diminished attention/concentration are also markers of suicide risk.
suicidal behavior: history of prior suicide attempts, aborted suicide attempts or self-injurious behavior. History of a suicide attempt dramatically increases future risk for suicide. Individuals who have attempted suicide constitute a very high risk for suicide – a rate of 50-100 times that of the general population.
Family history: of suicide, attempts or Axis 1 psychiatric diagnoses requiring hospitalization. Individuals who attempt or die by suicide are more likely to come from families with a history of suicidal behaviours. Family history of psychiatric difficulties (e.g., depression, suicide) also increases risk for suicide.
Precipitants/stressors: triggering events leading to humiliation, shame or despair (i.e., loss of relationship, financial or health status—real or anticipated). Ongoing medical illness (esp. CNS disorders, pain). History of abuse or neglect. Intoxication.
Interpersonal and circumstantial factors must be thoroughly assessed as they can contribute to an increased risk for suicide. Examples include interpersonal conflict (separation or divorce), periods of change, and real or perceived humiliation or loss.
Access to firearms or other lethal means
Easy access to firearms, large doses of medication, or other potentially lethal means can increase suicide risk considerably.
2. PROTECTIVE FACTORS Protective factors, even if present, may not counteract significant acute risk
Internal: ability to cope with stress, religious beliefs, frustration tolerance, absence of psychosis
external: responsibility to children or beloved pets, positive therapeutic relationships, social supports
Individual Factors
strong sense of competence effective interpersonal skills effective problem-solving skills adaptive coping skills
self-understanding optimistic outlook religious affiliation
Family Factors
sense of responsibility to family relationships characterized by warmth and belonging
Work Factors
sense of accomplishment positive peer support and colleague relationships supportive, non-punitive work environment professional development opportunities (e.g., career
development, stress management workshops) core values are present in the workplace
(e.g., integrity, honesty) access to employee assistance programs
opportunities to participate affordable, accessible supportive resources hope for the future community self-determination and solidarity
3. SUICIDE INQUIRY Specific questioning about thoughts, plans, behaviors, intent
Ideation: frequency, intensity, duration–in last 48 hours, past month and worst ever
Plan: timing, location, lethality, availability, preparatory acts
Behaviors: past attempts, aborted attempts, rehearsals (tying noose, loading gun), vs. non-suicidal self injurious actions
Intent: extent to which the patient (1) expects to carry out the plan and (2) believes the plan/act to be lethal vs. self-injurious;
Explore ambivalence: reasons to die vs. reasons to live
* Homicide Inquiry: when indicated, esp. postpartum, and in character disordered or paranoid males dealing with loss or humiliation. Inquire in four areas listed above.
Assessment of risk level is based on clinical judgment, after completing steps 1-3 Reassess as patient or environmental circumstances change
(This chart is intended to represent a range of risk levels and interventions, not actual determinations.)
5. DOCUMENT: Risk level and rationale; treatment plan to address/reduce current risk (i.e., medication, setting, E.C.T., contact with significant others, consultation); firearm instructions, if relevant; follow up plan.
The above suicide assessment tool is SAFE -T conceived by Douglas Jacobs, MD, and developed as a collaboration between Screening for Mental Health, Inc. and the Suicide Prevention Resource Center.
Also the below link “Working with the Client who is suicidal, ” is an excellent resource.
Well, that’s the initial introduction anyhow. There’s many more components to an assessment, if this type of stuff is useful I can share more of this workshop outline.
Kerry Rae