Severity and Chronicity

Clinical psychologists need to have the ability to work with people with a wide breadth of presentations, including those whose problems are severe and enduring (or chronic).

One way of defining severity and chronicity is to refer to the Global Assessment of Functioning (GAF) Scale, What follows is our adaptation of the scale, followed by the scale itself.

	Risk to self	Risk to other	Self-neglect	Mental health symptoms	Interpersonal functioning	Occupational functioning
mild	None present; or minimal current suicidal ideation, or ideation but no intent mild hopelessness many protective factors such as social support,	None present; or minimal thoughts of violence to others with no intention of carrying out acts	Drop in interest in or mild deterioration in appearance or usual activities	Distress, usually in response to an identifiable life event e.g. bereavement, diagnosis of health threat	Minor difficulties - e.g. current tendency to avoid intimacy, or some problems making or maintaining relationships, but not usual pattern Good social network not currently being fully utilised	Minor difficulties - e.g. brief periods of school or work missed, disinterest or difficulty concentrating whilst at work, anxiety or distress interfering with some aspects of role such as presentation
moderate	Suicidal ideation and previous self-harm with low likelihood of death	Violent thoughts (especially if towards specific individuals or groups) and a history of previous violence	Obvious deterioration in self-care or poor usual self-care Stopping usual activities, neglecting diet	Clear symptoms of mental distress: anxiety or other mood problems; possible psychotic phenomena with some 'insight'	Moderate disruption in social functioning, or poor general social skills or extensive avoidance of interpersonal relationships	Prolonged absence from school or work due to mental health problems, Severe under-functioning given ability level
severe	Repeated serious self-harm or recent suicide attempt with high likelihood of death e.g. attempts to prevent discovery, violent method, note written	Pattern of aggression towards others, usually history of problems with police	Severe self-neglect, poor personal hygiene Inability to occupy self May not be able to live independently	Severe and disabling mental health problems, psychotic phenomena with poor 'insight'	No or very limited social network Most contact with health care or social service professionals; usually would have an identifiable care system	Inability to attend school or work due to mental health functioning

For reference the GAF scale is as follows:

100-91	Superior functioning in a wide range of activities, life's problems never seem to get out of hand, is sought out by others because of his or her many positive qualities. No symptoms.
90-81	Absent or minimal symptoms (e.g., mild anxiety before an exam), good functioning in all areas, interested and involved in a wide range of activities, socially effective, generally satisfied with life, no more than everyday problems or concerns (e.g., an occasional argument with family members).
80-71	If symptoms are present, they are transient and expectable reactions to psychosocial stressors (e.g., difficulty concentrating after family argument); no more than slight impairment in social, occupational, or school functioning (e.g., temporarily falling behind in schoolwork).
70-61	Some mild symptoms (e.g., depressed mood and mild insomnia) OR some difficulty in social, occupational, or school functioning (e.g., occasional truancy, or theft within the household), but generally functioning pretty well, has some meaningful interpersonal relationships.
60-51	Moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) OR moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers).
50-41	Serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) OR any serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).
40-31	Some impairment in reality testing or communication (e.g., speech is at times illogical, obscure, or irrelevant) OR major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work; child frequently beats up younger children, is defiant at home, and is failing at school).
30-21	Behavior is considerably influenced by delusions or hallucinations OR serious impairment, in communication or judgment (e.g., sometimes incoherent, acts grossly inappropriately, suicidal preoccupation) OR inability to function in almost all areas (e.g., stays in bed all day, no job, home, or friends)
20-11	Some danger of hurting self or others (e.g., suicide attempts without clear expectation of death; frequently violent; manic excitement) OR occasionally fails to maintain minimal personal hygiene (e.g., smears feces) OR gross impairment in communication (e.g., largely incoherent or mute).
10-1	Persistent danger of severely hurting self or others (e.g., recurrent violence) OR persistent inability to maintain minimal personal hygiene OR serious suicidal act with clear expectation of death.
0	Inadequate information.

Clinical psychologists should be able to draw on knowledge of psychological theories which inform work with people with problems of different levels of severity and chronicity, and the ability to apply this knowledge and to develop skills with this population. They should also be familiar with the historical context and current policies and procedures relating to working with people with moderate to severe problems..

Specifically they should demonstrate:

An ability to engage people with differing severity/chronicity of problems.

An ability to assess people with problems of differing severity/chronicity.

An ability to formulate the range of problems presented by people with differing severity/chronicity of problems, and derive an intervention which is in line with realistic expectations of what is achievable, and which will usually identify the involvement of other professionals and their roles in the intervention

An ability to conduct an intervention with people of with differing severity/chronicity of problems, including the ability to work both directly and indirectly with other professionals

An ability to evaluate the work .

An ability to draw on knowledge to critically evaluate, plan, execute, and conduct research with people who have problems of different severity, being aware of issues that may be specific to client groups who differ in severity of presentation.

An ability to draw on knowledge to adapt their written and verbal communication to clients who have problems that affect their functioning to a greater or lesser degree.

An ability to draw on knowledge to inform their understanding of how services need to be delivered differently for people with problems of different levels of severity and chronicity, and use this understanding to facilitate their work in those settings.

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