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Clinical Interview: Final Assessment for Principles of Counseling Web Page Clinical Interview: Final Assessment for Principles of Counseling A clinical interview is a face-to-face encounter between a mental health professional and a patient in which the former observes the latter and gathers data about the persons behavior, attitudes, current situation, personality, and life history. The interview may be unstructured in which open-ended questions are asked, structured in which a specific set of questions according to an interview schedule are asked, or semi-structured, in which there is a pre-set list of questions but clinicians are able to follow up on specific issues that catch their attention. Review the types of Interviews here: Clinical Interview and Mental Status Examination | Abnormal Psychology (lumenlearning.com) Dr. Todd Grande – YouTube Types of Therapy (goodtherapy.org) The Counseling Modality you choose to use will determine the type of questions, interview structure, and style adapted in this session. This is called: the golden thread! The Golden Thread is the documentation that supports each decision, intervention, or client note that contributes to a complete record of client care that is error free and ready for reimbursement. The Golden Thread begins with the clinical assessment (identified needs), then pulls through the treatment plan (interventions and goals based on research and resources) to on-going progress notes (client’s effort, services provided, progress made towards goals). Each model has a specific set of threads that should be followed BASED on the client’s needs/goals and the research supporting modalities and techniques. Here is a resource on “The Golden Thread” Maintaining The Golden Thread 2020.docx (ctacny.org) A typical clinical interview will cover: * Age and Sex/Pronoun preference * Reason for referral/presenting problem/goals. * Consent to treat and ethical obligations. * Education and work history. * Current social situation. * Physical and mental health history. * Drug/alcohol use and current medication. * Family history (Dont forget bio-psycho-social components!) * Behavioral observations/lines of questioning with specific emphasis on your Counseling Model. The MODEL you choose will determine specific lines of questions/information gathering- don’t forget the Golden Thread! Mental Status Examination (MSE): Mental Status Exam (Worksheet) | Therapist Aid The MSE is an important part of the clinical assessment process. It is a structured way of observing and describing a patients psychological functioning at a given point in time, under the domains of appearance, attitude, behavior, mood, and affect, speech, thought process, thought content, perception, cognition, insight, and judgment. The purpose of the MSE is to obtain a description of the patients mental state, which, when combined with the biographical and historical information of the psychiatric history, allows the clinician to make an accurate diagnosis and formulation, which are required for coherent treatment planning. The mental status examination is a core skill of qualified (mental) health personnel. It is a systematic collection of data based on observation of the patients behavior while the patient is in the clinicians view during the interview. The purpose is to obtain evidence of symptoms and signs of mental disorders, including danger to self and others, that are present at the time of the interview. Further, information on the patients insight, judgment, and capacity for abstract reasoning is used to inform decisions about treatment strategy and the choice of an appropriate treatment setting. The information obtained in the MSE is used, together with the biographical and social information of the psychiatric history, to generate a diagnosis, a psychiatric formulation and a treatment plan. In abnormal psych, I ask students to create a treatment plan using the MSE and background (bio-psycho-social) information given a case study with specific diagnostic indicators. The mental status examination assesses behavioral and cognitive functioning. Behavioral components include, appearance and general behavior, level of consciousness and attentiveness, motor and speech activity, mood and affect, thought and perception, attitude and insight, and the reaction evoked in session. Cognitive components include alertness, language, memory, constructional ability, and abstract reasoning. A Generic Clinical Interviewing Model All clinical interviews follow a common process or outline. Shea (1998) offered a generic or atheoretical model, including five stages: (1) introduction, (2) opening, (3) body, (4) closing, and (5) termination. Each stage includes specific relational and technical tasks. This assignment will focus on the OPENING (abbreviated) and the BODY Opening The opening provides an initial focus. Most mental health practitioners begin clinical assessments by asking something like, What concerns bring you to counseling today? This question guides clients toward describing their presenting problem (i.e., psychiatrists refer to this as the chief complaint and psychotherapists call this the presenting problem.) Counselors should be aware that opening with questions that are more social (e.g., How are you today? or How was your week?) prompt clients in ways that can unintentionally facilitate a less focused and more rambling opening stage. Similarly, beginning with direct questioning before establishing rapport and trust can elicit defensiveness and guardedness. Many contemporary therapists prefer opening statements or questions with positive wording. For example, rather than asking about problems, therapists might ask, What are your goals for our meeting today? For clients with a diverse or minority identity, cultural adaptations may be needed to increase client comfort and make certain that opening questions are culturally appropriate and relevant. Some modalities have specific stages and you should adapt the opening/body to the theoretical parallels. Body The interview purpose governs what happens during the body stage. If the purpose is to collect information pertaining to psychiatric diagnosis, the body includes diagnostic-focused questions. In contrast, if the purpose is to initiate psychotherapy, the focus could quickly turn toward the history of the problem and what specific behaviors, people, and experiences (including previous therapy) clients have found more or less helpful. When the interview purpose is assessment, the body stage focuses on information gathering. Clinicians actively question clients about distressing symptoms, including their frequency, duration, intensity, and quality. During structured interviews, specific question protocols are followed. These protocols are designed to help clinicians stay focused and systematically collect reliable and valid assessment data. In this assignment, the model you choose will determine your body structure. Review Study.coms tutorial: Clinical Interviews in Psychological Assessment: Purpose, Process, & Limitations – Video & Lesson Transcript | Study.com Review Youtubes MANY examples of role-plays. I appreciate Dr. Grandes efforts, as he tends to try to present examples based on the modalities you are learning: What is Analytic Psychology? (Jungian Therapy) – YouTube (this link should take you to his whole modality playlist!) And, this should bring you to his whole intake/assessment playlist: Intake and Assessment Role-Play Part 1 – Referral and Presenting Problems – YouTube Review Open Access Multimedia Resources: Open-Access Multimedia Resources: FA20: PSYC-160 Sec 02 – Clinical Psychology (instructure.com) You will pair with another classmate or use a volunteer. Each of you will take turns being the therapist and then being in the role of the client. I will only be assessing YOU as the therapist! For your role play, you should roleplay prepared parts (have your demographic information and role ready- you dont have to be you- play a part if it is more comfortable!) * Roleplay the initial interview. This should include: Basic demographic and bio-psycho-social information, MSE, review of informed consent, including confidentiality and limits of confidentiality with the client. Therapist should offer time for clients questions to be addressed. Make time to sign intake forms. And, importantly should begin to explore the presenting problems with questions aligning to the modality you will use in your primary therapeutic process. This will be approximately 5 minutes of the total roleplay- though it can sometimes take several sessions in real therapy. This emphasizes the importance of roles/parts being predetermined! * The CORE of the assignment will be a 15 minute role play of a body session- start by summarizing what youve been working on (this gives us information that you may need to specify your modality). The rest of the time should be your demonstration of THAT modalitys focus, style, questions, emphasis, and structure. You MAY need to research these styles more thoroughly- PLEASE do… Watch examples of the style you use and model your scripts after this type of dialog- PLEASE be original and demonstrate academic integrity. DETAILS The assignment will be complete when you submit: * Your 20 minute roleplay If working with another student, each of you should play the therapist: THAT is what Im assessing…. * The script (which does not have to be exact- if adlibs occur, dont worry!) I will use this as evidence that you are following the theoretical trajectory (the golden thread) and ethical components of counseling practice. I SHOULD be able to see the rationale in your questions and within the dynamics of the interaction with this script! (No length requirement- THOUGH, it should reflect your 20 minutes of dialog!) * A completed MSE (this CAN be completed after the role play- but, we mentally note these components upon initial meeting! I will be watching for the MSE components, so if you’re unsure- collect the information after by watching your own work, and observing the mannerisms to fill it out- you will get better at these, and you will be able to fill them out as youre interviewing through observation. That can be a hard skill, so this is only practice!) IF you don’t know some vocabulary, PLEASE look it up! * And, at minimum, a two-page essay REFLECTING on the assignment, demonstrating the golden thread, using the course modules and resources to rationalize your modality and support why you asked the questions you asked (given the specific theory you chose), a description of why you selected the modality- what appealed to you, and how you decided to use that particular model. And, a summary of how you felt, overall, as the therapist AND as the client if you worked with a classmate. Use the core qualities, ethical and cultural competencies, and the vocabulary from the modules, etc. etc. This is a cumulative demonstration of your learning for the course. Please take your time and write a coherent, well-organized, essay!