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Thursday, September 3, 2009

T3 - Therapy Basics: Assessments

An assessment is a therapist's most basic tool. They all look different, include different questions in different orders. Some are very extensive, up to several pages long, while others are short and to the point (i.e., "Why are you here?").

The assessment I've used for years is around five pages and it includes the following:

Identifying Information Presenting Problem(s)
*Psychiatric Symptoms/Behaviors

Individual's Expectations

Developmental History

Educational History

Marital History

Work/Military History

Medical/Physical/Psychiatric History

Substance Abuse History

Legal/Incarceration History

Relevant Financial Issues

Relevant Ethnic/Cultural Considerations

History of Trauma (best to just know this up front, so I ask)
*Mental Status Exam

*Suicide Risk Assessment

*Assault Risk Assessment

Diagnostic Impressions
(where a diagnosis is assigned)
Clinical Summary/Impressions (overall)
Individual Strengths and Weaknesses

*Current Areas of Functional Impairment
(to focus treatment)
Treatment Referrals (either to a medical doctor for a physical; a lawyer for legal aide, etc.)
Final Plan
(what client agrees to)
*Release(s) of Information Obtained

Therapist Signature

Like I said, assessments differ as widely as the therapists who use them. I happen to like this assessment because it was developed to meet state requirements for someone on MediCal (which is the equivalent of Medicare for those who don't live in California). MediCal requirements are extensive, so I know my assessment is, too.

Breaking it down isn't that difficult because most of it is self-explanatory. I put a star next to those elements that might need a bit more explanation.

As you could see by the list, most of the information I gather is history, plain and simple. I have to know where a client is coming from before I can try to help them to where they want/need to go. So history gathering is extensive, and it can take more than one session to get everything down.

Psychiatric symptoms/behaviors are what I observe to be problematic during the initial interview. What symptoms of disorders are florid (very clearly exemplified)? Are they agitated? Tearful? Which symptoms does the client self-report (it can be that a client has panic attacks that I'd never see in the office, for example)? A knowledge of the Diagnostic and Statistical Manual is imperative for this type of assessment.

A mental status exam is kind of like a mini-assessment all by itself. I basically see if the person is in their right mind or not. Do they know who they are? What year it is? Who is president? What 2+2 is? Can they remember my name five minutes into our assessment after I gave it to them at the beginning? What is their speech pattern like? How are the groomed/dressed? These types of questions, if answered incorrectly, can automatically point a therapist to severe disorders like schizophrenia.

A suicide risk assessment and an assualt risk assessment are included to protect the therapist from litigation. No one would want a client to come to see them only to kill themselves hours later. So I've developed the habit of always broaching the subject of self harm and harm to others in the first session, just to see the client's reaction (are they shocked because they are offended, or because they have had suicidal thoughts?) and be able to note in my case notes for that client their response. This shows that I have acted as a reasonable therapist and protects me should I get sued (which thankfully I have never been!).

Current areas of functional impairment is just a fancy way of saying "What areas does this client struggle with the most?" How severe is the struggle? Moderate? Mild? None? Extreme? Here are the major areas I assess for:

1. Community Living

2. Community Participation

3. Community Contribution

4. Financial

5. Relationships with Others

6. Education and Learning

7. Physical and Emotional Health

8. Legal

And the release of information section is just to know who exactly I have permission to coordinate treatment with. I did a lot of school counseling, so I always had to have a release of information for the school. If you need to be in contact with a medical doctor, their name should be on a release somewhere. Having a list of all these contacts in one place is very handy.

So, this is what all I include in an assessment. This is not to be confused with intake paperwork a client fills out when they come into your office. An assessment is a document likely no client will see. Intake paperwork asks some of the same type information I've listed, and most therapists can compare the information to what the client actually tells them, looking for consistency, as well as use the intake paperwork to help fill in the assessment after the session is over (to spark their memory, etc.). It never hurts to repeat information in different places.

Join me next week as I discuss the Diagnostic and Statistical Manual-IV-TR, also known as the DSM or therapist's "bible."

Q4U: Have you or someone you know ever gone through an assessment similar to what I've described above? What might have been some areas left out of my assessment that were on yours?

Wordle: signature


Jessica Nelson said...

Wow, that's very in-depth. I haven't ever been through this myself.
A good friend of the family is a child psychologist and one of her patients tried to commit suicide. It was extremely hard on her. I can't imagine all the emotions involved with being a therapist, or how you're able to handle it.
Thanks for the run-down.
btw, a friend of mine thinks her son's friend is ADD. He's five. Have you ever done a thing on ADD? Is it possible to diagnose that at such a young age? Just curious...

Jeannie Campbell, LMFT said...

hey jessica. for your friend, have her type in Google search the following:

Vanderbilt ADHD Diagnostic Parent Rating Scale

or just go to this page.

i honestly thing it's pretty self-explanatory and will give her a really good idea if her son has it. (and yes, you can diagnose that young) there is also a teacher rating scale that applies to school settings. nothing definitive can be said about her son until she goes to a therapist, psychologist, etc.

i hope that helps!

Stephanie Faris said...

When I was going through my divorce, we went to church counseling...we did it together, then separately. I guess she was going through all of those steps...I don't know. She threw a lot of things at me that I remembered from college psychology classes. (I minored in psychology.)

Jessica Nelson said...

Thanks Jenni. :-) She's a teacher and she sounds sure of it, so she probably already has read this. But also, she doesn't have the internet because she had a baby and stays home now.
Thank you for the link! I'm actually going to go check that out...

Elana Johnson said...

Wow, I'm new here and uber-impressed! Thanks for this! Tuesdays and Thursdays just got busier. :) In a good way.

Jeannie Campbell, LMFT said...

welcome, elanaj! i'm glad you stopped by and found my blog interesting. :)

Katie Ganshert said...

This assessment thing would be a good thing to fill out for our characters!

Tabitha Bird said...

Wow, that is full on! I am not sure how different things are over here in Australia because although I am in counselling I am not a cousellor.
My counsellor never takes notes during the session, but she is incredibly present, if that makes sense. I have been seeing her for over a year and during the course of that time I have been suicidal (though that was at the beginning) and also self harmed. She would always ask me questions about where I was at and how far through the thought processes I was, I guess to see how big of a threat I was to myself. But as far as I know she never did any formal assessment. She also knows that I had and still have an amazing support network around me. I was always very honest with her. We have grown to trust each other's judgements and wisdom. And can I also so, in case any one is worried about me after having said all that, many of those issues are far behind me :)
I am always interested in your posts from a personal perspective. They are always insightful :)

Jeannie Campbell, LMFT said...

thanks for being so candid, tabitha. we've all been in emotionally unhealthy places from time to time. sounds like your counselor was definitely doing some assessment-like things with you. i don't usually take notes in session either. it's distracting to the client, i think. or at least i would be distracted in therapy with someone scribbling away. :) but during an assessment, i usually do - to make sure i don't miss something.

katie - you're right would be really helpful if we did an assessment on every character just for the background!

Tara McClendon said...

Great post. If I ever decide to find a therapist, I might just start stalking you. Wait. Does that mean I need therapy now? Thanks for the information.

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Both comments and questions are welcome. I hope you enjoyed your time on the couch today.