Professional Practices: Assessment Melody Kipp, PhD, LMHC Life & Work Soulutions, Inc.

Assessment An ongoing process through which the counselor collaborates with the client and others to gather and interpret information necessary for planning treatment and evaluating client progress, and making substance abuse diagnoses. (Florida Certification Board, 2004, p. 27). An ongoing process through which the counselor collaborates with the client and others to gather and interpret information necessary for planning treatment and evaluating client progress, and making substance abuse diagnoses. (Florida Certification Board, 2004, p. 27).

Assessment The Biopsychosocial Interview. The Biopsychosocial Interview. The purpose of the Biopsychosocial interview is to find out exactly what the problems are and where they come from. The purpose of the Biopsychosocial interview is to find out exactly what the problems are and where they come from. Biology – the cells. Biology – the cells. Psychology – the emotions, attitudes, and behavior. Psychology – the emotions, attitudes, and behavior. Sociology – the relationships and environment. Sociology – the relationships and environment.

Assessment The Biopsychosocial Assessment (Appendix 32) The Biopsychosocial Assessment (Appendix 32) Allow 1 to 2 hours: Allow 1 to 2 hours: Without distractions Without distractions Without interruptions Without interruptions

Assessment Beginning counselors often experience difficulty with the assessment because: Beginning counselors often experience difficulty with the assessment because: They become overwhelmed with too much information. They become overwhelmed with too much information. They begin treatment too early. They begin treatment too early. Becoming a skilled interviewer takes practice and experience. Becoming a skilled interviewer takes practice and experience.

Assessment The biopsychosocial assessment should address the following: The biopsychosocial assessment should address the following: The patient’s demographic information. The patient’s demographic information. History of present illness. History of present illness. Past history. Past history. Medical history. Medical history. Mental status exam. Mental status exam.

Assessment Imagine yourself sitting in a comfortable chair in your office. You are relaxed and ready to begin the Biopsychosocial Interview with the client sitting across from you. What will you say to the client as you begin the Biopsychosocial Interview? Imagine yourself sitting in a comfortable chair in your office. You are relaxed and ready to begin the Biopsychosocial Interview with the client sitting across from you. What will you say to the client as you begin the Biopsychosocial Interview?

Assessment After you have completed the practice interview, reflect on these questions: After you have completed the practice interview, reflect on these questions: How did you feel after the interview was completed? How did you feel after the interview was completed? What part of the interview was effortless for you? What part of the interview was effortless for you? What part required more effort than you thought? What part required more effort than you thought? Where do you believe you could improve? Where do you believe you could improve?

Assessment Ask the person you interviewed to give you some constructive feedback on how they felt during the interview and what they thought went well and what could use improvement. Ask the person you interviewed to give you some constructive feedback on how they felt during the interview and what they thought went well and what could use improvement.

Assessment You may also want to enlist the help of a seasoned professional counselor to observe you conducting the Biopsychosocial interview. That person could then offer you more constructive criticism that will help you improve your clinical skills. You may also want to enlist the help of a seasoned professional counselor to observe you conducting the Biopsychosocial interview. That person could then offer you more constructive criticism that will help you improve your clinical skills.

Assessment Look at the completed Sample Biopsychosocial Interview in Appendix 7. Using that sample as a guide, write a narrative summary of your interview using the following headings: Look at the completed Sample Biopsychosocial Interview in Appendix 7. Using that sample as a guide, write a narrative summary of your interview using the following headings: Patient Name Patient Name Demographic Data Demographic Data

Assessment Chief Complaint Chief Complaint History of the Present Illness History of the Present Illness Past History Past History Medical History Medical History Family History Family History Mental status Mental status

Assessment Summary and Impressions Summary and Impressions Include all of the problems that you have seen and give your impression of where the patient stands on each of the following dimensions: Include all of the problems that you have seen and give your impression of where the patient stands on each of the following dimensions: Acute intoxication or withdrawal complications Acute intoxication or withdrawal complications Biomedical conditions or complications Biomedical conditions or complications Emotional/behavioral complications Emotional/behavioral complications Treatment acceptance or resistance Treatment acceptance or resistance Relapse potential Relapse potential Recovery environment Recovery environment

Assessment Diagnostic Impressions: Diagnostic Impressions: Based on the information gathered during the Biopsychosocial Interview, a diagnosis is determined by consulting the DSM. What are your diagnostic impressions of your “pretend” client? Based on the information gathered during the Biopsychosocial Interview, a diagnosis is determined by consulting the DSM. What are your diagnostic impressions of your “pretend” client? Reminder: Only licensed clinicians or those supervised by licensed clinicians may diagnose patients. Reminder: Only licensed clinicians or those supervised by licensed clinicians may diagnose patients.