Essential Clinical Skills for Counselors Mental Status Exam & Suicide Assessment Sidney L. Shaw, EdD John Sommers-Flanagan, PhD Rita Sommers-Flanagan, PhD

Why the Clinical Interview?  Assessment & Intervention are ubiquitous counselor roles  Conducting Clinical Interviews can become automatic over time  The challenge of gathering assessment data while establishing rapport & emphasizing strengths

The Plan  Very quick overview of MSE  Specific focus on MSE categories of assessing affect/mood & judgment  Suicide assessment  The emphasis is on integrating strengths- based, constructive approaches

MSE Purpose  The MSE is a method of organizing clinical observations about current mental functioning.  The MSE is a primary method for communicating about cognitive or psychiatric symptoms in medical settings  Sample MSE reports are available at johnsommersflanagan.com

MSE General Categories  Appearance  Behavior/psychomotor activity  Attitude toward examiner (interviewer)  Affect and mood  Speech and thought  Perceptual disturbances  Orientation and consciousness  Memory and intelligence  Reliability, judgment, and insight

Evaluating Affect & Mood  Where are the struggles?  Where are the strengths?  Gathering assessment information.  Integrating strength-based, solution focused interventions.

judgment  Questions should address:  What are the impulses?  What are the responses to impulses?  Are there areas where judgment is clearly poor?  What sound judgments are exhibited?  Integrating strengths-based, solution focused interventions.

Video Clip – Carl  Watch for movement back and forth from the technical task of the MSE interview and less directive listening or strength-based intervention  Think about what symptoms you see and hear and how you might articulate them in an MSE report  The protocol being used is published and also available online

Cultural Issues  How does culture affect MSE process and MSE reports

Cultural issues: Generating Possible invalid conclusions CategoryObservation Invalid ConclusionExplanation Attitude toward examiner Uncooperative and hostile Oppositional- defiant or personality disorder Has had abusive experiences from dominant culture Affect and mood No affect linked to son’s death Inappropriate ly constricted affect Expression of emotion about death is unaccepted in client’s culture Reliability, judgment, and insight Lies about personal history Poor reliabilityDoes not trust White interviewer from dominant culture

MSE Common Pitfalls  Lack of focus on or knowledge of the categories  Single symptom generalization  Interpretation of client symptoms can become very idiosyncratic and based on our own experiences  Can, in a traditional method, reinforce or emphasize what’s wrong with the client.

Transforming the MSE  MSE to gather data about client deficits or pathology; also about client strengths  MSE as rapport enhancing  Focus the MSE also on wellness – integrating solution-focused interventions

Part II: Suicide Assessment  Preparation  Busting the Big MYTH  The New Narrative  The “state of the art (and science)” suicide assessment clinical interviewing  Suicide interventions  Resources

Preparation  Self-Preparation: Questions to ask yourself  What issues/ideas, etc., activate my suicide buttons?  What are my beliefs and attitudes about suicide?  What are my aims in approaching suicide assessment?

Busting the Big Myth (Narrative)  The Big MYTH or Old Narrative  Suicide ideation and gestures are signs of DEVIANCE  This is the old medical model perspective  It suggests that we, as medical authorities, assess and intervene with suicidal patients

The New Narrative  Suicide thoughts and gestures don’t represent deviance  Suicide thoughts and gestures represent DISTRESS  We have empathy WITH clients and their distress, viewing suicide ideation and behavior as a means through which they express their distress or unhappiness

New Narrative II  The old narrative emphasized diagnostic interviewing  The new narrative implies:  Using strength-based paraphrases  Carl Rogers with a twist (O’Hanlon)  Exception and externalizing questions  Resource questions  No assumption of mental illness

Video Clip  Tommie and John  Watch for directness  Watch for strength-based and solution-focused methods

Suicide Narratives Adapted from Meichenbaum  “I can't stand being so depressed anymore.” “I can stop this pain by killing myself.” (Schneidman, 2001 psychache and mental constriction)  “Suicide is the only choice I have.” (The word “only” is considered one of the most dangerous words in suicidology)

Suicide Interview Components  Suicide risk factors  Suicide ideation  Suicide plan (SLAP)  Self-control

Reformulating Suicide Assessment & Intervention  BALANCING YOUR QUESTIONING  Traditional suicide assessment and depression assessment focuses on asking about risk factors and depressive symptoms  We should balance this with positive questions about protective factors (reasons for living), hope, and positive behaviors (scaling)  Rationale: Differential activation theory

Brief Suicide Interventions  No suicide contracts vs. safety plans  Explore alternatives to suicide  3rd person exploration  Separate suicidal feelings from the self (the desire is to eradicate the feelings – not the self)

Decision-Making  Frequency and intensity and power of SI  Specificity and lethality of plan  Other risk factors and protective factors (RFL)  Self-control and intent  Responsiveness to interventions  Develop safety plan and/or hospitalize  Consultation and documentation

Closing Comments  Thanks for listening and participating  You can access free resources at: johnsommersflanagan.com  For detailed information on MSE & suicide assessment interviewing, see: Sommers- Flanagan & Sommers-Flanagan (2014). Clinical Interviewing (5 th ed.). Chapters 8 & 9; Hoboken, NJ: Wiley