Clinical Assesment Notes

Clinical Assessment

• Why Psychologists Assess People:
  • Diagnosis
  • Understanding personality dynamics influencing life and symptoms
  • Guiding psychotherapy goals
  • Answering external referral questions

Steps in Conducting a Psychological Assessment

• Determine the reason for referral and presenting problem
• Choose what to assess
• Select the method of assessment
• Gather the assessment data
• Consider the data and draw conclusions
• Convey the conclusions to appropriate parties

Clinical Interviewing

• Definition:
• Interview Types:
  • Crisis interview
  • Intake-admission interview
  • Social/Case history interview
  • Mental status examination
  • Diagnostic interview

Crisis Interview

• Conducted when: Somebody, self or other, is in immediate danger.
• Goals:
  • Meet the immediate problems of the client.
  • Decrease distress.
  • Motivate client to seek treatment in an appropriate place.
  • Keep the client (and others) safe.
  • Involuntary hospitalization if necessary.
• What is assessed?
  • Ideation, Plan, Means, Intent

Intake-Admission Interview

• Purposes:
  • Why are you here?
  • Is this the right place for you?
• What’s included?
• Conducted by whom?

Social History Interview

• Purposes:
  • To obtain through history
  • To understand context
  • To understand possible etiological mechanisms
• What’s included

Social History Interview: What’s Included?

• Childhood/family history
• Social/interpersonal history
• Trauma history
• Educational history
• Occupational history
• Medical history
• Psychiatric history
• Substance use history
• Legal history
• Sexual history
• Religious beliefs
• Hobbies
• etc.

The Mental Status Examination

• Assesses presence of in-the-moment cognitive, emotional, or behavioral characteristics
• Information gathered may or may not be relevant to the case.
• Often recorded as behavioral observations in the psychological report.

Mental Status Examination

• General presentation
• State of consciousness
• Attention and concentration
• Speech
• Orientation
• Mood and affect
• Thought processes & content
• Perceptual experiences
• Memory and intelligence
• Insight and judgment

Mini-Mental State Examination (MMSE)

• A cognitive assessment tool used to evaluate various mental functions.
• Includes questions and tasks assessing:
  • Orientation to time and place (e.g., What is the year? Where are we now?).
    • Orientation is assessed by asking the patient to identify the current year, season, date, day of the week, and month. Full points are awarded if the patient identifies all correctly.
  • Attention and Calculation (e.g., count backward from 100 by sevens).
    • Attention is assessed by asking the patient to count backward from 100 by sevens, stopping after five answers. An alternative method is to ask the patient to spell