Monthly Archives: February 2013

Clinical Interviewing

Mental Status Examination Video Clip

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Historically, the mental status examination (MSE) has held a revered place in psychiatry and medicine. In recent years, professional competence in conducting MSEs has expanded to include all mental health professionals, especially those who work within medical settings.As an example of how MSE skills have become more cross-disciplinary, the latest accreditation standards for professional counselors require coverage of MSE concepts and skills within master’s level counseling programs (Council for Accreditation of Counseling and Related Educational Programs, 2009). Overall, the MSE offers physicians, psychologists, counselors, and social workers a unique method for evaluating the internal mental condition of patients or clients.

Very recently, our publisher, John Wiley and Sons, posted a clip from a training DVD we filmed on MSE skills. Check it out at: http://www.youtube.com/watch?v=1lu50uciF5Y

 

Clinical Interviewing

Guidelines for Violence Risk Assessment

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Predicting violence is notoriously very difficult. Nevertheless, sometimes counselors, social workers, psychologists and psychiatrists are faced with situations where they need to make estimates or predictions of violence potential. The material below is a short preview from Clinical Interviewing, 5th edition. http://www.amazon.com/Clinical-Interviewing-John-Sommers-Flanagan/dp/1118270045/ref=dp_ob_title_bk

Research findings imply that therapists who hope to conduct accurate violence assessments should know actuarial violence prediction risk factors. However, as is often the case, scientific research doesn’t always parallel real-life situations faced by therapists. For example, while much of the actuarial violence research has been conducted on forensic or prison populations—with the designated outcome measure being violent recidivism—therapists typically face situations in schools, residential treatment centers, and private practice (Juhnke, Granello, & Granello, 2011). Consequently, although actuarial violence prediction risk factors may be helpful, they probably don’t generalize well to situations where a counselor is making a judgment about whether there’s duty to protect (and therefore warn) a shop teacher about a boy (who has never been incarcerated) who reports vivid images of slitting his shop teacher’s throat.

Given these limits, it’s best for us to call clinical interview-based assessments in school and agency settings violence assessment, rather than violence prediction. This distinction helps clarify the fact that what most clinicians do in general practice settings, including public and private schools, falls far short of scientific, actuarial-based violence prediction.

A Reasonable Approach to Violence Risk Assessment

Predicting violence is a challenging proposition. Despite the many shifting variables that change based on the specifics of any given situation and despite the low base rate, and therefore inherent unpredictability of violent behavior, this section provides general guidelines that may be helpful should you find yourself in a situation where violence assessment is necessary. Of course, in addition to this guide you should always pursue consultation and supervision support when working with potentially violent clients.

Table 12.2 includes a general guide to violence assessment. It doesn’t include common actuarial risk factors from two common instruments, the Violent Rate Appraisal Guide (Harris, Rice, & Quinsey, 1993) or the Psychopathy Checklist-Revised (Hare et al., 1990; Harpur, Hakstian, & Hare, 1988). If you find yourself intrigued with violence risk assessment you may want to explore a career in forensic psychology.

Table 12.2. A General Guide to Violence Assessment
The following checklist is offered as a general guide to conducting violence assessment. It should not be used as a substitute for actuarial prediction.
____1.  Ask direct and indirect questions about violent behavior history. Be especially alert to physical aggression and cruelty. If the violent behavior that’s being threatened is similar to a past violent behavior the risk of violence may be higher.

_____2. Because potentially violent individuals aren’t always honest about their violence history, you may need to ask collateral informants—someone other than the client—about the client’s history of violent behavior (assuming you have a release of information signed or have determined you have an ethical-legal responsibility to protect someone from harm).

____3.  You should listen for details that might help you identify potential victims. If the details are not forthcoming, you may need to ask specific questions in an effort to obtain those details. Identification of a specific victim increases violence risk (and provides you with information about whom you should warn).

____4. As clients talk about violent urges, you should listen for specifics about the plan. As needed, you may, through curious and indirect questioning, make efforts to further assess the specificity of the client’s violence plan. More specific plans are associated with increased violence risk.

____5. If clients don’t tell you about his or her access to a weapon or means for committing his or her planned violent act, you should ask. Similar to suicidal situations, access to lethal means increases violence risk.

____6. Historical information is doubly important. Generally speaking, the sooner violent behavior patterns began, the more likely they are to continue and clients raised in chaotic and violent environments (including gang involvement) are at higher risk for violence.

____7. Diagnostic information may be helpful. When looking at DSM diagnoses, the best violence predictors include items from list B** of the **DSM’s Antisocial Personality diagnostic criteria (see DSM-IV-TR**).

____8. Evaluate current cognitions. If clients have low expectations of being caught or of having consequences, risk may be higher.

____9. Consider substance use. Positive attitudes towards substance use and substance use when carrying weapons confer greater risk.

____10. Notice your intuition. Intuition isn’t a great predictor of anything, but if you have images of violence linked to a particular client, it’s reasonable to err on the conservative side and begin the process of warning potential victims.

**This information may change in the DSM-5

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Personal Reflections

Musings About Online Counseling

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As Rita and I updated the Clinical Interviewing text, we did a little web-searching for online counseling resources and the excerpt below includes our musings on this very interesting topic.

From Clinical Interviewing, 4th ed, updated, SF & SF, 2012

Online Counseling: Ethics and Reality

As a part of reviewing information for this chapter, we perused Internet therapy options available to potential consumers. Previous publications suggested a possible plethora of Internet counseling and psychotherapy providers with questionable professional credentials (Heinlen, Welfel, Richmond, & O’Donnell, 2003; Shaw & Shaw, 2006). Although we hoped that Internet service provision standards had improved, we weren’t overly impressed with our results. Generally, we found that most providers may have more expertise in business and marketing than they do in professional clinical work. Affixed on this foundation of business and marketing, we found two distinct approaches: the more ethical and the less ethical.

The Less Ethical Approach

Many providers offer online services but don’t acknowledge having specific credentials (e.g., a license) typically associated with clinical expertise. For example, practitioners with bachelor’s degrees (or less) made statements like the following:

“I am a counselor, life coach, and spiritual teacher with over 20 years of experience. I have studied the fields of counseling, psychology, personal growth, relationships, communications, business, computer programming and technology, languages, spirituality, metaphysics and energetic bodywork! In addition to my training, a [sic] 18-year relationship with my second husband has deepened my capacity to help others with relationship issues.”

This sort of enthusiastic introduction was typically followed by an equally enthusiastic statement about the breadth of services offered:

“My online counseling services specialties include, but are not limited to: anxiety/panic, self-esteem, highly sensitive people, couples counseling, relationship advice, life and career coaching, emotional intelligence, personal growth, affairs, guilt issues, work and career, trust issues, abuse/boundary issues, communication skills, conflict resolution, grief and loss, emotional numbness, spiritual development, stress management, blame, court-ordered counseling, codependency, problem resolution, jealousy, codependency and attachment, anger and depression, food and body, and developing peace of mind.”

Curiously, we found that the broad range of claims on websites such as these did not move us toward developing or experiencing peace of mind.

The More Ethical Approach

There were also websites that included professional, licensed providers. For example, one website listed and described eight licensed practitioners with backgrounds in professional counseling, social work, and psychology. These professionals offered webcam therapy, text therapy, e-mail therapy, and telephone therapy.

Prices included:

  • E-mail therapy: $25 per online counselor reply
  • Unlimited e-mail therapy: $200 per month
  • Chat therapy: $45 per 50-minute session
  • Telephone therapy: $80 per 50-minute session
  • Webcam therapy: $80 per 50-minute session

The more ethical professional Internet services also tended to include information related to theoretical orientation. For example, a “postmodern” approach was described as involving: “Staying positive . . . focused on the here and now . . . offering solutions that meet your needs . . . a collaborative and respectful environment . . . quick results . . .”

How to Choose an Internet Services Provider

The National Directory of Online Counselors now exists to help consumers choose an online provider. They state:

“We have personally verified the credentials and the websites of each therapist listed in the National Directory of Online Counselors. Feel assured that the therapists listed are state board licensed, have a Master’s Degree or Doctoral Degree in a mental health discipline, and have online counseling experience.”

The listed therapists and websites are set up and ready to handle secure communication, and offer various services such as eMail Sessions, Chat Sessions, and Telephone Sessions. All work conducted by the professional licensed therapists meet[s] strict confidentiality standards overseen by their professional state board.

Both of these distinct approaches to online therapy emphasize that help is only a mouse click away.