All posts by johnsommersflanagan

The Mental Status Examination: Key Terms and Resources

At first, conducting a mental status examination (MSE) can feel “different” and daunting to non-medical mental health professionals. However, even though the MSE is a modernist medical-psychiatric assessment tool, it’s also possible to conduct MSEs more collaboratively.

To help address a recent listserv request, below, I’ve pasted some Tables from the MSE chapter in Clinical Interviewing. These Tables are not comprehensive, but along with other resources provide relatively good coverage of how and when to administer an MSE and some useful vocabulary words.

In addition to the Tables below, Dr. Thom Field from City University of Seattle has a set of training videos. You can find them here: http://www.thomfield.com/mental-status-exam-training.html

Also, there are several other resources posted on this blog. In fact, the most viewed of all posts on this blog is titled “Two Sample Mental Status Examination Reports” https://johnsommersflanagan.com/2012/08/10/two-sample-mental-status-examination-reports/

In addition, there is a nifty (IMHO) MSE protocol here: https://johnsommersflanagan.com/mental%20status/

And another sample MSE report: https://johnsommersflanagan.com/2012/11/23/another-sample-mental-status-examination-report/

And an interesting post on “Psychic Communications . . . and Cultural Differences in Mental Status” https://johnsommersflanagan.com/2013/01/02/psychic-communications-and-cultural-differences-in-mental-status/

And a short MSE video clip: https://johnsommersflanagan.com/2013/02/28/mental-status-examination-video-clip/

Okay. Enough tangential speech from me. The Tables are below:

Table 8.1. Descriptors of Client Attitude Toward the Examiner
Aggressive: The client attacks the examiner physically or verbally or through grimaces and gestures. The client may “flip off” the examiner or simply say to an examiner something like, “That’s a stupid question” or “Of course I’m feeling angry, can’t you do anything but mimic back to me what I’ve already said?”
Cooperative: The client responds directly to interviewer comments or questions. There is a clear effort to work with the interviewer to gather data or solve problems. Frequent head nods and receptive body posture are common.
Guarded: The client is reluctant to share information about himself. When clients are mildly suspicious they may appear guarded in terms of personal disclosure or affective expression.
Hostile: The client is indirectly nasty or biting. Sarcasm, rolling of the eyes in response to an interviewer comment or question, or staring off into space may represent subtle, or not so subtle, hostility. This behavior pattern can be more common among young clients.
Impatient: The client is on the edge of his seat. The client is not very tolerant of pauses or of times when interviewer speech becomes deliberate. She may make statements about wanting an answer to concerns immediately. There may be associated hostility and competitiveness.
Indifferent: The client’s appearance and movements suggest lack of concern or interest in the interview. The client may yawn, drum fingers, or become distracted by irrelevant details. The client could also be described as apathetic.
Ingratiating: The client is overly solicitous of approval and interviewer reinforcement. He may try to present in an overly positive manner, or may agree with everything the interviewer says. There may be excessive head nodding, eye contact, and smiles.
Intense: The client’s eye contact is constant, or nearly so; the client’s body leans forward and listens closely to the interviewer’s every word. Client voice volume may be loud and voice tone forceful. The client is the opposite of indifferent.
Manipulative: The client tries to use the examiner for his or her own purpose. Examiner statements may be twisted to represent the client’s best interests. Statements such as “His behavior isn’t fair, is it Doctor?” are efforts to solicit agreement and may represent manipulation.
Negativistic: The client opposes virtually everything the examiner says. The client may disagree with reflections, paraphrases, or summaries that appear accurate. The client may refuse to answer questions or be completely silent. This behavior is also called oppositional.
Open: The client openly discusses problems and concerns. The client may also have a positive response to examiner ideas or interpretations.
Passive: The client offers little or no active opposition or participation in the interview. The client may say things like, “Whatever you think.” He may simply sit passively until told what to do or say.
Seductive: The client may move in seductive or suggestive ways. He or she may expose skin or make efforts to be “too close” to or to touch the examiner. The client may make flirtatious and suggestive verbal comments.
Suspicious: The client may repeatedly look around the room (e.g., checking for hidden microphones). Squinting or looking out of the corner of one’s eyes also may be interpreted as suspiciousness. Questions about the examiner’s notes or about why such information is needed may signal suspiciousness.
Table 8.2. Thought Process Descriptors
Blocking: Sudden cessation of speech in the midst of a stream of talk. There is no clear reason for the client to stop talking and little explanation. Blocking may indicate that the client was about to associate to an uncomfortable topic. It also can indicate intrusion of delusional thoughts or hallucinations.
Circumstantiality: Excessive and unnecessary detail provided by the client. Very intellectual people (e.g., college professors) can become circumstantial; they eventually make their point, but don’t do so directly and efficiently. Circumstantiality or overelaboration may be a sign of defensiveness and can be associated with paranoid thinking styles. (It can also simply be a sign the professor was not well-prepared for the lecture.)
Clang Associations: Combining unrelated words or phrases because they have similar sounds. Usually, this is manifest through rhyming or alliteration; for example: “I’m slime, dime, do some mime” or “When I think of my dad, rad, mad, pad, lad, sad.” Some clients who clang are also perseverating (see below). Clanging usually occurs among very disturbed clients (e.g., schizophrenics). As with all psychiatric symptoms, cultural norms may prompt the behavior (e.g., clang associations among rappers is normal).
Flight of Ideas: Speech in which the client’s ideas are fragmented. Usually, an idea is stimulated by either a previous idea or an external event, but the relationship among ideas or ideas and events is weak. In contrast to loose associations (see below), there are logical connections in the client’s thinking. However, unlike circumstantiality (see above), the client never gets to the point. Clients who exhibit flight of ideas often appear over-active or overstimulated (e.g., mania or hypomania). Many normal people exhibit flight of ideas after excessive caffeine intake—including one of the authors.
Loose Associations: Minimal logical connections between thoughts. The thinking process is nearly, but not completely random; for example: “I love you. Bread is the staff of life. Haven’t I seen you in church? I think incest is horrible.” In this example, the client thinks of attraction and love, then of God’s love as expressed through communion, then of church, and then of an incest presentation he heard in church. It may take effort to track the links. Loose associations may indicate schizotypal personality disorder, schizophrenia, or other psychotic or pre-psychotic disorders. Extremely creative people also regularly exhibit loosening of associations, but are able to find a socially acceptable vehicle through which to express their ideas.
Mutism: Virtually total unexpressiveness. There may be signs the client is in contact with others, but these are usually limited. Mutism can indicate autism or schizophrenia, catatonic subtype. Mutism may also be selective in that young clients will be able to speak freely at home, but become mute and apparently unable to speak at school or with professionals (see DSM-5, **).
Neologisms: Client-invented words. They’re often spontaneously and unintentionally created and associated with psychotic disorders; they’re products of the moment rather than of a thoughtful creative process. We’ve heard words such as “slibber” and “temperaturific.” It’s important to check with the client with regard to word meaning and origin. Unusual words may be taken from popular songs, television shows, or a product of combining languages.
Perseveration: Involuntary repetition of a single response or idea. The concept of perseveration applies to speech and/or movement. Perseveration is often associated with brain damage and psychotic disorders. After being told no, teenagers often engage in this behavior, although normal teenagers are being persistent rather than perseverative; that is, if properly motivated, they’re able to stop themselves voluntarily.
Tangential speech: Tangential speech is similar to loose associations, but connections between ideas are even less clear. Tangential speech is different from flight of ideas because flight of ideas involves pressured speech.
Word Salad: A series of unrelated words. Word salad indicates extremely disorganized thinking. Clients who exhibit word salad are incoherent. (See the second half of the preceding “Dear Bill” letter for an example of word salad.)
  Table 8.3. Characteristics of Different Perceptual Disturbances
  Hallucinations Illusions Flashbacks
Definition False sensory experiences Perceptual distortions Sudden and vivid sensory-laden recollections of previous experiences
Diagnostic Relevance Auditory hallucinations are most common and usually associated with schizophrenia, bipolar disorder, or a severe depressive episode Illusions are more common among clients who have vivid imaginations, who believe in the occult, or have other schizotypal personality disorder symptoms Flashbacks are most common among clients with post-traumatic stress disorder
Useful Questions Do you ever hear or see things that other people can’t see or hear?

When and where do you usually see or hear these things (checking for hypnogogic or hypnopompic experiences)?

Does the radio or television ever speak directly to you?

Has anyone been trying to steal your thoughts or read your mind?

What was happening in your surroundings when you saw (or experienced) what you saw (or experienced)?

Did the vision (or image or sounds) come out of nowhere, or was there something happening?

Have you had any similar experiences before in your life?

Sometimes when people have had very hard or bad things happen to them, they keep having those memories come back to them. Does that happen to you?

Was there anything happening that triggered this memory or flashback to the past?

Table 8.4. Mental Status Examination Checklist
Category Observation Hypothesis
Appearance    
Behavior/Psychomotor Activity    
Attitude Toward Examiner    
Affect and Mood    
Speech and Thought    
Perceptual Disturbances    
Orientation and Consciousness    
Memory and Intelligence    
Judgment, Reliability and Insight    

 

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Foundations of Parenting Education

ry

This is an excerpt from “How to Listen so Parents will Talk and Talk so Parents will Listen.” But BEFORE moving to the excerpt . . . you should know that the latest Practically Perfect Parenting Podcast focuses on the foundations of parenting education. You can listen here: http://practicallyperfectparenting.libsyn.com/how-to-listen-so-parents-will-talk-and-talk-so-parents-will-listen?tdest_id=431110

Or on iTunes: https://itunes.apple.com/us/podcast/practically-perfect-parenting-podcast/id1170841304?mt=2

Theory into Practice: The Three Parenting Educator Attitudes in Action

In the following example, Cassandra is discussing her son’s “strong-willed” behaviors with a parenting professional.

Case: “Wanna Piece of Me?”

Cassandra: My son is so stubborn. Everything is fine one minute, but if I ask him to do something, he goes ballistic. And then I can’t get him to do anything.

Consultant: Some kids seem built to focus on getting what they want. It sounds like your boy is very strong-willed. [A simple initial reflection using common language is used to quickly formulate the problem in a way that empathically resonates with the parent’s experience.]

Cassandra: He’s way beyond strong-willed. The other day I asked him to go upstairs and clean his room and he said “No!” [The mom wants the consultant to know that her son is not your ordinary strong-willed boy.]

Consultant: He just refused? What happened then? [The consultant shows appropriate interest and curiosity, which honors the parent’s perspective and helps build the collaborative relationship.]

Cassandra: I asked him again and then, while standing at the bottom of the stairs, he put his hands on his hips and yelled, “I said no! You wanna piece of me??!”

Consultant: Wow. You’re right. He is in the advanced class on how to be strong-willed. What did you do next? [The consultant accepts and validates the parent’s perception of having an exceptionally strong-willed child and continues with collaborative curiosity.]

Cassandra: I carried him upstairs and spanked his butt because, at that point, I did want a piece of him! [Mom discloses becoming angry and acting on her anger.]

Consultant: It’s funny how often when our kids challenge our authority so directly, like your son did, it really does make us want a piece of them. [The consultant is universalizing, validating, and accepting the mom’s anger as normal, but does not use the word anger.]

Cassandra: It sure gets me! [Mom acknowledges that her son can really get to her, but there’s still no mention of anger.]

Consultant: I know my next question is a cliché counseling question, but I can’t help but wonder how you feel about what happened in that situation. [This is a gentle and self-effacing effort to have the parent focus on herself and perhaps reflect on her behavior.]

Cassandra: I believe he got what he deserved. [Mom does not explore her feelings or question her behavior, but instead, shows a defensive side; this suggests the consultant may have been premature in trying to get the mom to critique her own behavior.]

Consultant: It sounds like you were pretty mad. You were thinking something like, “He’s being defiant and so I’m giving him what he deserves.” [The consultant provides a corrective empathic response and uses radical acceptance; there is no effort to judge or question whether the son “deserved” physical punishment, which might be a good question, but would be premature and would likely close down exploration; the consultant also uses the personal pronoun I when reflecting the mom’s perspective, which is an example of the Rogerian technique of “walking within.”]

Cassandra: Yes, I did. But I’m also here because I need to find other ways of dealing with him. I can’t keep hauling him up the stairs and spanking him forever. It’s unacceptable for him to be disrespectful to me, but I need other options. [Mom responds to radical acceptance and empathy by opening up and expressing her interest in exploring alternatives; Miller and Rollnick (2002) might classify the therapist’s strategy as a “coming alongside” response.]

Consultant: That’s a great reason for you to be here. Of course, he shouldn’t be disrespectful to you. You don’t deserve that. But I hear you saying that you want options beyond spanking and that’s exactly one of the things we can talk about today. [The consultant accepts and validates the mom’s perspective—both her reason for seeking a consultation and the fact that she doesn’t deserve disrespect; resonating with parents about their hurt over being disrespected can be very powerful.]

Cassandra: Thank you. It feels good to talk about this, but I do need other ideas for how to handle my wonderful little monster. [Mom expresses appreciation for the validation and continues to show interest in change.]

As noted previously, parents who come for professional help are often very ambivalent about their parenting behaviors. Although they feel insecure and want to do a better job, if parenting consultants  are initially judgmental, parents can quickly become defensive and may sometimes make rather absurd declarations like, “This is a free country! I can parent any way I want!”

In Cassandra’s case, she needed to establish her right to be respected by her child (or at least not disrespected). Consequently, until the consultant demonstrated respect or unconditional positive regard or radical acceptance for Cassandra in the session, collaboration could not begin.

Another underlying principle in this example is that premature educational interventions can carry an inherently judgmental message. They convey, “I see you’re doing something wrong and, as an authority, I know what you should do instead.” Providing an educational intervention too early with parents violates the attitudes of empathy, radical acceptance, and collaboration. Even though parents usually say that educational information is exactly what they want, unless they first receive empathy and acceptance and perceive an attitude of collaboration, they will often resist the educational message.

To summarize, in Cassandra’s case, theory translates into practice in the following ways:

  • Nonjudgmental listening and empathy increase parent openness and parent–clinician collaboration.
  • Radical acceptance of undesirable parenting behaviors or attitudes strengthens the working relationship.
  • Premature efforts to provide educational information violate the core attitudes of empathy, radical acceptance, and collaboration and therefore are likely to increase defensiveness.
  • Without an adequate collaborative relationship built on empathy and acceptance, direct educational interventions with parents will be less effective.

Upcoming Workshops: L.A., Chicago, Morgantown, and Greensburg (outside Pittsburg)

Rainbow 2017

October is almost always a big month for counseling and psychology conferences and workshops. This October is no exception. I’m posting my October workshop presentation schedule here, just in case you want to say hello and possible collect some continuing education credit.

On Thursday, October 5, I’ll be in Orange County for the California Association for School Psychologists conference. Here’s a link: https://event.casponline.org/#intro

On Sunday, October 8, I’ll be in Chicago for the Association of Counselor Educators and Supervisors to present on the Mental Status Examination with Thom Field of the City University of Seattle.

On Thursday, October 12, I’ll be in Morgantown, WV for an afternoon workshop with counseling and psychology students from West Virginia University.

On Friday, October 13, I’ll be in Greensburg, PA (just outside Pittsburgh) for an all-day workshop sponsored by Indiana University of Pennsylvania. The link: https://www.iup.edu/counseling/centers/upcoming-workshops-and-events/

Today is the first day of Autumn . . . I hope this signals the end of hurricanes, floods, fires, and other challenges so many people are facing.

 

Weekend Listening: The Practically Perfect Parenting Podcast is BACK!

John and Ry and Photo

You know you’ve been waiting for this moment, ever since Season 1 of the Practically Perfect Parenting Podcast ended with a thrilling cliffhanger.

And now, your long wait is suddenly over.

Today is the world premier of Season 2 of the Practically Perfect Parenting Podcast. You may be wondering: Did Rachel get back together with Ross? Who shot J.R.? Will carnage ensue in GoT Season 8?

As important as they are, the PPPP promises to answer none of the above. Instead, we will rivet your attention with a swashbuckling episode titled, “Technology as a Barrier or Bridge to Family Relationships”

Here’s the trailer (er, description):

This OPENING episode of Season 2 of the Practically Perfect Parenting Podcast is positively packed with information and tantalizing tips. TECHNOLOGY and SCREEN TIME is a huge issue for many parents. In this captivating episode, Dr. Sara and Dr. John are talking back to technology; they’re saying, “Hey technology, we’re taking you down! Well, not really. But the episode does include a range of AMAZING insights and tips to help parents understand and deal with the dangers and opportunities of technology and screen time. When you tune in, be sure to listen for:

  • Sara’s obsession with using contracts to manage her children’s screen-time
  • A clip from Dr. Dimitri Christakis’s TEDx Ranier talk where he provides a fun critique, partially narrated by Dr. Sara, on Baby Einstein (to watch Dr. Christakis’s full talk, go to: https://www.youtube.com/watch?v=BoT7qH_uVNo
  • How much a baby’s brain grows from birth to age 2 (can you guess?)
  • John’s four tips for raising children with healthy brains
  • Christakis’s three stage theory about how constantly changing screens contribute to children having attention problems
  • Sara’s and Dr. John’s thoughts on the appropriate use of technology and screens for families

Don’t wait. Sit your children down in front of the television (not serious here), grab your favorite personal device, and listen to your favorite podcasters launch themselves into SEASON 2!

To listen on iTunes: https://itunes.apple.com/us/podcast/practically-perfect-parenting-podcast/id1170841304?mt=2

To listen on Libsyn: http://practicallyperfectparenting.libsyn.com/technology-as-a-barrier-and-bridge-to-healthy-family-relationships

Email your ideas, reactions, hopes, dreams, questions, and commitments for underwriting support to: johnsf44@gmail.com

 

 

Evidence-Based Relationship Factors in Counseling and Psychotherapy

The medical model of psychotherapy . . . has led us to accept a view of clients as inert and passive objects on whom we operate and whom we medicate. Gene V. Glass, in The Great Psychotherapy Debate, 2001, p. ix

John and Max Seattle

In a 1957 publication in the Journal of Consulting Psychology, Carl Rogers boldly declared:

  1. No psychotherapy techniques or methods are needed to achieve psychotherapeutic change.
  2. Diagnostic knowledge is “for the most part, a colossal waste of time” (1957, p. 102).

Let’s pause for a moment and reflect on what Rogers was saying.

**PAUSE HERE FOR SERIOUS REFLECTION**

If diagnosis is a waste of time and therapy techniques are unnecessary, then what can counselors or therapists do to produce positive outcomes? Here’s what Rogers said:

All that is necessary and sufficient for change to occur in psychotherapy is a certain type of relationship between psychotherapist and client.

Rogers’s revolutionary statements refocused counseling and psychotherapy. Until Rogers, therapy was primarily about theoretically based methods, techniques, and interventions. After Rogers, writers and practitioners began debating whether the relationship between client and therapist—not the methods and techniques employed—might be producing positive therapy outcomes.

This debate continues today. Wampold (2001) has called it “the great psychotherapy debate.” This debate has been boiled down to a dichotomy captured by the question: “Do treatments cure disorders or do relationships heal people?” (Norcross & Lambert, p. 3).

Keep in mind that like lots of things on planet Earth, the techniques vs. relationship debate promotes a false dichotomy. IMHO, most “rational” professionals understand that therapy relationships and techniques are BOTH important to positive outcomes. Seriously, how could it be otherwise?

But there is a positive outcome from this debate. Various researchers around the world started focusing on how to define specific relationship factors that contribute to counseling outcomes. Previously, these relationship factors were lumped into a category called “common factors.” Common factors were viewed as the main reason why all therapy approaches tend to produce approximately equal positive outcomes.

Flowing from research on common factors, one of the most fascinating and important movements in counseling and psychotherapy is now called, “Evidence-based relationships” (Norcross, 2011). As it turns out, there’s a large body of existing and accumulating research to help us clearly identify what’s relationally therapeutic.

In the attached link, you’ll find the powerpoint slides that Kim Parrow and I developed for a supervisor training yesterday, at the University of Montana. Our goal was to describe, demonstrate, and discuss 10 specific and observable relationship factors that contribute to positive counseling outcomes. We call them Evidence-Based Relationship Factors (EBRFs). They include:

  1. Congruence
  2. Unconditional positive regard
  3. Empathic understanding
  4. WA1: Emotional bond
  5. WA2: Goal consensus – Focus on strengths
  6. WA3: Task collaboration
  7. Rupture and repair
  8. Countertransference (management)
  9. Progress monitoring (feedback)
  10. Culture and Cultural Humility

The link at the bottom of this post will take you to our powerpoint slides. Also, for more information, you can always check out various theories textbooks, including Counseling and Psychotherapy Theories in Context and Practice (from which this blog was adapted). https://www.amazon.com/Counseling-Psychotherapy-Theories-Practice-Resource/dp/1119084202/ref=sr_1_1?ie=UTF8&qid=1504292029&sr=8-1&keywords=counseling+and+psychotherapy+theories+in+context+and+practice

EBRFs for Supervisors 2017 FIN

Counseling Theories Lab Activities

With Wubbolding

Hi All.

Below I’m pasting links to a variety of lab activities that I’ve used in teaching Counseling and Psychotherapy Theories. Although I’ve got a textbook that I’d love you to use: http://www.wiley.com/WileyCDA/WileyTitle/productCd-1119084202.html, this post is about free stuff that I’m happy to share to help make your theories teaching experiences more practical and more fun.

Here are the activities:

This is a short guide to conducting an Adlerian Family Constellation Interview: Chapter 3 Family Constellation Interview and Earliest Memories

This is a short guide for doing and debriefing a person-centered interview: Chapter 5 Person Centered Activity

Dreamwork can be enlightening. This guide helps students explore each other’s dreams: Chapter 6 Jungian and Gestalt Dream Work

This handout helps your students practice conducting a behavioral or cognitively oriented symptom interview. Chapter 7 Analyzing Symptoms Interview

This isn’t really an activity, just a sample Ellis ABCDE form. Chapter 8 Ellis ABCDE

These two handouts provide tips for doing a CBT Six Column intervention, as well as a sample Six Column form, filled out using an angry teen example. Chapter 8 Six Column CBT Tips  and Chapter 8 Six Columns Youth Anger Example

Here’s a video clip (just a snippet) of me doing a CBT example:https://www.youtube.com/watch?v=LQ8hNDHoyDU

This is an interview activity to give students and role-play clients a taste of solution-focused interviewing: Chapter 11 Solution-Focused Activity

I hope these materials are helpful for you. As always, if you have feedback to share, you can share it on this blogsite or via email: johnsf@mso.umt.edu