Category Archives: Clinical Interviewing

The WACES Conference in Portland — Presentation I — The Mental Status Exam and Suicide Assessment

This post includes the powerpoint slides from my presentation on Teaching the Mental Status Examination and Suicide Assessment at the Western Association of Counselor Educators and Supervisors. It was a very nice conference organized and attended by some awesome Counselor Educators. WACES MSE

Practicing Humility When Conducting Mental Status Examinations

Perhaps more than any other assessment task, conducting a balanced mental status examination requires that professionals resist the natural temptation to make sweeping judgments about clients on the basis of appearance, specific behaviors, or single symptoms. For example, in a recently published book titled The mental status examination and brief social history in clinical psychology, Smith {{5681 III 2011;}} stated:

A Fu-Manchu mustache suggests the wearer doesn’t mind being thought of as “bad,” whereas a handlebar mustache tells you the person may be somewhat of a dandy or narcissist. (p. 4)

After reading the preceding excerpt, I decided to conduct a small research study by surveying men in Montana with Fu-Manchu mustaches. Whenever I saw men sporting a Fu-Manchu, I asked them to rate (on a seven-point Likert scale) whether they minded being thought of as “bad.” In contrast to Smith’s (2011) observations, I found that most men with Fu-Manchu’s actually thought they looked good and reported wearing the mustache in an effort to look attractive. Of course I didn’t really conduct this survey, but the fact that I thought about doing it and imagined the results carries approximately the same validity as the wild assumption that a mental status examiner can quickly “get into the head of” all clients with Fu-Manchu (or handlebar) mustaches and interpret their underlying personal beliefs or intentions, or even worse, extrapolate from a physical feature to a personality disorder diagnosis.

Although I’m poking fun at the sweeping generalizations that Smith (2011) made in his text, my intent is to point out how easy it is to grow overconfident when conducting MSEs. Like Smith, I’ve sometimes found myself making wild and highly personalized assumptions about the psychopathological meaning of very specific behaviors (some years ago I had my own personal theory about “tanning” behaviors being linked to narcissism).

The key to dealing with this natural tendency towards overconfidence is to use Stanley Sue’s (2006) concept of scientific mindedness. A single symptom should be viewed as a sign that the sensitive and ethical mental status examiner considers a hypothesis to explore. Another example from Smith (2011) may be helpful as another caution of the dangers of over-interpreting single symptoms. He stated: “If the person is unshaven, this may be a sign of depression, alcoholism, or other poor ability at social adaptation” (p. 4).

Smith may be correct in his hypotheses about unshaven clients. In fact, if a research study were conducted on diagnoses or symptoms commonly associated with unshaven-ness, it might show a small correlation with depressive symptoms, partly because poor hygiene can be a feature of some depressive disorders. However, in the absence of additional confirming evidence, an unshaven client is just an unshaven client. And when it comes to social adaptation, I should note that I know many young men (as well as a variety of movie stars) who consider the unshaven look as either desirable, sexy, or both. This could lead to an equally likely hypothesis that an unshaven client is particularly cool or has an especially high level of social adaptation.

In your own MSE work I encourage you to adopt the following three guidelines to help you avoid what might be called the overconfident clinician syndrome:

  1. When you spot a single symptom or client feature of particular interest, you should begin the scientific mindedness process.
  2. Remember that hypotheses are hypotheses and not conclusions; this is why hypotheses require additional supporting evidence.
  3. Don’t make wild inferential leaps without first consulting with colleagues and/or supervisors; it’s often easier to become overconfident and subsequently make inappropriate judgments when working in isolation.

Keep these preceding guidelines in minds as you conduct mental status examinations. You can find my DVD with a clip of a mental status exam at: http://www.amazon.com/Clinical-Interviewing-Skills-John-Sommers-Flanagan/dp/1118390121

Paper Writing Tips for Grad Students in Counseling and Psychology

I recently had the honor and privilege of reading the first set of papers submitted to me by graduate students this semester. The papers were generally of good quality, but a few repeating patterns inspired me to provide the following list of basic tips for graduate students seeking to become mental health professionals.

  1. There’s nothing quite like a clear and concise topic sentence in academic writing. The topic (or focus sentence) introduces the content included in the paragraph. When used well, it’s a beautiful organizing force that brings joy and comprehension to the hearts and minds of many a reader (especially moi).
  2. Although I absolutely hate the saying “More is less” (because, in fact, “more” is always “more” even though “less” can better), it’s a good general rule to make your sentences shorter rather than longer because all too often I find students, like myself in this particular sentence, trying to fit too much information into one sentence when it would be clearer and better to break it up into two or three sentences. A corollary to this rule is that fewer quotation marks and exclamation marks are better than more of those particular “Marks!”
  3. A transition sentence or two that describes what you’ll be covering in your paper and placed at the end of your opening paragraph or in your second paragraph is very helpful to your reader.
  4. Unless you’re a Brit, you should put your commas, periods, and ellipsis inside the quotation marks, “Like this. . .” Think about it this way: commas and periods like to be on the inside; they don’t like to be floating outside the quotation marks because, unless they live on the British Isles, it increases their existential sense of isolation.
  5. You don’t need to use a comma when you have a short list of only two thoughts because all you need in that case is the word “and.” For example, notice the absence of a comma in the following sentence: Max was feeling quite spry and decided to post a smiley face to his Facebook status. In this case we do not need or want a comma after the word “spry.”
  6. Keep in mind that in most cases it best to maintain consistency between singular and plural within the same sentence and paragraph. For example, if you write: “The counselor should work to have empathy with their client” it will cause me to wonder why you didn’t go with: “Counselors should have empathy with their clients.” Note: There is also a good reason to use what is now commonly referred to as the singular “they.” Using they or their as singular (representing an individual) is perfectly acceptable–especially when referring to individuals who are averse to the gender binary. However, in most cases, it’s easier and IMHO maintains better grammar-flow to shift to plural-plural whenever reasonable.
  7. Remember that your professor really likes the appropriate use of the Harvard comma. What this means is that when providing a list of more than two items, you should place a comma after the first item, second item, and before the and. An example: John very much enjoys running, walking, and dancing. If you leave out that last comma, it seems like the final two items are somehow joined together. Remember also, that although journalists don’t use it, the Harvard comma is consistent with APA style.
  8. When you’re quoting someone you should use the past tense; this is because the person whom you’re quoting has already said it. For example, in his book Working with challenging youth, Richardson stated: “Yada, yada, and yada.” Although it’s tempting to write, “Richardson states” the past is the past even though Gestalt therapists might want us to bring everything into the here-and-now.
  9. Please include the page number or numbers when you’re quoting someone so your reader, if so inclined, can confirm the accuracy of your quotation. This is also APA style. Always avoid anything that might be viewed as plagiarizing.
  10. In contrast and opposite of how I’m writing in this list of writing tips, APA style doesn’t like contractions. Instead, just like Commander Data in the Star Trek series, you do not use contractions when writing in APA format and you will see a little red mark on your paper if you write with the casual contraction.
  11. You may recall that Michael Jackson sang: “A, B, C is easy as 1, 2, 3.” Well, APA actually thinks that (a), (b), (c). . . is better than 1, 2, 3. . . when it comes to in-paragraph list-making.
  12. If you use capital letters when you don’t need to, I will think you’ve freshly arrived from Germany. Words like counselor and psychologist should not be capitalized and even though specific mental disorders like major depressive disorder are often capitalized, we shouldn’t privilege particular words just because we feel like it or just because the American Psychiatric Association would like those words to take on greater significance.
  13. My old statistics professor always used to say that you write numbers just like you write words. What he meant by this is that justlikeyouwouldneverwritelikethis, when writing an equation you should always put a space between the operation and the integer. For example, it’s always n = 1 and never n=1.
  14. Although corporations are people (according to SCOTUS, not me), people are not corporations. This means you should use “who” when referring to actual people and “that” “them” or “it” when referring to non-people. When it comes to addressing corporations, make no reference at all, just bow your head in deference.
  15. Although it’s very cool and good form to cite your professor’s work in your paper, you should do your best to spell his name correctly.

Introductions and Full Disclosure (at least in part)

When people ask me what I do for work, I often tell them I have the best job in the world; then I describe it to them: “Every spring our faculty intensely screens a group of about 50 applicants to our graduate programs in counseling down to about 20 students who are admitted. And then I have the summer off. And then the new group of students show up in the fall and they’re all smart and kind and compassionate and because they’re graduate students, they’re motivated and focused and they want to attend class and become the best darn counselors they can become. And then, when I have them in class I’m with this group of incredibly socially skilled and sensitive, nice people and they make eye contact, nod their heads, act like they’re listening to me, and laugh at my jokes and stories.” Pretty much after I describe this scenario whoever asked me the question has either walked away or has crumpled into a heap on the floor racked with pain and jealousy.

This past Friday I got to teach my first full-day class with our new students. And just like Mary Poppins, they were practically perfect in every way.

Students in our graduate programs school and mental health counseling have a plethora of opportunities to engage in role-plays. As you may guess, these opportunities may or may not be met with great enthusiasm. More often than not we suggest to our students that they think of a minor problem in their lives, exercise censorship, and actually play themselves in these role-play encounters. This is totally fun . . . at least for the faculty.

Because we ask so much from our students—we expect them to “bring it” every hour of every class—at the beginning we offer our first year graduate students an activity where they can come to the front of the room as ask faculty members any question they’d like. This is totally fun . . . at least for the students.

On Friday, I had the added joy of listening as our two newest faculty members, Dr. Kirsten Murray and Dr. Lindsey Nichols, got quizzed by the new students. It was fabulous. I was filled with pride and happiness over having colleagues who are amazing and cool. Then it was my turn.

Somehow, the very first question turned into an awkward explanation of my professional status. I’m pretty old and I’ve answered a gazillion student questions about myself over the years, but I still felt the inner warmth, the sudden presence of sweat on my skin, and that funny feeling of hearing my own voice from a distance (totally fun!).

The problem is that I’m trained as a clinical psychologist and I teach in a counselor education program. To some people, this is like blasphemy. It’s like I was born in the country of clinical psychology and immigrated to the country of counselor education. At some tiny level, I sense how it might feel to be in the marginalized category of acculturation. Sometimes, under stress, I start speaking the language of clinical psychology (one time at an editorial board meeting of the Journal of Counseling and Development I accidentally said “A-P-A” instead of “A-C-A” and thought for sure I might be stoned; but everyone acted like they didn’t notice; of course, they also acted like they didn’t notice me after the meeting—or maybe I was just imagining that and isolating myself?).

I love my country of origin—the country of clinical psychology. I could talk about Rorschach cards and what it means for me to have a spike 5 and subclinical 6-9 profile on my MMPI for days. Studying psychopathology was like the coolest thing ever.

But I also love the country I’ve immigrated to. I have pleasant flashbacks of my first ACA conference back in 1992 when I volunteered to participate in a group counseling demonstration with Jerry and Marianne Corey. They were fabulous and I was hooked. I still like going to APA conferences, but for me, ACA conferences are a little less anal and a little more fun. I mean like one time I got my photo taken with William Glasser and last year I got it taken with Robert Wubbolding. They’re starting to think of me like a Reality Therapy groupie. What’s not cool about that?

The problem is that some members of ACA and APA don’t really like each other all that well. And neither of them really like the NASW or that evil “other” APA. The turf issues around professional discipline strike me as silly and overdone. I’m pretty sure that at this point I’m completely unemployable as an academic anywhere but the University of Montana. Psychology departments wouldn’t touch me because of my counseling cooties and Counseling departments now have to abide by a rule where they can’t hire anyone who doesn’t have a doctorate in counselor education. This would be pretty funny stuff if it weren’t so ridiculous. Psychologists want prescription privileges, Counselors want to do psychological evaluations, Social Workers want to do everything and anything, and yet, in many ways, we’re all more alike than we are different. I’ve got no solutions here . . . just observations.

And so in the beginning I experienced only a mild dissociative episode as I squeezed out my full disclosure—admitting before God and the class and my fellow professors that I am, in fact, BOTH a clinical psychologist AND a counselor educator. And in the end, it felt good. We had more discussions and questions later and no one (at least while I was looking) made the sign of the cross and shrunk away. I was just part of an amazing group of people who want to help other people live happier and more fulfilling lives. It could have been a group of students studying psychology or social work or counseling or maybe even all three at once . . . . It was really very nice.

John Dancing at a Wedding Reception

 

Two Sample Mental Status Examination Reports

JSF Dance Party

This is a photo of me checking my mental status.

Generally, mental status examinations (MSEs) can have a more neurological focus or a more psychiatric focus. The following two fictional reports are samples of psychiatric-oriented MSEs. These sample reports can be helpful if you’re learning to conduct Mental Status Examinations and write MSE reports. They’re excerpted from the text, Clinical Interviewing (6th edition; 2017, John Wiley & Sons). Clinical Interviewing has a chapter devoted to the MSE, as well as chapters on suicide assessment interviewing and diagnostic interviewing (and many others chapter on other important topics). You can take a look at the book (and some darn good reviews) on Amazon: https://www.amazon.com/gp/product/1119215587/ref=dbs_a_def_rwt_bibl_vppi_i0

If you’d like to see a short video-clip MSE example, you can go to: http://www.youtube.com/watch?v=1lu50uciF5Y

Sample Mental Status Examination Reports

A good report is brief, clear, concise, and addresses the areas below:

1.  Appearance

2.  Behavior/psychomotor activity

3.  Attitude toward examiner (interviewer)

4.  Affect and mood

5.  Speech and thought

6.  Perceptual disturbances

7.  Orientation and consciousness

8.  Memory and intelligence

9.  Reliability, judgment, and insight

The following reports are provided as samples.

Mental Status Report 1

Gary Sparrow, a 48-year-old white male, was disheveled and unkempt on presentation to the hospital emergency room. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was agitated and restless, frequently changing seats. He was impatient and sometimes rude in his interactions with this examiner. Mr. Sparrow reported that today was the best day of his life, because he had decided to join the professional golf circuit. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15”). His speech was loud, pressured, and overelaborative. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Sparrow described grandiose delusions regarding his sexual and athletic performance. He reported auditory hallucinations (God had told him to quit his job and become a professional golfer) and was preoccupied with his athletic and sexual accomplishments. He was oriented to time and place, but claimed he was the illegitimate son of Jack Nicklaus. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Mr. Sparrow was unreliable and exhibited poor judgment. Insight was absent.

Mental Status Report 2

Ms. Rosa Jackson, a 67-year-old African American female, was evaluated during routine rounds at the Cedar Springs Nursing Home. She was about 5’ tall, wore a floral print summer dress, held tight to a matching purse, and appeared approximately her stated age. Her grooming was adequate and she was cooperative with the examination. She reported her mood as “desperate” because she had recently misplaced her glasses. Her affect was characterized by intermittent anxiety, generally associated with having misplaced items or with difficulty answering the examiner’s questions. Her speech was slow, halting, and soft. She repeatedly became concerned with her personal items, clothing, and general appearance, wondering where her scarf “ran off to” and occasionally inquiring as to whether her appearance was acceptable (e.g., “Do I look okay? You know, I have lots of visitors coming by later.”). Ms. Jackson was oriented to person and place, but indicated the date as January 9, 1981 (today is July 8, 2009). She was unable to calculate serial sevens and after recalling zero of three items, became briefly anxious and concerned, stating “Oh my, I guess you pulled another one over me, didn’t you, sonny?” She quickly recovered her pleasant style, stating “And you’re such a gem for coming to visit me again.” Her proverb interpretations were concrete. Judgment, reliability, and insight were significantly impaired.

 

To receive alerts about this and other related topics like clinical interviewing and counseling and psychotherapy, you should follow this blog. Also, if you want me to come to your organization to provide a workshop or keynote on this or on a related topic, email me at john.sf@mso.umt.edu.

Respecting the Client’s Perspective – Even When We Think We Know Better

There are so many ways we can . . . as therapists . . . subtly (or less so) disrespect our client’s perspective. Here’s a small example from the revision of Clinical Interviewing (5th ed).

Interviewers can negatively judge or disrespect the client’s perspective in many ways. Very recently, I (John) became somewhat preoccupied about convincing a client that she wasn’t really “bipolar.” Despite my good intentions (it seemed to me that the young woman would be better off without the bipolar label), there was something useful or important for the client about holding onto her bipolar identity. Of course, as a “psychological expert” I thought it was ludicrous. I thought it obscured her many personal strengths with a label that diminished her personhood. Therefore, I tried my best to shove my opinion into her belief system. For better or worse, I was unsuccessful.

What’s clear about this example is that, despite our general expertise in mental health matters, as mental health professionals we need to work hard to respect our clients’ worldviews. In recent years practitioners from many theoretical perspectives have become more firm about the need for the expert therapist to take a back seat to the client’s personal lived experience. It’s now more important than ever for interviewers to acknowledge and embrace client expertness. This may be partly due to our increasing awareness (as mental health professionals and advocates) that clients may have very divergent views of themselves and the world.

In the end, who am I to tell my client that she is better off without a bipolar label? What if that label somehow, perhaps even in a twisted way, offers her solace. Perhaps she feels comfort in a label that helps explain her behavior to herself. Perhaps she is not ready—yet—to let go of the bipolar label. Perhaps she never will—and that may be the best outcome.

Whatever their theoretical orientation, effective interviewers respect their client’s personal expertise or perspective. We need that expertise. If the client is unwilling to collaborate with us by sharing her or his expertise and experience, we lose at least some of our potency as helpers.

 Image

John offers his brother-in-law some advice.

Thoughts on the Relationship Between Cleavage and Professional Counseling and Psychotherapy

The following is a short discussion about cleavage in counseling and psychotherapy.  We’re not especially trying to be provocative (which is one reason why no photo accompanies this blog post) and so we’re interested in your thoughts on this short excerpt BEFORE we include it in the 5th edition of our Clinical Interviewing text.

[Excerpt starts here] For the first time ever in a textbook (and we’ve been writing them since 1993), we’ve decided to include a discussion on cleavage. Of course, this makes us feel exceptionally old, but we hope it also might reflect wisdom and perspective that comes with aging. 

In recent years we’ve noticed a greater tendency for female counseling and psychology students (especially younger females) to dress in ways that can be viewed as somewhat sexual. This includes, but is not limited to low necklines that show a considerable amount of cleavage. This issue was discussed on a series of postings on the Counselor Education and Supervision listserv which includes primarily participants who teach in master’s and doctoral programs in counseling. Most of the postings included some portion of the following themes.

  • Female (and male) students have the right to express themselves via how they dress
  • Commenting on how women dress and making specific recommendations may be viewed as sexist or inappropriately limiting
  • It is true that women should be able to dress any way they want
  • It is also true that specific agencies and institutions have the right to establish dress codes or otherwise dictate how their paid employees and volunteers dress
  • Despite egalitarian and feminist efforts to free women from the shackles of a patriarchal society, how women dress is still interpreted as having certain socially constructed messages that often, but not always, pertain to sex and sexuality
  • Although efforts to change socially constructed ideas about women dressing “sexy” can include activities like campus “slut-walks,” the clinical interview is probably not the appropriate venue for initiating a discourse on social and feminist change
  • For better or worse, it’s a fact that both middle-school males and middle-aged men (and many “populations” in between) are likely to be distracted—and their ability to profit from a counseling experience may be compromised—if they’re offered an opportunity for a close up view of their therapist’s breasts
  • At the very least, excessive cleavage (please don’t ask us to define this phrase) is less likely to contribute to positive therapy outcomes and more likely to stimulate sexual fantasies—which we believe is probably contrary to the goals of most therapists
  • It may be useful to have young women watch themselves on video from the viewpoint of a client (of either sex) that might feel attracted to them and then discuss how to manage sexual attraction that might occur during therapy

It’s obvious that when it comes to clinical interviewers showing cleavage, we don’t have all the perfect answers. Guidelines depend, in part, on interview setting and specific client populations. At the very least, we recommend that you take time to think about this issue and hope you might also consider discussing cleavage issuesJ with your class or your supervisor.

Info on Clinical Interviewing – the text and videos – is at: http://lp.wileypub.com/SommersFlanagan/