Choosing What to Include in Your Intake Report

The ethical guidelines of the National Association of Social Workers (NASW 1996) provide a good foundation for a discussion of what to include in the content of your report. They state Social workers' documentation should protect clients' privacy to the extent that it is possible and appropriate, and should include only that information that is directly relevant to the delivery of services. (p. 13) Notice the emphasis by NASW of two particular points. First, they state that we need to protect...

Choosing the Structure and Content of Your Report

The structure of your intake report varies based on your professional affiliation, professional setting, and personal preferences. For example, psychiatrists are more likely to emphasize medical history, mental status, and diagnosis, while social workers are more inclined to include lengthier sections on social and developmental history. The following suggested structure (and accompanying outline in Putting It in Practice 7.3) will not please everyone, but it can be easily modified to suit your...

Exploring Societys Contributions to Client Problems

That client problems must be viewed in their social and cultural context is an unarguable fact. Articulating this point for families in particular, Goldenberg and Goldenberg (2000) describe the discoveries made by renowned family therapist Salvador Minuchin (Minuchin, Rossman, & Baker, 1978). As Minuchin and his coworkers began to accumulate research and clinical data and to redefine the problem in family terms, successful interventions involving the entire family became possible. Later...

Suggested Readings And Resources

The helping interview (3rd ed.). Boston Houghton Mifflin Co. This classic text includes information in Chapter 1 on physical conditions such as the room, and in Chapter 4 on recording interviews. Davis, M., McKay, M., & Eshelman, E. R. (2000). The relaxation and stress reduction workbook. Oakland, CA New Harbinger. This practical and clearly written workbook is primarily for use with clients. However, because providing therapy is stressful, it makes sense for clinicians...

Obtaining Background and Historical Information

In an intake interview, three basic sources of information are used to assess the client's personality and mental condition 1. The client's personal history. 2. The client's manner of interacting with others. 3. Formal evaluation of client mental status. The remainder of this section discusses methods and issues related to obtaining a client's personal history and evaluating a client's interpersonal style (evaluating mental status is the focus of Chapter 8). Shifting to the Personal or...

Treatment Planning Application

You are working with Michael, a 26-year-old African American male. He is single, has a bachelor's degree in business management, and is employed as a manager at a local appliance store. He reports a history of hypertension (high blood pressure), which is well-managed using medication. During the session, he complains that although he can work with his employee team effectively and regularly meet individual and team sales goals, he has a long history of heterosexual social anxiety. He also...

Client Personal History

At least a minimal social or developmental history information is necessary for accurate diagnosis. Take the assessment of clinical depression as an example. Currently, DSM-IV-TR lists numerous disorders that have depressive symptoms as one of their primary features, including (a) dysthymic disorder, (b) major depression, (c) adjustment disorder with mixed anxiety and depression, (d) adjustment disorder with depressed mood, (e) bipolar I disorder, (f) bipolar II disorder, and (g) cyclothymic...

Telephone Contact

In some situations, the introduction phase actually begins before you see the client. You may set up your initial appointment with the client by telephone. Whether you do this yourself or a receptionist makes the call, be aware that the therapeutic relationship begins with the initial contact. The phone call, the paperwork, and the clarity and warmth with which clients are greeted can put them at ease or confuse and intimidate. Interviewers vary greatly in how they inform clients of financial...

Feeling Validation

Reflection of feeling is often confused with a technique referred to as feeling validation. Beginning textbooks normally do not distinguish between these two different responses (A. Ivey & Ivey, 1999 Meier & Davis, 2001). Feeling validation occurs when an interviewer acknowledges and approves of a client's stated feelings. The purpose of feeling validation is to help clients accept their feelings as a natural and normal part of being human. Feeling validation can serve as an ego boost...

User Friendly Assessment and Information Gathering Strategies

The purpose of formal assessment or evaluation procedures is to obtain information about client functioning that may be used to make diagnoses and treatment recommendations and or facilitate therapy (Peterson & Nisenholz, 1987). While many mental health professionals use traditional, formal assessment procedures (e.g., intellectual and personality testing, questionnaires) when interviewing children, many do not. Those who do not sometimes have negative attitudes toward assessment or view...

Desensitization and Objective Self Awareness

Objective self-awareness is the term coined by researchers to describe feelings of discomfort associated with listening to or viewing yourself on audio- or videotapes (Fenigstein, 1979). Discomfort comes from viewing physical aspects of yourself (e.g., voice quality, physical appearance, idiosyncratic mannerisms). To watch or listen to yourself produces increased self-awareness, which also increases self-consciousness and inhibition. Expect to experience moderate discomfort as you play back and...

Accurate Empathy

Empathy is a popular concept in clinical interviewing, counseling, and psychotherapy. Empathy is vital to initial rapport and, according to some schools of thought, crucial to eventual psychotherapeutic change (Kohut, 1984 C. Rogers, 1951 see Table 5.1). Unfortunately, empathy is as complex as it is popular. Take, for example, the definition of empathy in Webster's Dictionary Table 5.1. Empathy and Other Theoretical Orientations Writers and clinicians of various theoretical orientations and...

Reliability Judgment and Insight

Reliability refers to a client's credibility and trustworthiness. A reliable informant is one who is careful to present his or her life history and current personal information honestly and accurately. In contrast, some clients may be highly unreliable for one reason or another, they distort, confabulate, or blatantly lie about their life circumstances and personal history. It is often difficult to determine when a client is being untruthful during an interview. Even experienced interviewers...

Orientation and Consciousness

Mental status examiners routinely evaluate whether clients are oriented to (i.e., aware of) their current situation. The question of whether a client is oriented involves evaluating basic cognitive functions. The examiner asks a client three simple questions Where are you (i.e., what city or where in a particular building) When a client answers these queries correctly, the examiner might write in the progress notes that the client was OX3 (oriented times three), referring to the fact that the...

Current Situation and Functioning

This section of the intake report focuses on three main topics (a) usual daily activities, (b) client self-perception of personal strengths, and (c) apparent ability to adequately perform usual age-appropriate activities of daily living. Depending on your setting and preference, it is also possible to expand on this section by including a description of the client's psychological functioning, cognitive functioning, emotional functioning, or personality functioning. This provides the interviewer...

Exploring Your Personal Attitudes Toward Substances

In one way or another, everyone has a personal substance use or abuse history and an attitude toward alcohol and drug use worth examining. Whether you grew up in a family with strong prohibitions against drinking alcohol or a family with members suffering from cocaine addiction, your family experiences undoubtedly shaped how you think about people who use (or do not use) alcohol, cocaine, and other drugs. To become more effective in working with substance-abusing clients, you should reflect on...

Identifying Evaluating and Exploring Client Problems and Goals

Your first, and perhaps primary, objective is to find out about your client's distress. As an interviewer, your exploration of a client's chief complaint begins with your opening statement (e.g., What brings you here or How can I be of help see Chapter 6). After the opening statement, at least 5 to 15 minutes should be spent tracking the client and trying to understand exactly why he or she has come to see you (Shea, 1998). In some cases, clients clearly identify their reasons for seeking...

Attending Behavior

Ivey and Ivey 1999 consider attending behavior the foundation of interviewing. They define attending behavior as culturally and individually appropriate . . . eye contact, body language, vocal qualities, and verbal tracking p. 15 . To succeed, interviewers must pay attention to their clients in culturally and individually appropriate ways. If interviewers fail to look, sound, and act attentive, they will not have many clients. Most clients quit going to counseling if they think their...

Assessment of Current Functioning

After inquiring and exploring historical and interpersonal issues, interviewers should make one more major shift and focus on current functioning. Not only is it important to assess current functioning, but also it is equally important not to end an interview focused on the past. The shift to current functioning provides both a symbolic and a concrete return to the present. The end of the interview is also a time to encourage clients to focus on personal strengths and environmental resources,...

Attitude toward Examiner Interviewer

Parents, teachers, and mental health professionals often overuse the word attitude. When someone claims a student or client has an attitude problem or a bad attitude, it can be difficult to determine precisely what is being communicated. In the mental health field, attitude toward the interviewer refers to how clients behave in relation to the interviewer that is, attitude is defined as behavior that occurs in an interpersonal context. Observation of concrete physical characteristics and...

Summary

Clinical interviewing involves a systematic modification of normal social interactions. Although the relationship established between interviewer and client is a friendly one, it is much different from friendship. Clinical interviews serve a dual function to evaluate and to help clients. Clinical interviewing is defined in different ways by different writers. Our definition includes the following components a A professional relationship between interviewer and client is established b a client...

Motivational Interviewing A Contemporary Approach to Substance Abuse Interviewing

Over the past 20 plus years, the most well-respected and empirically validated approach to interviewing clients about substance use is largely, and perhaps surprisingly, non-confrontational. Drawing from his experiences treating problem drinkers, William Miller 1983 began writing about his beliefs and practices, calling his methodology motivational interviewing. He and his colleague Stephen Rollnick published a book by that name in 1991 a second edition in 2002 , and published a number of...

Using a Comprehensive Checklist for a Thorough Suicide Assessment

After practicing and gaining familiarity with risk factors, the following checklist can be used in practice sessions and role plays to help you conduct a thorough suicide assessment in almost any circumstance. It is important to practice actually obtaining the information from different types of clients because the energy, setting, time allotted, and so forth, can make for interesting challenges when it comes to getting this information. Either in pairs in class or with a willing friend or...

Basic Attending Listening And Action Skills

Meryt listened in stillness, watching my face as I recounted my mother's history, and the story My friend did not move or utter a sound, but her face revealed the workings of her heart, showing me horror, rage, sympathy, compassion. For the most part, we all know a good listener when we meet one. However, it's not quite so easy to figure out exactly what good listeners do to make it so comfortable for other people to talk openly and freely. This chapter analyzes the mechanics of effective...

Interpretive Reflection of Feeling

Interpretive feeling reflections are feeling-based statements made by interviewers that go beyond the client's obvious emotional expressions. The goal of interpretive feeling reflections is to uncover emotions that clients are only partially aware of. Interpretive feeling reflections may produce insight i.e., the client becomes aware of something that was previously unconscious or only partially conscious . Interpretive feeling reflections have been referred to elsewhere as advanced empathy...

Speech and Thought

In mental status exam formulations, speech and thought are intimately linked. It is primarily through speech that mental status examiners observe and evaluate thought process and content. There are, however, other ways for interviewers to observe and evaluate thought processes. Nonverbal behavior, sign language in deaf clients , and writing also provide valuable information about client thinking processes. In a mental status exam, speech and thought are evaluated both separately and together....

Resistance

At times, we are at odds with our clients. We want them to talk about their life history, and they want to talk about their last trip to the mall, the Olympic games, or some other matter that seems distant or irrelevant. If clients are avoiding important topics, yet at the same time wanting the benefits of therapy, it is likely that resistance is occurring. Some of the best examples of resistance come from the medical world. We avoid the dentist even though our tooth aches because we do not...

Cultural Background and Personal Space

You should be sensitive to cultural differences in eye contact, body language, vocal qualities, and verbal tracking. Although most Whites in North America interpret eye contact as a positive sign of interest, people from other cultures e.g., Asian and Native American tend to prefer less direct eye contact and may view excessive eye contact as disrespectful or invasive. During a visit to Europe and North Africa, we became acutely aware of cultural differences in body language. We had a limited...

Mental Status Examination Reports

Following are sample mental status reports. A good report is brief, clear, concise, and addresses all the areas noted in this chapter. Gary Sparrow, a 42-year-old Caucasian male, was disheveled and unkempt on presentation to the hospital emergency room. 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...

Affect and Mood

Affect is defined as the prevailing emotional tone observed by the interviewer during a mental status examination. In contrast, mood is the client's self-reported mood state. Affect is usually described in terms of its a content or type, b range and duration also known as variability and duration , c appropriateness, and d depth or intensity. Each of these descriptive terms is discussed further. Affect Content To begin, you should identify what affective state you observe in the client. Is it...

Paraphrase or Reflection of Content

The paraphrase is a verbal tracking skill and a cornerstone of effective communication. Its primary purpose is to let clients know you have accurately heard the central meaning of their messages. Secondarily, paraphrases allow clients to hear how someone else perceives them a clarification function , which can further facilitate expression. Paraphrasing is the act or process of restating or rewording Random House Unabridged Dictionary, 1993, p. 1409 . In clinical interviewing, the paraphrase is...

The Pros and Cons of Self Disclosure

Clients will ask you personal questions. It's only a matter of how many personal questions you get asked. In addition, from time to time you'll feel the urge to disclose something about yourself both appropriately and inappropriately to a client. Consequently, the big questions to ask right now include Is there anything basically wrong about self-disclosing personal information to clients Are there any benefits associated with therapist self-disclosure How much disclosure is too much Is it...

Evaluating Interpersonal Style

The claim that individuals have personality traits resulting in consistent or predictable patterns of behavior is more or less controversial, depending on a person's theoretical Table 7.1 Personal History Interview Sample Questions 2. Descriptions and memories of parents 3. Descriptions and memories of siblings 5. Peer relationships in and out of school 6. Middle school, high school, and college experiences What is your first memory How old were you then Do you have any very positive or...

Coping with Countertransference

Countertransference is defined as therapist emotional and behavioral reactions to clients. As an example, imagine an interviewer who lost his mother to cancer when he was a child. His father's grief was very severe. As a consequence, little emotional support was available when the interviewer was a child. The situation eventually improved, his father recovered, and the interviewer's conscious memory consists of a general sense that losing his mother was very difficult. Now, years later, he's a...

Open and Closed Questions

The four sets of questions that follow are designed to obtain information pertaining to the same topic. Imagine how you might answer these questions, and then compare your imagined responses. 1. Open How are you feeling about being in psychotherapy Closed Are you feeling okay about being in psychotherapy 2. Open What happened next, after you walked onto the subway and you felt your heart begin to pound Closed Did you feel lightheaded or dizzy after you walked onto the subway 3. Open What was it...