New Strategies for Mental Health Assessment: 5 Additional Required Techniques

“I went home and counted the number of days for me to return. My first visit with you was different, and I thank you for that.”  When Ralph articulated this, he was genuine and authentic in showing gratitude towards Karinn, his clinician and the entire staff at the Hope Clinic.

In a previous article entitled, New Strategies for Mental Health Assessment: 5 Required Techniques, I outlined how Karinn was able to instill trust and rapport, reach Ralph where he was at, and establish and remain therapeutic. Ralph came back, expressing his gratitude, and Karinn continued her work with him, following the principles and techniques of conducting an effective and comprehensive mental health assessment.

Below are five additional required techniques Karinn used, as she continued her work with Ralph.

Obtain your client’s explanatory model of illness or his or her formulation of the problem

“Ralph, what do you think is going on; how do you explain your problem; what do you call it?” Karinn asked Ralph these questions, because she wanted to understand his formulation of the problem, as part of the strategy to get his buy-in, make him part of the solution, and have a common ground with which to work. Karinn needed to obtain Ralph’s explanatory model of illness.

The next time you meet with your patient or client, seek to learn how he or she understands what seems to be going on and ask what he or she recommends as part of the solution. Both of you will be pleased with the outcome.

Ask permission and explain

Once you have asked and heard the explanatory model of illness from your patient or client or his or her formulation of the problem, be sure to validate, explain, and educate, as needed. Prior to doing so, however, remember to ask for permission.

“Thank you for your explanation.  Losing one’s son is indeed devastating … I would like to ask for your permission to add something.”

After getting permission from Ralph, Karinn added, “I would like to add that your long history of trauma, including your long years of incarceration, seems to also be an added factor to your current presentation.” “You are right, Karinn. I barely talk about my trauma. It is painful and I feel worse after I talk about it. I don’t think anything can be done about it,” responded Ralph.  The use of validation instead of confrontation helps prepare Ralph to hear Karinn’s explanation with an open mind. The trust and rapport established in the previous encounter have also been essential seeds planted by Karinn. Asking for permission also reminded Ralph that this was meant to be collaborative, and instead of speaking at or to him, Karinn was speaking with him. It was a subtle but significant difference.

Seek to understand their working solution and recommend

Once you have reached common ground on the formulation of the problem, it becomes easier to make a recommendation. However, prior to offering a recommendation, seek to understand what your patient or client thinks the solution to the problem might be. Once you have heard a working solution, you can then ask for permission to follow up with a recommendation.

Ralph thought the solution to his current presentation of insomnia, depressed mood, and impulsivity was to process the loss of his son. While these symptoms did intensify with the premature loss of his son, they had been present prior and were well related to his long history of trauma. Further, Ralph has been managing his pain through alcohol and cocaine use, another important component Karinn would address in her recommendations. He was once more open to Karinn’s suggestions, because the seed had been planted.

Collaborate and establish the next step

Collaboration between you and your patient or client is key to an effective and comprehensive mental health assessment, and it builds from the very beginning, even prior to the first visit.

Collaboration makes it easier to establish next steps, which in turn is best done by asking, “I have heard these three main concerns, if you could work on only one of them, which would be the first one for us to work on?”  Then follow with, “Why this one? How important is it for you to work on this specific concern? What are the three steps you need to take in order to solve this particular concern?” Karinn went through this exercise with Ralph, and he agreed that working on his cocaine use disorder might be the best first step towards recovery, because this will help with his mood, his impulsivity, and perhaps his insomnia.

Collaborate and agree on the next appointment date

Jill Harkaway, a gifted family and couples therapist, liked to say, “The goal of the first visit is a second one.”  I believe this to be true, and I see it every day. Once you have done enough assessments, you can easily predict, almost with certainty, which patient or client is likely to return for a second visit, which one is not, and which one will make it through the first two or three visits. The good news is that there are ways to increase the likelihood that your patient or client makes it to the second or third visit.

In addition to the principles and techniques of an effective and comprehensive mental health assessment, collaborating and agreeing on the next appointment date has been shown to increase the likelihood that your patient or client will show up for the follow up visit. Simply asking your patient or client when he or she would like to come back for a follow up visit and giving him or her a card to write down that specific date and time chosen creates commitment and expectation, and your patient or client will work hard to live up to this standard.

This is the fourth article of a series on New Strategies for Mental Health Assessment.

In the first article, I described the six reasons why of an effective and comprehensive mental health assessment. In the second article, I explained the principles of an effective and comprehensive mental health assessment, and in articles three and four, I outlined a total of ten techniques of an effective and comprehensive mental health assessment.

These fundamental components will surely serve as a good foundation for you to continue to hone your skills and obtain additional resources on this essential aspect of clinical practice. Work at them, implement them, and, once again, you will be pleased with the results.

References:

1. Shea SC: Psychiatric Interviewing, the Art of Understanding: A Practical Guide for Psychiatrists, Psychologists, Counselors, Social Workers, Nurses, and Other Mental Health Professionals, 2nd ed. Philadelphia, WB Saunders, 1998.

2. Carlat DJ: The Psychiatric Interview: A Practical Guide. Philadelphia, Lippincott Williams & Wilkins, 1999.

3. Pridmore S: Psychiatric Interview: A Guide to History Taking and the Mental State Exami- nation. New York, Taylor & Francis, 2000.

4. Margulies A, Havens LL: The initial encounter: what to do first? Am J Psychiatry 1981; 138:421–428.