Assessment Review for the NCMHCE Part 3

NCMHCE Assessment Review Part 3
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Assessment
– Categories of information
– Presenting issue
– Mental Status Exam
– Emotional
– Behavioral
– Physical
– Personality
– Coping Skills
– Family of Origin
– Culture
– Social Supports and interpersonal relationships
– Environment live and work
– Developmental stage
– Activities of daily living and ability for independence
– Motivation
Assessment
– Categories of Information
– Emotional Signs and symptoms
– Degree of emotional control
– Ability to feel and express a range of emotions
– Emotional appropriateness
– Emotional issues which may be a focus of clinical attention
– Anger
– Anxiety
– Depression
– Grief
– Guilt
Assessment
– Categories of information
– Psychiatric signs
– Looking for diagnostic criteria for disorders
– Affective, behavioral/physical, cognitive, social indicators of mood disorders
– Changes in thinking behavior associated with cognitive impairments
– Signs of a substance use disorder
– Discussing with client
– Exacerbating factors and triggers
– Mitigating factors and effective interventions
Assessment
– Categories of information
– Medical and Physical Symptoms and Issues
– Consider the possibility that symptoms are caused by a medical condition and refer for an evaluation
– Evaluate current medications and consider medication side effects
– Is the client intoxicated or in withdrawal from a substance
– Vegetative symptoms: Persistent problems with appetite, weight control, sleep, energy, sexual desire and function
Assessment
– Categories of information
– Medical and Physical Symptoms and Issues
– Somatoform Disorders: Physical symptoms with no detectable physiological cause
– Includes pain disorder and body dysmorphic disorder
– When tests and physical exams do not support the patient’s symptoms consider malingering of factitious disorders
Assessment
– Categories of information
– Personality Traits
– Patterns of behavior, thinking and perception that are pervasive can indicate a personality style such as aggressive, addictive, Type A or co-dependent or a personality disorder such as antisocial, histrionic, or borderline
– Ego functioning
– Self regulation/impulse control/frustration tolerance
– Defense mechanisms
– Healthy use limits dysphoric emotions without significantly disrupting a persons life

Assessment
– Categories of information
– Coping skills
– Coping abilities, resources and deficits
– Current coping strategies that are and are not effective
– Ways the client has responded to similar problems in the past (adaptive and maladaptive)
– Specific individual characteristics that impact coping ability such as developmental level, cognitive functioning, locus of control and sense of self-efficacy
– Family of Origin
– Cultural background
– Socioeconomic background

Assessment
– Categories of information
– Interpersonal Relationships and Social Supports
– Type, quality and effectiveness of current relationships
– If isolated, evaluate for voluntary withdrawal, poor social skills, alienation, shyness/social anxiety, substance misuse or compulsive behaviors, low self-esteem, PTSD
– Capacity for healthy interpersonal relationships (boundaries)

Assessment
– Categories of information
– Social Roles and Role Functioning
– Each role holds a set of role expectations
– What roles does the person fulfill (child, parent, spouse, employee, friend…)
– Is there role ambiguity or role conflict (parent/friend; parent/employee)
– Has there been a loss of an important role (empty nest, divorce)
– Is the client overwhelmed or ambivalent about the responsibilities associated with a role (parenting, employee, spouse)
– Are client’s normal dependency/affiliation needs being met in an appropriate way (boundaries)
– Is the client being victimized/manipulating or victimizing/manipulating someone else
Assessment
– Categories of information
– The Environment
– Living and working environment (safety, security, stressors)
– Maslow+: Shelter, food, economic resources, education, job opportunities, legal resources, transportation, religious and community groups (assistance, affiliation and support), sources of social support and affiliation (a farm in rural area vs. an urban environment)
– Developmental Stage
– Child development issues
– Current developmental tasks and issues
Assessment
– Categories of information
– Activities of Daily Living / Personal Independence (safety, effectiveness and ability to complete independently)
– Self-care skills
– Health care (exercise, sleep, nutrition/cooking, medications)
– Environmental skills (cleaning, laundry)
– Financial Skills
– Child care/parenting skills(if needed)
– Transportation

Assessment
– Categories of information
– Client’s motivation level
– What are the clients goals and expectations
– Help set SMART goals
– How does the client view his/her role (active, or passive)

Assessment
– Sources of Information
– Client self-report
– Provides the current, salient factors for the client
– May not include underlying issues
– May not be complete if client is not comfortable
– Observations of verbal and nonverbal behavior
– Observations of interactions with therapist, others
– Do observations match client reports?
– Has there been a physical workup to rule out medical causes of symptoms?

Assessment
– Sources of Information
– Collateral sources
– Medical referral/report
– Prior treatment history
– Relatives
– Caretakers
– Case workers
– Employers

Summary
– A comprehensive assessment should provide the factual evidence supporting your diagnosis
– The symptoms identified in the assessment will form the basis for the treatment plan
– Assessments should always involve collaboration with other professionals when permitted to rule out biological or other social/environmental causes (i.e. domestic violence, trauma, detox)
– No one person’s account will be truly unbiased.
Test Taking Tip
– In the initial question you are trying to uncover more clues to help you verify your hypothesis about the client’s diagnosis
– Do not get distracted by questions which would reveal interesting information but not relevant to the case.
– If you suspect the client has PTSD, gathering information about substance use will not provide you any additional information about that particular diagnosis. It may be a comorbid diagnosis, but the scenario is focused on the PRIMARY diagnosis.
NCMHCE Exam Review
Podcast
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NCMHCE Review
Part 4
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Objectives
– Define assessment
– Review acronyms to help you remember what to look for when assessing for a problem.
What is Assessment
– Assessment is the process of gathering, analyzing and integrating information into a comprehensive picture that describes
– The nature, frequency, intensity and duration of the client’s problems
– The roles the client, significant others and the environment/community play in the current issues
– The functioning of the client and significant others
– Client motivation to address presenting issues
– Resources needed to resolve problems and effectively participate in treatment.
Presenting Issue
– Represents the problems that are foremost in the client’s mind
– Denial of any problems may also provide information into client insight, judgement and motivation
Evaluating the presenting issue
– When did it begin?
– What makes it worse? Better?
– How often does it occur and to what intensity?
– If the client is reporting multiple symptoms, assess the above for each and identify which symptom presented first.
– What are the antecedents of (triggers/precipitants) the problem?
– How do you feel when the problem occurs? What are you thinking?
– Describe what happens right after the problem (reinforcers), habitual responses.
Stressors
– What stressors are occurring and what is their frequency, intensity and duration?
– How does the client deal with the stressors?
– Are the stressors impacting the course of the presenting problem?
Emotional Range
– Emotional control (dysregulation or flattening) can impact the client’s health, relationships and functioning at work or school.
– People who avoid dealing with emotions may develop depression, anger or anxiety
– People who experience dysregulation may also develop depression, anger or anxiety
– Trauma-induced changes in emotional range may also impact the client’s ability to function
– Remember that affect is the current, transient state. Always assess affect.
Mood Disorders
– When the client presents with mood symptoms, inquire about
– Previous episodes of the same symptoms
– How he or she has dealt with them before
– If there was a previous episode, was there full remission?

Depression
– What to look for
– Anhedonia
– Dysphoria
– Sleep changes
– Appetite changes
– Changes in psychomotor behavior
– Reduction in libido
– Reduced energy
– Nonverbals indicating any of the above

– Highly self-critical
– Cognitive distortions
– Hopelessness/pessimism
– Irritability
– Guilt/shame
– Difficulty concentrating
– Withdrawal from relationships

Depression Mnemonic A SAD FACES
– A = Appetite (Weight Change)
– S = Sleep (Insomnia / Hypersomnia)
– A = Anhedonia
– D = Dysphoria
– F = Fatigue
– A = Agitation / Retardation
– C = Concentration Diminished
– E = Esteem (Low) / Guilt
– S = Suicide / Thoughts of Death

Mania
– What to look for
– Elevated mood
– Grandiosity
– Irritability/aggression
– Pressured speech
– Flight of ideas
– Restlessness
– Hypersexuality
– Impulsivity

– Limited insight
– Poor concentration
– Impatience
– Gregariousness
– Provocativeness

Mania Mnemonic DIG FAST
– Distractibility
– Indiscretion
– Grandiosity
– Flight of ideas
– Activity increase
– Sleep deficit
– Talkativeness
Anxiety
– What to look for
– Irritability/edginess
– Uneasiness/worry
– Panic
– Hypervigilance
– Psychomotor agitation/Nervous habits
– Nonverbals indicative of worry

– Ruminating
– Persistent worrying about a variety of things
– Difficulty concentrating
– Withdrawal from relationships
– Highly critical of self
– Sleep problems
– Clinginess/dependency
Anxiety Mnemonic: Worry WARTS
– Worry

– Worn out
– Absentminded
– Restless
– Touchy
– Sleepless
PTSD
– What to look for:
– Exposure to a traumatic event
– Re-Experiencing (Dreams, memories, flashbacks)
– Avoidance of reminders
– Negative thoughts or feelings that began or worsened after the trauma and/or difficulty experiencing positive emotions
– Trauma related arousal and reactivity
PTSD
– Disinterest in usual activities
– Re-experience
– Event preceding symptoms
– Avoidance
– Month or more of symptoms
– Sympathetic arousal
Substance Abuse – SAD CLIPS
– Signs of intoxication or withdrawal
– Slowed reflexes
– Aroma of drugs
– Difficulty concentrating

– Confusion
– Lowered inhibitions
– Impaired Coordination
– Pupils
– Slurred speech

Physical Symptoms – CLASSED
– Is the client under a doctors care? If so why?
– If there are obvious long-standing physical/developmental issues, how have they impacted the client?
– Convulsions or seizures
– Libido
– Appetite
– Sleep
– Sex hormones
– Energy
– Dizziness or fainting
– Describe childhood health

Medical Referral- EAT LOADS
– Eating Disorder
– AIDS/HIV
– Tuburculosis

– Long standing depression
– Ongoing physical complaint (chest pain, dizziness, abdominal pain, chronic cough, fatigue)
– Abrupt personality or behavioral change
– Delirium/Dementia
– Substance abuse

Test Taking Tip
– Everything in the NCMHCE has one clear diagnosis and assumes a mutual respect between client and counselors. Thus, the test is measuring for ideal questions and treatments, even if those might not be appropriate or applicable in some real-world situations.
– In reading the initial scenario, focus on the symptoms and all components of the question.
– Does the question indicate the client is grieving and withdrawn? Then you would look for remedies that target that area such as support groups
– Consider whether the information that is being requested is actually beneficial and whether it will narrow down the diagnosis. Asking too many questions will lower your score
– Gather support FOR your diagnosis NOT to rule out other things.
NCMHCE Review
Episode 5
Assessment Part 3
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Objectives
– Continuation of the assessment review
Developmental Stage (and Unresolved Crises)
– Trust/Mistrust: Get needs met
– Autonomy: Control my own body and make choices
– Temper tantrums
– Initiative: Ability to make and carry out plans
– Stuttering/cluttering and speech problems should abate by 5years. Sudden onset after this point may indicate an emotional issue
– Bedwetting stops by the end of this phase
– Industry: Identify what they are good at
– Identity: Individuation
– Intimacy: Creation of new secure attachments
– Generativity: Commitment to wellbeing of future generations via work and activities
– Integrity: Acceptance of mortality
Self-Esteem
– Self efficacy
– Confidence
– Vindictiveness
– Argumentativeness
– Willing to accept responsibility or blames others
– Social anxiety
– Self-perception including body image

Social Functioning
– Information about social functioning can help you
– Determine what client’s behaviors are like outside of the session
– Identify the source of current problems
– Family History
– Childhood family
– Who was there
– How did they get along
– How frequent were moves
– History of abuse, neglect, DV, or MH issues
– Childhood friends
– School performance
– History of childhood trauma

Social Functioning
– Current Living Situation
– Where?
– Safety?
– Transportation?
– With whom?
– Quality of relationships with co-habitants?
– Financial Status
– Can client pay bills?
– Sources of income?
– Is client employed? How long? Work history?

Social Functioning
– Social Network
– Perception of support?
– Quality of relationships?
– Relationship with family?
– Relationship with adult children?
– Hobbies and leisure activities
– Sexual and Romantic Relationships
– What is the client’s sexual orientation?
– How has the client integrated his/her/their sexual orientation?

Social Functioning
– Sexual and Romantic Relationships
– Is the client in a LTR/marriage/partnership?
– Have there been previous LTR/m/ps? Why did they end?
– How do partners support each other?
– Has/have the partnership(s) contributed to the current problems?
– How have the current difficulties impacted the partnership(s)?
– How is the client’s current sex life and sexual functioning?
– Have there been relationships outside the partnership?
– Were these relationships CNM?

Social Functioning
– Children and Step Children
– Does the client have children/step? Ages?
– Relationships with children/step?
– Does the client agree with partner(s) about care of children?
– With step-children and children from a previous relationship, how does the client get along with the other caregiver?

Social Role Functioning
– Social role problems negatively impact clients’ abilities to fulfil expectations of their social roles
– Role ambiguity
– Role conflict
– Role loss
– Role incompetence
– Lack of knowledge
– Isolation
– Lack of role resources
– Power: Misuse or abuse or learned helplessness
– Ambivalence about role expectations
– Inability to fulfil role responsibilities (overwhelmed)
– Enmeshment (blocked) or detatchement (lack of support)

Environment
– Economic and basic needs
– Education and training
– Legal assistance (civil and criminal)
– Health and social services
– Community engagement
– Social supports
Distress Tolerance and Coping Abilities
– Coping Skills and Strengths
– Problem focused
– Emotion Focused (Distress Tolerance)
– Current strategies to cope with the presenting issue. What works? What doesn’t?
– How has client coped with similar problems in the past?
– If the client coped in the past, but not now, what is different?
– Dysfunctional Coping abilities include
– Ineffective coping skills (general or situational)
– Rigid coping skills
– Power-based coping/violence/NSSI
– Addictive behaviors
Personality Patterns
– What was the clients like before the onset of the current problems?
– Type A: Achievement oriented, impatient, competitive, workaholic, aggressive, stressed
– Addictive: Thrill seeker, impulsive, inability to set limits on pleasure
– Codependency: Difficulty identifying and communicating needs, need approval of others, low self esteem, unhealthy need to be in a relationship
– Schizoid: lack of interest in social relationships, a tendency towards a solitary or sheltered lifestyle, secretiveness, emotional coldness, detachment, and apathy.
– What is their normal mood?
– What were they like in adolescence?
– How do clients perceive others view them?

Other Things …
– Beliefs
– Listen for cognitive distortions and irrational beliefs
– Legal Issues
– Convictions/pending/arrest history: Criminal
– Any civil matters: Divorce, bankruptcy, civil lawsuits
– Culture
– Nationality
– Racial or ethnic identification
– Cultural identification (soldier, deaf, blind, “addict”)
– Religious identification
– Level of acculturation
– Cultural expectations and beliefs

Other Things …
– Motivation
– Precontemplation
– Contemplation
– Preparation
– Action
– Maintenance
– Dimensions
– Who are they changing for?
– Who is responsible for the change?
– What do they hope to get out of it?
– What obstacles do they anticipate?
– When do they envision making a change?

Integration
– Primary focus in the person-in-system (contextual)
– Recognize that a change in one area will impact all other areas
– Explore the reciprocal dynamics between the clients’ environments and their problems
– Clients’ actions and reactions impact the environment which in turn impact the client’s actions and reactions.
– The environment affects clients which impact their reactions which impact the environment
– The goal is to improve the person-environment fit
Interactions
– Anxiety can lead to depression and isolation which can reduce self efficacy and esteem
– Depression can impact social functioning, work functioning, pain, physical health, sleep
– Grief can impact people’s abilities to function at work and as a parent
– Addictive behaviors may be used to “self-medicate” environmental, social or occupational issues yet often make those issues worse…
Summary
– Self Esteem and efficacy
– Developmental stage and unresolved crises
– Current social relationships
– Social relationship patterns
– Personality styles and traits
– Environmental factors (housing, finances, community attachment etc.)
– https://www.americanmentalwellness.org/prevention/risk-and-protective-factors/
– https://youth.gov/youth-topics/youth-mental-health/risk-and-protective-factors-youth
– Integration using an interactive person in situation approach.

Test Taking Tips
– Assessment
– Integrate client assessment and observational data
– Identify precipitating problems or symptoms
– Identify individual and/or relationship functioning
– Identify relevant family issues.
– Make it Relevant
– Analyze the person-environment fit in the child throwing a tantrum in the store
– Think about the developmental stage children are at
– When you see conflict IRL or on TV, explore the potential factors that contributed to it

Test Taking Tips
– When Assessing Children
– Use descriptive statements to support and encourage the child.
– Encourage children to think about what they are doing, thinking, feeling, saying.
– Provide positive reinforcement for participation.
– Ask age appropriate questions
– When assessing adults look for common themes either across time or across situations