CFN9885 - SECTION 7: OVERVIEW OF CLINICAL ASSESSMENT
General Assessment Guidelines
In most counseling situations, assessment is the primary task of the first session with clients. However, assessment can be an ongoing process as clients begin to feel more comfortable sharing information with the clinician and as the clinician process progresses. Assessment may take various forms depending on the clinician’s orientation and client characteristics. The assessment process can include standardized assessment instruments, client filling out an assessment form, or the clinician interviewing the client to obtain the necessary information. A complete and accurate assessment should include:
- Identifying data: Get details such as name, age, sex, marital status, work/school, ethnic background, appearance, referral source, and payment/reimbursement information.
- Presenting problem(s): Why is the client is seeking counseling including a description of the problems, how long they have existed, who is impacted by the problems and in what way, and what has been done to deal with the problems?
- Living circumstances: Information in this area should include marital status and history, family relationships and history, other personal support systems (friends and associates), significant life events (financial, legal, employment, interpersonal, psychological, medical)
- Psychological analysis and assessment: What is the client’s general psychological condition; intellectual and psychological level of functioning (mental-status examination); client’s view of self (strengths and weaknesses); client’s dominant emotions (anxious, angry, withdrawn, etc.); client’s level of maturity; and client’s ability to realistically see their life situation and make meaningful decisions that impact their life.
- Psychosocial developmental history: Information in this area should include evidence of conflicts and problems originating in childhood, what were some of the critical turning points or crises in the client’s life and how were they handled, how did the client’s relationships with the family influence development and current life situation, does the client have a support system of family and/or friends.
- Health and medical history: Information in this area should include what is the client’s overall state of health; what is the client’s medical history; when did the client last see a physician; are there any signs of recent physical trauma or neglect; what is the client’s mental health; is there any history of mental or physical illness in the family; has the client taken, or is the client currently taking, any medications, and has the client been hospitalized for a physical or mental illness.
- Adjustment to work / school: Information in the work area should include what is the client’s work history, what does the client currently do or expect to do in terms of employment (employment both inside and outside the home), what is the meaning of employment for the client, what problems has the client had with employment, how satisfied is the client with his/her work. If the client is in school, information in this area should include successes and problems in school, if and how any problems were addressed, and what are the client’s and the family’s goals or expectations for school. Information should be gathered from the client, the client’s parents/guardians, and school officials
- Lethality: Information in this area should include is the client currently a danger to self (including suicide and injury to self) or others (including threatening or causing physical or emotional harm to others), have there been prior self-destructive acts or destructive behavior toward others, and what impact have these thoughts or actions had on the client.
- Present human relationships: This area includes a survey of information pertaining to social ties of the client now and in the past (family, friends, associates), satisfaction and problems with social relationships, how does the client deal with interpersonal conflicts, what support does the client get from others, and how would the client improve social relations.
- What has the client already tried to solve or address the problems: What internal and external resources does the client currently possess to address the presenting and related problems, what has the client already tried to address the problems, and what can be learned from these attempts?
- Description of the client during interview: What are the client’s physical appearance, affect or emotions, mental state, and degree of readiness to be in counseling?
- What are the client’s expectations for counseling: What limits are there to counseling (i.e., time and financial limits) and what does the client need from counseling at this time?
- Summary and case formulation: In this area the clinician should summarize the information obtained in the other areas including strengths, weaknesses, and problem areas, prioritized goals for counseling, and possible therapeutic interventions. The clinician and the client should decide if additional resources are needed in this case including referring the client to a physician/psychiatrists, attorney/financial consultant, assessment specialist, and other group or individual counseling or treatment. The clinician and the client should also determine if the client should continue working with the clinician or the case should be referred to another clinician or treatment program that would better suit the client’s needs. (Corey 2001c; Preston, 1998)
This information can be obtained from verbal discussions with the client, standardized tests, observation of the client in natural settings (i.e., at home, school, work), and input from significant other people in the client’s life and from other professionals.
Some agencies and clinicians prefer or require a formal intake interview and diagnosis typically conducted during the first session, while other agencies and clinicians take a more informal approach by allowing the clinician to gather the necessary information over a series of sessions. Some agencies require the client and/or the clinician to fill-out a formal intake interview form, while other agencies and clinicians take a more informal approach relying on the clinician to ask the appropriate questions to gain the necessary information.
An especially useful perspective is assessing client’s needs is the solution-focused approach. (DeJong & Berg, 2002) The problem-solving approach puts clients into the position of being the experts about their own lives by adopting the clinical posture of “not knowing.” The “not-knowing position” entails a general attitude or stance in which the clinician’s actions communicate a genuine curiosity.
That is, clinicians’ actions and attitudes express a need to know more about what has been said, rather than convey preconceived opinions and expectations about the client, the problem, or what must be changed. Clinicians, therefore, position themselves in such a way as always to be in a state of “being informed” by the client. (Anderson & Goolishian, 1992)
This is best accomplished by listening to the client’s story without filtering it through the clinician’s frame of reference. We are used to filtering what others tell us through our own experiences, beliefs, and values. Therefore, it is very difficult to suspend one’s own frame of reference and hear clients’ stories from the client’s point of view, that is, to put yourself in their shoes and see the situation from their perspective.
As clients describe what help they need, they talk about the people, relationships, and events that are significant to them. These things can be used to help clients develop solutions to their problems.
When clients describe why they came to counseling, they usually focus on what is wrong with their situation including what other people in their lives are doing wrong. Clients will often talk as though they are powerless in their situation. While it may be true that people in the client’s life need to change some of their thoughts and behaviors, the focus should be more on what they want to have happen differently and how they see themselves participating in finding solutions to their situation.
However, it is equally important to recognize that letting clients go on about their problems can also be discouraging to them and to you. Clinicians, in an attempt to be empathic, can amplify clients’ negative feelings. The focus should always be on finding solutions to the clients’ problems.
For example, when a client tells a clinician how difficult their marriage is and the clinician responds “that must be very hard for you,” the clinician’s response may have the effect of actually encouraging the client to focus on the negative aspects of his/her situation and not on finding solutions to their problem.
Asking Clients Questions
Interviewing clients is a process of formulating and asking questions, listening to the answers, and then formulating and asking more questions. The basic principle in developing good questions is to formulate the next question from the client’s earlier answers. Developing questions in this way will help you to truly listen to what your clients are saying and to use the information that they give you to help them to develop new awareness and possibilities. Asking questions can help to clarify clients’ statements. Getting details means asking questions about the who, what, when, where, and how of clients’ statements.
Questions are used to clarify clients’ current situations and to both clarify and amplify clients’ goals, strengths, and successes. It is crucial to solution building to listen carefully for and explore the words that clients’ use. Key words are the words clients use to capture their experiences and the meaning they attribute to these experiences.
Exploring the clients’ words is also an important way of demonstrating respect for the client. One way to do this is to echo or repeat clients’ words. For example, when a client says “my life is mess” or “I don’t think I am good at doing anything,” you can respond with the question “What do you mean by ‘a mess’” or “What do you mean by good.”
There are two basic types of questions, closed questions and open questions. Closed questions tend to ask for facts such as “Do you like your parents?” or “Would you like to have more friends?” Open questions ask for the client’s attitudes, thoughts, feelings, and perceptions such as “Tell me about your relationship with your parents?” or “Suppose things got better between with the friends at school, what would be different?”
Closed questions can be appropriate when they are used to set the stage for more open questions such as asking “Are there any of your friends whom you think like you?” When the client gives the name of the friend or even if the client say no one likes him, this can be followed up with the question “Why do you think he likes you?” or “Why do you think you have no friends at school?”
Another type of question tries to summarize or paraphrase what the client has said. You might ask “Let me see if I’ve got this correct?” then summarize what the client has said so far. You might want to paraphrase what the client has said if you want to move the conversation in a direction you think will be more helpful. You might say “So you’re unhappy with the way things are going with your parents and you would like them to give you more responsibility?”
Such summaries or paraphrasing can reassure the client that you are listening carefully to what they were saying, give the client the opportunity to correct anything you might have misunderstood, and, if they are presented in the proper way, encourage the client to say more about the situation.
A useful format to follow in the first sessions is to first find out about what brought the client to counseling. This can be done by asking such questions as: “How can I help you? What makes this a problem for you? What have you tried in the past to deal with this problem? Did this make a difference?”
Next you want to focus on developing some goals for your work with the client. This can be done by asking such questions as: “What do you want to be different as a result of coming here?”
An effective exercise in helping people to begin being more specific about what they like and dislike about their current situation is the use of the “miracle question.” The “miracle question” is presented in the following way:
Suppose one night while you are sleeping, a miracle takes place. The miracle is that the problem which brought you here is solved. However, because you were sleeping, you did not know that the miracle has happened. So, when you wake up, what will be different that will tell you that a miracle has happened and the problem which brought you here is solved?
Responding to this question is not easy for most clients because it requires them to make a dramatic shift from problem-saturated thinking and feeling to a focus on solutions. The person is then asked to describe the perceived changes and his/her feelings such as: “What will you notice that is different.” What will be the first thing that you notice? What else? Who else will notice when the miracle happens? What will he or she notice that is different about you? What else? When he or she notices that, what will he or she do differently? What else? When he or she does that, what will be different for you? What would be the first small thing you would do if the miracle happened? How might this be helpful?”
Their responses can identify things in their life that are working and things that are not working. This exercise can identify discrepancies in the person’s life and goals to be worked on in counseling or treatment. This exercise can also provide the person with a sense of hope and optimism that they can reach their goals.
While asking our clients questions is very important for helping us to understand them, it is also important to learn the value of being silent. Early in my training as a therapist, I sat in on group therapy sessions for parents of adolescents who had substance abuse problems. The therapist leading the group had little interest in including me as a co-leader, so I primarily watched and listened to the interactions between the therapist and the parents, and the parents with each other. I also remember doing co-therapy sessions with a very experienced therapist and not saying one word during some sessions because an additional voice would have been intrusive.
These experiences have helped me to learn the value of being attentive but silent, how to listen to my clients and truly hear what they were saying, and how to not let my own thoughts and feelings get in the way of what they are trying to tell me.
I have found that my silence encourages my clients to be less dependent upon me initiating or responding to them and they come to depend more upon themselves. While I need to be constantly reflecting both during and after each session, when I do talk I have found it better to ask questions than to answer them. If I give an answer, it should be one that confirms what my client has already felt and said in our sessions.
I have found that while I need to be able to accurately assess the client’s situation, develop a treatment plan and I am primarily responsible for setting the course of therapy, it is the client who should be primarily influencing what happens in individual sessions and what happens during the course of counseling.
I have also learned that it is not only important what we say, but how we say it. Clinicians need to pay attention both to the content - what clients are saying, and process - the way in which clients express what they are saying. Clients are often very sensitive to nonverbal cues we give them such as facial expressions, gestures, tone of voice, and eye contact.
As you begin to work with clients, pay attention to clients’ nonverbal reactions to your statements and questions. Their reactions are important indicators of whether your statements and questions are respectful of, and working within, clients’ frames of reference.
Sometimes, there are discrepancies between what the client is saying and how they are saying it, that is, they do not match. A client might say “I don’t need any friends” but say it with tears in his eyes. In a similar way, clients can sense when we are not being completely attentive to what is going on in the counseling session, when our affect does not match what we are saying and doing.
It is important to remember that while accurate assessment usually starts with the first session, it is an ongoing process - as the client feels more comfortable and trusting in the counseling process and working with you as the clinician, and feels comfortable in discussing intimate aspects of their life. Diagnosis should always be seen as being tentative to some degree and always open to new information.
The process of exploration of one area in clients’ lives may heighten their awareness of other areas or issues in their lives. It is also important to remember that clients’ problems may not be solely the result of psychological or interpersonal factors, rather other factors such as medical, social, and economic factors could also be playing significant roles. For this reason, a complete assessment should explore these other areas including a complete medical history and referral to a physician if necessary. (Welfel & Patterson, 2005)