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Essential Clinical Skills for Counselors
Mental Status Exam &Suicide Assessment
Sidney L. Shaw, EdD
John Sommers-Flanagan, PhD
Rita Sommers-Flanagan, PhD
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Why the Clinical Interview?
Assessment & Intervention are ubiquitous counselor roles
Conducting Clinical Interviews can become automatic over time
The challenge of gathering assessment data while establishing rapport & emphasizing strengths
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The Plan
Very quick overview of MSE
Specific focus on MSE categories of assessing affect/mood & judgment
Suicide assessment
The emphasis is on integrating strengths-based, constructive approaches
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MSE Purpose
The MSE is a method of organizing clinical observations about current mental functioning.
The MSE is a primary method for communicating about cognitive or psychiatric symptoms in medical settings
Sample MSE reports are available at johnsommersflanagan.com
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MSE General Categories
Appearance Behavior/psychomotor activity Attitude toward examiner (interviewer) Affect and mood Speech and thought Perceptual disturbances Orientation and consciousness Memory and intelligence Reliability, judgment, and insight
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Evaluating Affect & Mood
Where are the struggles?
Where are the strengths?
Gathering assessment information.
Integrating strength-based, solution focused interventions.
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judgment
Questions should address: What are the impulses?
What are the responses to impulses?
Are there areas where judgment is clearly poor?
What sound judgments are exhibited?
Integrating strengths-based, solution focused interventions.
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Video Clip – Carl
Watch for movement back and forth from the technical task of the MSE interview and less directive listening or strength-based intervention
Think about what symptoms you see and hear and how you might articulate them in an MSE report
The protocol being used is published and also available online
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Cultural Issues
How does culture affect MSE process and MSE reports
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Cultural issues: Generating Possible invalid conclusions
Category ObservationInvalid Conclusion Explanation
Attitude toward examiner
Uncooperative and hostile
Oppositional-defiant or personality disorder
Has had abusive experiences from dominant culture
Affect and mood
No affect linked to son’s death
Inappropriately constricted affect
Expression of emotion about death is unaccepted in client’s culture
Reliability, judgment, and insight
Lies about personal history
Poor reliability
Does not trust White interviewer from dominant culture
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MSE Common Pitfalls
Lack of focus on or knowledge of the categories
Single symptom generalization
Interpretation of client symptoms can become very idiosyncratic and based on our own experiences
Can, in a traditional method, reinforce or emphasize what’s wrong with the client.
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Transforming the MSE
MSE to gather data about client deficits or pathology; also about client strengths
MSE as rapport enhancing
Focus the MSE also on wellness – integrating solution-focused interventions
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Part II: Suicide Assessment Preparation Busting the Big MYTH The New Narrative The “state of the art (and science)”
suicide assessment clinical interviewing
Suicide interventions Resources
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Preparation
Self-Preparation: Questions to ask yourself
What issues/ideas, etc., activate my suicide buttons?
What are my beliefs and attitudes about suicide?
What are my aims in approaching suicide assessment?
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Busting the Big Myth (Narrative)
The Big MYTH or Old Narrative
Suicide ideation and gestures are signs of DEVIANCE
This is the old medical model perspective
It suggests that we, as medical authorities, assess and intervene with suicidal patients
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The New Narrative
Suicide thoughts and gestures don’t represent deviance
Suicide thoughts and gestures represent DISTRESS
We have empathy WITH clients and their distress, viewing suicide ideation and behavior as a means through which they express their distress or unhappiness
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New Narrative II
The old narrative emphasized diagnostic interviewing
The new narrative implies: Using strength-based paraphrases Carl Rogers with a twist (O’Hanlon) Exception and externalizing questions Resource questions No assumption of mental illness
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Video Clip
Tommie and John
Watch for directness
Watch for strength-based and solution-focused methods
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Suicide Narratives
Adapted from Meichenbaum
“I can't stand being so depressed anymore.” “I can stop this pain by killing myself.” (Schneidman, 2001 psychache and mental constriction)
“Suicide is the only choice I have.” (The word “only” is considered one of the most dangerous words in suicidology)
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Suicide Interview Components
Suicide risk factors Suicide ideation Suicide plan (SLAP) Self-control
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Reformulating Suicide Assessment & Intervention
BALANCING YOUR QUESTIONING Traditional suicide assessment and depression assessment focuses on
asking about risk factors and depressive symptoms
We should balance this with positive questions about protective factors (reasons for living), hope, and positive behaviors (scaling)
Rationale: Differential activation theory
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Brief Suicide Interventions
No suicide contracts vs. safety plans
Explore alternatives to suicide
3rd person exploration
Separate suicidal feelings from the self (the desire is to eradicate the feelings – not the self)
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Decision-Making
Frequency and intensity and power of SI
Specificity and lethality of plan
Other risk factors and protective factors (RFL)
Self-control and intent
Responsiveness to interventions
Develop safety plan and/or hospitalize
Consultation and documentation
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Closing Comments
Thanks for listening and participating
You can access free resources at: johnsommersflanagan.com
For detailed information on MSE & suicide assessment interviewing, see: Sommers-Flanagan & Sommers-Flanagan (2014). Clinical Interviewing (5th ed.). Chapters 8 & 9; Hoboken, NJ: Wiley