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Professional Practices: Assessment

Professional Practices: Assessment. Melody Kipp, PhD, LMHC Life & Work Soul utions, Inc. Assessment.

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Professional Practices: Assessment

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  1. Professional Practices:Assessment Melody Kipp, PhD, LMHC Life & Work Soulutions, Inc.

  2. Assessment • An ongoing process through which the counselor collaborates with the client and others to gather and interpret information necessary for planning treatment and evaluating client progress, and making substance abuse diagnoses. (Florida Certification Board, 2004, p. 27).

  3. Assessment • The Biopsychosocial Interview. • The purpose of the Biopsychosocial interview is to find out exactly what the problems are and where they come from. • Biology – the cells. • Psychology – the emotions, attitudes, and behavior. • Sociology – the relationships and environment.

  4. Assessment • The Biopsychosocial Assessment (Appendix 32) • Allow 1 to 2 hours: • Without distractions • Without interruptions

  5. Assessment • Beginning counselors often experience difficulty with the assessment because: • They become overwhelmed with too much information. • They begin treatment too early. • Becoming a skilled interviewer takes practice and experience.

  6. Assessment • The biopsychosocial assessment should address the following: • The patient’s demographic information. • History of present illness. • Past history. • Medical history. • Mental status exam.

  7. Assessment • Imagine yourself sitting in a comfortable chair in your office. You are relaxed and ready to begin the Biopsychosocial Interview with the client sitting across from you. What will you say to the client as you begin the Biopsychosocial Interview?

  8. Assessment • After you have completed the practice interview, reflect on these questions:   • How did you feel after the interview was completed? • What part of the interview was effortless for you? • What part required more effort than you thought? • Where do you believe you could improve?

  9. Assessment • Ask the person you interviewed to give you some constructive feedback on how they felt during the interview and what they thought went well and what could use improvement.

  10. Assessment • You may also want to enlist the help of a seasoned professional counselor to observe you conducting the Biopsychosocial interview. That person could then offer you more constructive criticism that will help you improve your clinical skills.

  11. Assessment • Look at the completed Sample Biopsychosocial Interview in Appendix 7. Using that sample as a guide, write a narrative summary of your interview using the following headings: • Patient Name • Demographic Data

  12. Assessment • Chief Complaint • History of the Present Illness • Past History • Medical History • Family History • Mental status

  13. Assessment • Summary and Impressions • Include all of the problems that you have seen and give your impression of where the patient stands on each of the following dimensions: • Acute intoxication or withdrawal complications • Biomedical conditions or complications • Emotional/behavioral complications • Treatment acceptance or resistance • Relapse potential • Recovery environment

  14. Assessment • Diagnostic Impressions: • Based on the information gathered during the Biopsychosocial Interview, a diagnosis is determined by consulting the DSM. What are your diagnostic impressions of your “pretend” client? • Reminder: Only licensed clinicians or those supervised by licensed clinicians may diagnose patients.

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