Essential Clinical Skills for Counselors

Mental Status Exam &Suicide Assessment

Sidney L. Shaw, EdD

John Sommers-Flanagan, PhD

Rita Sommers-Flanagan, PhD

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

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

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

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

Evaluating Affect & Mood

Where are the struggles?

Where are the strengths?

Gathering assessment information.

Integrating strength-based, solution focused interventions.

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.

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

Cultural Issues

How does culture affect MSE process and MSE reports

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

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.

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

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

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?

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

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

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

Video Clip

Tommie and John

Watch for directness

Watch for strength-based and solution-focused methods

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)

Suicide Interview Components

Suicide risk factors Suicide ideation Suicide plan (SLAP) Self-control

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

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)

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

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