Professional Professional Practices:Practices:

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Melody Kipp, PhD, LMHCMelody Kipp, PhD, LMHC

Life & Work Life & Work SoulSoulutions, utions, Inc.Inc.

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

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The Biopsychosocial Interview.The Biopsychosocial Interview. The purpose of the Biopsychosocial The purpose of the Biopsychosocial

interview is to find out exactly what the interview is to find out exactly what the problems are and where they come problems are and where they come from.from.

Biology – the cells.Biology – the cells. Psychology – the emotions, attitudes, and Psychology – the emotions, attitudes, and

behavior.behavior. Sociology – the relationships and Sociology – the relationships and

environment.environment.

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The Biopsychosocial Assessment The Biopsychosocial Assessment (Appendix 32)(Appendix 32)

Allow 1 to 2 hours: Allow 1 to 2 hours: Without distractionsWithout distractions Without interruptionsWithout interruptions

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Beginning counselors often Beginning counselors often experience difficulty with the experience difficulty with the assessment because:assessment because: They become overwhelmed with too They become overwhelmed with too

much information.much information. They begin treatment too early.They begin treatment too early.

Becoming a skilled interviewer Becoming a skilled interviewer takes practice and experience.takes practice and experience.

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The biopsychosocial assessment The biopsychosocial assessment should address the following:should address the following: The patient’s demographic The patient’s demographic

information.information. History of present illness.History of present illness. Past history.Past history. Medical history.Medical history. Mental status exam.Mental status exam.

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

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After you have completed the practice After you have completed the practice interview, reflect on these questions:  interview, reflect on these questions:   How did you feel after the interview was How did you feel after the interview was

completed?completed? What part of the interview was effortless What part of the interview was effortless

for you?for you? What part required more effort than you What part required more effort than you

thought?thought?   Where do you believe you could Where do you believe you could

improve?improve?  

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

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

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

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Chief ComplaintChief Complaint History of the Present IllnessHistory of the Present Illness Past HistoryPast History Medical HistoryMedical History Family HistoryFamily History Mental statusMental status

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Summary and ImpressionsSummary and Impressions Include all of the problems that you have Include all of the problems that you have

seen and give your impression of where the seen and give your impression of where the patient stands on each of the following patient stands on each of the following dimensions:dimensions:

Acute intoxication or withdrawal complicationsAcute intoxication or withdrawal complications Biomedical conditions or complicationsBiomedical conditions or complications Emotional/behavioral complicationsEmotional/behavioral complications Treatment acceptance or resistanceTreatment acceptance or resistance Relapse potentialRelapse potential Recovery environment Recovery environment

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Diagnostic Impressions:Diagnostic Impressions: Based on the information gathered Based on the information gathered

during the Biopsychosocial Interview, a during the Biopsychosocial Interview, a diagnosis is determined by consulting diagnosis is determined by consulting the DSM. What are your diagnostic the DSM. What are your diagnostic impressions of your “pretend” client?impressions of your “pretend” client?

Reminder: Only licensed clinicians Reminder: Only licensed clinicians or those supervised by licensed or those supervised by licensed clinicians may diagnose patients.clinicians may diagnose patients.