Initial Intake/Interview and Diagnosis

1. Initial Intake/Interview and Diagnosis Class Presentation Adeeb Saleh 6/11/07

2. Purpose of Intake • To gather information about the client that would allow the agency to understand what the underlying problem is, and to match up the client with the appropriate treatment and or/counselor. • To assess and respond to urgency of client’s situation. • To familiarize client with agency and counseling process.

3. Gathering Information: Who? • The person who conducts the initial intake process can be any staff member with the appropriate training to do so. This is usually an intake worker, or a counselor (MA, or BA, depending on the agency). • Assessor needs to be flexible, resourceful, and experienced enough to handle such a wide range of clients

4. Gathering Information: What? • Demographic information such as: Age, Sex, Race, Marital Status, Area of Residence or address etc. Also called preliminary information. • After gathering the preliminary information the staff member begins the initial interview in which he/she gathers information related to the problem at hand.

5. Gathering Information: What? (cont.) • The staff member would ask about the presenting problem, how long it has been occurring, treatment history, family of origin, educational history, employment history, medical history, and any relationship issues. • Collateral Contacts

6. Gathering Information: How? • Structured or Unstructured questionairs • The ICCF (initial client contact form) includes 11 sections that can provide data on many of the elements that are needed to complete a client’s chart. Sections include: • Client description/problem description, relevant history, mental status, Suicidal/homicidal ideations or plan, Medical history, current medication, allergies, substance use/abuse, previous mental health treatment, diagnostic impressions, recommendations

7. Gathering Information (cont.) • Multimodal assessment: focuses on 7 elements of client’s problem: (BASIC ID) • B – Behavior • A – Affect • S – sensations • I – imagery • C – cognitions • I – Interpersonal relationships • D – Drug (Substance use, fitness, diet, ect.)

8. Things to Consider • Length of time it takes to complete intake assessment depends on the client, available time, and assessor. • The need for a positive and supportive environment for the client is very important (Not too friendly and not too forward)

9. Diagnosis: Why? • Accurately diagnosing a client’s problems can facilitate effective treatment planning; research indicates that clients with some diagnoses respond better to certain kinds of treatments than to others. • Placing clients’ concerns in a diagnostic context can help counselors anticipate the nature and progress of the counseling process. • An understanding of diagnostic terminology helps counselors to communicate more effectively and professionally with social workers , psychologists, psychiatrists, etc. (Networking/Team Work).

10. Diagnosis: Why? (Cont.) • If a client relocates or is transferred from one counselor/agency to another, the use of a shared diagnostic language can promote continuity of service. • Diagnosis also helps agencies classify the clients they serve in order to determine needed services, demonstrate accountability, and justify the agencies role in the community • Also, counselors in private practice settings or fee-for-service agencies will have to provide diagnoses for clients with health insurance coverage

11. Diagnostic Process • In order to make an accurate diagnosis , counselors must gather information on clients’ prsenting concerns, their backgrounds and history, and their present situation (Intake process). • Using the Mental Status Exam is a good way to assess mental and emotional disorders. The MSE focuses on issues related to the client’s current signs/symptoms, affect, behavior, and cognition. • The process of reaching a diagnosis also allows the clinician to rule out a certain diagnosis due to a predisposing medical condition or recent substance abuse which could have caused the presenting problem.

12. Diagnostic References • The two main reference systems of diagnosis that are widely used today are the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and the Manual of International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD-10) • The DSM-IV provides a detailed description of all categories of mental illness

13. DSM-IV • For each disorder, the DSM-IV seeks to provide a general description which includes: 1. A list of the disorder’s essential features and a clinical sketch. 2. A summary of characteristics usually associated with the disorder. 3. Information on the typical onset and course of the disorder, the impairment caused, and potential complications. 4. Information on known predisposing factors and frequency of occurrence of the disorder. 5. Information on similar disorders to facilitate differential diagnosis. 6. Lastly it provides diagnostic criteria for the disorder

14. Multiaxial System • A full diagnosis of the client requires the use of a 5 axes system described in the DSM-IV. Each axes signifies a different aspect of the client’s presenting case/problem. • Axis 1 describes the main presenting problem or psychiatric disorder that the client is presenting • Axis 2 generally describes any personality disorders or developmental disorders which are generally not considered to be mental health illnesses by insurance providers • Axis 3 describes physical conditions or disorders as mentioned by clients (not a medical diagnosis made by clinician) • Axis 4 describes the severity of psychosocial stressors that may be putting pressure or disrupting the client’s life • Axis 5 describes the client’s current GAF score/level of functioning.

15. Things to Consider • For many counselors, diagnosing a client can be uncomfortable because the process of labeling a client with a certain diagnosis appears to the defeat the whole purpose of counseling. • Keep in mind that although diagnosis is important, as mentioned earlier, it is an imprecise science and should be treated as such. Counselors should seek consultation on difficult cases and label uncertain diagnoses as “provisional”.

16. Things to Consider (cont.) • There are five causes of low reliability in the diagnosis of mental health disorders (Seligman, 1986): 1. Subject Variance: the client may exhibit different conditions at different times. 2. Occasion Variance: Clients are at different stages of their conditions at different times 3. Information Variance: Different clinicians have different pieces and sources of information about their clients 4. Observation Variance: Clinicians view and notice different pieces of information and/or behavior as more or less important than another. 5. Criterion Variance: Clinicians may use different criteria for coming up with a diagnosis from the available data.

17. Practical Issues • Waiting time to actually have an initial intake appointment • Labeling in Diagnosis • Dealing with Different Clients: Voluntary, involuntary, Motivated, reluctant. • “Breaking the Ice”

18. Personal Experiences • Crisis Center: Intake Counseling • Role Playing Activity: Intake process

19. MacCluskie, K., & Ingersoll, R. (2001). Becoming a 21st Century Agency Counselor. Wadsworth/Thomson learning, Belmont, CA. The authors of the book discuss and cover relevant material about the initial intake process, information gathering strategies, and the use of the Mental Status Exam to gather information for the purpose of diagnosis. Seligman, L. (1986). Diagnosis and Treatment Planning in Counseling. Human Sciences Press, Inc. New York, NY. The author of this book goes over many important aspects related to the initial intake process, as well as the process of diagnosis. The author covers issues related to the different types of clients that may be seen for an initial intake interview, as well as the many different settings an initial intake interview may take place. The author also discusses the importance of diagnosis, the use of the DSM, and things to consider when making a solid diagnosis. Annotated Bibliography

20. Annotated Bibliography (cont.) • Whittenhall, J. (2007). The medical model of mental illness: Ethical and practical implications for diagnosis. Eye on Psi Chi, 11 (2), pp. 16-17. The author discusses the issues and concerns related to using the medical/categorical method of diagnosing mental illness and the reasons to why clinicians should instead use a more dimensional approach. He explains that the medical approach overlooks many important factors related to a client’s problems and tends to pile all the factors into one diagnosis/disorder. A dimensional approach looks at many aspects of the person and takes into consideration more than just the symptoms, but the external factors as well. Gallucci, G., Swartz, W., Florence, H. (2005). Impact of the wait for an initial appointment on the rate of kept appointments at a mental health center. Psychiatric Services, 56(3), pp. 344-346. The authors of this article look into the relationship between waiting periods to have an initial intake appointment schedule and the rate of those appointments being kept by clients over time. The authors found that when waiting periods to get appointments were shortened, the rate of kept appointments would increase over time.