1 Screening and Assessing for Mental Disorders Developed by DATA of Rhode Island through a special grant from the RI Department of Human Services

2 What is screening and assessment Screening and Assessment – encourages the description of a process rather than the study or identification of diagnosis of specific conditions. It is the first major step in problem recognition and intervention.

3 GOALS To familiarize trainees with common mental disorders experienced by persons with disabilities to introduce workers to a variety of techniques to help screen and assess clients for mental illness

4 The Purpose of an assessing process Identification of problems/needs Identification of strengths and assets Determine if there is immediate risk or threat Identify Special considerations Engage in recovery process

5 Client’s Approach to the interview Voluntary versus Involuntary Purpose or Motive Client’s Expectations Client’s Perception of the worker

6 Role Play The cat lady

7 Workers Approach to the interview Orientation – enforcer of the rules, caseworker ??? Personal Feelings, Value & Beliefs Understanding the Client & the “Problem”

8 Interpersonal Characteristics of an Effective Workers EmpathyGenuinenessWarmthRespect Positive regard Healthy Boundaries Ability to understand the client from their perspective Freedom to be oneself; lack of phoniness Quality of being open, responsive toward client Ability to convey clients have the power to change & participate in the process Ability to accept clients despite their negative behavior, attitudes or demeanor Maintain an appropriate role with a client that is neither over-involved or overly distant It is important that we explore these attitudes as some may enhance your work and some may be counterproductive.

9 Interviewing Skills and Process A variety of interviewing skills can be used to gather useful information to better understand a persons mental status A process for conducting a screening interview

10 Interview Phase 1 Introduction – Develop an understanding about the reason for the interview Major tasks – development of rapport & establishment of trust Clarifying purpose on interview

11 Interview Phase 2 Exploration Major tasks – development a better understanding for the presenting problem

12 Interview Phase 3 Hypothesis Testing – develop inquiries to test the hypothesis trying to put the problem into more of a context Major tasks – delve into other areas or situations in client’s life that may relate to problem

13 Interview Phase 4 Feedback/summarize – Worker highlights the screening/assessment findings with the client Works with client toward a common understanding

14 Interview Phase 5 Wrapping up –4 critical questions in the last 5 minutes: 1. Is there anything else you want to tell me that you feels is important? 2. Have we left anything out? 3. Do you have any questions for me? 4. Where do we go from here? Major tasks – develop a plan geared toward the attainment of mutually agreeable goals

15 Using Collateral Information Often times the worker will have collateral information regarding client behavior. This information can come from many sources including: other persons, co- workers, client’s family or direct observation This collateral information often is what prompts your meeting with the client

16 Interview Techniques 1 Questioning Direct Direct Open-ended Open-endedExample Client’s statement: “As a kid I was always in trouble” Client’s statement: “As a kid I was always in trouble” Worker Response: : “What kind of trouble were you in?” Worker Response: : “What kind of trouble were you in?”

17 Interview Techniques 2 Reflection Cognitive/Thoughts Cognitive/Thoughts Emotional/feelings Emotional/feelingsExample Client’s statement: “I just can’t seem to get anywhere in my life.” Client’s statement: “I just can’t seem to get anywhere in my life.” Therapist's Response: : “Your lack of progress frustrates you. Or sounds like your feeling really stuck” Therapist's Response: : “Your lack of progress frustrates you. Or sounds like your feeling really stuck”

18 Interview Techniques 3 Restatement Paraphrasing Paraphrasing Facilitates understanding Facilitates understandingExample Client’s statement: “Thoughts are racing in my mind. I just can’t concentrate. I’m so confused.” Client’s statement: “Thoughts are racing in my mind. I just can’t concentrate. I’m so confused.” Worker Response: : “Sounds like these thoughts in your head are troubling to you. What kind of thoughts are they?” Worker Response: : “Sounds like these thoughts in your head are troubling to you. What kind of thoughts are they?”

19 Interview Techniques 4 Clarification Questioning Questioning Paraphrasing Paraphrasing Restating RestatingExample Client’s statement: It seems like I am angry all the time. Client’s statement: It seems like I am angry all the time. Worker Response: : Is something going on that is making you feel so angry? Worker Response: : Is something going on that is making you feel so angry?

20 Interview Techniques 5 Confrontation Discrepancy between what is observed & stated Discrepancy between what is observed & stated Confrontation can be constructive or destructive Confrontation can be constructive or destructiveExample Client’s statement: “I only drink a couple of times a day and not every day.” Client’s statement: “I only drink a couple of times a day and not every day.” Worker Response: From our experience with you, you drink every day and by evening you are slurring your words, unsteady on your feet and look drunk.” Worker Response: From our experience with you, you drink every day and by evening you are slurring your words, unsteady on your feet and look drunk.”

21 Interview Techniques 6 Self-disclosure Worker conveys personal experiences or feelings Worker conveys personal experiences or feelings Intended to facilitate client self-disclosure Intended to facilitate client self-disclosureExample Client’s statement: “People don’t understand what it’s like not to be unable to remember. I’m so stupid.” Client’s statement: “People don’t understand what it’s like not to be unable to remember. I’m so stupid.” Worker Response: : “When I was in school, I was dyslexic. But, you can still do well in life despite having a problem. You’re not stupid, but we need to find out why you have problems remembering and what can be done. Worker Response: : “When I was in school, I was dyslexic. But, you can still do well in life despite having a problem. You’re not stupid, but we need to find out why you have problems remembering and what can be done.

22 Interview Techniques 7 Exploration “testing the limits” approach “testing the limits” approach How much insight the client has or how client responds to pressure How much insight the client has or how client responds to pressureExample Client’s statement: “My father used to beat me.” Client’s statement: “My father used to beat me.” Worker Response: : “I need a bit more information. How does that effect you today? Worker Response: : “I need a bit more information. How does that effect you today?

23 Interview Techniques 8 Reframing Therapist restate client’s attitudes, thoughts beliefs or feelings Therapist restate client’s attitudes, thoughts beliefs or feelings Used to promote new ways of thinking Used to promote new ways of thinkingExample Client’s statement: “I believe I will never change how I feel.” Client’s statement: “I believe I will never change how I feel.” Worker Response: : “I hear that is how you feel right now. That sounds like your depression talking. With some help that feeling can change.” Worker Response: : “I hear that is how you feel right now. That sounds like your depression talking. With some help that feeling can change.”

24 Screening for Mental Status 1 General Appearance State of consciousness - on a continuum from alertness to coma State of consciousness - on a continuum from alertness to coma Manner – on a continuum from manipulative to grateful Manner – on a continuum from manipulative to grateful Attitude – on a continuum from uncooperative to cooperative Attitude – on a continuum from uncooperative to cooperative Dress, hygiene Dress, hygiene

25 Mental Status 2 Physical Behavior Overall profile of motor activities – gait, frequency & speed of movement, rhythm & coordination, & the presence of or absence of abnormal movements Overall profile of motor activities – gait, frequency & speed of movement, rhythm & coordination, & the presence of or absence of abnormal movements Can range from hyperactive to hypoactive – foot tapping, pacing, restlessness or jerky shift of the body while sitting Can range from hyperactive to hypoactive – foot tapping, pacing, restlessness or jerky shift of the body while sitting

26 Mental Status 3 Affect & Mood Affect is the emotional tone observed by the worker Affect is the emotional tone observed by the worker Mood is self-reported & subjectively felt experience of the client Mood is self-reported & subjectively felt experience of the client Evaluate: amplitude of emotions, range of affect, inappropriate mood, constriction in range of affect, relatedness and labiality of affect Evaluate: amplitude of emotions, range of affect, inappropriate mood, constriction in range of affect, relatedness and labiality of affect

27 Mental Status 4 Speech & Thought 1. Quantity of thought – stream of thought & poverty of speech 2. Quality of association – continuity of thought 3. Content of thought – verbal expressions of experiences, thoughts perceptions & feelings; delusions, illogical thinking & obsession 4. Abstraction – ability to think symbolically & to conceptualize, problem solve & generalize

28 Mental Status 5 Suicidal or Homicidal Ideations Assess for presence of absence Assess for presence of absence Degree of lethality Degree of lethality Reversibility/Ambivalence Reversibility/Ambivalence Plan Plan Means Means Identified victim Identified victim Past attempt Past attempt Family history Family history Relation to SA Relation to SA Contract for safety Contract for safety

29 Mental Status 6 Perceptual Problems Hearing, seeing Hearing, seeing Hallucinations HallucinationsAuditoryVisualOlfactoryHaptic Depersonalization Depersonalization Derealization Derealization

30 Mental Status 7 Orientation Person Person What is your name? Who am I? Place Place Address; location Time Time Day; month; year; time of day Situation Situation Fails to recall or know purpose of interview Space Space Geographic orientation to a new environment

31 Mental Status 8 Attention & Concentration Attention – ability to attend to a stimuli Attention – ability to attend to a stimuli Concentration – concentrate on a task over time without being easily distracted by other environmental stimuli Concentration – concentrate on a task over time without being easily distracted by other environmental stimuli

32 Mental Status 9 Memory Immediate – ability to recall information within seconds or minutes Immediate – ability to recall information within seconds or minutes Recent - ability to recall events from past several days, weeks or months Recent - ability to recall events from past several days, weeks or months Remote- ability to recall events from many years ago Remote- ability to recall events from many years ago

33 Mental Status 10 Intellectual functioning Perception Perception Memory Memory Language verbal and reading and writing Language verbal and reading and writing Motor abilities Motor abilities Abstract thinking Abstract thinking

34 Mental Status 11 Reliability Insight- client’s awareness of problems & exhibits an understanding of the causes & developments of these problems Insight- client’s awareness of problems & exhibits an understanding of the causes & developments of these problems Judgment –ability to adjust to social demands & to deal appropriately with social encounters Judgment –ability to adjust to social demands & to deal appropriately with social encounters Truthfulness – All clients will withhold some amount of information from us and this is normal. Truthfulness – All clients will withhold some amount of information from us and this is normal. It is not our job to catch people in lies. It is to gather enough information that we can develop a reasonable plan. It is not our job to catch people in lies. It is to gather enough information that we can develop a reasonable plan.

35 Demonstration Role play of client intervew

36 Where to from here? Conclusion of a screening process is to identify the facts and the concerns not to render a diagnosis We are looking to engage the person in a common understanding of the issues and to engage in a a problem solving process In the upcoming modules on “enhancing client motivation for change and case planning, we will discuss how to move clients toward getting help and how to develop action plans Questions