Chapter 8 – Intake Interviewing and Report Writing PDF

Chapter 8 – Intake Interviewing and Report Writing  What’s an Intake Interview? ◼ The intake interview is the first meeting between client and therapist. ◼ It’s an initial assessment involving: ◼ problem identification (or diagnosis) ◼ goal-setting ◼ treatmen...

Chapter 8 – Intake Interviewing and Report Writing  What’s an Intake Interview? ◼ The intake interview is the first meeting between client and therapist. ◼ It’s an initial assessment involving: ◼ problem identification (or diagnosis) ◼ goal-setting ◼ treatment planning ◼ The intake can blend right into the treatment process  Three Overarching Objectives ◼ Initial questions for reflection: ◼ Identifying, evaluating, and exploring the client’s chief complaint (and goals) ◼ Obtaining info related to interpersonal behavior and psychosocial history ◼ Evaluating clients’ current life situation and functioning.  Identifying, Evaluating, and Exploring Client Problems and Goals ◼ The chief complaint is the client’s reason for seeking help. It answers the question: “Why are you here?” ◼ Client problems are intrinsically linked to goals... Even if clients can’t see their goals ◼ Reframing client problems into goals facilitates hope and initiates a positive goal-setting process  Identifying, Evaluating, and Exploring Client Problems and Goals II ◼ Problem and Goal Assessment includes: ◼ Prioritizing and Selecting Client Problems and Goals ◼ Analyzing Client Problems and Goals ◼ Using Questionnaires and Rating Scales ◼ Therapeutic Assessment ◼ The Behavioral ABCs  Prioritizing and Selecting Client Problems and Goals ◼ Most clients arrive with a variety of specific complaints or vague symptoms ◼ Problems need to be analyzed and prioritized ◼ Problem prioritization should be collaborative ◼ Follow the client’s lead first  Analyzing Client Problems and Goals ◼ Extensive questioning may be needed: ◼ When did the problem or symptoms first occur? ◼ Where were you and what exactly was happening when you first noticed the problem? ◼ How have you tried to cope with or eliminate this problem? ◼ What have you done that was successful? ◼ What else has been helpful? Analyzing Client Problems and Goals II ◼ Consider these question categories: ◼ Antecedent or Triggering Questions ◼ Questions Focusing on the Problem Experience ◼ Coping Questions ◼ Questions that Stimulate Client Reflections on the Problem  Using Questionnaires and Rating Scales ◼ Many questionnaires are available ◼ MMPI-2-RF ◼ BDI-2 ◼ OQ-45 ◼ What others do you know of or have used?  Collaborative and Therapeutic Assessment ◼ Stephen Finn’s model includes: ◼ The clinician collaborates ◼ Data are contextualized ◼ Assessment is intervention ◼ Clients are described, not labelled ◼ Clinicians respect client complexity  The Behavioral ABCs ◼ ABC model includes: ◼ Behavioral Antecedents ◼ The Behavior or problem itself ◼ Consequences  Obtaining Background and Historical Information ◼ Symptoms occur in the context of individual clients who come from family systems, neighborhoods, ethnic cultures, and who simultaneously hold multiple individual and collective identities ◼ Sources of info: ◼ The client’s personal or psychosocial history ◼ Observations and reports of client interpersonal behavior  Shifting to the Personal or Psychosocial History ◼ A possible bridge from problem exploration to personal or psychosocial history is the why now question: ◼ “I’m clear on why you’ve come for counseling, but I’d like to know more about is why you’ve chosen to come for counseling now” ◼ This gets at precipitating events  Shifting to the Personal or Psychosocial History II ◼ Nondirective historical leads are open questions or prompts that give clients control over what they talk about ◼ “Where would you like to start?” ◼ Directive historical leads help clients focus what they’ll be talking about ◼ This might include early memories or a structured psychosocial history  Shifting to the Personal or Psychosocial History III ◼ You may run into child abuse or other emotional topics ◼ If so, lend a supportive and empathic ear ◼ You can also listen for ways your client was strong during difficult times ◼ What else might you do?  Broaching Diversities ◼ Refers to “a consistent and ongoing attitude of openness with a genuine commitment by the counselor to continually invite the client to explore issues of diversity”-Day-Vines, 2007 ◼ Broaching includes (a) showing interest in diverse cultural, sexual, familial, and spiritual experiences, and (b) expressing non-judgmental openness to hearing whatever your clients might say ◼ Those who have experienced discrimination such as LGBTQIA+ individuals benefit from clear affirmation from therapists to establish trust and become vulnerable  Evaluating Interpersonal Behavior ◼ You have five potential data sources ◼ Client self-report of (a) past relationship interactions (e.g., childhood) and (b) current relationship interactions ◼ Clinician interpersonal observations during the interview ◼ Psych assessment data ◼ Past psychological records/reports. ◼ Information from collateral informants. Evaluating Interpersonal Behavior II ◼ Clients have: ◼ Internal working models that guide their interpersonal behaviors ◼ Cognitive therapists call these client schema or schemata ◼ Adlerian therapists call these lifestyle or style of life ◼ Psychoanalytic therapists call these core conflictual relational themes (CCRT) Assessment of Current Functioning ◼ Shift back to the present with a role induction and specific question ◼ Moving from the past to the present may be challenging ◼ There are many strategies and techniques for helping clients regain emotional control  Helping Clients Regain Emotional Control ◼ Focus on the present or immediate future ◼ Ask clients what’s emotionally soothing ◼ Change to a more positive issue ◼ Give a compliment and suggestion ◼ Acknowledge the negative while reviewing positives ◼ Engage in a centering activity  Reviewing Goals and Monitoring Change ◼ Many therapists pose future-oriented questions toward the end of an intake ◼ If therapy is successful what will change? ◼ How do you see yourself changing in the next several years? ◼ What personal (or career) goals are you striving toward?  Factors Affecting Intake Interview Procedures ◼ Client registration forms ◼ Institutional setting ◼ Theoretical orientation ◼ Professional background and affiliation  Brief Intake Interviewing ◼ Rely on registration forms and questionnaires to gather information ◼ Use more questions and allocate less time for client self-expression. ◼ Reduce time spent on psychosocial history and interpersonal behavior.  The Intake Report ◼ These issues are reviewed in the text: ◼ Remembering Your Audience ◼ The Ethics of Report Writing ◼ Choosing the Structure and Content of Your Report ◼ Writing Clearly and Concisely  Remembering Your Audience ◼ This could include: ◼ Your client ◼ Your supervisor ◼ Your agency administrator ◼ Your client’s attorney ◼ Your client’s former spouse ◼ Your client’s insurance company ◼ Your professional colleagues ◼ Your professional association’s ethics board ◼ Your local, state or professional ethics board  The Ethics of Report Writing ◼ Follow record keeping guidelines, and: ◼ Consider how to handle collateral information and informants ◼ Use non discriminatory language ◼ Be prepared to share intake reports with clients  Choosing the Structure and Content of Your Report ◼ Identifying information and reason for referral ◼ Behavior observations (and MSE) ◼ History of the present problem (or illness) ◼ Past personal and family treatment history ◼ Relevant medical history ◼ Developmental history ◼ Social and family history ◼ Current situation and functioning ◼ Formal assessment data ◼ Diagnostic impressions ◼ Case formulation and treatment plan  Writing Clearly and Concisely ◼ Tips include: ◼ Write the report as soon as possible ◼ Write an immediate draft without worrying about perfect wording or style ◼ Follow an outline ◼ Get clear information from your supervisor or employer about intake report writing expectations ◼ Check out sample reports ◼ Report writing becomes easier with practice