Ирина Архипова – English for Psychotherapy and Counselling: Handbook. Английский для психотерапии и консультирования: практическое руководство (страница 16)
3. Why is it important to understand the “presenting problem”?
4. What is a mental status examination?
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Understanding the Presenting Problem: Initial Assessment
When a client first contacts a psychologist, one of the most important tasks is conducting a comprehensive initial assessment or intake interview. This first session sets the foundation for the entire therapeutic relationship and treatment process. The psychologist gathers essential information, establishes rapport, and begins to understand the client’s difficulties within the context of their life.
The Purpose of Initial Assessment
The initial assessment serves multiple purposes. First, it allows the psychologist to understand why the client is seeking help – what professionals call the presenting problem or chief complaint. This is the primary issue or concern that brings the client to therapy, described in the client’s own words. Second, the assessment provides comprehensive background information about the client’s personal history, current life situation, and past experiences with mental health issues. Third, it helps the psychologist determine whether they can help the client or whether a referral to another professional would be more appropriate.
The initial assessment is also the beginning of the therapeutic relationship. During this first session, the psychologist works to establish rapport – a trusting, comfortable connection with the client. Without rapport, clients may not feel safe enough to share sensitive information or engage fully in the therapeutic process. The psychologist demonstrates empathy, active listening, and respect while maintaining professional boundaries and explaining important concepts like confidentiality.
Gathering the Presenting Problem
The assessment typically begins with an open-ended question designed to let the client tell their story in their own way. Common opening questions include: “What brings you here today?” or “What’s been happening that led you to seek help now?” These questions invite narrative responses rather than simple yes/no answers.
As the client describes their presenting problem, the psychologist listens carefully and asks follow-up questions to clarify the nature of the difficulty. Important aspects to explore include:
• Onset: When did the problem begin? Was there a specific event or trigger?
• Duration: How long has the problem been present?
• Frequency: How often does the problem occur?
• Severity: How much does the problem interfere with daily functioning?
• Previous attempts: What has the client tried to address the problem? What worked or didn’t work?
• Client’s understanding: What does the client think is causing the problem? What are their expectations for treatment?
For example, a client might say: “I’ve been feeling really anxious lately”. The psychologist would then explore: When did the anxiety start? What situations trigger it? How does it affect your daily life? What have you tried to manage it? This detailed exploration helps the psychologist understand not just the symptom, but the context surrounding it.
Taking the Psychosocial History
After exploring the presenting problem, the psychologist gathers information about the client’s psychosocial history – their personal, family, social, educational, occupational, and medical background. This comprehensive history helps the psychologist understand the client as a whole person and identify factors that may contribute to current difficulties.
Key areas of psychosocial history include:
Developmental and family history: information about childhood, family structure, relationships with parents and siblings, significant early experiences, and any history of abuse or trauma.
Educational and occupational history: school performance, level of education, current employment status, job satisfaction, and any work-related stress.
Relationship and social history: current and past romantic relationships, friendships, social support network, and quality of interpersonal relationships.
Medical history: physical health conditions, current medications, past surgeries or hospitalizations, and any chronic illnesses.
Past psychiatric history: previous mental health diagnoses, past therapy or counselling experiences, psychiatric hospitalizations, and any history of psychotropic medication use.
Substance use: current and past use of alcohol, tobacco, and other substances.
The psychologist uses a combination of open-ended and closed-ended questions to gather this information efficiently while still allowing the client to share their story. For example, a closed-ended question like “Are you currently employed?” establishes a fact, while an open-ended follow-up like “Tell me about your work situation invites the client to provide context and detail”.
Conducting a Mental Status Examination
An essential component of the initial assessment is the mental status examination (MSE) – a systematic observation and description of the client’s current psychological functioning. While some aspects of the MSE are observed naturally during the interview, psychologists may also ask specific questions to assess certain domains.
The MSE typically evaluates the following areas:
Appearance and behaviour: the psychologist observes how the client looks (grooming, clothing, hygiene) and behaves (eye contact, posture, motor activity, unusual movements).
Speech: rate, volume, tone, and any abnormalities in speech patterns.
Mood and affect: mood is the client’s subjective emotional state (how they say they feel), while affect is the observable emotional expression. Psychologists assess whether affect is appropriate to the content being discussed, its range (restricted, normal, or labile), and its intensity.
Thought process: how the client thinks – whether their thoughts are logical, organized, and goal-directed, or whether there are signs of disorganization, tangentiality, or circumstantiality.
Thought content: what the client thinks about – including any delusions, obsessions, preoccupations, or suicidal/homicidal ideation.
Perception: whether the client experiences hallucinations (seeing or hearing things that aren’t there) or other perceptual disturbances.
Cognition: assessment of orientation (awareness of time, place, and person), attention, concentration, memory, and general intellectual functioning.
Insight and judgment: the client’s awareness of their condition and their ability to make sound decisions.
The MSE provides a “snapshot” of the client’s mental state at the time of the assessment and helps identify symptoms that may indicate specific mental health conditions.
Risk Assessment
A critical component of any initial assessment is evaluating risk – particularly the risk of self-harm, suicide, or harm to others. Psychologists must directly but sensitively ask about these concerns. Contrary to common fears, asking about suicidal thoughts does not increase the risk; instead, it demonstrates care and creates an opportunity for the client to discuss difficult feelings.
Risk assessment questions might include: Have you had any thoughts of harming yourself? Have you had thoughts of ending your life? Do you have a specific plan? If a client endorses suicidal thoughts, the psychologist assesses the frequency, intensity, duration, and whether the person has means and intent to carry out a plan. Protective factors, such as reasons for living, social support, and future orientation, are also explored.
Formulating and Planning
At the conclusion of the initial assessment, the psychologist integrates all the information gathered to develop a preliminary understanding of the client’s difficulties. Many psychologists use a formulation framework called the Four Ps:
• Predisposing factors: background factors that make the person vulnerable (e.g., family history of mental illness, early trauma)
• Precipitating factors: recent events or stressors that triggered the current problem (e.g., job loss, relationship breakup)
• Perpetuating factors: factors that maintain or worsen the problem (e.g., poor coping strategies, lack of social support, avoidance behaviours)
• Protective factors: strengths and resources that can aid recovery (e.g., supportive relationships, resilience, motivation for change)
This formulation guides treatment planning and helps the psychologist and client work collaboratively toward meaningful goals.
Comprehension Questions
1. What is the purpose of the initial assessment?
2. What is the difference between “presenting problem” and “chief complaint”?
3. Why is rapport important in the first session?
4. What are the five key aspects to explore when gathering information about the presenting problem?
5. What types of information are included in a psychosocial history?
6. What is the difference between mood and affect in the MSE?
7. Why do psychologists ask about suicidal thoughts during initial assessment?
8. What are the “Four Ps” in formulation?
9. According to the text, what is the difference between open-ended and closed-ended questions?
10. What areas does a mental status examination cover?