COUN 5830 Week 3 Assignment

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Feb 20, 2024

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1 Unit 3: Intake, Clinical Assessment, and Ethical Documentation Andrea Merced Saldana Capella University COUN 5830: MHC Approaches and Interventions Dr. Kimberly Nelson January 28, 2024

2 Intake, Clinical Assessment, and Ethical Documentation The initial session is the foundation of any sessions to follow. (Oh et al., 2019) states, “Assessment within mental health professions refers to a systemic evaluation procedure that enables counselors to gather relevant information about clients and integrate it into an appropriate treatment plan” (p. 187). The focus here is to provide an overview of how an intake, clinical assessment, and ethical documentation must be conducted in the introduction, opening, and body of a session. This paper will allow the reader to learn about the case that has been selected, the summarization of skills that will be utilized, the exploration of ethical, legal, and cultural considerations, assessment identification, and the exploration of interview tasks. Rameen is a 27-year-old Pakistani female who currently resides with her parents. Rameen is employed at her family’s doctor’s office and is also pursuing her master’s degree in physical therapy. Rameen has never been married and has no children. Rameen reports having some difficulty with sexuality, as well as feelings of depression and anxiety and fear of her parents learning of this. Rameen reports she feels her parents might disown her or rather she be dead than gay, and although Rameen denies any history of suicidal ideation or suicidal attempt, she often experiences similar thoughts of being better off dead. Identification of Case and Summarization of Skills Rameen’s case scenario involves difficulty with her sexuality, depressive and anxiety symptoms, and fear of her family judging her emotional struggles and sexuality lifestyle. It is pertinent to guide clients during sessions as to avoid rushing or dwelling on certain topics and allows the counselor to ensure the goal of the session is reached in a timely manner (Sommers- Flanagan & Sommers-Flanagan, 2017). First and foremost, in order to establish a health counselor-client relationship, rapport should be established with the client, this may include

3 reflective listening and validating the client’s feelings, building trust with one another by using warm and welcoming tones as to provide a safe and nonjudgmental space for the client to express themselves, and setting the tone of the session by sharing relevant information about the therapeutic process, confidentiality, and establishing clear boundaries to create a foundation of trust. The opening of this session involves the counselor to ask open-ended questions, as to encourage clients to express their current thoughts, emotions, and concerns; goal setting to discuss and clarify the client’s goals for the session and the overall therapeutic process to align expectations; and reviewing progress by acknowledging the progress and achievements, as well as addressing any setbacks. Within the body of the session, it is crucial to actively engage with the client by demonstrating attunement to the client’s emotions and responding appropriately; empower the client by focusing on the client’s strengths, fostering a sense of empowerment, and promoting self-efficacy; and providing feedback and summarization of key points and collaboratively exploring insights gained during the session. Exploration of Ethical, Legal, and Cultural Considerations As professionals, it is vital that ethical codes, laws, and cultural considerations are kept in mind and being adhered to. Some ethical codes that should be followed include ACA Code of Ethics (2014) B.1.c. Respect for Confidentiality and E.8 Multicultural Issues/Diversity in Assessment. The respect for confidentiality describes the counselor’s duty to ensure all client information is kept confidential and provides information about when information may be disclosed at client’s discretion or due to legal or ethical justification (ACA, 2014, p. 7) and the multicultural issues/diversity in assessment describes the counselor’s knowledge of the utilization of specific assessments when it is most appropriate with diverse populations (ACA, 2014, p. 12). Confidentiality laws govern the confidentiality of client information, such as the

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4 Health Insurance Portability and Accountability Act of 1996 showcasing the legal obligation to protect the privacy of their clients and can only disclose information with the client’s informed consent or under specific legal exceptions. Cultural considerations, especially within the Muslim culture, include the stigma and integration of faith; stigma can be worked through by acknowledging the existence of stigma around mental health within some Muslim communities, encourage open conversations to reduce stigma and raise awareness, and explore how mental health treatment aligns with Islamic teachings, emphasizing that seeking help for mental health issues is not contradictory to religious beliefs. Rameen is currently struggling with feelings of depression and anxiety and fear of parents catching on; Elshamy et al. (2023) states, “self- stigmatization, however, ensures when members of a minority adopt these prevalent stigmatizing notions and begin to feel inferior to and rejected by most people” (p. 2). Assessment Identification Assuming rapport has been built between the counselor and the client, the client may feel comfortable disclosing any suicidal ideations. During Rameen’s intake interview, she does voice feeling her parents might disown her for being gay, and stating, “They might rather I was dead than gay. In fact, even I’ve thought that way. I mean, I don’t think I would ever kill myself. But it comes to mind sometimes” (2024). Due to this disclosure, completing a suicidal and mental status assessment is needed to ensure client safety. As for the Columbia Suicide Severity Rating Scale (C-SSRS) is a tool utilized to assess for the presence of suicidal ideations, the intensity of the suicidal ideations, presence of suicidal behaviors, and the lethality of the suicidal behaviors (Salameh et al., 2024). Along with the suicide assessment, conducting a mental status exam can also be helpful. The Mental Status Examination is an assessment oriented to assess a client’s speech patterns, tones and mood, insight and judgement, the presence of sensory experiences,

5 behaviors, cognitive processes, and orientation and consciousness (Sommers-Flanagan & Sommers-Flanagan, 2017). The rationale behind conducting these assessments is to ensure Rameen’s safety; it is vital that all questions are asked in a direct, clear, and concise manner as to avoid lines getting crossed from the interviewer to the interviewee. Communicating empathetically and utilizing a non-judgmental attitude and using open-ended questions can encourage the client to share their thoughts and feelings, as well as normalizing the topic of suicide by discussing that emotional struggle are a normal part of seeking help and assuring the client that they are not alone. Exploration of Interview Tasks In order to successfully accomplish my intake tasks during this phase of treatment, I must have established rapport, gathering of information, assessing present issues, exploring client expectations, and assessing for risk and safety. These can be accomplished using the following skills: provide a clear understanding of a client’s emotions and concerns, fostering a therapeutic alliance, understanding cultural competence, effective communication skills, proficiently assessing symptoms, and addressing any immediate issues or challenges. Some considerations that should take place are emphasizing the importance of confidentiality, the clear explanation of the therapeutic process, obtain informed consent, being mindful of the client’s cultural background, respecting the client’s autonomy, and developing a safety plan. Effectively working with a client involves employing various therapeutic strategies tailored to the individual’s needs, preferences, and presenting concerns. Some strategies that I would implement would be to clarify goals, practice mindfulness and relaxation techniques, and motivational interviewing. Collaboratively discussing and setting clear treatment goals and ensure the client’s expectations align with the therapeutic process and provide education on what

6 they can expect from therapy. Introducing mindfulness and relaxation exercises can help the client manage stress, increase self-awareness, and improve emotional regulation. Using motivational interviewing techniques to explore and enhance the client’s motivation for change; the approach can foster a collaborative and non-confrontational atmosphere. Some challenges I encountered while working through this activity are Rameen’s struggles with her sexuality, along with her religious beliefs. Key points with these challenges include navigating religious beliefs, the lack of social supports, and the disclosure of her sexuality. Navigating Rameen’s religious beliefs includes her struggle to reconcile her sexual orientation with religious beliefs that may view non-heteronormative identities as incompatible; challenge within itself is the balancing and respecting those religious beliefs while supporting clients in understand and affirming their sexual identity if they choose to do so. The lack of social support is present when Rameen voices not having told any of her friends about her sexuality. The challenge that is present is the facilitation of connecting Rameen to supportive communities, friends, or organizations, and helping her build a sense of belonging. The coming and disclosure of Rameen’s sexuality is emotionally complex and challenging, involving her fears of rejection, discrimination, or familial disapproval. The challenge present is providing support as Rameen navigates the coming-out process, helping her build a support network, and addressing potential negative reactions from others. Conclusion The foundation of building a client-counselor relationship is crucial as it foreshadows the outcomes of the sessions and the goals. It is most essential to ensure the skills that are utilized at the intake session and the sessions after are not just a standard practice but are competent for diverse populations. Ethical, legal, and cultural considerations are vital as it allows counselors to

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7 provide a safe and trusting environment for clients when they need it most. The many skills, codes, laws, and considerations mentioned in this paper are just a few of many where counselors may use to provide successful sessions.

8 References American Counseling Association. (2014). 2014. ACA code of ethics. https://www.counseling.org/docs/default-source/default-document-library/2014- code-of-ethics-finaladdress.pdf American Psychological Association. (2020). Publication manual of the American Psychological Association (7 th ed.). Elshamy, F., Hamadeh, A., Billings, J., & Alyafei, A. (2023). Mental illness and help-seeking behaviours among Middle Eastern cultures: A systematic review and meta-synthesis of qualitative data. PLos ONE, 18 (10), 1-25. https://doi-org.library.capella.edu/10.1371/journal.pone.0293525 Oh, S., Kim, N., Bennett, C. M., & Taylor, D. D. (2019). Multiculturally competent intake interview with LGBTQI + clients. Journal of Gay & Lesbian Mental Health , 23 (2), 186–204. https://doi.org/10.1080/19359705.2019.1568943 Rameen. (2024). Intake Interview. other. Retrieved 2024, from https://media.capella.edu/CourseMedia/COUN5830/Counseling_ClientIntake/wrapper.asp. Salameh, G., El Khoury, N., Hallit, R., Malaeb, D., Sakr, F., Dabbous, M., Fekih-Romdhane, F., Obeid, S., & Hallit, S. (2024). The mediating effect of dysmorphic concern in the association between between avoidant restrictive food intake disorder and suicidal ideation in adults. BMC Psychiatry, 24 (1), 1-8. https://doi-org.library.capella.edu/10.1186/s12888- 023-05490-5

9 Sommers-Flanagan, J., & Sommers-Flanagan, R. (2017). Clinical Interviewing (6th ed.). John Wiley & Sons.

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COUN 5830 Week 3 Assignment

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