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University of North Texas *

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4500

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Nursing

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Nov 24, 2024

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Uploaded by Chrisred518

Paul Estes, Anik Ladzekpo, Kati Gabhart, Christen George University of North Texas RHAB 4500-900: Assessment of Rehabilitation Dr Jamar Booth November 6. 2024

Mental health is a critical aspect of our overall well-being, and diagnosing and treating mental disorders is an integral part of the mental health field. The DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision) is a classification system that mental health professionals have used for many years to diagnose and treat. The DSM-IV-TR contains diagnostic criteria, descriptions, and other information about mental disorders that professionals use to make accurate diagnoses and develop effective treatment plans. A clinical interviewer would use the DSM-IV-TR as a guide to assess an individual's symptoms and determine a diagnosis. They would gather information from the individual about their current symptoms, medical history, family history, and other relevant factors. The interviewer will then use the diagnostic criteria in the DSM-IV-TR to determine if the individual meets the requirements for a specific disorder. The interviewer would consider each of the five axes of the DSM-IV-TR, including clinical disorders, personality disorders, and medical conditions, to gain a comprehensive understanding of the individual's functioning. They would also consider cultural or contextual factors influencing the individual's symptoms. the critical role of unstructured clinical interviews in master's level counseling settings such as mental health counseling, family therapy, and community counseling. They focused on developing diagnoses conforming to DSM-IV-TR. Although master's level counselors typically possess an education in diagnosis and are familiar with the DSM classification system, many may lack formal training in clinical interviewing. Jones asserts that this limitation could compromise the accuracy and effectiveness of DSM-IV-TR diagnostic tools. This article seeks to fill the void by offering insights into using unstructured clinical interviews for making DSM-IV-TR diagnoses with adult clients, particularly for Axis I and II disorders. This article emphasizes the critical role that an initial interview plays in counselor training, serving as both the start of counseling relationships

and as the cornerstone for later assessments. Mental health and community counseling settings often use unstructured, open-ended interviews as the preferred method for diagnosing mental disorders. Commonly referred to as clinical or diagnostic interviews, this process has since expanded beyond solely being the purview of psychiatrists into being shared among master 's level counselors. Jones highlights a notable discrepancy in counselor education programs. Although diagnostic training has become part of curriculum over the past 15-20 years, most counselors receive traditional interviewing techniques rather than clinical interviewing training. Traditional methods focus on gathering background history but fail to address identifying diagnostic signs and symptoms necessary for an accurate diagnosis. Given the importance of DSM-IV-TR diagnoses as the cornerstone for treatment planning, this article emphasizes the need for counselors to become skilled clinical interviewers. This article acknowledges the lack of information regarding clinical interviewing within counseling literature and assessment textbooks, with most books often favoring structured or semi-structured interviews that prioritize accuracy over patient satisfaction. However, the unstructured clinical interview remains the preferred assessment from among psychiatrists, psychologists, and counselors. This could be explained by its flexible nature that promotes building rapport with clients. Jones emphasizes the significance of interviewing for diagnosis, noting that counselors must become proficient at recognizing diagnostic clues and asking pertinent diagnostic questions during a clinical interview. In this article, a comprehensive outline for conducting unstructured clinical interviews is presented, outlining various content domains such as identification information, present chief complaint history and relationship, family, developmental history, education work history, medical substance use, legal history, previous counseling mental status

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examination, and others. Within each content domain, this article presents examples and answers for diagnostic clues and questions in each area. Under "Presenting Problem/Chief Complaint," counselors are advised to listen for psychological symptoms, maladjusted behavior patterns, stressors, and interpersonal conflicts as potential diagnosis sources; examples are provided to show how such clues may lead to specific diagnostic questions. This article offers counselors in masters level programs a comprehensive guide for employing unstructured clinical interviews effectively for diagnosing clients using DSM-IV-TR criteria by emphasizing clinical interviewing skills, recognizing diagnostic clues, and creating pertinent diagnostic questions. This article offers invaluable insight into their ongoing professional development and the importance of clinical interviewing in masters level counselor training, serving as the foundation for future assessments (combined with other assessment methods) and as a method for building therapeutic relationships. Part I of the clinical interview includes the client's medical history including medications, hospitalizations, etc. There is a section that includes who is at risk for medical problems associated with psychological difficulties and what medical problems are associated with psychiatric symptoms. Another part of this section involves clues that a medical problem could be related to the client’s symptoms such as family history of heritable medical problems and psychiatric symptoms onset after age 40. In part J of the article, substance use is discussed. The article states that it is important to rule out any substances as an underlying cause of client difficulties. It is stated that frequent questions are good to start out with relating to caffeine and nicotine then moving to alcohol and drug use. There is a note that points out the importance of understanding what is considered appropriate

drinking limits and what is defined as a standard drink. Indicators of substance use problems can be seen by asking about social aspects of life such as family, friends, and work. Section K of the article involves legal history such as warrants, arrests, convictions, etc. The article mentions that legal problems may be related to aggressive behavior and other disorders. Involvement in court systems may also serve as significant stressors for the client. Section L of the unstructured clinical interview format asks about previous counseling. This can give clues to current diagnoses since disorders can recur. If the client has previous psychiatric hospitalizations, it can indicate symptoms like suicidal behavior or even psychosis. Section M is the Mental Status Examination (MSE) which screens areas of emotional and cognitive functioning. There are some domains covered by the MSE including appearance and behavior, thought process and content, mood and affect, and cognitive functioning. It is noted that the MSE is not a primary diagnostic process and is not always appropriate or may be unnecessary.

References Jones, K. D. (2010). The Unstructured Clinical Interview. Journal of Counseling & Development , 88 (2), 220-226. https://doi.org/10.1002/j.1556-6678.2010.tb00013.x

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