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11 Cards in this Set

  • Front
  • Back
Clinical Assessment
Process Clinicians use to gather information about clients. Crucial for: Diagnosis, Formulation, Treatment Planning, Predictions
Typical Assessment Process
- Clinical Intake Interview
- Mental Status Examination
Two Aims of Clinical Interview
- Gather Information
- Establish Therapeutic Relationship
Clinical Interview
- Biographical Information (e.g. Name, Occupation)
- Referral Information (e.g. Self-Referred)
- Presenting Problems (symptoms and typography [e.g. frequency])
- History of Presenting Problem (Onset etc.)
- Medical History & Drug Use
- Family History
- Personal & Social History
- Strengths, Resources & Needs (e.g. Support Systems)
Mental State Examination (MSE)
Therapists observations and impressions of client's mental functioning at time of interview
Categories of Mental State Examination (MSE)
- Appearance (e.g. Grooming)
- Behaviour (e.g. Posture and Body Movements)
- Mood and Affect
- Speech (e.g. Fluency and Rate)
- Perceptual Disturbance (e.g. Hallucinations)
- Thought Process and Content (e.g. Tangentiality and Delusions)
- Cognition (e.g. Alertness)
- Insight and Judgement and Reliability
Mood
Predominant mood subjectively experienced and reported by client
Affect
Expression of emotion as observed by others
Holistic Assessment
Movement away from but includes symptomatology. Encompasses: Biological, Psychological, Social, Cultural, Spiritual.
Recent Stressors, Formulation and Readiness to Change.
Formulation
Explains processes that caused and maintained the problems
7P Formulation
Presentation
Pattern
Predisposition (factors that make them vulnerable to later psychiatric disorder)
Precipitation (trigger for initial onset/exacerbation of symptoms)
Perpetuation (maintain)
Potentials
Prognosis