NCMHCE Exam Review Assessment Part 1 | Counseling Continuing Education

Welcome to the NCMHCE Exam Review Podcast. I'm your host, Dr. Donnelly Snipes. This podcast is brought to you by Counselor toolbox podcast and allce.com counselor continuing education, where you can get unlimited on demand CEUs for $59 or unlimited live webinars for $40. Go to allce.com hey there everybody, and welcome to NCMHCE review part three. Today we're talking about assessment and this podcast is brought to you by allce.com counselor continuing education and Counselor Toolbox Podcast. In the assessment, you're going to gather a lot of information. But if you've done assessments, you know that because you know it takes a while to do a thorough assessment. Now remember, during your assessment you are going to be doing a mental status exam as well. But other things that you're going to use in your assessment are going to help you do a deep dive to gather information to validate a provisional diagnosis. We're going to look at the presenting issue. We're going to consider the mental status exam. We're going to look at emotional, behavioral and physical presentations, personality, coping skills, family of origin, cultural factors, social supports and interpersonal relationships, their environment where they live and work, their developmental stage, their activities of daily living and ability for independence and finally, their motivation for treatment. Let's start out with emotional signs and symptoms. We want to get an idea of the person's degree of emotional control. How are they doing? Sometimes you'll have clients come in, they sit down and you seem like you're talking to the person at the dmv. You know, it's just an average conversation. Sometimes people will come in and they are just completely crisis. So their degree of emotional control is much less their ability to feel and express a range of emotions. If somebody is presenting and they are just enraged all the time, and it seems like the only emotion they can feel or express is rage, or the only emotion they can feel or express is depression. That's different than someone who has good days and bad days and can feel positive as well as anxiety or anger feelings. What is their emotional appropriateness? If they are telling you about a traumatic situation and they're laughing about it, we want to look at that incongruence, emotional anger. Emotional issues, which may be a focus of clinical attention but not necessarily rise to the level of a clinical diagnosis are anger, anxiety, depression, grief, and guilt. Now, they did change the depression diagnoses in the DSM 5 with regard to bereavement. So it's important to take a look at that and know when you can give a diagnosis of clinical depression in a person who is bereaved. And I'll give you a hint, you can have bereavement concurrent with clinical depression. Now, psychiatric signs, looking for diagnostic criteria for disorders is the other thing that we're going to do. We're going to start really looking to validate. Remember, we're not doing a kitchen sink assessment and rule ruling out. What we're doing is ruling in if we think the person has anxiety or if they present and they say I've got anxiety, then we're going to want to rule in the anxiety and find criteria for provisional diagnosis. And I will put my own little 2 cents here. This is not how most of us do it in general practice. However, for the test, this is how they want you to do it. So when you're looking for diagnostic criteria for disorders, you're going to look for affective, behavioral, physical, cognitive and social indicators of mood disorders. What, what are their interpersonal relationships like? What are their mood indicators? What is their appetite? What is their sleep? And all of those things we're looking at. We'll look for changes in thinking behavior associated with cognitive impairments and any sign of substance use disorder. We're also going to discuss with the client exacerbating factors and triggers what makes your if they're presenting for anxiety, what makes your anxiety worse? What makes it better? And we'll want to look at mitigating factors and effective interventions. So when we're talking about the things that make your anxiety better, what are they and how can we use those to help you even more Deal with your anxiety on a day to day basis. Medical and Physical Symptoms and Issues we do want to consider the possibility that symptoms are caused by a medical condition such as hypo or hyperthyroid, polycystic ovarian syndrome, fibromyalgia, a variety of autoimmune disorders, cardiac problems. There's a variety of physiological causes. And if you go to counselortoolbox podcast, we do have several episodes on differential diagnosis as well as the mind body connection that can help you understand some of the physical symptoms that may cause physical issues that may cause depressive symptoms or anxiety symptoms. Evaluate current medications and consider medication side effects. Some medications will really hype somebody up your stimulant type medications. Some medications will really blunt people's affect and make them feel lethargic and depressed. Some medications will affect people's short and long term memory. What medications, including supplements and over the counter medications are they on? Identify if the client is intoxicated or in withdrawal from a substance. This can affect their presentation quite a bit. And look at vegetative symptoms such as persistent problems with appetite, weight control, sleep, energy and sexual desire and function. All of these will give us information. And most of our diagnoses do have some physical symptoms that are identified, or vegetative symptoms, as they call them, that are identified as part of the diagnostic criteria. When we think about somatoform disorders, remember we're talking about physical symptoms with no detectable physiological cause. This can include pain disorder and body dysmorphic disorder. They're not making something up. They actually have physical symptoms, but the medical community is not able to pinpoint a cause. We do want to pay attention to this. For the longest time, fibromyalgia was considered to be a non existent disorder because there are no physical tests that can actually definitively pinpoint, yes, this is fibromyalgia. There are clinical tests that doctors can do to say, yeah, it's pretty likely, but there is no blood test or anything that they can do yet that particularly identifies that. So your somatoform disorders are disorders in which the person has physical symptoms but no detectable physiological cause. And I hate it when I hear people say, oh, well, this person has whatever their pain condition is all in their head. Well, it's not all in their head. They're feeling actual pain, but we just don't know exactly what's causing it. When tests and physical exams do not support the patient's symptoms, consider malingering or fictitious disorders as well. When we're evaluating personality traits, we're looking at patterns of behavior, thinking and perception that are pervasive. They're pervasive over time as when they were adolescents and adults, for example. They're also pervasive in different environments, not just at work or just at home or just in romantic relationships. If they tend to be aggressive and narcissistic, it's with most people most of the time. There are personality styles that we often pay attention to and we have cute little names for like addictive personality type A or codependent. Those are not actually personality disorders. Those are clusters of characteristics that we have in the layperson land kind of put together and identified them as a personality style. Now, a personality disorder are those issues that are actually present in the DSM 5, such as antisocial personality disorder, histrionic, narcissistic, borderline, your cluster A, B and C personality disorders. Do be aware of the symptoms of each of those and how to Differentially diagnose them. When we talk about ego functioning, this is sort of a Freudian or psychoanalytic term, if you will. But ego functioning refers to people's ability to self regulate, control impulses and tolerate frustration. How well can your clients manage their emotions? How well can they tolerate distress? Ego functioning also involves the use of defense mechanism. Defense mechanisms in and of themselves can be healthy. Suppression, sublimation, you know, all of those things that you read about can be healthy in the right circumstance. Healthy use of defense mechanisms limits unpleasant or dysphoric emotions without significantly disrupting a person's life. If they are using them constantly, they never actually deal with the problem. They just ignore it, avoid it, compartmentalize it, and use defense mechanisms to try to push it away. But they never deal with it. Eventually that's probably going to become problematic. Coping skills refer to people's ability to deal with life on life's terms. How do they do it? What are their coping resources when they need to deal with life, when they need to solve problems, and where are their deficits? Some people may have really great coping skills, but they can't ever seem to actually implement them because they get so emotionally dysregulated, or they may have deficits in coping abilities when it comes to dealing with certain situations. We want to identify current coping strategies that they're using that are and are not effective. We don't want to call them bad because the coping strategies strategies they're using are helping them survive until now. But some may not be effective or healthy. For example, drinking. It's a way that some people cope with stress. Is it the healthiest alternative? No. However, I don't want to tell somebody what you're doing is bad. It's helped them survive and I'm glad they've survived. But I want to look at that and go, okay, what else could we do to help you deal with the stress of work besides having to go to the bar every night? We want to look at ways the client has responded to similar problems in the past, both adaptive ways and maladaptive ways. If you've had a death in the family in the past, how have you managed to deal with that in healthy ways and what other ways? You know, for example, sleeping and staying in bed for two weeks, Is that a way that you responded to grieving and death? Possibly. Was it the most healthy and helpful way? Maybe not. So we want to look at that. We want to ask about specific individual characteristics that impact coping ability, such as developmental level, a person with a low Developmental level may cope at the level of an 8 or a 9 or a 10 year old instead of their chronological age of 20. We want to look at their cognitive functioning. Someone who has impaired cognition, dementia, Alzheimer's, may cope, may have different strategies and different abilities to cope developmentally based on where they are because of their cognitive impairment. And we also want to evaluate their locus of control and sense of self efficacy. If somebody feels helpless and hopeless and they have an external locus of control, meaning they don't feel like anything they do will change the outcome, life just happens to them, then their coping skills are going to be very different than someone who believes that they have the ability to change what's going on and some amount of effort will actually improve the situation. We want to examine their family of origin for mental health issues as well as for stressors. We want to look at the cultural background for cultural ways of interpreting, you know, what is causing this symptom. Why is it that you think that you have depression and what do you think is the best approach to, to handling it? Different cultures have different ways of approaching mental health recovery. We want to evaluate their socioeconomic background to identify stressors as well as to identify access to resources that they may or may not already be accessing in terms of interpersonal relationships and social supports. Who are your friends? What are your interpersonal relationships like? Who do you hang out with? Who can you call at 2 in the morning if you are having a really bad night? And how effective are these relationships? Do you feel supported? Do you feel loved? Do you feel like it's a 5050 balance most of the time? Or do you feel like you're the one that's always giving? If the person reports that they're isolated, evaluate for voluntary withdrawal. Maybe they just got tired of those people and they voluntarily withdrew. This could be because of something going on with them like depression, or it could be because their social support network was that dysfunctional that they decided for their own mental health to withdraw. Some. They may have poor social skills, they may have social anxiety, they may be experiencing substance misuse or compulsive behaviors that they're trying to hide from other people. They may feel ashamed of them or may be afraid that if other people find out about their behaviors that they'd have to stop. They may be isolated because of low self esteem, they don't feel like anybody would want to be their friend or because of post traumatic stress disorder. The anxiety of being around people is just too overwhelming. The hyper vigilance is too much. They just want to withdraw and be isolated where they can feel safe. And we want to evaluate people's capacity for healthy interpersonal relationships. Can they effectively set boundaries, emotional and physical boundaries, to have a healthy relationship, that's give and take, where they're not constantly seeking approval and needing validation, and not constantly giving and giving in order to achieve or receive that validation. Then we move on to looking at social roles and role functioning. Every role we have has a set of expectations. So I am a child, I am a parent, I am a spouse, I am a business owner, I am a friend. Each one of those roles has different expectations that goes along with it. We want to talk with people about whether there's role ambiguity. They're not exactly sure what expectations go along with it, or if there's role conflict. If there is a conflict between, for example, my role as a parent, I want to go to my kid's ball game at 6 o' clock tonight, and my role as an employee, I. I didn't get my work done, so I really need to work overtime. You know, those two things can conflict. Especially if somebody is having to work two jobs, for example, and they feel guilty because they're not able to do things with their kids that they want to evaluate if there's been a loss of an important role, such as empty nest syndrome or divorce. Those things can really impact people's mood and mental health functioning. Is the client overwhelmed or ambivalent about the responsibilities associated with the role? Parenting can be overwhelming. I don't care who you are, and I don't care if it's your first or your sixth child. It can be overwhelming being an employee. I remember one place I worked and you know, I really loved the place that I worked. But every job I took or promotion I got, I would get into the position and I'd go, okay, where's the manual? And there they'd be like, well, there is none. Okay, what exactly am I supposed to do? You'll figure it out. And that drove me absolutely bonkers because there was too much ambiguity. Sometimes there's ambivalence. You know, you may be a parent, but it was an unplanned pregnancy and you didn't ever intend on being a parent. So. So you're not really committed to that. You're ambivalent about whether you want to be a parent or not. Same thing with marriages and being a spouse. Sometimes people become ambivalent about whether they want to stay married. So we do want to evaluate people's feelings toward their role. We want to look at Clients normal dependency affiliation needs and whether they're being met in an appropriate way. This goes back to boundaries and are they able to have healthy boundaries or are they needing somebody to validate them constantly? Do they have a certain amount of dependency or codependency? And obviously we want to assess to make sure the client is not being victimized, manipulated or victimizing or manipulating someone else. When we look at the environment, we're going to look at the living and working environment. Are they safe? Are they secure? What are their stressors that are going on? We want to make sure that we're helping them meet their Maslovian needs. So remember Maslow's pyramid. Do they have shelter, food, economic resources? Can they pay their light bill, education and job opportunities? Do they have access to legal resources if they need them? Both criminal and civilization? Do they have transportation? Do they have access to and do they participate in any religious or community groups in order to get assistance, affiliation or support? What are their sources of social support and affiliation? For example, if you live in a really rural area, there may be half a mile between you and your neighbor. So it's not like if you need something, you just walk next door. In an urban environment you might be able to knock on the wall and have your neighbor come over. So how accessible are their sources of social support and affiliation? If somebody doesn't have transportation and they live in a really rural area, they may have difficulty accessing a lot of the community groups and sources of assistance and support that, that other people don't have difficulty accessing. And what's the developmental stage? Do they have any current developmental tasks or issues going on? We want to look at their activities of daily living and ability to live independently. Are they able to perform self care skills? Are they able to cook for themselves? Are they able to bathe? And this is true for younger people. This is true for people who are in a psychotic episode, in a major depressive episode, or who might be experiencing levels of dementia or like I said, significant depression. Health care. Are they able to get adequate exercise, sleep and remember when to take their medications? Environmentally, are they able to keep a sanitary situation? Not everybody's definition of clean is the same. But are they able to keep a healthy environment where you don't have, you know, dog poop on the floor and rats crawling across the room? You know, that's what we're looking at here. Financial skills. Are they able to manage their money? Are they able to get their bills paid within reason? I mean, not everybody makes enough money to pay all their bills every month. We want to make sure we link them with resources. But what we're looking for is does somebody even have an inkling about how a checking account works and how to pay their bills? Do they have access to child care if needed, or assistance with parenting training if needed? And do they have transportation? In our society, most of the time we need access to transportation to get to the grocery store, to get to work, to get to child care, etc. To get to the doctor. Does this person know how to access transportation? Your first response may be, well, everybody can call an Uber. Well, yeah, everybody can call an Uber, but not everybody can afford an Uber. What is it that the person is able to access that can get them from point A to point B? And what is the client's motivation level we want to talk with the client about? What are your goals and expectations? You came in today, you told me that you're depressed. What do you think is causing your depression? What will it look like when you're not depressed anymore? And what do you think might help you move in that direction? Because most people have an idea about what might be helpful. Help them set smart goals. Remember, smart goals are specific, measurable, achievable, relevant, and time limited. And how does this client view his or her role in therapy? Some clients come in, they sit down and they say, fix me, and I have to break it to them that that's not how therapy works. Some clients will go to their doctor and they just want a pill to make their depression magically go away. So we want to know how the client views his or her role. Is it active? Do they expect to have to do something, or do they expect us to basically perform a procedure on them? When you're doing the assessment, obviously the majority of your time is probably going to be spent interviewing the client and getting information from them. The client's self report provides current salient factors, but it may not include underlying issues and it may not be complete if the client is not comfortable or if there's things he or she just doesn't want to share. We want to get observations of verbal and nonverbal behavior. So you're going to get remember in your SOAP notes, you're going to get your objective observations and your client reports. And you're also going to have subjective observations like from the mental status exam in order to help complete your picture, your observations of what was going on. You're also going to have to take into consideration observations of interactions with the therapist and with other people. How did the person interact with the front desk staff? How did they interact in the waiting room? How are they interacting with you? Do those observations match client reports? If the client says, oh, I get along with everybody and you watch the client and they seem to bully everybody, that gives you a little bit of information. And has there been a physical workup to rule out any medical causes of symptoms? We do want to get information from collateral sources, specifically a medical workup, because a lot of times there are potential underlying medical issues that are contributing to the presenting symptoms. So collateral sources that you want to consider getting information from. Remember, you've got to get a release of information, get a medical referral or report from the primary physician and any other treating physicians. So if they have a primary care provider, an endocrinologist and a pain management physician, ideally you get releases of information for all three of them. You want to find out about their prior treatment history. Again, not necessarily just from the client, but you want to be able to get a release to see what the therapist said, said information from relatives, you know, who they're living with, whatever, caretakers, caseworkers and employers. Now I can honestly say I have never gotten a release of information nor tried to interview an employer because I felt that would be too invasive for the person. They just didn't really want or need their employer knowing that they were seeking out mental health counseling. But that is one of those that is always listed as a potential collateral source of information. So a comprehensive assessment should provide the factual evidence supporting your diagnosis. When you're going through all those things you're going to have in the back of your head. I'm looking to see if this client meets the criteria for X diagnosis. Whatever diagnosis that I think they've got, this is what you, this is the way you do it. For the ncmhce, the symptoms identified in the assessment will form the basis for the treatment plan. Well, that's true all the time. Assessments should always involve collaboration with other professionals. When permitted to rule out biological or other social environmental causes, such as domestic violence, trauma, or if you find out that the person was recently in detox for substance abuse, it's good to get some information from any other providers. Why is this? Because no one person's account will be truly unbiased. Everybody sees the world through their own lens. So getting comprehensive information, getting collateral sources, gives you a more thorough picture in order to try to identify what might actually be going on. Now on to test taking tips. In the initial question, you're trying to uncover more clues to help you verify your hypothesis. About the client's diagnosis. So remember I told you your vignettes are generally very short, and if you've done any of the example questions, you know your initial vignette doesn't give you a whole lot to go on initially. You read that, you go, okay, this client may have X diagnosis. Let me start looking to see if that's true. Don't get distracted by questions which would reveal interesting information but not relevant to the case. For example, if you suspect the client has ptsd, gathering information about substance use is not going to provide you any additional information about PTSD diagnosis. It might be interesting, but it will not rule in or rule out ptsd. The scenario is focused on the primary diagnosis. You're looking for information that supports a PTSD diagnosis. All right, thank you for being with me, and I will see you in the next installment, which will be NCMHCE Exam Review Part 4. Thank you for joining me today. 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