NCMHCE Exam Review Mental Health Assessment Part 3

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 or unlimited live webinars for $40. Go to allce.com hey there everybody, and welcome to the NCMHCE Review Podcast. This is episode five and today we're going to continue talking about assessment. Yes, I know this is part three of the assessment series, but assessment is one of the main features of the ncmhce. Remember, you're wanting to read the vignette and be able to get an IDE about what the presenting issues may be and then gather information to kind of support your theory for the ncmhce. So the next thing that you're going to look at during assessment, remember we already had two segments on this, so we're kind of picking up in the middle of the assessment. The next thing you're going to look at is the developmental stage of the client and consider some possible unresolved crises. And this takes takes us back to Erikson, which and his developmental stages. It's important to know these and it's important to understand that problems can arise if the person does not successfully resolve these crises when they go through them. So let's talk about them real quick. Trust versus Mistrust. This is your infancy stage. This is when the child develops that secure attachment to a primary caregiver, learned that the world is not such a scary place that it can be somewhat predictable. The child has the ability to get his or her needs met. That all happens because of a responsive caregiver that's there that understands, you know, when the child's crying, is able to interpret the cries to identify whether the child needs food or they're cold or they're hot or whatever. Trust versus mistrust is also a time when the child starts determining or learning. Remember, this goes for about two years. The child starts learning how to identify, articulate what their needs are. You know, it goes past infancy and at this place, as the child gets older, you know, 18 months, etc. They're going to start asking for drinks, they're going to start asking for food, they're going to start identifying when they're sleepy. And this is an important stage for the caregiver to interact with the child to help them identify what they need. Too often we have clients come in and they don't know how to identify their own Needs. They weren't ever taught any of these skills. The second stage is autonomy versus shame and doubt. And this is during the potty training stage, if you will. And children are learning during this stage. This is two to three year olds, they're starting to potty train and they're generally starting to dress themselves and start making choices about what they want to eat. And you know, mom and dad or caregivers may say, what would you like for lunch today? And the child is starting to be able to articulate his or her preferences. And the child is starting to learn that they can control their own body. They're learning how, you know, obviously with potty training, that's one of them. But they're also learning to make this body work. The next stage, initiative versus guilt, is the child's ability to make and carry out plans. And this is three to five years old. This is sort of preschool, kindergarten age for some, but generally preschool age. And you see that the child starts determining what they want to do, what game they want to play. If you have been in a Montessori type preschool, you'll see that children are encouraged to take initiative and figure out things and ask. And when I was in Montessori, I remember we used to have a garden. So the teachers would ask us, what would you like to grow? And then we would talk about how to do that. And we would grow a little garden and harvest vegetables in order to eat for snack time. So initiative starts three to five years old. Some issues that may happen during the initiative stage, if people are, if their initiative is squelched, they are punished for, for trying to set plans, they are overly controlled, or likewise, they're not given any support in learning how to set goals. Then they may start having difficulty with motivation to take initiative. They may become extremely passive. Likewise, if they have to fight in order to get what they feel they need or they want, they may become extremely overbearing. So we want to look at initiative. Other things that we want to look at during this period, Bedwetting should have stopped by the end of this phase, which is five years old. If it hasn't, the DSM 5 says you can start diagnosing enuresis at the age of 5 or older. We do want to look at. Was there a period where the child didn't wet the bed, then suddenly they started wetting again. That could be due to emotional problems of some sort, could be, you know, abuse. It could be a lot of things. So we want to take a look at why did bedwetting start up again. If it had stopped for a while, if it had never stopped, then obviously encouraging the person to consult with the pediatrician and maybe look for what the cause of that might be. Another issue that happens during this time, stuttering and cluttering. We're all familiar with stuttering, where somebody feels like they get stuck on a particular syllable. Cluttering is when people's brains basically go faster than their mouth can go and they're trying to think of the words as and express themselves and they get kind of caught. So they fill the gaps. While they're trying to articulate their words and figure out what they're going to say next, they fill the gaps with repeating a word. So stuttering and cluttering are very different, but they're very important things to pay attention to. Between the ages of three and five, it's not unusual at all for people, children to have some sort of speech problems because their development is just going gangbusters at this point in time. But it should start to abate by about five years. If it hasn't, then a referral to an occupational therapist maybe, or a speech pathologist may be in order to. Sudden onset of stuttering or cluttering issues may also indicate an emotional issue in children who have high levels of social anxiety. For example, they may begin stuttering or cluttering when they advance to a new class or if something's going on at school, initiative versus guilt. Again, three to five years, five years old, and the child is figuring out that they can make and carry out plans. Industry is your next step. And this is basically early school age. And this is when the child identifies what they're good at. They figure out that, hey, I'm good in shop class, or hey, I'm good in gym class or whatever it is, and they start identifying their strengths. And this is where we as parents can really support them and going after the things that they're good at and helping them accept the fact that they're not going to be good at everything. The next phase is identity formation. And this is sort of, you want to think about it as sort of high school and early college. And this is when people are starting to individuate, decide what they stand for. They've been raised in an environment and that environment has taught them goals, values, ideals, all kinds of things. They went to school in an environment that may have shared the same values and ideals or not. They may have, you know, learned about other things. And they're taking all this information and they're saying, okay, now out of all this stuff, all these experiences that I've had and everything that I've learned, who am I and what do I stand for? The next stage, which comes in, you know, early adulthood is intimacy versus isolation. This is when the person starts creating new secure attachments. And we are really familiar with secure attachment from the trust mistrust phase and early childhood. But they found adult attachment as people leave the nest, so to speak, as they individuate, they figure out who they are and then they need to find a group of friends or romantic attachments or whatever where they find that they can also get their needs met. Whereas in early attachment relationships, one primary caregiver was generally the person responsible for helping the child get those needs met. In adulthood they find that people tend to have multiple secure attachments. And each secure attachment may serve a slightly different function, function, but it helps the person. And the person tends to be part of those people's secure attachments. And it's more bi directional in adult attachment. Whereas in childhood, a lot of times the secure attachment is sort of one way the child has needs, the caregiver meets those needs and bada bing, the child is not supposed to be responsible for meeting the caregiver's needs anyhow. So if people do not create these new secure attachments, then they are going to have difficulty potentially coping with life on life's terms because they don't have that social support. And when you start talking to them about their perception of social support, you'll get an idea about whether they understand or feel like they've got good support system going. If they don't, that can contribute to all kinds of stress, depression, anxiety related issues. The next step is generativity. And this is, you know, sort of middle age, if you want to think about it that way. And this is when people are committed to the well being of future generations via what they do at work and their activities. People start volunteering and they see that, you know, they are empowered to make a difference in the world and they want to leave it a better place for younger generations. If people don't feel like they are able to leave the universe a better place for future generations, then they can start having some developmental crises here. They're kind of going, well, what did I do all this work for? Why am I here? What's my function? What's my purpose if I can't improve life? And in the integrity stage comes in old age, if you will. And this is when people start accepting their mortality and they have wisdom to give to younger generations. But they've already made their mark and now is the time for them to reflect on what they've done and feel a sense of contentment and acceptance that you know, they've kind of, they've done their part. The way people resolve their developmental crises, whether they do or not, can also contribute a lot to self esteem. If going back here, If they don't feel like they can get their needs met, then they're going to tend to have low self efficacy. They may not feel like they're worthy of getting their needs met. If they were punished for having autonomy, they may feel like they are not smart enough or capable to make their own decisions. So they don't try to do things on their own. And they can present with more of a codependent type personality. If they don't discover their initiative, if they don't discover their abilities, then they may have low self esteem because they don't know what they're good at and they don't know what they can succeed at. So they tend to feel a sense of learned helplessness and for initiative, they don't feel like they can carry out plans, they don't feel motivated to try anything if they don't individuate, if they don't know who they are, if they don't develop an identity. It's hard to feel good about who you are if you don't know who you are. When they move up to intimacy, then that creation of new secure attachments, if that doesn't happen, then people may feel unlovable and feel unworthy again. And in generativity, if people aren't able to feel like they've made an impact, feel like they've done what they were supposed to do, then again it may impact their self esteem because they may feel ineffective in their life. So when we're looking at self esteem, we want to look at people's efficacy. How much control do they feel they have? What do they feel they have control over? How much confidence do they do they have that they can set goals, achieve them, make friends, be a good friend, get support when they need it, all that kind of stuff? How much confidence do they have that their environment is supportive of them as human beings? Likewise, you want to look for some clues that there may be problems. For example, if somebody has a high level of vindictiveness, this may be indicating a low self esteem and a desire to gain power by using aggression. If somebody is overly argumentative, then that may also indicate either an exaggerated sense of self confidence or a Lack of self confidence. So they're always wanting to prove other people wrong to kind of bring them down to their same level, if you will. If they're willing to accept responsibility for their own actions, that indicates a good level of self esteem. They're willing to say, I made a mistake, you know, I'm a good person, but sometimes I screw up, I'm sorry, how can we fix it? Or if they blame other people, then they may have a low sense of efficacy. If they're saying, you did this, that's a very external locus of control. Another issue that we're looking at with self esteem, if we see high levels of social anxiety, people may not feel efficacious at making relationships and garnering social support. We also want to talk in terms of self esteem, you know, not only who they are and what their capabilities are, but what is their perception of themselves, including their body image. Do they think they're a good person? Do they think they're attractive? Do they think they're lovable? You know, let's get an idea about who they think they are and why they think they're, you know, all that in a bag of chips or not. We want to look at social functioning and there's a lot we want to look at with social functioning because a lot of stuff on the NCMHCE involves evaluating the person in context. And it's really important to evaluate not only themselves. And if you want to go and look at Uri Brofenbrenner's ecological theory, that will give you a bigger understanding of really the things that you need to consider in treatment planning, which obviously means you need to address it in the assessment. So for social functioning, information about social functioning can help people determine what the client's behaviors are like outside of the session. Clients are going to be one person when they're in your office, and then they may behave completely differently when they're other places. They may be chameleon, like where they behave one way at home and one way at work and one way at their parents house. Or they may be oppositional, for example, or argumentative in all of their other relationships. They also may be argumentative in the office. So if they are argumentative in the office, then we want to look and see if that carries out into the, into their general relationships that may give us a clue about some of the problems that we're having. And social functioning information can also help us identify the source of current problems. If they tell us that their relationship with their significant other or others is not going well, then that could be a source of their current mood issues. That being said, you know, let's look first at family history. Let's get a background on what's going on. Let's talk about with them about their childhood family. Who was there? Who did you live with? Did you live with biological mom and dad? Did you live with, you know, biological mom and mom? You know, who was it that you lived with? Did you have siblings? Yada, yada? How did everybody in your family get along? Was it, you know, a great family relationship? Sort of like, what's the show I'm watching right now? Well, the name escapes me, but think about the Waltons. You know, that's a little bit over the top on the warm and fuzzy side. But you also have relationships that are more like the Simpsons, which tends to be more argumentative and dysfunctional. What were these relationships like? How frequently did they move? We know that low community engagement and frequent moves is a risk factor for mental health issues. And was there a history of abuse or neglect either to them or that they observed domestic violence, mental health issues, or addictions in the family? And if you go back and look at the adverse Childhood experiences survey, these are the things that fall under that ACES score that we want to take a look at because they do contribute to a whole host of development of later problems with mood and physical health and all that kind of stuff. So you can go to the website is acestoohigh aces T o o h I g h. You can go to ACES Too high and learn more about the Adverse Childhood experiences survey and the 10 things that they evaluated. I don't know that the NCMHCE is going to catch up and actually integrate ACEs onto the exam, but it is definitely worth noting and it does play into things that are good to ask about anyway. We also want to ask about childhood friends. What were their childhood relationships like? Were they loners? Were they social butterflies? Were they some somewhere in between? What was that like? Because that helped them create a map, so to speak, of what future relationships would be like. We want to ask about school performance. We know that low school performance is associated with a decrease self esteem and mood. So as people's school performance goes down, their likelihood of depression goes up. And we want to ask again about a history of childhood trauma. Not only the ACEs study, but also, you know, was there a history of trauma of some sort? Were they exposed to trauma? And let the person define that. If that was a hurricane or flooding or, or, you know, home invasion, robbery or whatever it is, it doesn't necessarily have to be a crime against them. There are lots of things that are traumatic, especially to young children. So ask them if there was trauma in their. In their childhood. We want to look at their current living situation. So we've assessed the past, gotten an idea of who this person is and how they grew up. You know, we're thinking kind of psychodynamic here. Now let's look at their current living situation. Where do they live? Do they live in an apartment, in a house, with mom and dad, with roommates, yada yada? Do they feel safe where they live? Do they feel like they're going to be able to stay there? Or are they always in limbo about whether they're going to be able to have a roof over their head? Do they have any transportation issues? If they do, based on their current living situation, maybe they live out in rural wherever and transportation is an issue for them. They may feel very safe where they are. But if they can't access groceries and medical appointments and those sorts of things, that could be a contributing issue that we need to look at. Again, who do they live with? If they live with roommates, that's fine. Just kind of get an idea of who's in the household. Because people tend to spend a lot of time in their house, at home, and they sleep at home. And if they feel safe and loved and nurtured in that place, great. If that is not a safe place, then it's going to contribute to a lot of dysfunction. So then we want to go on and ask about the quality of the relationship with the cohabitants. And I use that term really broadly, so I don't have to say, you know, with their spouse or their children or whoever's living in the house with you. And that can include maybe you live there with your significant other and their two children and your best friend from college or something, whatever. And all y' all live in the same house. What is the quality of the relationship between all of the cohabitants? Is there a lot of friction, or does everybody support one another? What is the client's financial status? We know that low socioeconomic status and financial problems contributes to a lot of mood issues as well as it can contribute to health issues. If people can't access, they can't afford their medication or access a doctor, so can the client pay their bills? And that means their electricity, their water, their housing bills, their medical bills, insurance, yada yada. What are their sources of income? Let's just have an idea about sources of Income and from sort of a social work perspective, this may be somewhere if they, that we can assess whether they would qualify for some sort of government related services. Is the client currently employed? If so, how long have they been at that job? Do they like their job? Is it a good place to work? They're there the lion's share of their waking hours during the work week. So if this is a dysfunctional place for them to be, then it's likely contributing to some of their current issues. We do want to take a look at that. We also want to look at their work history. Have they been at the same job for 20 years or do they seem to switch jobs every six months? If they switch jobs every six months, why is that? Do they not play nice in the sandbox with others? Do they get bored? Do they get fired? What's, what's going on? And then we move on to asking them about their social network. And this isn't just the people that live in their house or just the people they work with we want to look at. When you have a problem, who is it that you can call on? Do you have social support? Who's there for you? Who do you celebrate holidays with? What is the quality of those relationships in your perception? What is your relationship with your family? Those family that don't live with you? Some people are completely estranged from their family. Some people call their, you know, biological family two, three times a week. What is your relationship with your adult children, if there are any. Again, this gives you an idea, number one, about a sense of support and connectedness, but also about issues that may be currently contributing to their distress if they're estranged from family or estranged from their adult children. What are your hobbies and leisure activities? What people need time to rest and relax. So what do you do to rest and relax? And then we move on to sexual and romantic relationships. We ask about what's the client's sexual orientation and how has the client integrated his, her or their sexual orientation into their lifestyle? We will work with clients and you may see vignettes with clients who have just started to embrace their sexual orientation and others who have fully come out and people anywhere in between. When you get to sexual and romantic partnerships, and again on the ncmhce, they may not get to evolve to this point where they're open to multiple relationship styles as opposed to being binary in their approach to what's going on and emphasizing monogamy or, you know, those types of relationships. So I'm going to be a little bit off the beaten path here, but you do want to ask, is the client in a long term relationship? And leave it kind of open instead of saying are you married? Which again, on the ncmhce, that may be your only choice. But okay, but not everybody embraces monogamous marriage as their relationship style choice. So are you in a long term relationship, a committed long term relationship or partnership? And who's in that partnership? It may be one other person. If they're polyamorous, it may be up to seven or eight or who knows how many people. There's no limit on polyamory. Have there been previous long term relationships, marriages or partnerships? Ask people what they prefer to refer to their romantic relationships as. Why did those relationships end? You grew apart, there was infidelity, what was going on? And yes, there can be infidelity in consensual non monogamy and polyamory. It's a whole different class. But it is important to be sensitive to the fact that there are an increasing number of people who are rejecting the notion of a traditional monogamous partnership, regardless of the structure of their partnership. How do partners support each other? Have the partnerships contributed to the current problems? Just because somebody is in a non traditional relationship doesn't mean that that has caused their problems. You know, that could be the only thing supporting them right now. But we do want to ask the question, has this contributed in any way? And if not, okie dokie. How have the current difficulties impacted the partnership? And if the partners, for example, if the person is clinically depressed, how has that depression impacted your relationships with your significant others? How is the client's current sex life and sexual functioning? Have there been relationships outside of the partnership and in consensual non monogamy? Again, that's probably not going to be on the ncmhce, but one of my soapboxes that I think it's important for us to be sensitive to consensual non monogamy. There may be short term relationships outside of a committed partnership or there may not be. But that's something that you want to ask about in polyamory. You know, people will meet others outside of the partnership and may or may not bring them into the partnership, if you will. You know, kind of like dating. And it's important to recognize that when you ask about if there have been relationships outside the partnership, you know, again, ask about whether these relationships were part of consensual non monogamy or whether these were infidelity in a polyamorous relationship or in other relationship structures. Partners communicate Openly about the fact that they are seeing other people. And it's not seen as infidelity, it's seen as consensual, non monogamy. But if they are, even if they're in a polyamorous relationship, if they start sneaking around, then basically, for lack of a better term, then that can be seen as infidelity, even in a non monogamous situation. So once you get through all the sexuality and intimate relationship questions, you move on to children and stepchildren. Does the client have children or stepchildren? What are their ages and genders? You know, get an idea about, you know, what's going on. Do the children live with the client or do they live somewhere else? You know, they may not have permanent custody or whatever. What is their relationship with the children or stepchildren, how do they get along? And if there, it's a blended family where there's biological children from both or multiple adults in the household, how do the children get along? Does the client agree with their partners about the care of children or is parenting a constant struggle in the house? And if there are stepchildren or children from a previous relationship, how does the client get along with the other caregiver? So if you're a step parent, how do you get along with the other parent when there's a drop off? For example, if you are a step parent, how do you get along with the stepchildren? And how does everybody get along in the family? We want to recognize that that custodial parent who doesn't live or isn't part of this partnership and does impact the family situation. Social role problems negatively impact clients abilities to fulfill expectations of their social roles. There's a lot of reasons for this. One is role ambiguity. I don't exactly know what I'm supposed to do in this role when, especially for example, for young parents, you know, teenage parents, they may not know what it means to be a parent. They have no idea what they're supposed to do as an employee. You might start a job and have very little direction about exactly what you're supposed to do in a romantic relationship. You may never have had good models of what that's supposed to be like. So you're not sure how you're supposed to do that. So role ambiguity can be one thing for people who are beginning the process of embracing their sexual identity and their, their sexual orientation. Then the other thing that we need to recognize is they may have a lot of role ambiguity here too because they didn't have good role models of, for example, what it's what a gay male is supposed to be like. For example, there may be role conflict where you have conflict between, you know, everybody has multiple roles and there's a lot of times there's role conflict between your role as an employee or a business owner or whatever it is and your role as a family person. You know, do I stay late and work overtime to get this job done or do I leave or leave on time and go to my kids soccer game? So there may be role conflict. And when people feel overburdened and overwhelmed, they may have difficulty setting those boundaries and homework. Boundaries are very common areas for role conflict. Another role might be between their relationship with their significant other, their sexuality, and their role in terms of their religion and, you know, how can I be a good Catholic but also be, you know, homosexual or bisexual or whatever it is. Role loss is another place where you can have problems. Empty nest is your perfect example of role loss. When you don't have a role, a particular role that you've had before, you don't have it anymore. And this can be as a child, you know, when both parents die, this can be empty nest when a child leaves the home. And it can be, you know, if you used to be so and so's wife and you got divorced, that's a loss of a role. You're no longer someone's wife. Helping people re acclimate after a role loss and figure out how to integrate that loss and grieve it is going to be important. Role incompetence is another role issue that comes up. And people can be incompetent in their roles because of lack of knowledge. And this parallels and kind of overlaps some with role ambiguity. If somebody doesn't know how to be a parent, then they're gonna have difficulty being a good parent. If somebody doesn't know how to be a bus driver, then they're gonna have difficulty being a good bus driver. Isolation is another issue that comes up with role incompetence. If people don't know how to do something, they may withdraw because they're like, I don't know how to do that. I don't know how to make friends, I don't know how to, you know, do whatever. So they withdraw and it could result in some isolation. And if they were isolated, especially as the result of abuse, neglect or social anxiety, then they may never have learned how to be a good friend, how to do these other things because they were so withdrawn for whatever reason that they never developed the skills they needed to know how to fulfill this role. A lack of role resources can keep people from effectively fulfilling their role functioning. Parenting requires a lot of resources, and if you don't have access to those resources, transportation, good schools, you know, books, support people, the ability to buy food for good nutrition, whatever, then you may not be able to effectively fulfill that function power, and this is kind of an overarching term, that power can impact role functioning. Whether somebody misuses or abuses power in order to dominate other people. That can create problems in roles where they get into relationships and they feel like they've got to be a bully. Basically, the other end of the power spectrum is people who have gotten into relationships and they feel victimized or helpless, so they develop a sense of learned helplessness in their relationships, and they don't try. They get into these relationships and they. They do whatever they're told to do because they're afraid to try because they have been beaten down emotionally or cognitively or both. People can have ambivalence about role expectations as well. And we see this a lot, especially during that individuation process where people are trying to figure out, for example, you know, what are the role expectations for being a wife? If that's a role that you want to embrace, what are you? Or a successful woman, what does that mean? And do you embrace all of those expectations that go along with that role? And in today's culture, a lot of women don't embrace all of those cultures. They don't believe that they've got to have babies and keep a house and have a spouse and have a successful career and everything. They don't believe they've got to be superwoman anymore. So people may have ambivalence about role expectations when they're trying to say, well, do what, what does it mean to be successful? Because I don't really like some of those things that society tells me I need to do in order to be a, quote, successful woman. Inability to fulfill role responsibilities is another problem in role functioning. When people are just plum overwhelmed if they've got too many roles, too many hats they're trying to wear, and we've all been there at a time or another. You're trying to be a good employee, you're trying to be a good parent, you're trying to be a good significant other, you're trying to be a good friend, you're trying to be a good this and a good that, and you're just like, oh my gosh, there's not enough hours in the day. I don't even know Where I am, I've gotten lost in trying to be everything else to everybody else. So I may not be able to fulfill all my role expectations at this point. How do I figure out what I do and what I don't do? Enmeshment is the final one we're going to talk about as far as problems in role functioning. People who are in social roles where they're enmeshed and they're blocked from achieving something. For example, think about helicopter parenting where a child is wanting to do something and the parent is squelching their ability to do what they want to do and telling them, you are going to be in a dance competition or you are going to do this. That child may have difficulty in their role functioning and especially with individuation. The other side of that is detachment. And if the person doesn't feel that their social support for them to do what they want, they may have difficulty with their role functioning because they don't feel like they're supported, they don't feel like anybody has their back. So role functioning and social environment are huge factors to consider during the assessment. The next thing we want to look at is their environment. And I want you to think about again, you can look at Broffenbrenner's environment socioecon ecological model, but also just look at Maslow's hierarchy and think about that bottom level or bottom two levels, the biological needs and the safety needs. Do people have access to services or are they able to get their basic economic and medical needs met? Do they have food? Do they have shelter? Do they have health care? Those are kind of biggies and if you don't have those things, then there's going to be a cascade effect in terms of emotional and physical problems. Do they have access to effective education and training to help them meet their goals? Do they have access to legal assistance as needed for civil and criminal issues that might be going on? That can be everything from victim advocacy to defense representation to, you know, whatever. Do they have access to health and social services, case management, community support services? All of those things that you might think, you know, this person needs assistance. Let me call United Way Information and Referral. You know, that falls under health and social services. Are they engaged in the community? I said earlier, and I'm going to say it again because it's really important as a protective factor. The more people are engaged in their community, the less likely they are to have mental health and substance abuse issues. So community engagement is a huge thing. It can be going to meetup groups, it can be clubs that they belong to, it can be their religious organization, whatever it is. But being involved has been shown to be very important to mitigating problems. And again, their social supports. In their environment, do they perceive them as helpful and present or do they perceive them as non existent? You also need to assess people's distress tolerance and coping abilities. So we've talked about their environment, we've talked about their developmental stage, we've talked about their relationships. Now let's talk about within them. How do they deal with distress? Because sometimes life is going to hand them lemons. We can't expect, we can set. We can't expect to set up a utopian environment where they're never going to experience distress. So when they do experience distress, what are their coping skills and strengths? What sort of problem focused coping do they use and what sort of emotion focused or distress tolerance skills do they have? And if you ask people these questions straight out, they're probably going to look at you like you got two heads. So you're going to want to listen for and make a note of their emotion focused and problem focused coping. Ask them what are your current strategies for coping with your presenting issue. You know, how are you coping with your depression? How are you coping with the fact that life at home is really stressful right now, or you hate your job? What works, what helps you deal with it and what doesn't, you know? And I tell clients I want to know what doesn't work because I don't want to ask them to do something that they already know doesn't work. So what is working for them right now? And that gives me an idea about some of their problem focused strategies. How has the client coped with similar problems in the past? Again, gives you insight to coping strategies. If the client was able to cope with this problem or something similar in the past, but they're not able to cope now, what's different? And we want to take a look at that and see what changed in their environment where suddenly they're not able to cope like they used. And we want to be on the lookout or the listen out if you will, for dysfunctional coping skills, including ineffective coping skills that people use like screaming, throwing a temper tantrum, getting aggressive, withdrawing, going to sleep, just deciding they're going to go to bed, smoking, eating anything that is likely to cause them harm in some way, shape or form, and typically does nothing to address the issue is what we're talking about ineffective coping skills. We want to look for rigid coping skills. They only know how to Deal with this particular situation in this particular way and if that doesn't work, they don't know what to do. We see that a lot with parenting. They only know how to deal with their child misbehaving in this one particular way and they're out of options after that. Do they use power based coping such as violence, aggression or non suicidal self injury? And that's something you do want to be on the lookout for. It's often associated with borderline personality disorder, but not always. NSSI is behavior that can often be seen in people whose coping skills seem to be overwhelmed. And they use it as a way to help them cope. And again that falls under that dysfunctional coping area. But they don't want to die. They just can't deal with what's going on right now. And this is the only way they know how to deal with it. And we want to examine addictive behaviors, everything from pornography to gambling to substance use when they get stressed out. And substance use can also extend into things like cigarette use. When you get stressed out, what do you do? Well, I go outside and I smoke. Okay. And looking at that as more of a distress tolerance skill, helping them decompress or re regulate after they've been dysregulated can help you see the function of that behavior. You always want to ask yourself how is this behavior rewarding or beneficial to the person. We also want to look at personality patterns and remember these are not diet. Well, one of them is. But type A addictive and codependent are not personality disorders. They're personality patterns or types if you will. And I wish we didn't use that nomenclature, but we do. We want to think about and ask about what the client was like before the onset of the current problems in addition to what are they like now personality wise? If they're type A, they may be really achievement oriented. They may tend to be impatient, competitive, a workaholic, aggressive and or stressed all the time. These are the people that are wound really tight, so to speak. If they have an addictive personality, they are often a thrill seeker, they are an adrenaline junkie, they may be impulsive and they often have difficulty setting limits on pleasure. They see something that they want and they kind of go after it, you know, be damned the consequences which goes with the impulsivity. Codependent personality type. The person has difficulty in identifying and communicating their needs. They may need the approval or they definitely need the approval of others pretty much at their own expense. So they will do whatever they've got to do to get somebody's approval. They often have low self esteem and an unhealthy need to be in a relationship. One of the flags I see when I'm doing assessments for, for people who tend to be have some codependency issues is the fact that they have to be in a relationship and they define themselves as so and so's significant other or so and so's mother or so and so's somebody they're not. They can't say they're just a person. They have to be attached to somebody else in order to give their life meaning. Now the one in here that is a diagnosis and not a personality pattern. But I think you need to be aware of and remember. And yes, you need to review all your personality disorders. But when you're looking at personality patterns, you also want to look at schizoid personality disorder. And people with schizoid personality disorder often lack interest in social relationships, have a tendency towards solitary or sheltered lifestyle. They tend to be secretive, emotionally cold, detached, and just sort of apathetic about things. Now, you will want to differentially diagnose schizoid personality disorder from autism and major depressive disorder, obviously, but do be aware of the characteristics because schizoid is not uncommon. To show up on the ncmhce, we want to ask people what their normal mood is like and what they were like in adolescence. Do they remember being really moody or irritable in adolescence? And how do they think others view them? You know, do they think that others think they're the greatest thing since sliced bread? Or do they think everybody hates them? You know, what is their perception of their impact on other people? Other things to assess. And we're quickly getting to the end. I know there's a lot. And remember, the NCMHCE is primarily a test to make sure that you can diagnose and formulate a treatment plan for different issues. So there's not a lot of, you know, there's not a lot of focus on specific interventions, so to speak. There's a lot of emphasis on treatment planning and assessment. So anyway, their beliefs, you're going to listen for cognitive distortions and irrational beliefs. These are things that may need to be addressed. Again, you're going to want to look at legal issues. You're going to want to ask about convictions pending arrests or their arrest history in order to identify any criminal patterns of behavior may give you a clue into antisocial behavior and it may give you a clue into interpersonal problems. If, for example, they have multiple arrests for domestic violence, you know, that might give you a clue regarding their impulse control issues, their anger, social functioning. There's a whole host of things that can be impacted. And ask about any civil divorce, bankruptcy, civil lawsuits. Sometimes clients will need assistance connecting with resources for civil representation and culture. You could put it anywhere in the assessment, but it is important to assess culture and remember, culture is not just race or ethnicity or nationality. There are cultures associated with most roles that we embrace. So we do want to ask about their nationality and racial or ethnic identification, but we also want to ask about other cultural identifications that they may embrace, such as being a soldier or being deaf or blind. The people that are in the deaf community are very passionate about their community and they embrace it quite readily. They are not. Many people in the deaf community are not open to becoming hearing capable. That's not something they want to do because that's not what their culture is about. Being sensitive to these things. And people who are in recovery from addictions may refer to themselves as an addict. I've always been taught to put the person before the problem. And so I talk about a person with an addiction. But some people self identify as an addict, especially people who embrace 12 step philosophy. There's a whole host of behaviors and role expectations that go along with being a person in recovery from an addiction. We want to ask about religious identification. Again, there's a lot of things that go along with that role of being a good Catholic or a good Baptist or a good Muslim. What does that mean to them? What is their level of acculturation in each of their roles? You know, how much do they embrace that role versus the majority cultural role? And what are the cultural expectations and beliefs of each cultural role that they know of and that helps define who they are? And we want to look at motivation. Why are they here? And in substance abuse, they break it down really simply. Pre contemplation, Contemplation, preparation, action and maintenance. What does that mean? That means some people in pre contemplation, they don't think they got a problem. They're here because somebody's forcing them to be here. And whether it's their significant other or their doctor or their lawyer, somebody's making them be here and they're not interested in change at all at this point. What they are interested in is getting that person or that agency off their back. Okay, well, we know what their motivation is now. Contemplation. The person may believe that, okay, yeah, you know what I'm doing? I may have a problem with it or I may be a little grumpy lately or whatever. They don't see it as a problem needing professional intervention, but they're starting to consider the fact that there might be a problem with that. We want to provide education about what's going on and feedback about what options there are. Preparation. The person recognizes they're a problem and they're preparing to take the next step. They're preparing to do something. They're not ready to make changes yet. They're just preparing. You know, it's like packing to go on a vacation. They're looking, looking towards going on that vacation and they're figuring out everything. They need to get packed. They're not quite ready to start relaxing it in the action phase. They are ready to change. They're there. They're sick and tired of being sick and tired, and they're ready to make this change. And then in maintenance, they've made the change and they're keeping their. Keeping their gains. If somebody presents in counseling in the action phase, they can be in the action phase of change for one thing, not for the other. We'll take the client who's in pre contemplation, you know, maybe they are sent there by their employer for drinking, and they don't think they've got a problem with drinking, but they want their employer off their back. So they're in the action phase of change for getting their employer off their back. They're in the pre contemplation stage of change about their drinking. So we can work together and go, okay, to get your employer off your back. What needs to happen? We want to assess who the person is changing for. Are they doing this? Are they here because they want to be here and they want to change for themselves? Are they changing because they think, you know, they need to for their kids? You know, what's the motivation? Who's responsible for the change? Are they expecting to have to do some of the work, or are they expecting you to fix them, so to speak? What do they hope to get out of counseling? You know, when they are done, when they're completed, what's going to be different? What will it look like? What obstacles do they anticipate in getting through this process to achieve whatever goal it is that they're motivated to achieve? And when do they envision starting to make this change? You know, is it, let's get started now, Doc, or Yeah, you know, things are kind of busy right now, so in a couple of weeks, I think I'll be ready to get started getting an idea. So you're going to take all this information you've gathered from the assessment, and no matter what assessment you do, there is a lot of thinking information to integrate into the clinical formulation for the scenarios. You know, you don't have nearly as much on the ncmhce, which is a blessing and a curse in some ways. But you want to remember when you're taking this information, the primary focus is on the person in context or the person in the system. So when you take this person and you pluck them out of your office and put them into the real world, what is it in the real world that is contributing to their distress and how are they maintaining that? You want to recognize that a change in one area is going to impact all other areas. So if, for example, the person's relationship at home tends to be very chaotic and argumentative and conflictual, then if you start providing that person different tools to deal with the conflict in their house, that's not only going to affect how they feel and how they act, but it's going to impact that system. Ideally, it's going to reduce some of the conflict. When the conflict in the system is reduced, how is that going to affect your client? Ideally, it's going to make them feel more relaxed, etc. Remember, there's a bi directional interaction. Whenever the client makes a change, it affects the system. And that changed system has an effect on the client. So explore those reciprocal dynamics between the client's environments and their problems. Look at the client's actions and reactions and how they impact the environment. If the client comes home and just lays into people and is great big old grumpy Gus, how does that impact everybody in the household? And then how does that impact the client? So if everybody cowers when Sally comes home and is just a great big old grump, everybody cowers. Well, that rewards that behavior. So it makes it more likely that Sally's going to come home and be aggressive again because in some way that behavior was rewarded. The goal is to improve the person environment fit. We want the environment to be supportive of the individual and the individual to be able to be supportive of the environment. So think about some interactions. For example, anxiety. We know that people who are anxious for a long period of time, it can lead to depression, they're worried, they're stressed. Eventually it leads to a sense of hopelessness and helplessness and people may start to isolate, which can reduce a sense of self efficacy and self esteem. They don't feel like they can control anything, they feel like failures, yada yada. Depression can impact social functioning, work functioning, pain perception, physical health and sleep. And when any of those is out of whack, it can intensified depression. Grief can impact people's abilities to function at work or in their social relationships and that can contribute to intensifying the grief if it draws them away, for example, if it draws them away from their social supports. And addictive behaviors can be used to self medicate. When things are not going well, the person may engage in an addictive behavior to feel better or to numb the pain, which can make those issues worse. You know, they're just kind of burying their head in the sand and that can make those issues worse. When they sober up, issues are worse, makes them go back to that addictive behavior and you're in this negative downward spiral. So in your assessment, don't forget to check self help, self esteem and self efficacy. Look at people's developmental stage and their unresolved crises and how those may be impacting their current situation. If they feel if they don't feel effective at goal setting, if they don't feel effective at forming secure attachments and relationships. If they don't know who they are because they never individuated. Evaluate their current social relationships and their social relationship patterns. Are they healthy? Are they conflictual? Are they codependent? Look at their personality styles and traits to get an idea about how they function. Remember, a personality trait tends to be stable across situations. And then assess environmental factors such as housing, finances, community and attachment. And a couple places that you can go. You can go to americanwellness.org or youth.gov to find a list and it's an abbreviated list but it was still too long to go through in this particular presentation of risk and protective factors. That will give you an idea about things to look for in terms of risk factors and protective factors in terms of things you might want to add in or make sure the client has access to in order to mitigate their risk. And remember, when you take all that information and you integrate it using an interactive bi directional person in situation approach, if you change the person it's going to change the system and if you change the system it's going to affect the person. You've got to see that bi directionality. As promised. Test taking tips Remember, on your assessment, the goal is to integrate client assessment and observational data. Identify precipitating problems or symptoms, identify individual and or relationship functioning and relevant family issues. Those are the four things that NBCC really wants you to focus on on the ncmhce. So how can you remember all this stuff? Because there's. I mean, you're cramming everything you learned in graduate school into one test. Start right now, making it relevant. Everywhere you go is your little mental petri dish. If you will, analyze the person environment fit, for example, in the child that's throwing a tantrum in the store. Think about what their precipitating problems are and what in the environment might be contributing to that temper tantrum, what interventions you might use, how that might affect the environment. Think it through. Think about the developmental stage the child is at, or any child. You know, every time you see a child, think, oh, that child is probably at, you know, the industry versus inferiority stage or whatever. Get familiar with those and remind yourself, okay, at this stage, this is what the child is trying to develop. This is the developmental task that he or she has to accomplish. When you see conflict in real life or on tv, explore the potential factors that contributed to it. And this can make watching a movie or a sitcom or something really frustrating after the test is over, because sometimes it's hard to turn off that analytical mind. But it can help you really drive some of these concepts home if you start looking at it and going, okay, what would, you know, counselor me say in this situation? What things would I want to know in order to get a better idea of what's going on? And what interventions might I implement in order to improve the person environment fit? When you're assessing children, even if you're not going to assess children in real life, you know, you're going to only work with adults. You may have to do it on the ncmhce. So when you're assessing children, use descriptive statements to assess to support and encourage the child. So I really like how you colored that picture. That was awesome. I really like how interactive you're being with the toys here. Whatever you want to say, encourage the child, tell them what they're doing, right? Focus on enhancing and highlighting the positive. Encourage children to think about what they're doing, thinking, feeling, or saying. So you may say, you know, tell me about what you're doing with the action figures right there, or what were you thinking when you had the. What were you thinking about when you had the little action figure do this, that, or the other? What were you feeling when Johnny took your ball when you were at school today? Or whatever happened. Encouraging the child to think doesn't have to be necessarily in the moment. It can be when somebody does this to you. What are you thinking when somebody pushes you off the swing at the playground. What are you thinking and feeling and what do you do? Why? You know, encourage them to really articulate that. Just be curious, not judgmental, just curious what was going on. Provide positive reinforcement for participation, even if they're not giving you the answers you want, which generally they're not, you know, or they wouldn't be in your office, you know, thank you for trusting me with that or thank you for sharing that with me. That means a lot. And remember to ask if age appropriate questions. You know, children don't really develop a great emotional vocabulary until they get to be a little bit older. So it's important when you're asking feeling or thinking questions to potentially use pictograms or ask things that are on their level if you want to. If you're Talking to a 4 year old, you're not going to say, did that make you feel dysregulated or overwhelmed? That probably doesn't mean anything to the kid. Did that make you feel. Feel scared? That's meaningful to the child. When you're assessing adults, look for common themes either across time, so you know, over the past 15 years, this is something that keeps consistently happening, or across situations in the present. When you're with your parents, when you're at family gatherings, it tends to always end in an argument. At home, it's a very conflictual setting. At work, you have difficulty getting along with your peers. Okay, well, there's conflict in three different situations, so let's look at what's causing that conflict. So assessing across time and situations because you want to improve that person environment fit what needs to change in the person and what may need to change in the environment. Thank you for joining me today. Subscribe to the NCMHCE Exam Review podcast to be notified when new episodes are released. And while you're at it, subscribe to CounselorToolbox podcast to stay up to date on current trends in counseling and earn your continuing education on the go.