Clinical Assessment – The Process
When we do a clinical assessment we have been asked by the client to help them with some form of mental health problem. This could be ADHD, depression, one of the anxiety conditions, bipolar disorder or any other DSM IV diagnosable condition.
Does this mean we are labeling people? No. Diagnoses are not labels. Labels are things like “lazy”, “bad attitude”, “irresponsible.” Diagnoses are the names of medical conditions of any kind, and in our case, medical conditions of the mental health variety. Without a diagnosis, we can’t be sure we are working on the right problem. Think about it. When you go to the car mechanic do you want him to diagnose the problem or just start mucking around in your engine? When you go to the doctor do you want her to be sure what the problem is or to just start prescribing medicine of whatever kind?
The process goes like this:
We ask clients what’s on their minds, what’s bothering them, what brings them to see us, how we can help. We ask questions but we need the client to about 90% of the talking so we can learn from them. We listen for symptom descriptions and ask for more detail. We might give the client a standardized inventory or questionnaire to go along with the information. We ask them what THEY think might be the problem. We ask about past treatments.
We also want to know about their physical health and any substance use.
Finally, we want to know about their personal, family, and social life. When people have mental health problems these parts of life suffer and getting all of this back in order is part of treatment. It also helps us gauge progress as these parts of life improve.
Yes, there will be a diagnosis. Today’s treatment methods have research as their base. This is a science. The research tells us what works so we need a diagnosis to make sure we pick the right, research based treatments. Insurance companies require diagnosis, not just from us, but from ALL medical professionals.
Privacy
All information is private and confidential. Before we can share information outside the office the client has to want us to, and have given us written permission. We discuss this with clients before we share records to make sure it is in the client’s best interest and not just something some other practitioner has routinely asked them to do.
Any questions about assessment? – contact us.
