Hey there, fellow mental health therapists and soon-to-be super therapists! Today, we're going over some very basic tips for initial assessments. First sessions are the launching pad for the therapeutic journey and can set the tone for your entire therapeutic relationship. So, let's make them as smooth and successful as possible.
1. Prep Like a Pro
Ah, preparation - the unsung hero of the initial assessment. Before your client walks through the door (or onto the virtual screen), be sure you've got everything in order. Understand your intake forms, prep your informed consent speech, place tabs in your DSM for common diagnoses, or look up the translations for uncommon words (if you're doing the assessment in another language).
2. Set Clear Expectations
Yes, this includes informed consent and limits to confidentiality. But also, assessments can be awkward. I tell my clients, "first of all, I know it's awkward to have a stranger in your business. BUT, I need to know at least a general idea of what's wrong and what could be causing the problem. Imagine if a doctor treated you for a stomach ache by giving you a medication without testing if you had appendicitis vs the flu vs internal bleeding! Also, this assessment can be tough for me too when I have to ask very personal questions and then move on. Please know that I care, and we will have more time to talk in future sessions."
Also, since I do some assessments online, I tell my clients, "it may look like I'm staring blankly at you. I promise I'm not. I'm probably not even looking at you. I'm probably just typing. I can listen when I type, but I can't type and type. So, feel free to talk because I'm always listening."
3. Use Technology as Your Friend (if applicable)
Whether doing telehealth assessments or in-person assessments. I, personally prefer to type my assessment directly into my Electronic Health Record (EHR) system. I know this isn't for everyone. Also, if you do this, save often and make sure you have good WiFi! Here's a few reasons why I like this option:
A. Use Google to search up reference diagnoses. Let's say you start to suspect ADHD. Meeting the ADHD criteria is pretty tricky. Don't assess based on your memory of symptoms alone. Pulling up the diagnosis can help inform your questions.
B. Type and leave blanks (____). For example, I copy and paste the following after clusters of symptoms/behaviors:
(Onset: _____; Frequency: ______; Duration: ______; Severity: _____). This way, I know, based on the blanks, if I missed anything.
Also I type this to establish medical necessity if needed: Client reports the following functional impairments: _____ (ie. ____) and _______ (ie ______). Again, the blanks remind me to ask about impairments.
C. Less work for you if you will later have to type everything anyway!
4. Ask about Symptoms in Different Ways
Everyone conceptualizes their problems/symptoms/behaviors differently. Asking about symptoms/behaviors in 2-3 different ways might help you better understand the issue. BUT be careful to not push too hard; we don't want any "false positive" symptoms. Be casual.
Example:
"Have you ever had a period of time when you felt consistently sad or irritable?"
"How about a time when you felt like you wanted to avoid your usual activities or other people?"
"What about a time when you felt numb or nothing-ness?"
Example 2:
"Do you have any problems sleeping?"
"Do you sleep through the night?"
"Do you have any problems falling asleep or waking up?"
"How about when you wake up, do you feel tired even after getting up?"
5. Ask the Funky Questions
Sometimes, we skip questions because we think it's an obvious no. For example, maybe we don't ask about substance use in young children. But some kids do try substances very young. Also, in some cultures it is totally normal and appropriate to have caffeine.
Ask about hallucinations. Ask about delusions. Ask if they know their name, where they are, and what you're doing.
Ask about possible manic episodes. Ask about their family.
Examples:
"What is your favorite thing about your family? Least favorite?"
"What was/is meal time with your family?"
"Is there someone you look/looked up to?"
"When you have been wide awake, have you ever seen/heard something other people cannot hear/see?"
Bonus: Speak How You Speak
Don't get caught up in therapeutic jargon. You can write your assessment professionally, but speak warmly and (reasonably) casually. "Do you struggle with insomnia?" is different than "Do you have any problems sleeping?"
You're the expert, no doubt about it, but remember to keep things simple and digestible for your clients. Therapy-speak can sometimes feel like a foreign language. Break it down, use relatable metaphors, and be patient. Educating your clients about the therapeutic process can demystify what can often seem like an intimidating journey.
Take these tips to heart, and let's make those initial assessments an awesome experience for both you and your clients. Remember, the first impression is a lasting one, so let's make it a positive and impactful one! Happy healing!