Chapter 2 of 612% of exam

Intake, Assessment, and Diagnosis

This domain covers the interviews, observations and instruments that turn a first meeting into a working picture of the client: the mental status exam, risk assessment, substance use screening, test selection and score interpretation. Many items require reading a score or naming what a test result can and cannot tell you.

Interviews and the mental status exam

Intake combines a biopsychosocial interview, the client's own report and the counselor's observations. The MSE is a structured description of the person at this moment, organized by domains; knowing which domain a finding belongs to is a frequent test point.

Mood versus affect
Mood is what the client reports feeling; affect is the emotion others can see. A mismatch is noted as incongruence.
Minnesota DHS, Mental Status Examination description
Memory
Recall of three named objects after 5 to 10 minutes checks short-term memory; life history checks long-term memory.
Minnesota DHS, Mental Status Examination description
Abstract thinking
Proverb interpretation shows whether the client grasps abstract meaning or answers concretely.
Minnesota DHS, Mental Status Examination description
Perception
Hearing or seeing things others do not is recorded as a perceptual disturbance.
Minnesota DHS, Mental Status Examination description

Risk and substance use screening

Assessment for suicide, harm to others and substance use runs through the whole relationship, not only intake. SAMHSA separates direct warning signs, which need immediate action, from indirect ones that need follow-up questions.

Direct warning signs
Suicidal communication, seeking access to a method, and making preparations get the highest priority.
SAMHSA TIP 50
IS PATH WARM
Ideation, substance abuse, purposelessness, anxiety, trapped, hopelessness, withdrawal, anger, recklessness, mood changes: indirect signs that call for follow-up.
SAMHSA TIP 50
Alcohol screening
The WHO's 10-item AUDIT screens for hazardous drinking, dependence symptoms and alcohol-related harm.
WHO AUDIT Guidelines, 2nd ed. (2001)
Depression screening
PHQ-9 cut points of 5, 10, 15 and 20 mark mild, moderate, moderately severe and severe depression; a screen does not replace a diagnostic interview.
Kroenke, Spitzer & Williams, J Gen Intern Med 2001

Reliability, validity and score interpretation

Test questions reward fluency with the normal curve and the vocabulary of reliability and validity. Work from the mean and standard deviation to a z-score, then to a percentile.

Normal curve
About 68% of scores fall within 1 SD of the mean and about 95% within 2 SD; +1 SD is roughly the 84th percentile.
Normal distribution properties
Standard scores
z has mean 0 and SD 1; T has mean 50 and SD 10; deviation IQ has mean 100 and SD 15.
Standard score conventions
Reliability types
Test-retest (stability over time), alternate forms, internal consistency (one sitting), interrater (agreement between scorers).
AERA/APA/NCME Standards (2014), Ch. 2
Standard error of measurement
The observed score plus or minus 1 SEM gives about a 68% band, plus or minus 2 SEM about 95%.
AERA/APA/NCME Standards (2014), Ch. 2
Norm- versus criterion-referenced
Norm-referenced scores compare a person with a group; criterion-referenced scores compare with a fixed standard.
AERA/APA/NCME Standards (2014), Ch. 5

Ethical use of assessment and diagnosis

The codes treat assessment as part of counseling, subject to consent, competence and cultural caution. Nonstandard administration and mismatched norms do not forbid testing, but they change what can be claimed.

Explain first
Before assessment, explain its nature, purpose and who will receive the results, in language the client understands.
ACA Code of Ethics (2014), E.3.a
Norms from other populations
Use such instruments with caution and interpret results in light of culture, language and other factors.
ACA Code of Ethics (2014), E.8
Nonstandard administration
Accommodations are noted in the interpretation, and results may be of questionable validity.
ACA Code of Ethics (2014), E.7.a
Culture in diagnosis
Culture shapes how problems are defined and experienced; counselors watch for historical and social prejudice in diagnosis.
ACA Code of Ethics (2014), E.5.b-E.5.c

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