Interviewing &

Assessment
SOCW 601

Psychosocial
You all know the general purpose and structure of this,
but here we will:
Review general aspects
Highlight the slight changes that are made for a clinical
assessment

Assessment (general)
Assessment involves gathering and analyzing information
about the client, the story to date, and the contextual or
larger system influences affecting the client and the story
Assessment is an on-going process as we continue to get
more information and learn more about the person, their
world and their life we continue to formulate, adapt and
refine our treatment plan
Continue to gather information and formulate working
conceptualization, hypothesis, explanation, continue to
organize and understand information and provide a
direction of where to go, what to do

Assessment (general)
Attempting to understand behavior aides assessment,
identifying what is present
Assessment guides conceptualization, our working
understanding and explanation of what factors and
dynamics are present and how they are related to one
another and how they interact
Conceptualization guides and informs intervention;
what we do, how we respond

Assessment (general)
Assessment-what details you obtain, how much information you get (how
detailed and thorough) and how information is interpreted is impacted by:
Theoretical orientation of the worker
Type of assessment ex. Vocational assessment-vs.-mental health assessment
Agency expectation (most have established assessment formats, information they
specify)
Practicality (ex. time constraints, etc.)
The person-what they decide to share, how much, how accurate the information is
There is no perfect assessment, In some way it will be incomplete, Often
information is limited to time, purpose
Assessment is based on and is only as good as the amount and accuracy
of the information we have to that point

Initial Assessment
Clinicians are often asked to do formal, reasonably structured assessments of
individuals for the purpose of diagnosis, treatment planning, or research to
determine eligibility for specialized services such as disability assistance
payments, residential placements, or inpatient treatment
Often done when the person first presents for services. Information is gathered
about a number of areas of life, history and functioning to ascertain what the
challenges, strengths and resources are and to determine direction of services
Sometimes called:
Initial assessment/evaluation
Diagnostic assessment/evaluation
Intake assessment/evaluation
Admission assessment/evaluation
Psychosocial assessment/evaluation

Initial Assessment
Although the form/format and the type and amount of information
expected/emphasized will vary from agency to agency, the general
process and structure of assessment is the same
We learn generally to do assessment and then we can adapt to the
specific format and requirements of the agency
Some places still have a narrative assessment format where the
clinician is summarizing and conveying the details in a narrative form
Some assessments are not narratives and look more like check boxes
and fill in the blanks
Some of these will include some space for narrative
With the increased use of electronic medical records (EMRs) there is
more of a push to pre-populated choices, boxes, drop down menus, etc.

Initial Assessment
Identifying Information
Presenting Problem/Concern; History of Presenting Illness
Past Psychiatric History
Medical history
Alcohol and Drug History
Family/Social History
Employment History
Strengths and Resources
Mental Status Exam
Summary/Impressions
Diagnosis; Diagnostic Impressions
Treatment Plan
These categories are sometimes named differently by agencies, sometimes combined
together

Initial Assessment
We will focus the most on:
Presenting Problem/Concern; History of Presenting Illness
Past Psychiatric History
Diagnosis; Diagnostic Impressions (well, not really-this is just where
you list your diagnoses (code and name in order of attention,
significance)
Mental Status Exam
But first lets briefly review the others
We need to become thorough, detailed oriented history takers, and it
is Important to remember that all information we get is functional

Ecological/Systems Model

Identifying Information
Brief details of:
Descriptive demographic information-the persons
name, age, gender, race/ethnicity, marital and
employment status
Brief statement of reason for presentation/referral; why
they are coming (sometimes this is separated off to its
own brief section called Chief Complaint)
Referral source (if applicable) or self-referral

Medical History
Any current or past health problems?
Current and past treatment: Are they receiving treatment and if so
where and from whom?
Do they have a doctor? If so who? How many and what type?
(Primary care physician, cardiologist, etc.)
Current medications (names, doses etc.), any known drug allergies
Problems with treatment, receiving treatment or accessing care? Past
If the history is negative then report that:
Theres always something to report
The absence of something is still something

Alcohol and Drug History

If this is their presenting problem then this information will be at the
beginning of the assessment
Regardless the details are the same, but we will review these later
If this is not the presenting problem remember there still might be
relevant data here.
If the history is negative then report that:
Theres always something to report
The absence of something is still something
Client denies/does not report any current/past use and/or issues with
substance use/addiction or related difficulties
Patient denies any current/past treatment or involvement with recovery.

Family/Social History
Whats the family structure like (past, present)?
Whats their relationship with their family like (past, present): supportive
and close? Conflicts and estranged?
Are they married or in a relationship?
If so how long?
How is the relationship? Any problems in the relationship (current, past)?
Children? If so how many, ages, gender, any problems?
Do they have friends and spend time with others? How are their
relationships with others: supportive or conflictual?
What activities/hobbies do they enjoy?
Religious involvement?

Family/Social History
Academic history
Whats the highest schooling they received?
Problems in school with grades/behavior/socialization and peers?
Learning disabilities/special education?
Plans/hopes on returning to school?
Military history
Did they serve? In what branch? For how long? What did they do?
Were they deployed and if so where and how many times? Combat?
What was their experience in the military like? Any problems in the
service? What type of discharge (honorable, medical, less than honorable,
etc.)

Family/Social history
Living arrangements
Do they live alone? With others?
Apartment or house?
Homeless and/or at shelter?
Any financial problems?
Legal history
Are they currently facing legal charges or on probation/parole?
If so why and what type (non-reporting, reporting, etc.)
Any legal problems in the past?
History of incarceration (County, state, federal)? If incarcerated in past where
and what was their experience like?

Employment/Vocational/Work history
Sometimes this section is not its own section and is part of the social
history
Are they currently working?
If so full or part-time? Where and what type of work?
Are they satisfied with work?
Any problems/conflicts at work or concerns over work performance,
relationships with coworkers or management?
If unemployed how long and where/what type of work did they do?
Past work history and vocational training
If disabled are they receiving disability benefits or are they in the process
of applying/appealing?

Strengths and Resources

Admittedly this section often does not appear on many assessments as its own
stand alone section (but should)
Up to us to identify and include information on strengths throughout the
assessment
What do they do well?
What do they see as their positive traits/strengths?
What are the good things about them?
Resources-who is in their life that can/is helping them (people/agencies)?
How have they dealt with problems before?
What in their life can help them with this?
What have they accomplished?
What have they overcome in the past?

Summary/Impressions
This is where you summarize and bring information
together
Condenses, integrates, and analyzes information from
the assessment
Sometimes asked to give a prognosis (likelihood for
improvement or lack thereof)
Form general impressions/working conceptualization
Initial treatment plan/goal formulation
Recommended/planned services and/or referrals

Organization Within Categories

In addition to organizing information in these general
categories, we also want to organize the information
within the categories so that information that is related
is expressed/described together
Ex. Social history has information on family,
relationships, education-organize information with each
of these together, not jumbled
Organize academic information with academic
information, vocational information with vocational
information, like info with like info

Treatment Plan
Name and format varies from agency to agency
Often a formal process and document whose development and
periodic review is required and monitored by agencies and payers
(ex. Medicaid) Often includes specifying/identifying the problem, need
or issue
Often includes specifying/identifying an overall, broad or general goal
Includes more specific treatment goals
List of resources/services that will be utilized, type and frequency of
services, or planned referrals
A treatment plan is a living document in that it changes over
times and actively guides intervention/services

Presenting Problem or Concern

This section is where you provide an overview, a description of
current problems
Here you list and describe symptoms they are reporting
In addition to listing symptom also important to provide, describe
example(s) of how that looks for them
Ex. Markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day
Client reports loss of interest and pleasure in most all activities. He
describes no longer getting as much joy from his woodworking. He
has ceased going to his club meetings, is no longer in contact with
his family and friends as he once was, and he isolates at home

Presenting Problem or Concern

History of these difficulties: when did they start (onset)? How long have
they been occurring (duration)? Have the symptoms changed over time:
gotten worse? Better? Development of new or different symptoms
(course)? Have there been any periods of remission/escalation?
How is it affecting or disrupting their life and functioning?
What related or other problems is the problem causing?
Again important to provide details from the clients specific experience
that illustrate and support
We cant possibly memorize every symptom for every condition but it is
important to know as much as we can because that helps us to know
what questions to ask to support the diagnosis (specific symptoms, time
frames, etc.)

Past Psychiatric History

Sometimes this is included in the Presenting Problem section
Current/past psychiatric difficulties/diagnoses
Past treatment episodes:
When, where, with whom, for how long
What kind of treatment (IP/OP, meds, etc.)
Outcome of care and their experience-how was treatment for them?
Did they find it helpful? What was it like working with their previous
provider?
If applicable list current/past psychiatric medications tried and
effects/response (helped? Not? Any side effects?), possibly doses and
who prescribed it to them

Alcohol and Drug History

If this is their presenting problem, why they are coming and the services you
provide then this will be the first main section
Current/past substance use
Type of drug(s) they use(d) and possibly drug of choice
When first used, when last used, how long person has used, how often
(frequency) and how much used (amount) and once they use for how long at a
time might they use (duration)
Any previous efforts to quit or reduce use and if so how successful, how long did
they cease or change use?
Any problems caused by use now or in the past (legal, financial, relationship,
occupational, recreational)
Current/past treatment, if so name of provider(s), type of care (outpatient, IOP,
residential/IP, detox)

Alcohol and Drug History

Can assess for gambling
Current/past involvement in recovery
Current/past 12-step participation?
Sponsor, home group?
Past success, problems with recovery?
Support system or lack thereof
Do the people in their life also use/encourage use?
Do their family and friends think they have a problem?
Do they have family and/or friends who are supporting and
encouraging change efforts and helping out?

Sources of Assessment Information

We receive and synthesize several sources of information. How much weight we give to
each is based on our own assessment and discernment
Clinical interview-this will always be our primary source of information. Still, we have to
weigh information we get from the interview against ancillary information
Observation-can be both formal and informal
Testing-results of psychological testing, lab/imaging results
Review of records-from previous providers
Can both be very valuable and not valuable
Not everyone does a good or thorough job diagnosing
Collaborative information (from family, friends)
Can both be very valuable and not valuable
Sometimes corroborates, sometimes conflicts with clients account, have to assess the
reliability of source and whether or not they might have a hidden agenda

Mental Status Exam (MSE)

The MSE is our observation, description and assessment of how the client
appears and interacts with us in the interview
Some parts we will simply describe what we observe
Sometimes we will ask specific questions (ex. Asking about mood, thinking)
Sometimes might ask specific sets of questions (Ex. Memory)
Certain characteristics of presentation or changes and disturbances in mental
status can be suggestive of certain diagnoses or psychiatric crisis
Also improvements in MSE can sometimes be observed if people are getting
better
Starts the minute we lay eyes on them
Many places now use checkboxes, but still need to know what areas are
Has several categories, six main components with several subcomponents

MSE
Appearance, Attitude, and Behavior
Mood and Affect
Thought Process
Thought Content
Cognition
Insight, judgment and Intellect

Appearance, Attitude and Behavior

Appearance
Do they appear their stated age or appear younger or older?
Clothing: type of clothing, appropriateness of clothing to season and setting,
condition (clean, dirty, worn, etc.)
Hygiene and grooming: Do they appear clean and well kempt? Unkempt?
Dirty, malodorous? Disheveled?
[Be sensitive to personal and cultural preferences, economic realities]
Posture: sit upright? Slumped? Rigid or tense?
Attitude
Describe their overall attitude towards the interview and interviewer
Friendly and cooperative? Guarded? Suspicious? Hostile? Overly familiar?

Appearance, Attitude and Behavior

Behavior
How they act during the interview, level of motor activity
Agitated? Restless? Settled? Slowed/retarded movement?
Do they seem to be displaying any abnormal movements (tics,
gestures, tremors, stereotyped behaviors)
Gait, coordination
Psychomotor retardation-slowed movements, reactions or speech
Psychomotor agitation-excessive activity associated with a sense
of tension; pacing, fidgeting, inability to sit still, wringing of hands,
tugging on clothes

Appearance, Attitude and Behavior

Eye contact: do they maintain eye contact, look down, or look away?
Glaring, fixed?
Speech: rate and volume
Pressured speech-rapid, drive speech where it seems difficult for
the person not to keep talking; continued speech despite perhaps not
really talking to anyone or not really in response to interviewer, hard
to interrupt
Clanging-when words are chosen for their sound as opposed to their
meaning
Word salad-an apparently random and illogical mixture of words and
sounds

Mood and Affect

Mood-an emotional attitude reported by the individual; how they say they
are feeling
Affect-range and intensity of how the person conveys or expresses their
emotions
Flat affect-absence or near absence of any sign of affective expression
Blunted affect-significant reduction in the intensity of emotional expression
Restricted affect-mild reduction in range and intensity of emotional
expression
Labile affect-expression of emotion shifts quickly, intensely
Inappropriate affect-incongruence, discordance between what they are
describing and expressing

Thought Process
Thought process-How they are thinking
Thought process appeared logical, sequential, relevant, organized
and spontaneous
Derailment can include:
Tangential thinking-when one line of thought goes off to another
(or many others), often with excessive or irrelevant details, and the
person never returns to or completes original thought; thinking gets
derailed
Circumstantial thinking-when one line of thought goes off to
another (or many others), often with excessive or irrelevant details,
but the person eventually comes back to the original point

Thought Process
Flight of ideas-a nearly continuous flow of accelerated thinking with
abrupt changes from topic to topic that are usually based on
understandable associations, distracting stimuli, or plays on words
Looseness of associations-rapid leaps from one line of thought to
another without clear connection between the topics or the
person being aware of the rapid shifts
Response latency-significant gap between question and response
Thought blocking-when a persons train of thought abruptly and
unexpectedly stops
Autistic thinking-a preoccupation with ones own private internal
world and ideas, often illogical, makes sense only to the person

Thought Content
Thought content-What they are thinking, or reporting about their
thinking
Hallucinations-a perception-like experience with the clarity and impact
of a true perception but without the external stimulation of the relevant
sensory organ; the person may or may not recognize that the
experience is not grounded in reality, can be:
Auditory (often voices, sometimes other sounds)
Visual (seeing people or flashes of light, geometric shapes)
Olfactory-smell (usually unpleasant)
Gustatory-taste (unpleasant, metallic)
Tactile-touch, such as insects being under the skin

Thought Content
Delusions-a false belief based on incorrect inference
about external reality that is firmly held despite what
almost everyone else believes and despite what
constitutes incontrovertible and obvious proof or
evidence to the contrary
Delusions can be unsystematized or systematized,
meaning that that are united by a common theme or
represent a complete and relatively well-organized
network of beliefs
Delusions can be mood-congruent or mood-incongruent

Thought Content
Types of delusions can include:
Bizarre-involves phenomenon that the persons culture would
regard as physically impossible; patently absurd or weird
Jealousy-delusion that suspects a rival or ones sexual partner
is unfaithful
Erotomanic-delusion that another person, usually of higher
status, is in love with the individual
Grandiose-delusion of inflated sense of worth, importance,
power, knowledge, ability, identity, or special relationship to a
deity or famous person

Thought Content
Being controlled-delusion where the person believes their feelings, thoughts,
impulses, actions are under the control of some external force rather then
being under their control
Of reference-delusion in which events, objects or other persons in ones
immediate environment are seen as having a particular and unusual
significance. These delusions are usually of a negative or pejorative nature
but also can be grandiose in content
Ex. A red car parked across the street means that I will be fired from my job
Idea of reference-overvalued idea where the person is virtually, but not
totally, convinced that objects, people or events in their immediate
environment have personal significance to them (when its a delusion there
is no doubt)

Thought Content
Persecutory-delusion where the central theme is that
someone (possibly someone close to them) is being attacked,
harassed, cheated, persecuted or conspired against
Thought broadcasting-delusion that ones thoughts are being
broadcasted out loud so that they can be perceived by others
Thought insertion-delusion that certain thoughts are not
ones own, but rather are inserted into ones mind
Somatic-delusion whose main content pertains to the
appearance or functioning of ones body

Thought Content
Nihilistic-delusions involving themes of nonexistence
Ex. Belief one is dead or doesnt exist; Aint no heart in there John, my insides
are gone
Sin or guilt-delusion where person believes they have committed a terrible
act/sin and done something unforgiveable. Person becomes excessively and
inappropriately preoccupied. May focus on acts from childhood or events where
the person thinks they are responsible for a disaster (ex. Fire, accident) but they
had no connection to it. Can have religious focus or person might believe they
deserve to be punished and often seek to confess to others
Religious-delusion where person is preoccupied with false beliefs of a religious
nature. May exist within the context of established religion, or blend different
traditions, or may be an entirely new system. Can include sense of grandiosity

Thought Content
Paranoia-idea that someone(s) will or wants to harm person, characterized
by sense of persecution, suspiciousness, jealousy, resentment. Can lead to
someone being guarded, jealous, sullen, rigid, humorless and hypersensitive
to injustice allegedly being done to them [Can exist without being delusional,
but can also be delusional]
Magical thinking-person is convinced that their words, thoughts or feelings
or actions will produce or prevent a specific outcome that defies all laws of
cause and effect [Can exist without being delusional, but can also be
delusional]
Obsession-recurrent and persistent thoughts, urges, or images that are
experienced as unwanted and intrusive . Often person tries to ignore,
suppress or neutralize them with some other thought or action, often
repetitive and ritualistic (Compulsion)

Thought Content
Dissociation-The splitting off of clusters of mental
content from conscious awareness; sense of separation
and distance from experience, can include being unable
to recall or remember
Depersonalization-the feeling of being detached from,
and as if one is an outside observer of, ones mental
processes, body or actions (feeling as if in a dream,
perceptual alterations, numbing and sense of unreality)
Derealization-the experience of feeling detached from,
and as if one is an outside observer of, ones
surroundings (other individuals or objects are
experienced as unreal, dreamlike, foggy, lifeless)

Suicidality/Homicidality
Ideation-presence of thoughts, images, impulses
Plan-degree to which they have developed a way or decided to act
Access to means-do they have access to the items, ways they would
use
Intent-degree to which they intend to act on ideation and plan
Also important to assess:
Number and nature of past attempts, means used, result (medical
treatment, hospitalization, etc.)
Ability to identify reasons for not acting, willingness to contract for safety
Ideation, specificity of plan, and intent very and increase in intensity and
severity

Suicidality/Homicidality
High (Red)-clear ideation, clear plan, access to means, expressed intent, less
ability to identify reasons for not ending life, less willing (or unwilling) to
contract for safety and develop a safety plan
Very specific ideation, plan, intent
Medium (Yellow)-thoughts about ending ones life are now more specific,
intense, frequent, but no plan, or there may be an identified plan or the person
might have several ways they have considered but not decided, may have
access to means or may not, no intent to act on these thoughts, can still
readily identify reasons for not ending life, more willing to contract for safety
and develop a safety plan
More specific ideation, plan, intent
Low (Green)-vague, occasional, passing, fleeting transient thoughts (often of
shorter intensity and duration) of wishing one were dead, believing they and
others would be better off, thoughts of ending life that are not specific, no
identified plan, able to identify reasons for not ending their life
Vague or absence of ideation, plan, intent

Suicidality/Homicidality
There are several risk factors; more risk factors someone has, higher the risk

S-sex of person
A-age
D-depression, helplessness, hopelessness
P-previous attempts
E-ethanol and other drug abuse
R-rational thinking loss (hallucinations, delusions)

S-social supports lacking

O-organized plan
N-no spouse/significant other
S-sickness (physical illness/pain)

Wall of Resistance to Suicide

Counselor or therapist

Duty to others

Good Health

Medication Compliance

Job Security
Or Job Skills

Responsibility for
children

Difficult Access to means

Pet(s)
Best Friend(s)

Others?
Fear
Support of
Significant other(s)

A sense of HOPE

Religious
Prohibition

Calm
Environment

Safety Agreement
--SOBRIETY--

Protective Factors

Positive Self-esteem
AA or NA Sponsor
Treatment Availability

Reacting to Suicide
Remain calm and objective; as best you can try not react in a
critical/judgmental, dismissive/indifferent or panicked way
Be supportive
Identify strengths (especially their seeking help and addressing
it), supports and resources
Identify the immediate problem
Decrease isolation
Explore past coping mechanisms
Avoid clichs
Examine a menu of potential options

Suicidality/Homicidality
Important to know your agencys procedure and policy
for risk assessment and responding to suicidality and
homicidality
Expected review, supervision (supervisor, physician,
etc.)
Document what you did, who you talked to, steps you
took, how you responded

Cognition
Orientation and memory/concentration
Orientation-usually refer to orientation X3 or all spheres
Orientation to:
Time-are they aware of what day it is, date, time of day, month, season,
year?
Place-do they know where they are, country, state, town, location?
Person-do they know who they are (practically, not existentially)
Purpose-do they know what is happening, context for interview?
With some of these it will be very apparent that there are not deficits in
these areas, so you dont always have to ask, but with some conditions and
presentations there can be disturbances and worker may more formally
assess these areas

Cognition
Memory and concentration
Immediate memory, short-term memory and long-term
When more formally assessed immediate memory is often assessed by saying
three unrelated words or three digits and asking the person to repeat those back
to you
When more formally assessed short-term memory is often assessed by asking
the person to recall the three items after a period of three to five minutes
When more formally assessed long-term memory is often assessed by asking
the person about events from the past days, weeks, years of their life or asking
about general information covering topics that are commonly known
Ex., president(s), number of states, notable events
Have to take into account persons intelligence, education and
experiences/preferences

Cognition
Calculation, abstraction, attention and concentration
When ability to calculate is more formally assessed often person
is asked to complete
Serial 7s or serial threes where starting with 100 (or another
starting point) the person is asked to subtract by seven or three
back to 0, you note how far they get of how many mistakes
made, usually only asking them to do about 5 or so subtractions)
Might be asked to do simple calculations like making change
Might ask the person to spell a word backwards or to list items
(animals, words that start with D, etc.)

Cognition
Abstraction is the persons ability to think abstractly, metaphorically,
symbolically. When more formally assessed person might be asked
to explain/interpret phrases, such as proverbs:
Dont cry over spilt milk; people who live in glass houses shouldnt
throw stones
What are the similarities and differences between a car and a truck?
Concentration is often generally assessed by how well they attend to
the interview and stay on task, their attention to what is being
discussed, responding to questions asked but sometimes
concentration might be more formally assessed by psychological
testing

Cognition
The degree to which you formally or informally assess
Cognition(orientation, memory, abstraction, calculation,
attention) will depend upon the nature of the issue you
are addressing, the requirements of your agency, the
type of evaluation you are doing
Ex. Some disability and placement evaluations (like
nursing homes) may require or expect for formal
assessment
There are formal ways of assessing, such as the Mini
Mental Status Exam (MMSE)

Insight, Judgment, and Intellect

Insight-to what capacity do they seem to be aware of and understand the
nature of their difficulties, the cause-effect relationship or correlational
nature of dynamics, their awareness and understanding of their condition,
as well as need for and/or type of services received
Judgment-be careful on judging judgment. Phrase tentatively (ex. Appears,
seems), reflects sense of their choices or priorities and whether or not
those create damage or harm for their functioning and well-being or others
Intellect-often general estimation is made based off word choice, ability to
communicate, provide information, etc.
Person appears to be of average, below average, above average intelligence
Can be more formally assessed through psychological testing
Important to note ability to read and/or write or deficits

Reminders
Just like diagnoses these terms give us a common vocabulary for communicating to
other providers so important to learn
Someone always has a mental status. Their mental status may be incredibly normal
and functional, but it is still a mental status.
With more severe conditions, however, there can be very drastic disruptions in all
areas across the mental status. Many items are interrelated and interdependent,
and certain disruptions are more characteristic of some conditions than others (i.e.
the mental status for individuals with schizophrenia will look different than someone
with an anxiety disorder, but individuals with schizophrenia share many common
disruptions as do individuals with anxiety disorders)
Significant disruptions in mental status are related to impairments in functioning
and risk of danger, but also can be signs of improvement
Many places now have this as a checklist or drop-down screens to choose prepopulated terms, but still important to know which terms and descriptions are most
applicable for your client