Week 3: The Diagnostic Interview: The Mental Status Exam and Risk and Safety Assessments

The process of clinical diagnosis begins with a diagnostic interview. During this interview, a social worker conducts a Mental Status Exam (MSE) and assesses suicide, violence, and other safety risks. Suicide risk is on the rise in the United States overall and within many populations, such as teens. Suicide attempts are common in individuals with mood disorders, posttraumatic stress disorder, substance use disorders, and borderline personality disorder. The diagnostic interview plays an important role, then, not only in understanding a client’s mental state and presenting symptoms but in identifying potential for self-harm.

This week, you focus on individual elements of the diagnostic process. You start with how to conduct a diagnostic interview and MSE. You also consider the risk assessments that are part of the diagnostic interview, particularly how to respond to a positive suicide risk assessment.

Learning Objectives

Students will:

• Analyze an example of a suicide assessment
• Develop a safety and response plan based on a suicide risk assessment
• Analyze an example of a diagnostic interview
• Develop a Mental Status Exam (MSE) write-up based on a case

Learning Resources

Required Readings

Morrison, J. (2014). Diagnosis made easier: Principles and techniques for mental health clinicians (2nd ed.). New York, NY: Guilford Press.
Chapter 10, “Diagnosis and the Mental Status Exam” (pp. 119–126)
Chapter 17, “Beyond Diagnosis: Compliance, Suicide, Violence” (pp. 271–280)

American Psychiatric Association. (2013t). Use of the manual. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.UseofDSM5

American Psychiatric Association. (2013b). Assessment measures. In Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. doi:10.1176/appi.books.9780890425596.AssessmentMeasures

Focus on the “Cross-Cutting Symptom Measures” section.

Chu, J., Floyd, R., Diep, H., Pardo, S., Goldblum, P., & Bongar, B. (2013). A tool for the culturally competent assessment of suicide: The Cultural Assessment of Risk for Suicide (CARS) measure. Psychological Assessment, 25(2), 424–434. doi:10.1037/a0031264

Osteen, P. J., Jacobson, J. M., & Sharpe, T. L. (2014). Suicide prevention in social work education: How prepared are social work students?. Journal of Social Work Education, 50(2), 349-364.

Blackboard. (2018). Collaborate Ultra help for moderators. Retrieved from https://help.blackboard.com/Collaborate/Ultra/Moderator

Note: Beginning in Week 4, you will be using a feature in your online classroom called Collaborate Ultra. Your Instructor will assign you a partner and then give you moderator access to a Collaborate Ultra meeting room. This link provides an overview and help features for use in the moderator role.

Document: Case Collaboration Meeting Guidelines (Word document)

Document: Collaborating With Your Partner (PDF)

Document: Diagnostic Summary Example (Word document)

Note: This is an example of a diagnostic summary that can be used as a template for Part I of the Assignment.    

Required Media

Accessible player –Downloads–Download Video w/CCDownload AudioDownload TranscriptLaureate Education (Producer). (2018b). Psychopathology and diagnosis for social work practice podcast: The diagnostic interview, the mental status exam, risk and safety assessments [Audio podcast]. Baltimore, MD: Author.

MedLecturesMadeEasy. (2017, May 29). Mental status exam [Video file]. Retrieved from https://youtu.be/RdmG739KFF8 

Sommers-Flanagan, J., & Sommers-Flanagan, R. (Producers). (2014). Clinical interviewing: Intake, assessment and therapeutic alliance [Video file].

Watch the “Suicide Assessment Interview” segment starting at 01:44:37. This is the interview with Tommi, which will be used for the Discussion.
Watch the “Mental Status Examination” segment starting at 01:22:23. This is the case of Carl, which will be used for the Application.

Optional Resources

First, M. B. (2014). Handbook of differential diagnosis. Washington, DC: American Psychiatric Association

Chapter 1, “Differential Diagnosis Step by Step” (pp. 14–24)

Document: Suggested Further Reading for SOCW 6090 (PDF)

Note: This is the same document introduced in Week 1.

Discussion: Assessing Suicide Risk

As a social worker, you will likely at some point have a client with a positive suicide risk assessment. Many individuals with suicidal ideation also have a plan, and that plan may be imminent. Even when the risk is not urgent at a given moment, current research shows that most suicides occur within 3 months of the risk being assessed within a formal appointment. Ideation can quickly become a suicide.

For this Discussion, you view an initial suicide risk assessment. As you evaluate the social worker’s actions, imagine yourself in their place. What would you do, and why?

To prepare:

• Explore an evidence-based tool about suicide risk assessment and safety planning. See the Week 3 document Suggested Further Reading for SOCW 6090 (PDF) for a list of resources to review.
• Watch the “Suicide Assessment Interview” segment in the Sommers-Flanagan (2014) video to assess how it compares to your findings.
• Access the Walden Library to research scholarly resources related to suicide and Native American populations.

By Day 3

Post a response in which you address the following:

• Identify elements of Dr. Sommers-Flanagan’s suicide risk assessment.
• Describe any personal emotional responses you would have to Tommi’s revelations and reflect on reasons you might experience these emotions.
• Describe the elements of safety planning that you would put in place as Tommi’s social worker in the first week and in the first months.
• Identify a suicide risk assessment tool you would use at future sessions to identify changes in her risk level. Explain why you would use this tool.
• Explain any adjustments or enhancements that might be helpful given Tommi’s cultural background. Support your ideas with scholarly resources.

By Day 6

Respond to at least two colleagues in the following ways:

• Provide suggestions to manage the emotional responses your colleague identified.
• Explain why consideration of culture is important when working with diverse clients.

response 1

 Meishalette Allen Wk 3 DiscussionCOLLAPSE

In the session with Tommi, Dr. Sommer-Flanagan did a great job gathering vital information regarding triggers, warnings and coping mechanism in relation to her suicidal attempts in the past and current ideations. The elements in Dr, Sommer-Flanagan suicide risk assessment include: Identifying suicide risk factors, evaluating for symptoms of depression, exploring the patients suicidal ideation, exploring the patients plans for suicide, determining the reasons for suicide intent and reasons to live and exploring self control (Sommers-Flanagan, J., & Sommers-Flanagan, R., 2014). Dr. Sommers-Flanagan was able to incorporate Tommi’s experiences and joys in life into assessment as a safety plan. Additionally, Dr. Sommers-Flanagan approached to the use of contacting 911 for assistance when she has exhausted all other safety plans.

Personal emotional responses that I have towards Tommi after watching her session is an extreme amount of concern and worry. I was also able to empathize Tommi’s experiences and understand/relate to some. During the session, Tommi displayed an ample amount of dry, monotone dialogue. Tommi went through the session in a mood displayed physical as empty, hopeless and unbothered. I was concerned when Tommi explained that she had her suicidal ideations due to her wanting to get back at her parent. At some points during the session, I was able to empathize and relate to Tommi because mental illness runs in my family, along with addiction. From my own experience, some of the feelings I endured as a child I am able to comprehend and understand. I never had suicidal ideations like Tommi, but I remember thinking about what it would be like if I wasn’t here. That’s when I was able to relate to Tommi about the effects on others this would create. As for myself, I researched the emotions I was experiencing and took myself to a doctor for evaluation. In Tommi’s experience, she also had got in contact with a psychiatrist. Unfortunately, like mentioned in the session, each suicidal assessment is different because everyone is different. I am not fully capable of understanding Tommi’s situation since I did not grow up in the same life as her. I do wonder if Tommi has become dazed by the feelings she tirelessly live with.

Per the National Institute of Mental Health (2017), safety planning is defined as developing a plan that describes ways of limiting access to lethal means such as pills, poisons and firearms. Additionally, it lists coping strategies as well as people and other resources that can assist in a crisis (National Institute of Mental Health., 2017). Depending on the clients, these protocols will be put in place. Furthermore, limiting exposure to harmful objects such as glass, blades and knives would benefit reducing self-harming thoughts. Within the first wee of working with Tommi, I would start off with questions regarding her suicide attempts and thoughts. Next, I would identify the situations, thoughts and other triggers that start these suicidal thoughts from occurring. Tommi would then document those moments to potentially help her avoid them from happening. Following the first week with Tommi, we would work on coping skills. Tommi mentioned that she enjoys poems, singing karaoke, working out and being a positive influence for her brother (Sommers-Flanagan, J., & Sommers-Flanagan, R., 2014). I would encourage Tommi to engage in these activities when she is feeling down. I would additionally explore more activities for Tommi so she could engage with other individuals and gain friendships, Thereafter, I would assist Tommi in identifying two to three individuals who she is comfortable in discussing her emotions with when she is feeling down. Besides my own contact information, I would then assist Tommi in collecting any other professional contact information where she could reach out to when she is feeling down. Another step I would assist Tommi in is finding safe places where she could go to when she is feeling down or not feeling safe. Lastly, I would encourage Tommi to reach out and call 911 or the suicide hotline when the other opinions are not successful. 

A suicide risk assessment tool that I would use in future sessions with Tommi is the Columbia-Suicide Severity Rating Scale (C-SSRS). When using the C-SSRS, the answers allow the users in identifying whether or not someone is at risk for suicide, assess the severity and immediacy of that risk, and gauge the levels of support that individual needs (About the Protocol The Columbia Lighthouse Project., n.d). The C-SSRS also is the only risk assessment tool that is identified by the US Food and Drug Administration (FDA) (About the Protocol The Columbia Lighthouse Project., n. d). I would use this tool because it would allow whether Tommi’s suicidal risk factors are increasing or decreasing.

It has been found that American Indians and Alaska Native have higher rates of suicide than those of other racial/ethnic groups in The United States of America (Keavitt, R. A., et al., 2018). We did not find out the exact geographical locations of Tommi’s home but we were capable of finding out the name of her tribe. Nor are we aware if this is her first time being assessed for this condition either. It is helpful to know that in rural areas, there is lower availability and use of mental health services due to their being provider shortages, social barriers that include lack of culturally competent care and stigma (Leavitt, R. A., et al, 2018). Due to Tommi’s age, we can only assume this could be the reason she is now seeking help for her condition. Within tribes and others cultures, there is stigma facing mental health and could be the result of Tommi’s attempts.

References:

About the Protocol The Columbia Lighthouse Project. (n.d.). Retrieved from https://cssrs.columbia.edu/the-columbia-scale-c-ssrs/about-the-scale/

Leavitt, R. A., Ertl, A., Sheats, K., Petrosky, E., Ivey-Stephenson, A., & Fowler, K. A. (2018). Suicides Among American Indian/Alaska Natives – National Violent Death Reporting System, 18 States, 2003-2014

National Institute of Mental  Health. (2017). Suicide prevention. Retrieved from https:///www.nimh.nih.gov/health/topics/suicide-prevention/index.shtml

Sommers-Flanagan, J., & Sommers-Flanagan, R. (Producers). (2014). Clinical interviewing Intake, assessment and the therapeutic alliances

Response 2

 Casey Jordan Assessing Suicide RiskCOLLAPSE

Dr. Sommers-Flanagan: Strengths & Weaknesses Suicide Risk Assessment

Suicide presents a significant social and public health problem, especially among Native Americans, 40 percent of those who die by suicide are between the ages of 15 and 24 and among young adults ages 18 to 24, Native American have higher rates of suicide than any other ethnicity, and higher than the general population (Le & Gobert, 2015). A report published by the CDC’s National Center for Health Statistics highlights that suicide among Native youth is a crisis and one that is not receiving the attention it needs. As I watched Dr. Sommers-Flanagan video, I felt how difficult and challenging it was for him to conduct the assessment interview. Flanagan described the suicide assessment as tough in that people are unique and there is no exact formula for addressing suicidality. I felt there were some extremely positive things done by Dr. Sommers-Flanagan. I thought it was great how he guided his session toward being more positive and focusing on maybe more therapeutic questions and what’s going well for Tommi and perhaps ignored a little bit of negative side. On the negative, I think when Tommi talked about her past suicidal plan, which was a good thing, Dr. Sommers-Flanagan did not go deeper into allowing her to talk about past suicidal attempts. It seemed like she wanted to discuss it a little further.  When clients experience trauma or a crisis, it is often good to talk about it to identify feelings and thoughts in order to address the crisis and in the case of Tommi, address what exactly lead up to her two previous attempts, what actions did she take and what were her thoughts afterward. Having more information on Tommi’s previous suicidal attempts would be an important factor in the suicide assessment. Researchers have identified several risks and protective factors for Native American suicide. Many of which conceptualize suicide as a problem originating at an individual level rather than a societal one and additionally, described the co-occurrence of suicidal behaviors, alcohol and drug use in many Native communities, documenting that more than half of the people who have exhibited suicidal behavior were intoxicated at the time (Wexler et al., 2015).

 Another great assessment tool is TIES (Transitions & Developmental Stages, Interpersonal Areas, Environmental Systems, Special Considerations, Social Context, and Spirituality), this tool allows workers the ability to establish a client-centered, strength-based and culturally sensitive partnership and enhances the client- social worker relationship.

Safety Planning

Safety planning is an essential intervention with individuals at risk for suicide. It can be done in a variety of settings including emergency departments, primary care, and mental health. It is a key component of an effective and evidence-based care management plan. It can be used with individuals who have made a suicide attempt, experience suicidal ideation, or are determined to be at risk for suicide. Safety planning is not to be confused with contracts for safety or no-suicide contracts. There is no evidence that these contracts are effective, and they can provide a false sense of security for the provider. Crisis response planning or safety planning has been found to be more effective than a contract for safety.

Safety planning is a brief intervention involving a prioritized list of coping strategies and supports developed collaboratively between an individual and a clinician. Often, individuals at risk for suicide who are not admitted to treatment by emergency departments or crisis services are referred to outpatient mental health treatment. It is likely that the patient will continue to struggle with suicidal thoughts or emotional crises. The safety plan is an intervention to provide patients with a set of specific, concrete strategies tailored to their individual needs and circumstances that they can use to decrease the risk of suicidal behavior and increase treatment motivation and compliance. Safety plans incorporate elements of several evidence-based suicide risk reduction strategies that are a part of the Zero Suicide approach, including means reduction, brief problem-solving and coping skills, social and emergency crisis support, and motivational enhancement for treatment.

Research shows that individuals with higher-quality safety plans are less likely to be hospitalized in the year after safety planning. Dr. Sommers-Flanagan discussed with Tommi some healthy things she can do to make herself safe (safety plan) when suicidal thoughts appear. She mentioned singing, working out, writing poetry, and talking with her sister. All of those things are great and I would use them in my safety plan with Tommi but also include a total of three people Tommi can reach out to for help, a few places Tommi can go in order to distract herself and give her access to a safe environment. I would also include mindfulness into Tommi’s coping strategy. While Native American youth are particularly at high risk for suicide because of cumulative risk factors including historical and intergenerational trauma, alcohol use and dependency disorders, family substance use, high rates of poverty and unemployment, and family violence (Le & Gobert, 2015). Mindfulness and Suicide Prevention Mindfulness is a potentially effective prevention intervention strategy for suicide by providing individuals with important tools to recognize and manage self-destructive thoughts and emotions along with developing the capacity to be with difficult thoughts and emotions (distress tolerance). Individuals who are at-risk or suffer from suicidal tendencies often have difficulties regulating their emotions and discursive thoughts (Le & Gobert, 2015).  

Suicide Risk Assessment Tool

 The Suicide Assessment Tool I would use is the SAFE-T card. This tool guides clinicians through five steps that address the patient’s level of suicide risk and suggest appropriate interventions. It is intended to provide an accessible and portable resource to the mental health professional whose clinical practice includes suicide assessment. The card lists key risk and protective factors that should be considered in the course of completing the five steps. SAFE-T provides protocols for conducting a comprehensive suicide assessment, estimating suicide risk, identifying protective factors, and developing treatment plans and interventions responsive to the risk level of patients. The pocket card includes triage and documentation guidelines for clinicians. It was developed through collaboration between Screening for Mental Health, Inc. (SMH) and the Suicide Prevention Resource Center (SPRC). The protocols and guidelines featured on the card were developed based on the American Psychiatric Association Practice Guidelines for the Assessment and Treatment of Patients with Suicidal Behaviors. Clinicians are able to conduct a comprehensive suicide assessment and triage, estimating suicide risk and developing treatment plans and interventions responsive to the risk level of patients, identify individuals at risk for suicide and protect and plan the care of individuals at risk for suicide.

References

Le, T., & Gobert, J. (2015). Translating and Implementing a Mindfulness-Based Youth Suicide Prevention Intervention in a Native American Community. Journal Of Child & Family Studies, 24(1), 12-23. doi:10.1007/s10826-013-9809-z

 Sommers Flanagan, J. & Sommers-Flanagan, R. (2014). Clinical Interviewing: Intake, assessment and therapeutic alliance [Video file]. Retrieved from http://www.psychotherapy.net.ezp.waldenulibrary.org/stream/waldenu/video?vid=276

 Wexler, L., Chandler, M., Gone, J. P., Cwik, M., Kirmayer, L. J., LaFromboise, T., & … Allen, J. (2015). FRAMING HEALTH MATTERS. Advancing Suicide Prevention Research with Rural American Indian and Alaska Native Populations. American Journal of Public Health, 105(5), 891-899. doi:10.2105/AJPH.2014.302517

Note: You are required to create a thread for your initial Discussion post before you will be able to view other colleagues’ postings in this forum. If you have not yet visited the weekly resources and assignments, you should visit that area now to access the complete set of directions and guidelines for this discussion.

Submission and Grading Information

Grading Criteria

To access your rubric:
Week 3 Discussion Rubric

Post by Day 3 and Respond by Day 6

To participate in this Discussion:
Week 3 Discussion

Assignment: Conducting a Diagnostic Interview With a Mental Status Exam

Before moving through diagnostic decision making, a social worker needs to conduct an interview that builds on a biopsychosocial assessment. New parts are added that clarify the timing, nature, and sequence of symptoms in the diagnostic interview. The Mental Status Exam (MSE) is a part of that process.

The MSE is designed to systematically help diagnosticians recognize patterns or syndromes of a person’s cognitive functioning. It includes very particular, direct observations about affect and other signs of which the client might not be directly aware.

When the diagnostic interview is complete, the diagnostician has far more detail about the fluctuations and history of symptoms the patient self-reports, along with the direct observations of the MSE. This combination greatly improves the chances of accurate diagnosis. Conducting the MSE and other special diagnostic elements in a structured but client-sensitive manner supports that goal. In this Assignment, you take on the role of a social worker conducting an MSE.

To prepare:

• Watch the video describing an MSE. Then watch the Sommers-Flanagan (2014) “Mental Status Exam” video clip. Make sure to take notes on the nine domains of the interview.
• Review the Morrison (2014) reading on the elements of a diagnostic interview.
• Review the 9 Areas to evaluate for a Mental Status Exam and example diagnostic summary write-up provided in this Week’s resources.
• Review the case example of a diagnostic summary write-up provided in this Week’s resources.
• Write up a Diagnostic Summary including the Mental Status Exam for Carl based upon his interview with Dr. Sommers-Flanagan.

By Day 7

Submit a 2- to 3-page case presentation paper in which you complete both parts outlined below:    

Part I: Diagnostic Summary and MSE

Provide a diagnostic summary of the client, Carl. Within this summary include:

• Identifying Data/Client demographics
• Chief complaint/Presenting Problem
• Present illness
• Past psychiatric illness
• Substance use history
• Past medical history
• Family history
• Mental Status Exam (Be professional and concise for all nine areas)
  • Appearance
  • Behavior or psychomotor activity
  • Attitudes toward the interviewer or examiner
  • Affect and mood
  • Speech and thought
  • Perceptual disturbances
  • Orientation and consciousness
  • Memory and intelligence
  • Reliability, judgment, and insight

Part II: Analysis of MSE

After completing Part I of the Assignment, provide an analysis and demonstrate critical thought (supported by references) in your response to the following:

• Identify any areas in your MSE that require follow-up data collection.
• Explain how using the cross-cutting measure would add to the information gathered.
• Do Carl’s answers add to your ability to diagnose him in any specific way? Why or why not?
• Would you discuss a possible diagnosis with Carl at time point in time? Why?

Support Part II with citations/references. The DSM 5 and case study do not need to be cited.  Utilize the other course readings to support your response.