We at PsychAssist receive so many questions from Psychology Students/Graduates around life after graduation. Recently we received a barrage of messages around what actually happens when a client comes into a service for the first time. For many, this is a real source of anxiety as many psych grads become overwhelmed with a sense of Imposter Syndrome once they are face to face with a service user. Nevertheless, PsychAssist is here to alleviate any concerns you have around what to do in an Initial Clinical Assessment. Within this post we will explore the main themes within every Initial Assessment so you can prepare for when you are eventually doing these types of assessments.
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Majority of Clinicians will start with the current concerns a client (or a parent/carers) may have. All this basically means is, you ask the client how they’re doing and what’s been going on. Nevertheless, it must be noted that this question could open up a whole can of worms as people don’t tend to access mental health services if everything is ok. I know from experience the unpredictability of this question, especially if there is very little information from the referrer. On the other hand, it is our job to support and emotionally contain our clients in a safe space.
PsychAssist Tip: Don’t worry, you’ll be fine. All you need is time and experience as that will equip you to handle anything that comes through the door. It may also help to let the service user know why you’ve asked to see them and what your service can (or cannot) offer.
This is where we get into the nitty-gritty stuff. This section is basically asking the client (or parent/carer) about how they were growing up. Obviously there are limitations on how much the service user can remember which is why it always helps to have a parent/carer to help fill in the blanks. This section also tests your formulation skills as there could be certain markers you are looking out for depending on the nature of your service.
PsychAssist Tip: Whatever service you’re working within, it’s always good to brush up on the criteria’s for different disorder. The reason being; similar to a medical doctor, clients are expecting you to give some sort of explanation for the difficulties they are having. Now this doesn’t mean you have to know everything, but just enough that you can spot different possibilities.
Now I know what you’re thinking, this is a scary topic right? You’re not alone as many clinicians dread asking these types of sensitive questions. This is why many services have put in set questions within an initial assessment as standard. Also, you would be surprised how many people are grateful for a clinician asking these types of questions. I know a lot of clinicians who begin to ask these types of questions by saying “these are questions we ask everyone” in order for clients/families to not feel they are being targeted or wrongfully accused of something.
PsychAssist Tip: KNOW YOUR SERVICES SAFEGAURDING PROCEDURES!! I can’t stress this enough. One day you WILL be in a situation that requires you to follow your services safeguarding procedures so you NEED to know them. Trust me, it’s better to know and not need than need and not know.
Hobbies and Interests
Now this is the fun part. You will most likely ask the service user what their hobbies and interests are. The purpose of this section is to start building a rapport with the client; whilst also gathering potential protective factors within a person’s life. This is absolutely fundamental as it will help you and any other clinician to gain a therapeutic relationship which is paramount within psychology.
Finally we have the formulation. This basically means that you would have gathered all the information within the session and are now expected to do something with it or develop next steps. Now depending on the service, you could be asked to present your formulation to the client/family whilst you’re still in the room; or be expected to liaise with the team. Either way you’re the lead clinician and will ultimately have the best insight into a client’s situation.
PsychAssist Tip: UTILISE SUPERVISION! (How to Best Utilise Supervision, Pre-Qualified!) This is exactly the type of work you need to bring to supervision. Have a conversation with your supervisor around your formulation. Don’t be afraid to fight for your view whilst also being open to the fact that you could be wrong. Don’t forget that everything is a learning curve.
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