It is important to be respectful to all clients, but Asian American clients may respond especially well to being treated with formal respect. Using Mr., Mrs., and Ms.

and a last name is a signal of respect and should not be discontinued until the client directly invites a ?rst name address. However, be aware that traditionally, in most Asian countries, women keep their own family surnames and may wish to be called by that surname even if, because of customs in the United States, she has begun to use her husband’s surname. A simple inquiry along these lines indicates respect.

Spiritual and Religious Matters

A common practice among many Asian cultures has been the keeping of an ancestor altar. A reverence toward ancestors and various beliefs regarding ancestral spirits, wishes, or presence in family matters can be central to individual and family function386 Interviewing Special Populations

Working with an Asian American Client

In a recent issue of Psychotherapy, John Chambers Christopher, a colleague of ours, reports on the following case: Simon, an East Asian international student, referred himself to the university counseling center after about one year of studying in the United States. Simon reported low self esteem, dif?culty concentrating, and problems with socializing. His stated goal for therapy was to become “more assertive in his interactions with others” . In particular, Simon expressed a desire to become more similar to his American roommates and less like other international students from his homeland.

Presented by a different therapist and/or a different client, this case might simply be cast into the rather straightforward mold of assertiveness training.

Finally, counselors should consider an effort reward for children who prove they do not have the ability to sustain attention and effort for a reward that is distant in time .

Inferring Attachment Issues

Some people, when they have taken too much and have been driven beyond the point of endurance, simply crumble and give up. There are others, though they are not many, who will for some reason always be unconquerable. You meet them in time of war and also in time of peace. They have an indomitable spirit and nothing, neither pain nor torture nor threat of death will cause them to give up. Little Peter Watson was one of these.

-Roald Dahl, The Swan Children’s lives-their emotional, intellectual, and physical development, their attitudes and beliefs, their opportunities and hindrances-are directly and radically affected by their early caretakers and the quality of the attachment to these ?gures . Recently, therapists have become more oriented to attachment dynamics in children and adolescents . Consequently, formal measures of attachment can now be administered to clients at the beginning of or during therapy. However, rather than relying on questionnaire administration, the approach we present here focuses on therapist ratings of client attachment behaviors based on Bartholomew’s reformulation of Hazan and Shaver’s and Bowlby’s attachment models. Speci?cally, therapists can categorize their young clients’ attachment behaviors into one of Bartholomew’s four attachment styles: Secure prototype: Clients appear comfortable and open interacting with the interviewer or therapist. They are capable of being emotionally close to others. There are no signi?cant problems with separation from parents or with separation from the interviewer when the session ends.

Step 1 Problem Selection: Step 2 Problem De?nition: Step 3 Goal Development: Step 4 Objective Construction: Step 5 Intervention Creation: Step 6 Diagnosis Determination: Putting It in Practice 10.21. Gain the most complete understanding of client problem possible, given the limits of time; client expressive abilities; and client awareness. Use Lazarus’s BASIC ID or some other guide to remind you of the many complex aspects of a client in need of assistance. Often, we use a model that includes a review of social, cognitive, emotional, physical, behavioral, and cultural aspects of the individual’s functioning.

Gain the most complete understanding of your client’s goal that you can. Ask clients what their life would look like if things were better. What would be a tolerable outcome? What would be the best imaginable outcome? Sometimes, projective questions such as de Shazer’s “miracle question” help clients articulate their goals .

Do your homework, part one: Go over what you know about your clients and their problems. Ask yourself what you still need to know to ?ll in any crucial gaps and make every effort to obtain this information. If you have time limits regarding when you must have your treatment plan completed , you may need to ask clients to wait for a minute or two as you sort through the information they have given you. Then, moving back to a collaborative mode, summarize your thoughts about primary and secondary problems and establish a provisional treatment plan.

Do your homework, part two: After the session, review a short list of viable treatment options, given what you know from your problem conceptualization and client goal statements. If you are unable to identify clear and appropriate treatment interventions, read, consult, and, if needed, obtain supervision. At that point, you can rank order the intervention alternatives and present them to your client during session two.

Robinson, D. J. . Brain calipers: Descriptive psychopathology and the psychiatric mental status examination . Port Huron, MI: Rapid Psychler Press. This article provides an overview of the mental status examination with examples, sample questions, and discussions of the relevance of particular ?ndings. It uses an entertaining approach complete with illustrations, humor, mnemonics, and summary diagrams. It also has a helpful chapter on the Mini Mental State exam.

Strub, R. L., & Black, W. . The mental status examination in neurology . Philadelphia: F. A. Davis. This is a very popular and classic mental status examination training text for medical students. It provides excellent practical and sensitive methods for determining client mental status along with some norms for evaluating patient performance on speci?c cognitive tasks.

Zuckerman, E. L. . Clinician’s thesaurus: The guidebook for writing psychological reports . New York: Guilford Press. This guidebook has a practical section on conducting and writing up the mental status evaluation. It also includes reproducible forms for documenting client mental status.

The Mental Status Examination SUICIDE ASSESSMENT There was no answer. The door of the lighthouse was ajar. They pushed it open and walked into a shuttered twilight. Through an archway on the further side of the room they could see the bottom of the staircase that led up to the higher ?oors. Just under the crown of the arch dangled a pair of feet.

-Aldous Huxley, Brave New World There are two basic, albeit contradictory, truths about suicide: Suicide should never be committed when one is depressed ; and almost every suicide is committed for reasons that make sense to the person who does it.

For each category addressed in the traditional mental status examination, try to think of cultures that would behave very differently but still be within “normal” parameters for their cultural or racial group. Examples include differences in cultural manifestations of grief, stress, humiliation, or trauma. In addition, persons from minority cultures who have recently been displaced may display confusion, fear, or resistance that is entirely appropriate to the situation. Further, in traumatic or stressful situations, persons with disabilities may be misunderstood.

Work with a partner to generate multicultural mental status observations that might lead an interviewer to an inappropriate and invalid conclusion regarding client mental status. Use the mental status categories listed below:

Category Observation Invalid Conclusion

Appearance: Behavior/psychomotor activity: Attitude toward examiner: Affect and mood: Speech and thought: Perceptual disturbances: Orientation and consciousness: Memory and intelligence: Reliability, judgment, and insight: INDIVIDUAL AND CULTURAL HIGHLIGHT 8.1Appearance refers to client physical and demographic characteristics, such as sex, age, and race. Behavior or psychomotor activity refers to physical movements made by clients during an interview. Movements may be excessive, limited, absent, or bizarre.

Documentation of client movement during an interview is important evidence that may support your mental status conclusions.

Client attitude toward the evaluator is assessed primarily as interpersonal behavior toward the examiner or interview. Determination of client attitude may be affected by an interviewer’s emotional reactions during an interview; therefore, interviewers should exercise caution when labeling client attitude.

Mental status examiners usually describe degree of client insight by referring to one of four descriptors: Absent: Clients who are labeled as having an absence of insight usually do not admit to having any problems. They may blame someone else for being referred for treatment or for being hospitalized. Obviously, these clients show no evidence of grasping a reasonable explanation for their symptoms because they deny that they have The Mental Status Examination 237any problematic symptoms. If an interviewer suggests that a problem may exist, this type of client usually becomes very defensive.

Poor:Clients who admit to having a minor problem or some nuisance symptoms, but rely exclusively on physical, medical, or situational explanations for symptoms, are often referred to as having poor insight. There is resistance to accepting the fact that life situations or emotional states can contribute-at all-to personal problems or illnesses. These clients deny the existence of any personal responsibility or nonphysical factors contributing to their problems. If they admit a problem exists, they are likely to rely solely on medications, surgery, or getting away from people they blame for their problems, as treatment for their condition.

Partial: Clients who admit, more often than not, that they have a problem that may warrant treatment are considered as having partial insight; however, this insight can pass and such clients often leave treatment prematurely. These clients can occasionally articulate how situational or emotional factors contribute to their condition and how their own behavior may contribute to their problems. They are reluctant to focus on such factors, but gentle reminders motivate them to work with nonmedical treatment approaches.

Thought Process

Observation and evaluation of thought is usually broken into two broad categories: thought process and thought content. Thought process refers to how clients express themselves. In other words, does thinking proceed in a systematic, organized, and logical manner? Can clients “get to the point” when expressing themselves? In many cases, it is useful to obtain a verbatim sample of client speech to capture psychopathological processes. The following sample was taken from a client’s letter to his therapist, who was relocating to seek further professional education.

Dear Bill: My success ?nally came around and I ?nally made plenty of good common sense with my attitude and I hope your sister will come along just ?ne really now and learn maybe at her elementary school whatever she may ask will not really develop to bad a complication of any kind I don’t know for sure whether you’re married or not yet but I hope you come along just ?ne with yourself and your plans on being a doctor somewhere or whatever or however too maybe well now so. I suppose I’ll be at one of those inside sanitariums where it’ll work out . . . and it’ll come around okay really, Bye for now.

The client who wrote this letter clearly had a thinking process dysfunction. His thinking is disorganized and minimally coherent. Initially, his communication is characterized by a loosening of association; then, after writing the word doctor, the client decompensates into complete incoherence .

There are many ways to describe speech or thought processes. Some of the most common thought process descriptors are listed and de?ned in Table 8.2. When describing client speech and thought process, a mental status examiner might state: The client’s speech was loud and pressured. Her communication was sometimes incoherent; she exhibited ?ight of ideas and neologisms.

Inappropriate with respect to speech content and life situation : .

Shallow : referring to little depth or maintenance of emotion .

The preceding client might be described as having a . . . labile, primarily euphoric affect that showed signs of being inappropriate and shallow.

Mood

In a mental status exam, mood is different from affect. Mood is de?ned simply as the client’s self report regarding his or her prevailing emotional state. Mood should be evaluated directly through a simple, nonleading, open ended question such as, “How The Mental Status Examination 221have you been feeling lately?” or “Would you describe your mood for me?” rather than a closed and leading question that suggests an answer to the client: “Are you depressed?” When asked about their emotional state, some patients respond with a description of their physical condition or a description of their current life situation. If so, simply listen and then follow up with, “And how about emotionally? How are you feeling about ?” It is desirable to record a client’s response to your mood question verbatim. This makes it easier to compare a client’s self reported mood on one occasion with his or her self reported mood on another occasion. In addition, it is important to compare selfreported mood with your evaluation of client affect. Self reported mood should also be compared with self reported thought content, because the thought content may account for the predominance of a particular mood.

Mood can be distinguished from affect on the basis of several features. Mood tends to last longer than affect. Mood changes less spontaneously than affect. Mood constitutes the emotional background. Mood is reported by the client, whereas affect is observed by the interviewer . Put another way , mood is to affect as climate is to weather.

Hostile: The client is indirectly nasty or biting. Sarcasm, rolling back one’s eyes in apparent disgust over an interviewer comment or question, or staring off with a sour grimace may represent subtle, or not so subtle, hostility. This behavior pattern is especially common among delinquent teenagers .

Impatient: The client is on the edge of his or her seat. The client is not very tolerant of pauses or of times when interviewer speech becomes deliberate. He or she may make statements about wanting an answer to concerns immediately. There may be associated hostility and competitiveness in the case of Type A personality styles.

Indifferent: The client’s appearance and movements suggest lack of concern or interest in the interview. The client may yawn, drum ?ngers, or become distracted by irrelevant issues or details.

The client could also be described as apathetic.

Ingratiating: The client is obsequious and overly solicitous of approval and interviewer reinforcement. He or she may try to present self in an overly positive manner, or may agree with everything and anything the interviewer says. There may be excessive head nodding, eye contact, and smiles.

Intense: The client’s eye contact is constant, or almost so; the client’s body leans forward and listens intensely to the interviewer’s every word. Client voice volume may be loud and voice tone forceful. The client is the opposite of indifferent.

Manipulative: The client tries to use the examiner for the client’s own purpose or edi?cation. He or she may interpret examiner statements to represent own best interests. Statements such as “His behavior isn’t fair, is it Doctor?” are efforts to solicit agreement and may represent manipulation.

Additionally, observations regarding client responsiveness to interviewer questions, including nonverbal factors such as voice tone, eye contact, and body posture, as well as verbal factors such as response latency and directiveness or evasiveness of response, all help interviewers determine their client’s attitude.

This portion of the mental status exam bene?ts from the emotional subjectivity discussed earlier. Interviewers must allow themselves to respond honestly to clients and then scrutinize their own reactions for clues to clients’ attitudes. Such judgments are based on the interviewer’s internal cognitive and emotional processes and, consequently, are subject to personal bias. For example, a male interviewer may infer seductiveness from the behavior of an attractive female because of his wish that she behave seductively, rather than any actual seductive behavior. Furthermore, what is considered seductive by the examiner may not be considered seductive by the client. Differences may be based on individual or cultural background. It is the interviewer’s professional responsibility to avoid overinterpreting client behavior by attributing it to a general client attitude or, in some cases, a personality trait. When making judgments or attributions about client behavior, you should recall the criteria for disordered behavior presented in Chapter 6 and ask yourself: Is the behavior unusual or statistically infrequent? Is the behavior disturbing to the client or to others in the client’s environment at home or work? Is the behavior maladaptive; that is, does it contribute to the client’s dif?culty? Is the client’s behavior justi?able based on present environmental or cultural factors? There are many ways a client can relate to an interviewer. Words commonly used to describe client attitude toward the interview or interviewer are listed in Table 8.1.