As the Director of Admissions for a residential treatment center for over seven years, I learned the hard way why initial assessments are crucial. I have found it to be essential from the inception of a clinical relationship to have as much information and as broad an overview of your new client as possible. The assessment components I have found to be most beneficial are the following:

A preliminary conversation with the potential client to explore compatibility issues. Those issues include personality types, the theoretical orientation of the therapist, level experience the therapist has with the client’s presenting issues and the least comfortable part, fees and insurance benefits.

An Assessment Interview.
These can be done in person or by phone and should be quite comprehensive. I recommend they cover both historical and current information, include personal as well as family history of addictions, mental illness, suicides and suicidal ideation. Experiences with prior therapy and treatment, medications, drug and alcohol use, sexual and relationship history, eating patterns and psychotic or dissociative symptoms are also very important areas. Not only is this interview a great way to obtain critical information that may otherwise take months to obtain but it provides a good chance to develop rapport and connection with the client.

Ask the tough questions.
Don’t be afraid to ask questions that may be uncomfortable such as sexual history or patterns around relapse. If you have developed a connection and established some sense of trust with the client, they will almost always answer you honestly. If they are unable to talk about a certain topic or experience or you sense they are holding something back that is diagnostic as well. Be sure to be non judgmental and remind them that all information is confidential (within legal, ethical and HIPAA guidelines of course).

Gather information from past providers.
Reviewing records or talking directly with previous treatment centers, psychiatrists and therapists can be very enlightening as well as saving you a lot of time in therapy. Another benefit is that you can get a good idea of a client’s pattern in recovery, with relapse behaviors as well as what has worked well and what has not.

Be honest if you feel you are not qualified to treat the client.
If you feel you may not be the best therapist for the client let them know that and refer the case elsewhere. If you can, make a specific recommendation for an appropriate provider and if not I encourage you to assist them in finding the right person. If you find you are already working with a client that has needs that you may not be able to meet, but still want to continue the therapeutic relationship, consider referring to a specialist for that particular issue or enter into clinical supervision yourself.

If you would like to discuss any of these points further or consult about how to implement some of these ideas in your practice please feel free to contact us. We would love to hear from you., 888-301-9425.

Author's Bio: 

Amy Lashway, MA, LPC, NCC is a licensed, master level therapist and a nationally certified counselor and has been in the field of mental health and addictions since 1989. She graduated from The University of Massachusetts in 1991 with a BS in Psychology and from The University of New Mexico in 1997 with her Masters in Counselor Education. Amy has trained in a variety of settings such as residential treatment centers, crisis shelters, psychiatric hospitals, private practice and intensive workshops. For nine years she worked at The Life Healing Center of Santa Fe as The Director of Admissions and Aftercare, a Primary and Individual Therapist and Director of Medical Records and later as a consultant.

In 2004 Amy established Treatment Coordination and Advocacy, a national treatment placement and private clinical case management service. Treatment Coordination specializes in complex and multi diagnosed clients who are in need of professional help to further their recovery and healing processes.

In 2006 Amy and her business partner, Lynn Sucher, MS, LPC, NCC, CEDS created Treatment Consultants, an international consulting business that works exclusively with mental health and addiction professionals. Services are offered to treatment centers and treatment programs in the areas of clinical program development, marketing, policy and procedure, case consultation, staff training and intake and case management.

Amy has successfully combined her extensive knowledge of eating disorders, addictions, sexual abuse, emotional trauma, affective disorders, sexual compulsivity and personality disorders with the skills of clinical assessment, individual treatment planning, implementation, program development, marketing and quality assurance. Additionally, Amy has years of management experience and places a premium on a team approach to treatment.

Amy’s personal philosophy is that everyone deserves the gift of recovery and that all individuals, no matter how profoundly wounded, can heal.