Intake, Clinical Assessment and Ethical Documentation
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Intake, Clinical Assessment and Ethical Documentation
Introduction
The process of diagnosing and planning a treatment procedure for a client which includes the collection of the required information and details to identify, analyze, evaluate and address the problem the client has is referred to as clinical assessment (Kuo, 2017). In most cases, counselling and therapy ways are used. Documentation is essential during clinical assessment both for the client and the clinician too. It offers written evidence of the details of the client, including the name, age, background, among other personal information. This document allows details of the problem the client is suffering from (Henry et al. 2016). It is also a platform whereby family members are allowed to track the treatment progress of their client. The recorded information help and support the clinician to come up with the proper treatment plan and offer the best services to the patient.
Similarly, the client intake process is the ideal opportunity whereby the clinician can get every required detail about the client to complete the given project (Kuo, 2017). It is during this stage of collecting information from the client that the clinician can create a good relationship and does the work to be more comfortable. Both the documentation and intake are part of conducting the clinical assessment. A combination of interviewing and use of assessment tools aids in the better results at the end. The purpose of this discussion was to identify the procedure followed and how the case of Markus was carried out to come up with the best solution.
Identification of the case and summarization of the skills
The chosen case is of the man named Markus, who is 42 years old. He is a black American, heterosexual and a Christian. Further to this, he is a high school graduate who also studied management and currently working as the manager in a tire company warehouse (Thompson, 2018). During his early childhood, his father was not present for him, but on several occasions, he demonstrated fatherly lobe toward hm. His mother, on the other hand, was always present for him and he felt completely loved.
He was once married, but his marriage did not work. However, the marriage left him, two kids. In his early 30s, he underwent gall bladder minor surgery and had an underlying condition which is asthma. This condition, however, does not prevent him from performing his duties perfect well (Henry et al. 2016). He has insomnia for the last two years.
Since he was divorced, Markus has been a victim of depression and turned to alcohol too. He reported that his problem began when the wife left him for another man. Due to depression, he gets easily agitated with his colleagues, kids and friends. He said that he is anxious and unable to control his thoughts, thus overthinking (Rekman et al. 2018). He gets afraid of the future and has not adopted to the fact that he is alone, which makes him feel lonely.
Some of the most valuable therapeutic skills that were used to create a good relationship between the client and the clinicians were the listening and observation skills (Thompson, 2018). Active listening is whereby a client is given ample time to express themselves and talk out while the clinician is giving attention to what he or she is saying without interacting (Thompson, 2018). Verbal listening was also used whereby the clinician used words like (yes) or (go on) to show that he is giving attention.
Empathy was also used as a skill. The clinician was able to put him or herself in the shoes of the client to understand the client’s feelings in the experience (Rekman et al. 2018). This skill was adopted to help come up with the basic plan to help out. Another power is the reflection which was used to describe the client state of mind and to feel accurate. By asking questions, the clinician was able to learn more about the client state of health both physically and mentally. Counsellor self- disclosure skill was used as well (Rekman et al. 2018). The clinician shared personal information that was beneficial during the therapeutical process as well as help the client open up to the clinician without an issue. Through these skills, a good rapport was created between the client and the clinician.
Exploration of Ethical, Legal and Cultural Considerations
Ethical codes that were successfully applied include honesty, integrity, respect resilience, competence, fairness, courage, wisdom, humility and confidential, all this code worked for good to achieve the best results (Henry et al. 2016). The purpose of the ethical codes was to help control internal disagreement and protect the client from the incompetent counsellors, especially in the deeply personal issues.
The counsellor needs to understand the client’s background, ethnicity and belief system. This is important to help them to respect their differences and opinions, values and attitudes to various situation. Culture influences the expectations on the relationship between the two parties and Interaction as well as understanding that the healing process (Rekman et al. 2018).
Assessment Identification
Out of the client information taken as well as the excellent relationship that was created, Markus was able to disclose the fact that he has suicidal thoughts. This was seen since he suffered from depression and turned into alcoholism. Markus kept on asking himself why his wife would leave him for another man, and yet he would provide everything that she needed (Rekman et al. 2018). The purpose of conducting a suicidal assessment, in this case, was to identify the intent of the patient and assess the seriousness of the suicidal attempt.
Standardized mini-mental state examination assessment tool was also used to read the mental health of Markus. In this case, the clinician introduced himself to the client, which created the confidence of the person (Thompson, 2018). After that, Mark was asked a few questions and given a specific task. This tool was used to determine the mental condition of the client. This method was vital as it helped assess the cognitive part of the client.
Exploration of Interview Tasks
It is necessary that during counselling and therapy assessment is critical. It is crucial because one can know the state of mind of the individuals. In Markus condition, it is through evaluation that it was identified why he had suicidal thoughts (Mc Lennan, 2018). After discovering that he had suicidal ideas and depression and kept on blaming himself for what had begotten of him, helped the counsellor to come up with better ways for treatment which made him accept himself.
During therapy, the main objective is to achieve success and help the client to make the desired healing. Therefore, exploration and well-planned process are necessary. The most crucial process is to establish a good relationship (Thompson, 2018). This means that the client must gain trust with the counsellor to be able to open up and express oneself without fear.
Through listening and observing this was achieved by giving enough time to the client to express themselves and talk out their issues. Having excellent listening skills while counselling created a unique platform of ensuring that trust is established therefore allowing the client to open up and disclose what is in their hearts encouraging both the parties to share emotions (Henry et al. 2016). Active listening makes the client feel appreciated, respected and worth. It makes communication remain positive and open.
By reflecting and paraphrasing a client feels appreciated and knows that his story is being listened. It was achieved by paraphrasing what the client said. It means that the counsellor involved can decide how to help the client (Mc Lennan, 2018). It is through reflection that the therapist is also able to reveal how they feel in response to the client.
Questions in counselling are crucial to both parties that are involved. It is a fundamental skill whereby the counsellor uses open items to get clarification where necessary. He also uses this skill to understand the feeling of the client. During questioning, more information is obtained, which is very helpful to the counselling session (Henry et al. 2016). As a counsellor, I would involve the client by asking more open questions to get more information, and this will help me find the best way out to help the patient recover. It is good to note that leading questions should not be asked and should be avoided to avoid terminating the rapport that is created.
Being sympathetic is very important during the counselling session. As earlier showing sympathy is a skill used to help the counsellor understand the client. It is during this skill that one is advised not to be judgmental or get too sympathetic to the extent of getting emotional (Henry et al. 2016). When the client sees that the counsellor is not judging him or her, he can open more and feel accepted. The person who is undergoing therapy thinks that in their grief they are not alone.
Strategies for Success
While carrying out counselling sessions, the main objective is to offer the best services to the clients. In this case, the strategies that were used as identification of the problem the client faced. It was achieved through interviewing, questions and answering and use of a questionnaire. After that, analyzing these problems through several meetings and having known the depth to which they had affected the client, the counsellor was able to come up with a lasting solution that made the client satisfied and happy (Rekman et al. 2018).
Having a working relationship with the client is very important. The counsellor is the one who should be able to come up with the kind of relationship he wants for the client (Rekman et al. 2018). A respectful, friendly and understanding relationship is the best during therapy. Once this kind of relationship is achieved, there will be less resistance and successfully engages the client towards the mutually defined goals.
Another strategy that was used in the Markus case to attain success is through the provision of a flexible working schedule. This is whereby both the parties chose a time where they were available without fail. The many meetings are essential in ensuring that the counselling process finally succeed and the goal is achieved (Mc Lennan, 2018). It is advisable not to create too many hours for treatment for clients as it can be seen to be difficult and challenging.
Challenges
During counselling, the clients need to be given enough attention, especially during the first few weeks of treatment (Hariri et al. 2019). It is because they feel vulnerable and ambivalent. It is a difficult period for the counsellor because he or she needs to keep in touch with the client to enhance retention.
Many dropouts and readmissions are one of the significant challenges the counsellors face. It is whereby most of the clients drop the treatment sessions and fail to show up again before achieving stable recovery. This means the same clients have to be readmitted back and restart their treatment again (Hariri, et al. 2019). This readmission creates a situation where the client may feel tired and tend to give up. For example, in the case of Markus, he almost gave up the therapy sessions because he felt that the meetings were too much. However, through consistent follow-up, success was reached.
Another challenge faced during counselling is whereby the client finds it hard to share and open up. Where there is no proper environment or where a good relationship is not created the client may find it hard to open up entirely on the issues they are facing, and this limits the counsellor to offering better services (Mc Lennan, 2018). It is therefore essential that the client should feel free to open up without hiding some of the details.
In conclusion, counselling sessions are essential in ensuring that people who suffer from mental sessions are crucial and are believed to achieve better results. Clinical assessment is critical in figuring out the treatment method to a client.
References
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McLennan, V., Ryan, K., & Randall, C. (2018). Ethical Dilemmas Experienced by Australian Rehabilitation Counsellors. Online Journal of Health Ethics, 14(1), 7.
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