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Ask the Mental Health Expert Archives 2001-2004

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Counselling Patients

Q. When dealing with mental health patients in a counselling situation, how would you assess if the patient is grounded in reality, is a potential risk to himself (self-harm) and harm to others?

A. You are inquiring about two separate, though related, areas of investigation--each of which would require a chapter of its own to answer thoroughly! The first issue is that of so-called reality testing--whether the patient shows any psychotic-level disturbance of thinking or behavior. This assessment is normally part of the initial mental status exam, performed at time of intake.

It involves questions that probe for (1) paranoid or other delusional ideas; (2) psychotic-level experiences, such as feeling that one's thoughts are being read or controlled by others; feeling that one is getting messages from the radio or TV; etc., and (3) psychotic level perceptual disturbances, such as hearing voices discussing one's behavior or issuing commands; or seeing things that nobody else sees. This sort of assessment must be done with great tact, lest the patient react with alarm or anger.

A very helpful way to approach this is to begin with very general questions, such as "How have you been feeling lately?" and "Have you had any very unusual thoughts or experiences lately?" As you move toward more and more pointed questions probing for psychosis, you can shift to what is sometimes called a counter-projective technique (described by Leston Havens and others). This avoids asking the patient directly, "Do you hear voices?", for example, and begins instead with the phrase, "Some people?". For example, you might say, "Some people experience unusual noises in their head now and then. Has this ever happened to you?" Or, "Some people feel very frightened around other people or feel that others are out to harm them. Does this feeling ever come up for you?"

By using this technique, you help normalize the content of the question, and reduce the patient's underlying fear that "You must think I'm crazy". The issue of danger to self or others is also guided by a similar pyramidal principle of questioning: begin at the base of the pyramid with very general questions, then become more and more specific. For example, "How have you been feeling lately?" If the person indicates he or she has not been feeling good, you begin to probe for suicidal ideation, intentions, or plans: "How bad have you been feeling? Have these feelings ever gotten to the point where you felt like not going on with life? [If so: "Has it ever gotten to the point where you felt like harming yourself in any way? "Have you made any specific plans to do so?" etc.].Here, too, using the "some people" approach may be useful; e.g., "Some people get so depressed at times that they begin to think about harming themselves. Has this ever happened to you?".

For more information on the assessment of dangerousness to self or others, I recommend you see supplement 2 to the Journal of Clinical Psychiatry, 1999. This contains a number of helpful articles. For an excellent text on the clinical interview and diagnosis, I recommend "The Clinical Interview Using DSM-IV", volume 1, by E. Othmer and SC. Othmer (American Psychiatric Press, 1994).

January 2003

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