Assessment and Intervention Planning
What you must know
Assessment rests on the biopsychosocial-spiritual interview, the mental status exam, DSM-5-TR criteria (duration, severity, functional impairment, rule-outs), differential diagnosis, and medical rule-outs. Risk assessment is the top priority: suicide (ideation, plan, intent, means, protective factors), violence, and abuse or neglect with mandated reporting. For standardized instruments, know reliability (consistency) versus validity (accuracy), the normed population, sensitivity and specificity, and cultural bias. Intervention planning requires measurable, client-centered goals in SMART form, the least restrictive setting, interdisciplinary collaboration, and measurement-based care. Obtain informed consent for assessment and treatment, and honor the client's right to refuse.
Traps
- Diagnosing from a single symptom, or ignoring substance use and medical conditions that mimic psychiatric symptoms.
- Using an instrument normed on a different population without adjusting interpretation.
- Writing vague or provider-centered goals ("client will feel better") instead of measurable ones.
- Skipping risk assessment because the client appears calm and cooperative.
- Confusing prevalence (existing cases) with incidence (new cases).
- Assuming a diagnosis is required before services can be provided.
Worked example
An adult reports insomnia, poor concentration, and low mood for three weeks after a job loss. Distractors point to major depressive disorder. The better answer gathers duration, severity, and functional impairment, rules out substance use and medical causes, and assesses suicide risk before diagnosing. Rule of thumb: assess risk first, rule out medical and substance causes second, diagnose third.