Vignette 4: Introduction to a Mental Health Assessment

Shawn is a 16 year old boy who has come to an outpatient clinic for a mental health assessment. As with many, if not most adolescent boys, the appointment is not his idea and he is not happy to be at the clinic. The provider must use a technique to engage him in a way that helps him feel that it was worth his while to come. He must help the patient get beyond his closed off presentation and help the boy talk about himself.

In this vignette:

  • The provider informs the patient about confidentiality, an important part of every introductory medical and mental health appointment.
  • The patient presents as angry and disinterested. The provider asks why he has come to the clinic, and he responds that it was his mother’s idea. The provider tries to empathize about the patient’s lack of understanding about the reason for the visit, but this attempt is not well received. The provider then states that he would like to get to know the patient– a friendly gesture.
  • The provider asks about school. The patient speaks negatively about school and continues to have an angry demeanor, but begins to talk more.
  • When the patient says his mother thinks he has an “anger management” problem, the provider challenges him, saying that his mother must have a reason for thinking this. The provider’s tone of voice and facial expressions indicate that he is having some negative feelings about this patient. This alienates the patient, who withdraws.
  • The provider re–engages the patient by asking him about his own views. This is respectful of the patient as it communicates that the provider believes that the patient has his own thoughts and feelings worth finding out about. The patient responds by becoming more verbal and making better eye contact.
  • The patient says he doesn’t like it when his mother “keeps nagging him” to talk about his feelings. The provider should see this as a developmental issue as well as a family issue, as adolescent boys do not generally want to talk to their mothers about their feelings. The provider should also recognize that the patient is saying that talking about his feelings is hard for him and he feels angry when he is pushed to try. The provider reflects and normalizes the patient’s aversion to talking to his mother in a humorous way. This resonates with the patient and helps him become more connected. He indicates this with agreement and a laugh.
  • The provider asks about other people in the patient’s life and finds out that he is more comfortable relating to his girlfriend and his coach. The patient shows more warmth and becomes more genuine when talking about other relationships.
  • The provider formulates that the patient is appreciative when people listen to him rather than pressure him. The patient affirms this both verbally and in body language, and he and the provider go on to have a more comfortable conversation.

The positive elements in this vignette are:

  • The provider tries to engage the patient with questions about school.
  • The provider seeks the patient’s view about the problems he is having.
  • The provider uses humor to empathize with the patient’s frustration with his mother, and gets a positive response from the patient.
  • The provider articulates for the patient the patient’s need to be listened to and not feel pressured into disclosing his feelings.

The negative elements in this vignette are:

  • The provider initially makes a clumsy attempt to empathize with the patient. It is not received well.
  • The provider expresses irritation with the patient through an edgy tone of voice and a challenging statement about his mother having a reason for his being there. This alienates the patient.
  • The provider doesn’t elicit strategies for the patient to communicate with his mother more effectively.
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