Clinical Refresher
Module

More than just information gathering

Assessment is a collaborative, iterative process — not a one-off intake. You are building a working understanding of the person, not filling in boxes. The quality of your assessment directly determines the quality of your intervention.

The therapeutic relationship begins the moment the client enters. How you conduct assessment shapes whether they trust you enough to be honest about what's really going on.

What good assessment achieves

✅ Establishes the presenting problem — in the client's own words, not just a label

✅ Identifies maintaining factors — what keeps the problem going, not just what started it

✅ Uncovers strengths and resources — what the intervention can build on

✅ Begins to orient the client — often, being heard is itself therapeutic

✅ Screens for risk — always, from the very first session

Why formulation beats diagnosis

A diagnosis tells you what a person has. A formulation tells you why this person has this problem now, and crucially, how it's being maintained. The 5Ps give you a structured way to build that story.

A critical distinction

📌 Predisposing: "Has always been a perfectionist since school" — a trait that existed years before.

📌 Precipitating: "Received a formal performance warning last month" — a specific recent event that triggered the current episode.

Both might be present. They serve different roles in the formulation.

Why systems thinking matters clinically

A client's difficulties don't exist in isolation. The workplace is a dynamic system — staff shortages change workload, workload changes behaviour, behaviour changes relationships, relationships change culture, culture changes wellbeing. Intervening at the individual level alone may be insufficient if systemic factors are driving the problem.

The key clinical skill is identifying the entry point — the most accessible place in the cycle to intervene. This requires you to understand the cycle first.

What risk assessment covers

🔴 Suicidal ideation: Passive ("I wish I wasn't here") vs active ("I have a plan"). Both require exploration — the distinction matters for urgency, not for whether to explore.

🟠 Self-harm: Understand function (regulation, punishment, communication, expression) — not just frequency or method.

🟡 Harm to others: Screen for ideation, intent, and access to means. Rarely disclosed but legally and ethically critical.

🟢 Self-neglect: Not eating, not seeking medical care, social isolation, not sleeping. Chronic and often invisible.

🔵 Deterioration: Compare current functioning to the client's own baseline — what has significantly changed?

Common errors that create risk

❌ Asking once and assuming it stays stable — risk changes with life events. Reassess regularly.

❌ Using clinical jargon — ask "have you had thoughts of ending your life?" not "do you have suicidal ideation?"

❌ Assuming protective factors prevent risk — having a loving family does not make someone safe. Never assume.

❌ Avoiding the question — research consistently shows that asking about suicide does not increase risk. It reduces distress.

❌ Normalising without exploring — "lots of people feel that way" shuts down disclosure before it begins.

When to refer — the nuanced version

Referral is not binary. It exists on a spectrum from consultation (seeking peer guidance), to parallel working (co-existing support), to full transfer of care. Knowing which you're doing and why is essential.

Refer when: (1) risk exceeds your competence, (2) the presentation requires specialist training you don't have, or (3) the client is not progressing despite appropriate intervention.

A referral is not a failure. Knowing your scope of practice is what protects both the client and you.

What makes a formulation good?

A formulation is a working hypothesis, not a diagnosis. It should be:

✅ Individualised — specific to this person, not a template

✅ Explanatory — tells the story of how the problem developed and is maintained

✅ Collaborative — ideally shared with and contributed to by the client

✅ Testable — generates predictions about what intervention will help

✅ Revisable — updated as you learn more; never treated as fixed truth