Clinical Impressions

As a budding clinician, I'm learning so much at the end of my education journey. I only have one term and a few weeks left and am just now learning about clinical impressions. I presume the reason this is coming to me now is because the previous couple years of graduate school was working on a foundation for me to base my clinical impressions off of.

So, what is a clinical impression? I've been wondering this myself and have searched high and low to get a better grasp and understanding. As practitioners, we assess the client's individual status by formulating an opinion. This formulation and assessment is an ongoing process, capturing and integrating information discovered during the assessment process and the issues uncovered throughout the first few sessions.

My struggle with this is developing the clinical language around the matter, what words to say, and what words might appear judgmental or biased. Grounding myself and checking my biases, using my supervisor as a sounding board, are a couple of ways I'm working through this.

The key to a clinical impression is to be sensitive to what is being said, what is not said, what my Spidey (therapy) senses say, and follow my therapeutic intuition.

To gather the language bit of Clinical Impressions, I did a little Googling and found some examples on Yourceus.com which include some of the following:

The individual appears to be a reliable informant with sincere commitment to achieving goals by adherence to the development plan.

Okay, that one sounded very dry and boring, not at all my style of what feels natural to me.

The individual exhibits moderate difficulty in social and occupational functioning that is compounded by significant medical, financial, and legal problems.

This one paints a better picture. I'm not going to share the other examples, as they are not profound to me.

Next, I'll try to come up with some of my own examples of a clinical impression. Please comment below to let me know what you think and if there are some examples you'd like to share.

It is this clinician's impression that the client is experiencing a depressive mood, backed by their reports of having a hard time getting out of the house, being tearful, having a poor relationship with food by overeating, reports of lacking in a self-care regimen, and getting dressed for the day,

Although the client did not express anxiety about their recent transition into the school dorms, they shared that their service dog was nervous and anxious. The client seemed nervous and anxious sharing this, including bouncing their leg.