Mental Status Assessment

Instructions attached

COUC 5

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Benchmark Intake Part Two: Mental Status Exam (MSE) Assignment Instructions

Important

For assessment purposes, it is important that you submit both parts of the intake assignment in one document in both Canvas and Tevera. Simply add this part of the assignment (
Intake Part Two: Mental Status Exam (MSE) Assignment) to the first part (
Intake Part One: Initial Interview Assignment) and submit them as one Microsoft word document. Your assignment will not be considered complete until you upload both parts together.

Overview

One task in the initial interview is a gathering of information about the client’s mental status. You already have gathered background information in the
Intake Part One: Initial Interview Assignment. In this
Intake Part Two: Mental Status Exam (MSE) Assignment, you will write up the Mental Status Exam (MSE) portion of that
Benchmark Initial Interview Assignment. In the
Initial Interview Assignment report, you primarily focused on what the client revealed to you. For the
Mental Status Exam (MSE) Assignment, most of what you report on will be based on your observations from that initial interview (appearance, behaviors, mood, affect, thought processes, etc.), from specific questions you would ask in the initial interview. These observations provide information about the client that is not readily discernable from the initial interview data.

Instructions

·
Length of
Mental Status Exam (MSE) Assignment
: 600-900 words (not including the title page)

·
Format of
Mental Status Exam (MSE) Assignment
: APA for font (Times New Roman, 12 pt.), title page, margins, and section headings

·
Number of citations: none

·
Acceptable sources: none

For this
Mental Status Exam (MSE) Assignment, you will continue to the fictional character that you interviewed for the initial interview. Remember, the client that you selected is a relatively well-adjusted individual who has already passed the initial interview process with the referring agency. Therefore, your
Mental Status Exam (MSE) Assignment will mainly indicate functioning that is considered within the normal limits (WNL) of adaptive functioning.

Important points regarding the Initial Interview:

1. Because the psychological evaluation was

not
performed for clinical, forensic, or legal reasons, your character did not have a life-threatening
medical condition, a chronic or debilitating
psychological disorder, or an
extensive criminal history.

2. Report all applicable MSE information.

Format of the Mental Status Exam:

1. Gather the MSE information using the categories from pages 345-346 of the Sheperis et al. (2020) text and the “How to Conduct a Mental Status Exam” handout. Report the information using the Mental Status Exam Rubric as a guideline. Remember, you will use this information for another project. As you can see, there are various ways to organize and present MSE information (e.g., the text, the handout, and the sample is up to you). However, for the purposes of this
Benchmark Mental Status Exam (MSE) Assignment, make sure that you have all of the information required on the grading rubric.

2. Please make sure to note if the functioning is adaptive. For example, if no delusional thoughts are present, state it. If you do not specifically note this, the reader does not know if the client did not have delusions or if the counselor simply forgot to ask.

3. Written in the third person (e.g., “Mr. Jones is a 42 years old…,” or “His greatest strengths are…”).

4. Be sure that the information is consistent with the Initial Interview. Remember that your client is a well-adjusted individual that does not present with severe pathology.

Note: Your assignment will be checked for originality via the Turnitin plagiarism tool.

Be sure to review the
Benchmark
Mental Status Exam (MSE) Grading Rubric before beginning the
Benchmark Mental Status Exam (MSE) Assignment.

Categories of
Mental Status Exam from the Text

Appearance:
How was the client dressed and groomed (e.g., neat, disheveled, unkempt)?

Behavior/Psychomotor Activity:
Did the client exhibit slow movement, restlessness, or agitation? Did the client have any unusual behaviors such as tics, mannerisms, gestures?

Attitude toward Examiner:
Was the client’s attitude toward the examiner cooperative, friendly, attentive, defensive, hostile, evasive, guarded, and so forth?

Affect and Mood:
Did the client have sad, angry, depressed, or anxious mood? Was the client emotionally responsive (affect)? Was affect congruent with mood?

Speech:
How was the quantity, rate of production, and quality of the client’s speech (e.g., minimal – mostly yes and no answers; talkative; rapid/pressured speech)?

Perceptual Disturbances:
Did the client experience hallucinations or illusions? If so, what sensory system did they involve (e.g., auditory, visual, olfactory, tactile)?

Thought:
Did the client have any disturbances in thought process, which involves the rate of thoughts and how they flow and are connected (e.g., racing thoughts, flight of ideas, tangential). Were there any disturbances in thought content, such as delusions, obsessions, preoccupations, or suicidal or homicidal thoughts?

Orientation:
Was the client aware of (a) the date and time, (b) where he or she was, and

(c) who the people around him or her were (i.e., oriented to time, place, and person)?

Memory:
How was the client’s recent memory (e.g., what did he or she have for breakfast?) and remote memory (e.g., memories from childhood)?

Concentration and Attention:
Was the client’s concentration or attention impaired? Was the client distractible?

Information and Intelligence:
Can the client accomplish mental tasks that would be expected of a person of his or her educational level and background?

Judgment and Insight:
Does the client have the capacity for social judgment? Does the client have insight into the nature of his or her illness?

Reliability:
How accurately was the client able to report his or her situation?

Categories of
Mental Status Exam from the Handout

Appearance:

Presenting Appearance
(including sex, chronological and apparent age, ethnicity, build, physical deformities;

Basic Grooming and Hygiene
(plus appropriateness of attire, accessories like glasses or a cane;

Gait and Motor Coordination
(plus posture, work speed, any noteworthy mannerisms or gestures).

Manner and Approach
:

Interpersonal Characteristics and Approach to Evaluation
(resistant, submissive, defensive, open and friendly, candid and cooperative, showed subdued mistrust and hostility, excessive shyness);

Behavioral Approach
(distant, indifferent, anxious, alert, etc.)

Speech
(normal rate and volume, pressured, slow, etc.);

Eye Contact
(makes, avoids, etc.);

Expressive Language
(circumstantial and tangential responses, mumbling, etc.);

Receptive Language
(normal, difficulty understanding questions);

Recall and Memory
(can explain recent and past events in their personal history, recalls three words, etc.).

Orientation, Alertness, and Thought Processes:
Orientation
(person, place, time); Alertness (sleepy, alert);

Coherence
(coherent and easy to understand, overly detailed and difficult to follow);

Concentration and Attention
(naming the days of the week in reverse order, ABC’s backwards);

Thought Processes
(loose associations, flight of ideas, delusions);

Hallucinations and Delusions
;

Judgment and Insight; Intellectual Ability; Abstraction Skills

Mood and Affect:
Mood
(feels most days: happy, sad, anxious, angry);

Affect
(felt at any given moment);

Rapport
(easy to establish, easily upset);

Facial and Emotional Expressions
(relaxed, tense, smiled, laughed);

Suicidal and Homicidal Ideation; Risk for Violence; Impulsivity

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Page 1 of 3

Criteria Ratings Points

Content

Appearance
&
Psychomotor

16 to >14.

0 pts

Advanced

This section clearly
addresses and covers the
client’s presenting
appearance, suitability,
basic grooming and
hygiene, gait, and motor
coordination.

14 to >12.0 pts

Proficient

This section reasonably
addresses and covers the
client’s presenting
appearance, suitability,
basic grooming and
hygiene, gait, and motor
coordination.

12 to >0.0 pts

Developing

This section minimally
addresses and does not
cover the client’s
presenting appearance,
suitability, basic grooming
and hygiene, gait and
motor coordination.

0 pts

Not
Present

16 pts

Content

Manner &
Approach

18 to >16.0 pts

Advanced

This section clearly
addresses and covers the
client’s interpersonal
characteristics and
attitude towards
evaluation; behavioral
approach; speech; eye
contact; expressive and
receptive language; recall
and memory.

16 to >14.0 pts

Proficient

This section reasonably
addresses and covers the
client’s interpersonal
characteristics and
attitude towards
evaluation; behavioral
approach; speech; eye
contact; expressive and
receptive language; recall
and memory.

14 to >0.0 pts

Developing

This section minimally
addresses and does not
cover the client’s
interpersonal
characteristics and attitude
towards evaluation;
behavioral approach;
speech; eye contact;
expressive and receptive
language; recall and
memory.

0 pts

Not
Present

18 pts

Content

Orientation,
Alertness,
Thought
Processes

18 to >16.0 pts

Advanced

This section clearly
addresses and covers the
client’s orientation;
coherence; concentration
and attention; thought
processes; hallucinations
and delusions; judgment
and insight; intellectual
ability; and abstraction
skills.

16 to >14.0 pts

Proficient

This section reasonably
addresses and covers the
client’s orientation;
coherence; concentration
and attention; thought
processes; hallucinations
and delusions; judgment
and insight; intellectual
ability; and abstraction
skills.

14 to >0.0 pts

Developing

This section minimally
addresses and does not
cover the client’s
orientation; coherence;
concentration and
attention; thought
processes; hallucinations
and delusions; judgment
and insight; intellectual
ability; and abstraction
skills.

0 pts

Not
Present

18 pts

Benchmark Intake Report Part Two: Mental Status Exam (MSE)
Grading Rubric | COUC521_B05_202240

Criteria Ratings Points

Content

Mood &
Affect

18 to >16.0 pts

Advanced

This section clearly
addresses and covers the
client’s mood; affect;
rapport; facial and
emotional expressions;
suicidal and homicidal
ideation; risk for violence;
and impulsivity.

16 to >14.0 pts

Proficient

This section reasonably
addresses and covers the
client’s mood; affect;
rapport; facial and
emotional expressions;
suicidal and homicidal
ideation; risk for violence;
and impulsivity.

14 to >0.0 pts

Developing

This section minimally
addresses and does not
cover the client’s mood;
affect; rapport; facial and
emotional expressions;
suicidal and homicidal
ideation; risk for violence;
and impulsivity.

0 pts

Not
Present

18 pts

Structure

Paper:
Grammar &
Spelling

15 to >13.0 pts

Advanced

Spelling and grammar are
correct. Sentences are
complete, clear, and
concise. Paragraphs
contain appropriately
varied sentence
structures.

13 to >11.0 pts

Proficient

Spelling and grammar
have some errors.
Sentences are presented
well. Paragraphs contain
some varied sentence
structures.

11 to >0.0 pts

Developing

Spelling and grammar
errors distract. Sentences
are incomplete or unclear.
Paragraphs are poorly
formed.

0 pts

Not
Present

15 pts

Structure

Paper:
Length &
APA
Formatting

15 to >13.0 pts

Advanced

Paper is 600-900 words
in length (not including
the title page). Paper is
formatted in APA
including font, title page,
margins, and section
headings.

13 to >11.0 pts

Proficient

Paper is 450-599 words in
length. Paper is mostly
formatted in APA including
font, title page, margins,
and section headings.

11 to >0.0 pts

Developing

Paper is 449 words or less
in length. Paper is not
accurately formatted in
APA including font, title
page, margins, and section
headings.

0 pts

Not
Present

15 pts

Total Points: 100

Benchmark Intake Report Part Two: Mental Status Exam (MSE)
Grading Rubric | COUC521_B05_202240

COUC 5

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Benchmark Intake Report Part Two: Mental Status Exam (MSE) Assignment Template

Note: This template includes Part One of the assignment because it should be included in Part Two

Identifying Information

Client name, address, phone number, DOB, gender, marital status, occupation, work/school, work phone, emergency contact, date of interview

Reason for Referral

Referral source, reason for referral (why has the client been sent to you [e.g., consultation, clinical intake, counseling]); presenting complaint (hint: they are coming in for an evaluation)

Current Situation and Functioning

A description of typical daily activities, ability to complete normal activities of daily living (ADLs); general assessment of coping/character skills (e.g., stress management skills, emotional regulation ability; problem-solving, conflict resolution, empathy, cooperation, etc.); self-perceived strengths and weaknesses

Relevant Medical History

Previous and
current medical problems (major illnesses and injuries), medications, hospitalizations, and disabilities; any significant major medical disorders in blood relatives (e.g., cancer, diabetes, seizure disorders, thyroid disease, etc.)

Psychiatric Treatment History

Description of previous treatment received, including hospitalization, medications, psychotherapy or counseling, case management, etc. Include a description of all psychiatric and substance abuse disorders found in all blood relatives (i.e., at least parents, siblings, grandparents, and children, but also possibly aunts, uncles, and cousins)

Family History

Information about the client’s family background, including information about first-degree relatives (parents, siblings), the composition of the family during the client’s childhood and

adolescence, and the quality of relationships with family members both past and present.

Social and Developmental History

Significant developmental events that may influence current problems or circumstances. This should include, as aplplicable, issues surrounding pregnancy or birth; social, behavioral, and cognitive milestones; and relational history (include interaction with peers, people in authority, academic performance, and extra-curricular activities – e.g., sports, clubs, etc.); current and previous marital/non-marital relationships, children, and social supports.

Educational and Occupational History

Schools attended, educational level attained, and any professional, technical, and/or vocational training; current employment status, length of tenure on past jobs, military service (rank and duties), job performance, job losses, leaves of absence, and occupational injuries.

Cultural Influences

Potential assessment issues (see chapter 3) when working with a diverse populations.

Mental Status Exam

Appearance and Behavior

Susan C. is a 5’4” single White female of average weight. At the time of the interview, she had a pasty white complexion and several scars from adolescent acne. She presented herself in a cooperative, friendly manner during the interview, was appropriately dressed for the season, and answered questions in a direct fashion. Her eye contact was appropriate. Psychomotor activity was within normal limits as she moved comfortably during the interview. No atypical physical characteristics were noted. Her speech patterns and expressive/receptive language were within normal limits. No evidence of current drug or alcohol intoxication was observed.

Sensorium and Mental Ability

During the interview, Susan C. appeared alert and oriented x4. While not formally assessed, she appears to have average to above average intelligence as evidenced by her vocabulary and reported GPA in college. There was no difficulty with questions assessing her recent or remote memory, or mathematical calculations. Some abstract thinking difficulty was observed in her difficulty describing what the difference was between a lie and a mistake.

Thought

Susan displayed a logical, sequential, coherent flow of thought. No tangential thinking, flight of ideas, or looseness of associations were noted. Thought content appeared to be within normal limits. No evidence of hallucinations, delusions, paranoid ideation, or ruminations was apparent. No compulsions or obsessions were reported.

Sensory Motor and Perceptual Processes

Sensory motor and perceptual processes appeared within normal limits. Susan C. was able to adequately duplicate the drawing of a clock. There was no evidence of fine motor tremor, auditory, or perceptual difficulties.

Affect and Mood

During the interview, Susan displayed a moderately depressed affect. While eye contact was appropriate, she seldom smiled even when an amusing incident occurred while we were in the office. Her voice tone had monotone qualities and she often sighed during the interview. She verbalized feeling depressed since her recent miscarriage (3 weeks ago). No history of manic-like symptoms was reported. She denied suicidal and homicidal ideation. There was no evidence of a risk for violence or impulsivity.

Self-regulation

Susan C. displayed adequate impulse control and judgment. These interview qualities are consistent with her history.

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INITIAL INTERVIEW 2

Intake Report for George Wesley

David Evans

School of Behavioral Sciences, Liberty University

Identifying Information

· George Wesley

· 1234 Fair Oaks Boulevard, Sacramento, CA 95825

· 1 (252) 867-3294

· January 10, 1977

· Male

· Divorced

· Firefighter/Pastor

· California Department of Fire Emergency Services

· No work phone recorded

· Esther Nadene Wesley (daughter)

· August 30, 2022

Reason for Referral

George W. Wesley was referred by Bishop Boyd. Bishop Boyd presides over the Northern Virginia Baptist Convention. Bishop Boyd is considering Pastor George for a position leading a large city congregation. Bishop Boyd believes this evaluation will aid in determining whether George is a good fit for the Senior Pastor job of a large city church. George has never presided over a congregation of more than 200 persons. All of his pastoral roles were in smaller congregations with congregants over age fifty. These villages were mostly in rural areas. George reported having no prior experience with millennials.

Current Situation and Functioning

George is well-dressed and groomed, and has a lean, athletic build. Throughout the interview, he kept eye contact and articulated ideas well. However, he had moments where he appeared fearful about his lack of experience to lead an assembly of that magnitude. He admitted to being concerned about the interview because it could jeopardize his opportunity to move into the new role. In other moments during the interview, George spoke candidly with confidence the interview. He considered himself an experienced pastor and had the knowledge and training to back it up. George was attentive to all interview questions and responded astutely.

He denies having any difficulties in his daily life. He constantly tapped his leg and asked if he could switch on the ceiling fan. Although he frequently devotes his free time to church activities, his long working hours allow him to hide his anxieties and avoid church concerns. George sees this as a major weakness and knows he needs to “work on it.” When he gets stressed, he talks to his mother. He considers being able to quickly recognize his stress triggers a strength. He loves reading, which helps him when he cannot sleep on holiday nights.

Relevant Medical History

George appears to be in good health with the exception to the discoloration of the eyes. His doctor recommended that he take a multivitamin, during his most recent check-up. The doctor reported that George’s Prostate-specific Antigen, cholesterol, glycated hemoglobin, kidney, and liver all show healthy functionality or fell within healthy limits. George was nervous about the stress test, but it also yielded favorable results.

George was hospitalized in 2017 after going unconscious and falling from a ladder during training. During this incident, he tore his meniscus (left knee). He denies losing consciousness and being hospitalized. He has no other medical issues. He has a sister who suffers with diabetes, which he believes is due to obesity. All other siblings are otherwise healthy.

Psychiatric Treatment History

George denies that his family has a history of mental illness. He has been diagnosed with Acute Stress Disorder (ASD) twice. Both instances were tied to traumatic work experiences. He believed he could have saved the children if he had driven faster or busted down the door. He has completed all employer mandated individual and group treatments. George also received 30 days of paid leave for each event. He underwent treatment for six months, the most recent being two years ago. George was prescribed lorazepam (Ativan) for anxiety and zolpidem (Ambien) to help him sleep two years ago. He is faithful taking his multivitamin but refuses to take any prescribed medication. George reported no psychiatric or substance abuse challenges with any of his siblings or immediate relatives.

Family History

George’s mother lives in Central California near his brothers. George’s mother was a nurse. His father was murdered when he was 11 years old. His father was a police officer killed in action. George’s mother is 78 years old. His maternal grandparents are alive and well. They are 98 (grandfather) and 94 (grandmother) years of age respectively. At 99 years old, George’s paternal grandfather is still alive as well. His maternal grandmother has previously passed away. He has three sisters who are 50, 53 and 55 years old. Brothers aged 58 and 56. George is the youngest.

Both of his grandfathers were ministers. His mother’s father was the pastor of the largest church in Youngsville, LA. As a child, he remembers how kind and loving they were and how they never lost their cool. His grandmother was very patient and a good cook. For as long as George can remember, his Sunday lunch was at his grandparents’ house. His mother’s family reunites twice a year, and his father’s family once. He never misses his family events. George’s most memorable childhood experience was helping on a farm. He liked to pick green beans and tomatoes. George hated it when his grandmother sent him to get eggs.

Social Development and History

George sees himself as an introvert who adapts to the needs of those around him. He prefers to stay home alone. George attributes this to the fact that he is always among people. He shared his bedroom with his brother until he went off to college. He loves the Lord and finds refuge through salvation in Christ. He finds peace reading the Bible and listening to Christian music. He lacks a social life and feels that this affects him a lot; he often works extra shifts as a distraction. George’s work as a Fire Chief requires him to be on shift for 24-hours a day for several consecutive days. George’s last relationship was mentally draining, and he currently has no desire to date. He dated a selfish woman, and he feels God revealed to him the woman’s selfish character over time. George believes she did not understand her role as a First Lady and was unwilling to take on the virtue of being a Christian woman. George still co-parents with his ex-wife raising their daughter who is currently a junior in college.

Education and Occupational History

George graduated from high school at the age of 16. He was a Junior Reserve Officer Training Corps (JROTC), United States Army. Although he participated and competed in the JROCT All 3 years of high school, George decided not to join the military. George discovered a sudden interest in becoming a Firefighter instead. George’s mom encouraged him to attend college before applying for firefighting jobs. George decided to attend a junior firefighting program offered by the county during his junior year of college. He received all the training necessary to become a volunteer firefighter. He holds a BA in Fire Science with a minor in Biblical Studies from Central North Carolina University. He earned a master’s degree in fire protection engineering from the University of Maryland. He earned a doctoral degree in theology from the Baptist Bible College.

After being hired in 2003, he received additional training from his current job. His on-the-job training included training as a paramedic. George passed his paramedic certification exam in 2007. That license is current. During his 19 years, he served with the District of Columbia’s Fire and Emergency Services. As Fire Chief, George oversees and directs the duties of the 32 men and women assigned to their assigned fire department. He is responsible for the safety of all assigned employees during his shift. George is a highly decorated firefighter and an excellent fire captain and always gets good performance reviews. The only occupational injuries he claims are the case of his torn meniscus and the acute stress injury, resulting in two separate medical leave statuses.

Cultural Influences

George’s Haitian heritage could cause a grading challenge. To establish which culture he most closely identifies with, an acculturation test maybe necessary. George was raised with a heavy cultural influence that was not indicative of his own. His parents were Haitian, but he was raised in a rural African American community. His primary language is French Creole. However, he also speaks English fluently. These facts may need further consideration and possible testing for validation, as client behavior is a crucial part of determining if any further assessments/testing is necessary.