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The Mental Status Exam (MSE)
- It is the process of noting the observable in some systematic way
- It is different from the biopsychosocial assessment
- Based mostly on facts about the client’s life
- Description of the problem provided by the client
- The MSE is basically our observations
- It’s a very useful tool for assessing a client over time
2. Helpful questions for the MSE
- What has changed?
- When did it change?
- Has it change for the better or the worse?
- Ask for further explanation when you don’t understand something the client has told you
- Document what is worth noting
- Start by describing those things that anyone looking at the client would notice
- It does not matter when the MSE is completed
- Remember that a good clinician is a good observer
- To infer meaning from what you are actually seeing
- To see things that are in reality just your assumptions
- How does the client look and behave?
- How does the client speak?
- What is the client’s mood/affect?
- How does the client feel most of the time?
- How does the client appear to be feeling during the interview with you?
- Thought process and content
- How does the client think?
- Circumstantiality – takes a while to get to the point
- Perseveration – repeating phrase or returning to same subject
- Association – how does the client get from one idea to the next?
- How does the client think?
- What does the client think about?
- Sensory perception
- Mental Capacities
- Is the client oriented in time, place, and person?
- What is your estimate of the client’s intellingence?
- Can the client remember and concentrate?
- How are the client’s judgment and insight?
- Attitude toward the interviewer
- Client’s attitude towards you
- Does it change over time?
- Does he/she respond to empathy?
- Does he/she appear to be capable of empathy?
Contributor: Yvette McBride Thomas
Diagnosis— the meaning or interpretation that is derived from assessment information and is usually translated in the form of some type of classification system.
- A description of a person’s condition and not a judgment of a person’s worth
- A common misconception is that a classification of mental disorders classifies people, when actually what are being classified are mental disorders that people have. For this reason, the text of DSM-IV…avoids the use of such expressions as ‘a schizophrenic’ or ‘an alcoholic’ and instead uses the more accurate, but admittedly more cumbersome, ‘an individual with schizophrenia’ or ‘an individual with alcohol dependence’” (DSM IV-TR, APA, p. xxxi).
- Diagnoses are important for:
- Insurance company reimbursement
- Developing a proper treatment plan
- To be able to communicate with other professionals, counselors must be able to speak about, understand, or report a client diagnosis
- Diagnostic decisions are an evolving process and not a static event.
- Diagnosis and treatment planning are now such standard components of counseling practice that a failure to diagnose on some level or a lack of professional diagnostic training may be construed as unethical (p. 335).
- Dual diagnosis—a substance abuse diagnosis with a co-occurring mental health diagnosis in the same individual.
- Substance abuse counselors (e.g. LCDCs, ADCs) do not diagnose mental health disorders. We can only diagnose alcohol/drug addiction problems.
Resource: Gladding, S.T. (2011). Counseling: A comprehensive profession (7th ed.). Upper Saddle, NJ: Pearson-Merrill.
While screening is used to determine whether a client is eligible for admission into a particular program, assessment is an ongoing process to evaluate the treatment plan the client’s progress in treatment.
There are different assessment tools and we must select the one that is more appropriate, based on age, gender, racial and ethnic background, and disabilities.
Assessment tools include:
- History of alcohol and drug use
- Physical and mental health
- Addiction treatment histories
- Family issues
- Work issues
- History of criminality
- Psychological and emotional issues
- Current physical and mental health, and substance use/abuse issues
- Education and basic life skills
- Socioeconomic situation and lifestyle
- Current legal status
- Use of community resources
- Level of readiness for treatment
- Level of cognitive and behavioral functioning
When selecting and administering assessment instruments, we need to know which are the current validated instruments and protocols (remember validity and reliability); we also need to take into consideration the limitations of both the assessment instruments and the counselor’s training and education. Our responsibility is to use these instruments appropriately, so we must recognized when we need assistance from a supervisor (remember: consultation with other professionals).
Extra training, and therefore commitment, is required in order to learn how to analyze and interpret assessment results. In order to determine treatment recommendations, treatment plan modifications, and whether somethings are working better that others, we must be knowledgeable about:
- Scoring methods for assessment instruments
- How to analyze and interpret results
- Available treatment options
Remember that we want that our client participates actively in the treatment process, so we must introduce and explain the purpose of ongoing evaluations.
Finally, we need to keep in mind our agency’s protocols and procedures; appropriate terminology and abbreviations (avoid jargon!); legal implications of actions and documentation; and how to maintain client’s confidentiality (always important in everything we do).
In order to provide a competent practice, addiction counselors need to learn and understand the 8 Practice Dimensions and the knowledge, skills, and attitudes associated with each of them.
Clinical evaluation is a systematic approach to recognizing and diagnosing substance abuse problems, including the potential for co-occurring mental disorders.
There are two elements included in the clinical evaluation process:
Screening allows us to review the client’s current situation, including symptoms and other information, in order to determine the most appropriate course of action, taking into consideration the needs and characteristics of the client and the resources available within the community.
This is basically the first interaction between the client and significant others, and the counselor. It is very important how this first interaction is conducted.
Our goal is to establish rapport with our client and her/his significant others. We need to know:
- Why it is important to build rapport.
- The purpose of building rapport.
- The range of human emotions and feelings.
- What constitutes a crisis.
- How to prevent and manage a crisis situation.
- How to identify situations and conditions when additional professional assistance is necessary.
- Sources of assistance available.
The way in which we interact with our client is very important. The client may be experiencing anxiety, anger, fear, going through withdrawals, etc. Here is what we need to do:
- Demonstrate effective verbal and nonverbal communication.
- Identify the client’s beliefs.
- Reflect the client’s feelings and message –Active listening.
- Recognize dangerous situations.
- Treat the client with empathy, respect, and genuineness – Unconditional positive regard.
Screening is a data-gathering process. Data is gathered from the client and other sources such as family, friends, employer, and coworkers. There are different screening instruments and we must select the ones that are sensitive to age, developmental level, culture, and gender. The data we will gather should include a history of current and past substance use/abuse and substance abuse treatment; physical and mental health; mental and functional statuses; and current socio-economic and environmental problems.
A competent substance abuse counselor must have knowledge in the following:
- Validated screening instruments for substance abuse and mental status.
- Purpose, application, and limitations of those instruments.
- Reliability and validity.
- How to administer and score screening instruments.
- Interpretation of results.
- How to communicate effectively during emotionally charged situations.
- How to write accurately, concisely, and legibly.
The screening process includes determining whether a client is appropriate and eligible for admission into a particular program, so we need to be familiar with:
- Symptoms of intoxication, withdrawal, and toxicity for all psychoactive substances, alone and in combination with others.
- The physical pharmacological, and psychological effects of substance use.
- Acute and Chronic effects.
- Available resources for help with drug reactions, withdrawal, and violent behavior.
- Options, limitations, and legal implications of toxicity screening.
- Meaning of toxicology reports.
- Toxicology language.
- Relationship between psychoactive substance use and violence.
- Diagnostic criteria for suicide risk and danger to others.
- Mental and physical conditions that overlap symptoms of drug intoxication and withdrawal.
Working with the client during the screening process includes helping the client identify the effects of substance use or abuse on her/his current life problems. A very useful tool is Motivational Interviewing (MI). MI will help us assess the client’s readiness to address substance abuse issues; interpret the client’s perception of her/his experiences; and assess the client’s stage of change.
Substance abuse counselor must be familiar with:
- Denial and other defense mechanisms.
- Stages of readiness.
- Stages of change
- Treatment options and their philosophies.
- The client’s needs and preferences.
- Available resources for admission and referral.