Psychology (Mental Status Examination/ MFT)

11804Case Assignment:
For this assignment you will complete a clinical interview and a mental
status exam and then write up a report of your findings. The goal here
is to get practical experience, to approximate some of the process of
what goes into a psychological report, and to display your ability to
complete a clinical interview with mental status and to display your
ability to write up the results in a professional format.
Here are the steps for this assignment:
1) Find an individual to complete this assignment on. It can be a
friend, a stranger, a peer, or a client- if you are on practicum.
2) Complete the clinical interview handout with the individual,
answering all sections (found in module 3 reading tab).
3) Complete the MSE using the Rapid Record Form (found in module 3
reading tab).
4) Write a report of your findings that follows the format of the sample
report we looked at (found in module 3 reading tab).
5) Append your raw data so I can see that your interview was
thorough. This includes your clinical interview handout and the rapid
record form. Please merge all of this into one document so you can
upload it into the system at once.
The sections in your report should include:
Reason for Referral
Evaluation Process
Early development
Childhood
Adolescence
Adulthood
Romantic Relationships

Work History
Psychiatric History
Substance Abuse History
Mental Status/Behavioral Observations
You’ll be leaving out the testing section, the diagnosis section, and
the treatment section.
Also, make sure to redact any personal information that would
compromise the person’s confidentiality, including the person’s real
name.
This assignment is due at the end of the module, Sunday by 11:59 pm
PST. Please use APA style and write 5-8 pages minimum. This Case
Assignment represents 20% of your overall grade for the course.

____________________-
Reason for Referral

The client was referred to me by his primary care physician for a mental health evaluation. The physician was concerned about the client’s increasing anxiety and depression. The client has been experiencing these symptoms for the past several months.

Evaluation Process

I met with the client for a 90-minute individual interview. During the interview, I gathered information about the client’s history, symptoms, and current functioning. I also administered a mental status exam.

Early Development

The client was born and raised in a small town. He was the youngest of three children. His parents were both teachers. The client described his childhood as happy and uneventful. He was an average student and had a close group of friends.

Childhood

The client’s childhood was marked by some significant stressors. His parents divorced when he was 10 years old. The divorce was difficult for the client, and he struggled to adjust to his new living situation. He also began to experience anxiety and depression during this time.

Adolescence

The client’s adolescence was also challenging. He struggled with his grades and his relationships. He began to use alcohol and drugs to cope with his anxiety and depression. He also began to self-harm.

Adulthood

The client’s adulthood has been marked by periods of stability and instability. He has been able to maintain stable employment and relationships for periods of time. However, he has also experienced periods of relapse, during which he has used alcohol and drugs heavily and has engaged in self-harm.

Romantic Relationships

The client has had a number of romantic relationships. He has been married twice. His first marriage ended in divorce after two years. His second marriage is currently in a state of crisis. The client’s wife is struggling with her own mental health issues, and the couple is having difficulty communicating with each other.

Work History

The client has had a number of different jobs. He has worked in the retail, food service, and construction industries. He has been able to maintain stable employment for periods of time. However, he has also experienced periods of unemployment, during which he has struggled to make ends meet.

Psychiatric History

The client has a history of anxiety and depression. He has been diagnosed with generalized anxiety disorder and major depressive disorder. He has been treated with medication and therapy.

Substance Abuse History

The client has a history of alcohol and drug abuse. He has been addicted to alcohol and cocaine. He has been in and out of treatment for his substance abuse.

Mental Status/Behavioral Observations

The client is a well-groomed, well-dressed man in his early 40s. He is cooperative and polite during the interview. He is able to follow instructions and answer questions in a clear and concise manner. He appears to be oriented to time, place, and person. His mood is anxious and depressed. His affect is flat. He has no delusions or hallucinations. His thought process is linear and logical. His judgment is impaired.

Conclusion

The client is a complex individual with a long history of mental health issues. He is currently experiencing significant symptoms of anxiety and depression. He is also struggling with his substance abuse. The client is at risk for self-harm and suicide. He would benefit from a comprehensive treatment plan that includes medication, therapy, and support groups.

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