The mental status examination: its use by professional counselors: EBSCOhost

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• First, suggested preliminary psychosocial aspects to be covered in the written report may include (a) identifying data; (b) presenting problem or complaint; (c) informants; (d) history of present problem; (e) personal, family, and social history; and (f) counseling and treatment history.

• The level of engagement is instrumental in the process of gaining information that is accurate and comprehensive, and thus counseling skills related to forming a therapeutic relationship with the client are key to the effective use of the MSE.

• counselor's case conceptualization skills enable the optimal use of that information to form an accurate diagnosis and an effective counseling intervention

• Building rapport is essential to good interviewing as well as applying the MSE

• Counselor influences on the client should always be taken into account

• usually appropriate, at first, to follow the client's lead regarding attempts to make eye contact while also assessing ease and comfort of eye contact

• Demonstrating willingness to hear what the client has to report and communicating confidence are crucial

• If open-ended questions do not succeed, a more direct approach should be used

• the counselor may want to reassure the client that the questions are routine and used with all new clients

• It is important to remember that any test of mental functioning can be stressful, particularly for a client with fears of failing. Therefore, supportive comments and reassurances may be needed.

• Second, in the absence of abnormality, it is useful to indicate that an area of dysfunction was not observed (e.g., "no motor disorders were observed")

• Third, when reporting mood, language, and suicidal information, it is useful to include the client's own words.

• Fourth, in describing the client's mental status, the counselor will want to include any details necessary to support diagnoses.

• Finally, it is important to remember that written mental health records are documents that can be subpoenaed by attorneys or requested by clients themselves. Thus, counselors need to be certain that the tone and wording of their managed care reports will withstand scrutiny

• The MSE interview format also affords a holistic view of the client in that biological, social, and psychological information are woven together to substantiate hypotheses regarding a client's condition

• not a formal psychometric instrument

• The MSE is used to obtain information about the client's level of functioning and self-presentation.

• Generally conducted (formally or informally) during the initial or intake interview, the MSE can also provide counselors with a helpful format for organizing objective (observations of clients) and subjective (data provided by clients) information to use in diagnosis and treatment planning.

• the information gathered by the MSE provides a foundation for evaluating individuals, across the life span, who present in crisis or with any variety of concerns in schools, colleges and universities, the workplace, or other settings in which counselors may provide clinical services

• provides counselors with a format for organizing objective (observations of clients) and subjective (data provided by clients) screening information to use in diagnosis and treatment planning and to monitor treatment progress.