Practicing Humility When Conducting Mental Status Examinations


Perhaps more than any other assessment task, conducting a balanced mental status examination requires that professionals resist the natural temptation to make sweeping judgments about clients on the basis of appearance, specific behaviors, or single symptoms. For example, in a recently published book titled The mental status examination and brief social history in clinical psychology, Smith {{5681 III 2011;}} stated:

A Fu-Manchu mustache suggests the wearer doesn’t mind being thought of as “bad,” whereas a handlebar mustache tells you the person may be somewhat of a dandy or narcissist. (p. 4)

After reading the preceding excerpt, I decided to conduct a small research study by surveying men in Montana with Fu-Manchu mustaches. Whenever I saw men sporting a Fu-Manchu, I asked them to rate (on a seven-point Likert scale) whether they minded being thought of as “bad.” In contrast to Smith’s (2011) observations, I found that most men with Fu-Manchu’s actually thought they looked good and reported wearing the mustache in an effort to look attractive. Of course I didn’t really conduct this survey, but the fact that I thought about doing it and imagined the results carries approximately the same validity as the wild assumption that a mental status examiner can quickly “get into the head of” all clients with Fu-Manchu (or handlebar) mustaches and interpret their underlying personal beliefs or intentions, or even worse, extrapolate from a physical feature to a personality disorder diagnosis.

Although I’m poking fun at the sweeping generalizations that Smith (2011) made in his text, my intent is to point out how easy it is to grow overconfident when conducting MSEs. Like Smith, I’ve sometimes found myself making wild and highly personalized assumptions about the psychopathological meaning of very specific behaviors (some years ago I had my own personal theory about “tanning” behaviors being linked to narcissism).

The key to dealing with this natural tendency towards overconfidence is to use Stanley Sue’s (2006) concept of scientific mindedness. A single symptom should be viewed as a sign that the sensitive and ethical mental status examiner considers a hypothesis to explore. Another example from Smith (2011) may be helpful as another caution of the dangers of over-interpreting single symptoms. He stated: “If the person is unshaven, this may be a sign of depression, alcoholism, or other poor ability at social adaptation” (p. 4).

Smith may be correct in his hypotheses about unshaven clients. In fact, if a research study were conducted on diagnoses or symptoms commonly associated with unshaven-ness, it might show a small correlation with depressive symptoms, partly because poor hygiene can be a feature of some depressive disorders. However, in the absence of additional confirming evidence, an unshaven client is just an unshaven client. And when it comes to social adaptation, I should note that I know many young men (as well as a variety of movie stars) who consider the unshaven look as either desirable, sexy, or both. This could lead to an equally likely hypothesis that an unshaven client is particularly cool or has an especially high level of social adaptation.

In your own MSE work I encourage you to adopt the following three guidelines to help you avoid what might be called the overconfident clinician syndrome:

  1. When you spot a single symptom or client feature of particular interest, you should begin the scientific mindedness process.
  2. Remember that hypotheses are hypotheses and not conclusions; this is why hypotheses require additional supporting evidence.
  3. Don’t make wild inferential leaps without first consulting with colleagues and/or supervisors; it’s often easier to become overconfident and subsequently make inappropriate judgments when working in isolation.

Keep these preceding guidelines in minds as you conduct mental status examinations. You can find my DVD with a clip of a mental status exam at: http://www.amazon.com/Clinical-Interviewing-Skills-John-Sommers-Flanagan/dp/1118390121

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