Tag Archives: Psychotherapy

Two Sample Mental Status Examination Reports

JSF Dance Party

This is a photo of me checking my mental status.

Generally, mental status examinations (MSEs) can have a more neurological focus or a more psychiatric focus. The following two fictional reports are samples of psychiatric-oriented MSEs. These sample reports can be helpful if you’re learning to conduct Mental Status Examinations and write MSE reports. They’re excerpted from the text, Clinical Interviewing (6th edition; 2017, John Wiley & Sons). Clinical Interviewing has a chapter devoted to the MSE, as well as chapters on suicide assessment interviewing and diagnostic interviewing (and many others chapter on other important topics). You can take a look at the book (and some darn good reviews) on Amazon: https://www.amazon.com/gp/product/1119215587/ref=dbs_a_def_rwt_bibl_vppi_i0

If you’d like to see a short video-clip MSE example, you can go to: http://www.youtube.com/watch?v=1lu50uciF5Y

Sample Mental Status Examination Reports

A good report is brief, clear, concise, and addresses the areas below:

1.  Appearance

2.  Behavior/psychomotor activity

3.  Attitude toward examiner (interviewer)

4.  Affect and mood

5.  Speech and thought

6.  Perceptual disturbances

7.  Orientation and consciousness

8.  Memory and intelligence

9.  Reliability, judgment, and insight

The following reports are provided as samples.

Mental Status Report 1

Gary Sparrow, a 48-year-old white male, was disheveled and unkempt on presentation to the hospital emergency room. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was agitated and restless, frequently changing seats. He was impatient and sometimes rude in his interactions with this examiner. Mr. Sparrow reported that today was the best day of his life, because he had decided to join the professional golf circuit. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15”). His speech was loud, pressured, and overelaborative. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Sparrow described grandiose delusions regarding his sexual and athletic performance. He reported auditory hallucinations (God had told him to quit his job and become a professional golfer) and was preoccupied with his athletic and sexual accomplishments. He was oriented to time and place, but claimed he was the illegitimate son of Jack Nicklaus. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Mr. Sparrow was unreliable and exhibited poor judgment. Insight was absent.

Mental Status Report 2

Ms. Rosa Jackson, a 67-year-old African American female, was evaluated during routine rounds at the Cedar Springs Nursing Home. She was about 5’ tall, wore a floral print summer dress, held tight to a matching purse, and appeared approximately her stated age. Her grooming was adequate and she was cooperative with the examination. She reported her mood as “desperate” because she had recently misplaced her glasses. Her affect was characterized by intermittent anxiety, generally associated with having misplaced items or with difficulty answering the examiner’s questions. Her speech was slow, halting, and soft. She repeatedly became concerned with her personal items, clothing, and general appearance, wondering where her scarf “ran off to” and occasionally inquiring as to whether her appearance was acceptable (e.g., “Do I look okay? You know, I have lots of visitors coming by later.”). Ms. Jackson was oriented to person and place, but indicated the date as January 9, 1981 (today is July 8, 2009). She was unable to calculate serial sevens and after recalling zero of three items, became briefly anxious and concerned, stating “Oh my, I guess you pulled another one over me, didn’t you, sonny?” She quickly recovered her pleasant style, stating “And you’re such a gem for coming to visit me again.” Her proverb interpretations were concrete. Judgment, reliability, and insight were significantly impaired.

 

To receive alerts about this and other related topics like clinical interviewing and counseling and psychotherapy, you should follow this blog. Also, if you want me to come to your organization to provide a workshop or keynote on this or on a related topic, email me at john.sf@mso.umt.edu.

Respecting the Client’s Perspective – Even When We Think We Know Better

There are so many ways we can . . . as therapists . . . subtly (or less so) disrespect our client’s perspective. Here’s a small example from the revision of Clinical Interviewing (5th ed).

Interviewers can negatively judge or disrespect the client’s perspective in many ways. Very recently, I (John) became somewhat preoccupied about convincing a client that she wasn’t really “bipolar.” Despite my good intentions (it seemed to me that the young woman would be better off without the bipolar label), there was something useful or important for the client about holding onto her bipolar identity. Of course, as a “psychological expert” I thought it was ludicrous. I thought it obscured her many personal strengths with a label that diminished her personhood. Therefore, I tried my best to shove my opinion into her belief system. For better or worse, I was unsuccessful.

What’s clear about this example is that, despite our general expertise in mental health matters, as mental health professionals we need to work hard to respect our clients’ worldviews. In recent years practitioners from many theoretical perspectives have become more firm about the need for the expert therapist to take a back seat to the client’s personal lived experience. It’s now more important than ever for interviewers to acknowledge and embrace client expertness. This may be partly due to our increasing awareness (as mental health professionals and advocates) that clients may have very divergent views of themselves and the world.

In the end, who am I to tell my client that she is better off without a bipolar label? What if that label somehow, perhaps even in a twisted way, offers her solace. Perhaps she feels comfort in a label that helps explain her behavior to herself. Perhaps she is not ready—yet—to let go of the bipolar label. Perhaps she never will—and that may be the best outcome.

Whatever their theoretical orientation, effective interviewers respect their client’s personal expertise or perspective. We need that expertise. If the client is unwilling to collaborate with us by sharing her or his expertise and experience, we lose at least some of our potency as helpers.

 Image

John offers his brother-in-law some advice.

A Wiley Website with Info about our Brand New Counseling and Psychotherapy Videos

This spring and summer Rita and I have been working with John Wiley & Sons to produce DVDs to go with our textbooks Clinical Interviewing and Counseling and Psychotherapy Theories in Context and Practice. The Clinical Interviewing DVD is out and the Theories DVD will be available soon. There’s a new website with information about this at: http://lp.wileypub.com/SommersFlanagan/

Image

John reading the new textbooks to his twin grandchildren (who look quite excited about learning how to do psychotherapy).

 

Is Solution-Focused Therapy as Powerfully Effective as Solution-Focused Therapists Would Have Us Believe?

[This Blog is adapted from a previous blog posted on psychotherapy.net]

Solution-focused therapy is very popular. But is it effective?

Beginning in the 1980s, solution-focused therapy hit the mainstream and many mental health providers (and third-party payers) continue to sing the praises of its brevity and effectiveness. For example, in a 2009 book chapter Sara Smock claimed, “. . . there are numerous studies, several reviews of the research, and a few meta-analyses completed that showcase [solution-focused therapy’s] effectiveness.”

Really?

Solution-focused counseling and psychotherapy has deep roots in post-modern constructive theory. As Michael Hoyt once famously articulated, this perspective is based on “the construction that we are constructive.” In other words, solution-focused therapists believe clients and therapists build their own realities.

Ever since 2003, my personal construction of reality has been laced with skepticism. That was the year President George W. Bush included 63 references to “weapons of mass destruction” in his State of the Union address (I’m estimating here, using my own particular spin, but that’s the nature of a constructive perspective). As it turned out, there were no weapons of mass destruction, but President Bush’s “If I say it enough, it will become reality” message had a powerful effect on public perception.

From the constructive or solution-focused perspective, perception IS reality. Remember that. It applies to the solution-focused therapist’s view of solution-focused therapy effectiveness.

I recall hearing many presenters tell me that solution-focused therapy is powerful and effective. Or maybe it was powerfully effective. And I recall reading books and articles that similarly referred to the power and effectiveness of solution-focused therapy. Now we could just take their word for it, but I still can’t help but wonder: “What does the scientific research say about the efficacy of solution-focused therapy anyway?”

Here’s a quick historical tour of scientific reality.

  • In 1996, Scott Miller and colleagues noted: “In spite of having been around for ten years, no well-controlled, scientifically sound outcome studies on solution-focused therapy have ever been conducted or published in any peer-reviewed professional journal.”
  • In 2000, Gingerich & Eisengart identified 15 studies and after analyzing the research, they stated: “. . . we cannot conclude that [solution-focused brief therapy] has been shown to be efficacious.”
  • In 2008, Johnny Kim reported on 22 solution-focused outcomes studies. He noted that the only studies to show statistical significance were 12 studies focusing on internalizing disorders. Kim reported an effect size of d = .26 for these 12 studies [this is a rather small effect size].
  • In 2009, Jacqueline Corcoran and Vijayan Pillai concluded: “. . . practitioners should understand there is not a strong evidence basis for solution-focused therapy at this point in time.”

Now don’t get me wrong. As a mental health professional and professor, I believe solution-focused techniques and approaches can be very helpful . . . sometimes. However, my scientific training stops me from claiming that solution-focused approaches are highly effective. Although solution-focused techniques can be useful, psychotherapy often requires long term work that focuses not only on strengths, but problems as well.

So what’s the bottom line?

While in a heated argument with an umpire, Yogi Berra once said: “I wouldn’t have seen it if I hadn’t believed it!” This is, of course, an apt description of the powerful confirmation bias that affects everyone. We can’t help but look for evidence to support our pre-existing beliefs . . . which is one of the reasons why even modernist scientific research can’t always be trusted.  But this is why we bother doing the research. We need to step back from our constructed and enthusiastic realities and try to see things as objectively as possible, recognizing that absolute objectivity is impossible.

Despite strong beliefs to the contrary, there were no weapons of mass destruction. And currently, the evidence indicates that solution-focused therapy is NOT powerfully effective.

 

John Dreams About Counseling and Psychotherapy Theories

One morning, long ago, John woke up in the midst of a dream about having written a theories book. Over breakfast, John shared his dream with Rita. Rita said, “John go sit down, relax, and I’ll sit behind you as you free associate to the dream” (see Chapter 2, Psychoanalytic Approaches).

As John was free-associating, Rita tried to gently share her perspective using a two-person, relational psychotherapy model. She noted it had been her lived experience that, in fact, they had already written a theories text together and that he must have been dreaming of a 2nd edition. John jumped out of his seat and shouted, “You’re right! I AM dreaming about a 2nd edition.”

This profound insight led to further therapeutic exploration. Rita had John look at the purpose of his dream (see Chapter 3, Individual Psychology); then he acted out the dream, playing the role of each object and character (see Chapter 6; Gestalt therapy). When he acted out the role of Rita, he became exceedingly enthusiastic about the 2nd edition. She, of course, accused him of projection while he suggested that perhaps he had absorbed her thoughts in a psychic process related to Jung’s idea of the collective unconscious. Rita noted that was a possibility, but then suggested we leave Jung and the collective unconscious online where it belongs (see the Jungian chapter in the big contemporary collective unconscious of the internet online at ** ).

For the next week, Rita listened to and resonated with John as he talked about the 2nd edition. She provided an environment characterized by congruence, unconditional positive regard, and empathic understanding (see Chapter 5, Person-Centered approaches). John flourished in that environment, but sneakily decided to play a little behavioral trick on Rita. Every time she mentioned the word theories he would say “Yesss!,” pat her affectionately on the shoulder and offer her a piece of dark chocolate (see Chapter 7, Behavior therapy). Later he took a big risk and allowed a little cognition into the scenario, asking her: “Hey, what are you thinking?” (see Chapter 8, Cognitive-behavioral therapy).

Rita WAS still thinking it was too much work and not enough play. John responded by offering to update his feminist views and involvement if she would only reconsider (see Chapter 10, Feminist therapy); he also emphasized to Rita that writing a second edition would help them discover more meaning in life and perhaps they would experience the splendor of awe (see Chapter 4, Existential therapy). Rita still seemed ambivalent and so John asked himself the four questions of choice theory (see Chapter 9, Choice theory and reality therapy):

  1. What do you want?
  2. What are you doing?
  3. Is it working?
  4. Should you make a new plan?

It was time for a new plan, which led John to develop a new narrative (see Chapter 11, Narrative therapy).  He had a sparkling moment where he brought in and articulated many different minority voices whose discourse had been neglected (see Chapter 13; Multicultural therapy). He also got his daughters to support him and conducted a short family intervention (see Chapter 12, Family systems therapy).

Something in the mix seemed to work: Rita came to him and said . . . “I’ve got the solution, we need to do something different while we’re doing something the same and approach this whole thing with a new attitude of mindful acceptance” (see Chapter 11, Solution-focused therapy and Chapter 14, Integrational approaches). To this John responded with his own version of radical acceptance saying: “That’s a perfect idea and you know, I think it will get even better over a nice dinner.” It was at that nice dinner that they began to articulate their main goals for the second edition of Counseling and Psychotherapy Theories in Context and Practice.

The Efficacy of Solution-Focused Therapy

The Efficacy of Solution-Focused Therapy

For years I’ve wondered about what the research says about the efficacy of solution-focused therapy. While revising our theories text, I reviewed some of the literature. If you’re interested, I published a short blog about it on psychotherapy.net. Check it out. http://www.psychotherapy.net/blog/title/the-miraculous-or-not-efficacy-of-solution-focused-therapy