Mental Status Exam Final Paper Description
Write a 10-12 page paper addressing each of the elements below. Utilize APA format, 12 point Times New Roman font, and 1 inch margins in your paper. The paper should be double spaced.
I. Present (fictitious) demographic characteristics for your client. These include a name, age, race/ethnicity, sex, gender identification, and sexual orientation as well as any others that are relevant to your case conceptualization.
II. Identify the presenting problem. Include any existing diagnoses as well as a recent (approx. 6 weeks) behavioral and emotional profile.
III. Describe the history of the problem. Include any historical diagnoses as well as history of treatment including inpatient/ residential, outpatient (individual, family, group), and psychiatric medication as well as responses to these forms of treatment.
IV. Identify the client’s current living situation. Identify characteristics of the situation that facilitate and hinder the client’s functioning, if any.
V. Describe the client’s current level of functioning in the following domains as relevant:
VI. Identify and assess any current or historical suicidal or homicidal ideation or behavior.
VII. Identify and describe any current or historical evidence of psychosis – delusions or hallucinations.
VIII. Conduct a mental status examination and describe the results as they align with the following domains:
a. Orientation (person, place, time)
c. Behavior (you can refer to sections II and III if relevant)
g. Thought Process (you can refer to section VII if relevant)
h. Thought Content (you can refer to section VII if relevant)
i. Cognition / Memory
j. Insight / Judgment
k. Attitude / Rapport
IX. Identify any physical health needs, medical intervention, and impact on the client’s functioning if relevant.
X. Identify any substance abuse history and treatment history if relevant.
XI. Describe any trauma history, trauma symptoms, and impact the trauma history has on the client’s current functioning if relevant.
XII. Identify any relevant legal history / involvement including criminal justice involvement if relevant.
XIII. Identify any relevant academic history.
XIV. Briefly describe relevant considerations pertaining to the client’s family of origin. Characteristics may include the functioning of the client’s parents along with any attachment considerations, client’s economic circumstances and residential mobility growing up, and birth / developmental history.
XV. Describe the client’s peer relationships and social support along with any significant relationship history.
XVI. Address the ways in which diversity and difference have impacted the client’s experience.
a. Address the ways in which diversity and difference related to any personal characteristics, which could include race / ethnicity, gender identity or orientation, religion, and others have impacted identify formation for this client (Competency 2.a).
b. Identify ways in which this client has experienced oppression, discrimination, marginalization, or alientation in their life and the ways in which those experiences have impacted the client’s functioning (Competency 2.c).
XVII. Diagnosis: Explain how the diagnosis was arrived at; specify diagnostic criteria met and not met; identify alternative diagnoses that were considered and explain why they were discarded; describe characteristics of client (e.g. age of onset) that align or do not align with diagnostic features and associated features of this diagnosis.
a. Discuss the relationship that you have (or, if the client is based on a case scenario, the relationship that you believe you would have) with this client. In what ways are you similar to and different from this client? In what ways do you experience power and authority in the clinical relationship, and in what ways does the client experience these dynamics (Competency 2.b)?
b. What types of personal biases might you experience when working with this client? How would you identify and manage those biases (Competency 1.c)?
c. What social work value / values particularly pertain to the way you might experience working with this client in a clinical context? Explain (Competency 2.d, Competency 1.a).
d. What are the tools you would rely upon to support your use of ethical decision-making in relationship to this client? Give an example of a scenario that could arise that would result in the need to consider ethical decision-making in the clinical context (Competency 1.a, Competency 1.b).
e. In what ways are you well-prepared to work with this client, and what additional education or professional development might you need to effectively serve this client? If you were in a professional practice context, how would you go about preparing yourself to best be able to serve this client (Competency 1.e)?
f. In what ways would you be required to interact with technology in your provision of services to this client? How would you ensure that your use of technology is ethical and in keeping with social work values (Competency 1.f)?
Desmond is a 61-year-old, Caucasian male, unemployed, he only receives SSI about $800 per month. Desmond dropped out of school after the 9th grade. He has only lived in Milwaukee, WI his whole life. Desmond is single (never married), Desmond reports that he has one child (age 12), but only seen him about 3-4 times since he was born. He reports that he has last seen his son in 2019 and doesn’t know where he lives and doesn’t speak to the mother of his child. Desmond worked at a funeral home before being homeless. Desmond has one older brother and 1 sister. In 2014, his brother (Steve) died from drinking alcohol, and he doesn’t speak to his sister, who lives in Arizona. Desmond refused to speak to his sister (Tina) and hasn’t shared why he refuses to speak to her. Desmond speaks very negatively about Tina.
Desmond has a history of being homeless, he was homeless for 8 years in Milwaukee County. In 2016, he got approved for the MyHome Voucher (Milwaukee County Housing division program for people who have been chronically homeless for at least 12 months or months). He lived at Mercy House (formerly known as The Johnston Center) for three years.
In 2017, Desmond enrolled mental health services through Milwaukee County called Comprehensive Community Services (CCS). During that time, he was diagnosed with Major Depressive disorder and Alcohol intoxication. Desmond was prescribed medication, such as Prozac, but he refuses to take medication because he feels that he is not crazy and doesn’t need it. Desmond started receiving SSI, $800 per month, and $16 in food stamps.
In 2019, he was evicted through the Milwaukee County courthouse from Mery House due to being verbal aggressive behavior towards staff and residents and destroyed property. When Desmond drinks he is very aggressive, using profanity, and has destroyed his apartment door due to misplacing his keys when he returns home from drinking. Mark was then placed in another apartment building.
In June of 2021, the apartment owner refused to renew his lease due to him being verbal aggressive behavior towards the tenant due to his drinking. Desmond refused to move out of the home, due to the COVID-19 pandemic. In November 2021, Desmond was evicted from the apartment, Desmond was then displaced from his home. Due to it being winter, Desmond was placed in a hotel through Milwaukee County until he could find permanent housing. However, due to Desmond having an eviction on his record, property managers refused to rent to him. While in the hotel, Desmond’s drinking has increased significantly, which has become a challenge in finding housing and making his medical appts. Desmond continues to refuse to attend his psych appt, take medication, and meet with service providers. Desmond has a therapist that he is supposed to meet with weekly but hasn’t seen a therapist in over 5 months.
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