Mental Health Assignment: Mental State Examination Of A Patient

Question

Task:
This video needs to be watched before preparing this mental health assignment: https://www.youtube.com/watch?v=4YhpWZCdiZc and then the following parts needs to be addressed.

Part A: MSE documentation

Write a comprehensive Mental State Examination on the consumer in the video.

Part B: Therapeutic Communication

Reflect on the interviewer’s (clinician’s) therapeutic communication skills. Discuss what components of this communication you thought were helpful and/or not helpful and support with literature.

Answer

Mental Health
MSE Documentation of a case considered in the mental health assignment:
Alison Wells is a thirty eight years old Caucasian woman who is vising a general psychiatrist (GP), as she is suffering from low mood. She is divorced and live with two children, one eleven and another nine years old. Currently, Alison works at a supermarket. She recently had a break up with her current boyfriend, Dave.

She is wearing pink top and brown pants, with her hair is unkempt. She looks overweight.

She is feeling fade up and dismayed for the last few months. She is not being able to cope with things, and she is feeling heavy as things are piling up. Alison is feels very black, miserable, low, tearful, and dismayed every morning. Even she is failing to keep a descent conversation with her kids. She is breaking into tears after doing trivial mistakes, such as dropping the sugar at home. She used to go with her kids to the school or for swimming, now she just spends the day lying down on the sofa or just go to the job. She doesn’t bother to make food for her kids anymore. However, she is not being able to go to supermarket where she works, very frequently, as she feels very exhausted too often. The supermarket has cut her wages and now she has got trouble with the bills. She is not being able to meet the expectations of kids by buying them what they want – such as new games and other stuffs. Alison is also having trouble falling asleep, she just stare at the clock. She not having sufficient sleep and waking up at 4 o’clock and since then she is not able to sleep. She feels that her brain hasn’t switched off. Her appetite has gone low lately.

She used to read books regularly, which, however she has stopped doing lately. Her concentration span has become shorter, often she thinks about something else while watching television. At the same time, she has become forgetful which is evident from the incident of not being able to pay the swimming fees for her kids. She has lost interest in the things she used to once enjoy – such as going out with friends and watching movies.

Alison reported that she recently had a break up with boyfriend who has stopped contacting her. When Alison was in a relationship with her boyfriend, she found that her libido has gone low. She didn’t indulge herself in having sex with Dave. Before Dave, her husband also left her.

She also has a feeling of worthlessness as she is no longer being able to help her kids. She feels that she is a mess and burden to everybody. She reported that she tried to harm herself four years ago by taking roughly twelve paracetamol tablets with a few glasses of wine. However, this activity wasn’t pre-planned and she assumes that it happened in a spur of moment probably because of the wine. She felt very sick when she woke up after a couple of hours.

Alison has no intention to hurt anyone, especially her children. She says that she loves her children a lot. Alison’s sister is very supportive and she has also got a few good friends to lean on.

Therapeutic Documentation:
Greeting and Introduction:
The GP, Dr. Taylor, greeted Alison formally and with respect. As soon as the patient entered the GP requested her to take a seat. This behaviour reflects adequate professional ethics of respecting the patient. She introduced herself with her name and designation; and asked Alison how would she liked to be called. This behaviour makes the clinical environment confortable to the patient and helps the patient to open up (Bipeta, 2019).

Knowing the History of the patient:
Dr. Taylor, the GP, take a mental note of how the patient is feeling and how long the patient is feeling this way. The GP asks the patient is she is willing to talk about her background and how she is feeling in more detail and only then asks the detail. She didn’t force the patient to talk about her feelings and other details (Bipeta, 2019).

She keenly listens to the family history, marital status, current relationship status, job status and relationship with the children of the patient.

Reflection of empathy:
The GP shows certain level of empathy towards her patient by handing over a box of tissue, as the patient broke into tears (Ross & Watling, 2017). We have noticed that the GP didn’t break the professional code of ethics by drowning herself into empathy or by being very cold towards the patient (Ybañez-Llorente, 2018). When the patient was asked if she has lost interest in doing her favourite things or she doesn’t bother about it at all, the patient refused to talk about it. Dr. Taylor seemed to show respect towards her decision and stopped asking the same question (Bipeta, 2019; Jain et al., 2017).

Making risk assessment:
Dr. Taylor took the effort of diligently making the risk assessment by asking Alison if her plan of committing suicide was planned or just happened at a spur of a moment. Dr. Taylor, also asked how Alison felt when she found herself alive, and if she again made any plan of harming and/or killing herself. Dr. Taylor also assessed if Alison has any tendency or ideation of harming others, especially her children. Finally, she asked if she feels good about anything in her life and if she can depend on anyone who is supportive even when Alison is in a dire condition (Chaimowitz et al., 2020).

Giving an explanation to the patient:
It feels better when a person knows what is wrong with him or her. The GP explains Alison that she is diagnosed with depression. Since, Alison doesn’t know much about depression, the GP explains the primary signs of depression to her and explains how the symptoms of depression corroborate with the signs Alison is lately showing (Jain et al., 2017; Camargo et al., 2019).

Seeking consent from the patient before starting the treatment:
The GP seeks permission from the patient before starting the treatment. This reflects that she abided by the codes of professional ethics such as seeking consent of treatment and respect for consent (Shah et al., 2021).

References
Bipeta, R. (2019). Legal and Ethical Aspects of Mental Health Care. Indian Journal Of Psychological Medicine, 41(2), 108-112. https://doi.org/10.4103/ijpsym.ijpsym_59_19

Camargo, A., Mari, J., Reis, E., & Citero, V. (2019). Benefits of using the Psychiatric Risk Assessment Checklist (PRE-CL) to assess risk in general hospital inpatients. Brazilian Journal Of Psychiatry, 41(1), 90-91. https://doi.org/10.1590/1516-4446-2017-0004

Chaimowitz, G., Mamak, M., Moulden, H., Furimsky, I., & Olagunju, A. (2020). Implementation of risk assessment tools in psychiatric services. Journal Of Healthcare Risk Management, 40(1), 33-43. https://doi.org/10.1002/jhrm.21405

Jain, S., Kuppili, P., Pattanayak, R., & Sagar, R. (2017). Ethics in Psychiatric Research: Issues and Recommendations. Mental health assignment Indian Journal Of Psychological Medicine, 39(5), 558-565. https://doi.org/10.4103/ijpsym.ijpsym_131_17

Ross, J., & Watling, C. (2017). Use of empathy in psychiatric practice: Constructivist grounded theory study. Bjpsych Open, 3(1), 26-33. https://doi.org/10.1192/bjpo.bp.116.004242

Shah, P., Thornton, I., Turrin, D., & Hipskind, J. (2021). Informed Consent. Ncbi.nlm.nih.gov. Retrieved 19 March 2022, from https://www.ncbi.nlm.nih.gov/books/NBK430827/.

Ybañez-Llorente, K. (2018). Counseling.org. Retrieved 19 March 2022, from https://www.counseling.org/docs/default-source/ethics/ethics-columns/ethics_june_2018_compassion-professionalism.pdf?sfvrsn=b1dc522c_4.