The correct tool for information gathering will depend on the client and the context of the situation. However, in almost all instances outside of a crisis or disaster/trauma response scenario, it will be appropriate to take a biopsychosocial history and complete a mental status exam. These two elements will provide for a basic picture of the client in their context and allow for educated planning for further assessment or case disposition.
Briefly, the biopsychosocial assessment is a tool that provides the clinician with information on the current or presenting issue or issues, the clients past and present physical health, including developmental milestones, the clients emotional functioning, educational/vocational background, cultural issues, spiritual and religious beliefs, environmental issues and social functioning. Each issue may be reviewed for its relationship or impact with the presenting issue.
The Mental Status Exam (MSE) is a structured approach to attain a comprehensive cross-section of the clients state of mind. Areas specifically explored include speech, thought process, thought content, perception, cognition, judgment, insight, mood and affect, behavior, attitude and appearance. Information is gathered through unstructured observation and direct interaction. Sometimes individuals confuse the MSE with the Mini-Mental Status Exam (MMSE); however, the two instruments are very different psychological tools. The MMSE is a brief neuropsychological tool used for quick assessment and screening of dementia.
These two protocols provide educated guidance for which DSM-IV-TR diagnostic decision tree or algorithm to use. If a formal diagnostic assessment is not the purpose of the interview, such as in disaster response or other crisis oriented intervention, the MSE can guide crucial intervention strategies that may prevent both imminent pitfalls and minimize long-term detrimental effects.
Additional information gathering to supplement client self-report in the primary protocols reviewed may be required. While clients may be forthcoming about their situations, they may have reasons not to be honest, such as fear of being disliked, shame, lack of trust, desire to please the clinician, fears of retribution, distorted thinking, legal concerns and a constellation of issues that may relate to being an involuntary client. Because self-report is flawed, having collateral sources of information can be invaluable. Sources of collateral information may be a significant other, teacher, parent, other family member, spouse, employer, hospital discharge summary, medical records, caseworker or many other sources. Remember, it is vital that permission is received from the client and documented appropriately (release of information, parental permission with release of information).
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