In the field of mental health and psychiatry, mental status examination is an important component of patient interview as it helps to classify and interpret type and severity of mental disorders in patient. Apart from the use of clinical skills to complete the mental status examination, skills related to establishing rapport with client during the assessment and use of appropriate questions enhance the quality of therapeutic relationship. The report provides an overview about a mental status assessment done for a client with mental issues and critically evaluates the approach used to develop rapport with client during the mental status examination and risk assessment. This would help to develop understanding regarding multifaceted elements that influence therapeutic relationship in mental health nursing.
Ms. Ketty (hypothetical client) is a 35 year old lady who came to the mental health clinic presenting with symptoms of poor mood, irritation and suicide ideation. The review of patient information revealed Ms. Ketty used to work as bank employee and she left the job two months back. She lives alone in her apartment and her elder sister lives nearby. Her mother died because of cancer two years back and her father died when she was 10 years old. After her mother’s death, she was in depression for five-six months and has to take anti-depressant to cope with her mother’s death. She was in stable mental status after getting job in a bank. However, since two months, her mental state worsened and she left her job too.
The current issue for Ms. Ketty is that her symptoms of poor mood and irritation have continued since the past one month. She restricts herself in one room throughout the day and does not interact with anyone. She also tried to attempt suicide on two occasions. Because of her worsening mental state, her sister has come to be with her and support her. One of the major issue is the development of suicide ideation which was never seen before even while reviewing past history of depression. Hence, to prevent risk of suicide and harm to Ketty in the future, contacting mental health clinic was important.
Since the death of Ketty’s mother, she has become very isolated. Getting no emotional support and attachment from family members and living alone is one of the perpetuating factors has deteriorated client’s level of mental health and well-being. She is 35 years old and poor relationship experiences in the past is also a reason for her dissatisfaction with life.
Being employed and economically independent after getting a job was a source of strength for her as her job helped her to positively cope with her mother’s death. However, relationship issues with boyfriends disturbed her so much that her feelings of low mood and irritation affected her job performance. She was finally fired from her job. This event worsened her mental state. Her elder sister is only her source of support and strength now. However, since she is married with two children, her elder sister finds less time to visit Ketty. Her elderly sister is now staying with her because of her two suicide attempts and poor mental condition.
Mental status examination for Ms. Ketty was done as part of clinical assessment process to analyse different domains of behavioural issues for client and diagnose type of mental health disorder for Ms. Ketty. The following are the details for mental state examination done for Ms. Ketty:
Appearance and general behaviour: Assessment of appearance and general behaviour was done by observing client and asking self-reflecting questions like ‘Is the client well-dressed or is the clothing appropriate for the occasion?’. Ms. Ketty was found wearing dull clothes and her hair looked tangled too. Her clothes were tidy, however her nails were very dirty. She was very restless and anxious.
Speech: Speech pattern of client was assessed by means of observation methods. During the interaction, Ms. Ketty was found to have monotonous speech and low volume of speech.
Mood and affect: Mood and affect was assessed by asking questions like ‘How are you feeling now?’. Ms. Ketty was found to be irritated, depressed, anxious and hopeless. She faced difficulty in initiating a conversation.
Thought processes: Thought process was inquired by asking general questions like ‘Do you know what is affecting you right now’. The response of patients was irrelevant and she had vague idea about her future life.
Thought content: Thought content was evaluated by inquiring about ideas and beliefs of client related to her current mental problem. For example questions like ‘Why do you detach yourself from social gathering?’ and ‘Do you have any unshared beliefs?’ were used to conduct mental status assessment. No delusion was found, however suicide ideation was present.
Perceptual disturbances: Perceptual disturbances were judged by analysing whether client has experiences any hallucinations and illusions or not. No disturbance related to hallucination was found. However, extreme feelings of detachment from the surrounding people or environment existed.
Sensorium and cognition: This was done by assessment throughout the interview regarding orientation and concentration of client. Ms. Ketty had good abstract reasoning, however her concentration was poor.
Insight: Insight of Ms. Ketty was determined by asking questions that defined client’s awareness and understanding about illness. She was regarding her mental state; however she had poor insight regarding the way to manage her illness.
Judgment: Client’s judgment level was inferred throughout the interview by critically evaluating Ms. Ketty’s understanding about ways to manage his or her behaviour. Judgment level of Ketty is poor and she has negative coping styles to deal with her life issues and stressors.
Risk assessment for patients with depression is important to identify the likelihood of harm to self and others. Major depression is one of the significant risk factor for suicide and risk assessment process provided health care professionals the opportunity to identify at risk individual and intervene at the right to prevent future events of suicide or harm. For the risk assessment of Ms. Ketty, the square risk assessment tool and the brief risk assessment form has been used. The main advantage of using a risk assessment tool is that it helps in checking for known risk factors of suicide, eliciting suicide ideation and also identifying whether patients is at imminent risk of suicide or not (Singhal et al., 2014). In the context of risk assessment for Ms. Ketty, the square risk assessment tool helped to obtain data related to severity of harm to self and others.
As Ms. Ketty was found to suffer from extreme depression, comprehensive risk assessment for the client was important to determine whether her condition can cause harm to her or others. The square risk assessment tool was to conduct risk assessment. The square risk assessment tool identifies risk in mentally ill patient by parameters like risk of harm to, level of problem with functioning, level of support available, history of response to treatment and attitude and engagement to treatment. The outcome for each of the parameters was as follows:
Risk of harm to: Significant level of harm to self was identified based on current thoughts/past impulsive actions and harm to others.
Level of problem with functioning: Serious impairment was found in the area of social and occupational functioning. This can be said because severe impairment affected both her occupational performance and social engagement.
Level of support available: Her level of support available was found to be minimal as only her sister was involved to provide support and Ms. Ketty had no contact with family members.
History of response to treatment: During her past episodes of depression, she received moderate response to treatment.
From the risk assessment using the square risk assessment tool, moderate risk of harm to self has been identified. This is evident from the fact the fact Ms. Ketty was involved in past suicide attempts. Her recurrent episodes of depression and feelings of hopelessness are also significant markers for suicide risk. Ng, How and Ng (2017) argues that pervasive thoughts of hopelessness and additional psychiatric co-morbidities like substance abuse, poor physical health, social isolation and having stressful life event are also risk factors of suicide. Few of the psychiatric co-morbidities were also found for Ms. Ketty as she expressed stressful life events, social isolation in the past.
The risk assessment revealed significant impairment in social and occupational functioning of Ms. Ketty suggesting the severity of problem for patient. She has limited area of support in her life. Living alone and social isolation is regarded as one major risk factor contributing to suicide ideation for the client. Many research studies have confirmed the association between loneliness and suicide ideation. Pereira and Cardoso (2017) gave the insight that loneliness, social anxiety, higher level of depressive symptoms and lack of trust in others are the common symptoms identified in people with suicide ideation. For Ketty, death of her parents and marriage of her elder sister limited her attachment with families. She could get very short episodes of attachment with family members who affected her interpersonal relationship and social engagement. Schinka et al. (2012) also established association between loneliness and suicidality by explaining that loneliness leads to suicidal thoughts and suicidal behaviour.
Lack of parental support is one major disadvantage and risk factor identified for Ms. Ketty which increases life stress as well as suicide ideation for Ms. Ketty. Kang et al. (2017) supports the fact that youth suicide is a major social problem and lack of protective factors like parental support also increases suicide attempts for patient. Supportive relationship with parents helps youth to manage multiple stressors. However, being deprive of social support affected mental health and well-being for Ms. Ketty. As Ketty’s depression has affected her occupational and social functioning and contributed to suicide ideation, it is evident that she is at moderate risk of self-harm. Her safety should be prioritised and psychological intervention is important to treat her depression and promote mental health and well-being for the client.
Patients with depression avoid engagement in social occasions and interacting with people in social situations. They like being alone and asking to many questions also increase their irritability and emotional outcomes. For mental health care professional, dealing with clients with suicide ideation and depression is a challenging task. Their symptom of irritability and violence during social situation can act as a major while conducting mental health assessment (Turecki & Brent, 2016). As Mrs. Ketty was a client with depressive symptoms and suicidal ideation, it was evident that challenges may be encountered while conducting mental status examination and risk assessment. Hence, several strategies related to counselling skills for developing rapport with client and use of appropriate line of question was used to conduct the mental status examination and risk assessment process.
While initiating the mental status assessment process, one of the major focus was to build rapport with client. This was because Ms. Ketty avoided social engagement and it was imminent that collecting information from her related to her mental health condition would be difficult. The method that was applied to build rapport included use of effective communication skills and displaying respect and empathy to client (Kiosses et al., 2015). The initial approach was to use values of empathy and communication skills to make the client comfortable and develop trust with the client while conducting the assessment. Non-verbal expression of empathy such as forward lean, direct body orientation and head nodding was used to give the client the feeling that their well-being was important. The advantage of using non-verbal expression of empathy was that it reinforces the message to client that the clinician or the staff conducting assessment is sensitive to understand their concerns (Lorié et al., 2017).
The conversation was started with client first by initiating conversation with non-threatening topics and avoiding use of direct questions related to her mental health condition. This helped to avoid situations of irritations for clients in the first instance of communication. To ensure that Ms. Ketty feels included but not interrogated during the assessment, the rapport building strategy was to mirror the body language of client. Non-verbal strategies to build rapport included maintaining rapport by matching non-verbal signals including body positioning, eye contact, tone of voice and facial expressions with the client (Hershkowitz et al., 2015). Bodie et al. (2015) explained that eye contact is an indication of active listening skills. Abbe and Brandon (2014) supported the fact that mirroring patient’s perception and body language during mental examination enables building therapeutic relationship with client and ensure that client disclose all information willingly without any resistance. Similar rate of speech and vocal tones ensured that client do not feel interrupted during the assessment. This would help to establish common ground and ensure that client is at ease to provide the message. The value of empathy and reassurance was constantly used so that the client feels confident and develops the trust to disclose all her problem. Malin and Pos (2015) also supports the fact that empathy significantly promotes alliance building while working with clients with depression. Utilization of cognitive and emotional functions while responding empathically to clients help to convey understanding and increase interaction with patients with depression.
To ensure that the client provides correct information related to her mental state and not become irritated too, open ended questions were used. The advantage of using this strategy was that it provided Ms. Ketty the freedom to respond to the question as per her will. She could give long answers or she could have given very brief response too. Pietkiewicz and Smith (2014) argues that open-ended questions encourage clients to talk at ends and also use prompts. Oberjé et al. (2015) supported the fact that open-ended questionnaire is a reliable tool too capture behaviour change information from patient. However, this approach might limit collecting useful data if the client gives very short answers. Too avoid such situation, the strategy of referring back to what the client had said would help client disclose more about their condition without feeling interrupted. Rautalinko (2013) gave the evidence that reflective listening and open-ended questions improves the evaluation skills of counsellors. Similar approach can also work for health care professionals who are conducting assessment in mentally ill patients. Paraphrasing and summarizing also helps to verify information, extract more information and demonstrate engagement in the conversation. Hence, open-ended questions and communication skills like back questioning is a useful strategy to extract information from difficult clients.
The alignment to recovery oriented practice was done during the risk assessment process by ensuring that two-way communication process existed during the assessment. This was done by agreeing with client’s response in certain occasion as well as providing honest feedback regarding things or perception which is not correct. Chester et al. (2016) expressed that patients should be empowered and motivated to change their behaviour by honestly showing them their weakness and giving the encouragement that new course of actions would help them to overcome the stressors in life. Recovery oriented practice was also followed by giving the knowledge to client regarding the need to take control of their health.
Conclusion:
The report gave an insight into the process used to conduct risk assessment and mental status examination for patient with depression. Ms. Ketty contacted mental health care service following episodes of depression and past suicide attempts. The mental status assessment gave the indication that patient is suffering from major depression. The risk assessment process revealed social isolation and lack of social support as major risk factor for suicide ideation. The process used for rapport building and conducting risk assessment with client gives the insight that communication strategies like eye contact, mirroring body language, appropriate voice tone, empathy and respect is essential to collect information from client without any issues or challenges.
References:
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Bodie, G. D., Vickery, A. J., Cannava, K., & Jones, S. M. (2015). The role of “active listening” in informal helping conversations: Impact on perceptions of listener helpfulness, sensitivity, and supportiveness and discloser emotional improvement. Western Journal of Communication, 79(2), 151-173.
Chester, P., Ehrlich, C., Warburton, L., Baker, D., Kendall, E., & Crompton, D. (2016). What is the work of recovery oriented practice? A systematic literature review. International journal of mental health nursing, 25(4), 270-285.
Hershkowitz, I., Lamb, M. E., Katz, C., & Malloy, L. C. (2015). Does enhanced rapport-building alter the dynamics of investigative interviews with suspected victims of intra-familial abuse?. Journal of Police and Criminal Psychology, 30(1), 6-14.
Kang, B.-H., Kang, J.-H., Park, H.-A., Cho, Y.-G., Hur, Y.-I., Sim, W. Y., … Kim, K. (2017). The Mediating Role of Parental Support in the Relationship between Life Stress and Suicidal Ideation among Middle School Students. Korean Journal of Family Medicine, 38(4), 213–219. https://doi.org/10.4082/kjfm.2017.38.4.213
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