The Mental Status Exam paper will focus on the ethical social work activity of completing a multi-dimensional assessment using the DSM–5-TR. In addition to the Mental Status Exam (MSE), emphasis will be placed on ethical considerations and respect for diversity and inclusion based on the context of the client presented in the case scenario. Students will be expected to use diagnostic criteria from the DSM–5-TR and additional supporting readings to demonstrate knowledge applied to the case scenario. 

This assignment should be based on an actual client with whom the student has worked in professional or internship settings. If this is not possible, please meet with the instructor to discuss alternatives. Students are not to use themselves, a family member, or close personal contact as the subject of this paper due to professional, ethical expectations prohibiting dual relationships. ( go ahead and make this up but make it very clear and detailed, throw in some mental and family issues.)

Papers must be 10–12 pages and utilize the APA 7th edition format for formatting and references, including a title page, introduction, body of the paper, conclusion, reference page, 12-point Times New Roman font, and 1-inch margins in your paper. The paper must be double-spaced.

Papers must include each of the elements below.

Present de-identified 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.

Identify the presenting problem. Include any existing diagnoses and a recent (approx. six weeks) behavioral and emotional profile.

Describe the history of the problem. Include any historical diagnoses and history of treatment, including inpatient/ residential, outpatient (individual, family, group), and psychiatric medication, as well as responses to these forms of treatment.

Identify the client’s current living situation. Identify characteristics of the situation that facilitate and hinder the client’s functioning, if any.

1. Describe the client’s current level of functioning in the following domains as relevant:
2. Work

School

• Family

Social

1. Sleep
2. Appetite

Identify and assess any current or historical suicidal or homicidal ideation or behavior.

1. Identify and describe any current or historical evidence of psychosis – delusions or hallucinations.
2. Conduct a mental status examination and describe the results as they align with the following domains:
3. Orientation (person, place, time)
4. Appearance
5. Behavior (you can refer to sections II and III if relevant)
6. Speech
7. Mood

Affect

• Thought Process (you can refer to section VII if relevant)
• Thought Content (you can refer to section VII if relevant)

Cognition / Memory

1. Insight / Judgment
2. Attitude / Rapport
3. Identify any physical health needs, medical intervention, and impact on the client’s functioning if relevant.
4. Identify any substance abuse history and treatment history if relevant.
5. Describe any trauma history, trauma symptoms, and impact the trauma history has on the client’s current functioning if relevant.
6. Identify any relevant legal history/involvement, including criminal justice involvement if relevant.
7. Identify any relevant academic history.
8. Briefly describe relevant considerations pertaining to the client’s family of origin. Characteristics may include the functioning of the client’s parents, attachment considerations, client’s economic circumstances and residential mobility growing up, and birth / developmental history.
9. Describe the client’s peer relationships, social support, and any significant relationship history.
10. 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 the client (e.g., age of onset) that align or do not align with diagnostic features and associated features of this diagnosis.
11. Reflection:

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)?

1. What types of personal biases might you experience when working with this client? How would you identify and manage those biases (Competency 1.c)?
2. 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).
3. What tools would you rely upon to support your use of ethical decision-making in relation 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).

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 prepare yourself to best serve this client (Competency 1.e)?

• 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)?
• Address how diversity and difference related to any personal characteristics, which could include race/ethnicity, gender identity or orientation, religion, and others, have impacted identity formation for this client.
• Identify ways in which this client has experienced oppression, discrimination, marginalization, or alienation in their life and how those experiences have impacted the client’s functioning.