Performing a mental examination in therapy is a fundamental part of the psychological evaluation process that allows the therapist to gather relevant information about the mental and emotional condition of their patient. Through this examination, symptoms, thought patterns, emotions, and behaviors can be identified that will help the therapist better understand the individual and develop an effective treatment plan.
1. Prior preparation
Before beginning the mental examination, it is important that the therapist prepares adequately. This includes reviewing the patient's medical history, establishing a safe and trusting environment in the session, and becoming familiar with the techniques and tools that will be used during the evaluation.
2. Establish rapport
Creating an empathetic connection with the patient is essential so that they feel comfortable and willing to share personal information during the exam. Actively listening, showing empathy and generating an atmosphere of trust are key to establishing effective rapport.
3. Start the interview
Begin the interview with open-ended, exploratory questions to allow the patient to tell their story and describe their symptoms. This will provide the therapist with an overview of the situation and will serve as a starting point for the more detailed mental examination.
4. Evaluate general aspects
4.1 Mood
Observe and ask about the patient's current mood. Explore whether there are symptoms of depression, anxiety or mania, and how these affect your daily life.
4.2 Cognition
Assess mental clarity, ability to concentrate, memory and level patient alert. Be alert for possible signs of cognitive dysfunction.
5. Examine thinking
5.1 Thought content
Inquire about the patient's predominant thoughts. Analyze if there is the presence of delusional ideas, obsessions, or recurring negative thoughts.
5.2 Thought process
Observe the way in which the patient elaborates his ideas. Pay attention to speed of thought, coherence, tangentiality, or flight of ideas.
6. Explore perception
6.1 Hallucinations
Ask about the presence of visual, auditory, or other perceptual hallucinations. It is important to determine the nature and content of these experiences.
6.2 Illusions
Investigate whether the patient experiences perceptual distortions, such as misinterpreting real sensory stimuli.
7. Evaluate orientation
Check if the patient is oriented in time, space and person. Disorientation may be indicative of cognitive or dissociative problems.
8. Test memory
8.1 Short-term memory
Perform simple tests to assess the patient's ability to retain short-term information, such as remembering a list of words or numbers.
p>8.2 Long-term memory
Ask about significant memories from the past and assess the patient's ability to remember events, important dates, or autobiographical details.
9. Explore affectivity
9.1 Predominant emotions
Identify the emotions that the patient experiences most frequently. Analyze for emotional fluctuations, inappropriate emotions, or emotional apathy.
9.2 Emotional Expression
Observe how the patient expresses his or her emotions, both verbally and nonverbally. Pay attention to the congruence between your emotional language and your facial and body expression.
10. Evaluate behavior
10.1 Observable behavior
Observe the patient's behavior during the interview. Note if there is agitation, withdrawal, repetitive movements, or other abnormal behaviors.
10.2 Behavior Related to Symptoms
Relate the patient's behavior to his or her reported symptoms. Look for patterns of behavior that may provide additional information about your condition.
11. Review the medical history
Review the patient's medical and psychological history, including previous treatments, hospitalizations, family history, and any factors relevant to understanding the patient's current condition.
12. Use standardized tests
In some cases, it may be useful to complement the mental examination with standardized psychological tests to more objectively evaluate specific aspects, such as depression, anxiety or personality.
13 . Integrate information
Once all relevant information has been collected, the therapist must integrate it to form a complete and coherent picture of the patient's situation. This will help establish an accurate diagnosis and design an individualized treatment plan.
14. Communicate the findings
It is essential that the therapist clearly and understandably communicate the findings of the mental examination to the patient. This will help build a strong therapeutic alliance and involve the patient in his or her own treatment process.
15. Monitoring and review
Periodically monitor the patient and review the initial mental examination throughout treatment to evaluate progress, adjust interventions as necessary, and ensure compliance. effectiveness of the therapeutic process.
Performing a mental examination in therapy is not only a diagnostic tool, but also a therapeutic process in itself that allows the therapist to build an empathetic and collaborative relationship with the patient, identify areas of intervention and provide the necessary support to promote emotional and mental well-being.