A crucial component of the assessment process is the evaluation of the client’s mental state and presentation. An assessment of mental state should include:
- Speech and language.
- Mood and affect.
- Thought content.
- Insight and judgement.
The type of information sought in each of the above domains is outlined in Table 18. It should be noted that all of the aforementioned factors may be affected by intoxication or withdrawal from substances. The mental state examination should not consist of a series of direct questions, but rather should be based on an overall evaluation of the client during the assessment (or preferably a number of assessments). A record of the mental state examination should be completed after (rather than during) conversations with the client. In addition to noting unusual or abnormal client behaviours, it is also good practice to record normal behaviours (e.g., no speech disturbances noted, no unusual thought content noted) . Appendix F presents a form which may be useful in guiding note-taking for the mental state examination.