The MSE Interview Protocol below is Adapted from Clinical Interviewing (5th ed., 2014), published by John Wiley & Sons. For information on that title, go to: http://www.wiley.com/WileyCDA/WileyTitle/productCd-1118270045,subjectCd-PS77.html
Extended Mental Status Examination—Interview Protocol
This appendix contains a structured protocol for conducting a face-to-face (FtF), telephone, or videoconferencing mental status examination (MSE) interview. Some of the material is modified from the Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975). We encourage you to modify the content or process in ways that work well within your particular setting.
You will notice this protocol includes space for writing notes and scoring whether clients responded accurately to some questions. However, we want to emphasize that this procedure is not standardized and has no normative sample. Consequently, we recommend that you use it qualitatively. Gathering data using this protocol will allow you to write a clear and concise mental status examination report. It also may support a much more extensive psychological or evaluation report. For a standardized process complete with norms, an alternative approach should be used (e.g., see the Mini-Mental State Exam, 2nd edition [MMSE-2]).
The following protocol generates qualitative assessment data. However, using your own clinical judgment, you can, if desired, generally organize the data into three broad evaluation categories:
1. No concerns
2. Mild concerns
3. Significant concerns
A mental status examination (MSE) is primary based on interviewer observation. Although there are traditional and specific methods for obtaining MSE data, an MSE interview doesn’t always involve the same procedures; an MSE is also not necessarily highly structured. The process involves an interviewer interacting with a client in such a way as to glean data about client functioning that can be organized into the nine categories typically included in a mental status examination report. Detailed information about MSE process and content is in Chapter 8 of this book. Reviewing Chapter 8 can help provide a foundation for conducting this interview more thoroughly and skillfully.
In some cases, the structured nature of this interview assessment protocol (and all structured interviews) may greatly facilitate relationship development and interviewer/counselor credibility. In other cases, if the interview isn’t well framed or used in a manner consistent with your personal and professional style, it can adversely affect rapport and credibility. We generally recommend using the protocol flexibly while emphasizing the development and maintenance of a collaborative relationship. Research suggests that collaborative assessment procedures and the development of a positive working relationship are linked to more positive assessment and therapy outcomes (Smith, 2011).
This MSE protocol is divided broadly into three sections. Sections include preparation steps, traditional MSE categories (in the order of administration, but not the order of an MSE report), and evaluating and communicating MSE results.
Mental status examiners should have a private setting and materials available for note taking.
The Importance of Small Talk (e.g., Charlar en Espanol)
When using this or any structured interview protocol, it’s important to engage in comfortable small talk before formally initiating the interview. After informed consent is obtained, if you’re interviewing from a distance, you might ask about the local weather, what room the client is in, and whether he or she is comfortable and ready to begin. To prepare for small talk, you can go online and skim through local newspapers to check on recent news events. For example, when interviewing clients from remote areas it can enhance rapport if you can comment on and ask about popular local news items (e.g., a moose wandering into a small town, performance of local sports teams, etc.).
Introducing the Assessment Protocol to the Client
After a bit of small talk, you should transition to the formal assessment process. You can use the following script to guide what you say, while at the same time feeling free to use your own words:
In just a few minutes I’ll start a more formal method of getting to know you that involves me asking you lots of questions. It will include easier and harder questions, some questions that might seem different or odd, and even a little mental math. This interview is just a standard process to help me to get to know you better and for me to understand a little more about how your brain works. As we go through this interview you can ask me questions at any time and I’ll try my best to answer them. Do you have any questions before we start? [Answer directly and honestly whatever questions are asked; after the client’s questions are answered, proceed with the formal assessment process.]
Are you ready? [Hopefully you’ll get an affirmative answer here. If not, keep answering questions and chatting or conversing about the process and anything else that seems necessary.]
You can use the following outline to guide your interview process. You may want to write down client responses in the spaces provided.
Orientation and Consciousness
This is the technical opening of the MSE interview. Say something like: “We’ll start with some easier things and then get to some harder things.”
Then ask: “What is your full name?” _______________________________________________
Ask: “What is today’s date?” _______________________________________________
Ask: “What day of the week is it today?” _______________________________________________
Ask: “What season of the year is it?” _______________________________________________
Ask: “What’s the name of the town or city where you’re living now?” _______________________________________________
Say, “Now, this might be a hard one.” Then ask: “Who is the governor of your state?” ___________________________________________________________
Evaluation of consciousness is conducted by observation. After the examination is over, you should identify and circle which of the following words is the best descriptor of your client’s level of consciousness:
Alert, Confused, Clouded, Stuporous, Unconscious/Comatose
Ask: “Is it okay if I do a little test of your memory?”
Then say, “I’m going to say three items and then I’ll stop and have you say them back to me. Ready? Cup, newspaper, banana. Okay, now repeat those back to me.”
Write down how many items the client immediately recalls. _______________________________________________
If the client can’t recall all three items, go ahead and repeat them back. Continue repeating them and having the client try again until it’s clear the client will likely not get them. Up to six trials are recommended in the Mini-Mental State Examination, but depending on frustration level and persistence you can stop sooner or later.
Attention and Calculation
Depending on how your client did with the first memory task, you might say something like: “Now I’ve got a harder one for you” or “How do you feel about numbers?” Then say: “I’d like you to start with the number 100 and then count backward by 7s. It’s like 100, minus 7, and so on.”
Many clients will work hard at this (or not). Either way, you can stop after five subtractions (93, 86, 79, 72, 65). You can think about the client’s response categorically from no errors to one error to two errors to three errors to being unable to complete the task. You can also watch for the client’s self-talk and strategies for dealing with a cognitive challenge.
If the client has difficulty with the task, be sure to express empathy or validation: “That’s a hard one. Many college students struggle with subtracting 7s.”
The attention and calculation category is useful for observing the client’s level of consciousness, memory, mathematical ability (and mathematical confidence or self-efficacy), and/or ability to concentrate and calculate.
Intermediate or Remote Memory
Ask the client: “Who is currently president of the United States?”
Follow that question with: “Who was president before him?”
Continue asking about presidents. The correct order going back in time is: Obama, Bush, Clinton, Bush, Reagan, Carter, Ford, Nixon, Johnson, Kennedy. You can stop when the client gets stuck or when he or she makes it to Reagan. If the client is from a different cultural or an international setting, ask about recent and present political leaders there. Although this task technically involves memory assessment, it’s also a reasonable gauge of fund of knowledge or exposure to news and information.
Mood and Affect
After making a transition statement like, “Now I have some different questions for you, ask the client: “How do you feel right now?” _____________________________________________ (This question is a direct assessment of mood, which is the client’s self-report of his or her prevailing emotional state.)
Ask: “Rate your mood right now, with 0 being the worst possible mood you could have—0 would mean you’re totally depressed and you’re just going to kill yourself. A rating of 10 is the best possible mood. It would mean that you’re totally happy and maybe up on the roof dancing. What rating would you give your mood right now?” ______________________________________________
Ask: “Now, what’s the worst or lowest mood rating you’ve ever had?” ______________________________________________
Ask: “What was going on then to make you feel so down?” ______________________________________________
Ask: “Now, what would be a normal mood rating for you on a normal day?” ______________________________________________
Ask: “Now tell me, what’s the best mood rating you think you’ve ever had?” ______________________________________________
Ask: “What was going on then to help you have such a high mood rating?” _______________________________________________________
Affect is the client’s observable moment-to-moment emotional tone. Affect is observed and measured in terms of:
Affect content (circle one): Angry, Anxious, Ashamed, Euphoric, Fearful, Guilty, Happy, Irritable, Joyful, Sad, Surprised, Other _______________
Affect range (circle one): Blunted, Constricted, Expansive, Flat, Labile, Other ______________
Affect appropriateness (circle one): Appropriate or Inappropriate; Observations: ___________________________________________________________
Affect depth or intensity (circle one): Shallow, Normal, Intense
Intermediate Memory Recall
Tell the client: “Now I’ve got a tricky question. Ready?”
Say: “Remember a while ago I asked you to remember three items. Can you remember those three items now?”
Circle the items recalled: Cup, Newspaper, Banana
Total number recalled without prompts: _____________________
For this item, be sure to wait for the client to make a sincere effort. After 15 to 20 seconds, you can test to see (for each item) if the client can use a cue to recapture a trace memory (the purpose of this is to see if a prompt can help with memory retrieval, which is of less concern than complete absence of recall).
For cup, you can say: “It’s something you might drink from.”
For newspaper, you can say: “It’s something you read.”
For banana, you can say: “It’s a type of fruit.”
Total number recalled with prompts: _____________________
Speech and Thought
Say: “Now I’m going to ask you a few questions about your thoughts and thinking. Are you ready?”
Ask: “Do you ever have particular thoughts that get stuck in your head that you think over and over?” _________________________ (This focuses on obsessional thoughts.)
If the client says yes, ask: “What’s an example of a type of thought that might get stuck in your head?” _______________________________________________
If warranted, ask: “How do you finally manage to get that thought back out of your head?” [If the client’s response suggests obsessive thinking, you should explore this with a few follow up questions exploring frequency, intensity, duration, and so on.] ___________________________________________________________
Ask: “Do you have any beliefs that some people consider unusual or odd? If so, what are they?” [Again, explore these beliefs as appropriate.] ___________________________________________________________
Ask the client to repeat the phrase: “No ifs, ands, or buts.” _______________________________________________
You should be observing the client’s speech throughout the MSE.
Note whether the client’s speech is: Loud, Normal, or Soft; Fast (pressured), Normal, or Slow (poverty of speech).
Also rate the speech as: Spontaneous, Labored, Blocked.
Note the presence of: Stuttering, Cluttering, Dysarthria, Dysprosody (see the MSE chapter for more information on this.]
Be sure to track your client’s thinking process. Circle one or more of the following terms:
Circumstantiality, Clang associations, Flight of ideas, Mutism, Neologisms, Perseveration, Tangentiality, Word salad
Ask: “Do you ever see or hear things that other people don’t see or hear?” ___________________
If the answer is yes, gently explore the client’s experience with questions like:
“What do you see/hear that others don’t?” _______________________________________________
“Can you give me an example?” _______________________________________________
“How do you know others can’t also hear/see this?” _______________________________________________
Ask: “Do you ever think the radio or television is speaking directly about you or directly to you?” __________________
If yes, ask: “Can you think of an example of that?” _______________________________________________
Ask: “Has anyone ever tried to steal your thoughts or read your mind?” _______________________________________________
If yes, ask: “Can you think of an example of that?” _______________________________________________
Cognitive Skills (Intelligence), Abstract Thinking, and Social Judgment
Ask the following questions:
“Name six large U.S. cities.” ___________________________________________________________________________________________________________
“What poisonous chemical is in automobile exhaust?” ________________________________________________
“In what way are a pencil and computer alike?” ________________________________________________
“What would you do if you found a gun hidden in the bushes near your home?” ________________________________________________________________________________________________
“If you won a million dollars, what would you do?” ________________________________________________________________________________________________
“What would you do if a person who was much smaller than you tried to pick a fight with you?” _________________________________________________
“What would you do if a person who was much bigger than you tried to pick a fight with you?”
“What would you do if you had a close friend who obviously had a drug or alcohol problem?” _________________________________________________
Insight and Reliability
Insight and reliability are difficult to measure directly. You may be able to infer them from the preceding questions and activities. Reliability is especially difficult because it’s hard to tell if someone is being honest or dishonest. Do your best to rate both insight and reliability.
Insight: Absent, Poor, Partial, Good
Reliability: Unreliable, Questionable, Reliable and honest
End the interview with thanks and by asking the interviewee if he or she has any questions for you. Answer whatever questions the interviewee may have as directly, honestly, and gently as you can. For example, if a client had difficulty with a portion of the assessment, you could say: “It seemed like there were parts of the interview that were harder for you. You had trouble with subtracting 7s and remembering presidents, but you did better with some of the other questions.”
Client appearance cannot be evaluated unless you’re conducting an assessment face-to-face or via video link. If you were able to observe your client’s appearance, consider which of the following adjectives best describes his or her appearance.
Note anything unusual about the appearance of the client’s eyes, facial expression, posture, clothing, makeup, and other observables. Also note whether the client looks older, younger, or about his or her actual age. __________________________________________________________
Behavior or Psychomotor Activity
Client behavior or psychomotor activity cannot be evaluated unless you conducted an assessment face-to-face or via video link. If you were able to observe your client’s behavior, write down anything unusual or distinctive about his or her client’s physical movements, gestures, repeated behaviors, and so on.
Attitude Toward the Examiner (and Examination)
Clients will have different responses to participating in an MSE. When determining a client’s attitude toward the examiner, you’re relying on observational data. No direct questions are asked about this. After completing the assessment, come back to this section and circle the words that best describe your observations of the client’s attitude.
Cooperative, Resistant, Hostile, Indifferent, Ingratiating, Seductive, Suspicious, Impatient, Pleasant, Open, Curious
Evaluating and Communicating MSE Results
As noted previously, this protocol is not standardized and therefore can only yield qualitative information about your client. Additionally, we should emphasize that when you initially begin using the protocol you may feel odd or awkward or unsure how to use the data effectively. Keep in mind that experience helps, as does discussion and exploration of the specific items with classmates and with your instructor. It’s an excellent idea to “dissect” the questions and tasks in small groups. For example, consider different possible responses to the “Million dollar” question. Typically responses include ideas about: (a) saving money, (b) spending money, and (c) giving away money. Analyzing client responses can give you a sense of their values and judgment. Obviously there are no correct or incorrect answers, but the client who tells you, “Hell, I’d just book a trip to Hawaii, buy a bunch of pot, and smoke it all up” conveys something distinctly different than the client who says, “I’d invest half of it in something safe, buy a decent house, and then give 10% away to charity.”
The goal of a mental status examination is to evaluate client mental state as well as other client dimensions. This makes the process inherently judgmental. It also makes it all the more important for you to be tentative in your conclusions and, whenever possible, to stick with a reporting of your observations instead of making strong inferences about your observations. For guidance in writing up a mental status examination report, you should review chapter 8 of the Clinical Interviewing textbook.
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