MSE (Mental Status Examination)

MSE means Mental Status

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:

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).

Protocol Overview

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.

Materials Needed

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?” ___________________________________________________________

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