Understanding The Mental State Examination (MSE): A Basic Training Guide

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Understanding theMental StateExamination (MSE):a basic training guideDeveloped by the Perth Co-occurring Disorders CapacityBuilding Project Consortium (Non-Residential)

The Understanding the Mental State Examination (MSE):a basic training guide is funded by the Australian Governmentunder the Improved Services for People with Drug and AlcoholProblems and Mental Illness (Improved Services Initiative),through the Department of Health and Ageing. 2011 Perth Co-occurring Disorders Capacity Building Project (Non-Residential). Permission granted toreproduce for personal and educational use only. Commercial copying, hiring, lending is prohibited.For more information about this DVD or for further copies please contact:Palmerston Association IncADDRESSFax3/73 Hay St, Subiaco, WA 6008PO Box 8241, Subiaco East, WA 6008(08) 6380 1376PhoneEMAIL(08) 9287 5400mail@palmerston.org.auLegal DisclaimerThis DVD and booklet are a guide only, based on evidence-based information available at the time ofpublication. The DVD is designed to assist clinical practice and assessment and is to be followed together witha clinician’s judgement in each individual case.ForewordOn behalf of the Perth Co-occurring DisordersCapacity Building Project (PCDCBP) Consortium,I have pleasure in presenting the DVD, Understandingthe Mental State Examination (MSE): a basictraining guide. This resource has been designed tostrengthen the capacity of alcohol and other drug(AOD) clinicians in completing a baseline MentalState Examination (MSE) with their clients. TheDVD has been designed using visual case studyscenarios, and is accompanied by this instructionaltraining booklet, to help clinicians test their skills incompleting an MSE. The overall purpose of the DVDis to introduce clinicians to the MSE assessment toolwith the view that more comprehensive training onthe MSE be completed in the future.Although designed primarily for the AOD sector,trainers and clinicians working in the mentalhealth field may find this resource useful. Manyexperienced mental health and alcohol and otherdrug professionals were involved in the developmentof this resource, producing a training tool that can beused by any clinician who needs to screen clients forthe presence of mental health issues.A considerable amount of time and effort hasbeen put into the development of the DVD andbooklet. For this, I would like to thank all the projectstaff, consultants, clinicians and consumers, whocontributed to the development of the DVD andbooklet and provided feedback during the ‘roadtesting’ of the resource. Having so many peopleinvolved in the project meant that many valuablepartnerships were formed, especially betweenAOD agencies and mental health service providers.The final product demonstrates how collaborativepartnerships between both sectors can result inthe development and delivery of quality serviceimprovement initiatives.I would also like to thank and acknowledge thesupport and advice from consortium members in theconceptual and developmental stages of this trainingresource. This has been an important undertaking bythe Consortium.In closing, the consortium members anticipate thatthe AOD and mental health sectors will find thisresource useful in providing their staff with baselineMSE training. Having a better skilled workforcewho work very often with clients presenting toAOD services with mental health symptoms will nodoubt contribute to the delivery of improved servicesto our clients.Sheila McHaleChief Executive OfficerPalmerston Association Inc(lead agency for the PCDCBPConsortium)

AcknowledgmentsWe would like to acknowledge the hard work and assistance ofa number of individuals who helped develop and produce thistraining resource:We also offer thanks to:Wendy ShannonPalmerston Association Inc – project staff and talentLeith MaddockPalmerston Association Inc – project staff and talentBrendan Mounter and the staff at Professional Public Relations Pty Ltd who produced theDVD and booklet.Sandra HarrisPalmerston Association Inc – project staff and talentPalmerston Association Inc staff who assisted with various tasks throughout the developmentof this resource.Jodee HarleyPalmerston Association Inc – project staffAll of the consortium members for their support and advice.Leanne Mirabella Palmerston Association Inc – project staffSheila McHalePalmerston Association Inc – Chief Executive OfficerKathryn KempDrug and Alcohol Office, Government of Western Australia –consultancy and adviceCalum RossDrug and Alcohol Support Service, Department of Psychiatry,Royal Perth Hospital, Health Department of WA – consultancy and adviceWesley ElliottSwan Kalamunda Health Service, Government of Western Australia –consultancy and adviceThe clinicians, carers and consumers who provided invaluable feedback on theDVD and booklet.

Contents1 Introduction2 Conducting a baseline MSEcase studies for3 Visualbaseline MSE trainingof an MSE assessment4 Exampleon each visual case scenario5 Emergency and after hours contacts6 References6Understanding the Mental State Examination (MSE): a basic training guide8 -1112-2122-2324-373839

1 Introduction1 IntroductionPurposeThe intention of this Mental State Examination(MSE) DVD and accompanying bookletis to assist alcohol and other drug (AOD)clinicians to be more confident in completinga baseline MSE on their clients. The DVDhas been designed to be an introductoryinstructional training tool on the baseline MSE.It is recommended that AOD clinicians seekadditional comprehensive training on theMSE to be clinically competent in theassessment tool.The DVD contains three visual case studyscenarios which clinicians can use to testtheir knowledge and skills in conductingan MSE. Firstly however, it is stronglyrecommended that clinicians readsections 1, 2 and 3 of this instructionalbooklet before watching the DVD.Where guided to do so on page 22, pleasedownload the relevant forms from the internet.You will need these to assist you in carryingout an MSE on the visual case study scenarios.The following pages briefly define the MSE andthe domains of this mental health assessmenttool. Further information on mental health8conditions and assessments can be accessedfrom the Guidelines on the management ofco-occurring alcohol and other drug andmental health conditions in alcohol and otherdrug treatment settings 1What is meant by abaseline Mental eb.nsf/page/Comorbidity GuidelinesThis DVD and booklet present a pared downversion of the MSE, which we have called abaseline MSE. AOD clinicians need to be ableto assess a client’s mental state sufficientlyto be able to identify a mental health issue,especially in terms of any immediate risk issuesfor the client or others. Further training wouldbe needed to carry out a comprehensive MSE.Diagnosis and treatment of co-occurring (orcomorbid) mental health issues remain therealm of qualified mental health professionals.What is a Mental StateExamination?A Mental State Examination (MSE) is theprocess of assessing an individual’s mentalstate and behaviour at the time of an interview.It uses a common format and language torecord information, which can be readilyunderstood across different services. The goalis to identify signs and symptoms of mentalillness to ensure appropriate assistance canbe given to the client and that any risks areaddressed. The MSE can be brief or morethorough depending on the circumstances(i.e. in an emergency it would be brief) andcan be repeated during the period of a client’streatment to observe changes over time.Understanding the Mental State Examination (MSE): a basic training guideThe AOD clinician also needs to be able todiscern if the client is suitable for ongoingtreatment at the AOD service without specialistmental health intervention, or if there is aneed to refer the client for a more thoroughMSE and possible medical, psychiatric orpsychological intervention.Why do AOD cliniciansneed to know how todo a baseline MentalState Examination?A high prevalence of comorbidity amongclients of AOD services means that agencyclinicians are frequently faced with the needto manage very complex mental healthsymptoms and/or problems, which caninterfere with the clinician’s ability to treat aclient’s AOD use effectively. In view of this, itbecomes very important that AOD clinicianshave the knowledge and skills to identifymental health symptoms, and in turn areskilled in how to manage the symptoms. TheMSE is one tool used in mental health settingsto screen for mental health symptoms. TrainingAOD clinicians in the baseline MSE will enablethem to feel more confident in identifyingmental health disorders/issues. Onceidentified, mental health disorders/issues canbe more appropriately addressed throughother assessments and/or referrals to qualifiedmental health professionals.9

Why do AOD cliniciansneed to know how to doa baseline Mental StateExamination?10 Understanding the Mental State Examination (MSE): a basic training guide“ more than one-third of individualswith an AOD use disorder have at leastone comorbid mental health disorder;however, the rate is even higher amongthose in AOD treatment programs.”(Mills et. al, 2009: p viii)11

2 Conducting a baseline Mental State Examination2 Conducting a baseline Mental State ExaminationThe importanceof rapport buildingin undertaking abaseline Mental StateExaminationTaking the time to establish rapport with aclient, before embarking on an MSE, is veryimportant. Consumer feedback tells us thatcontinuing to acknowledge the client’s feelingsand experiences during the informationgathering process is important for the successof the interview and ongoing engagement.Clinicians need to listen closely to what theclient has to say and ask for clarification orexamples if needed. Showing empathy toa client’s distressing thoughts and beliefs(without indicating an uncritical acceptanceof the person’s ideas and impulses) isappropriate.How to do abaseline MentalState ExaminationWhilst there is a comprehensive list ofcriteria and psychiatric terminology used in acomprehensive MSE, it is not necessary forAOD clinicians to have a detailed knowledgeof all of these for a baseline MSE. Whatis essential is for the clinician to have anunderstanding of the basic concepts used inan MSE. An AOD clinician will need to be ableto recognise the basic concepts in a client’spresentation and then describe them in theclinician’s own words. These descriptions willneed to be put in a client’s clinical notes.A baseline MSE is done in the normal courseof a session with a client. The clinician usestheir observational and listening skills to obtainthe information that they require to undertakethe MSE. Open ended questions are alsouseful for gathering relevant information.The MSE is not a series of questions but anevaluation process based on the clinician’sobservations and interactions with the client.12 Understanding the Mental State Examination (MSE): a basic training guideIf mental health issues are identified duringthe course of an MSE, then more directquestioning about the client’s experiencemay be required. An MSE can occur duringan initial assessment or as part of an ongoingseries of appointments.Format of thebaseline Mental StateExaminationThere are varying formats for carrying out anMSE. For the purpose of this training DVD,the format outlined in the Guidelines on themanagement of co-occurring alcohol andother drug and mental health conditions inalcohol and other drug treatment settings 1will be used.They are:1.Appearance2.Behaviour3.Speech and language4.Mood and affect (feelings)5.Thought content (thinking)6.Perception7.Cognition8.Insight and judgementPages 14 to 18 provide a brief description ofeach of the domains listed above.The following format can be used forrecording the observations made during anMSE. Primarily there are eight domains thatneed to be considered and assessed.13

2 Conducting a baseline Mental State Examination2 Conducting a baseline Mental State ExaminationAppearanceSpeech and languageAccurately and non-judgementally describeyour observations of the person’s physicalappearance. How does the client look?Consider: age, gender, race/ethnicity, build,hair style & colour, grooming, posture, levelof hygiene, mode of dress, apparent level ofhealth, signs of AOD use.Describe:-BehaviourAccurately and non-judgementally describeyour observations of the person’s behaviour.Avoiding assumptions is important so signsof illness can be separated from culturallyappropriate behaviours. How does the clientbehave? Consider: general behaviour, facialexpression, eye contact, body movementsand gestures. How is the client reactingto being in the session? i.e. co-operative,angry, hostile, withdrawn, inappropriate, afraid,suspicious, evasive.(a) How is the client talking (speech)?››››››››rate – rapid, pressured, slow, retarded››quality – stutter, slurring or anyatypical qualitiesvolume – loud, whispered, quiettone – monotone, variedquantity of information – poverty orpressure of speech, mute/silent(b) How does the client express himself/herself (language [form of thought])?Mood and affect(feelings)››How does the client describe his/heremotional state (mood)? Exploring moodinappropriate – expressing aninconsistent emotion to what they aretalking about (i.e. laughing when talkingabout a loved one’s death).››“high” or elevated – excessivelyhappy or overly animated in theirexpressions and gestures.is very important because it can give anindication of potential risk to self or others. Usethe client’s own words if possible. Is the clientdown, depressed, sad, anxious, angry, irritable,happy, ok, fearful, or “up”?What do you observe about the person’semotional state (affect)? A person’s mood andaffect should be congruent with each other.So when describing a person’s affect, whatdo you observe about the client’s emotionalstate?››incoherent/illogical – disorganisedor senseless speech››derailment – unrelated or looselyconnected ideas››››tangentiality or loosening ofassociation – unrelated or incompleterepliesdepressed – is the person “flat”,restricted, tearful, deflated, has bluntedfacial expressions?››anxious – is the person agitated, fiddly,distressed, fearful, irritable, distracted?absence or slowing of thought››angry – is the person hostile, defensive,easily provoked?››labile – rapidly changing their mood.››››thought blocking – thought flow isbriefly interrupted or absent14 Understanding the Mental State Examination (MSE): a basic training guideThought content(thinking)What is the person thinking about?Consider the following:››the amount of thought and its rateof production – Does the client’sspeech flow easily? Does theconversation stay on track? Is thereevidence of any limitation in the client’sability to think (i.e. look for slow/hesitantspeech)?››continuity of ideas – Do the thoughtsbeing expressed flow logically andstay on track? Are certain wordsor ideas repeated? Are there gapsin the flow of thinking?For example consider the following:15

2 Conducting a baseline Mental State Examination2 Conducting a baseline Mental State Examination››››››››disturbances of language – Is theclient’s communication coherent andwell organised? Are the correct wordsbeing used?delusional thoughts – Does theclient have any false beliefs that arenot in keeping with cultural, religiousand social norms? These delusionscan present in many different waysincluding delusions of persecution,bizarre thoughts, grandiose ideas, selfreferential thoughts, delusions of control.preoccupations – These thoughtsare very prominent in the client’s mindbut are not as firmly held as delusions.These include paranoid, depressive,anxious and obsessional thoughts andovervalued ideas.thoughts of harm to self or others –Has the client expressed thoughts ofharming themselves or others?This criterion also includes non-suicidalself harm such as cutting, excessivepicking, burning of self. Evidence ofany suicidal, self harming or homicidalthoughts need to be followed by athorough risk assessment. This trainingDVD does not train clinicians on how tohallucinations or ‘hearing voices’although they can be experienced in anyof the five senses:›› sight (visual)›› smell (olfactory)›› hearing (auditory)›› touch (tactile)›› taste (gustatory).conduct a risk assessment. Informationon risk assessments in AOD settingsis covered in the Guidelines on themanagement of co-occurring alcoholand other drug and mental healthconditions in alcohol and other drugtreatment settings, pages 46, 157,158, 159. This document can beaccessed at:Hallucinations seem real to the personexperiencing them. Note the degreeof distress or fear associated with theparticular hallucination. It is importantto explore command hallucinations,where the voices tell the person todo a particular thing, as there may beassociated Comorbidity GuidelinesPerceptionThe purpose of this domain is to ascertainwhether the person displays behaviouralevidence of hallucinations or other perceptualdisturbances.››Consider the following:››hallucinations are false perceptions inthe absence of any stimulus. They arethe most common form of perceptualdisturbance, particularlyauditory16 Understanding the Mental State Examination (MSE): a basic training guide››dissociative symptoms such as:›› derealisation (the external worldseems strange or unreal)›› depersonalisation (the person feelsdetached from their own thoughtprocesses or body).illusions, where the person misinterpretssensory stimuli (e.g. hearing rustlingleaves as voices).CognitionThe purpose of this domain is to ascertainwhether or not the person is alert and orientedto time and place. There is no need for AODclinicians to undertake a complex explorationof cognition. Cognition can be observedduring the course of the appointment processor explored further by asking simple directquestions.Consider the client’s:››level of consciousness – is the clientalert?››attention – can the client stayfocussed during the appointment?››memory – can the client tell you whathe/she did yesterday/last week?››orientation – can the client tell youwhat day of the week it is?››concentration – can the client focuson a simple mental task, such asadding?››abstract thinking – can the clientidentify similarities between two relateditems?17

2 Conducting a baseline Mental State Examination2 Conducting a baseline Mental State ExaminationInsight and judgementThe counsellor can then decide whetherthe client:Insight refers to the client’s capacity torecognise his/her own problems andsymptoms. Judgement refers to the client’scapacity to make sound, reasoned andresponsible decisions.››is appropriate for ongoing AODcounselling; or››is appropriate for ongoing AODcounselling in conjunction with GPfollow-up; orOnce the MSE is completed,a formulation can be made andan action decided upon.››requires psychiatric assessment andintervention before counselling canproceed.Formulationand action:Once a baseline MSE has been completedthe AOD clinician can make a formulation.The formulation summarises the informationgathered so the clinician can systematicallydevelop a hypothesis about the client’s mentalstate, which is then used to inform any actiontaken.The formulation should include the natureand severity of symptoms and any risk issues.It can also include information about theclient’s recent and past drug use.If unsure, the AOD clinician should consultwith their supervisor or team before makingthe formulation and any subsequent referral.The MSE, formulation and action should bereviewed regularly to monitor any changes inthe client’s mental state.Carers, familymembers and othersupports:If during an MSE a client is found to besignificantly unwell, it is recommended thatthe client be asked if they would like a carer,family member or another significant other18 Understanding the Mental State Examination (MSE): a basic training guideto be contacted for support and assistance.If it is assessed that a client’s judgement issignificantly impaired (and they refuse anysupport person to be contacted) it may beappropriate to contact the client’s registerednext of kin. However, this should only becarried out after consulting with a clinicalsupervisor.IncorporatingAOD factors in thebaseline Mental StateExaminationWhen completing an MSE with AOD clients,their current AOD use must be considered as itmay affect the way the client presents.These factors include:››››››how recent was their last AOD use?is he/she still intoxicated?the presence of AOD withdrawalsymptoms (depression, hallucinations,delirium tremens).››medication being used to assist withwithdrawal.››any acquired brain injury from AOD use.If the client is very intoxicated, or in activewithdrawal, it is not appropriate to do an MSE.However, due to developed tolerance to theirdrug of choice, it is common for AOD clientsto attend appointments whilst intoxicated andwithout obvious impairment to their normallevel of functioning. A baseline MSE may beappropriate under these circumstances butshould be discussed with a supervisor andreviewed at the earliest opportunity.Referral processUrgent matters (i.e. risk of harm to selfor others): If a client is already known to amental health service, the case manageror duty officer can be contacted and askedto follow up on the concerns raised. Pleasediscuss this with your supervisor if you are notsure how to proceed.19

2 Conducting a baseline Mental State Examination2 Conducting a baseline Mental State ExaminationIf the client is not known to a mental healthservice, and the matter is urgent, then theAOD clinician can suggest to the client thefollowing:If the AOD clinician is unsure how to accessappropriate mental health support they cancall the duty officer at the local mental healthservice and discuss the referral processwith them.››go to the nearestdepartment (ED)››››go to their general practitioner (GP)Less urgent matters (i.e. no immediaterisk): If the client is already a client of acontact the Mental Health EmergencyResponse Line (MHERL)mental health service the case manager orduty officer can be contacted and asked tofollow up on the concerns raised.emergencyIt may be appropriate, depending on theservice, for the AOD clinician to contact EDor the GP and discuss their concerns prior tothe client being seen, or even accompany theclient when they attend for assessment.If the client is not willing to seek help and theAOD clinician is concerned about the risk ofharm to self/others then this matter shouldbe referred to a senior manager for furtherassessment. The police or other emergencyservices may become involved if this isdetermined to be the appropriate action fromthe management of a service. As there is aduty of care in this situation confidentialitycan be breached. All actions taken should bedocumented.If the client has not previously sought help formental health issues they should be referred toa GP for further assessment and treatment orreferral. It may be appropriate, depending onthe service, for the AOD clinician to contact theclient’s GP and discuss their concerns prior tothe client being seen, or even accompany theclient when they are assessed. It is commonfor AOD clients not to have a GP so assistancewith making an appointment may also berequired.Some emergency and after hours contactnumbers have been provided in section 5 ofthis booklet.20 Understanding the Mental State Examination (MSE): a basic training guide21

3 Visual case studies for baseline MSE training3 Visual case studies for baseline MSE trainingBefore continuing you should:Instructions for use1.Read the previous sections of thisbooklet.2.Download the Assessment of MentalState table fromEach case study has been developed to allowa clinician to practise their knowledge andskills on conducting an Download the Mental State Assessmentform for each case scenario you arecompleting (three in total if you intendto complete an assessment on allthree visual case studies) .Please note: Some versions ofWindows Media Player do notsupport the playing of DVDs. If you arehaving trouble playing this DVD via yourPC, its recommended you downloadVLC Player (www.vlc.org). If youare unable to access this website,please consult your IT administrator.Press “Start” to watch the introduction tothe DVD. This will briefly explain the purposeof the DVD and will then return to the mainmenu for you to select your case studyscenarios. It is suggested that you completeat least two case study scenarios to practiseyour MSE knowledge and skills. The firstcase study scenario entitled ‘Lisa withoutcommentary’ and ‘Lisa with commentary’is suggested for all clinicians.In all cases, the case study scenario “withoutcommentary” should be played first. Onceyou have finished watching the “withoutcommentary” case study scenario, returnto the main menu of the DVD. Then usingthe table and MSE form (that you havedownloaded from the internet) attempt tocomplete an MSE on the client presented.Once you have finished, watch the “withcommentary” case study scenario in itsentirety. The scenario “with commentary”should only be played after you have watched22 Understanding the Mental State Examination (MSE): a basic training guidethe “without commentary” case study, asthis will replay the same case study but willalso contain some additional comments onhow to carry out an MSE on that client.If necessary, you can take notes whilewatching the case study scenarios. Remember,there is no “right” or “wrong” way of writingyour assessment and observations of a client.Try to use simple language that is nonjudgemental and follow the MSE guidelines inthe Assessment of Mental State table to thebest of your ability.To view an example of an MSE on eachclient (on Lisa, Glen and Barry) please go tosection 4 of this booklet. It may be useful toread these examples after you have finishedcompleting your MSE on each case studyscenario, and while you are watching the“with commentary” version of the casestudy scenario.23

4 Example of an MSE assessment on each visual case study scenarioThe following pages provide an example of an MSE assessmenton each visual case study scenario. Please note that theseresponses are to be used as a guide only and may differaccording to clinical judgement.4 Exampleof an MSEassessmenton each visualcase studyscenario24 Understanding the Mental State Examination (MSE): a basic training guide25

4 Lisa: MSE Assessment Example4 Lisa: MSE Assessment ExampleAppearance:Lisa is a 26 year old Caucasian woman, ofslim build with long dark hair. She was dressedin crumpled jeans, which appeared dirty, anda T-shirt. She appeared to be in good healthoverall but with a poor level of personal careand grooming (which is unusual for Lisa whois known to the service).Behaviour:Lisa was agitated and restless, moving inher chair and playing with her hair during theappointment. Her eye contact was intermittent.She was distracted in the session and at timesshe seemed to be responding to unseenstimuli (voices). Despite appearing to beunwell she communicated freely and was cooperative.LisaSpeech and language:Mood and affect(feelings):Lisa’s mood was not depressed or elevatedbut she appeared anxious, fearful and agitated.Thought content(thinking):Lisa’s speech flowed easily and she expressedherself clearly. She sometimes pausedmid-sentence, appearing to be distractedby unseen stimuli, and at times had to berefocussed on the conversation.Lisa showed signs of paranoid and delusionalthinking. She believed people were spyingon her with cameras and microphones in herhome. This is why she slept in the gardenshed. She also thought her boyfriend hadinserted a transmitter into her stomach whileshe was asleep. To her, this meant that herthoughts were being monitored.Lisa’s speech was of normal tone and rate.visual case study scenario27

4 Lisa: MSE Assessment Example4 Lisa: continued.Thoughts of harm to self or others(risk assessment): Lisa holds the belief thather boyfriend wants to harm her, so she isprotecting herself by sleeping in the gardenshed with a knife under her pillow. There is nohistory of domestic violence in the relationshipnor does Lisa’s boyfriend have a history ofharming others. While Lisa holds the belief thather boyfriend wants to harm her, there may bea risk of harm to him. Lisa has no previoushistory of self harm or harm to others.Perception:Lisa was experiencing auditory hallucinations.She reported she was hearing different voicessaying “horrible” things such as “you are nogood”, “you are ugly”’ and that she needs toprotect herself from her boyfriend. She wasobserved replying to what appeared to bevoices during the appointment.Cognition:Lisa had misplaced her medications and couldnot remember when she had last taken hertablets. She usually relies on her parents givingher the medication. Lisa also found it difficultto concentrate during the session. Otherwiseshe was alert and oriented to time and place.Insight and judgement:Lisa showed insight and judgement. She waswilling to consider that the experiences shewas having could be due to a recurrence ofher mental illness and was agreeable to theMental Health Service being contacted forfurther assessment.Formulation:Lisa’s mood and affect are congruent.She said she felt worried and she presentedas fearful. Her speech was normal in rate andtone. She showed signs of delusional andparanoid thinking, believing she was beingspied upon by cameras in the house andthat her boyfriend had planted a transmitterin her stomach so everyone would knowwhat she was thinking. She said she washearing derogatory voices and was seento be actively listening and replying to themduring the appointment. The voices are also28 Understanding the Mental State Examination (MSE): a basic training guidec

scenarios, and is accompanied by this instructional training booklet, to help clinicians test their skills in completing an MSE. The overall purpose of the DVD is to introduce clinicians to the MSE assessment tool with the view that more comprehensive training on the MSE be completed in the future. Although designed primarily for the AOD sector,

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