LET ME SAY right at the beginning that I will be expressing a personal view here. Other psychiatrists may approach assessment differently.
Ultimately, the assessment of a client within litigation proceedings is essentially the same process as the assessment of a patient for treatment, but clearly for a very different purpose and with a very different result.
In the former case, the assessor should listen carefully to and record the client’s own version of events, seek clarification whenever necessary but never offer comment or advice.
I often explain at the outset that I am going to act rather like a sponge – specifically, that I will listen, absorb, assimilate and (I hope) understand but not challenge or reassure. Of course, I always explain that I must, of necessity, follow the Civil Procedure Rules and that my role ultimately is to assist the court on all matters within my expertise. I explain also the limited confidentiality of my eventual report.
What about preliminaries? When I receive a letter of instruction, I read it carefully to assess the extent of the task. I also glance through the (often extensive) bundle of documentation to gain a feel for the issues in dispute. Then I do no more until the day of assessment.
The essentials
I usually explain to the client that, quite deliberately, I have grasped no more than the essentials of the case as I would wish to hear from them first. Generally, I find this approach most helpful as I particularly wish to avoid clouding my mind with other peoples’ accounts, views or opinions. Essentially I seek to make up my own mind first and then see what other people have to say (and perhaps then reconsider my views in the light of any new information).
So how does an assessment actually proceed? Well, firstly, never ignore the basics: full name, date of birth, current address. It’s surprising how often, when flicking through the documents, you find three or four different dates of birth. Then, if possible, let the client tell their story in their own words. Just sit back and relax, or at least give the impression of so doing. Actually this is the most vital part of the assessment.
Two-pronged approach
The assessor’s art is to do two things at once, one subjective and one objective. Subjectively, the assessor seeks to engage with the client, offering encouragement and promoting rapport.
Essentially the aim is to extract the best from the client and provide them with the maximum opportunity to say whatever they wish.
Objectively, the assessor needs to stand outside the situation (at least metaphorically) and ask ‘What is going on here?’
Perhaps an illustrative example will help. If the client suddenly bursts into tears, the assessor might reasonably pause, offer a box of tissues and give the client an opportunity to compose themselves.
Objectively, however, the assessor notes that the clientís tear gland is secreting, that a sensitive issue has just been addressed and that the client has a capacity for consciously experiencing painful emotional states. All well and good. These observations are obviously all indicators of normality.
But what if the client is not distressed by matters which would upset almost anybody? What if the client becomes distressed by an apparent triviality? What if the client is so persistently distressed that they are rendered quite incapable of providing any coherent account of themselves?
All these observations can reveal far more about a client, in particular their mental condition, than ever could be gained from their history alone.
Of course, you can’t really do two things at once, or at least I can’t, so the assessor’s art is to flick back and forth between subjective mode and objective mode as the client’s story gradually unfolds. To achieve this effectively requires a lot of practice.
Essential component
And, of course, never omit the mental state examination, an essential component of any assessment. Perhaps the specific details of the examination are not so important for this article. Essentially, the assessor seeks evidence of the client’s level of consciousness, degree of orientation to their environment, extent of cognitive functioning, mood state and mental contents generally.
Often, all this can be covered within the ongoing conversation with the client, but sometimes specific interrogation is necessary. In essence, the aim is to seek evidence concerning the client’s current mental processes.
Having completed the interview and mental state examination, the difficult part of the assessment process then begins. The documentation, usually including voluminous medical records, needs to be read carefully and with understanding. Significant points are noted and annotated so that they can be located again. The whole process can take many hours in complicated cases.
Tentative conclusion
In any psychiatric report prepared for a court, it would be usual to offer an opinion first and foremost on the client’s current mental condition (or diagnosis, if any). This can include an opinion on personality as well as the identification of any active mental illness.
Necessarily, any conclusions must be somewhat tentative, since often the supporting information will have been gathered from just a single interview with the client. However, the courts will understand this and expect any opinion to be based simply on a balance of probabilities.
Most importantly, the assessor should express an unambiguous conclusion on diagnosis (commenting on any areas of uncertainty) and indeed all other relevant matters.
Any conclusion should ultimately be the most parsimonious hypothesis that can account for all available observations. At least in psychiatric practice, Kraeplin’s symptom hierarchy is often a good starting point. The remainder of the report then should offer opinions on all questions raised by instructing solicitors.
And finally, the take-away message: never forget that you are assisting the court, not the client (no matter how persuasive their case), so keep to the point and write in a formal but lucid style.