What’s in a psychiatric assessment?

By our Medical Director Dr Catherine Pyves  

It all starts with a review, to get the client’s full background: medical notes, social work chronology, police records, court bundles and any other documentation that sheds light on their physical and mental health.  

Equipped with this information, and the reasons for the court order, we can put together a flexible assessment.  

This takes the form of a structured conversation, rather than a set list of interrogations. It’s a natural discovery process, built on trust and rapport, where we draw out their life stories from an evolving dialogue. Then slowly – piece by piece – a picture starts to emerge. 

Trust is perhaps the most important factor here. So we’ll always set clear, transparent ground rules, especially on the thorny issue of confidentiality. We’ll stress that we have to disclose anything that involves harm to another person – so they’ll always know the consequences of anything they choose to share. 

Turning to the assessment itself, let’s take alcohol misuse for illustration. 

Our first priority is to establish their pattern of drinking. We need to understand recency, type of alcohol, quantities, repetitions, and the behavioural impact of both drinking and cessation.  

To this end, their drinking history is imperative. We’ll explore: 

• Their first encounter with alcohol 

• How the habit progressed 
• How alcohol has affected them: the impact on work or education, relationships, personal health, criminality and more 
• How they’ve coped through periods of abstinence  
• Triggers that have led to relapses – including relationship dynamics 
• Plus any lessons learned through diagnosis or treatment 

As we start to gain this deeper insight, we can also consider predisposing factors. Here, we’re looking to answer a wide range of questions – including: 

• Is there a family history of alcohol dependency? (Experts have long been debating the notion of a ‘drinking gene’, and the impact of being raised in an alcohol-heavy environment.) 
• How were they shaped by early life events – the loss of a parent, divorce or separation, exposure to domestic violence, child abuse, or any other incident that could involve social services? 
• Did they experience problems in school, like isolation, low attainment, bullying or exclusion? 
• Are they trying to quit other substances, and using alcohol as a diversion? 

• Is alcohol harming their mental health – and is poor mental health increasing their consumption? (One problem often exacerbates the other, which part-explains why alcohol is so often implicated in suicide.) 

Once we’ve weighed these and other factors, we can move towards a clinical diagnosis: are they a social drinker, binge drinker or alcohol-dependent? Or is their condition even more problematic – requiring a deeper mental state examination? 

Following diagnosis, we can determine treatment and make our recommendations to the court, knowing we understand the type and level of risk presented. 

This (briefly) describes the assessment process where alcohol is involved – and it’s a similar tale for drug use.  

Again, it’s about understanding the deep-seated causes, the level of dependency and the behavioural impact – ultimately, to establish the level of risk that the client may present to themselves and their family. 

It can be a lengthy process – the first interview alone will often take 4 hours or more. But in complex cases, where data is unclear or the risk is harder to quantify, it’s the only way to give the court a fully considered – and balanced – medical opinion.