Psychiatry for Lawyers – The assessment process

I will now discuss how I go about assessing a typical medicolegal patient.

LETTER OF INSTRUCTION From the medical point of view, the assessment process starts with the letter of instruction.

The psychiatrist will find it easier if this contains detailed questions. Since the Woolf reforms, however, instructions in personal injury cases are now frequently in a standard form of words.

Sometimes, the letter is phrased in search a general way, that the crucial points on which the expert's opinion is being sought are unclear.

Experts may therefore need to contact those instructing them for clarification. However, care will need to be taken in such contacts, especially if the expert is jointly instructed. All parties need to be kept informed, with records of any discussions. Email can be ideal.

MODE OF ASSESSMENT Occasionally, one will be instructed to review the notes or other reports or video. However, generally speaking, one is required to see the patient for a face to face interview.

Interview by video link is possible. For example, it may be possible for instructing solicitors to arrange for the expert to visit a local court or police station, and see a patient who is currently in prison, using a justice system review conferencing network. However, this would need to be followed by a proper face-to-face interview at some stage.

PLACE OF ASSESSMENT This can be anywhere convenient to psychiatrist and patient. In criminal or Mental Health Act cases, it may perforce have to happen in a prison or hospital. Usually, however, it will be in a hospital outpatient clinic or private consulting rooms.

In my trips round the UK seeing patients, I often use hotel meeting-rooms as an alternative. They tend to be more convenient for patients in some mundane but important respects, such as parking and being near the motorways. The free coffee and biscuits sometimes available can help to establish a friendly atmosphere in the interview.

Occasionally, it will be necessary, for example if the patient says they cannot travel, for the interview to take place at the patient's home. This seldom fails to add perspective to the assessment of the patient's home, family or social circumstances.

It is a somewhat curious fact that patients who are able to go to foreign parts on holiday are nevertheless unable to travel a few miles to a clinic and insist on a home visit.

Patients sometimes ask "Where's the couch?", but contrary to this popular stereotype about psychiatrists, the patient will be invited to sit on a chair.

(Use of a couch is confined to old-fashioned psychoanalysis, which has little place in mainstream clinical psychiatry, let alone medicolegal work, these days.)

WHOLE-PERSON EVALUATION The spirit of the assessment should be holistic. The psychiatrist should try to gain an understanding of the patient as an individual, bearing in mind that the reaction to a trauma or other mental health problem is individual and unpredictable- even idiosyncratic.

The assessment must be cautious, bearing in mind that anything in the resultant report may have to be justified in a Court, Tribunal or other legal forum. Even a report to an insurance company about income protection insurance (permanent health insurance) can end up with the Ombudsman or the Financial Services Authority; disgruntled patients even occasionally complain to the GMC.

Therefore the report must be properly argued, and backed up with evidence. Nothing should be in the report which cannot be justified.

The process of arranging the appointment for interview sometimes throws up potentially important information, for example that the patient is living at a different address from that given in the letter of instruction, or that they seem for some reason unusually keen or unusually reluctant to attend. (One's astute PA or secretary should be encouraged to record and pass on these impressions).

Enquiry into these practical matters at the ensuing interview can be illuminating.

INTERVIEW WITH THE PATIENT This proceeds as for a standard psychiatric assessment, typically taking between 1 and 2 hours. Ideally there will also be an interview with an informant, such as a friend or relative, in order to gain corroboration (though obviously this is not necessarily an unbiassed account).

The interview comprises 3 parts:

Introductions begin the interview, and a relaxed atmosphere is attempted to be established. Even in 2006, many people remain nervous at the idea of seeing a psychiatrist.

Often it is helps the patient to relax if they are accompanied by a friend or relative. If present, they should not contribute until the end of the interview, lest the account recorded becomes a joint effort of patient and relative. (This will be of lessened value medicolegally, if the expert is unable later to say who said exactly what in his report. Contributions of the friend or relative must be clearly marked in the report as such.

EXPLANATION of the purpose of the interview comes next: that it is for assessment only (in most cases) and that the report will not, generally speaking, go directly into their own medical notes.

CONFIDENTIALITY The limits of confidentially are likely to be different from a standard clinical interview, where the doctor is treating the patient.

In normal clinical practice, confidentiality will only be broken in very restricted circumstances, for example if there is imminent severe risk to the patient or another, for example, a definite plan to commit suicide or homicide.

In the medicolegal setting, however, the doctor may need to check with the patient that he understands the limits of confidentiality in the medicolegal setting.

If it is a personal injury case, for example, one must explain that the report will be seen by the court and by the other side. Occasionally, the patient may ask the doctor to leave out of the report matters which may potentially be embarrassing to them (for example, references in the GP notes to an extramarital relationship).

The doctor clearly has no need to put irrelevant material into his report, but must not leave potentially important matters out. The relevance must ultimately be decided by the Court. If in doubt, it must go in.

"CAN I HAVE A COPY OF THE REPORT?" is often the next question the patient will ask. ìYes, probably, though not directly from me,î would be the short answer, as the Data Protection Act gives people the right to see personal information held about them (unless the information is judged likely to be harmful to them).

However, the report is not the property of the psychiatrist, but is for the instructing solicitor or other party. So it should not generally be released directly to the patient, unless there are specific instructions to do so.

In personal injury cases, claimants often seem to review the report in conjunction with their solicitor.

The patient should therefore be advised to ask the solicitor or other instructing party if they wish to see the report eventually.

The Access to Medical Reports Act allows the patient to see the report before despatch, but only applies if the author of the report has previously treated the patient.

STARTING FROM SCRATCH The psychiatrist must get a full account afresh from the patient; he should explain that this might mean the patient going over something which he has described before, perhaps many times, which can potentially be irritating and upsetting for the patient.

However, they are usually reassured on this point if the doctor explains that he wishes to come to his own view, based on the patientís own words, so that he will not be biassed by the previous accounts which may be in the bundle.

BIOGRAPHICAL INFORMATION such as name, date of birth, address, marital status, current occupation, etc should be checked at the beginning.

Patients occasionally grumble that "You've already got all that, doctor," but it is essential that the doctor satisfy himself that the person being seen is the person in question.

Photo ID to be shown by the patient is increasingly asked for by instructing parties, and / or the patient being asked to sign a declaration that they are indeed the person concerned.

DISCREPANCIES at this stage are surprisingly common, and need to be clarified, if not immediately, then later in the interview. For example, the patient may reveal that they are not living at the address given, but are "staying with my mother at the moment". Has their marriage broken down? Has their house been repossessed? If so, is this linked to the matter on which one has been instructed?

Elucidating these factors may be very important in the assessment, as such family and other social problems, often influence the causation and outcome of psychiatric problems.

As one of my teachers once said to me, "Dr. Gill, it is no use taking the most extensive psychiatric history in the world if you have not found out that the patient's gas has been cut off."

CONSISTENCY of the patient's account, both within itself and with previous accounts, is of course one of the hallmarks of a reliable informant. The doctor should clarify apparent inconsistencies as they come up. There is no reason for a genuine patient to be evasive or defensive about them if the enquiry is made in a polite way. On the other hand, "too perfect" consistency could give rise to a concern that the patient might have pre-rehearsed their account- or been "coached".

BACKGROUND HISTORY Having spent a little time setting the agenda with the patient, which will form the introduction to the finished report, the psychiatrist is now ready to take a full history.

This means a history not only of the current problem but also of the background: this includes, a full personal history, including an account of their

Patients understandably sometimes cannot see the necessity to enquire into their background, from perhaps many years before the current problem. However, patients generally accept it if one explains that the same illness or injury can have very different effects on two different people, and that therefore we need to know about the person as well as the illness or injury.

They can, in short, appreciate that the individual person who has suffered the psychiatric problem has been formed by his previous experiences, that "the child is father of the man".

SUMMARY SO FAR By this point in the interview, therefore, the psychiatrist has taken a history up to the point of the patient leaving education. He will have a preliminary impression of the person as coming from a stable background or not, turning into a young adult, well adjusted or otherwise to face the adult world of work and relationships.

It is then convenient to cover a number of briefer, more factual topics, including the patient's

Then the patient is invited to give some description of their personality before they became ill. This needs a little care, as even the most anxious and isolated individuals seem to describe themselves as "I was always affable, happy-go-lucky". So more specific enquiry is necessary:

HISTORY OF THE PRESENT PROBLEM. I find it better to cover this after the background information. If one starts with the present problem, which is the natural tendency of doctor and patient, then it can be difficult to leave enough time to obtain the full background history.

The history of the present problem is of little use in isolation, as the effects of it can only be properly assessed in the context of an overall appreciation of the individual.

In this part of the interview, obviously, we concentrate on the particular type of mental health problems, which are presenting for assessment.

Not only symptoms, also effects on the patients ability to live their life must be recorded. The latter will include

WORK Ability to work is vital in most cases, for example in determining the amount of damages in personal injury cases, so it is important to be as clear as possible about why - if they do- the present problems appear to be interfering in ability to work.

So a practical understanding of the actual duties of the patientís job is needed: the job title itself is not enough, and can be so vague as to be meaningless (e.g. ìcivil servantî could cover everything from a senior adviser to government to a municipal ratcatcher).

Work comes in many forms; casual, voluntary and part-time work need to be covered as well as the main occupation. Many people have more than one job: are they both/ all affected? If not, can the difference be explained?

CASE EXAMPLE For example, a young man was off sick from his job as a lorry driver, where he had to unload the lorry himself; but he was able to continue to do agency work for another firm, driving a lorry which was unloaded by others.

Unpaid work in the home must also be enquired about: ìjust a housewifeî is not a phrase one should accept at face value. Running a household successfully implies an ability to do a number of things, and therefore require a good level of function.

Then comes a description of the current symptoms, plus an account of how the patient spends a typical day, including activities of daily living .

Finally, the patient's social circumstances: composition of household and overall financial circumstances: enquiry about exact amounts would be intrusive, but it is vital to have a rough idea of the current adequacy or otherwise of the family's means.

MENTAL STATE EXAMINATION This is the equivalent of the detailed physical examination in other branches of medicine. An orthopaedic surgeon, say, will get a detailed subjective description from the patient about their back problems (ìtake a historyî), and then proceed to his own objective examination of the back.

So, the psychiatrist, having completed the history, the patientís subjective account of their background and health problem, now proceeds to an objective assessment of the psychiatric status called the mental state examination.

Usually, one will have made an assessment of most aspects of the mental state already during the course of the conversation. So, in fact, the section in the report entitled mental state examination describes data mostly gathered during the whole interview, rather than one specific part.

COGNITION The main exception to this would be the specific tests of intellectual functioning which would be done as part of the mental state examination if there is a question of dementia or head injury or memory problems, for example.

Psychiatrists, as an initial step, generally assess cognitive function ìat the bedsideî, that is to say, without the need for any special equipment or questionnaires. Three aspects are examined, and typical questions used would include:

Orientation Can the patient correctly name their name, the place they are currently in (e.g. a hospital, and if so, which one?), and the current day, date and time. Psychiatrists often refer to the result of this in terms such as ìMrs Jones was fully oriented in person, place and time.î

Concentration There are several tests which can be used; ìserial sevensî is popular, the patient being asked to subtract 7 from 100 and then keep subtracting 7 from the remainder.

Memory Short-term memory can be assessed by the patentís ability to recall three objects or (more difficult) a name and address. Long term memory can be assessed by their awareness of news and current affairs (so the psychiatrist may need to make arrangements to update himself re soccer, celebrities, etc in order to know what the patient may respond here).

INSIGHT The final category of the mental state examination, denoted "insight", sounds somewhat unimportant but it in fact crucial as it is shorthand for the

Patients who feel they are going to get better and take ownership of the process of treatment and rehabilitation tend to do better than pessimistic patients who rely entirely on the outside world to effect a cure. Insight is therefore closely linked to prognosis- and hence to quantum.

THE PLACE OF TICKBOX QUESTIONNAIRES AND STRUCTURED INTERVIEWS in medicolegal assessment is unclear, although they are popular with psychologists. These instruments are mainly designed for use in research, and to a lesser extent in clinical practice. Few, if any, have been validated for use in the forensic setting. Excessive reliance on such instruments can blind the expert to the necessary holistic and common sense aspects.

A senior psychologist once commented to me ìthe more graphs, numerical tables and statistics I see in a report, the less weight I tend to give it; I see them mainly as comfort blankets for the inexperienced practitioner.î

PHYSICAL EXAMINATION is part of the overall assessment. The psychiatrist will note indicators of general health such as the patient's skin and hair, signs of anxiety such as tremor, and sweaty palms on handshake. Occasionally, he may encounter a patient whose hoary hands, with ingrained dirt, throw doubt on a story of inability to work. Or a ìrecoveredî alcoholic with an overwhelming smell of cologne- to mask that of alcohol?

However, apart from such general indicators, a full physical examination will not usually be done by him personally. The role of the psychiatrist here is to make sure that appropriate physical examinations and investigations have been done by others whose specific role this is, such as the patient's GP and other specialists involved.

In particular, the psychiatrist must ensure that physical causes of supposedly psychiatric symptoms such as depression or anxiety have not been missed. Conditions presenting as depression or fatigue or indeed almost any psychiatric picture may turn out, after investigation, to be due to underlying medical conditions such as anaemia or thyroid disease, to name but two. However, this is uncommon.

He may occasionally need to organise blood tests or scans himself, but, as indicated, his job is usually to check that these have been done by others.

SUPPORTING EVIDENCE The interview with the patient, however diligently carried out, is ultimately no more than a snapshot of the patient at one particular point in time. Corroboration is therefore always necessary. This comes- or not, as the case may be- from speaking to an informant and from reviewing the other documents.

INTERVIEW WITH FRIEND OR RELATIVE This must be done whenever possible, though obviously requires the patient's consent. It is not a completely independent view- the informant, if a family member, may have a stake in the matter as does the patient, and therefore a desire for a particular outcome of the assessment. Even so, speaking to a friend or relative seldom fails to add perspective.

MEDICAL NOTES Crucially, the GP medical notes must be obtained. Since Lloyd George in the early 20th century, the UK has had a system of each person being registered with a GP, who is the first point of contact for all (state-sponsored) medical care.

His ideas were developed in 1948, with the introduction of a National Health Service. Since that time, the NHS has been responsible for almost all General Practice, and also almost all Accident and Emergency work, in the UK.

Even if the patient is seeing a private specialist, it is infrequent for patients to refer themselves directly (indeed, the General Medical Council has until fairly recently discouraged specialists from accepting such approaches). So, even if patients do see a private specialist, this is usually through referral by the (NHS) GP, and there will be letters from the Consultant back to the GP about the patientís treatment and progress.

Hence, this ìgatekeepingî role of the NHS GP builds up a ìcradle-to-graveî medical record for most patients, to the extent that ìgapsî in the record need to be explained if possible. (Was the patient well? or abroad? or a guest of Her Majesty? etc.)

This is not the case in most other countries, where patients dot around from doctor to doctor, and there is no one practitioner who is building up a medical record through time.

The unique value of the NHS medical record should thus never be underestimated in medicolegal assessments.

PREVIOUS REPORTS should also be read carefully, from whatever speciality. In personal injury, orthopaedic surgeon reports are probably the most commonly encountered. Although ìorthopodsî sometimes lampoon themselves as ìjust simple carpentersî, there is in my experience frequently a good deal of shrewd observation and overall assessment of the patient in their reports.

VIDEO and other surveillance information may be made available, either at the time of the preparation of the initial report or subsequently. Sometimes, the appearance in the film is, at first glance, dramatically different from the account given by the patient, but usually it is less clear-cut. It is very important that the report contains an account of current function, not just symptoms, as this is the area which video highlights.

Experience (sometimes bitter) suggests that reports should be written bearing in mind the possibility of later disclosure of video evidence.

WRITING UP please see the diagnosis section for a discussion as to how the information to hand is synthesised into the final diagnosis and conclusions.


	IMPORTANT DISCLAIMER This website is provided in good faith for general information only, based on Dr Gill's understanding of psychiatry in the UK. It does not represent the views of any organisation with which he has a relationship. It is not to be taken as advice or opinion on any specific case or issue whatsoever. In particular, material provided about the method of assessment in medicolegal cases or about any other matters is not to be taken out of context. Opinion expressed by Dr. Gill in an individual medicolegal case and method of assessment may adhere to or depart from the material on this website entirely according to his professional judgement. Nothing on this website forms part of his terms and conditions for medicolegal work, let alone part of his reports. Nor does Dr. Gill holds himself out as an authority on these matters. Other views undoubtedly exist on most if not all matters covered, which may be just as valid as his. No liability is accepted for any use of this website, or for any error or omission. By using the site, you agree to these terms. The text partly derives from Outline of Psychiatry, a textbook originated by Dr Jenny Barroclough, later prepared jointly, and the most recent edition by Dr Gill.
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