ASSESSMENT IN MENTAL

HEALTH PRACTICE
 What is Assessment?
• The process of systematically gathering
information about a person in relation to his
or her environment so that decisions can be
made, based on this information that is in the
best interests of the individual.
Two key questions have to be asked;
• What do we want to know about the
problem?
• How do we go about it?
 Assessment cont’d
There are several areas of emphasis in the
clinical assessment process and these
include;
Demographic data
Physical complaints
Cognitive complaints
Emotional complaints
Environmental factors.
 Psychiatric History
• Psychological distress and mental illness may be
influenced by past and present experiences and
circumstances.
• A psychiatric history is a description of the habits,
activities, relationships, and physical conditions that
have shaped the way one feels, thinks, and
behaves.
• The psychiatric history is obtained by interviewing
the individual or asking a series of questions
associated with their psychological functioning.
Elements of Psychiatric History
• Identifying data – name, age, race, sex
• Chief complaint – a concise statement of the
patient’s psychiatric problem in his or her own
words
• History of present illness – current circumstances
in which current psychiatric symptoms have
occurred.
• Previous psychiatric history – any prior psychiatric
symptoms, treatment (therapy or medication);
 Elements of Psychiatric History cont’d
• Medical history – history of significant medical conditions,
treatments/surgeries; current medications; history of allergies
to medications or other agents; history of head injuries;
seizures; loss of consciousness or other neurological disorders.
• Family psychiatric history – any blood relatives with history of
psychiatric symptoms, treatment, or psychiatric hospitalizations.
• History of alcohol or drug abuse or dependence – length or
period of abuse/dependence; date and amount of last use;
history of drug treatment or rehabilitation programs.
• Social history – place of birth; description of family members;
marital status; education obtained; occupations past and
present.
 Mental Status Examination
• The purpose of MSE is to assess the individual’s
current emotional state and capacity for mental
function.
• The mental status examination is an organized
systematic framework for noting observations that
are made while interviewing individuals.
• In general, it involves categorizing observations in
terms of behavior and appearance; thought,
feelings, judgment, insight, and other functions
such as memory and concentration.
 ASSESSMENT TOOLS
Mental health professionals use more than
one assessment tool in gathering
information about their clients. There are
four main tools;
• Interviews
• Psychological Tests
• Observations
• Life records
 Interview
• This refers to a conversation between two or
more people with the clinician asking
questions and seeking clarifications.
• It helps to know what is going on with the
client.
• It is very important as it provides both verbal
and non-verbal information
• It can also take place anywhere
 Psychological Tests
• These are standardized procedures used to gather
information about an individual or a group of
people. –Projective and Objective Tests
• Testing involves the use of formal tests such as
questionnaires or checklists.
• Examples include: MMPI, DASS, HADS, BDI, etc
• They are easy and economical.
• There are established norms to aid the
interpretation of scores.
 Observations
• The focus of this assessment tool is to
find out information beyond what the
client reports.
• Actions speak louder than words.
• It provides information on behaviour in
its original setting but could be affected
by observer errors and biases.
 Life Records
• Academic records
• Marital history
• Employment record
• Medical records
• Police records
 Multiple Assessment
• Helps to cross-check
information.
• Evaluation of a therapeutic
approach.
• It reveals excesses in behavior
change