Contextual influences on assessment

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The place of assessment should not be regarded as automatically fixed in the outpatient or other clinical premises. One or more assessment interviews at home should be considered/35 since the patient and family may feel much more at ease and therefore likely to express themselves more freely in familiar surroundings, but with the proviso that privacy may be more difficult to achieve. The assessor will often be surprised how much useful information about the home and family circumstances is gained from an interview at home, even when there appeared to be no special reason for this at first. In addition, the behaviour of both the patient and family members in the clinic or hospital is often different from that observed in familiar home surroundings. There are also obvious advantages to both assessment and care at home for mothers who have psychiatric disorders in the puerperium. (36>

Interviews on primary care premises are also often appreciated by patients who dislike going to hospitals of any sort, and the ease of consultation with the general practitioner is an additional advantage. The adoption of regular visits by a consultant psychiatrist to primary care premises as a major element in cooperation between psychiatrists and general practitioners is a style of work that seems to be spreading, with advantages to all concerned. (3Z>

Privacy of interviewing and confidentiality of what is discussed need careful consideration; there are few absolute rules, but the following points of procedure should be explained clearly to both patient and relatives from the start. First, the patient and any member of the family should know that if they wish they are entitled to speak to the doctor in private, and they must be able to feel that what they say will not be conveyed to any other member of the family unless they request this. Second, in addition to the usual rules of professional secrecy, the patient must agree not to question other family members about what they said to the doctor, and vice versa. These may seem to be elementary points to trained professionals, but they are often not appreciated by patients or relatives who may be in fear of each other, or at least apprehensive about the reaction of the other on learning that statements they might construe as critical have been made about them. These are all points by which trust is established and maintained between patient and doctor, and for the same reason any attempts by relatives to seek interviews on condition that the occasion is kept secret from the patient should be firmly resisted.

An interpreter should always be sought if the patient cannot speak freely in the language of the interviewer. Mental health professionals who can also act as interpreters are increasingly available nowadays due to the presence in almost all communities of sizeable ethnic minorities. Because of the issues of confidentiality noted above, a professional of the same sex as the patient should always be preferred to family members when interpretation is needed.

Language barriers are usually, but not always, accompanied by a cultural difference. The interviewer must remember that the concept of a private interview between two strangers in which personal and often unpleasant events and experiences are discussed freely comes from 'middle-class Western' culture, and is not necessarily shared by persons from other cultures. A discussion of this point before the interview with a mental health professional familiar with the patient's background will help the interviewer to determine what to aim at in terms of intimate or possibly distressing information.

Multiple sources of information are always an advantage for those topics (mainly events) for which objective accounts are possible. Clinical experience is the best guide as to which account to use when conflicts of information arise. Serious conflicts of information arising during the initial assessment that involve the patient's account of events are best resolved by trying to obtain more information. Confrontation of the patient with important conflicts of information should be avoided since it easily leads to misunderstandings. If done at all, confrontation should be reserved for later stages in the overall management when it forms part of a planned intervention with a special purpose.

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