Mental health reporting

by TheEditor

Categories: Diagnosis, Expertise, Reporting

What is mental health reporting?

Mental health reporting is the creation of Mental Health Reports that assists the interests of those who are associated with mental health matters. Most mental health reports are required for courts.

Are all Mental Health Reports for courts?

No. Many are for insurance purposes. Some are for employers. Some for disciplinary or regulatory bodies with statutory power e.g. the General Medical Council.

What is a Mental Health Report?

This is a report, normally constructed by a qualified consultant psychiatrist, to inform someone or some organisation on certain mental health issues in an individual. Is that like an expert report? Exactly. The person constructing such a report should have been trained to do such reporting – and not merely a jobbing psychiatrist. Some mental health reports are done by psychologists, nurses, and probation officers.

What do you mean?

Constructing reports is a delicate and largely misunderstood skill.

Why pray tell?

It requires a lot of skill to extract the relevant information and put it into a format that is reasonably easy to be understood by a lay person. That’s not easy. It requires very careful consideration and balance. Normally a good expert will become very close to the case. S/he will have studied every scrap of written information provided. S/he would have carefully considered all information obtained in interviews. S/he would have cross referenced interview material against written material, looking for consistencies and inconsistencies.

Why would courts require a report?

The courts may request an ‘expert report’ from someone who is considered to be an expert in his field. Ideally that should help the court to better understand what is happening in certain complex issues. Experts are not there to decide guilt, innocence or liability. Those are matters for the court.

So what does the expert comment on?

The expert is meant to confine himself largely to the substance of instructions he accepts from counsel. For example if the instructions were: “Elucidate what was the accused’s mental state at the time of the offence” – the expert would interview the accused and study all available collateral information, in coming to a reasoned perspective about the accused’s state of mind at the time of the offence. At the time of the offence would mean shortly before, during and after the offence. To give a context to that mental state, the expert may ask for other relevant information e.g. witness statements, CCTV, any audiorecordings that may exist.

What other kind of information could be relevant?

It is difficult to predict. In the case of matricide, it may be relevant what was the accused’s relationship to his mother. Psychodynamic factors may have been relevant from the past in the accused’s mental state at the time.

What if the expert requests information that is irrelevant?

Caution is advised. Whilst there are some experts who wish to bump up their fee for studying irrelevant materials, there are some who will know better than you why a seemingly irrelevant piece of information is required. Don’t have an email discussion about it. Get on the phone or meet in person to talk about it. An expert is entitled or obliged to declare in a report that certain information was requested and not provided. Their report may contain caveats on reliability of opinions that are not based on information requested. This can cause delays at court.

So what exactly is mental state?

Whilst mental state is largely about the state of mind at a particular time, that snapshot is not entirely static. The idea is to understand the mental state and this is similar to understanding physical state.

So (in physical state) whilst damage to internal organs is important, a snapshot description does not give a full understanding. Why? Because an end point could be arrived at from several different processes. And similarly in mental state reporting – the accused’s mental state could arise from several different factors. The expert can rightly comment on how the mental state may have arisen, in terms of contributory factors.

Does mental state say if there is madness?

The answer is ‘no’, in most cases. This may appear surprising to many, and madness is not a term used by psychiatrists in formal reporting language. The reason why mental state often tells so little, is because on most occasions the following may be the case:

– The client is much better at the time of interview.
– The client withholds on reporting symptoms of illness for whatever reason.
– The client dissimulates. That means the client pretends to be well.
– The absence of depressed affect seems to work against diagnoses of depression (which isn’t madness).
– The mental state assessment is not carried out in sufficient depth.

For mental state examinations/assessments to say anything of substance, they must be carried out with extreme care and search for detail. A good report will not just give summary statements of opinion or observation, but will give some actual substance of the interview, often times some verbatim.

Can you give an example of poorly done mental state examination?
Sure thing. See below:

Appearance: normal. tattoo on right arm. Lots of smiles.
Speech: No problems, no formal thought disorder.
Mood: essentially normal but feels sad sometimes. No diurnal mood variation. He is not suicidal.
Experiences: nil of hallucinations. not psychotic. denied psychotic experiences.
Thought: concerned about his mother. Indifferent to prison rules.
Insight: He does not think he is ill. He takes his medication because it helps him to sleep.
Cognition: Grossly intact.
Personality: Says he is happy go lucky and does not cause trouble, but it was difficult to understand how he could say that with such a long criminal record.

The above is a particularly poor mental state report. Some other bad mental state examinations merely add padding to the above.

What’s required in a mental health report?

Three words: clarityclarity and clarity. MHR’s need to provide a clear picture of what is happening and what are the key issues. Normally solicitors or barristers instruct an expert. The instructions as they are called are matters that they need the expert to consider and clarify for the court.

Normally mental health reports contain information that may at first glance appear irrelevant.

Some who read these reports may not understand for example why the expert mentions ‘lack of cruelty to animals’, or ‘bedwetting to the age of 7, or ‘separation from his mother at age 9’, – this kind of detail is important because it shows, for example, that the expert has considered factors relevant to personality development.

Some experts tend to brush over these matters, and be too succinct e.g. “there were no abnormalities in his childhood. Such statements are to be regarded as lacking substance or evidence that a childhood history was actually taken. Brief reports may serve the ease of reading of those who do not deal with the intricacies of legal matters. Good mental health reports strike a balance between succinctness, providing evidence, clarity, analysis of the facts, and reasoning that demonstrates the soundness of conclusions drawn. It is a difficult balancing act.

I thought the expert was acting for the instructing lawyers? Isn’t that the case?

No. The expert’s first and foremost duty is to the court – even if a group of lawyers instruct the expert. There is no negotiation on this. It is been laid down by the courts and the Civil Procedure Rules(CPR). Many people are still affected by court room scenes on TV – mostly from American films – where the expert is on the ‘side’ of the client. This is really just sensationalist stuff. The expert in the UK is not on anybody’s side, even if paid by one side. The CPR has provisions to appoint an independent joint expert.

So it isn’t just about reporting?

That’s right. A good expert must be prepared to stand up in court and defend the substance of his report. But at the same time, he must be prepared to evaluate new information and change his point of view if new evidence compels consideration of a different conclusion to what was in his report. There is no shame in this. Instead, it demonstrates the quality of the expert and his level of objectivity.

How do I contact you?

Call:  07017-EXPERT (calls are automatically recorded without negotiation).

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