What is a clinical assessment?

A clinical assessment consists of interviews and tests conducted by a qualified mental health expert, using professional industry guidelines and experience, to determine the health and wellbeing of a patient.

A comprehensive substance use assessment takes into account the patient's perception of their use, readiness to change, and the type of substance, the amount, frequency, and effects of their substance use. We also review the patient's past medical and mental health history and check for any co-occurring psychiatric disorders. We examine familial history and psychosocial elements that might encourage substance use or make treatment easier. We perform a general physical exam and, if necessary, order lab tests.

The key items that the counsellor will look for include:

  • Mental and physical health
  • Pattern of substance usage
  • Pattern of behaviour
  • Environmental circumstances
  • Employment situation
  • Financial situation
  • Medical history
  • Family history
  • Social life

Types of clinical assessments

Primary assessments: Needed to establish whether or not a disorder exists, as well as the severity of the disorder. This may be in the form of a relatively simple interview to identify the problem the patient is dealing with, or a more thorough assessment when appropriate.

Personalised treatment program assessments: Further analysis and tests done to determine the full extent of the patient’s history, circumstances, functional capacity and health condition. This is used to design a comprehensive, personalised treatment program.

Review assessments: Assessments done during the treatment cycle, to compensate for new information that emerges during treatment. This is used to make adjustments to the current program, in order to accommodate the changes.

Are clinical assessments necessary?

Obviously, without a diagnosis, there can be no certainty about a patient’s actual condition. In some cases, patients may deny or downplay the presence of a disorder, or may even be unaware of it, in which case a clinical assessment can clear up any doubt.

In order to design a comprehensive, personalised rehabilitation program, a thorough assessment must be done to identify all the factors involved. This must be monitored and the program adjusted during the treatment process to compensate for new information that emerges during treatment.

In many cases, spouses, partners, family members and other people may be affected and may also require individual counselling, even though they are often unaware of it. If such a need exists, it will emerge during a clinical assessment.

In certain judicial cases, a court may force a person to undergo a clinical assessment, or an assessment can be offered by the defence, in order to alleviate a sentence.

Are patients “guilty”?

In the presence of a substance or behaviour disorder, there may be a strong presence of anger, frustration and other negative emotions affecting the patient and the people in contact with them. However, as with any disorder or illness, there should be no blame involved. These disorders are as valid as any medical condition, such as diabetes, etc. In most cases, these disorders result from health dysfunctions that existed prior to the manifestation of behaviour and the patient had no control over it.

Individuals and their conditions differ widely and this necessitates a personalised treatment program that addresses the unique characteristics of each patient. However, this uniqueness does not indicate that the patient is an exceptional burden. Uniqueness is common to almost any known illness.

When patients suffer from acute discomfort, such as anxiety, in the absence of substance usage, they often lack the capacity to heal themselves. Just because an ailment is not physically visible, does not mean that it does not exist, or that it is of less importance than any other type of illness, or that it is less worthy of professional intervention.

Are clinical assessments efficient?

The health industry and judicial systems worldwide, regard clinical assessments as not only efficient, but also a dire necessity. As a result, the mental health industry does extensive and ongoing research and development of new techniques. There can be no doubt that the industry currently has the capacity to fullfill this role effectively.