Clinical Assessment & Evaluation: An Overview Jennie Ashwal Psychopathology 18 February 2008 The written psychiatric consultation is the

e distillation, the official permanent record, and the one universal element of the consultation process (Garrick & Stotland, 1982, p. 849) Introduction: Clinical assessments are said to have originated from the development of psychosomatic medicine in the 1920s by George Henry, M.D who suggested the coalition between psychiatrists and general physicians in order to provide a more detailed assessment in the hospital setting. (Karasu, Plutchik, Conte, Siegel, Steinmuller & Rosenbaum, 1977). Today a clinical assessment is conducted by a mental health professional through a process of gaining a holistic consolidation of biological, psychological and social factors of a clients life including the primary complaint and their history through a comprehensive evaluation. A thorough clinical assessment then helps the client, their family and the clinical teams involved make more informed decisions regarding the diagnosis(es) and treatment required (Clinical Assessment). It is important to note that each clinical assessment is designed according to the specific aims of the evaluation, the setting of the practice, the clients presenting problem and to latest techniques and trends available. Purpose and Aims of a Clinical Assessment The purpose and method of a clinical assessment is dependent on several variables. One of these variables is who the individual is that requests the evaluation. In most general clinical settings or outpatient facilities the individual may wish to gain an understanding into their condition, behaviors or emotions and therefore request the assessment. There may also be instances where the client involuntarily enters treatment when those surrounding them feel that either the client or others are at high risk. Another variable is why the assessment is being requested, or otherwise known as the referral question. The referral question again may come from the client themselves or from other individuals. This question is usually based on the clients presenting problem in order to shape the aims and treatment of the individual (Anonymous, 1995). The role that the mental health professional plays in the future treatment and care of the client also is a variable to consider. For example, the professional may be doing an evaluation in an emergency ward setting in a hospital and therefore the treatment and aims will be focused around immediate diagnosis and treatment. In another situation the individual may be seeking a professional for long term evaluation and treatment. Ultimately the aim(s) dependent on these variables are then focused on providing a clinical formulation, diagnosis, treatment plan, recommendations and prognosis for these parties involved in the clients assessment.

Types of Assessments a. The General Psychiatric Evaluation Typically a general assessment is conducted voluntarily between the individual with the presenting problem and the mental health professional. Although a thorough evaluation using collateral sources may be performed, the patients willingness to complete an intensive series of interviews and evaluations makes the aims of the assessment much easier to conclude. (Anonymous, 1995). A comprehensive clinical assessment usually cannot be completed in one session and usually takes several visits and phases including: 1. Helping the consumer/family articulate their question(s). 2. Choosing and conducting assessment procedures to obtain the most relevant information. 3. Integrating (combining) all the findings from the past and present clinical assessments. 4. Providing understandable information and practical recommendations to the consumer, family, and relevant professionals and care-providers (Clinical Assessment, 6). During this process, the values, knowledge, skills, and experience of the mental health clinician are paramount, because each phase requires careful and complex consideration. The results of the assessment process will heavily depend upon the clinicians competence. b. The Emergency Assessment In situations when there is violent or self-injurious behavior, threats of harm to self or others, failure to care for oneself, deterioration of mental status, bizarre or confused behavior, or intense expressions of distress (Anonymous, 1995, p. 64) an emergency assessment is needed. Psychiatric emergency wards or hospitals often are the primary entry point for individuals with severe mental disorders into the mental health treatment with a hope of successful treatment (Gerson & Bassuk, 1980). The emergency evaluation includes the same format as the general evaluation except the sense of urgency is much greater therefore the prioritization of these evaluations come first. Many times the patients entering the psychiatric emergency rooms are prepared and/or motivated to relieve themselves of their suffering but may consciously or unconsciously want to keep the details of their history, feelings and behaviors to themselves when they have perceptions of fear and shame. It is crucial that the psychiatrist encourages a straightforward, honest, non-threatening relationship with the client in order to achieve the desired aims of the assessment (Sadock & Sadock, 2003). The aims of an emergency evaluation vary slightly from a general or referred evaluation in the sense that the results may have major effects on the bio, psycho and social well-being of the patients, families and others associated with the patient. For example, premature release could

lead to an increased risk of suicide, crime, decreased functioning, social stigmas, and a number of other highly detrimental possibilities (Way & Banks, 2001). Some of these aims include: 1. 2. 3. 4. Establishing a short-term diagnosis most likely presenting and to identify other possible or confounding diagnoses or conditions. Identify key factors pertinent to immediate treatment options Determine the patients ability to proceed with the assessment process and if so, what measures can be placed in order to protect from the high risk situations or whether involuntary care may be required. To formulate an immediate treatment plan and determining the level of care and supervision required (Anonymous, 1995).

c. The Clinical Consultation or Referral It is often the case that referrals for assessments are made by those who may be experiencing or observing problems with relationships, work, eating, substance use feelings, behaviors or a combination of these by an individual close to them. (Comprehensive Psychiatric Evaluation, n.d). Clinical consultations are the assessments requested by such individuals including their physician, health care professionals, family members, or employers. These assessments are done using the same methods as a general evaluation. These may be comprehensive but tend to focus more on a specific question, such as the recommended treatment plan for an individual with a known disorder or condition. The client ideally should be made aware that the purpose of their assessment is to advise the individual(s) who referred them. Although information used by these collateral sources is often considered in the evaluation and the aims are focused on the referring parties this is not usually discussed with the client. (Anonymous, 1995). Clinical Settings There are a variety of options for treatment settings available to individuals needing assessment and treatment. It is suggested that the evaluations be conducted in the most private setting compatible with the safety of the patient and others (Anonymous, 1995, p.12) The effectiveness of these treatment settings rely heavily on the resources and capacity of the center (Pauw, 2008). a. Outpatient Outpatient treatment and assessments are done in a variety of different settings including; partial hospitilsation, half-way houses, after-care services, clinics and private practices (Sadock & Sadock, 2003). Typically the outpatient setting is less intensive of an environment for the client seeking treatment. There is generally less involvement from the mental health professionals in terms of interviews, observations and protection (Anonymous, 1995).

Outpatient is usually referred to a patient who has been progressing in treatment in an inpatient setting in order to re-introduce them into society and to promote a functional life without relapsing. In some circumstances individuals can also be placed into involuntary outpatient treatment which is often court ordered where they must report to designated clinics for medications, therapy, assessments and relevant training (Sadock & Sadock, 2003). Some advantages of the outpatient setting for the client include costs of treatment, independence and a long term perspectives on the patients well-being. Appropriate observation and treatment from professionals and other collateral sources provides an understanding into just how manageable the individual is in society but the risks involved place the client at a greater risk of relapse and must be closely monitored (Anonymous, 1995). It is up to the discretion of the professional involved to determine the fit of the clinical setting and the decision to change or maintain the setting is based on the clients mental status and behavior (Anonymous, 1995). b. Inpatient A person admitted into an inpatient setting such as a general hospital psychiatric unit or to a specialized psychiatric hospital is primarily evaluated with an emergency assessment. The method for a person entering an inpatient setting varies on severity and the individuals willingness to seek treatment. The Mental Health Care Act (MHCA), of 2002 regulates the care, treatment and rehabilitation of persons who are mentally ill. This act clearly stipulates the different admission processes under South African legislation When an individual voluntarily agrees to be admitted to a mental health facility for in-patient treatment the process becomes much easier to manage. Unfortunately voluntary admission is not always possible especially for those who are incapable of making informed decisions regarding the level of care needed. In this situation the client will need to be placed involuntarily (Pauw, 2008). The legislated steps for involuntary admission are:

The spouse, next of kin, partner, associate, parent or guardian can fill in an application form. These are obtainable at hospital admission wards, clinics and police stations. The person must then be examined by two mental health care practitioners. At least one of them must be able to conduct physical examinations. If the findings of the two differ, the superintendent must arrange for a third practitioner to examine him/her. Once it is established that assisted care is necessary, the person must be informed of the decision in writing and must be admitted within 48 hours. A medical practitioner and mental health care practitioner must assess the physical and mental health status of the user for a period of 72 hours. They must decide if the involuntary care must be continued and whether it should be on an out- or in-patient basis.

The superintendent must inform the applicant of the findings 24 hours after this 72 hourperiod. If the superintendent does not agree that person needs involuntary care, he/she will be discharged. If the person needs outpatient treatment, he/she will be discharged under certain conditions. Should the person require inpatient treatment, the superintendent must submit a written report to the Review Board for approval. If the Review Board grants the request, they have to submit the documents to the High Court. The patient, spouse, next of kin, partner, associate, parent or guardian may lodge an appeal against the decision within the first 30 days. In such cases, the Review Board will have to investigate and make a final decision (Pauw, 2008, , 12).

Assisted care is used in situations such as a homeless individual who is mentally ill and is incapable of making informed decisions about their medical and psychiatric needs. The legislated steps for assisted care are:

An application can be made by the spouse, next of kin, partner, associate, parent or guardian. If the above are incapable, unwilling or not available, a health care provider may apply. The Act stipulates that the applicant must have seen this professional in the preceding seven days. The person must then be examined by two mental health care practitioners. At least one of them must be able to conduct physical examinations. If the findings of the two differ, the superintendent must arrange for a third practitioner to examine the person. Once it is established that assisted care is necessary, the person must be informed of the decision in writing and the superintendent must arrange for the person to be admitted within five days. A copy of the application must be sent to the relevant Review Board and the latter must investigate the matter within 30 days. Based on the investigation, they could either request the hospital to continue treatment or to discharge the patient. The patient has a right to lodge an appeal during this 30-day period. The patient's mental health status must be reviewed after six month and every 12 months thereafter (Pauw, 2008, , 9).

In either of these situations if the client regains their ability to make informed decisions or recovers, they will either be discharged or remain seeking voluntary treatment. *See Appendix B for the full details on Chapter V of the Mental Health Care Act of 2002. c. Other Settings It is often the case that patients entering the emergency room setting in hospitals or even in general medical settings like clinics or GPs are assessed for possible mental disorders based on behavioral and emotions observed. Other settings include half-way houses, residential treatment facilities, nursing homes, prisons, and schools.

The focus and attention in these environments are not ideal due to inadequate speed, safety, accuracy, specialization, and confidentiality for individuals needing urgent treatment and therefore are often referred to more specialized unit or settings (Anonymous, 1995). South African Ethical Codes and Guidelines and Standards The same regulated guidelines, standards and ethical considerations that need to be adhered to in the American Medical Associations Principles of Medical Ethics, the American Psychiatric Associations Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry and the American College of Physicians Ethics Manual and the American Psychological Association's (2002) Ethical Principles of Psychologists and Code of Conduct, need to be considered in the South African context. These can be found in the listed Mental Health Care Act 17 of 2002 Appendix A. The Evaluation Process & Clinical Report As discussed the emphasis of the assessment conducted is geared around the individual whom requested the evaluation, the presenting problem and the purpose of the evaluation. The psychiatrist or clinician utilizes their professional skills, capacity and judgment in order to obtain the most thorough assessment according to the situation unique to the individual. Care and precaution must be followed when conducting the evaluation and in drawing up the clinical assessment, as important decisions are made based on the information provided. One needs to expect that the information may be reviewed by those other than the client and clinician. The report should be comprehensive, objective and accurate. The adequacy of the assessment can be determined by the professionals alignment with the aims, practice setting, presenting problem with the effective utilization of new and evolving methodologies and skill (Anonymous, 1995). Based on these factors there is not one generally accepted assessment or reporting method used and the process described will be a general comprehensive overview of what should be considered when conducting a clinical assessment and report. Evaluation Methods A comprehensive evaluation is conducted through as many sources and methods as possible necessary for the care of the individuals involved. The clinician will generally start with the patient interview which is a critical component of an evaluation. It is in this face-to-face method that the Mental Status Examination is performed and the questions can range from basic things like the individuals name to more abstract such as those around the clients thoughts and intentions. With permission, the clinician can acquire information from individuals that the client knows such as members of the clients family, physicians, previous mental health practitioners, and friends. With this information the clinician gains valuable insight into difference between the clients normal behavior versus abnormal behavior. They can describe the individuals behavior, personality characteristics, preferences, and other factors that appear to affect their profile (Clinical Assessment).

Other methods include structured interviews or the more quantitative evaluation methods such as questionnaires, rating scales, observations and diagnostic tests. These in conjunction with interviewing are the most commonly accepted and approved methodology. The Assessment: Gathering Information The Chief Complaint The reason for an evaluation or assessment usually is developed around the chief complaint, but is definitely not limited to this alone as the process may reveal other disorders or co-morbid diagnoses. The chief complaint or presenting problem is the exact reason why the individual came for an assessment (ideally in the clients own words).This would include clients symptoms, the observed signs from either the client or possibly other collateral sources (Sadock & Sadock, 2003). History History of Present Illness The history of the present illness is written up chronologically based on the clients current symptoms, recent relapses or remissions, previous treatment and the response to such treatment. It is also important to look at the transference and counter transference issues around the effects of previous professionals treatment and other issues that the client believes to be relevant to the current illness (Sadock & Sadock, 2003). The information gathered should come from a collective source including the client, the referring professional and the family if necessary. Previous Psychiatric History This history should also include a chronological summary of all past psychiatric episodes, symptoms, diagnoses, treatments and responses to treatment (Anonymous, 1995). The psychiatric history should also come from the individual and the collateral team. Medical History Information should be gathered about the patients known illnesses, diseases, hospitalizations, operations, medications and treatments (Sadock & Sadock, 2003). This should also include undiagnosed health problems, including psychosomatic disorders that have impaired or impacted the client. Substance Use History Relevant information with regards to the individuals substance use history would include the past and present use of legal and illegal substances, the frequency, the methods used, the pattern of use, the consequences of use and perceived benefits of use.

An ideal approach to gathering this information would be a non-threatening or nonconfrontational inquiry using different questions or slang words in order to obtain accurate information (Anonymous, 1995). Personal/Developmental History This includes a detailed history of the clients life from in the womb to present to the extent that the individual can recall. This information should include specific memories or phases of life and the emotions associated with them (See Table 1). Table 1 Personal History 1. Early childhood (through age 3) a. Prenatal history and mothers pregnancy and delivery: Length of pregnancy, spontaneity and normality, birth trauma, whether patient was planned and wanted, birth defects b. Feeding habits: Breast-fed or bottle-fed, eating problems c. Early development: Maternal deprivation, language development, motor development, signs of unmet needs, sleep pattern, object constancy, stranger anxiety, separation anxiety d. Toilet training: Age, attitude of parents, feelings about it e. Symptoms of behavior problems: Thumb sucking, temper tantrums, tics, head bumping, rocking, night terrors, fears, bed-wetting or bed soiling, nail biting, masturbation f. Personality and temperament as a child: Shy, restless, overactive, withdrawn, studios, outgoing, timid, athletic, friendly patterns of play, reactions to siblings 2. Middle childhood (ages 3 to 11): Early school history feelings about going to school, early adjustment, gender identification, conscience development, punishment; social relationship, attitudes toward siblings and playmates 3. Later childhood (prepuberty through adolescence) a. Peer relationships: Number and closeness of friends, leader or follower, social popularity, participation in group or gang activities, idealized figures; patterns of aggression, passivity, anxiety, antisocial behavior b. School history: how far the patient went, adjustment to school, relationships with teachers teachers pet or rebellious favorite studies or interests, particular abilities or assets, extracurricular activities, sports, hobbies, relationships of problems or symptoms to any school period c. Cognitive and motor development: Learning to read and other intellectual and motor skills, minimal cerebral dysfunction, learning disabilities their management and effects on the child d. Particular adolescent emotional or physical problems: nightmares, phobias, masturbation, bed-wetting, running away, delinquency, smoking, drug or alcohol use, weight problems, feeling of inferiority e. Psychosexual history i. Early curiosity, infantile masturbation, sex play ii. Acquiring of sexual knowledge, attitude of parents towards sex, sexual abuse iii. Onset of puberty, feelings about it, kind of preparation, feelings about menstruation, development of secondary sexual characteristics iv. Adolescent sexual activity: Crushes, parties, dating, petting,

masturbation, wet dreams and attitudes towards them v. Attitudes towards same and opposite sex: Timid, shy, aggressive, need to impress, seductive, sexual conquests, anxiety vi. Sexual practices: Sexual problems, homosexual and heterosexual experiences, paraphilias, promiscuity f. Religious background: Strict, liberal, mixed (possible conflicts), relation of background to current religious practices 4. Adulthood a. Occupational history: Choice of occupation, training, ambitions, conflicts; relations with authority, peers and subordinates; number of jobs and duration; changes in job status; current job and feelings about it b. Social activity: Whether patient has friends or not; is patient withdrawn or socializing well; social, intellectual, and physical interest; relationships with same sex and opposite sex; depth, duration, and quality of human relations c. Adult sexuality i. Premarital sexual relationships, age of first coitus, sexual orientation ii. Marital history: Common-law marriages, legal marriages, description of courtship and role played by each partner, age at marriage, family planning and contraception, names of children, attitudes toward raising children, problems of any family members, housing difficulties if important to the marriage, sexual adjustment, extramarital affairs, areas of agreement and disagreement, management of money, role of in-laws iii. Sexual symptoms: Anorgasmia, impotence, premature ejaculation, lack of desire iv. Attitudes toward pregnancy and having children; contraceptive practices and feelings about them v. Sexual practices: Paraphilias such as sadism, fetishes, voyeurism; attitude toward fellatio, cunnilingus; coital techniques, frequency d. Military history: General adjustment, combat, injuries, referral to psychiatrists, type of discharge, veteran status e. Value systems: Whether children are seen as a burden or a joy; whether work is seen as a necessary evil, an avoidable chore, or an opportunity; current attitude about religion; belief in heaven and hell Adapted from Sadock and Sadock (2003), pps. 243 & 244 Family History With its lines, boxes, circles, and symbols, the genogram records important facts, lifechanging events, and complex relationships of a family system. These deceptively simple explanations capture the essence of a complex clinical and consulting instrument that depicts nuances of description and relationship that may be lost in larger narratives or omitted in an overly intense focus upon self( Stanberry, n.d) ).. The individuals family history is generally recorded from information received by the patient as well as others in the home in order to gain a more objective perspective of the events, traditions, members of the home. A clinician may choose to construct a genogram, a graphic representation that maps out relationships and traits that may otherwise be missed on a family tree (see Table 2).

The origination of genograms is believed to have been developed around Murray Bowens Model Family Systems model which describes emotional family dynamics (Becvar & Becvar, 2000 as cited in Stanberry, n.d.) With the publication of their book, Genograms in Family Assessment (1985), Monica McGoldrick and Randy Gerson first developed and popularized the used of genograms in clinical settings (Introduction). Genograms allow a therapist and his patient to quickly identify and understand various hereditary patterns and psychological factors in the patient's family history which may have had an influence on the patient's current state of mind. In a diverse environment like South Africa, a genogram is extremely useful in understanding the cultural issues affect the clients, families and clinical teams involved and thus the clinicians sensitivity and awareness to cultural issues can influence the quality and outcome of the patient, their respective families and the prognosis (Shellenberger, Dent, Davis-Smith, Seale, Weintraut and Wright, 2007). Table 2 Genogram Example

As cited in, Introduction to the Genogram, http://www.genopro.com/genogram/ Cross -Cultural Considerations When conducting an assessment in the South African context it is helpful to adapt the ideals associated with Cultural Psychiatry which deals with cultural factors in a biopsychosocial context involved in psychiatric conditions (Carabello, Hamid, Lee, McQuery, Rho, Kramer, Lim and Lu, 2006). In the DSM-IV-TR (2000), The American Psychiatric Association developed the Cultural Formulation tool which identifies five areas that are imperative in evaluating the effect that culture has on a client and their respective illness. These include; 1. Cultural Identity 2.Cultural Explanation of the Individuals Illness 3.Cultural Factors Related to Psychosocial, Environmental and Functionality Factors 4.Cultural Elements of the Relationship between the Individual and 5.The Clinician and Overall Cultural Assessment for Diagnosis and Care

The DSM is unable to list all possible syndromes that may be relevant to a particular client and therefore it is important to know culturally specific symptoms in each client. In any cross-cultural assessment the clinician must be sure not make assumptions regarding the clients culture and to know an understand the relevant Cultural Bound Syndromes (APA as cited in Carabello et. al, 2006). The clinician must be familiar with nuances of speech, slang words and customs particular to the individual. In situations where the clinician and the client do not speak the same native language it may be advantageous to use an interpreter, or in last resort situations a relative (Sadock & Sadock, 2003). The APA (2000) list several cross-cultural syndromes that do not correspond to any universal diagnostic categories. A few that are relevant in the South African community may include: Amafufanyane (Zulu of Southern Africa) Sleep paralysis is common symptom, which occurs in normal people, in patients with narcolepsy, and in psychiatric syndromes caused by witchcraft (as in young female in the Zulu population of southern Africa; if often contains sexual content and symbols). The somatic symptoms include abdominal pains, paralysis, blindness, hysterical seizures, shouting, sobbing, and amnesia (conversion disassociation). (Henderson & Nguyen 552) Ufufuyane, saka (Kenya, Southern Africa; Bantu, Zulu; and affiliated groups) May be related to aluro (Nigeria), phii pob (Thailand), and zar (Egypt, Ethiopia, Sudan). Anxiety state attributed to the effects of magical potions (given to them by rejected lovers) or spirit possession, with characteristic sobbing, repeated neologisms, paralysis, trance-like states, or loss of consciousness. Seen in young, unmarried women, who may also experience nightmares with sexual themes, and rarely episodes of temporary blindness.

Mental Status Examination The Mental Status Examination (MSE) which is conducted during the interview stage is the structured outline of the professionals observations and impressions of the client. Where the clients history is unchanging, the MSE provides a systematic collection of data on the shifting characteristics of the individual including their appearance, speech, mood, actions and thoughts at the time of that particular assessment. It is important to objectively describe the observations and not to explain or interpret them (Anonymous, 1995). The MSE demonstrates that psychiatrists, like other medical specialists, base their conclusions on an orderly series of evaluations (Garick & Stotland, 1982, p. 852) The outline for the MSE is outlined in Table 3. Table 3. Outline for the Mental Status Examination 1. Appearance 2. Speech 3. Mood a. Subjective b. Objective 4. Thinking a. Form

b. Content 5. Perceptions 6. Sensorium a. Alertness b. Orientation (person, place time) c. Concentration d. Memory (immediate, recent, long term) e. Calculations f. Fund of knowledge g. Abstract reasoning 7. Insight 8. Judgment Adapted from: Sadock & Sadock, 2003, p.238 Diagnosis A psychiatric diagnosis is only good as the knowledge and skill of the clinician who is making it (Sadock & Sadock, 2003, p. 229). Sadock & Sadock (2003) explain that unlike physical disease and medical diagnosis where the clinician has physical evidence and laboratory tests to work from, a psychiatric diagnosis as specified in the Diagnostic and Statistical Manual of Mental Disorders (DSM) looks at phenomenological variables. In doing so the reliability of the psychiatric diagnosis is questioned due to instances when multiple clinicians come up with different diagnosis for the same individual. The reliability of clinical assessments are controlled by focusing on gathering observed rather than inferred, or interpretive information from the clinician. A diagnosis is from the DSM-IV-TR multiaxial classification system based on numerous variables of the clients disorder along five axes (See Table 4). Table 4 Multi-Axial System Axis I: clinical disorders, including major mental disorders, as well as developmental and learning disorders Axis II: underlying pervasive or personality conditions, as well as mental retardation Axis III: Acute medical conditions and Physical disorders. Axis IV: psychosocial and environmental factors contributing to the disorder Axis V: Global Assessment of Functioning or Childrens Global Assessment Scale for children under the age of 18. (on a scale from 100 to 0) Adapted from: American Psychiatric Association [DSM-IV-TR], 2000 Case Formulation The science of formulations must be combined with art. Something vital is lost if the formulation does not capture the essence of the case (Denman, 1994 as cited in Sim, Peng Gwee & Bateman, 2005).

Case formulation is a conceptual tool that places the clients diagnosis within the context of their life. It is the equivalent of the physicians pathophysiology of the individuals medical problem (Blatner, 2006). What differentiates a diagnosis and a formulation is that every formulation is unique to the individual and even the occasion when they are in assessment and these need to be tailored to each assessment. This involves making inferences about the individuals problem whilst considering the real of normal and/or pathological development (Blatner, 2006). Some common foundations for formulation include the psychosocial and developmental factors that may have led to the clients current disorder(s) (Anonymous, 1995). A rule of thumb is that A good formulation should be a kind of story, weaving together many threads, and ideally should take at least twenty minutes to present (Blatner, 2006, 6). If the formulation is too short that the clinician has not reflected the clients story properly and may need to re-assess the individual. Case formulation skills are key in providing effective treatment particularly those with co-morbid disorders (Eels, Kendjelic and Lucas, 1998) and can provide insights into the integrative, explanatory, prescriptive, predictive, and therapist aspects of a case (Sim, et al., 2005). Initial Treatment Plan, Recommendations & Prognosis The recommendations constitute a comprehensive approach to the clinical problem and a careful delineation of immediate and long-term management(Garrick & Stotland, 1982). The initial treatment plan is only developed as soon as a diagnosis has been made. Although the treatment and recommendations are intended for the client it is vital for active participation from the family or those who involved in the clients wellbeing (Comprehensive Psychiatric Evaluation). In alignment with aims set out, the initial treatment plan begins with setting the diagnostic, therapeutic and rehabilitative goals for the client and the respective parties. The goals set out may also require further diagnostic tests, observations, or more secure settings for the client (Anonymous, 1995). The treatment plan is drawn up as a report but is regarded as a contract between the client and clinician. These recommendations are often the only information concerning the client that they read. It is in this report that the individual looks for solutions to their problems and therefore the tone and layout must be carefully considered. After the treatment plan is established the clinician will then determine the prognosis of the individuals case. A prognosis is the prediction or opinion of the mental health professional in regards to the probable future course, extent, and outcome of the disorder; good and bad prognostic factor; specific goals of therapy (Sadock & Sadock, 2003, p. 246).

Conclusion Although there are multiple variations to clinical assessments there are several underlying commonalities that are common in most conducted. These being that a trained professional must conduct the assessment in a safe, controlled, and ethical manner with the aims of providing a diagnosis, initial treatment plan, and a formulation. The variables that may differ involve the person initially requesting the evaluation, the presenting problem of the client, cross-cultural considerations, the type of assessment requested and the setting that the assessment will take place. The more information gathered from the assessment the more likely the aims will be met thoroughly and effectively and the more promising the prognosis is for the client.

References: Anonymous. (1995). Practice guideline for psychiatric evaluation of adults. The American Journal of Psychiatry, Vol. 152, Iss. 11, 63-80. Retrieved from ProQuest database. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (Revised 4th ed.). Washington, DC: Author. Becvar, D. S., and Becvar, R. J. (2000). Family Therapy: A Systemic Integration, 4th edition. Boston: Allyn and Bacon. Caraballo A, Hamid H, Lee J.R, McQuery J, Rho Y, Kramer E.J, Lim R.F, & Lu F. A Residents Guide to the Cultural Formulation: Clinical Manual of Cultural Psychiatry. APPI, Washington, DC, 2006. Carlat, D.J. (2005). The psychiatric interview (2nd ed.). London: Lippincott Williams & Wilkins. (For presentation). Clinical Assessment in Mental Health. Mental Health and Developmental Disabilities Center. Retrieved from 13 February 2008 from http://npi.ucla.edu/mhdd/INFO/modules/clinicalassessment.htm Comprehensive Psychiatric Evaluation. University of Virginia Health System. Retrieved from 13 February 2008 from http://www.healthsystem.virginia.edu/UVAHealth/adult_mentalhealth/evaluat.cfm Eels, T.D, Kendjeleic, E.M., and Lucas, C.P. (1998). Whats in a case formulation. The Journal of Psychotherapy Practice, 7, 144-153. Emsley, R. (2001). Focus on psychiatry in South Africa. The British Journal of Psychiatry, 178, 382-386. Retrieved from ProQuest database. (For presentation) Garrick, T.R., & Stotland, N.L. (1982). How to write a psychiatric consultation. The American Journal of Psychiatry, 139:7, 849-855. Retrieved from ProQuest database. Gerson, S., & Bassuk, E. (1980). Psychiatric emergencies: An overview. The American Journal of Psychiatry, 137:1, 1-11. Retrieve from ProQuest database. Hardy, K.V., & Laszloffy, T.A. (1995). The cultural genogram: Key to training culturally competent family therapists. Journal of Marital and Family Therapy, Vol. 21, Iss. 3, 227-237. Retrieved from ProQuest database. (For presentation) Pauw, I. (2008). Psychiatric admissions: the steps. Retrieved February 13, 2008, from http://www.health24.com/mind/Medication/1284-1306,30806.asp Karasu, T.B., Plutchik, R., Conte, H., Siegel, B., Steinmuller, R., & Rosenbaum, M. (1977). What do physicians want from a psychiatric consultation service? Comprehensive Psychiatry, Vol. 18, No. 1 (January/February), 73-81. Retrieved from ProQuest database. Mental Health Care Act, No. 17 of 2002. Government Gazette of the Republic of South Africa 145 (5692), 06 November 2002: 449

Petit, Jorge. (1993). The Handbook of Emergency Psychiatry. Philadelphia: Lippincott Williams & Wilkins Sadock, B., & Sadock, V., (2003). Kaplan & Sadocks Synopsis of Psychiatry (9th ed.). London. Lippincott Williams & Wilkins. Shellenberger, Sylvia; Dent, M. Marie; Davis-Smith, Monique; Seale, J. Paul; Weintraut, Roberta; Wright, Tamara. Cultural genogram: A tool for teaching and practice . Families, Systems, & Health. 2007 Dec Vol 25(4) 367-381. Retrieved from ProQuest database Sim, K., Peng Gwee, K. and Bateman A. (2005). Case formulation in psychotherapy: Revitalizing its usefulness as a clinical tool. Academic Psychiatry, 29:3, 289-292. Retrieved from ProQuest database South African Society of Psychiatrists. (n.d.). Guidelines to the management of disability claims on psychiatric grounds (Second edition). SASOP: South African Society of Psychiatry. (For presentation) Stanberry, J. (n.d). Family Diagrammatic Assessment Genogram. Retrieved February 14, 2008, from http://family.jrank.org/pages/526/Family-Diagrammatic-Assessment-GENOGRAM.html Way, B.B., & Banks, S. (2001). Clinical factors related to admission and release decisions in psychiatric emergency services. Psychiatric Services, 52, 214-218. Retrieved from ProQuest database. * Henry GW (1929), Some aspects of psychiatry in general hospital practice. Am J Psychiatry 7:481-499. Retrieved from ProQuest database

Appendix A RIGHTS AND DUTIES RELATING TO MENTAL HEALTH CARE USERS Application of chapter 7. (1) The rights and duties of persons, bodies or institutions set out in this Chapter are 35 in addition to any rights and duties that they may have in terms of any other law. (2) In exercising the rights and in performing the duties set out in this Chapter, regard must be had for what is in the best interests of the mental health care user. Respect, human dignity and privacy 8. (1) The person, human dignity and privacy of every mental health care user must 40 be respected. (2) Every mental health care user must be provided with care, treatment and rehabilitation services that improve the mental capacity of the user to develop to full potential and to facilitate his or her integration into community life. (3) The care, treatment and rehabilitation services administered to a mental health 45 care user must he proportionate to his or her mental health status and may intrude only as little as possible to give effect to the appropriate care, treatment and rehabilitation. 18 No. 24024 GOVERNMENT GAZETTE, 6 NOVEMBER 2002 Act No. 17, 2002 MENTAL HEALTH CARE ACT, 200 2 Consent to care, treatment and rehabilitation services and admission to health establishments 9. (1) A health care provider or a health establishment may provide care, treatment and rehabilitation services to or admit a mental health care user only if(a) the user has consented to the care, treatment and rehabilitation services or to 5 admission; (b) authorized by a court order or a Review Board; or (c) due to mental illness, any delay in providing care, treatment and rehabilitation services or admission may result in the(i) death or irreversible harm to the health of the user; 10 (ii) user inflicting serious harm to himself or herself or others; o r (iii) user causing serious damage to or loss of property belonging to him or her or others. (2) Any person or health establishment that provides care, treatment and rehabilitation services to a mental health care user or admits the user in circumstances referred to in 15 subsection (1)(c)(a) must report this fact in writing in the prescribed manner to the relevant Review Board; and (b) may not continue to provide care, treatment and rehabilitation services to the user concerned for longer than 24-hours unless an application in terms of 20 Chapter V is made within the 24-hour period. Unfair discrimination 10. (1) A mental health care user may not be unfairly discriminated against on the grounds of his or her mental health status. (2) Every mental health care user must receive care, treatment and rehabilitation 25 services according to standards equivalent to those applicable to any other health car e user. (3) Policies and programmes aimed at promoting the mental health status of a person must be implemented with regard to the mental capacity of the person concerned. Exploitation and abuse 30 11. (1) Every person, body, organisation or health establishment providing care, treatment and rehabilitation services to a mental health care user must take steps t o

ensure that(a) users are protected from exploitation, abuse and any degrading treatment; (b) users are not subjected to forced labour; and 35 (c) care, treatment and rehabilitation services are not used as punishment or for the convenience of other people. (2) A person witnessing any form of abuse set out in subsection (1) against a mental health care user must report this fact in the prescribed manner. Determinations concerning mental health status 40 12. (1) Any determination concerning the mental health status of any person must be based on factors exclusively relevant to that person's mental health status or, for the 20 No. 24024 GOVERNMENT GAZETTE, 6 NOVEMBER 2002 Act No. 17, 2002 MENTAL HEALTH CARE ACT, 2002 purposes of giving effect to the Criminal Procedure Act, and not on socio-political or economic status, cultural or religious background or affinity. (2) A determination concerning the mental health status of a user may only be made or referred to for purposes directly relevant to the mental health status of that user . Disclosure of information 5 13. (1) A person or health establishment may not disclose any information which a mental health care user is entitled to keep confidential in terms of any other law. (2) Despite subsection (1), the head of the national department, a head of provincial department or the head of a health establishment concerned may disclose such information if failure to do so would seriously prejudice the health of the mental health 10 care user or of other people. (3) A mental health care provider may temporarily deny mental health care users access to information contained in their health records, if disclosure of that information is likely to(a) seriously prejudice the user; or 15 (b) cause the user to conduct himself or herself in a manner that may seriously prejudice him or her or the health of other people . Limitation on intimate adult relationships 14. Subject to conditions applicable to providing care, treatment and rehabilitation services in health establishments, the head of a health establishment may limit intimate 20 relationships of adult mental health care users only if due to mental illness, the ability of the user to consent is diminished. Right to representation 15. (1) A mental health care user is entitled to a representative, including a legal representative, when- 25 (a) submitting an application; (b) lodging an appeal; or (c) appearing before a magistrate, judge or a Review Board, subject to the laws governing rights of appearances at a court of law. (2) An indigent mental health care user is entitled to legal aid provided by the State in 30 respect of any proceeding instituted or conducted in terms of this Act subject to any condition fixed in terms of section 3(d) of the Legal Aid Act, 1969 (Act No. 22 of 1969) . Discharge reports 16. The head of a health establishment must, in a prescribed form, issue a discharge report to the user who was admitted for purposes of receiving care, treatment and 35 rehabilitation services. Knowledge of rights 17. Every health care provider must, before administering any care, treatment and

rehabilitation services, inform a mental health care user in an appropriate manner of hi s or her rights, unless the user has been admitted under circumstances referred to in 40 section 9(l)(c). MENTAL HEALTH CARE ACT 17 OF 2002 [ASSENTED TO 28 OCTOBER 2002] [DATE OF COMMENCEMENT 15 December 2004 GG 27116, 15 Dec 2004, Proc R. 61] Appendix B CHAPTER V VOLUNTARY, ASSISTED AND INVOLUNTARY MENTAL HEALTH CAR E Voluntary care, treatment and rehabilitation service s 25. A mental health care user who submits voluntarily to a health establishment for 45 care, treatment and rehabilitation services, is entitled to appropriate care, treatment and rehabilitation services or to be referred to an appropriate health establishment. Care, treatment and rehabilitation services for mental health care users incapable of making informed decisions 26. Subject to section 9(l)(c), a mental health care user may not be provided with assisted care, treatment and rehabilitation services at a health establishment as an outpatient or inpatient without his or her consent, unless- 5 (a) a written application for care, treatment and rehabilitation services is made to the head of the health establishment concerned and he or she approves it; and (b) at the time of making the application(i) there is a reasonable belief that the mental health care user is suffering from a mental illness or severe or profound mental disability, and 10 requires care, treatment and rehabilitation services for his or her health or safety, or for the health and safety of other people; and (ii) the mental health care user is incapable of making an informed decision on the need for the care, treatment and rehabilitation services. Application for assisted care, treatment and rehabilitation services 15 27. (1) (a) An application referred to in section 26 may only be made by the spouse, next of kin, partner, associate, parent or guardian of a mental health care user, but where the(i) user is below the age of 18 years on the date of the application, the application must be made by the parent or guardian of the user; or 20 (ii) spouse, next of kin, partner, associate, parent or guardian of the user is unwilling, incapable or not available to make such an application, the application may be made by a health care provider. (b) The applicants referred to in paragraph (a) must have seen the mental health care user within seven days before making the application. 25 (2) Such application must be made in the prescribed manner, and must(a) set out the relationship of the applicant to the mental health care user; (b) if the applicant is a health care provider, state(i) the reasons why he or she is making the application; and (ii) what steps were taken to locate the relatives of the user in order to 30 determine their capability or availability to make the application; (c) set out grounds on which the applicant believes that care, treatment and rehabilitation services are required; and

(d) state the date, time and place where the user was last seen by the applicant within seven days before the application is made. 35 (3) An application referred to in subsection (1) may be withdrawn at any time. (4) (a) On receipt of the application, the head of a health establishment concerned must cause the mental health care user to be examined by two mental health care practitioners. (b) Such mental health care practitioners must not be the persons making the 40 application and at least one of them must be qualified to conduct physical examinations. 28 No. 24024 GOVERNMENT GAZETTE, 6 NOVEMBER 2002 Act No. 17, 2002 MENTAL HEALTH CARE ACT, 2002 (5) On completion of the examination referred to in subsection (4), the mental health care practitioners must submit their written findings to the head of the health establishment concerned on whether the(a) circumstances referred to in section 26(b) are applicable; and (b) mental health care user should receive assisted care, treatment and rehabili - 5 tation services as an outpatient or inpatient . (6) (a) If the findings of the two mental health care practitioners differ, the head of the health establishment concerned must cause the mental health care user to be examined by another mental health care practitioner . (b) That mental health care practitioner must, on completion of such examination, in 10 writing, submit a report on the aspects referred to in subsection (5) . (7) The head of the health establishment may only approve the application if the findings of two of the mental health care practitioners referred to in subsection (4) or (6) concur that conditions for assisted care, treatment and rehabilitation exist. (8) The head of the health establishment may only approve assisted care, treatment 15 and rehabilitation of a prospective user as an inpatient if(a) the findings of two mental health care practitioners concur that conditions for inpatient care, treatment and rehabilitation exist; and (b) satisfied that the restrictions and intrusions on the rights of the mental health care user to movement, privacy and dignity are proportionate to the care, 20 treatment and rehabilitation services required. (9) If satisfied, the head of the health establishment must give written notice to the applicant of his or her decision concerning assisted care, treatment and rehabilitation in question and reasons thereof. (10) If the head of the health establishment approves the application for inpatient 25 assisted care, treatment and rehabilitation services, he or she must, within five days, cause the mental health care user to be admitted to that health establishment or to be referred to another health establishment with appropriate facilities. Initial review of assisted mental health care user by Review Board 28. (1) The head of the health establishment concerned must, within seven days of his 30 or her decision made under section 27(9), send a copy of the application to the relevant Review Board together with a confirmation of his or her decision. (2) Within 30 days of receipt of the documents referred to in subsection (1), the Review Board must conduct an investigation into the(a) incapacity of the mental health care user to make an informed decision on the 35 need for the assisted care, treatment and rehabilitation services; and (b) circumstances under which the mental health care user is receiving care, treatment and rehabilitation services. (3) On completion of the investigation, the Review Board must -

(a) request the head of the health establishment to- 40 (i) continue providing the mental health care user with the appropriate care, treatment and rehabilitation services; or (ii) discharge the mental health care user according to accepted clinical practice; and (b) report on its findings and the steps taken to the head of the relevant provincial 45 department. 30 No. 24024 GOVERNMENT GAZETTE, 6 NOVEMBER 2002 Act No. 17, 2002 MENTAL HEALTH CARE ACT, 2002 (4) If at any stage before the completion of the investigation, an appeal is lodged in terms of section 29, the Review Board must stop the investigation and consider the appeal in question. Appeal against decision of head of health establishment to approve application for assisted care, treatment and rehabilitation 5 29. (1) (a) A mental health care user, spouse, next of kin, partner, associate, parent o r guardian may, within 30 days of the date of the written notice issued in terms of section 27(9), appeal against the decision of the head of the health establishment to the Review Board. (b) Such an appeal must contain the facts and the grounds upon which the appeal is 10 based. (2) Within 30 days after receipt of the appeal, the Review Board must (a) consider the appeal in the prescribed manner; (b) provide the appellant, applicant, the relevant mental health care practitioner s and the head of the health establishment concerned an opportunity to make 15 oral or written representations on the merits of the appeal; and (c) send a written notice of its decision together with reasons for such decision to the appellant, applicant, head of the health establishment in question and the e relevant mental health care practitioner. (3) If the Review Board upholds an appeal, all care, treatment and rehabilitation 20 services administered to a mental health care user must be stopped according to accepted clinical practices and the user, if admitted, must be discharged by the health establishment, unless the user consents to the care, treatment and rehabilitation services . Periodic review and annual reports on assisted health care users 30. (1) Six months after the commencement of care, treatment and rehabilitation 25 services, and every 12 months thereafter, the head of the health establishment concerned must cause the mental health status of an assisted mental health care user to be reviewed . (2) Such review must(a) state the capacity of the mental health care user to express himself or herself on the need for care, treatment and rehabilitation services; 30 (b) state whether there are other care, treatment and rehabilitation services that are less restrictive or intrusive on the right to movement, privacy and dignity of the user; and (c) make recommendations regarding a plan for further care, treatment and rehabilitation services. 35 (3) A summary report of the review must be submitted to the Review Board. (4) Within 30 days after receipt of the report, the Review Board(a) may consult with any person who may have information concerning the mental health status of the user; (b) must decide on the review; and 40 (c) must send a written notice of its decision and the reasons thereof to the mental

health care user in question, applicant concerned, head of the health establishment where the user is admitted and the head of the relevant provincial department. (5) (a) If the Review Board concerned decides to discharge the assisted mental health 45 care user32 No. 24024 GOVERNMENT GAZETTE, 6 NOVEMBER 2002 Act No. 17, 2002 MENTAL HEALTH CARE ACT, 2002 (i) all care, treatment and rehabilitation services must be stopped according to accepted clinical practices; and (ii) if admitted, the user must be discharged from the relevant health establishment, unless the user consents to the care, treatment and rehabilitation services. (b) The head of the health establishment concerned must comply with the decision of the Review Board, Recovery of capacity of assisted mental health care users to make informed decisions 31. (1) If the head of a health establishment, at any stage after approving an 10 application for assisted care, treatment and rehabilitation services, has reason to believe e from personal observation, from information obtained or on receipt of representations by the user that an assisted mental health care user has recovered the capacity to make informed decisions, he or she must enquire from the user whether the user is willing t o voluntarily continue with care, treatment and rehabilitation services. 15 (2) If the assisted mental health care user consents to further care, treatment and rehabilitation services, section 25 applies. (3) If the assisted mental health care user is unwilling to continue with care, treatment and rehabilitation services, and the head of the health establishment is satisfied that the user is- 20 (a) no longer suffering from the mental illness or mental disability referred to in section 26(b), the head of the health establishment concerned must immedi ately cause the user to be discharged according to accepted clinical practices ; or (b) still suffering from the mental illness or mental disability referred to in section 25 26(b), the head of the health establishment concerned must, in writing, inform the(i) person who made the application in terms of section 27; and (ii) mental health care practitioner, registered social worker or nurse e administering care, treatment and rehabilitation services to that mental 30 health care user. (4) The head of the health establishment must advise the persons referred to in subsection (3)(b) that they may make an application within 30 days of receipt of such report to the head of the relevant health establishment to provide involuntary care , treatment and rehabilitation services to the user and that sections 32 and 33 apply. 35 (5) If the application is not made within 30 days, the assisted mental health care user must be discharged. Care, treatment and rehabilitation of mental health care users without consent 32. A mental health care user must be provided with care, treatment and rehabilitation services without his or her consent at a health establishment on an outpatient or inpatient 40 basis if(a) an application in writing is made to the head of the health establishment

concerned to obtain the necessary care, treatment and rehabilitation services and the application is granted; (b) at the time of making the application, there is reasonable belief that the mental 45 health care user has a mental illness of such a nature that34 No. 24024 GOVERNMENT GAZETTE, 6 NOVEMBER 2002 Act No. 17, 2002 MENTAL HEALTH CARE ACT, 2002 (i) the user is likely to inflict serious harm to himself or herself or others; or (ii) care, treatment and rehabilitation of the user is necessary for the protection of the financial interests or reputation of the user; an d (c) at the time of the application the mental health care user is incapable of making an informed decision on the need for the care, treatment and rehabilitation services and is unwilling to receive the care, treatment and rehabilitation required. Application to obtain involuntary care, treatment and rehabilitation 33. (1) (a) An application for involuntary care, treatment and rehabilitation services may only be made by the spouse, next of kin, partner, associate, parent or guardian of a 10 mental health care user, but where the(i) user is below the age of 18 years on the date of the application, the application must be made by the parent or guardian of the user; or (ii) spouse, next of kin, partner, associate, parent or guardian of the user is unwilling, incapable or is not available to make such application, the 15 application may be made by a health care provider. (b) The applicants referred to in paragraph (a) must have seen the mental health care user within seven days before making the application. (2) Such application must be made in the prescribed manner, and must(a) set out the relationship of the applicant to the mental health care user; 20 (b) if the applicant is a health care provider, state (i) the reasons why the application is made by him or her; an d (ii) what steps were taken to locate the relatives of the user to determine their capability or availability to make the application; (c) set out grounds on which the applicant believes that care, treatment and 25 rehabilitation are required; and (d) state the date, time and place where the user was last seen by the applicant within seven days before making the application. (3) An application referred to in subsection (1) may be withdrawn at any time. (4) (a) On receipt of the application, the head of the health establishment concerned 30 must cause the mental health care user to be examined by two mental health care practitioners. (b) Such mental health care practitioners must not be the person making the application and at least one of them must be qualified to conduct physical examinations. (5) On completion of the examination the mental health care practitioners must 35 submit to the head of the health establishment their written findings on whether the(a) circumstances referred to in section 32(b) and (c) are applicable; and (b) mental health care user must receive involuntary care, treatment and rehabilitation services. (6) (a) If the findings of the two mental health care practitioners differ, the head of the 40 health establishment concerned must cause the mental health care user to be examined by another mental health care practitioner . (b) That mental health care practitioner must, on completion of such examination

submit a written report on the aspects referred to in subsection (5). 36 No. 24024 GOVERNMENT GAZETTE, 6 NOVEMBER 2002 Act No. 17, 2002 MENTAL HEALTH CARE ACT, 2002 (7) The head of the health establishment may only approve the application if the findings of two of the mental health care practitioners referred to in subsection (4) or (6) concur that conditions for involuntary care, treatment and rehabilitation exist . (8) The head of the health establishment must, in writing, inform the applicant and give reasons on whether to provide involuntary care, treatment and rehabilitation 5 services. (9) If the head of the health establishment approves involuntary care, treatment and rehabilitation services, he or she must(a) within 48 hours cause the mental health care user to be admitted to that health establishment; or 10 (b) with the concurrence of the head of any other health establishment with the appropriate facilities, refer the user to that health establishment. 72-Hour assessment and subsequent provision of further involuntary care, treatment and rehabilitation 34. (1) If the head of the health establishment grants the application for involuntary 15 care, treatment and rehabilitation services, he or she must(a) ensure that the user is given appropriate care, treatment and rehabilitation n services; (b) admit the user and request a medical practitioner and another mental health h care practitioner to assess the physical and mental health status of the user for 20 a. period of 72 hours in the manner prescribed; and (c) ensure that the practitioners also consider whether (i) the involuntary care, treatment and rehabilitation services must be continued; and (ii) such care, treatment and rehabilitation services must be provided on an 25 outpatient or inpatient basis. (2) The head of the health establishment must, within 24 hours after the expiry of the 72-hour assessment period make available the findings of the assessment to the applicant. (3) If the head of the health establishment following the assessment, is of the opinion 30 that the mental health status of the mental health care user(a) does not warrant involuntary care, treatment and rehabilitation services, the user must be discharged immediately, unless the user consents to the care , treatment and rehabilitation services; or (b) warrants further involuntary care, treatment and rehabilitation services on an 35 outpatient basis, he or she must(i) discharge the user subject to the prescribed conditions or procedures relating to his or her outpatient care, treatment and rehabilitation services; and (ii) in writing, inform the Review Board. 40 (c) warrants further involuntary care, treatment and rehabilitation services on an inpatient basis, the head of the health establishment must(i) within seven days after the expiry of the 72-hour assessment period submit a written request to the Review Board to approve further involuntary care, treatment and rehabilitation services on an inpatient 45 basis containing(cia) a copy of the application referred to in section 33;

(bb) a copy of the notice given in terms of section 33(8); (cc) a copy of the assessment findings; and (dd) the basis for the request; and 50 38 No. 24024 GOVERNMENT GAZETTE, 6 NOVEMBER 200 2 Act No. 17, 2002 MENTAL HEALTH CARE ACT, 2002 (ii) give notice to the applicant of the date on which the relevant documents were submitted to the Review Board. (4) If the mental health care user is to be cared for, treated and rehabilitated on an inpatient basis and the user has been admitted to a health establishment which is (a) a psychiatric hospital, that hospital must keep, care for, treat and rehabilitate 5 the user; or (b) not a psychiatric hospital, that user must be transferred to a psychiatric hospital for care, treatment and rehabilitation services , until the Review Board makes its decision. (5) If at any time after the expiry of the 72-hour assessment period, the head of the 10 health establishment is of the opinion that the user who was admitted on an involuntary inpatient basis is fit to be an outpatient, he or she must(a) discharge the user according to the prescribed conditions or procedures; and (b) inform the Review Board in writing. (6) The head of the health establishment may cancel the discharge and request the user 15 to return to the health establishment on an involuntary inpatient basis, if he or she has reason to believe that the user fails to comply with the terms and conditions of such discharge. (7) The Review Board must, within 30 days of receipt of documents referred to in subsection (3)(c)(i)- 20 (a) consider the request in the prescribed manner, and give the applicant, mental health care practitioners referred to in section 33 or an independent mental health care practitioner, if any, and the head of the health establishment a n opportunity to make oral or written representations on the merits of the request; 25 (b) send a decision in writing with reasons to the applicant and the head of the health establishment; and (c) if the Review Board decides to grant the request, submit to the Registrar of a High Court the documents referred to in subsection (3)(c)(i) and the written notice for consideration by a High Court. 30 (8) 11 at any stage before making a decision on further involuntary care, treatment and rehabilitation services on an inpatient basis, an appeal is lodged against the decision of the head of the health establishment in terms of section 35, the Review Board must stop the review proceedings and consider the appeal. Appeal against decision of head of health establishment on involuntary care, 35 treatment and rehabilitation 35. (1) (a) A mental health care user, or the spouse, next of kin, partner, associate, parent or guardian of the mental health care user may, within 30 days of the date of the written notice issued in terms of section 33(8), appeal against the decision of head of the health establishment to the Review Board. 40 (b) Such an appeal must contain the facts and the grounds on which the appeal is based. (2) Within 30 days after receipt of the notice of appeal, the Review Board must(a) obtain from the head of the health establishment concerned, a copy of the application made in terms of section 33, notice given in terms of section 33(8) 45

and a copy of the findings of the assessment conducted in terms of section 34 (1), if applicable; (b) give the appellant, applicant, mental health practitioners referred to in section 33, an independent mental health care practitioner, if any, and the head of the 40 No. 24024 GOVERNMENT GAZETTE, 6 NOVEMBER 2002 Act No. 17, 2002 MENTAL HEALTH CARE ACT, 2002 health establishment concerned an opportunity to make written or oral representations on the merits of the appeal. (c) consider the appeal in the prescribed manner; and (d) send a written notice of its decision and the reasons for such decision to the appellant, applicant, the head of the health establishment concerned and head 5 of the relevant provincial department. (3) If the Review Board upholds the appeal(a) all care, treatment and rehabilitation services administered to the mental health care user must be stopped according to accepted clinical practices; and (b) the user, if admitted, must be discharged by the head of the health 10 establishment, unless the user consents to the care, treatment and rehabilitation services. (4) If the Review Board does not uphold the appeal, it must submit the documents referred to in subsection (2)(a) and (d) to the Registrar of a High Court for the review by the High Court. 15 Judicial review on need for further involuntary care, treatment and rehabilitation services 36. Within 30 days after receipt of the documents submitted by the Review Board i n terms of section 34(7) or 35(4), the High Court(a) must consider information submitted and any other representations made by 20 any person referred to in section 35(1) ; (b) may obtain information from any relevant person; and (c) must thereafter order(i) further hospitalisation of the mental health care user and, if necessary, the financial affairs of the mental health care user be managed and 25 administered according to the provisions of Chapter VIII; or (ii) immediate discharge of the mental health care user . Periodic review and annual reports on involuntary mental health care users 37. (1) Six months after the commencement of care, treatment and rehabilitation services, and every 12 months thereafter, the head of the health establishment concerned 30 must cause the mental health status of an involuntary mental health care user to be reviewed. (2) Such review must(a) state the capacity of the mental health care user to express himself or hersel f on the need for care, treatment and rehabilitation services; 35 (b) state whether the mental health care user is likely to inflict serious harm on himself or herself or other people; (c) state whether there is other care, treatment and rehabilitation services that ar e less restrictive or intrusive on the right of the mental health care user to movement, privacy and dignity; and 40 (d) make recommendations regarding a plan for further care, treatment or rehabilitation service. (3) The head of the health establishment must submit a summary report of the review to the Review Board.

(4) Within 30 days after receipt of the report, the Review Board must- 45 42 No, 24024 GOVERNMENT GAZETTE, 6 NOVEMBER 2002 Act No. 17, 2002 MENTAL HEALTH CARE ACT, 200 2 (a) consider the report including obtaining information from any relevant person ; and (b) send a written notice of its decision to the mental health care user, applicant, head of the health establishment concerned and head of the provincial department stating the reasons for the decision. 5 (5) (a) If the Review Board decides that the involuntary mental health care user be discharged(i) all care, treatment and rehabilitation services administered to the user must be stopped according to accepted clinical practices; and (ii) the user, if admitted, must be discharged by the health establishment 10 concerned, unless the user consents to the care, treatment and rehabilitation services. (b) The head of the health establishment must comply with the decision of the Review Board. (6) The Registrar of the High Court must be notified in writing of a discharge made 15 in terms of this section. Recovery of capacity of involuntary mental health care users to make informed decisions 38. (1) If the head of a health establishment is of the opinion from personal observation, information obtained or on receipt of representations by the user, that an 20 involuntary mental health care user is capable of making informed decisions, he or she must enquire from the user whether the user is willing to voluntarily continue with the care, treatment and rehabilitation services . (2) If the involuntary mental health care user consents to further care, treatment and rehabilitation services, section 25 applies. 25 (3) If the involuntary mental health care user is unwilling to continue with care, treatment and rehabilitation services and the head of the health establishment is satisfied that the user no longer has a mental illness as referred to in section 32(b), the head of the health establishment concerned must immediately cause the user to be discharged according to accepted clinical practices. 30 Transfer of mental health care users to maximum security facilities 39. (1) The head of a health establishment may submit a request in writing to the relevant Review Board for an order for transfer of an assisted or involuntary mental health care user to a health establishment with maximum security facilities if the user has- 35 (a) previously absconded or attempted to abscond; or (b) inflicted or is likely to inflict harm on others in the health establishment. (2) The head of the health establishment must submit a copy of the report to the applicant to enable the applicant to submit representations to the Review Board on the merits of the transfer. 40 (3) The Review Board must not approve the request(a) in order to punish the mental health care user concerned; o r (b) if not satisfied that the mental health status of the user warrants a transfer to maximum security facilities. (4) If the Review Board approves the request it must forward a copy of the order 45 concerned to the head of the health establishment and the head of the relevant provincial department.

44 No. 24024 GOVERNMENT GAZETTE, 6 NOVEMBER 2002 Act No. 17, 2002 MENTAL HEALTH CARE ACT, 200 2 (5) Within 14 days of receipt of the order, the head of the provincial department concerned must make the necessary arrangements with the appropriate health establishment and effect the transfer as ordered. (6) The head of a health establishment may, with the concurrence of the head of the health establishment with maximum security facilities, effect transfer pending the decision of the Review Board if the conduct of the mental health care user has or is likely to give rise to an emergency. Intervention by members of South African Police Service 40. (1) If a member of the South African Police Service has reason to believe, fro m personal observation or from information obtained from a mental health care 10 practitioner, that a person due to his or her mental illness or severe or profound intellectual disability is likely to inflict serious harm to himself or herself or others, the member must apprehend the person and cause that person to be(a) taken to an appropriate health establishment administered under the auspices of the State for assessment of the mental health status of that person; and 15 (b) handed over into custody of the head of the health establishment or any other person designated by the head of the health establishment to receive such persons. (2) If a mental health care practitioner, after the assessment referred to in subsection (1), is of the view that the person apprehended is- 20 (a) due to mental illness or severe or profound intellectual disability, likely to inflict serious harm to himself or herself or others, must admit the person t o the health establishment for a period not exceeding 24 hours for an application to be made in terms of section 33; or (b) unlikely to cause harm, he or she must release the person immediately. 25 (3) If an application is not made within the 24 hour period, the person apprehended must be discharged immediately. (4) If an assisted or involuntary mental health care user has absconded or is deemed to have absconded or if the user has to be transferred under sections 27(10), 33(9) , 34(4)(b), 34(6) and 39, the head of the health establishment may request assistance from 30 the South African Police Service to(a) locate, apprehend and return the user to the health establishment concerned; or (b) transfer the user in the prescribed manner. (5) The South African Police Service must comply with the request. (6) When requesting the assistance, the South African Police Service must be 35 informed of the estimated level of dangerousness of the assisted or involuntary mental health care user. (7) A person apprehended in terms of subsection (4) may be held in custody at a police station for such period as prescribed to effect the return or the transfer in the prescribed manner. 40 (8) A member of the South African Police Service, may use such constraining measures as may be necessary and proportionate in the circumstances when apprehending a person or performing any function in terms of this section.