Many patients, when they first set up an initial appointment, are mystified as to what will happen in the first session. That initial session looks very similar to the way a visit to a general physician might be structured. It begins with a statement about the chief complaint and how it and when it developed. The next step is to discuss any medication that the patient may be on and how it has helped or hasn’t. There is also discussion about whether the patients had any past therapy and how that was carried out and with what effect or benefit or lack there of. That is followed by questions about the patient’s social life, marriage and children as well as extended family. Other details looked into will be occupational history, satisfaction with present job and any job stresses.
Next will follow a discussion about present and past stresses. A great deal of time is spent on developmental history such as early childhood, the structure of the family of origin and the personalities and relationships with each the parents, and questions as to what kind of person the patient was as a teenager and young adult. The patient will then need to discuss medical and surgical history, any legal issues such as involvements with law enforcement and attorneys in divorce actions, and whether there was any drug or alcohol abuse. An important question is whether there has been any sexual physical or emotional abuse in the past. It is crucial to establish that item because it forms the basis of the many mental problems that patients might have and will require resolution in therapy.
Initial assessment ends with a mental status examination for the purpose of establishing a psychiatric diagnosis. By the end of the session it should be clear as to what the treatment plan should be, and that is explained to the patient. At this point, the patient is given an opportunity to discuss the treatment plan and whether it seems acceptable to him or her.
The process of the initial evaluation is thus very straightforward but tends to be mystifying and even scary to new patients. Because it is such an unknown item, patients approach the first visit with much anxiety since they don’t know what will happen. The intention of posting this brief essay is to dispel that anxiety and make it easier for patients to feel comfortable during their initial evaluation.