The goal of psychological assessment really is the report. After all, what's the point of going through all this if you can not share what you have found in a way that is meaningful to others?

Reports serve several functions:

  • they document results
  • they answer specific questions
  • they provide guidelines for intervention

A basic outline

  • What's the purpose of a report? Answering the referral question(s)
  • Writing points to keep in mind
    • be pithy and concise
    • avoid Barnum Statements (unprovable or always true)
    • be specific, clear, and concrete, especially about what are facts vs inferences
    • stick to the data; don't present as more sure than you are, but avoid too many somewhats, possibles, prone tos, may at times... (Zuckerman says they are "leeches in the pond of prose, sucking the blood of words")
    • never give data without interpretation (scores or behaviors) because the reader needs you to tell them what and why something is important
    • lower reading level if possible for maximum clarity
    • report information in context (what are facts, documented information, reported information, others' observations, others' opinions)
    • avoid jargon and technical language; don't violate test security but some examples of questions and answers can be illustrative
    • lawyer devil on the shoulder; if this were taken out of context or quoted without the previous sentence, how would it sound
    • first name for a child, last name for an adult, Ms/Mrs
    • research is helpful when clear, but if it needs too many qualifiers it isn't helpful
    • balance (length with clarity, old with new information, realistic versus ideal recommendations, positive and negative findings, your ideas and alternative ideas)
    • imagine reading it to the client

Content of the Report

  • Intro
    • title
    • demographics, identifying information (name, dob, sex, age, ethnicity, marital status, occupation)
    • place, date(s), examiner of assessment
    • reason for referral (who, why, why now, to what end)
    • records reviewed, source, title, date, helpfulness, all that were requested
    • arrival, ability to consent and undergo evaluation, cooperation, time investment, reliability of client and validity of results
    • consent obtained
    • confidentiality issues
  • Background
    • consider reporting the history by date or by topic
    • childhood (where born, who raised, view of parents, relationship with parents then and now, sibs, placement in sibship, relationship with sibs, childhood memories and evaluative description, abuse or traumas, extended family, who is alive/deceased and when)
    • education (type of school, number of schools, years completed, trouble reading, writing, spelling, math, held back, promoted, special ed, behavioral ed, tutored, extracurricular activities, family attitude toward, GED completed/failed)
    • employment (first job, age, lasted how long, same for next job..., fired how many times, quit how many times, best job, worst job, job strengths, job weaknesses, problems on job, how financially supports self and how well)
    • medical health (illness, age at diagnosis, reason for seeking treatment, treatments, effectiveness, doctor problems, impairment in life, prognosis, coping with stress of illness, hospitalization, doctor-patient relationship, medications, managing side effects)
    • mental health (ever sought services, what kind, did they help, how long lasted, what helped, what would have been better, considered going back, hospitalization, doctor-patient relationship, medications, managing side effects)
    • substance use (see section in interviewing)
    • daily life (time to rise, diet, chores, work, relationships, hobbies...)
    • family life (who, married or divorced, contact, responsibilities, joys and sorrows)
    • current stressors
    • conduct (lawsuits, bankruptcies, fire setting, manipulated others and enjoyed it, destroyed property, fights, shoplifting or theft, bullying, arrests, warnings, prosecutions, convictions, time services, parole)
    • military (reason to enlist, time, discharge type, reason for it)
    • culture (religion, neighborhood, resources, clashes, current and future activities, monitored news, readings, hobbies)
    • current activities (hobbies, responsibilities, work toward goals)
    • social (number of acquaintances, close friends, frequency of contact, quality and stability of relationships, dating, how long since)
  • Behavioral Observations and Mental Status Exam
  • Test Results
    • test-by-test vs integrative approach or results-and-discussion vs integrative approach
    • tests administered
    • notes on use of the information (disclaimer)
    • intellectual, achievement, neurological test results
    • memory results
    • activities of daily living or functional capacities in daily life
    • personality functioning
    • vocational interests
    • parenting skills
  • Personality Results
    • test-by-test (as in objectives first and projects second for legal settings) vs integration
    • my personality conceptualization
      • intro and brief summary to orient reader
      • cognitive (resources, coping skills, problem solving style, defenses, understanding of environment, current stresses and responses to stress, kinds of mistakes, learning from mistakes)
      • emotional (specific emotions client experiences if possible, source if reasonable to speculate, conflicts between emotions and loyalties, understanding of emotions, severity of pathology, ways they impact client, how the client sees themselves, dealing with and expressing feelings, impact on empathy for others)
      • relationships (view of the world, view of others, orientation toward relationships, kinds of relationships, efforts and abilities to maintain or end, others' likely view of them)
      • particular strengths or weaknesses of note
    • Common Defenses
      • Hysteric - denial and repression
      • Obsessive/Compulsive - intellectualization, isolation, rationalization
      • PA - displacement
      • Narc - compensation
      • Paranoid - denial, reaction formation, projection
      • Borderline - denial, splitting
      • Antisocial - regression
      • Mania - reaction formation, compensation, sublimation
    • Checklist of strengths
      • Social
        • extensive support system or extended family
        • long term relationship
        • membership in social groups
      • Interpersonal
        • social skills, respectful, competent in some area, accepts feedback, and tolerant
        • likeable, friendly, sense of humor
        • empathic, good listener, good boundaries
        • nurturing, modest, generous
        • assertive, leadership potential, strong
      • Occupational
        • able to maintain employment, financially independent
      • Personality
        • shows integrity, honest, dependable, reliable, accepts responsibility for actions
        • spiritual or strong religious conviction
        • insight into thoughts and feelings
        • high motivation, drive for achievement
        • coped with past stressors, benefitted from therapy
        • self-confidence, self-esteem
      • Affective
        • comfort with a range of emotions, aware of others' feelings
        • controls emotions, integrates thoughts and feelings
        • tolerates painful emotions
        • good emotional intelligence
      • Cognitive
        • attention, concentration, memory intact
        • intelligent, skilled, articulate
        • creative and imaginative
        • adaptive, has common-sense, realistic thinking, accurate assessment of demands
      • Physical
        • healthy, exercises, good diet and nutrition
  • Summary
    • to refresh careful reader's memory
    • to clue in the speed reader
  • Conceptualization
    • dealing with referral questions
    • restate and answer
    • case conceptualization

      • either should make recommendations seem obvious and well-supported
    • prognosis
    • issues to deal with in recommendations
  • Diagnosis
    • yes
    • no
    • yes but with a note
  • Recommendations - Based on the above, what would be needed in the case, with some special pointers, such as:
    • therapy (type, duration, sex of therapist, level of training) and whether it is "traditional" in focus or recommended as an "inoculation." For example, step-family formation is a traumatic process that can lead to two to three years of distress for the family if the family is unclear on what to expect and how to handle it. Therapy to educate the family on how it will likely go and what it will be like can prevent some problems, help them prepare for others, and minimize the damage caused by some issues)
    • educational intervention (IEP, teacher and parent suggestions for an LD or ADHD child, tutoring, extended testing, reconsideration of placement, mainstreaming, special education or therapeutic day school placement)
    • remediation efforts or skills training (vocational training, parenting support group, anger management classes, assertiveness skills, GED program, reading and literacy workshops)
    • psychiatric or medication evaluation (for what problem, what diagnostic confusion might be had, any special preparation the client or family will need)
    • substance abuse treatment (inpatient, outpatient, support groups and attendance schedule, urine screenings, comorbid disorders that would complicate treatment)
    • group services (therapy, victims of abuse support, single parents, 12 Step, grief and loss group, depression or other diagnosis treatment group, couples workshop)
    • psychological evaluation (what for and when, and I've started adding by whom and alternatives if this can't be paid for by the agency, such that the therapist might be able to offer an evaluation... some therapists don't want this put on them though, as being placed in a clearly evaluative setting can compromise their therapeutic work)
    • community services (church, Big Brothers/Sister, after school activities, adult social group, stress management classes)
    • warning on suicide, violence, relapse risk
    • re-evaluation as needed (hearing and vision, neurological, speech, vocational, IEP... when and why). I also suggest that the referral source let the next evaluator know of this evaluation since some of the tests could be duplicated and then practice effects would skew the results
    • hospitalization due to noted reason (e.g., decompensation, failure of outpatient treatment, suicide risk, eating disorder that presents a risk to physical health, risk to harm others, bizarre or progressively risky behaviors that present a danger to self, dementia)
  • Closing
    • thanks
    • further questions
    • further notes for reader (reliability, confidentiality, use, feedback)
  • Post Report
    • Client Feedback
    • test by test explanation (here's what we did and why I had us do this)
    • point out key data, departures from norm, and possible hypothesis
    • point out the well-supported hypothesis and how they led to conclusions
    • ask for feedback
    • don't argue, pressure, of "just try to get them to see the truth"