THE PSYCHOLOGICAL REPORT

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Presented by: Ma. Nenita L. Magallanes, MASP

Introduction
The psychological report:
- End product of the assessment
- Represents the clinician’s efforts to integrate assessment
data into functional whole
- Requires clinicians to give not merely test results, but also
interact with data that makes conclusions useful in
answering the referral question, making decisions, and
solve problems
 Manner of presentation

 Depends on the purpose for which the report is intended

 Individual style and orientation of the practitioner
 Format: merely a suggested outline that follows common and practical
guidelines --- includes methods for elaborating referral question,
behavioral observations, relevant history, impressions
(interpretations), and recommendations
 Format is appropriate for evaluations that are problem-oriented and
that offer specific prescriptions for change
 Additional alternatives: use a letter format, give only summary and
recommendations, focus on a specific problem, summarize the results
test by test, write directly to the client, or provide client descriptions
around particular theory of personality
 General styles of writing

 “Shotgun” report (Tallent, 1992, 1993) – style to be

avoided: provides wide variety of often-fragmented
descriptions; usually vague, stereotyped, and
overinclusive; recommendations for treatment are
neither specific nor practical; most frequent reason is a
referral question that is too general, vague, and therefore
poorly understood
 “Case-focused” report – centers on specific problems
outlined by the referring person; reveals unique aspects
of the client and provides specific accurate descriptions;
recommendations for treatment are both specific and
practical; general approach is not what is to be known,
rather why different types of information are important
 Basic principles of case-focused report

- Use action-oriented language (links the person with specific behaviors, forces reports to address specific therapeutic
issues, and conveys a better understanding of the client’s active role in the testing situation) rather than metapsychological
abstractions (client’s ongoing behaviors and likely personality processes should be described in relation to different situations)
- Recommendations need to directly relate to what specifically can be
done in the particular environment
- There should be a focus on that which differentiates one person from
another
- The report should be written with an awareness of the point of view of
the intended readers
- The quality and usefulness of the report is typically enhanced if the
practitioner is knowledgeable about the area or type of issue the client is
experiencing
 GENERAL GUIDELINES OF WRITING THE REPORT

 Length  Length
 Style - typical psychological report is
between 5 and 7 single-spaced pages
 Presenting the interpretation
- length can vary based on the
 Topics purpose of the report, context, and
 Deciding what to include expectations of the referral source
- medical context: 2-page report
 Emphasis is not uncommon
 Use of raw data - legal context: 7-10 pages due
to greater need for documentation
 Terminology combined with more extensive referral
 Content overload questions
 Feedback - the more moderate 5-7 pages
is prevalent in educational, psychological
and vocational contexts
 GUIDELINES, cntd.
 Style or “flavor” of the report is
influenced primarily by the training and
orientation of the examiner/clinician
- literary approach: uses
everyday language, is creative, and often
dramatic; often imprecise and prone to
exaggerations
- clinical approach: focuses on
the pathological dimension of the person;
describes the client’s abnormal features,
defenses, dynamics involved in
maladjustment, and typical reactions to
stress
- scientific approach: emphasizes
normative comparisons, tends to be more
academic, and relates to the nature of
client’s pathology;
it looks at and describes test findings in an
objective, factual manner
- professional style (Ownby,
1997): characterized by short words that
are of common usage and that have precise
meanings; combines accuracy, clarity,
integration, and readability
• Presenting test interpretation:
Clinicians generally prefer to
orient their reports around specific
hypotheses or different relevant domains, or
adhere to interpreting data test by test.
- hypothesis-oriented model
focuses on answering specific questions
asked by the referral source; the report
tends to be highly focused, well integrated,
and avoids any extraneous material
 GUIDELINES, cntd.
- domain-oriented report
discusses the client in relation to specific
topics such as cognitive abilities,
interpersonal relationships, vocational
abilities, or sexuality; has the potential to
provide too much information, thus
overloading the reader
- presenting each test results,
one at a time: clarifies the source of data
and enables the reader to understand
more clearly how the clinician made
his/her inferences; easy for the examiner
to organize the results; can distract the
reader and tends to reduce the client
from a person to a series of test numbers;
reflects a failure to integrate data
 Topics
- serve as conceptual tools to
give form and direction to the information
that report writers are trying to
communicate
- 3 common topics: cognitive
functioning, emotional functioning
(affect/mood), and interpersonal relations
- additional topics include
personal strengths, vocational aptitudes,
suicidal potential, defenses, areas of
conflict, behavior under stress,
impulsiveness, or sexuality (see Table
15.1 for a list of topics that may be
considered for inclusion in an evaluation)
 GUIDELINES, cntd.
 Deciding what to include
- the clinician must strike a
balance between providing too much
information and providing too little, and
between being too cold and being too
dramatic
- as a rule, information should be
included only if it serves to increase the
understanding of the client
- basic guidelines relate to the
needs of the referral setting, background of
the readers, purpose of testing, relative
usefulness of the information, and whether
the information describes unique
characteristics of the person
- (after all these general guidelines have been
considered, the next step) to focus on and organize
the information derive from the tests
- (a further general rule) information
should focus on the client’s unique method
of psychological functioning (not so much with how
the client is similar to the average person as in what ways
he/she is different)
Barnum effect (in reference to Phineas
Barnum’s saying “There is a fool born every
minute): uncritical acceptance of universally
valid statements which, though they may
add to the subjective validity of the report,
should be avoided in favor of stressing the
person’s essential uniqueness
 GUIDELINES, cntd.
 Emphasis
- appropriate emphasis of
conclusions, particularly when indicating the
relative intensity of a client’s behavior (e.g. “this
client’s level of depression is characteristic of inpatient
populations”), or the relative intensity of certain
aspects of client’s disorder may be more
specifically discussed
- to discuss and give emphasis the
appropriate degree of emphasis to client’s
pathology, his/her psychological strengths
need to be compared with his/her relative
weaknesses
- the report should not discuss
areas of minor relevance unless they
somehow relate to the purpose of the
evaluation
- to achieve proper emphasis, the
examiner and the referral source must
clarify and agree on the purpose of
evaluation
- when clinicians present their conclusions, it
is essential that they indicate their relative
degree of certainty, whether the conclusion
is based on an objective fact, or the
clinician is merely presenting a speculation
(e.g., “John scored in the dull normal range of intelligence” is an
objective fact.. However, if only mild supporting data is available
or if clinicians are merely presenting speculation, phrases such
as “it appears…”, “tends to…”, or “probably…” should be used,
especially when clinicians are attempting to predict a person’s
behavior since it has not yet been observed.)
- if a statement made in a report
is a speculation, it should be clearly
indicated that it has only moderate or small
degree of certainty, and which should be
relevant to the referral question
 GUIDELINES, cntd.
- improper emphasis can reflect
an incorrect interpretation by the examiner,
and this misinterpretation is then passed
down to the reader (clinicians sometimes arrive at
incorrect conclusions coz their personal bias results in
selective perception of the data; from factors such as restrictive
theoretical orientation, incorrect subjective feelings regarding
the client, or overemphasis on pathology.)
- if speculations are overly
assertive, this may not only lead the reader
to develop incorrect conclusions, but also
the report may become overly authoritative
and dogmatic, leading readers to become
irritated and skeptical
- misinterpretations can also
result from vague and ambiguously worded
sentences that place incorrect and
misleading emphasis on client’s behavior
(e.g., statement such as “the client lacks social skills” is
technically incorrect coz the client must have some social skills,
although these skills may be inadequate. A more correct
description would be to state that the client’s social skills are
“poorly developed” or “below average.” or statements could be
rephrased to include more behaviorally oriented descriptions.)
- to emphasize results is to place
the most relevant sections in italics or bold-
face (this enables persons reading the report to more easily
absorb the most salient features and can easily relocate major
points that have been made.)
- responsibility for a report’s
conclusions rest on the clinician and should
not and cannot be transferred to the tests
themselves; conclusions and decisions
regarding people should always be in the
hands of responsible persons
 GUIDELINES,cntd…
 Use of raw data
- report writer should avoid
adhering too closely to the raw data (when
writing the impressions/interpretation section of the report)
- for certain purposes, it may be
useful to include raw data or even to
describe the tests themselves (e.g., “Mr. A had
an average level of recall for short-term visual information,
as indicated by his being able to accurately recall and
reproduce five out of possible nine geometric designs that
he had previously worked with for five minutes.)
- test descriptions allow
untrained persons to know specific
behaviors the client engaged in rather
than merely the final inferences; test
description is apt to give the reader more
in-depth, precise, and familiar reference
regarding the subject’s abilities
- the purpose of providing data
and behavioral descriptions is to enrich
and illustrate the topic and not to enable
the reader to follow the clinician’s line of
reasoning or document the inferences
that have been made
- in certain types of reports (such
as those for legal purposes), it might be helpful to
include some raw data to substantiate
that the inferences are data based, to
provide a point of reference for
discussing the results, and to indicate
what assessment procedures were used
 GUIDELINES, cntd…
 Terminology
- arguments whether to use
technical or nontechnical language in
psychological reports: technical
terminology is precise and economical,
increases the credibility of the writer, and
can communicate concepts that are
impossible to convey through
nontechnical language
- many consumers of reports do
not have the necessary background to
interpret technical terminology accurately
- precision of technical terms is
only helpful in a particular context and
with a reader who has the proper
background
- technical terms also run the
danger of becoming nominalisms in
which, by merely naming the phenome
non, persons develop an illusory sense of
understanding more than is actually the
case
- technical terms are often used
inappropriately (e.g., person who is
sensitive and cautious in interpersonal
relationships is labeled paranoid, or
compulsive is used to describe someone
who is merely careful, conscientious, and
effective in dealing with details)
- W. Klopfer (1960 cited in
Groth-Marnat, 2003) provides excellent
and relevant rationale for using basic
English rather than technical terminology
 Use of basic English allows the
examiner, through his/her report, to
communicate with and affect a wide
audience
 GUIDELINES, cntd…
 Basic English is more specific and
descriptive of an individual’s
uniqueness, whereas technical terms
tend to deal with generalities
 The use of basic English generally
indicates that the examiner has more
in-depth comprehension of the
information he/she is dealing with, and
can communicate this comprehension
in a precise, concrete manner (the report
should be understandable to any literate person of at
least average intelligence)
- Ownby (1990, 1997)
recommends combining any conclusion
or generalization with specific behaviors
or test observations
 Content overload
- no specific rule to follow in
determining how much information to
include in a report
- general guideline is to
estimate how much information a reader
can assimilate realistically
- if too many details are given,
the information may become poorly
defined and vague, and therefore lack
impact or usefulness
- clinician should focus on
areas that are most relevant to the
purpose of the report
 GUIDELINES, cntd…
 Feedback
- then of psychological
assessment: examiners often kept the
results carefully concealed from client
- now of psychological
assessment: examiners provide the client
with clear, direct, and accurate feedback
regarding the results of an evaluation
- providing feedback to client is
motivated by several factors:
 Regulations have supported a growing
list of consumer rights, including the
right to various types of information
 It might be perceived as a violation if
the client did not receive feedback
regarding the results of testing after
he/she had been subjected to several
hours of assessment
 Examiners cannot safely assume that
the original referral source will provide
feedback to the client
 There is increasing evidence that
providing clients with test feedback
can result in significant therapeutic
benefits
- rationale for allowing client to
actually read the report is that doing so
enables the client to experience the
product of assessment in a direct
manner, and also enables a practitioner
to explain any areas that are unclear
 GUIDELINES,cntd…/FORMAT FOR A PSYCHOLOGICAL REPORT

- feedback should be not only a FORMAT

neutral conveyance of data but also a Name:
clinical intervention; the information Age (date of birth):
should provide the client with new Sex:
perspectives and options and should aid
Ethnicity:
in the client’s own problem solving
Date of Report:
- one possibility of providing
Name of Examiner:
feedback is to prepare a personalized
report designed specifically for the client Referred by:
which forces the practitioner to write in I. Referral Question
clear, straightforward style; such reports II. Evaluation Procedures
are more likely to emphasize III. Behavioral Observations
recommendations and adaptation rather IV. Background Information (relevant
than pathology history)
- optimal communication style V. Test Results
is an informal letter written to and for the VI. Impressions and Interpretations
client VII. Summary and Recommendations
 FORMAT FOR A PSYCHOLOGICAL REPORT
- no single agreed-on format that
exists, but every report should integrate old
information as well as provide new and
unique perspective on the person
- old information should include
identifying information (name, birth date,
etc.), reason for referral, and relevant
history
- new information should include
assessment results, impressions,
summary/conclusions, and
recommendations
- at the top of the report,
practitioners should indicate its confidential
nature by writing “Confidential
Psychological Evaluation”
- presented outline represents
the frequently encountered format though,
there are many variations:
 Some practitioners prefer to include the
client’s marital status, occupational
status, and handedness (for
neuropsychological reports) at the top of
the report along with other demographic
information
 Other practitioners prefer to exclude the
test results section or include additional
sections on diagnosis, case formulation,
or summary
 Still others like to include subheadings in
the Impressions and Interpretation
section (cognitive functioning and
ideation, coping styles,
affect/mood/emotional control)
 FORMAT, cntd…
 More appropriate to eliminate all or
most of the headings and write the
report directly to the referral source in
a letter format (“Dear Dr. James…)
- each practitioner needs to
develop both the format and style that
most effectively meet his/her client’s and
referral source’s needs
- different assessment contexts
require different styles and areas of focus
 Referral Question
- provides brief description of the
client and a statement of the general reason
for conducting the evaluation
- should include brief description of
the nature of the problem
- should begin with brief, orienting
sentence that includes essential information
about the client (e.g., “Mrs. Aban is a 45-year-
old, Caucasian, female with college education
who presents with complaints of paranoia and
hallucinations.”)
- clinician develops adequate
clarification of the referral question
- purpose of testing should be
stated in precise and problem-oriented
manner, and include both the specific purpose
of the evaluation and decisions facing the
referral source (please refer to the list of possible
reasons for referral on p. 635)
- effective referral question should
accurately describe the client’s and the
referral source’s current problems
 FORMAT, cntd…
 Evaluation Procedures
- simply lists the tests and other
evaluation procedures used but does not
include the actual test results
- full test names are included along
with their abbreviations [e.g., Wechsler Adult
Intelligence Scale (WAIS)]
- for legal evaluations and other
occasions in which precise details of
administration are essential, it is important to
include the date on which different tests were
administered and the length of time required
to complete each one
- may also be important to include
whether clinical interview or mental status
examination was given, the degree of
structure and the amount of time required
- may not necessarily be restricted
to testing and interviews with the client, but
includes review of relevant records, such as
medical reports, nursing notes, military
records, police records, previous
psychological/psychiatric reports, or
educational records, interviews with
individuals who can provide relevant
information
- might end with statement
summarizing the total time required for the
evaluation
 Behavioral Observations
- include physical appearance
(focus on any unusual features relating to
facial expressions, clothes, body type,
mannerisms, and movements)
 FORMAT, cntd…
- include behavior toward the
task/test material and examiner (behaviors
that reflect the person’s level of affect,
manifest anxiety, presence of depression, or
degree of hostility, any unusual verbalizations
that the client makes about the test material,
level of cooperation)
- events before testing, such as
situational crises, previous night’s sleep, or
use of medication
- behavioral observations should
usually be kept concise, specific, and relevant
(the focus should be on client behaviors that
create unique impression)
- relative length varies from few
brief sentences to considerably longer
depending on the amount of relevant
information the clinician has noticed
- clinicians who prefer behavioral
assessment procedures might wish to
emphasize the behavioral observation section
by providing more in-depth descriptions of
relevant antecedents
- at the end of the section, it is
customary and appropriate to include a
statement indicating the validity of the
assessment procedures (e.g., “Given the
consistency and detail of the client’s
responses, the client’s high level of
motivation, and validity indicators on MMPI-2,
the assessment appears to be an accurate
evaluation of this person’s current level of
functioning.”)
 FORMAT, cntd…
 Background Information (Relevant History)
- include aspects of person’s
history that are relevant to the problem the
person is confronting and to the interpretation
of test results
- should include a good history of
the problem, along with areas such as
important life events, family dynamics, work
history, personal interests, daily activities, and
past and present interpersonal relationships
- important to specify where the
information came from (“The client reported
that…”) which is particularly essential when
there may be some questions regarding the
truth of the client’s self-reports or when the
history has been obtained from multiple
sources
- history usually begins with a brief
summary of the client’s general background,
followed by sections describing family
background, personal history, medical history,
history of the problem, and current life
situation
- family and personal histories
usually reveal information relating to the
predisposing cause of client’s difficulties,
whereas the history of the problem often
provides an elaboration of the precipitating
and reinforcing causes
- the history is of even greater
significance than test results; thus, the history
needs to be complete and must address a
number of areas that are not ordinarily
covered in personality evaluation
 FORMAT, cntd…
- in condensing the client’s history
into the report, it is important to avoid
superfluous material and continually question
whether the information obtained is relevant
to the general purpose of the report
- some practitioners might restrict
the length of this section (background
information) to a single paragraph
 Test Results
- for certain reports, it may not be
necessary to list test scores; however, it is
usually recommended that test scores be
included, especially in legal reports or when
professionals who are knowledgeable about
testing will read the report
- if the report is too test/data
oriented or serves to unnecessarily “clutter”
the report, test data, including the actual
profiles, might be inserted in an appendix
- if actual test scores are included,
standard (rather than raw) scores should be
the mode of presentation; clinicians may also
wish to indicate the relative magnitude of the
relevant scores (i.e., Very high, High, etc.) or
whether the scores exceed some clinically
meaningful cutoff
- intelligence test scores are
traditionally listed first and, for the Wechsler
scales, should include IQ scores (Verbal,
Performance, Full Scale), index scores, and
subtest scaled scores (indicating strengths
and weaknesses)
- following are other cognitive test
results such as the Bender; Bender results
can simply be summarized by a statement
such as: “Empirically not in the organic range,
although there were difficulties organizing the
 FORMAT, cntd…
designs and frequent erasures; MMPI results
are often listed in the order in which they
appear on the profile sheet
- objective personality tests should
always be referred to by their standardized
scores and not their raw scores
- Rorschach summary sheet may
be included, but the results of projective
drawings and the TAT are usually omitted
- should a clinician wish to
summarize projective drawings, a brief
statement is usually sufficient, such as
“Human figure drawings are miniaturized and
immature,” with the inclusion of two
transparencies
- TAT scores, likewise can be
summarized by a brief statement of the
strongest needs and press, and a mention of
the most common themes encountered in the
stories
 Impressions and Interpretations (also
referred to as Discussion)
- considered the main body of the
report; requires that the main findings of the
evaluation be presented in the form of
integrated hypotheses
- areas discussed and style of
presentation vary according to the personal
orientation of the clinician, the purpose of
testing, the individual being tested, and the
types of tests administered
- assessment data should be
organized according to different integrated
topics or presented as a chronological
narrative of the person
 FORMAT, cntd…
- a test-by-test presentation is
strongly discouraged
- to organize information from
assessment, W. Klopfer recommends using a
grid (please refer to Table 15.3 p.643); the list
of evaluation procedures is dependent on
which tests the examiner/clinician
administered, but the topics can be chosen
and arranged according to areas the clinician
would like to focus on
- all inferences made should be
based on an integration of test data,
behavioral observations, relevant history, and
additional available data
- conclusions and discussion may
relate to areas such as the client’s overt
behavior, self-concept, family background,
intellectual abilities, emotional difficulties,
medical disorders, school problems, or
interpersonal conflicts
- discussion of the client’s
intellectual abilities usually occurs first; should
include a general estimate of the person’s
intelligence as indicated by IQ scores
- also important to provide
discussion of more specific abilities which
may include an analysis of areas such as
memory, problem solving, abstract reasoning,
concentration, and fund of information
- whenever possible, a discussion
of the client’s intellectual strengths and
weaknesses may follow after the presentation
of the general estimate of intelligence, which
may involve elaborating on the difference
between Verbal IQ and Performance IQ or a
discussion of subtest scatter
- if the referral question is clearly
focused on a specific problem, it may be
 FORMAT, cntd…
necessary to elaborate on only two or three
topics; but, if the referral question is too
general, a wider approach, in which six or
more topics are discussed, may be required
- usually, client’s greatest conflicts
center on difficulties with dependency,
hostility, and sexuality; whether these
difficulties will continue or, if currently absent,
recur should be a frequent consideration
- if the client’s future prospects are
poor, clinician should explain that this is
caused by factors such as a strong need to
appear hypernormal, poor insight, and a high
level of defensiveness
- likewise, favorable predictions
should include a summary of the client’s
assets and resources, such as psychological
mindedness, motivation to change, and social
supports
- sometimes clinicians wish to
include a separate section on diagnosis;
however, whether to include a DSM diagnosis
has been an area of hot controversy
- clinicians feel that labels should
be avoided because they may result in self-
fulfilling prophecies, be overly reductionistic,
and allow clients to avoid responsibility for
their own behavior
- researchers feel that many of the
terms are not scientifically valid and are not
particularly useful in planning interventiions
- if the clinician does decide to give
a diagnosis, he/she must have clear
operational knowledge of diagnostic terms,
he/she should include client’s premorbid level
of adjustment, and the severity and frequency
of the disturbance
 FORMAT, cntd…
 Summary and Recommendations
- purpose of the summary is to
restate succinctly the primary findings and
conclusions; requires that the practitioner
selects only the most important issues and
that he/she be careful not to overwhelm the
reader with needless details
- useful strategy in the summary is
to provide brief bulleted/numbered answers to
each of the referral questions
- the ultimate practical purpose of
the report is contained in the
recommendations because they suggest what
steps can be taken to solve problems; such
recommendations should be clear, practical,
and obtainable, and should relate directly to
the purpose of the report
- the best reports are those that
help the referral sources and/or the clients
solve the problems they are facing; they must
answer the referral question and have
decisional value
- thus, a recommendation that
states “The client should begin
psychotherapy” is not as useful as a
statement of the need for “individual therapy
focusing on the following areas: increased
assertiveness, relaxation techniques for
reducing anxiety, and increased awareness of
the self-defeating patterns he creates in
relationships.”
- after the report, with its
recommendations, has been submitted,
continued contact should be made with the
reader(s) to make sure that the report has not
been filed and forgottent
 THE PSYCHOLOGICAL REPORT

Even the best report is not functional unless the recommendations are
practical, obtainable, and actually put into action!



THANK YOU!!!

nen