Unit:2.

3
Case history method
Suman sharma
 Case History
• A case history sometimes called the
psychological history, is a detailed description of
a clients background.
• A case history provides information that may be
necessary to formulate a complete portrait of a
person to complete diagnosis.
• Knowing client’s history also helps the clinicians
to understand how the present problems fits the
boarder context of the persons life.
 Case history…
• For diagnosis or treatment it is required to
understand the detailed psychosocial history
of a clients.
• Case history interviews tends to be broadly
focused. The relevant information is gathered
from the clients itself as well as concerned
person.
 Case history…
• Typical information gathered in a case history interview might
include:
1. Birth and development
2. Family origin
3. Education
4. Employment
5. recreational/Leisure
6. Sexual history
7. Dating and marital
8. Alcohol and drugs
9. Physical health
 Case history…
• Birth and Development: were the complication in pregnancy or
during birth? Did the client reach developmental milestones (eg.
Walking, talking, toileting) at normal ages?
• Family of Origin: Who raised the client? Did the family remain
intact? What was the clients relationship like with parents,
siblings, extended family? Have any family members
experienced mental health, substance abuse, significant medical
or legal problems?
• Education: how far did the client go to school? Did client repeat
any grade or receive special education services? Were there any
significant behavioral problem in school (eg. Suspensions or
expulsion)?
 Case history…
• Employment: What types of job has the client held? Has
the client ever been fired? If so why? Has the client
changed job often? Why?
• Recreation/Leisure: How does the client spend his or her
free time? What are the interests and hobbies?
• Sexual history: How did the clients learn about sex? What
is the nature of client’s current sexual functioning?
• Dating and Marital: When did the client start dating?
Significant romantic relationship? How many times has the
client’s been married? At what age clients get married?
 Case history…
• Alcohol and Drugs: What is the nature and
pattern of client’s alcohol and drugs use? Has
the clients experienced legal, employment, or
social problems secondary to alcohol or drug
use?
• Physical health: Has the client had significant
medical problems ( eg. Chronic illness, head
injuries, etc…)?
 Case history…
• While gathering all these information, practitioners has
opportunity to make observation about the client’s speech
pattern, thought processes, emotion, memory and other
processes.
• Most competent adult can give information by themselves
where as children as well as severely disabled adult,
however, it is often necessary to rely upon other sources
of information.
• It can be gather information from employers, spouses,
previous mental health providers, or the friends of
interviewee..
 Unit:2.5
Assessment Process
Suman Sharma
• Process..????
• Planning
• Data coll
• Intrepret data..
• Conclusion
• Communication..
 Process of Assessment
Process of Assessment can be broken into four
parts.
• 1. Planning the assessment
 Determination of questions to be addressed in the assessment
 Determination of the methods, sources for information
collection

• 2. Data Collection
 Involves gathering information via observations interviews,
testing , and report reviews
 Process…
• 3. Data Processing
 Information are organized and interpreted

• 4. Communicating Findings
 Communicate the assessment findings and results

• In practice, each stages of the assessment overlaps

with the others. The assessment plan(stage 1) modified
as more information is collected(stage 2),
interpreted(stage 3) and communicate results findings
(stage 4).
 Stage 1: Planning the assessment
• Psychological assessment starts with referral question.
• Someone wants to know something about an individual and
believes that a psychologist can find it out.
• Sometimes the person asking referral question can be a
clients, primary care physicians, school system, the court,
parents, etc..
• Acquiring knowledge relating to content of the problem.
• Psychologist assess clients before initiating treatment. Is this
person likely to helped by psychotherapy? What are the
treatment goals? What are the psychological and situational
factors underlying the problems ?
 2. Data collection
• Clinical interview is undoubtedly the most
common method for gathering information.
• Different types of Psychological testing.
• Behavioral as well as other observation.
• Academic, employment, hospital record, etc..
• Different means of sources…
• Parents, peers, teachers, co-workers etc…..
 3. Processing Assessment Data
• Clinical judgment. (decision making about
clients)
• Inferences can be made.
• Analyze information and prediction.
• Reducing impact of bias.
• computer assisted assessment.
4. Communicating Assessment findings
• Report which brings all the information together.
• Findings and recommendation that how
effectively communicate them.
• Addresses the goal of assessment.
• Writing styles.
• Using clear and everyday language.
• Avoid Jargon if it need to communicate to clients
and client parties.
 Three-stage process of assessment

• information input (collecting

assessment data)
• information evaluation (interpreting
assessment data)
• Information output (utilizing
descriptions of respondents to formulate
conclusions and recommendations)
 Information Input
Initial phase of collecting data of appropriate kind and in sufficient amount to address the
question in meaningful and useful ways. It involves-
• Formulating Goals
• Selecting Tests
– Psychometric Adequacy
– Relevance
– Incremental Validity
– Additive, Confirmatory, and Complementary Functions of Tests
• Examiner Issues
– Qualifications and Competence
– Personal Influence
– Respondent Issues
• Data Management Issues
– Computerized Data Collection
– Test Security
– Confidentiality
 Information Evaluation
• In this phase assessment data are interpreted in a manner
that provides accurate description of respondents
psychological characteristics and behavioral tendencies.
• Helps to draw inferences about client’s psychological
characteristics and description of psychological functioning.
• It can be based on either empirical or conceptual approach
which provides adequacy of explanation.
• It can be based on statistical rules and clinical judgment.
• It can be based on nomothetic and idiographic emphasis.
• It can be helpful detecting Malingering and Defensiveness .
 Information Output
• It is a final phase
• Process of utilizing description of respondents to formulate
conclusion and recommendation that help to address the
referral question.
• Conduct the assessment using best practices and to facilitates
honest feedback.
• Bias and Base Rates need to consider.
• Conclusion need to make carefully by considering Culture and
Context
• Conclusion and treatment recommendation by the help
of clinical judgment and cutting score.
 Unit:2.6
Psychological Assessment and Treatment Planning

Suman Sharma
 Psychological assessment and Treatment
Planning
• Ultimate goal of assessment is to help solve problem by
providing information and recommendations relevant to making
the optimum decision related for client welfare.
• Make recommendation related to treatment setting
( inpatient/outpatients), intensity (frequency and duration),
goals, mode (individual, group, family) and specific strategies
and techniques.
• Requires no of knowledge and skills other than test
interpretation. Such as need to specifies of the problem,
understand client’s personal characteristics and environmental
circumstances as well as client’s resources available in the
community and recommend the appropriate one.
 Psychological assessment and Treatment
Planning
• Clinicians must make recommendations related to
treatment settings.
• Diagnosis can be made after interpretation of test
results and develop the plan for effective treatment.
• It helps to stimulate client’s self awareness and
exploration.
• Assessment can be therapeutic when it will promote
positive change in client’s behavior.
• In counseling it will help to make effective decision for
the clients.
Approaches to Treatment Planning.
• Specific case Management: Gordon Paul (1967) ambitiously
stated this agenda with a question: “ What treatment, by whom,
is most effective for this individual with that specific problem, and
under which set of circumstances? ”
• General Case Management: The general purpose of assessment
is to identify the most relevant client characteristics of symptom
behavior and match these with optimal interventions.
• For example from the ancient times, the Vedas discuss the
differential effects of telling appropriate metaphors to clients
according to their needs. Similarly, Sufism has had a well-
developed tradition of storytelling designed to create specific
impacts on the participants.
Systematic Approach to Treatment Selection

• When a clinicians is confronted with client,

based on the relevant information acquired, a
series of decisions and recommendation
should be developed.
• Beutler and his colleagues(1990) have
identified six patient dimensions and related
these to different types of decisions.
 Functional Impairment
• An evaluation of the severity of the problem, interferences
with daily social, occupational and intrapersonal functioning.
• Might have a direct relationship to the clients ability to cope,
ego strength, level of insight and chronicity of the symptoms.
• Distress to self/others.
• Eg, an antisocial personalities who create suffering for others
but do not feel particularly distressed themselves and
schizoid personalities who are functioning on the fringes of
society but do not feel particularly worried about their
marginal status and level of dysfunction.
 Functional imparment
There are numerous formal and informal assessment procedures
for assessing functional impairment. Beutler and his
colleagues,1995) have summarized the relevant assessment
dimensions to include the following:
• A problem that interferes with the client’s ability to function
during the interview.
• Poor concentration during assessment tasks.
• Distraction by minor events.
• General incapacity to function.
• Difficulty interacting with the clinician.
• Multiple impaired areas of performance in the client’s daily life.
 Functional impairment…
Assessment Measures includes
• Elevations are found on scales on the right side of the MMPI –2/ MMPI-A (Paranoia,
Schizophrenia, Hypomania).
• High Beck Depression Inventory-II (BDI-II) scores (30 or above General elevations on
the MCM I-III scales also suggest a high level of functional impairment.
• Impairment can be more severe if there are diagnoses on both Axis I and II and if
there is the presence of severe disorders in the psychotic domain (schizophrenia,
bipolar).
• In addition, the DSM -IV Global Assessment of Functioning rating provide an
assessment of the level of functioning over the past year on a scale between 1 and
100 .
• (T above 63 ) on the Brief Symptom Inventory
• (T above 55 ) on the Trait Anxiety scale of the State-Trait Anxiety, etc..
Treatment planning varies according to the severity of the level of impairment.
( High/Low)
 High level of Functional Impairment
High levels of functional impairment have
implications for the following five areas:
• restrictiveness(inpatient/outpatient)
• intensity of interventions (duration and
frequency),
• medical/somatic versus psychosocial interventions,
• prognosis, and
• the urgency of achieving initial goals
 Restrictiveness
• Severe problems, particularly if the client is suicidal or
cannot function in daily activities may require immediate
inpatient care. Eg. The patient require inpatient care
include bipolar mood disorders, psychotic conditions,
major depression with suicidal intentions, acute substance
abuse requiring detoxification, and some organic
conditions.
• Whereas, Outpatient interventions would be appropriate
for the vast majority of clients whose problems are of mild
to moderate severity (e.g., adjustment reactions, mild to
moderate depression) and have greater resources.
 Intensivity of intervention
The intensity of treatment (duration and frequency) varies from client
to client based primarily on functional impairment. Greater duration
of treatment is generally suggested for the following types of patients:
• Those with more serious diagnoses (e.g., borderline personality).
• Poor premorbid functioning.
• External stress seemingly of minor importance in the development
and maintenance of the disorder.
• Age between 25 and 50 years.
• Client expectation that change takes time, and the technique used
will be exploratory and insight oriented.
• Low level of social support.
 Intensity of intervention
In contrast, the following indicators suggest short duration of
interventions:
• An acute disorder (e.g., adjustment disorder, acute reactive
psychosis).
• External stress that seems to be of primary causal
significance.
• Good premorbid level of functioning.
• Clients who expect change to occur quickly.
• Symptom-oriented focus of treatment, or crisis intervention.
• Structured, directive, and active interventions.
• Person who is either child/adolescent or elderly.
• High level of social support.
 Pharmacological vs Psychologigal
• Conditions such as schizophrenia, bipolar disorder, or severe anxiety
states might require medical intervention (pharmacotherapy,
electroconvulsive therapy) to enable clients to function well enough
to become engaged in psychosocial or environmental interventions.
• Severe subjective distress, and less client resources (employment,
abilities, social support) will have difficulty overcoming it because it
has progressed to such an extensive level.
• high degree of psychiatric symptoms associated with the presence
of somatic complaints (headaches, irritable bowel syndrome) is
likely to suggest a poor prognosis.
• A final principle in prognosis is that clients with low levels of social
support are not as likely to improve as those with high support
 Urgency..
• Finally, severe problems suggest that the
urgency of treatment is greater as causing the
client the greatest distress.
• Less severe problems mean that the urgency
of change is less and the goals can change and
be negotiated over time.
 Low Functional Impairment: Treatment
planning
In contrast to the previously described treatment
considerations,
• Low functional impairment suggests that treatment
can be in an unrestricted setting (outpatient) and of
relatively low frequency and duration.
• Psychosocial interventions will more likely be the
predominant form of intervention, and there will be
less urgency to rapidly define and achieve specific,
symptom-oriented goals.
 Social Support
• Level of environmental support refers to the presence of a strong
cohesive family and a secure form of employment.
• Support can often modify the impact of stressor, response to
treatment and ability to maintain the gains made through
treatment.
• High social support has also been associated with a favorable
response to treatment as well as the ability to maintain throughout
treatment.
• Not only are the treatment gains higher for persons with high social
support, but also they achieved these gains in a shorter period.
• In contrast, clients with low social support required more time to
benefit from therapy.
 Social support
Informal assessment of social support can be achieved by
noting the following characteristics:
• The extent to which the client feels trusted and respected by
the people in his or her life.
• The extent and quality of people he or she can confide in.
• Level of experienced loneliness.
• The extent he or she feels abandoned by family or friends.
• The extent to which the client feels a part of his or her family
network.
• The number of friends the client has common interests with.
 Social support..
Formal assessment for social support
• Social support questionare.
• MMPI-2
relative elevation in scale 0(social introversion),
high score on Paranoia and schizophrenia suggest that both the number as well as
quality of social support is low.
High score on hypochondriasis and hysteria may indicate that social support is
may be high but quality of the support may be poor.
• MCMI
High scores on Schizoid, Avoidant, Schizotypal, Paranoid, and Thought Disorder
each might indicate both a low number, as well as low quality, of social support.
As well as elevated scales on these, Dependent, Histrionic, Narcissistic, Passive-
Aggressive (Negativistic), S elf-Defeating, and Border- line may have moderate to
high social supports but these supports are also likely to be quite conflicted.
 Social Support
High social support suggests,
• A shorter duration of therapy.
• Long-term intervention may even be
contraindicated.
• Therapeutic gains are likely to occur relatively
rapidly and be maintained.
• Effective therapeutic relationship maintained,
• In contrast, Directive therapies( cognitive and
behavioral) are likely to be less effective.
 Social support..
Low Social support suggests,
• cognitive behavioral therapy is more effective
than therapies designed to enhance relationships.
• Both longer duration of therapy and the
possibility of medication are indicated.
• It may be possible that a supportive group
intervention would be useful in providing
sufficient support to activate additional more
relationship/interpersonal types of therapies.
 Problem Complexity/Chronicity
• Problem complexity refers to underlying thematic patterns in
the person’s life that may or may not result in a high level of
impairment.
• For eg, a client may be functioning at a rather high level (low
functional impairment) but still be quite troubled by chronic
dissatisfactions in his or her relationships,(alcoholics)
• Whereas problems might be quite directly caused and
reinforced by the environment (e.g., habits, reactions to
stress)
• complex problems are likely to involve personality patterns
that are spread across a wide variety of domains.
 Problem complexity/chronicity
(Beutler and his colleagues, 1995 ) have summarized indicators of
problem complexity based on the following background information
and behavioral observations:
• Behaviors are repeated as themes across unrelated situations.
• Behaviors are ritualized efforts to resolve underlying interpersonal
or dynamic conflicts.
• Interactions seem primarily related to past rather than present
relationships.
• Suffering rather than gratification is the result of the repetitive
behavior.
• Problems are symbolic expressions of underlying unresolved
conflicts.
 Problem complexity/chronicity
In contrast, noncomplex problems are more
often characterized as being:
• Situation-specific.
• Transient.
• Based on inadequate knowledge or skills.
• Having a direct relationship to initiating
events.
• Stemming from chronic habits.
 Problem complexity/chronicity
Assessment Techniques
• MMPI
• MCPI
• TAT
• DSM/ICD classification
• Various Rating Scales
 High Problem Complexity: Treatment
Planning
Complex problems are likely to respond best to broad treatments that are
directed toward resolving long-standing underlying conflicts and changing
patterns of interpersonal relationships. Depending on the problem, specific
techniques might include:
• Two-chair work.
• Group or family therapy exploring patterns of responses.
• Dream work.
• Cathartic discharge.
• Enacting opposite patterns of how the client typically behaves.
• Exploring thematic patterns in behavior and relationships.
• Interpreting the transference.
• Interpreting resistance.
• Free association.
Low Problem Complexity: Treatment Planning.

Noncomplex problems can be effectively treated by targeting specific symptoms, antecedents

that elicit these symptoms, and consequences that maintain them. Depending on the problem,
specific techniques might include:
• Behavioral contracting.
• Social skills training.
• Graded exposure.
• Reinforcement of target behaviors.
• Contingency management.
• Challenging dysfunctional cognitions.
• Practicing alternative cognitions.
• Practicing new self-statements.
• Self-monitoring.
• Paradoxical strategies.
• Counterconditioning.
• Relaxation.
• Deep muscle relaxation.
• Biofeedback.
 Coping Style
Theory, research, and clinical observations indicate that client coping style
varies on a continuum between externalization to internalization.
• Externalizers cope with their problems by impulsively acting out,
externalizing blame, attributing the cause of their difficulties to bad luck
or fate, and actively attempting to avoid their problems.
• They are not psychologically minded and, as a result, do not respond
well to insight.
• In contrast, internalizers are more prone to blame themselves based in
part on the perception that they do not have the sufficient skills or
abilities to overcome their difficulties.
• Accordingly, , internalizers tend to experience more subjective distress
than externalizers. To cope with this distress, they are likely to attempt
to understand their difficulties in more depth.
 Coping style
Clinical indicators for externalization based on history and behavioral
observations include the following (G aw & Beutler, 1995 ):
• Projection.
• Blaming others for their problems.
• Paranoia.
• Low frustration tolerance.
• Extroversion.
• Un-socialized aggression.
• Manipulation of others.
• Distraction through seeking stimulation.
• Somatization with a focus on seeking secondary gains.
 Coping style
In contrast, internalizers are more likely to have the following
characteristics:
• Introversion.
• Intellectualization.
• Constricted or over controlled emotions.
• Denial.
• Repression.
• Reaction formation.
• Minimizing difficulties.
• Social withdrawal.
• Somatization with symptoms related to the autonomic nervous
system.
 Treatment Planning: High Externalizers

• Clients using externalizing coping strategies

have better treatment outcomes when
behavioral, symptom-oriented interventions,
or specific techniques for building skills are
used.
• In contrast, they do relatively poorly with
techniques that attempt to enhance
awareness and create insight.
 Treatment Planning: High Externalizers
Techniques that are likely to be effective with externalizers
include:
• Social skills enhancement.
• Assertiveness training.
• Group interventions. • Anger management.
• Graded exposure. • Reinforcement.
• Contingency contracting. • Behavioral contracting.
• Questioning dysfunctional beliefs. • Practicing alternate
thinking.
• Stimulus control. • Thought stopping.
• Counterconditioning.• Relaxation.
 Treatment Planning: High Internalizers
High internalizers benefit the most from techniques that
emphasize the development of insight and the development
of emotional awareness. Specific techniques might include:
• Cathartic discharge.( emotionally purging)
• Therapist-directed imagery.
• Dream interpretation.• Direct instruction.

• Outside reading (biblio therapy).

• Interpreting transference reactions.
• Interpreting resistance.• Two-chair work.
 Resistance
• Resistance is frequently a defense against
what they perceive as others attempting to
exert or intrude on their sense of control.
• Structured, directive approach can potentially
result in actual increases in client dysfunction.
• Understandably, highly reactant clients are
likely to have a poorer prognosis than those
who are more responsive and receptive.
 Resistance
Clinical indicators that may suggest high resistance
include the following:
• Extreme need to maintain autonomy.
• Opposition to external influences.• Dominance.
• Anxious oppositional style. • History of
interpersonal conflict.
• Poor response to previous treatment.
• Refusal to accept therapist interpretations.
• Incompletion of homework assignments.
 Resistance
In contrast, a low level of resistance is suggested
by the following:
• Seeks direction.• Submissive to authority.
• Open to experience.
• Accepts therapist interpretations.
• Agrees to and follows through with homework
assignments.
•Indicates a tolerance to events beyond his or her
control.
 High Resistance: Treatment Planning
Strong empirical relationships have been found between positive treatment
outcome and the use of nondirective, supportive, self-directed interventions
for resistant clients.
Specific techniques might include:
• Self-monitoring.
• Therapist reflection.
• Support and reassurance.
• Supportive interpretation of transference.
In addition, paradoxical techniques have been found particularly effective
with reactant clients and might include:
• Encouraging relapse.
• Prescribing that no change occur.
• Exaggeration of the symptom.
 Low Resistance: Treatment Planning
Clients who are responsive and compliant are likely to achieve the most gains when
therapists use a more directive, structured approach.
Specific techniques might include:
• Behavior contracting.
• Contingency management.
• Graded exposure.

• Direct hypnotic suggestion.

• Stimulus control.
• Cognitive restructuring.
• Developing alternative client self-statements.
• Directed imagery.
• Advice.
• Thought stopping.
• Therapist interpretation.
 Subjective Distress
• Subjective distress relates to the degree to which the person
subjectively experiences his or her problem and is manifested
primarily in heightened anxiety, confusion, or depression.
• A moderate level of subjective distress is useful because it
motivates a client to become involved with change. It can lead
to cognitive improvements including enhanced memory,
faster performance, and higher intellectual efficiency.
• If a client’s distress becomes too high, it will be disruptive and
result in deteriorated ability to function.
• A client whose level of subjective distress is too low will have
difficulty becoming engaged in actively working to change
behavior. Thus, there is an optimum window of distress that
clinicians should try to achieve
 Subjective distress
Specific indicators of high distress include the following
(Beutler & Beutler,1995):
• Motor agitation.
• High emotional arousal. • Poor concentration.
• Unsteady voice.
• Autonomic symptoms.
• Hyperventilation.
• Hyper vigilance.
• Excited affect.
• Intense feelings.
 Subjective distress..
In contrast, low levels of distress are indicated by:
• Reduced motor activity.
• Poor emotional investment in treatment.
• Low energy level.
• Blunted or constricted affect.
• Slow speech.
• Unmodulated verbalizations.
• Absence of symptoms.
High Subjective Distress: Treatment Planning
If subjective distress is quite high, an immediate goal is to reduce the anxiety
level. This would be particularly urgent if the distress is sufficiently high to
result in a significant disruption in the ability to cope.
If a client’s arousal is primarily expressed through physiological signs,
techniques targeted at this level are warranted and might include the following:
• Progressive muscle relaxation.
• Hypnotically assisted physiological relaxation.
• Guided imagery.
• Biofeedback.
• Aerobic exercise. • Cathartic discharge.
• Graded exposure. • Meditation.
• Reassurance. • Emotional support.
Pharmacotherapy might be useful but should be accompanied by learning new
coping skills so that medication can be discontinued as soon as possible.
Low Subjective Distress: Treatment Planning
Possible techniques are:
• Two-chair work.
• Symptom exaggeration.
• Experiential role plays.
• Confrontation.
• Family therapy initially focusing on the impact of client behavior on family members.
• Overt practice.
• Predicting the recurrence of symptoms.
• Discussing painful memories.
• Accessing affective responses.
• Directed imagery.
• Interpretation of the transference.
• Interpretation of resistance.
 Problem Solving Phase
• Prochaska and DiClemente (1984 , 1992) have described
the following five stages in the change process: pre
contemplation, contemplation, preparation, action, and
maintenance. Each stage has a different set of tasks that
must be accomplished before proceeding to the next
stage.
• The first three stages are processes that occur before any
actual change or actual attempts at concrete change.
• The final two steps in the change process focus on actually
implementing the change and ensuring that it is
maintained.
 Pre contemplation Stage
• This is often, although not necessarily, consistent with in-
voluntary referrals.
• As a result, resistance level may be high and subjective
distress low, such that interventions would need to be
made accordingly (e.g., increase arousal; use
nondirective, supportive techniques; paradoxical
interventions).
• Because these clients might feel ambivalent about
treatment, it is crucial to spend time building rapport and
discussing areas that work or don’t work in their lives.
Contemplation and Preparation Stages.
• As in the previous stage, enhancing the relationship is particularly
important. Providing understanding and awareness is also crucial.
• This should include exploring the interpersonal or behavioral
patterns of the client, reasons for and against changing, and the
different strategies for creating change.
• An inventory of client strengths or resources and weaknesses
might also be useful.
• The first three stages might be most consistent with humanistic
or psychodynamic approaches that stress, insight, exploration,
value clarification, novel experiences, and clarification of
personal goals.
 Action Stage
• A wide variety of specific, concrete techniques might be used.
The selection of these techniques depends in part on areas such
as functional impairment, problem complexity, subjective
distress, and resistance.
• Specific strategies can be implemented that might involve
changes in concrete behavior, patterns of interpersonal
relationships, self-statements, or ways of experiencing the
world.
• Cognitive or behavioral techniques might be most effective at
this point, particularly stimulus control, graded exposure,
cognitive restructuring, role plays, social skills training, or
counterconditioning.
 Maintenance Stage
At this point, the therapist can be come like a coach or a
consultant who advises and encourages the client.
• A crucial consideration is how relapse is most likely to
occur and to develop countermeasures to prevent these
situations from occurring or at least to minimize their
impact over a longer period.
• Specific techniques might include stimulus control, social
contracting, enhancing social support, anger management,
or a behavioral contract requiring the person to take
preventive measures if relapse seems likely.
Psychological Report Writing

Suman Sharma
Trichandra Multiple Campus
 Psychological Report
• Psychological report is the end product of assessment.
• Report represents the clinician’s efforts to integrate
the assessment data into a functional whole so that
the information can help the client to solve problems
and make decisions.
• In Report clinicians do not give merely test results, but
also interact with their data in a way that makes their
conclusions useful in answering the referral question,
making decisions, and helping to solve problems.
 Psychological Report
• It includes methods for elaborating on essential areas
such as the referral question, behavioral observations,
relevant history, impressions, and recommendations.
• Additional organizing the report are to use a letter format,
give only the summary and recommendations, focus on a
specific problem, summarize the results test by test,
• Usually are based on a combination of
– test data,
– interviews, and
– observations.
 General guidelines for Report
1. Length: The typical psychological report is between five
and seven single-spaced pages (Finn, Moes, & Kaplan,
2001).
• However, the length can vary substantially based on the
purpose of the report, context, and expectations of the
referral source. In medical contexts, a two-page report is
not uncommon.
• In contrast, legal contexts often require reports that are
from seven to ten pages because of the greater need for
documentation combined with more extensive referral
questions
 General guidelines for Report
2. Style: The clinician can choose from four general report-writing approaches:
literary, clinical, scientific, and professional.
• The literary approach uses everyday language, is creative, and often dramatic.
• The clinical approach focuses on the pathological dimensions of a person.
• The scientific approach to report writing emphasizes normative comparisons,
tends to be more academic.
• The most important style to use in report writing is what he refers to as a
professional style . This is characterized by short words that are of common
usage and that have precise meanings.
• APA urge writers to use short words, short sentences, and short paragraphs
as well as recommends varying the lengths of sentences and paragraphs. The
result should be a report that combines accuracy, clarity, integration, and
readability.
 General guidelines for Report
3. Presenting Test Interpretations:
• Occasionally, a report is organized by presenting the results of each
test.
• This approach clarifies the source of the data and enables the
reader to understand more clearly how the clinician made his or
her inferences.
• It is also relatively easy for the examiner to organize the results.
• The emphasis on tests can distract the reader and tends to reduce
the client from a person to a series of test numbers.
• The existing literature is unanimous in discouraging a test-by-test
style and, instead, strongly recommends an integrated, case-
focused, problem-solving style.
 General guidelines for Report
4. Topics:
• The three most common topics are likely to be related to
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.
• For example, a highly focused report may elaborate on one
or two significant areas of functioning, whereas a more
general evaluation may discuss seven or eight relevant
topics.
 General guidelines for Report
5. Decide what to include:
• In this context, 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 guideline is to address 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.
 General guidelines for Report
6. Emphasis:
• Careful consideration should be given to the appropriate
emphasis of conclusions, particularly when indicating the
relative intensity of a client’s behavior.
• Improper emphasis can reflect an incorrect interpretation by
the examiner, and this misinterpretation is then passed
down to the reader.
• One technique of emphasizing results is to place the most
relevant sections in bold- face or italics. For example, the
major identified symptoms, most important findings, and the
major recommendations could all be placed in boldface.
 General guidelines for Report
7. Use of Raw data:
• 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 but not
always.
 General guidelines for Report
8. Terminology:
• Technical terminology need precise and economical,
increases the credibility of the writer, and can
communicate concepts that are impossible to convey
through nontechnical language.
• Furthermore, technical terms are often used
inappropriately (e.g., a person who is sensitive and
cautious in interpersonal relationships is labeled paranoid ,
or compulsive is used to describe someone who is merely
careful and effective in dealing with details).
 General guidelines for Report
9. Content Overload:
• A general guideline is to estimate how much
information a reader can realistically be expected
to assimilate.
• If too many details are given, the information
may begin to become poorly defined and vague
and, therefore, lack impact or usefulness.
• The clinician should focus on the areas that are
most relevant to the purpose of the report.
 General guidelines for Report
10. Feedback:
• During the earlier days the assessment results were too complex and
mysterious for the client to understand.
• In contrast, current practices are to provide the client with clear, direct,
and accurate feedback regarding the results of an evaluation.
• One particularly important misconception is that some- times clients
mistakenly fear that the purpose of assessment is to evaluate their
sanity. Practitioners must also select the most essential information to
be conveyed to the client during feedback.
• Feedback should be not only a neutral conveyance of data but also a
clinical intervention. The information should provide the client with
new perspectives and options and should aid in the client’s own
problem solving.
 Format (outline) for a Psychological Report.
Name:
Age (date of birth):
Sex:
Ethnicity:
Date of Report:
Name of Examiner:
Referred by:
I. Referral Question
II. Evaluation Procedures
III. Behavioral Observations
IV. Background Information (relevant history)
V. Test Results
VI. Impressions and Interpretations
VII. Summary and Recommendations
 Format of Psychological Report
Referral question: provides a brief description of a client and
a statement of the general reason for conducting the
evaluation.
• Effective referral question should accurately describes the
clients and referral source problem.
Evaluation procedure: simply list the tests and other
evaluation procedure but does not include actual test result.
• For legal evaluation or other occasions in which precise
details of administration are essential, it is important to
include date as well as duration of test administration.
 Format of Psychological Report
Behavioral Observation: Relevant behavioral observations
during the interview include physical appearance, gesture,
postures, body languages, of the client. This should be
observed for the informatin for the report.
Background Information: the background information
should be include aspect fo the personal history that are
relevant to the problem of the person is confronting and to
the interpretation of the test result.
• It is important to specify where and how the information
come from.
 Format of Psychological Report
Test Results: the usual recommendation of the report is the
test result in which the scores of the individual is included.
• It provides the psychological interpretation and scoring
information of the client in the report.
Impression and Interpretation: All inferences made in this
section should be on an integration of the test data,
behavioral observation, relevant history and additional
available data.
• The conclusion and discussion may relate to areas such as
the client overt behavior, self-concept, family background,
intellectual ability etc..
 Format of Psychological Report
Summary and Recommendation: The purpose of the
summary is to restate the primary findings and
conclusions.
• Summary provides brief bulleted answer of each of
the findings.
• The ultimate practical purpose of the report is
contained in the recommendations because they
suggest what steps can be taken to solve problem.
• Such recommendation should be clear practical and
obtainable.