Nicohwilliam

Textbook:

Neukrug, E.S. and Fawcett, R. C. (2020). The essentials of testing and assessment , 3rd ed. Enhanced, Stamford, CT: Cengage Learning (ISBN: 978-1-285-45424-5)

Chapter 4

Purpose of the Assessment Report

The assessment report is the “deliverable” or “end product” of the assessment process whose purpose is to synthesize an assortment of assessment techniques so that a deeper understanding of the examinee is made and recommended courses of action are offered (Goldfinger & Pomerantz, 2010; Lichtenberger, Mather, Kaufman, & Kaufman, 2004; Spores, 2013). Such courses of action can vary dramatically, based on the reason the individual is being assessed. For instance, some of the many purposes of reports include the following:

To respond to the referral questions being asked;

To provide insight to clients for therapy;

To assist in the case-conceptualization process;

To develop treatment options in counseling (e.g., type of counseling, use of medications, and so on);

To suggest educational services for students with special needs (e.g., for students who are mentally retarded, learning disabled, or gifted);

To offer direction when providing vocational rehabilitation services;

To offer insight about and treatment options for individuals who have incurred a cognitive impairment (e.g., brain injury, senility);

To assist the courts in making difficult decisions (e.g., custody decisions, sanity defenses, and determination of guilt or innocence);

To provide evidence for placement in schools and at jobs; and

To challenge decisions made by institutions and agencies (social security disability, Individual Educational Plans (IEPs) in schools).

Because complex decisions regarding clients’ lives are often based on the assessment report, synthesizing the information gathered and placing it in the report is only accomplished after the examiner can conduct interviews successfully, administer assessment procedures proficiently, and write reports skillfully. One of the first steps in this process is to ensure that any information gathered is directly related to the purpose of the assessment and is of high quality.

Gathering Information for the Report: Garbage in, Garbage Out

Gathering information for the report is as important as writing the report, because your report will reflect the methods you used to obtain your information. If you choose inappropriate instruments or conduct a poor interview (“garbage in”), your report will be filled with error and bias (“garbage out”). To help ensure that the information you are gathering is of high quality, you should always take into account the breadth and depth of your assessment procedures.

The breadth of the assessment has to do with casting a wide enough net to ensure that the examiner has done all that is necessary to adequately assess what he or she is looking for. Breadth should be based on the purpose of the assessment. For instance, if a middle school student came to see a school counselor to examine career possibilities, the counselor would likely conduct an interview focused on vocational interests and offer a broad-based career interest inventory to gather information from the student about his or her general interests. However, if an adult came to a counseling center as a result of depression, anxiety, and general discontent in life, a very broad assessment might be called for to help establish a diagnosis and determine treatment goals. In this case, it would not be unusual to conduct a clinical interview, administer a number of objective and projective personality tests, and perhaps interview others to assess the client’s relationships at home and at work.

The depth of the assessment has to do with ensuring that one is using techniques that reflect the intensity of the issue(s) being examined. As with breadth, depth is also dependent on the purpose for which the client is being assessed. For instance, conducting an in-depth clinical interview and offering a rather complex interest inventory that helps the middle school student determine a career would be too involved—too much depth. On the other hand, offering a personality inventory like the Myers–Briggs for the individual suffering from depression, anxiety, and discontentment in life would not entail enough depth. You could simply miss too much because you have not delved more deeply into this client’s issues.

In establishing the breadth and depth of the interview, it is important that you are able to establish trust and rapport and assure confidentiality within the limits of the purpose the individual is being assessed. The better the interviewer is able to build trust, the more likely the information obtained will be reliable. With these points in mind, examiners need to determine whether a structured, unstructured, or semi-structured interview would be best when assessing the client.

Structured, Unstructured, and Semi-Structured Interviews

Determining the kind of interview to conduct is critical to gathering information successfully because the clinical interview accomplishes a number of tasks not possible through the use of other assessment techniques. For instance, the interview

sets the tone for the types of information that will be covered during the assessment process,

allows the client to become desensitized to information that can be very intimate and personal,

allows the examiner to assess the nonverbal signals of the client while he or she is talking about sensitive information, thus giving the examiner a sense of what might be important to focus on,

allows the examiner to learn firsthand the problem areas of the client and place them in perspective, and

gives the client and examiner the opportunity to study each other’s personality style to assure that they can work together.

Interviewers generally have a choice between three kinds of interviews: structured, unstructured, or semi-structured. With advantages and disadvantages to both, which one to choose is not always easy (Bruchmuller, Margraf, Suppiger, & Schneider, 2011; Goldfinger & Pomerantz, 2010; Lichtenberger et al., 2004). For instance, completed verbally or in response to written items, the structured interview has the examiner ask the examinee to respond to preestablished items. This kind of interview can provide the following benefits:

It offers broad enough areas of content to cover topics a practitioner may otherwise have missed or forgotten to ask (assures breadth of coverage).

It increases the reliability of results by ensuring that all prescribed items will be covered.

It ensures that the examiner will cover all of the items because they are listed in detail and there is an expectation that they all will be covered.

It ensures that items will not be missed due to interviewer or interviewee embarrassment.

On the other hand, the structured interview can have the following drawbacks:

The examiner may miss information due to the fact that items are predetermined and the examiner does not feel free to go off on a tangent or a “hunch.”

Clients may experience the interview as dehumanizing.

Clients, particularly minorities, may misinterpret or be unfamiliar with certain items.

Follow-up by the examiner to alleviate any confusion on the part of the examinee is less likely as compared to other kinds of interviewing.

It does not always allow for depth of information to be covered because the interviewer is more concerned with gathering all the information than going into detail about one potentially sensitive area.

Contrast the structured interview with the unstructured interview, where the examiner does not have a preestablished list of items or questions to which the client can respond. In this case, examinee responses to inquiries will set the direction for follow-up questioning. The unstructured interview offers the following advantages:

It creates an atmosphere that is more conducive to building rapport.

It allows the client to feel as if he or she is directing the interview, thus allowing the client to discuss items that he or she deems important.

It offers the potential for greater depth of information because the clinician can focus on a potentially sensitive area and possibly uncover underlying issues that the client might otherwise avoid revealing.

On the other hand, the unstructured interview may have the following disadvantages:

Because it does not allow for breadth of coverage, the interviewer might miss information because he or she is “caught up” in the client’s story instead of following a prescribed set of questions.

The interviewer may end up spending more time on some items than he or she might like.

Drawing from the advantages of both the structured and unstructured interview, examiners will often conduct a semi-structured interview. This kind of interview uses prescribed items, which allows the examiner to obtain the necessary information within a relatively short amount of time. However, it also gives leeway to the examiner should the client need to “drift” during the interview process. Allowing the client to discuss potentially emotion-filled topics can be cathartic, open up new issues of importance, and be an important tool in the rapport-building process. The skilled examiner can easily flow back and forth between structured and unstructured approaches. If time is not an issue, a semi-structured interview can provide the breadth and depth needed when interviewing clients while still allowing the examiner to focus in on building the relationship (see Box 4.1).

Box

4.1.

Missing Substance Abuse

When I first started doing counseling I tended to use unstructured interview style. I believed it was critical to let the client take the interview where he or she wanted it to go. However, after a number of years of missing alcohol abuse as well as other “hidden” issues, I slowly began to make the switch to a more semi-structured interview style where I would go through a list of predetermined items and also have clients complete a genogram (see Chapter 12). I had learned that clients were often embarrassed about revealing some very important information that sometimes ended up being the focus of treatment. The switch to a semi-structured interview style allowed me to quickly pick up on these issues and immediately address what in the past had been hidden.

Computer-Driven Assessment

Today, computers are frequently used when conducting a structured or semi-structured interview and in the report generation. For instance, many agencies now use electronic health records (EHR) where information about a client is stored on a computer. Interviewers and interviewees can jointly sit down and complete specific items included in the EHR, and this information can be stored with other, related, medical and psychological information (Cimino, 2013). There are also programs for purchase that can assist in the interview process. One such program has the interviewer or the client complete 120 items that requests information about a wide range of personal issues, and the user receives a computer-generated report that describes the client’s presenting problems, legal issues, current living situation, tentative diagnosis, emotional state, treatment recommendations, mental status, health and habits, disposition, and behavioral/physical descriptions (see Schinka, 2012). Computer-assisted questioning is as reliable, or sometimes more reliable, than structured interviews and can provide an accurate diagnosis at a minimal cost (Farmer, McGuffin, & Williams, 2002).

In addition to assisting in the interviewing process, computers can generate test reports, and oftentimes pieces of these reports can be moved directly into the examiner’s written assessment report (Berger, 2006; Michaels, 2006). Final assessment reports generated by computer-driven programs have become so sophisticated that most well-trained clinicians cannot tell them apart from reports written by seasoned professionals. However, whether it is a computer-generated report that resulted from a client interview or a report that includes aspects of computer-generated tests reports, it is still up to the examiner to make sure that the correct questions are being asked of the client, the correct assessment procedures are being used, and that the material used in the development of the examiner’s assessment report is chosen wisely by the examiner.

While the computer may administer these [tests] and even prepare a report, what the test looks like, how it responds, what it achieves and any reports generated, are predetermined by the author, and it is a person who puts it all together to make the interpretation. (Berger, 2006, p. 70)

Choosing an Appropriate Assessment Instrument

Only choose assessment technique to match purpose of testing

After the interview, clinicians can consider the purpose of their assessment as well as the breadth and depth of other needed information. Then clinicians can choose from a broad array of assessment instruments, such as those we will examine later in this book, including assessment of educational ability (Chapter 8), assessment of intellectual and cognitive functioning through intelligence testing and neuropsychological assessment (Chapter 9), career and occupational assessment (Chapter 10), clinical assessment (Chapter 11), and informal assessment (Chapter 12). During this process, it is important that clinicians carefully reflect on which are the most appropriate instruments to use, for it is unethical to assess an individual using instruments that are not related to the purpose of the assessment being undertaken (see American Counseling Association [ACA], 2005; American Psychological Association [APA], 2010) (see Box 4.2).

Counselors are responsible for the appropriate application, scoring, interpretation, and use of assessment instruments relevant to the needs of the client, whether they score and interpret such assessments themselves or use technology or other services. (ACA, Section E.2.b)

and

Psychologists administer, adapt, score, interpret, or use assessment techniques, interviews, tests, or instruments in a manner and for purposes that are appropriate in light of the research on or evidence of the usefulness and proper application of the techniques. (APA, Section 9.02.a)

Box

4.2.

Proper Assessment of a Client

I was once hired to write an assessment report for the expressed purpose of challenging the denial of a client’s social security disability payments despite the fact that she had been diagnosed as having a multiple personality disorder (also discussed in Chapter 11). Aware of her disorder, and having worked hard to integrate her various personalities in therapy, she was, however, quite depressed and at times would dissociate. Because the task at hand was to assess the client’s ability to work rather than to affirm her diagnosis, it was important to choose instruments that would only address the assessment question: Could this client effectively hold down employment?

Writing the Report

After you have conducted a thorough assessment of your client, you will be ready to write your report. Reports are scrutinized today more than ever before because they are the mechanism used by the interviewer to communicate his or her assessment to stakeholders and are often used by funding agencies and supervisors when evaluating a clinician’s work. In addition, as a result of laws passed over the years, such as the Family Educational Rights and Privacy Act (FERPA), the Freedom of Information Act, and the Health Insurance Portability and Accountability Act (HIPAA) (see Chapter 2), clients will generally have access to their records if they choose to review them. Keeping all of this in mind, Box 4.3 offers a summary of a number suggestions concerning how to write a report (Lichtenberger et al, 2004; Wiener & Costaris, 2012).

Box

4.3.

Fifteen Suggestions for Writing Reports

Omit passive verbs.

Be nonjudgmental.

Reduce the use of jargon.

Do not use a patronizing tone.

Increase the use of subheadings.

Reduce the use of and define acronyms.

Minimize the number of difficult words.

Try to use shorter rather than longer words.

Make sure paragraphs are concise and flow well.

Point out strengths and weaknesses of your client.

Don’t try to dazzle the reader of your report with your brilliance.

When possible, describe behaviors that are representative of client issues.

Only label when it is necessary and valuable to do so for the client’s well-being.

Write the report so a non–mental-health professional can understand it (e.g., a teacher).

Don’t be afraid to take a stand if you feel strongly that the information warrants it (e.g., the information leads you to believe a client is in danger of harming self).

© Cengage

Although many clinicians these days are asked to write involved reports, the actual format of the report tends to vary from setting to setting. For example, a large mental health clinic may specify a preferred or required format for its therapists. Similarly, a social worker in private practice may be driven to a particular format by insurance provider requirements, while a school counselor may have to use an established format required by the system-wide school counseling director.

Although report formats vary, they will often include some or all of the following sections:

(1)demographic information,

(2)presenting problem or reason for referral,

(3)family background,

(4)significant medical/counseling history,

(5)substance use and abuse,

(6)educational and vocational history,

(7)other pertinent information,

(8)mental status,

(9)assessment results,

(10)diagnosis,

(11)summary and conclusions, and

(12)recommendations.

Let’s take a look at each of these areas in more detail.

Demographic Information

In this section, we find basic information about the client, including such items as the client’s name, address, phone number, e-mail address, date of birth, age, sex, ethnicity, and date of interview. Also, it is in this section that the name of the interviewer is placed. Often, this information is included at the top of the report. The following is an example of the demographic information gathered from a fictitious client, Mr. Unclear.

Name: Eduardo (Ed) Unclear DOB: 1/8/1971

Address: 223 Confused Lane Coconut Creek, Florida Age: 48

  Sex: Male

Phone: 954-969-5555 Ethnicity: Hispanic (Cuban-American)

E-mail: [email protected]  

Name of Interviewer: Sigmund Freud, MD Date of Interview: 10/22/2019

Presenting Problem or Reason for Referral

In this section, the person who referred the client is generally noted (e.g., self-referred, physician, counselor, etc.) and an explanation is given as to why the individual has come for counseling and/or why the examiner has been asked to do the assessment. For instance, here it might be explained that a social worker has been asked to do a court assessment of a child for a custody hearing; a school psychologist has been asked to assess a child who has been exhibiting severe behavioral problems at school, for a possible diagnosis of emotional disturbance; or a licensed clinician in private practice might suggest to a client an assessment to help sort out a diagnosis and to set treatment goals. Continuing with our example of Mr. Unclear, we might include the following information:

Eduardo Unclear is a 48-year-old Hispanic male of average stature and build. He was self-referred to counseling due to stress and inability to sleep. The client reported feeling anxious for approximately two years and intermittently depressed for approximately seven or eight years. He states that he feels discontent with his marriage and confused about his future. Mr. Unclear appeared appropriately dressed and was attentive during the session. An assessment was conducted to determine differential diagnosis and the course of treatment.

Family Background

The family background section of the report is an opportunity to give the reader an understanding of possible factors concerning the client’s upbringing that may be related to his or her presenting problem. Trivial bits of information should be left out of this section, and opinions regarding this information should be saved for the summary and conclusions section of the report.

In this section, it is often useful to mention where the individual grew up, sexes and ages of siblings, whether the client came from an intact family, who were the major caretakers, and significant others who may have had an impact on the client’s life. The examiner may also want to relay important stories from childhood that have affected how the client defines himself or herself. For adults, one should also include such items as marital status, marital or relationship issues, ages and sexes of any children, and significant others. Using our example, we might include the following information:

Mr. Unclear was raised in Miami, Florida. When he was five years old, his parents fled from Cuba on a fishing boat with him and his two brothers, José, who is two years older, and Juan, who is two years younger. Mr. Unclear comes from an intact family. He reports that his father was a bookkeeper and his mother was a stay-at-home mom. He states that his parents were “loving but strict” and notes that his father was “in charge” of the family and would often “take a belt to me.” He reports that he and his brothers were always close and that both brothers currently live within 1 mile of his home. He states that his younger brother is married and has two children. He describes his other brother as single and “gay but not out.” He and his brothers went to Catholic school, and he states that he was a good student and had the “normal” number of friends. His father died approximately four years ago of a “heart disorder.” His mother currently resides in a retirement community in North Miami Beach. Mr. Unclear notes that he met his wife Carla in college when he was 20. They married when he was 21 and quickly had two children, Carlita and Carmen, who are now 27 and 26. Both daughters are college-educated, have professional jobs, and are married. Carlita has two children aged 3 and 4, while Carmen has one child aged 5. He notes that both daughters and their families live close to him, and he maintains positive relationships with them. He states that although his marriage was “good” for the first 20 years, in recent years he has found himself feeling unloved and depressed. He wonders if he should remain in the marriage.

Significant Medical/Counseling History

This section of the report delineates any significant medical history, especially any physical conditions that may be affecting the client’s psychological state. Any prescribed medication, with dosage, should be noted. In addition, any history of counseling should be noted in this section. Mr. Unclear’s medical and counseling history is summarized below:

Mr. Unclear reports that approximately four years ago he was in a serious car accident that subsequently left him with chronic back pain. Although he is prescribed medication for the pain (Flexeril, 5mg), he prefers not to take it, stating that he mostly tries to “live without drugs.” He notes that he often feels fatigued and has trouble sleeping, usually sleeping around four hours a night. He reports that a recent medical exam revealed no apparent medical reason for his fatigue and sleep difficulties. He notes that in the past two years he has had obsessive worry related to fears of dying of a heart attack. He describes his eating habits as “normal” and reports no other significant medical history. Mr. Unclear explained that after the birth of his second child, his wife required surgery to repair vaginal tears. He states that since that time she has experienced pain during intercourse and their level of intimacy has significantly decreased. He notes that he and his wife attended couples counseling for about two months approximately 15 years ago. He feels that counseling did not help, and he reports that it “particularly did nothing to help our sex life.”

Substance Use and Abuse

This section reports the use and abuse of any legal or illegal substances that may be addictive or potentially harmful to the client. Thus, the interviewer should note the use or abuse of food, cigarettes, alcohol, prescription medication, and illegal drugs. In reference to Mr. Unclear, we include the following information:

Mr. Unclear states that he does not smoke cigarettes but does occasionally smoke cigars, adding that he “will never smoke a Cuban cigar.” He describes himself as a moderate alcohol user, stating that he has a “couple of beers a day” but rarely drinks “hard liquor.” He reports taking prescription medication intermittently for chronic back pain, and he denies the use of illegal substances.

Educational and Vocational History

This section describes the client’s educational background and delineates his or her job path and career focus. For Mr. Unclear, we include the following information:

Mr. Unclear attended Catholic school in Miami, Florida. He reports that he excelled in math but had difficulty with reading and spelling. After high school, he attended college at the University of Miami, where he majored in business administration. After graduating with his bachelor’s degree, he obtained a job as an accountant at a major tobacco import company, where he worked for 17 years. During that time, he began to work on his master’s in business administration but stated he never finished his degree because it was “boring.” Approximately eight years ago he changed jobs to “make more money.” He obtained employment as an accountant at a local new car company. Mr. Unclear states that as an accountant, his “books were always perfect,” although he went on to note that he was embarrassed by his inability to prepare a well-written report. He expresses dissatisfaction with his career path and wants to “do something more meaningful with his life.” He adds, however, that “I am probably too old to change careers now.”

Other Pertinent Information

This “catch-all” category addresses any significant information that has not been noted elsewhere. Issues that might be addressed in this section could be related to sexual orientation, changes in sexual desires, sexual dysfunction; current or past legal problems that may be affecting functioning; and financial problems the client may be having. For Mr. Unclear we include the following information:

Mr. Unclear states that he is unhappy with his sex life and reports limited intimacy with his wife. He denies an extramarital affair but states “I would have one if I met the right person.” He notes that he is “just making it” financially and that it was difficult to support his two children through college. He denies any problems with the law.

Mental Status

A mental status exam is an assessment of the client’s appearance and behavior, emotional state, thought components, and cognitive functioning. This assessment is used to assist the interviewer in making a diagnosis and in treatment planning (Akiskal, 2008; Polanski & Hinkle, 2000; Sommers-Flanagan & Sommers-Flanagan, 2012). A short synopsis of each of the four areas of the mental status exam follows and definitions of common words used in mental status exam can be found in Table 4.1.

Table

4.1.

Common Terms and Definitions or Descriptions Used in the Mental Status Exam

Category Term Definition or Description

Appearance and Behavior Appearance Appropriate or baseline, eccentric or odd, abnormal movement or gait, good or poor grooming, or hygiene

  Eye contact Good or poor

  Speech Within normal limits, loud, soft, pressured, hesitant

Emotional State—Affect Appropriate or inappropriate Appropriate or inappropriate to mood (e.g., laughing while talking of recent death)

  Full and reactive Full range of emotions correctly associated with the conversation

  Labile Uncontrollable crying or laughing

  Blunted Reduced expression of emotional intensity

  Flat No or very little expression of emotional intensity

Emotional State—Mood Euthymic Normal mood

  Depressed Sad, dysphoric, discontent

  Euphoric Extreme happiness or joy

  Anxious Worried

  Anhedonic Unable to derive pleasure from previously enjoyable activities

  Angry/hostile Annoyed, irritated, irate, etc.

  Alexithymic Unable to describe mood

Thought Components—Content Hallucinations False perception of reality: may be auditory, visual, tactile (touch), olfactory (smell), or taste

  Ideas of reference Misinterpreting casual and external events as being related to self (e.g., newspaper headlines, TV stories, or song lyrics are about the client)

  Delusions False belief (e.g., “satellites are tracking me”); may be grandiose, persecutory (to be harmed), somatic (physical symptom with no medical condition), erotic

  Derealization External world seems unreal (e.g., watching it like a movie)

  Depersonlization Feeling detached from self often with no control (e.g., “I feel like I’m living a dream”)

  Suicidality and homicidality Ranges from none, ideation, plan, means, preparation, rehearsal, and intent

Thought Components—Process Logical and organized Normal state where one’s thoughts are rational and structured

  Poverty Lack of verbal content or brief responses

  Blocking Difficulty or unable to complete statements

  Clang Emphasis on using words that rhyme together rather than on meaning

  Echolalia “Echoing” clients own speech or your speech; repeating

  Flight of ideas Rapid thoughts almost incoherent

  Perseveration Thoughts keep returning to the same idea

  Circumstantial Explanations are long and often irrelevant but eventually get to the point

  Tangential Responses never get to the point of the question

  Loose Thoughts have little or no association to the conversation or to each other

  Redirectable Responses may get off track, but you can direct them back to the topic

Cognition Orientation Knows who they are, where they are, and date

  Memory Ability to remember events from recent, immediate, and long-term

  Insight Ability to recognize his or her mental illness; good, limited, or none

  Judgment Ability to make sound decisions; good, fair, or poor

© Cengage

Appearance and Behavior

This part of the mental status exam reports the client’s observable appearance and behaviors during the clinical interview. Thus, such items as manner of dress, hygiene, body posture, tics, significant nonverbal behaviors (eye contact or the lack thereof, wringing of hands, swaying), and manner of speech (e.g., stuttering, tone) are often reported.

Emotional State

When assessing emotional state, the examiner describes the client’s affect and mood. The affect is the client’s current, prevailing feeling state (e.g., happy, sad, joyful, angry, depressed, etc.) and may also be reported as constricted or full, appropriate or inappropriate to content, labile, flat, blunted, exaggerated, and so forth. The client’s mood, on the other hand, represents the long-term, underlying emotional well-being of the client and is usually assessed through client self-report. Thus, a client may seem anxious and sad during the session (affect) and report that his or her mood has been depressed.

Thought Components

The manner in which a client thinks can reveal much about how he or she comes to understand and make meaning of the world. Thought components are generally broken down into the content and the process of thinking. Clinicians will often make statements about thought content by addressing whether the client has delusions, distortions of body image, hallucinations, obsessions, suicidal or homicidal ideation (see Box 4.4), and so forth. The kinds of thought processes often identified include circumstantiality, coherence, flight of ideas, logical thinking, intact as opposed to loose associations, organization, and tangentiality.

Box

4.4.

Assessment of Lethality

It is important to assess for the risk of suicide or homicide. Both of these can be thought of occurring along a continuum ranging from ideation (thinking about it), developing a plan, means to carry out the plan, preparation stage, rehearsing the plan, and finally acting it out (Commonwealth of Virginia Knowledge Center [COVKC], 2010). Hence, determining where the client might be on the continuum is helpful in determining how much risk he or she may have for harming self or others.

© Cengage

It can also be important to evaluate both risk and protective factors (COVKC). Risk factors can include having a history of psychiatric treatment, non-medication compliance, substance abuse, prior attempts, recent losses, or other significant problems. Protective factors to consider are strong family or social supports, adherence to medications, stable employment, children under the age of 18, religious beliefs, or fear of killing one’s. Finally, determine if this individual will contract for safety in verbal or written format.

© Cengage

Cognition

Cognition includes a statement as to whether the client is oriented to time, place, and person (knows what time it is, where he or she is, and who he or she is); an assessment of the client’s short- and long-term memory; an evaluation of the client’s knowledge base and intellectual functioning; and a statement about the client’s level of insight and ability to make judgments.

Although much more can be said about each of these four areas, generally, when incorporating a mental status into a report, all four areas are collapsed into a one- or two-paragraph statement about the client’s presentation. Usually, a statement about the client’s demeanor, orientation, affect, intellectual functioning, judgment, insight, and suicidal or homicidal ideation are included. Other areas are generally reported only if they are deemed significant (see Exercise 4.1). A description of Mr. Unclear’s mental status follows:

Eduardo Unclear appeared for his appointment casually but neatly dressed and groomed. He was able to maintain appropriate eye contact and was oriented to time, place, and person. Visual acuity appeared to be within normal limits; audition and speech were unremarkable. During the interview he appeared anxious, often rubbing his hands together. Mr. Unclear was cooperative with the examiner and demonstrated satisfactory levels of motivation, interest, and energy. He is currently prescribed pain medication, which he only takes occasionally for chronic back pain. He stated that he often feels fatigued because he usually sleeps approximately four hours a night. He described himself as feeling intermittently depressed over the past seven or eight years. He appeared to be of above average intelligence and his memory was intact. His judgment seemed fair and his insight fair to good. He stated that he has some suicidal ideation but denies he has a plan or would kill himself, noting that it is “against my religion.” He denied homicidal ideation.

Exercise

4.1.

Writing the Mental Status Report

Your instructor may ask a student to role-play a client being interviewed. (It might also help if the student chose to reflect a diagnosis in the DSM-5.) After the role-play is complete, all other students in class should write a mental-status report. Share your reports with the instructor, and come up with one mental status report for the class. Compare your own report to the final version produced in class. This type of role-play can be repeated in small groups if you would like to gain further practice writing mental-status exams.

Assessment Results

It is often helpful to begin this section with a simple list of the assessment procedures that were used. Next, the results of the assessment procedures are generally presented. When presenting test results, it is important to not just give out raw scores. Instead, offering converted or standardized test scores that the reader will understand is usually more helpful (discussed in Chapter 7). It should be remembered that the client, parents, or some other nonprofessional may read these results, so it is important to state the results in language that is unbiased and understandable to the reader. An example might be, “Johnny scored a 300 on his SAT, which is 2 standard deviations below the mean and places him at about the 2nd percentile as compared to his peers in the 12th grade.”

The results of the assessment should be concise, yet cover all items that are clearly relevant to the presenting concerns or that stand out as a result of the assessment. Results should be presented objectively, and interpretations should be kept to a minimum, if used at all. In the summary and conclusions section, the examiner will have the opportunity to hypothesize about what is happening with the client. The following is an example of the assessment section of the report for Mr. Unclear. (We will discuss these specific tests in Section III of this book. For now pay attention to the formatting as these examples will be more meaningful near the end of the semester.)

Mr. Unclear was administered a battery of objective and projective personality tests, including the Beck Depression Inventory-II (the BDI-II), the Minnesota Multiphasic Personality Inventory-II (the MMPI-II), the Rorschach Inkblot Test (the Rorschach), the Thematic Apperception Test (TAT), the Kinetic Family Drawing (KFD), the Sentence Completion Test, the Strong Interest Inventory (the Strong), and the Wide Range Achievement Test-5 (the WRAT). Through self-report of the past two weeks, Mr. Unclear’s score on the BDI-II indicates that he has moderate depression (raw score = 24). His responses showed some evidence of possible suicidal ideation. The BDI-II is not only able to diagnose depression due to its consistency with the DSM diagnostic criteria, but it can also determine the severity of depressive symptoms. The MMPI-II supports this finding of moderate to severe depression and also indicates some mild anxiety. The MMPI-II, which reveals dissatisfaction with one’s life, demonstrates that Mr. Unclear is generally “discontent with the world” and feels a lack of intimacy in his life. It suggests assessing for possible suicidal ideation. The Rorschach and the TAT are projective assessment tools used to evaluate psychological functioning. Both demonstrated that Mr. Unclear is grounded in reality and open to testing, as evidenced by his willingness to readily respond to initial inkblots and TAT cards, his ability to complete stories in the TAT, and the fact that many of his responses were “common” responses. Feelings of depression and hopelessness are evident in a number of responses, such as not readily seeing color in many of the responses to the “color cards” of the Rorschach and making a number of pessimistic stories that generally had depressive endings to them on the TAT. When he was administered the KFD, a projective test that asks the client to draw his family all doing something together, Mr. Unclear placed his father as an angel in the sky and included his wife, mother, children, and grandchildren. His mother was standing next to him while his wife was off to the side with the grandchildren. He also placed himself in a chair and when describing the picture stated, “I’m sitting because my back hurts.” The picture showed the client and his family at his mother’s house having a Sunday dinner while it rained outside. Rain could be indicative of depressive feelings. A cross was prominent in the background and was larger than most of the people in the picture, which is likely an indication of strong religious beliefs and could also indicate a need to be taken care of. On the Sentence Completion Test Mr. Unclear made a number of references to missing his father, such as “The thing I think most about is missing my father.” He also referenced continual back pain. Finally, he noted discontent with his marriage, including the statement, “Sex is nonexistent.” On the Strong, a self-report assessment tool used to evaluate both personality and career interest, Mr. Unclear’s two highest personality codes were Conventional and Enterprising, respectively. All the other codes were significantly lower. Individuals of the Conventional type are stable, controlled, conservative, sociable, and like to follow instructions. Enterprising individuals are self-confident, adventurous, and sociable. They have good persuasive skills, and prefer positions of leadership. Careers in business and industry where persuasive skills are important are good choices for these individuals. On the WRAT-5, Mr. Unclear scored at the 86th percentile in math, 75th percentile in reading, 64th percentile in sentence comprehension, and 42nd percentile in spelling. His reading composite score was at the 69th percentile. These results could indicate a possible learning disorder in spelling, although cross-cultural considerations should be taken into account due to the fact that Mr. Unclear was an immigrant to this country at a young age.

Diagnosis

This is the section where a clinical diagnosis is generally made using the criteria from the Diagnostic and Statistical Manual for Mental Disorder, fifth edition (DSM-5; APA, 2013) (see Chapter 3). The diagnosis is an outgrowth of the whole assessment process and is based on the integration of all of the knowledge gained (Seligman, 2004). As mentioned in Chapter 3, the older DSM-IV-TR (APA, 2000) offered separate axes that included medical conditions, psychosocial and environmental conditions, and global assessment of functioning. Although the current DSM uses a single mental disorder axis, you may want to include V (or Z) codes, which reflect psychosocial and environmental conditions. In addition, you may want to provide medical diagnoses from the International Classification of Disease, ninth revision (ICD-9) or ICD-10, dependent on the audience of the report. For example, if this report is for a court or some portion of the medical community, it might be useful to include the ICD diagnosis and codes. However, if the report is going to a mental health professional or directly to a client, reporting medical conditions in layman’s terms may be more helpful. There is a fine balance between making the report accurate and professional using correct terminology while also keeping it readable and understandable for the end user. Below we list Mr. Unclear’s diagnosis. Note that the first diagnostic number is the ICD-9 code and ICD-10 is followed in parenthesis.

296.22 (F32.1) Major depression, single episode, moderate

309.28 (F43.23) Rule out: Adjustment disorder with mixed Anxiety and depressed mood

V62.29 (Z56.9) Problems related to employment

V61.10 (Z63.0) Relationship distress with spouse

722.0 Displacement cervical intervertebral disc (Chronic Back Pain)

In this example, the diagnosis describes a client who is experiencing symptoms of a moderate episode of major depression, including ongoing feelings of depression, fatigue, and sleep problems; may be having difficulty adjusting to a new life circumstance; has problems related to work and his relationship with his wife, and has difficulties with chronic back pain.

Summary and Conclusions

Report summary should have no new information

This section is the examiner’s chance to pull together all of the information that has been gathered. Often, this is the only section of the report that is read by others, so it is important that it is accurate and does not leave out any main points. However, it should not be excessively long. Making it accurate, succinct, and relevant is the key to writing a good summary. One major error in writing summaries, we have found, is adding information that has not been included elsewhere. The summary should have no new information. Although inferences can be made in this section, they must be logical, sound, defendable, and based on facts that are mentioned in your report. We also generally recommend writing a paragraph or two about the strengths of the individual. All too often, we have found that this is left out of reports. The following might be a summary and conclusions section based on the information we have gathered from Mr. Unclear:

Mr. Unclear is a 48-year-old married male who was self-referred due to feelings of depression, anxiety, and discontent with his job and his marriage. Mr. Unclear fled from Cuba to Miami, Florida with his parents and two siblings when he was 5 years old. He describes his family as close, and he continues to live near his children, siblings, and mother. His father died approximately four years ago. He married while in college. He and his wife subsequently raised two girls who are now in their mid-20s, married, and have their own children. Mr. Unclear finished college with a degree in business and has been working as an accountant for the past 25 years. He reports feeling dissatisfied in his career and states that he wants to “do something more meaningful with his life.” He also reports marital discord, which he attributes partly to medical problems his wife had after the birth of their second child. These problems, he states, resulted in diminishing sexual relations with his wife. Mr. Unclear was oriented during the session but appeared anxious and talked about feelings of depression. He noted that he often feels fatigued, has difficulty sleeping, and has fleeting thoughts of suicide, which he states he would not act upon. Recently, he has had obsessive worries about having a heart attack, although there is no medical reason to support his concerns. Chronic back pain due to a car accident a few years ago seems to exacerbate his current feelings of depression. Throughout testing the consistent themes of depression, isolation, and hopelessness emerged. High scores on the BDI-II and the MMPI-II depression scale evidenced this. This was additionally indicated by specific responses to the Rorschach, TAT cards, the KFD, and the sentence completion. Dissatisfaction with his marriage, sadness about the loss of his father, and chronic pain were also major themes that arose during testing. Testing also revealed a person whose career is a good match for his personality. However, he might be more challenged if he entered a position requiring additional responsibilities and leadership skills. Such a change may be disadvantageous if Mr. Unclear does not receive treatment for his depression. Finally, testing also shows a possible learning disability in spelling, although cross-cultural issues may have affected his score. On a positive note, testing and the clinical interview showed a man who was neatly dressed and open to collaborating with the examiner. He has worked hard in his life and is proud of the family he has raised. He was grounded in reality, willing to engage interpersonally, and showed fair to good judgment and insight. He seems to be aware of many of his most pressing concerns and showed some willingness to address them.

Recommendations

This last section of the report should be based on all of the information gathered. It should make logical sense to the reader. Although some prefer writing this section in paragraph form, we prefer listing each recommendation, as we believe this format is clearer to the reader. The signature of the examiner generally follows this last section. The following might be some recommendations for Mr. Unclear:

Counseling, 1 hour a week for depression, possible anxiety, marital discord, and career dissatisfaction.

Possible marital counseling with particular focus on sexual relations of the couple.

Referral to a physician/psychiatrist for medication, possibly antidepressants.

Possible further assessment for learning problems.

Long-term consideration of a career move following alleviation of depressive feelings and addressing possible learning problems.

Possible orthopedic reevaluation of back problems.

 

Signature of the Examiner

Summarizing the Writing of an Assessment Report

As you can see, a great deal of information is gathered from the client, and much of it is included in the report. Although one could probably write a short novel about a client after gathering information from an in-depth interview, generally the skilled examiner will keep the report between two and five pages, single-spaced. Box 4.5 summarizes the major points that should be gathered in an assessment report, and in Appendix D you can see Mr. Unclear’s report in its entirety.

Box

4.5.

Summary of Assessment Report

The following categories are generally assessed in a report:

Demographic Information

Name:

DOB.:

Address:

Age:

Phone:

Sex:

Ethnicity:

E-mail address:

Date of interview:

Name of interviewer:

Presenting Problem or Reason for Referral

Who referred the client to the agency?

What is the main reason the client contacted the agency?

Reason for assessment

Family Background

Significant factors from family of origin

Significant factors from current family

Some specific issues that may be mentioned: where the individual grew up, sexes and ages of siblings, whether the client came from an intact family, who were the major caretakers, important stories from childhood, sexes and ages of current children, significant others, and marital concerns

Significant Medical/Counseling History

Significant medical history, particularly anything related to the client’s assessment (e.g., psychiatric hospitalization, heart disease leading to depression)

Types and dates of previous counseling

Substance Use and Abuse

Use or abuse of food, cigarettes, alcohol, prescription medication, or illegal drugs

Counseling related to use and abuse

Educational and Vocational History

Educational history (e.g., level of education and possibly names of institutions)

Vocational history and career path (names and types of jobs)

Satisfaction with educational level and career path

Significant leisure activities

Other Pertinent Information

Legal concerns and history of problems with the law

Issues related to sexuality (e.g., sexual orientation, sexual dysfunction)

Financial problems

Other concerns

The Mental Status Exam

Appearance and behavior (e.g., dress, hygiene, posture, tics, nonverbals, and manner of speech)

Emotional state (e.g., affect and mood)

Thought components (e.g., content and process: delusions, distortions of body image, hallucinations, obsessions, suicidal or homicidal ideation, circumstantiality, coherence, flight of ideas, logical thinking, intact as opposed to loose associations, organization, and tangentiality)

Cognitive functioning (e.g., orientation to time, place, and person; short- and long-term memory; knowledge base and intellectual functioning; insight and judgment)

Assessment Results

List assessment and test instruments used

Summarize results

Avoid raw scores and state results in unbiased manner

Consider using standardized test scores and percentiles

Diagnosis

DSM-5 diagnoses

Include V and/or Z codes if appropriate

Include other diagnoses such as medical, rehabilitation, or other salient factors

Summary and Conclusions

Integration of all previous information

Accurate, succinct, and relevant

No new information

Inferences that are logical, sound, defendable, and based on facts in the report

At least one paragraph that speaks to the client’s strengths

Recommendations

Based on all the information gathered

Should make logical sense to reader

In paragraph form or as a listing

Usually followed by signature of examiner