Chapter 12

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Chapter12

The Assessment Report Process: Interviewing the Client and Writing

the Report

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Purpose of the Assessment Report

The assessment report is the “deliverable” or “end product” of the assessment process.

Reports have been used:1. To respond to the referral questions being

asked.2. To provide insight to clients for therapy.3. To assist in the case-conceptualization process.4. To develop treatment options in counseling

(e.g., type of counseling, use of medications, etc.)

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

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Purpose of the Assessment Report (Cont’d)

Reports have been used (Cont’d):6. To offer direction when providing vocational

rehabilitation services.7. To offer insight about and treatment options

for individuals who have incurred a cognitive impairment (e.g., brain injury, senility).

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

9. To providence evidence for placement into schools and jobs.

10. To challenge decisions made by institutions and agencies (social security disability, school IEPs).

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Gathering Information for the Report: Garbage In, Garbage Out

How you gather information for the report is as important as writing the report.

In gathering information take into account the breadth and depth of your assessment procedures. Breadth: Based on purpose of the report and it’s

when you cast a wide enough net. Depth: Assuring that one is using techniques

that reflect the intensity of the issue(s) being examined

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Structured, Unstructured, and Semi-Structured Interviews

Interview accomplishes the following: sets the tone allows client to become desensitized very

intimate and personal info allows examiner to assess nonverbal to

determine what might be important to focus upon

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

gives client and examiner the opportunity to see if they can work together

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Benefits of Structured Interview

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

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Drawbacks of Structured Interview

Examiner may miss information because items are predetermined and examiner does not feel free as free to go off on a tangent or a “hunch”Clients may experience the interview as dehumanizingClients, particularly minorities, may misinterpret or be unfamiliar with certain itemsFollow-up by the examiner to alleviate any confusion on the part of the examinee is less likely as compared to other kinds of interviewingDoes not always allow for depth because interviewer is more concerned with gathering info than detail about a particular sensitive area

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Benefits of Unstructured Interview

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 upon a potentially sensitive area and possibly uncover underlying issues that the client might otherwise avoid revealing

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Drawbacks of Unstructured Interview

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

Semi-structured interview: Has advantages (and drawbacks) of both the structured and unstructured

See Box 12.1, p. 264

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Computer-Driven Assessment

Computer-driven assessment reports have become very sophisticated and as reliable as structured interviews

Such programs ask clients to divulge detailed info (e.g.,): presenting problems, legal issues, current living situation, tentative diagnoses, emotional state, treatment recommendations, mental status, health and habits, disposition, behavioral/physical descriptions

Can “cut and paste” some of the computer-generated report into your assessment report

However, examiner is still responsible for the “end product” of the report

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Choosing an Appropriate Assessment Instrument

Based on purpose of assessment and breadth and depth needed to do adequate assessment

After considering the above, choose from all the kinds of assessment instruments such as what is been discussed in this text

Important to only use instruments that are appropriate for the purpose of your assessment—otherwise you are practicing unethically

See Box 12.2, p. 265

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Choosing an Appropriate Assessment Instrument

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 technologyor other services. (ACA, Section E.2.b)

andPsychologists 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 9.01.a)

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Writing the Report

After you have conducted a thorough assessment of your client, you will be ready to write your report.Clients will generally have access to their records, due to laws past over the years (see Chapter 2): Family Educational Rights and Privacy Act (FERPA) Freedom of Information Act Health Insurance Portability and Accountability Act

(HIPAA)

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Writing The Report: Points to Consider

Fifteen suggests for writing the report (from Box, 12.3, p. 266)1. Omit passive verbs2. Be nonjudgmental3. Reduce the use of jargon4. Do not use a patronizing tone5. Increase the use of subheadings6. Reduce the use of and define acronyms7. Minimize the number of difficult words8. Try to use shorter rather than longer words9. Make sure paragraphs are concise and flow well10.Point out strengths and weaknesses of your client

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Writing The Report: Points to Consider

Fifteen suggests for writing the report (from Box, 12.3, p. 266)

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

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

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

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

15. 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)

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Writing the Report: Format

Although formats can vary, often they will include: demographic information, presenting problem or reason for the report, family background, significant medical/counseling history, substance use and abuse, vocational and educational history, other pertinent background information, mental status, assessment or test results, diagnosis, summary and conclusions, and recommendations.

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Writing the Report: Format (Cont’d)(Follow Along with Case Report Example in Appendix F)

Demographic Info: Basic information about the client, including client’s name,

address, phone number, e-mail address, date of birth, age, sex, ethnicity, date of interview, name of interviewer.

Presenting Problem or Reason for Referral Person who referred the client is generally noted (e.g., self-

referred, physician, counselor). Explanation as to why the individual has come for

counseling and/or why the examiner has been asked to do the assessment.

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Writing the Report: Format (Cont’d) (Follow Along with Case Report Example in Appendix F)

Family Background Factors re: client’s upbringing related to presenting problem. Often useful to mention:

where the individual grew up sex and ages of siblings whether the client came from an intact family who were the major caretakers significant others who may have impacted on client’s life important stories from childhood that have affected how

the client defines himself or herself. for adults include: marital status, marital issues, age and

sex of children, and significant others.

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Writing the Report: Format (Cont’d) Follow Along with Case Report Example In Appendix F)

Significant Medical/Counseling History

Delineate significant medical history, especially any that affected the client’s psychological state.

Note history of any counseling.

Substance Use and Abuse

Report use and abuse of any legal or illegal substances that may be addictive or potentially harmful.

E.g., the use or abuse of food, cigarettes, alcohol, prescription medication, and illegal drugs.

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Writing the Report: Format (Cont’d) (Follow Along with Case Report Example in Appendix F)

Educational and Vocational History

Describe client’s educational background and delineate his or her job path and career focus.

Other Pertinent Information

Add other information such as issues related to legal concerns, sexuality, financial problems, etc.

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Writing the Report: Format (Cont’d) (Follow Along with Case Report Example in Appendix F)

The Mental Status Exam Often a one or two paragraph statement which is an

assessment of client’s: 1. appearance and behavior2. emotional state3. thought components4. cognitive functioning

1. Appearance and behavior: Client’s observable appearance and behaviors during the interview, including: dress, hygiene, body posture, tics, significant nonverbals (eye contact, wringing of hands, swaying), and manner of speech (e.g., stuttering, tone).

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Writing the Report: Format (Cont’d) (Follow Along with Case Report Example in Appendix F)

Mental Status Continued:

2. Emotional state: Affect and mood are examined. Affect: current feeling state (e.g., happy, sad, joyful, angry,

depressed, etc.). May also be reported as constricted or full, appropriate or inappropriate to content, labile, flat, blunted, exaggerated, and more.

Mood: Long-term, underlying emotional well-being of client. Client may seem anxious and sad during session (affect) and report that his or her mood has been depressed.

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Writing the Report: Format (Cont’d) (Follow Along with Case Report Example in Appendix F)

Mental Status Continued (Do Exercise 12.1, p. 271):

3. Thought Components: Often addresses whether client has delusions, distortions of body image, hallucinations, obsessions, suicidal or homicidal ideation, and so forth. Often include: circumstantially, coherence, flight of ideas, logical thinking, intact as opposed to loose associations, organization, and tangentiality.

4. Cognition: Cognition includes whether the client is oriented to time, place, and person; an assessment of 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.

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Writing the Report: Format (Cont’d) (Follow Along with Case Report Example in Appendix F)

Assessment Results: Begin with a list of assessment procedures used. Next, offer the results of the assessment procedures. Try not to give out raw scores. Offer converted or standardized

scores that reader will understand (e.g., percentiles, DIQs, etc.). Remember: client, parents, or non-professional may read

results. State results in understandable, unbiased language. Be concise, yet cover all items relevant to presenting concerns,

or items that clearly stand out as a result of the assessment. Present results objectively. Interpretations should be kept to a

minimum, if used at all.

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Writing the Report: Format (Cont’d) (Follow Along with Case Report Example in Appendix F)

Diagnosis Make diagnosis using the criteria from Diagnostic and

Statistical Manual (DSM-IV-TR) Diagnosis is based on whole assessment process and on

integration of all knowledge gained Make a five-axes diagnosis (see Chapter 11):

Axis I: Clinical Disorders and Other Conditions That May Be a Focus of Clinical Attention

Axis II: Personality Disorders and Mental Retardation Axis III: General Medical Conditions Axis IV: Psychosocial and Environmental Problems Axis V: Global Assessment of Functioning, or GAF Scale

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Writing the Report: Format (Cont’d) (Follow Along with Case Report Example in Appendix F)

Summary and Conclusions Examiner’s chance to pull together all of the information

that has been gathered Often, only section of the report that is read by others, so

must be accurate and does not leave out any main points. Should be succinct, and relevant Do not add any new information Although inferences can be made, they must be logical,

sound, defendable, and based on facts that are in report. Recommend that a paragraph or two address strengths of

the individual.

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Writing the Report: Format (Cont’d) (Follow Along with Case Report Example in Appendix F)

Recommendations

Last section of report.

Should be based on all of the information gathered.

Should make logical sense to the reader.

Some prefer writing this section in paragraph form, others prefer listing each recommendation.

The signature of the examiner generally follows this last section.

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Writing the Report

Summarizing the Writing of an Assessment Report

See Box 12.4 on p. 275-276.

Review Appendix F

Practice Writing a Report