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Topic of the Day

What Makes a Good Psychological Report?
(or Why did they even bother to write this up?)

My answer: certainly not a great deal of what comes across my desk these days.  All too often when preparing to evaluate a student for a school or for parents I have the feeling I am part of a huge conspiratorial joke.  I get that feeling when I read many of the "reports" already in the student's file because so many of them are just plain bad reports from all sorts of "professionals".

I'm not the world's leading expert on assessment, never claimed to be and don't really want to be that person.  Most of my work is directed at changing dysfunctional behavior so that kids, and the people around them, can live better lives.   The problem is that often one needs to look deeper into what may be contributing to the problem or what the child is capable of in order to maximize the help provided to that child.  I've taught psychological assessment to doctoral candidates in clinical programs, supervised pre-doctoral practica and post-doctoral fellows on assessment, and worked with a variety of non-doctoral level psychometrists over the years.  I have done traditional psychometric (IQ, Achievement, etc.), personality (MMPI, MMPI-A, MMPI-II, etc.), and Functional Behavior Assessments (direct observations, ABC charting, etc.) over the years and have even managed to integrate the various forms of assessment into the same evaluation.  When teaching and supervising students doing psychological assessments, I expect to see mistakes, but I also expect the basics to be done by anyone who wants to apply any psychological knowledge to real human beings.  This means that BEFORE they go around administering tests and interacting with real live patients with actual reasons to be evaluated the students have to have mastered a good bit of basic knowledge.  I require such preparation work by anyone (no matter what their degree status or level of training).  It is therefore very strange to see so many reports, that I would never have allowed students to have begun, with signatures on them in files as if they were finished. 

One thing that most psychologists of my acquaintance don't appear to understand is that most psychological evaluations are not written for use by other psychologists, or even other mental health professionals, but for use by parents, teachers, administrators, lawyers, and even by the student themselves.  For this reason a psychological report needs to include accurate, objective, timely, and useful information in a manner in which a reasonably well informed lay-person can access.   When an evaluation is written in jargon or does not include enough information it it then easy for any of these consumers to take the wrong information from the evaluation and make decisions based on this mis-information.  I'm not talking about simple typos, which are easy to make and easily corrected.  Let me give just one example: a report I read recently stated that the child was the product of a full-term normal delivery (what everyone hopes for because this presents the fewest problems in a number of ways for both the mother and child).  So, you might ask, "What is the problem?"   Well, that child was the subject of a lawsuit in which the parents were suing the obstetrician for negligence during the caesarian delivery of their 2 month pre-mature infant!  Did the psychologist even bother to ask the mother, father, or even the lawyer that referred the child to him any of this or did he simply start typing his report over an old one on his work-processor and forget to change that material?  In either case this is unacceptable performance for a "professional".  There are some specific learning issues that go along with premature birth, and so if this report remained in the file and the child went to school with it available to the teachers it might have undercut the appropriate evaluation of that child for learning problems.  So why is it that so many reports are inadequate, bad, or just plain wrong?

Assuming that the examiner can adequately administer and score/interpret the devices used in assessing someone, there are two main ways that a psychological evaluation can be inadequate.  In the first, the examiner can fail to review the background material and previous reports thoroughly.  In the second,  the examiner can present a battery of devices (tests) which do not address the areas of concern (either completely enough or at all).  When asked to evaluate a student the first question that should be asked is "Why?".  What is the "referral question" that the person asking for the report wants answered - essentially why did they think an evaluation by a psychologist would be helpful and what specifically are they looking for from the report.  Early in my career I worked in several medical settings with physicians.  Now physicians know a great deal about the biology of behavior and the drugs that can be used to alter behavior, thought, and emotions but they know darn little about psychological assessment and formal psychometrics because they just aren't trained in those areas.  I would routinely have physicians write orders for me to do "projectives" on a child without any rationale or "context".  Now it might be fine for a physician, who knows more about such things than the nurse, to order blood work and to specify the blood tests to be run by the nurse or technician - but this does not work for psychological tests because they need a context in which to be placed and the physician normally just doesn't possess the training to make the right selection.  Most of the time I would just talk with the physician and ask them what they were thinking and what question they wanted answered and then tell them I would do such-and-such tests and that worked out fine.  Occasionally I would run into a real "gunner" who would reiterate their "order" for "projectives" and instead of butting heads with them I would read as much about the patient as I could (in order to develop a context) and do the tests I thought appropriate.  More often than not such "gunners" would thank me for having done the "projectives" even when none were conducted or included in the report!  The right tool for the right job should be the watch words of anyone psychologically evaluating anyone under any circumstances.

Does this mean that I look over a patient, their records, and decide what tests to do for the evaluation and then just do it?  Of course not.  A good evaluation is an evolving process in which questions are formulated, tests administered, information reviewed, theories constructed, additional assessments done, and both confirming and disconfirming information integrated into some coherent picture of the person being evaluated.  However, there are indications in both the question and the history that point an aware evaluator to certain starting points among the vast array of testing devices available today.

The second thing that an evaluator should require is for copies of all past evaluations (including social, emotional, learning/cognitive, psycho-motor, neurological and neuropsychological, speech/language, physical and occupational therapy, and medical) to be made available for review.  This information, the question and the history, provides the context in which the psychologist operates when designing and conducting the evaluation.   This context is the foundation upon which the selection between various devices and procedures is initially based by the psychologist.  Without a context such a process is worse than useless - it is a waste of resources (both time and money) better spent elsewhere.  An inadequate foundation renders any information gathered  meaningless - just as any series of words taken out of context are devoid of a broader meaning.  I can not tell you the number of reports I review annually that do not have a referral question, a detailed history of the person being "evaluated", or specific recommendations about what to do to help the person.

The answer to the question "What makes a Good Psychological Report" is - a solid understanding of the questions being asked and a complete review of the materials available including history and previous evaluations which lead to questions being formulated, tests administered, information reviewed, theories constructed, additional assessments done, and both confirming and disconfirming information integrated into some coherent picture of the person being evaluated.  This leads to diagnostic clarity, an understanding of the person's unique presentation (because they are NOT their disorder), and probably most important of all - specific recommendations on what to do to help that person.  The resulting report will be functional and useful to those who are working with the person - and that is the true purpose of any psychological report.


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