Psychological Report Writing Assistant

Gary Groth-Marnat, Ari Davis

• Editorial: Wiley
• Año: 2013
• ISBN:
  9781118234853
• Edición: 1
• Categoría: Psychologie
• Categoría: Forschung & Methodik in der Psychologie

Expert Report Writing Software—provides a step-by-step guide to writing clinically sound and rich psychological reports

The Psychological Report Writing Assistant software is a highly interactive program that guides the report writer through all phases of writing a report that is comprehensive, includes integrated interpretation, uses everyday language, and answers the referral questions. Key features include:

• A composition screen with links to resources to facilitate report writing
• Sample reports with links to guidelines on how to write sections of the report
• A comprehensive menu of treatment recommendations
• Search function to identify problem phrases with suggestions for alternative wording
• Compatible with Microsoft Windows

Blending the best of science with an appreciation for the art of doing clinical work, the accompanying guide:

• Describes six core qualities of an optimal psychological report
• Provides an overview of cognitive, neuropsychological, personality, psychoeducational, and forensic reports
• Offers guidelines for formatting and completing various sections of a report
• Discusses recommendations for treatment and for tailoring the report to the individual
• Includes instructions for navigating the software

Filling the need for an easy-to-use, intuitive tool for organizing and writing relevant psychological reports, Psychological Report Writing Assistant will help you quickly and easily create thorough and complete psychological reports.

Chapter 1

Introduction

The goal of psychological assessment is to integrate a variety of sources into a user-friendly, problem-focused, well-integrated psychological report that both describes a person and provides guidance in making optimal decisions. The above goal and associated procedures draw on a wide number of skills and knowledge ranging from technical psychometric knowledge to an ability to understand the lived experience of the persons being evaluated. Given these multiple demands, writing a high-quality psychological report is often a difficult task. This book and software will guide practitioners through the process of organizing and integrating data so as to provide accurate, user-friendly descriptions of persons being evaluated. These resources should not only improve the quality of reports, but should also make report writing more time efficient. It will also serve as a companion to and extension of Groth-Marnat’s Handbook of Psychological Assessment (5th ed.).

Who This Book and Software Are For

This book and software will be most useful for professional psychologists in training, beginning-level professional psychologists, and practicing professionals who write only occasional reports. It may also enable experienced assessment psychologists to write their reports more quickly and ensure that important dimensions of a report have not been overlooked. Specific resources included in this book are a description of the core qualities of optimal reports, report format, guidelines for completing various sections of the report, discussion of treatment recommendations, overview of different types of reports, and strategies for navigating the Psychological Report Writing Assistant (PRWA). Based on this information, a wide number of corresponding resources have been incorporated into the PRWA software. The software is divided into modules for writing the following five most common types of reports: cognitive, neuropsychological, psychoeducational, personality, and forensic (see Chapter 3). It is hoped that report writers will use these resources to easily assemble assessment data into an integrated report. Ideally, writers will find the “voice” of an expert guiding them through each step of the process. The result should be that not only will report writing proceed more quickly, but the quality of reports will be significantly better than for persons not using the PRWA.

Rationale and Philosophy for Report Writing: An Integrative Approach

The report writing rationale and philosophy incorporated in this book/software emphasizes integration and has been described by various authors (see Beutler & Groth-Marnat, 2003; Blais & Smith, 2008; Groth-Marnat, 2009a, 2009b; Harwood, Beutler, & Groth-Marnat, 2011; Kvaal, Choca, Groth-Marnat, Davis, 2011; Levak, Hogan, Beutler, & Song, 2011; Wright, 2011). Integration can be understood on several different levels. One essential feature of integration is making sense of apparent contradictions that often occur when reviewing assessment information. For example, a parent may report that his or her child has problems with attention, but, when formally assessed, the child’s test scores appear in the average/normal range. A possible reason for this discrepancy may be that the test situation is highly structured such that the child followed the directions of the assessor and did not have to compete with real-world distractions. His or her performance outside the assessment situation might be quite different. Another example might be scores on a self-report instrument such as the Personality Assessment Inventory that indicate that the client has an absence of disordered thoughts. In contrast, the Rorschach might indicate quite confused thinking, possibly consistent with an underlying thought disorder. This may be due to the more ambiguous, less structured, performance-based task of the Rorschach’s being more sensitive to the presence of a subtle, underlying thought disorder. An integrative approach would work to make sense of these contradictions, and only when these contradictions were resolved would a narrative interpretation be developed and inserted into the report. In contrast, many traditional approaches to writing a report simply discuss test results one test at a time (e.g., “Test scores on the Personality Assessment Inventory indicate . . .,” etc.). The most problematic example of this would be simply cutting and pasting from an interpretive text or a computer-generated computer narrative “interpretation.” One purpose of this book is to expand on contradictory assessment results along with suggestions on how to resolve them. In addition, the Psychological Report Writing Assistant provides an Integrated Information Manager that helps users integrate their assessment results into integrated interpretations focusing on various domains of functioning.

Another central feature of this book and software is integrating the results of assessment with the consumer. The consumer refers to both the referral source as well as the person being evaluated. Integration with the referral source first of all means understanding their needs and expectations. This typically begins with carefully clarifying the referral questions. This can often be done by exploring what client decisions need to be made. It also means understanding the context the referral source is working in (see Chapter 5). For example, reports written within a medical context would mean that the report writer should become knowledgeable regarding options for cognitive and other forms of rehabilitation. This should be reflected in the type of assessment information that is obtained as well as the choice of recommendations. Another example is that sometimes referrals from school settings don’t want recommendations included in reports because it is often felt that recommendations should be developed by a team rather than by the individual psychologist. These and many other considerations are discussed and will enable report writers to best integrate their reports into various assessment settings.

Another example of integrating the report with referral sources is to make sure that the interpretations made about the client are accurate. While this may seem obvious, reports that focus solely on tests and test scores can potentially provide considerable inaccurate information by providing cut-and-paste “interpretations” and qualify these by saying “People with these types of profiles . . . .” The inaccuracy of unintegrated cut-and-paste interpretations is highlighted in that typically half of all interpretations generated by computer-based reports will not be accurate for the person being assessed (see the section on core strategy 3 in Chapter 2). However, the referral source may mistakenly believe that all or most of the descriptors listed will be accurate. Thus, it is incumbent on clinicians to work with interpretive descriptors to determine which ones are, and which ones are not, accurate for their client. The Psychological Report Writing Assistant’s Integrated Information Manager will help clinicians to organize their information and thus more easily make these differentiations. It should also be emphasized that for some reports, particularly in forensic settings, it may be desirable and even necessary to stay close to the “facts” by describing test scores and then detailing the reasoning process the clinician used in coming to their opinions. In these cases, the integration of results is typically placed in the summary rather than the impressions and interpretations (and summary).

Integration also involves using language that connects with and makes sense to both the referral source and the client. Thus, an integrative report is typically written in user-friendly, everyday language that is clear while still being sufficiently professional. There is minimal use of jargon, tests scores, statistics, and the clinician’s reasoning processes. For example, instead of simply stating the defense mechanism of “rationalization,” report writers are encouraged to write something like “. . . the client convinces himself that no wrongs were done by developing convenient excuses that make himself look acceptable to himself and others.” The PRWA uses a search function to identify common examples of overly technical and other forms of problematic language. Once these are highlighted, a rationale is given for why the phrases might be problematic, and alternative language is provided that can be easily extracted, edited, and integrated into the report. User-friendly language is also encouraged in the form of giving everyday examples of the types of problems the client might confront. For example, a client with poor spatial skills might have problems following maps, understanding directions, or finding where something is in a house. In addition, user-friendly language is encouraged in reports through using wording that indicates empathy, is likely to facilitate change, and tries to understand the world through the perspective of the client (see Finn, 2012; Finn, Fischer, & Handler, 2012; Fischer, 2012; Levak, Siegel, Nichols, & Stolberg, 2011). For example, instead of stating that a histrionic-type client is “somatizing,” “dissociating,” and “converting,” report writers might alternatively describe the person as follows: “. . . She is working so hard to hold her feelings inside and trying to stay positive that these efforts are putting stress on her body, and this is most likely why she is experiencing headaches, backaches, and neck aches.” (Levak et al., 1991)

A further goal of integration is that components of the report connect, flow, summarize, answer the referral question, and are easily accessible. In particular, it should be clear what the report is intending to do, and it should be easy to determine whether it has accomplished these goals. One strategy is to connect the referral questions with corresponding and numbered answers to these questions. The PRWA software provides various formats and guidelines to help ensure that the report is structured in a clear, coherent manner such that the various components of the report are most likely to accomplish its intended goals. In addition, the language should be easy to read. This can be enhanced by using a wizard embedded into the PRWA that easily provides users with a menu of common report writing phrases. In some cases these are entire paragraphs for interpretive domains that can be edited based on information derived from the client and organized using the Integrated Information Manager.

A final principle is that recommendations need to be integrated with the needs of the referral source, client, and resources in the community. They should also be sufficiently comprehensive. The PRWA provides suggestions, guidelines, and examples that should enhance this process. In addition, there is a wizard in the form of a comprehensive menu of recommendations tailored toward each type of psychological report. Users of the program can easily transfer these recommendations into their reports, where they can be further edited to address the specifics of the case. The menu of recommendations is sufficiently broad that it will help users to consider a full range of possibilities organized according to treatment, referral, placement, further evaluation, alteration in environment, and self-help.

The preceding principles represent an ideal. Various sources have recommended many of these principles (see Armengol, Kaplan, & Moes, 2001; Beutler & Groth-Marnat, 2003; Blais & Smith, 2008; Brenner, 2003; Groth-Marnat, 2009a, 2009b; Harvey, 2006; Levak & Hogan, 2011). Despite these recommendations, the modal report in practice is often suboptimal (Groth-Marnat & Horvath, 2006; Harvey, 2006; Tallent, 1993). This research, often based on consumer feedback, makes it clear that report writers often become focused on individual test scores, write reports that are difficult to understand, and often do not work to resolve contradictory assessment results (Harvey, 2006; Levak & Hogan, 2011). The results are reports that are not well received by consumers, are filled with jargon, are overly technical, describe test scores rather than clients, and do not connect to the client’s everyday life experience (Groth-Marnat, 2009a; Groth-Marnat & Horvath 2006; Harvey, 2006). Once this pattern is established in graduate training, clinicians are likely to continue to write suboptimal reports throughout the remainder of their career.

The reasons for poorly written reports are numerous. Harvey (1997, 2006) found that professionals in training were likely to write overly technical, non–user-friendly reports for the following reasons: they were taught to provide data without explaining the data sufficiently; they had limited awareness that many readers will not understand the terms that are used; and they lacked clarity regarding the intended audience. In addition, reports that focused on tests and test scores were easier and quicker to write since they required less conceptual effort on the part of the writer. In other words, the tests dictate what will be written rather than the integration of more complex and sometimes contradictory information. In addition, the sheer number of report writing guidelines presented to practitioners often means it is easy to overlook some of these guidelines.

An Introduction to the Psychological Report Writing Assistant

The PRWA has been prepared to assist professional psychologists in writing high-quality reports. Knowing how to develop high-quality reports is based in part on knowing the core strategies involved in preparing the types of reports that are likely to be well received by consumers. These core strategies are not only detailed in Chapter 2, but are integrated throughout the PRWA software. The PRWA itself is a highly graphic, interactive program that has been developed as a software tutor and expert system. The orientation of the PRWA is to combine education with professional assistance in an entertaining and intuitive medium. The PRWA guides the report writer through the principal phases of report development that are most conducive to comprehensiveness, integrated interpretation, therapeutic insight, and optimum recommendations in clear response to the referral questions. The application toolkit provides clinical reasoning Wizards and a knowledge base for work in the educational, psychiatric, legal, psychological clinic, and medical consultation venues.

When working through the PRWA, practitioners fill in the required data based on the appropriate template for a cognitive, neuropsychological, personality, psychoeducational, or forensic report. Throughout report development, the PRWA displays a hierarchical outline of the report that maintains a view of the whole while defining the proper sequence, structure, and necessary categories of information most relevant for the referral source and referral questions. While working on a defined section of the report, the user is supervised with context- and topic-sensitive professional guidelines, exemplary sample text, and client information that have been previously integrated across domains and test instruments for the section of the report under development. By clicking on various sections of the report outline, users can easily and quickly bring the desired section of the report into view for editing.

The feature set and multiphased working environment of the PRWA allows the preceding toolset to accommodate a wide variety of requirements and specifications. It helps users to answer the referral questions in a professionally succinct, communicable manner, which narrates the personal story of the individual and promotes the optimum treatment recommendations for collaborative discussion and implementation.

The PRWA includes numerous useful phrases, alerts report writers to potentially problematic phrases, and provides a comprehensive menu of recommendations tailored to different types of reports. Sample phrases are included throughout the software. Examples include how to articulate interpretations and to express appropriate opinions (e.g.,“The findings are consistent with although not necessarily diagnostic of . . .”). In addition, there is a scan function that can review the draft of the report and identify areas that might be problematic. Such areas might include overly technical language, inaccurate terminology, too much detailing of reasoning processes, colloquialisms, or language suggesting that the assessment results have not been adequately integrated. The alerts provide a rationale as to why the phrases might be problematic as well as suggestions on how the section could be reworded. A final feature is extensive lists of recommendations tailored to the various types of reports. These can be added to the draft of the report by simply putting a check next to the recommendation. Guidelines are provided on how the recommendations can be edited to best meet the requirements of the report.

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RAPID REFERENCE 1.1: KEY FEATURES OF THE PSYCHOLOGICAL REPORT WRITING ASSISTANT

• Modules for five categories of reports: cognitive, neuropsychological, personality, psychoeducational, and forensic
• Guidelines for constructing subsections of reports
• Composition screen with wizards linking resources to facilitate report writing
• Sample reports with sections linked to guidelines
• Integrated Information Manager
• Menu of common phrases that can be inserted into report narrative and edited
• Search wizard to identify problem (“red flag”) phrases: listing of phrase, rationale for why it might be problematic, suggestions for alternative wording
• Menu of recommendations
• Wizard for developing psychotherapy treatment recommendations

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The preceding information provides a general overview of the PRWA. Additional features are described throughout the book. In addition, Chapter 6 details the major features and provides specific operating instructions. Each of the instructions is illustrated with relevant screenshots.

From Software to the Real World

In order to develop the PRWA, it was necessary to decide on common formats and to emphasize an integrated, user-friendly style of presentation. This was based on the implications of research on psychological reports combined with over 30 years of teaching assessment, clinical experience, and reviewing thousands of reports. At the same time, it should be emphasized that there is no single way to write a report. Sometimes report writers may wish to edit various sections of reports based on their own preferences. Often, agencies have their own format with corresponding guidelines that all employees are required to follow. There may also be other idiosyncratic aspects of the assessment context or demands of the referral source that strongly influence how a report is written. For example, the resources provided in this book and the PRWA emphasize not using jargon and minimizing references to tests and test scores. However, there may be situations where it may be necessary to use technical terms as well as to detail test results. It should be noted, however, that there is flexibility built into the PRWA to enable report writers to edit all aspects of their reports according to their needs. Report writers should always consider the guidelines, strategies, examples, and recommendations provided in this book/software program, but the decision is ultimately based on the report writer’s unique situation and background.

The report formats presented in this book and the PRWA were developed to be generic and sufficiently broad so that most components of reports would be included. It should be acknowledged that other guides to writing reports have sometimes used different titles for the various subsections. For example, the Background Information section has sometimes been refe...