Clinical Psychology

The Level of Detail. The question often arises as
to how detailed a report should be. Again, the
answer depends largely on the audience. In general,
however, it seems desirable to include a mix of
abstract generalities, specific behavioral illustrations,
and some testing detail. For example, in reporting
depressive tendencies, a few illustrations of the test
responses that led to the inference would be in
order. A few of the relevant behavioral observations
that were made during testing could also be quite
helpful. A certain amount of detail can give readers
the feeling that they can evaluate the clinician’s
conclusions and interpretations. The exclusive use
of abstract generalities places the reader at the
mercy of the clinician’s inferential processes.

Some Comments on the Antonio Ramirez

Report. The primary function of a report is com-

munication. It should not be an ego trip for the

writer. In general, the report on Antonio Ramirez

could be read and understood by a layperson; it

included little of a technical nature. However,

some of the language used (e.g., “intense inner

experiences,”“reality testing”) may only be familiar

to other mental health professionals.

Another positive feature is the level of detail.

The report begins with some background material,

along with references to the patient’s accounts of

his behavior and feelings. It also includes some

behavioral observations by the clinician. It then

moves to a discussion of test responses and some

A Case Illustration of a Clinical Report

To illustrate several of the points that this chapter has

made regarding clinical judgment and communication,

let us consider a specific clinical case report (Corbishley &

Yost, 1995, pp. 322–340).

Identifying Information

Name: Antonio Ramirez

Date of birth: 7/4/62

Sex: Male

Dates of examination: 8/22/94, 8/23/94

Referral Question

Antonio Ramirez, a 32-year-old Latino male, is a ser-

geant with the Detroit, Michigan, Police Department,

currently working as a narcotics officer. In the past few

weeks, he has exhibited signs of stress but has refused

to take sick leave, claiming that there is nothing

wrong. He was referred by his commanding officer for

psychological assessment to determine the extent to

which recent events in Mr. Ramirez’s life may have

affected his ability to continue with his present duties.

Assessment Procedures

Mr. Ramirez’s personnel file and the referring physi-

cian’s report were reviewed, and Mr. Ramirez reluc-

tantly agreed to allow his wife, Donna, to be

interviewed. On August 22, 1994, Mrs. Ramirez was

interviewed for 1 hour while her husband took the

Minnesota Multiphasic Personality Inventory–2 (MMPI-

2). He complained of headache and blurred vision,

which he claimed prevented further assessment that

day. He returned the next day for a 1-hour interview,

after which he completed the Rorschach and the

Wechsler Adult Intelligence Scale–Revised (WAIS-R).

Background

Mr. Ramirez is currently living with his wife of 8 years,

a 6-year-old daughter, and a 4-year-old son. He has

been employed by the Detroit Police Department since

1984 and has a satisfactory record. In general his health

is good, and he expresses satisfaction with his job and

marriage. His social life is limited, which he attributes

to the fact that as a police officer he is viewed with

unease by potential friends, and also to the unpredict-

able hours he must work.

He has good relationships with his siblings but

sees them rarely, as they all live in distant parts of the

country. He has no hobbies and spends his limited

spare time at home, occasionally playing with his chil-

dren, but primarily maintaining his house and yard. His

relationship with his wife is by his report close, but he

says they rarely discuss feelings and he would not bur-

den her with his worries. His wife describes him as a

good husband, faithful, even-tempered, and a loving

father, but she says he takes life too seriously, and

would like him to learn to have more fun.

Mr. Ramirez was raised by his mother in consider-

able poverty, his father having died in an industrial

accident when Antonio was 8 years old. He remembers

his father as“stern, but you knew he loved you.”He

(Continued)

CLINICAL JUDGMENT 303