Individualized Reports. We observed earlier in
this chapter the importance of avoiding the
Barnum effect, and it is appropriate to repeat the
point here. The distinctive (be it current character-
istics, development, or learning history) is preferred
over the general. To say“Jack is insecure”hardly
distinguishes him from 90% of all psychotherapy
patients. To say that Jack’s insecurity stems from a
history of living with several different relatives as a
child and that it will become particularly acute
whenever he must make a decision that will
take him away (even temporarily) from wife and
home is considerably more meaningful. In this
case, a general characteristic has been distinctly
qualified by both antecedent and subsequent
conditions.T A B L E 10-2 Sample Outline of Psychological Report
I. Identifying information
A. Name of patient
B. Sex
C. Age
D. Ethnicity
E. Date of evaluation
F. Referring clinician
II. Referral question
III. Assessment procedures
IV. Background
A. Information relevant to clarifying the referral question
B. A statement of the probable reliability/validity of conclusions
V. Summary of impressions and findings
A. Cognitive level
■ Current intellectual and cognitive functioning (e.g., ideation, intelligence, memory, perception)
■ Degree (amount of) impairment compared to premorbid level
■ Probable cause of impairment
(By end of this subsection, referrer should know whether the patient has a thought disorder, mental
retardation, organicity.)
B. Affective and mood levels
■ Mood, affect at present—compare this with premorbid levels
■ Degree of disturbance (mild, moderate, severe)
■ Chronic vs. acute nature of disturbance
■ Lability—how well can the person modulate, control affect with his/her cognitive resources?
(By end of this subsection, referrer should know whether there is a mood disturbance, what the patient’s
affects are, and how well controlled his/her emotions are.)
C. Interpersonal–intrapersonal level
■ Primary interpersonal and intrapersonal conflicts, and their significance
■ Interpersonal and intrapersonal coping strategies (including major defenses)
■ Formulation of personality
VI. Diagnostic impressions
A. Series of impressions about cognitive and affective functioning,or
B. The most probable diagnoses
VII. Recommendations
A. Assessment of risk, need for confinement, medication
B. Duration, modality, frequency of treatment
SOURCE: Beutler, L. E., "Integrating and communicating findings," in L. E. Beutler & M. R. Berren (Eds.),Integrative Assessment of Adult Personality
(pp. 25–64). Copyright © 1995 Guilford Publications, Inc. Reprinted with permission.
302 CHAPTER 10