4.

THE PSYCHOLOGICAL ASSESSMENT REPORT

Inmaculada Montoya Castilla
Usue de la Barrera Marzal

1. PRESENTATION OF ACTIVITIES
This chapter presents a set of activities aimed at deepening the preparation of
psychological reports. The report is the last phase of the psychological
assessment process and is carried out through a return interview, giving an oral
report, and if appropriate, also a writing report. The report follows a specific
structure and content regarding the information collected from the patient or
client. In some cases, the report is the end of the assessment process.

2. OBJECTIVES
– To discriminate between the different ways of communicating the results
in the psychological assessment.
– To recognize the purposes for the preparation of a psychological report.
– To learn the basic characteristics that a good psychological assessment
report must have.
– To identify the different types of psychological assessment reports, based
on their theory, techniques or problem.
– To indicate the structure and the most relevant contents of a psychological
assessment report based on the different types of reports

3. BIBLIOGRAPHY
Buela-Casal, G. y Sierra, J.C. (1997). Manual de evaluación psicológica.
Fundamentos, técnicas y aplicaciones. Siglo XXI. Capítulo 10.
Fernández-Ballesteros, R. (2004). Evaluación Psicológica: concepto, método y
estudios de casos. Madrid: Pirámide. Capítulo 2.
Moreno-Rosset, C. (2005). Evaluación Psicológica. Concepto, proceso y
aplicación en las áreas del desarrollo y de la inteligencia. Sanz y Torres.
Capítulo 10.
4. ACTIVITIES
For further development of the activities, a summary of a case is presented at the
end of this unit (Annex: Sara's Case). It is a chapter tittled “Duelo patológico en
hermana de enfermo oncológico” Barahona, T., Montoya, I. y González B. (2001)
Extracted from the book: Evaluación psicológica en la infancia y adolescencia.
Madrid: Tea Ediciones S.A.

Activity 1
Indicate the missing information in the “Identification” section of the psychological
report:

PSYCHOLOGICAL REPORT –Identification-

Made by: Mary
Assessed individual´s name: Sara.
Gender: woman
Age: 17 years old.
Academic level: 2nd year of Professional Education

Activity 2
Indicate the section of the Psychological Report in which the following fragments
should appear:
a) An interview was held with the parents and the patient. The patient completed
the following assessment instruments.
Section: _______________________________________________________
b) Sara and her parents go to the clinic because she feels sad, she cannot
concentrate on her studies and, claims that she is useless. The main reasons
being that she thinks she is responsible for her sister's illness and that she fears
suffering from the same disease herself.
Section: _______________________________________________________
c) Throughout the exploration, Sara has collaborated in sessions of more than
one hour. No relevant motor or verbal alterations have been observed.
Section: _______________________________________________________
d) One year after the treatment, the patient reports that her capacity for
concentration has increased, and her feelings of guilt have diminished, no longer
interfering in her daily life.
Section: _______________________________________________________
e) Sara's family is made up of her parents (41-year-old father and 38-year-old
mother). As her sister died at the age of 8, when Sara was only 14 years old. The
disease´s process and the treatments lasted 3 years
Section: _______________________________________________________
f) The results obtained in the Beck Depression Inventory (Raw Score = 20,
Percentile = 63) correspond to a moderate depression.
Section: _______________________________________________________
g) Both her parents were integrated into their daughter´s therapeutic process.
Section: _______________________________________________________

Activity 3
Working in groups of 4, structure a script ´s case to offer an oral report to the
client. Point out at least five aspects to highlight in this verbal report and decide
on the order in which you would perform it (positive aspects, onset, evolution ...).

Activity 4
Working in groups of 4, write a paragraph about how you would use a written
report to raise to her parents the possibility of their daughter Sara´s unresolved
grief, hypochondria, emotional lability and recurring thoughts of guilt. Remember
the importance of the communicative function of the report.

Activity 5
Working in groups of 4, write briefly the conclusions and recommendations
section of the psychological report of Sara's case.

Activity 6
Point out which of the following ideas presented in the Sara's report would be a
good communication vehicle for Sara´s parents.
□ 1. The scores obtained by Sara in the anxiety questionnaire are within the limit
considered clinically significant in the Anxiety Trait (Raw Score = 20, Percentile
= 63).

□ 2. Sara presents an image of unresolved grief with marked anxiety and

depressive symptoms, in addition to recurring ideas of guilt and hypochondria.

□ 3. One of the diagnostic hypotheses in Sara´s case is hypochondria (irrational

fear of suffering a disease).
□ 4. Sara`s serious problems are due to the fact that she refuses to accept that
her sister has been dead for several years.

□ 5. Sara`s score on the Anxiety State corresponds to a medium-low level (Raw

Score = 20, Percentile = 45). That is below 45% of young people her age and is
within the usual limits.

□ 6. The psychologist recommended Sara beginning a treatment based on

techniques of cognitive restructuration and assertiveness.

Activity 7
Complete the missing words (reason; recommendations; written report;
certificate; high; data) in the following the sentences which are related to the
psychological assessment report.

A _______________ percentage of people prefer general results about their

personality instead of specific aspects in their reports.

b. The purpose of the report is to facilitate the _______________ and

__________________ so that an intervention can be launched by the
corresponding person.

c. The _________________________ can be considered as a legal document

insofar as it is a source of information about a person and decisions can be
supported in a trial.

d. The ______________________ of the assessment must be included in the

references and objectives section of the report.

e. The _______________________ is an assertion made by a professional

regarding any circumstance related to his client, his treatment or special events
derived from the established relationship. It should also be as short as possible.

Activity 8
Indicate which type of report is related to the following statements:

1. This report is issued at the request of the patient a. Forensic report

in order to apply for an allowance.

b.Inter-session
2. The patient shows behavioural disturbance and report
concentration difficulties, so neurological tests are
requested.

3. It is recommended for the patient to undergo c. Personal report

psychological treatment and continue with the
medical treatment prescribed by their psychiatrist.

4. The patient presents difficulties paying d. Certificate

attention which negatively affected their school
performance.
e. Academic report
5. In the first stage of the assessment,
psychotechnical tests have been administered to
the applicants, as described below ...
f. Recruitment
report
6. The conclusions made by the insurance
company assessors are presented below.

Activity 9
SELF-EVALUATION EXERCISES

1. Based on the following sentence taken from a psychological report: “High

loaded emotional situations produced anxiety in the patient and prevent he/she
from achieving the performance that is normal in other situations low loaded
emotionally”, we can say ….
a) It is a Pigmalion effect
b) It is a Barnum effect
c) It is a diagnosis

2. Which psychological report is written for another professional and is open to

discussion and exchange of views?
a) Personal report
b) Technique report
c) Certificate
3. In the psychological reports ……
a) It is enough to write the acronyms of the questionnaires used if they are
well known, it is not necessary to include all the data
b) The patient's current biographical data is described, but not the past data
c) The integration of the results section is written according to the theoretical
framework of the psychologist

4.The certificate, as a psychological report ……

a) Is brief
b) It should include the diagnosis process description
c) Is valid at any time

5. The three basic features of a psychological report are……

a) To be useful for the patient and family, brief, and to be a scientific
document.
b) To be a scientific document, useful and serve as a communication vehicle.
c) To be a written scientific document, serve to certify the origin of a disorder
and be a useful document including a diagnosis

5. RESOURCES, DOCUMENTS AND RECOMMENDED WEBS

─ Pérez, E., Muñoz, M., y Ausín, B (2003). Diez claves para la elaboración
de informes psicológicos clínicos (de acuerdo a las principales leyes,
estándares, normas y guías actuales). Papeles del Psicólogo, 86.
http://www.papelesdelpsicologo.es/resumen?pii=1113

REPORT: SARA´S CASE

Sara is a 17-year-old teenager, currently in the 2nd year of Professional Education. She
has symptoms of anxiety, and a fear of cancer after the death of her sister caused by
Wilms tumour (kidney tumour) three years ago. Currently, Sara has problems with her
school performance and issues with her interpersonal and familiar relationships. She
goes to the psychologist with her parents because she feels sad, she cannot concentrate
on her studies and according to herself, “she is useless”. She thinks that she is
responsible for her sister's illness, as she hit her accidentally in the area where the
tumour later developed. In addition, she is afraid of suffering the same disease herself.
Her parents feel unable to help her and seek guidance and treatment for their daughter.
Sara's family is made up of her parents (41-year-old father and 38-year-old mother). As
her sister died at the age of 8, when Sara was only 14 years old. The disease´s process
and treatments lasted for 3 years. During the course of the disease, Sara felt a sense of
abandonment and jealousy of her sister. After her sister's death, her parents´ protective
attitudes and behaviour intensified towards Sara. The family´s socio-cultural level is
medium-low, the father has been unemployed for four years and the mother tends to the
house.
During the first session, an interview was conducted with Sara and her parents. It was
observed that the mother exercises a mediator role in the family, and that there were
communication difficulties between the father and daughter. Moreover, the sister's room
remains intact since her death. However, the mother has adaptive and collaborative
attitudes to grief over the loss of her daughter, unlike the father shows signs of contained
anger towards the illness situation that his deceased daughter experienced, and towards
relatives and friends when not receiving the social support he required. His attitude of
distrust causes him to exercise an intense overprotection towards Sara.
The diagnostic hypothesis would focus on unresolved grief due to the death of her little
sister, depressive symptoms and anxiety and hypochondria or phobia of the disease
(Table 1).

Diagnostic Source
Justification Instrument
hypothesis
Sara Parents
Unresolved - Guilt Structured interview X X
grief - Room intact since the Role playing
sister´s death Self-records
-Interferences in activities
Anxiety and - Low self-esteem BDI (Beck et al., X
depression - Emotional lability 1983)
symptoms - Early awakening STAI (Spielberger et
al., 1988)
Hypocondria/ - Irrational fear of suffering HSPQ (Cattell y X X
Illness cancer Cattell, 1989)
phobia Activity Diary
Interview
BDI: Beck Depression Inventory; HPSQ: High School Personality Questionnaire; STAI: State-Trait Anxiety
Inventory

Assessment of unresolved grief: Good attitude towards parents, more proximity to the
mother. She considers her family as special and that they treat her well, but she would
need to understand her more. She values her teachers, interpersonal relationships, and
friends in a positive manner. Her anguishes and fears are marked by the death of her
sister, as well as by the blows she gave her, which she considers "the biggest mistake".
Of the seven days in a week, she had thoughts about the cause of her sister death, six
days out of seven. She is also worried about her studies, although she has projects for
her future by making the goal of her life to finish them and form a family.
Depressive and anxiety symptoms: The results obtained in the Beck Depression
Inventory (Raw Score = 20, Percentile = 63), correspond to a moderate depression. The
qualitative study of the results indicates high scores in "I feel continually sad and I cannot
help it", "I blame myself for everything bad that happens to me" and "I cry continuously".
Regarding anxiety, it was observed that in State Anxiety the scores correspond to
medium-low levels: Raw Score = 20, Percentile = 45. However, in Trait Anxiety the score
is within the limit considered clinically significant: Raw score = 30; Percentile = 77). Sara
seems like a sensitive person who is affected by her experiences, causing a state of
anxiety that makes her unable to implement appropriate coping strategies. These high
levels of anxiety may be the result of the time she had been confronted with unresolved
guilt. The highest scores are observed in "I see the difficulties piling up and I cannot
handle them" and "I feel sad". Although it should also be noted that anxiety levels
increase during adolescence.
Hypochondria: HSPQ results indicate a stable profile within normality (Sten Score <5:
Submissive-Dominant, Tender-Soft Sensitivity, Sure-Dubitative, More-Less integrated
Sten Score 5-6: Emotionally Affected-Stable, Calm-Excitable, Sober-Enthusiastic,
Carefree-Conscious, Self-Indulgent, Serene-Apprehensive, Sten Score > 6: Reserved-
Open, Sociable-Self-Sufficient, Relaxed-Tense). However, there is a tendency to anxiety
and in adverse situations it is marked by excitability / sensitivity and dependence on other
people.
In conclusion, the assessment conducted found no evidence of a pathology to justify the
problems that Sara presented, except for the intense feeling of guilt and her tendency to
react with high anxiety in stressful situations. All this seems to indicate that her feelings
are associated with the loss of her sister, which has become the recurrent thought that
seems to be affecting her general functioning and especially her academic performance,
as it constitutes a constant element of distraction. This same fact seems to be the basis
of her possible phobia to suffer the same disease as her sister, which can be understood
as a way to atone for the guilt or as the fear to suffer like her sister did.
Possible diagnostic hypotheses (DSM-V and ICD-10) are persistent depressive
disorder (dysthymia), generalized anxiety disorder and hypochondria. However, the
unresolved grief seems to be the hypothesis that best integrates and relates to the
symptomatology that Sara presents. Both anxious and depressive symptomatology are
present. Specifically, we can observe a depressed mood, as well as a greater concern
for everyday events, which may be at the root of her anxiety, which is also related to a
feeling of guilt. If we also consider the difficulties of communication with her father, it
could exacerbate the symptomatology developed as a consequence of the traumatic
experience of the death of her sister.