This lecture emphasizes psychological report writing, psychological testing, and the use of forensic classification and evaluation instruments in the clinical mental health (non-academic) setting. What appears on this page is intended to follow-up on the more basic Forensic Psychology lecture.

There's no one "perfect" way to write a psychological report, despite dozens of guides on how to do it. The problem is that there are numerous "how-to" guides but few, if any, resources on "why" or the theory of it. Another problem is that there are no specific psychological tools that clearly apply to the forensic arena. In other words, there are no psychological tests that specifically test for forensic issues. For example, there's no such thing as an "incompetency to stand trial" paper and pencil test, nor ones for "insanity" (a legal concept), "potential for rehabilitation", or "potential for violence." All that psychology has to offer is indirect, imperfect tools, at best. It all depends upon the practitioner and how knowledgeable he/she is in certain content areas, and what the law expects from them.

Forensic psychologists achieved almost the same legal status as psychiatrists in 1962 when Judge David Bazelon (in Jenkins v. US 307 F. 2d 637) declared, over the objections of the APA, that a psychologist was competent to testify as an expert witness on the presence or absence of mental disease or defect. Judge Bazelon said that it depended upon the actual experience of the witness and the probative value of his/her opinion. This decision, from a prominent judge, was a landmark for forensic psychology, which had only previously been involved in eyewitness reliability. After 1962, the door was open to all sorts of forensic issues, such as the controversial "malingering" diagnosis, numerous attempts to clinically predict violence, various competency opinions, and the thing that probably made police hate psychologists the most -- testimony about who was capable of appreciating their rights in custody, which culminated in Miranda waiver decisions. Indeed, forensic psychology impacted some significant legal reforms in the 1960s.

A rash of "syndromes" as novel defenses appeared in the 1970s as part of what might be called the "diminished capacity" movement, a concept introduced by the ALI (American Law Institute) in the Model Penal Code of the late 1960s. Some states don't recognize diminished capacity, which is theoretically a state in-between sane and insane, but most jurisdictions allow syndromes to serve as factors in mitigation, resulting in a lighter, or reduced sentence. Some mental health syndromes are bizarre, such as the Twinkie defense, but they do result in shorter prison terms for those who raise them. Juries seem able to relate.

In the 1980s, the key event was John Hinckley's assassination attempt on President Reagan. It was witnessed on TV by millions of viewers, but a jury acquitted Hinckley on a verdict of not guilty by reason of insanity. The nation was outraged, and jurisdictions all across America shifted the burden of proving insanity from the state to the defense and/or devised new, revised verdict options of guilty but insane. Forensic psychologists were quite active in those days, busy defending their turf and practices.

The 1990s saw the emergence of professional standards in mental health and law. It's now considered a "growth area" for all sorts of legal concepts such as:

The important qualifier is "substantial" since most laws require the mental impairment, disease or defect to be substantial, a qualitative distinction that depends on the case and the circumstances (a situational characteristic that distinguishes legal concepts from psychological concepts). There are no clear guidelines in forensic psychology (even in the code of ethics) for determining what "substantial" means. It has been defined as "what would convince the unprejudiced mind of a qualified psychologist of the authenticity and proof of a clinical fact." The renowned DSM-IV (Diagnostic and Statistical Manual) is of little help, either, since it doesn't use the word "substantial", only the word "severe", and courts don't accept severe as automatically substantial. Instead, courts rely upon well-documented and well-presented reports and evaluations. Hence, the importance of psychological report writing.

A well-written psychological report is an "X-ray" of the personality. It should explain to the reader what personality dynamics are going on at a level below the manifest personality or the behavior. Hypothesis testing is expected; hunches are not allowed. Everything should be based on objective data. The evaluation should also produce firm conclusions or recommendations. There's no room for wishy-washy language.

There are three (3) sources of information that the psychologist has to work with:

With CLINICAL HISTORY, all sorts of background information is available, including social, legal, medical, and mental health. Medication history is especially important, as is family mental health history. The MENTAL STATUS EXAM involves the psychologist's personal observations and impressions. The most important part of a MSE is not to trust the patient's own opinion of their mood. That's why psychologists use words like "flat", "shallow", or "elevated" to describe mood and/or affect. TEST DATA will consist of whatever psychometrics are done, such as the MCMI-III or MMPI-2. It's often the case that test data are administered by a separate professional, called a psychometrician, who may or may not be involved in the interpretation. Rarely should a report be based on only one single test. Some psychologists prefer a "domain" approach where different testing instruments reveal different aspects of the personality. For example, a Rorschach ink blot test taps a different dimension of personality than the MMPI. Medications that a person is on at the time of testing should be reported.

It is important to note the difference between responsibility and competency (both legal concepts). Responsibility refers to mental state at the time of the offense. Competency refers to abilities at the present time. Psychologists are often asked to work backwards from competency to responsibility. The two should be kept separate, however, to avoid mixing background and foreground information. On the other hand, if the patient has a history of being in and out of treatment (or in and out of trouble with the law), one can infer certain long-term patterns (or velocities) from coping behaviors between treatments. Evidence rules may prohibit such inferences, however, from being admitted in a court of law. Criminal law, however, differs from civil law precisely in that with criminal dangerousness, the evaluator can presume at least one previous act of dangerousness while with civil law (and civil commitment standards of dangerousness), there is no such presumption, and the determination of dangerousness must be based on anticipatory harm or danger.

It's also important to note the difference between prediction and assessment of risk. Mental health professionals are often drawn unwittingly into statements of prediction, which are yes-no statements across time and circumstances. Risk is a much safer term, especially when couched in terms of relative risk (given various environmental factors, such as maintenance of treatment contact, family support, etc.) which is future-oriented, but not the same as prediction.

Child custody evaluations are somewhat different. In these cases, the psychologist is evaluating a whole set of relationships, a whole family history. When child abuse is involved, the evaluator's recommendations will usually carry the full weight of a decision. In short, predictions are expected, and even more than that, often statements about past, present, and future personality dynamics. This is because the evaluator is expected to be biased "in the best interests of the child", a legal standard that replaced the "tender years doctrine" sometime in the late 1960s.

Perhaps the best examples of the evaluation process can be found in the areas of malingering and workers' compensation cases. Malingering is a military term for avoiding military duty, but it has come to refer to any presenting of self as disabled to achieve some identifiable goal or benefit, usually of a financial nature. I say it's a good example of the evaluation process because the evaluator must systematically, through a process of elimination, rule out all sorts of alternative hypotheses, one-by-one. That is, you first rule out the psychoses, then the neuroses, then the personality disorders, etc., etc. until you are left with nothing in the DSM IV to diagnose the person with. All well-written psychological reports will contain at least a "differential diagnosis" section, and an explanation of why or why not it applies and/or what else can be ruled out. Workers' compensation evaluations also deal with malingering or secondary gain, but what's exemplary about them are "apportionment" guidelines (how much a pre-existing condition contributed to a disability) and the fairly quantitative way serious, severe, and substantial impairment levels are tied to specific benefit amounts (a fingertip is worth $5000, for example). Forensic crime-related assessment, however, rarely has such clarity and exactness.

Suppose, for example, you had to match up psychological conditions, as in column A, with legal conditions, as in column B. If so, you would be engaging in forensic psychology since you would be expected to relate known treatment possibilities to criminal sentencing possibilities.

Column A:
Psychosis (delirium, hallucinations)
Schizophrenia (breaks with reality)
Depression (major clinical depression)
Anxiety (major clinical anxiety disorder)
Malingering (faking a disorder)
Gender identity disorder (sexual confusion)
Eating disorder (anorexia, binge eating)
Sleep disorder (sleeplessness, sleepiness)
Personality disorder (antisocial, borderline)
Mental retardation (low IQ)
Sexual Impulse Disorder (strong sex urges)

Column B:
Fine
Fine with Probation
Probation only
Treatment Program
Treatment with probation
Halfway house
Boot camp
Maximum security prison
Medium security prison
Minimum security prison
Death penalty

The proper format for a psychological report contains the following section headings:

The TITLE AND DEMOGRAPHICS section should begin with an appropriate and centered title at the top of the page. Titles typically start with the words Confidential Psychological Evaluation of ... or Confidential Psychological Assessment of .... with the .... filled in with the person's name. The demographic information should cover at least one-quarter of the page, and can be in a two-column format with at least the following information contained: (a) date of birth, or approximate age; (b) race or ethnicity; (c) sex or gender; (d) marital status; (e) employment status (f) date of evaluation; (g) referral source; (h) other professionals associated with the person, such as primary physician, primary therapist, social worker, etc.. The demographics should lend themselves to sentence format like a 21 year old African American male, unmarried and a college student, who was evaluated on November 17, 2000, referred by Acme Mental Health whose primary care physician is Dr. Heisenweimer, primary therapist is Mrs. Throcklesworth, and social worker is Mr. Hepburn.

The REASON FOR REFERRAL section is very important. It's what is driving the purpose of your evaluation. Some typical reasons for referral include but are not limited to the following examples:

John Doe was referred for psychological evaluation in order to ascertain if he is competent to stand trial.

John Doe was referred for psychological evaluation in order to ascertain if he is insane under the ALI rule.

John Doe was referred for psychological evaluation in order to clarify a differential diagnosis between psychosis and malingering.

John Doe was referred for psychological evaluation because "reported feeling depressed" was mentioned in a social work report.

John Doe was referred for psychological evaluation because the subject complains of sleep and appetite disturbances.

This section is also likely to report any specific instructions you were given in writing, such as Please evaluate for any self-destructiveness or Please evaluate for any dangerousness to self and others.

The ASSESSMENT PROCEDURES is usually the shortest section of the report and contains a list of tests that are indicated for this type of evaluation, what family members you think you should talk to, and whether or not an interview with the subject themself is indicated. This section should read as a grammatically incorrect sentence, like this, if you were to use a battery of tests:

Wechsler Adult Intelligence Scale-Revised, Rorschach Inkblot Technique, Thematic Apperception Test, Minnesota Multiphasic Personality Inventory-2, Incomplete Sentences Test, Kinetic Family Drawing Test, Bender Gestalt, review of patient's record, clinical interview with patient's only living parent, his mother, clinical interview with patient.

The SOCIAL HISTORY (or background information) section is rarely more than one paragraph, and should repeat the sentence you created on the top or title page (a 21 year old African American male, ...) as well as go into detail on family history. Why is the person unmarried or married, for example. Why do they only have one living parent? What is their relationship to parents, other family members, and significant others? Have they or have they not fostered children of their own? This section should also contain some details on occupation and educational history. If they are a college student, how are they doing in school? What is their major? If they are employed, what previous careers did they have? How long have they stayed in any one career? Another important area is health history. Especially relevant is any history of suicide attempt. Also relevant is history of alcohol/drug involvement. Sexual history is sometimes included. When you write this section, you should indicated which answers come from the subject himself and which ones come from secondary sources.

The BEHAVIORAL OBSERVATIONS section describes your interview or dealings with the person and you should write as vividly as possible. Do they seem to be concerned about their personal hygiene? Are they well-kept and clean? Describe their overall physical appearance. Next, describe any attitudes, mood, or emotional condition they were in at the time. What did they complain about? Report if you were able to establish a rapport with the subject, if they trusted you, or were suspicious of you. Were they motivated to participate in the assessment process? What did they think about their present problems? If the subject is drooling and/or undulating, explore whether this is due to some medication they are taking, or if that's a common behavior for them. All aberrant and/or bizarre behavior should be noted, as in during the interview, the subject stood up, snapped to attention, and said "Yes, sir" which the subject later said was a mocking gesture, but at the time seemed like an uncontrollable impulse.

The ASSESSMENT RESULTS section will contain four (4) subsections, which are:

The first subsection, Intellectual and Cognitive Functioning, reports such things as your impression of how rich the person's vocabulary is, how well they express themselves, how good their memory is, how clear or clouded their judgment seems to be, and their overall level of intellectual functioning. The most important thing to report is called the sensorium, or how "oriented" the person is to person, place, and time. Generally, this is accomplished by seeing how well the person remembers names (orientation to person), directions to and/or from someplace (orientation to place), and time or when something happened (orientation to time). You, the evaluator, might start the interview with something like I'm going to tell you a name now and I want you to remember it at the end of the interview; OK, the name is Howard Days Funderling and if the person can't remember the name later, you report that the person isn't oriented to person. You might ask them to give directions to the back entrance of a center from some nearby Interstate, and if they can't give clear directions, you report they are not oriented to place. If they can't get the right order for the last five Presidents, you report they are not oriented to time. If the person has no problems on all three, you report the person is oriented times three, or oriented to person, place, and time. Most people with some type of mental illness are only oriented to one, perhaps two, as in the subject was not oriented to place or time. There are lots of other things that need to go in this section, such as calculation, or how well they can keep subtracting sevens starting from 100; how much focus, concentration, or attention they seem to have; and, of course, their judgment, such as what would you do if you got a flat tire on a deserted road late at night.

The second subsection, Emotional State, gets at the prevailing mood of the person. Do they stay in the same mood or does it vary? Do they seem able to control their emotions, or are they overcontrolling their emotions? How does the subject handle stress? When they talk about things that trouble them, are they logical about it, or is there a fanciful flight of ideas and/or looseness of associations? At the very least, you should ask the person about what they do when they feel extremely angry, or at least angry, about something. You want to find out how much acting-out takes place with anger, and what substances, others, and/or defense mechanisms are involved. It's also important to talk to the subject about sadness to determine if there's any suicidal ideation. The same is true of homicidal ideation.

The third subsection, Intrapsychic, is perhaps the most challenging part of the report as it deals with the complexities and forces inside the person that only they can understand about themselves. To get at it, you need to ask probing questions that explore why the person seems to want to project a certain image. Are there any underlying, long-standing hostilities and tensions? If so, what is its probably etiology. What is the person's self-image? Do they have any identity problems or issues getting people to see them as a real person? What do they think drives their personality? What is the level of their own self-insight? You want to report on the main defense mechanism they seem to use to cover something up, and assess whether they are working on any deficiencies they see in themselves, or if they admit to no deficiencies.

The fourth subsection, Interpersonal, gets at how independent the person is. Do they always seem to need someone, or do they always seem to need group belonging? Do they feel that they fit into society, or do they feel alienated and/or rebellious? Try to report on their dependency needs, for family, friends, and lovers. Uncover any trust issues that might be latent for them. Analyze whatever interpersonal conflicts (breakups) they may have had with someone. Also, report your impression of their level of social skills.

The SUMMARY AND RECOMMENDATIONS section will contain an "impressions" paragraph and a DSM IV listing as the following example illustrates:

Overall, John Doe appears to be experiencing a great deal of sadness as reflected in his mood, affect, and orientation to person only. This condition borders on clinical depression as evidenced by appetite and sleep disturbance, self-destructive ideation, and complaints about others at school not understanding him. There is no indication of psychosis or thought disorder, and the subject is functioning as well as can be expected given his recent breakup with a girlfriend of three months duration.

    Axis I: 296.22 Major depression, Single Episode, Mild
    Axis II: 301.60 Paranoid Personality Disorder
    Axis III: Deferred
    Axis IV: 3 - Moderate
    Axis V: Current GAF (Global Assessment of Functioning) 55, Highest GAF 70

This final section will also lead into specific recommendations for treatment, the most important of which is the prognosis, or prospects for successful treatment. The evaluator should indicate which type of treatment (individual or group counseling) is most appropriate and how long the treatment should go on until progress is seen. Something like "group therapy is recommended with an emphasis on social skills training and discussion of trust and identity issues" might be appropriate for John Doe (above). If the recommendation is in favor of legal incompetency or insanity, the report might read something like "diversion from prosecution is recommended with an indefinite stay in an institutionalized mental health setting..."

PRINTED RESOURCES
Carson, R. (1990). "Assessment: What Role the Assessor?" Journal of Personality Assessment 54, 50-60.
Klopher. W. (1960). The Psychological Report. NY: Grune & Stratton.
Maloney, M. (1985). A Clinician's Guide to Forensic Psychological Assessment. NY: Free Press.
Mordock, J. (1997). Custody Evaluations: A Clinician's Guide to Report Writing. NY: Manisses.
Ownby, R. (1997). Psychological Reports. NY: Wiley & Sons.
Tallent, N. (1992). Psychological Report Writing. NJ: Prentice Hall.
Wolber, G. & Carne, W. (1998). Writing Psychological Reports. Sarasota: PRP Press.