Treatment reports: Do’s and don’ts

Simon Milton – Professional Officer

Psychologists providing treatment in clinical or counselling settings often receive requests from their clients for court reports. For example, an opinion may be sought about custody arrangements or parenting competency. Reports may also be requested for insurance or workers’ compensation cases. When a client faces criminal charges, the psychologist may be asked to comment on the relationship between the alleged offence and the client’s psychological condition or to make a judgement about the likelihood of recidivism. Often the psychologist feels bound to assist their client in such circumstances and agrees to provide the report, despite having limited experience in report writing and failing to realise the pitfalls for both the client and the psychologist.  

Initially, psychologists should remember that they are under no obligation to provide a report if the client initially engaged their services for treatment. Further, it would be unethical to provide a report if the psychologist believed they were not competent to do so. If the psychologist does decide to provide a report, they might consider only providing a treatment report, regardless of what has been requested by the client or their lawyers.

A treatment report helps to ensure that the treating psychologist does not veer outside their area of competency and that they are not drawn into providing opinions about matters they have not assessed or where their opinion is or will appear to be biased. 

The following is a basic structure that can be used when providing a treatment report:

  • List your qualifications and area of expertise.
  • Discuss the context in which the report is being provided. State that you are the client's treating psychologist, the reasons for writing the report, the questions that you have been asked, and the limitations of the report due to your clinical relationship with the client.
  • State the presenting problem.
  • List the information available to you when preparing the report.
  • Provide details of your assessment including the results of any psychometric tests.
  • Provide a general description of the intervention provided.
  • Report the client's engagement with treatment.
  • Report objective measures of treatment outcome.
  • Provide recommendations for future treatment.

It is important to recognise that the purpose of any court report is to assist the court in making its decision. Although the report may ultimately assist the client, the first priority is to provide objective information to the court.

Psychologists are often asked to answer questions or give opinions in their reports that are beyond their competency or that require an assessment that is not typically undertaken in a treatment setting. For example, a psychologist may be asked to provide an opinion on whether a client is likely to reoffend. A treating psychologist is unlikely to be in a position to provide an objective or an evidence-based opinion on such a matter. As such, it is quite reasonable for the psychologist to decline the request and suggest the type of assessment required to address that question.

Treating psychologists are also asked to give opinions on people they have not assessed. For example, a psychologist may be asked to give an opinion on the parenting skills of a client's ex-partner despite having never assessed the ex-partner. Reports providing such opinions may be severely criticised by the courts and can lead to a complaint being made against the psychologist. Again, it is quite reasonable for the psychologist to not provide an opinion. Further, all psychologists should practice extreme caution when asked to provide clinical opinions about people they have not directly assessed.

The Council receives many complaints about court reports written by treating psychologists. Unsubstantiated and unsupported statements can cause distress to members of the public and can lead to the court rejecting the report to the detriment of the client. Seeking supervision and undertaking professional development can help avoid many of these problems.

Dr Rebecca Matthews has provided an excellent summary of this topic on which this article has drawn. See: Matthews, R (2015). How to prepare a psychological report as a treating practitioner that may be used in court. InPsych, 37(5), 35.