Clinical Practice Reports (CPRs) Marking Guidelines and Marking Forms:

Guidelines for the Submission of the Clinical Practice Report (CPR)

1. General guidelines

1.1 CPR requirementsFour written Clinical Practice Reports must be presented during your training. The clinical practice work chosen should be selected to demonstrate the candidate’s competence to put a piece of clinical work they have undertaken explicitly within a research, theoretical and professional context. Practically, CPR material could come from the same placement but across the board it should cover a wide range of types of problems and clinical procedures/interventions. The portfolio of the submitted CCRs should reflect the breadth of experience relevant for a clinical psychologist and in addition to individual clinical practice works/client work should involve work with groups or families or experience of teaching, supervision or consultancy. Evidence of knowledge of more than one psychological model is required either within one or across all the submitted CPRs (whatever is appropriate). Some examples of suitable clinical activity are: individual and group work with clients (see also section 2.1 and 2.4.); working with families; indirect work with a client’s carers; teaching programmes to clients, staff or carers; service development and consultancy (see also section 2.2.); psychometric assessment (see also section 2.3.). Clinical Practice Report should also cover a range of areas of supervised experience across the life span: adult psychological problems; child and adolescent psychological problems; work with people with learning disabilities (adults and children); work with older adults. Trainees should consider that also work that did not go to plan is suitable for submission as CPR. Care should then be taken to address any issues in the critical reflection section under 1.4.

It is not normally appropriate to include amongst the Clinical Practice Reports material that has been submitted for another examination.

1.2. Content of CPRsThe Reports submitted should enable the assessor to have a clear idea of the problem to which the Report refers and of the way in which it was approached. Assessors will be looking for a systematic approach to the problem which integrates theory with practice and addresses the issue of outcome. Assessors attach particular importance to the application of psychological knowledge in the formulation of the problem and the candidate’s demonstrated ability to evaluate clinical work critically and reflectively and to learn from it.

1.3. Structure of CPRsClinical Practice Reports could be structured using the framework below. Variations to this structure outlined below are acceptable (e.g. trainees might find it easier to give context information about their clinical practice work before or after the theoretical background section) but candidates should

present their work in a coherent way that addresses all points outlined in (a) to (c).

If the CPR is describing complex clinical practice work (either an individual case or multi-disciplinary/multi-agency working; multiple complex presenting problems; and complex systemic issues), then trainees need to set their clinical work in the context of the overall problem and the overall intervention, whilst reporting in detail on their own work/approach. Trainees are recommended to discuss complex clinical practice work for CPRs with their supervisor and clinical tutor at placement review.

a. Background and Context. Good theory practice links should be demonstrated throughout the report in relating activity to research findings and theoretical models. This can be in the form of a critical review section at the beginning of the report for the relevant research and theory, which should give a clear rationale for the selection of the theory(ies) with particular reference to the existing evidence base. It should place the work within the relevant context and give a clear justification for the choice of method used in the practical work. Alternatively trainees may feel that it is easier to address this aspect separately under each of the sections below (b, c).

b. Description of Clinical Work. A concise and clear description of the clinical work undertaken with sufficient detail for the reader to understand and evaluate what was done. The practical work should follow logically and sequentially from the preceding section and should demonstrate a high standard of professional practice. Reports will typically include the following sections:

Reason for Referral. A clear and concise statement of the reason(s) for referral (i.e., how and/or why the problem came to the candidate or their supervisor) with a copy of the referral letter appended but care must be taken to ensure that identifying details are removed to ensure confidentiality for your client. This section may sit well at the beginning of the report.

Initial Assessment. This must set the scene of the problem. An initial assessment might include information from interviews, clinical practice work notes, meetings, telephone calls, psychometric measures, observations or daily diaries. Such assessment should form the basis for subsequent action including assessment of outcome. Trainees need to specify who conducted each aspect of the assessment process and to clearly specify their input. Trainees must inform clients of their trainee status at the assessment session and seek their consent to treatment and sharing of information including the write-up (see guidelines in handbook section C-120).

The initial assessment will need to include past interventions if the clinical practice work is a complex one. The assessment may then focus on a more specific area, including a discussion of the reasons / thinking that led to this specific focus, and provide a more detailed description of that assessment;

We will expect a systematic and thorough approach to assessment to be reflected in this section. It should contain details of the assessment protocol as well as information gathered. It is intended that this section should place the presenting problem(s) in a relevant context. Any assessment tools used and methods should be specified.

For individual client work, reporting of psychometric measures needs to include information which will enable the examiner to understand the results presented from the text alone eg. the test name, range of scores possible, mean score for ‘normal’ population, where the client’s score falls eg. > 2 SDs from the mean. It is further expected that information relating to predisposing, precipitating and maintaining factors will be considered at a range of levels, i.e., sociocultural, interpersonal, individual and biological. If a specific trigger is identified then the assessment should include a statement of the meaning of this event for the client. Protective factors should also be considered, e.g. the client’s existing strengths and expertise together with resources available in the professional and lay communities. A description of the client(s)’s initial presentation (how they looked, behaved and related in the first meeting) should be included as should the client(s)’s perception of the problem(s) where appropriate.

For work with groups or within an organizational context, teaching and consultancy some specific guidelines can be found in section 2.

Initial Formulation and Preliminary Hypotheses. An initial formulation consists of a statement about how the problem was understood after the assessment phase or during the early stages of assessment if the whole intervention was an extended assessment. Such an initial formulation could turn out to be wrong but should lead coherently to the initial interventions.

If the clinical practice work is complex, then the initial formulation must be based within a framework of the overall formulation of the presenting problem/s, and this overall formulation must be outlined. The formulation may then focus on some areas in more detail, and in order to generate an action plan that leads coherently to the initial interventions;

The information gathered from assessment and the theoretical and research knowledge pertinent to the client or the clinical practice work should be brought together in a formulation, which provides a clear and compelling account of the psychological mechanisms thought to underpin the presenting problem. The formulation may be based on a single theoretical approach, but in this clinical practice work the critical review would be expected to address alternative perspectives from a comparative or integrative stance. Some guiding hypotheses should follow from the formulation that inform the intervention (throughout it is expected that the report will be respectful of the client(s)’s perspective and particular circumstances).

Management Proposals (Action Plan) and Intervention. A management proposal/action plan following logically from the initial assessment and formulation of the problem should be presented. This action plan might involve further detailed assessment, and/or an outline of the therapeutic intervention, and/or proposals for service development, and/or a teaching programme. Where relevant it should refer to the professional and ethical issues raised. Mention needs to be given to engagement issues including the client’s motivation to change.

If the clinical practice work is a complex one in which the trainee is only focussing on one aspect, the action plan needs to provide an overview of the interventions that are indicated by the initial formulation. The focus should then be placed on the trainee’s own planned intervention;

Intervention. A description of how the action plan was implemented. Although not a verbatim account, this should provide enough detail and/or examples to enable the assessors to have a clear picture of which procedures were adopted. It is important to demonstrate the link between theory and practice in this section and relate procedures to established research findings; a brief, but important section should describe how the end of the work was planned and carried out.

For individual client work, if the clinical practice work is complex, which requires that the majority of the trainee’s time on placement is spent establishing a sound therapeutic alliance and/or gaining a detailed assessment of the client’s history (which might involve substantial liaison with other agencies) and it is not possible to describe an intervention and outcome, then the trainee must demonstrate how the assessment and formulation process has moved the clinical practice work forward and provide an outline of a plan for intervention on the basis of the information gained. In the light of the client(s)’s response or in the case of new information becoming available, evidence should be presented of a review of the formulation and the impact on subsequent therapy. For work with groups or within an organizational context, teaching and consultancy some specific guidelines can be found in section 2.

Positive approach to risk management. The report should show evidence of the awareness of and a balanced approach to risk either involving the client or others and detail how decisions were reached about risk and what factors influenced the judgements made and actions taken. This does not imply that a formal risk assessment should necessarily be undertaken by the trainee, but where possible risk is identified through the referral letter or assessment, then it should be made clear what action the trainee took (e.g., discussed with supervisor) and what action followed from that (e.g., separate risk assessment implemented). Ideally, awareness of and responsiveness to risk will be evident in the trainee’s approach through all phases of their clinical work.

Evaluation and Outcome. The report should present a description of what was achieved clearly with supportive evidence, showing consideration of effectiveness, acceptability and the broader impact of the intervention. This might include accounts and/or measures of change in psychological functioning, skills, settings, management practice, effectiveness of teaching programmes. Follow-up details should be described in this section e.g. was follow-up possible, who was due to conduct the follow-up? Photocopied examples of completed diary sheets/measures, with identifying information blanked out, need to be included rather than blank forms.

If the clinical practice work is complex, the focus should be on the trainee’s own input, but could also include a brief update on overall progress, if appropriate / available;

A re-formulation of the problem. This should initially focus on the trainee’s own input, and should then lead to an overall reformulation;

Critical Review. The report should be concluded with a reflective, balanced and professional critical review. This should focus on the strengths and weaknesses of the trainee’s clinical work and the trainee’s capacity to think reflectively (demonstrating what the trainee learned from carrying out the work, what worked well, what was difficult/challenging, alternative ways of viewing the experience, reflections on ethical/clinical issues, how effectively

he/she made use of supervision and what he/she would do differently in the future).

If the CPR reports a complex clinical practice work, the critical review should show an awareness of the strengths and weaknesses of the intervention as a whole. Consideration should be given to alternative formulations and interventions and awareness should be shown of the professional, legal and ethical issues that can arise when working in complex clinical contexts.

Discussion. In this section, clear and constructive links are made between the theoretical and research background and the piece of clinical work that is described. The review shows evidence of critical reflection upon that practice. Critiques that focus on a particular assessment or therapeutic intervention should detail reasons for referral, assessment, hypotheses and formulation, intervention, clinical practice work closure and how the work was evaluated, but care will be needed in summarising the process so as to conform to the word limit.

Candidates should include a contents page.

Each Clinical Practice Report should include, as an appendix, copies of any letters or official reports written by the candidate and details of communications with parties involved in the referral. It should be noted that report writing, as a professional communication skill will also be assessed. Please do not include copies of published material such as tests/scales for which there is copyright. Instead, make sure that you have described them adequately in your write up.

Consideration should be given to obtaining the client’s consent (Please see Clinical Handbook section C-120) and it is important to note that maintaining confidentiality is mandatory and breaches of confidentiality are regarded as serious professional issue which will be communicated to the appraisor. Any work that breaches client confidentiality will be returned for correction before marking and if this happens repeatedly or if the nature of the breach is very serious, the matter will be reported to the Board of Examiners.

1.4. Word countWhilst it is recognised that reports prepared for placement purposes may be lengthy, the Programme requires that trainees gain the experience of succinctly summarising clinical work. The Clinical Practice Reports submitted may vary in length. However individual reports should be no more than 5000 words in length (any submissions over this limit will be returned for shortening within 48 hours before marking). The Reports should be able to be read without constant reference to the appendices. A draft copy should be prepared for the supervisor in good time, as they will need to sign the front sheet to confirm that the description of the clinical work is a true description of the work you have undertaken.

1.5. Preparation of CPRs

These should be typed with double line spacing, paginated and follow the Publication Manual of the American Psychological Association, 6th Edition (American Psychological Association. (2009). Publication Manual (6th Edition). Washington, DC: APA.)As the Reports are marked anonymously, only one copy of the title page should include the candidate’s name.

1. Specific guidelines

The following guidelines offer potential content and structure for alternative pieces of work, however trainees should make sure that they cover the main areas in the generic CPR guidelines where possible.

2.1. Additional guidelines on writing up group work

There should be a clear and focussed discussion of the rationale for the use of group intervention.

Key principles used in selection of members should be outlined. This may include a summary of the inclusion and exclusion criteria, or outline of staff team/home needs.

Details of assessment should be given of prospective members (if appropriate) including any psychometric assessment or baseline measures.

Brief details should be provided of all members involved. This may include a formulation of the difficulties of individual members, or more likely, a summary of the nature of the problem faced by group members or staff team/group home. Consent issues should be discussed.

A clear outline should be given of the intended aim and theoretical basis of the intervention for group members or carers. If a standard intervention is used (e.g. anxiety management or anger management programme) an outline should be provided as to how it will benefit both clients and carers. Consideration should be given as to how the group will impact on the context/system. Details should be given of the main components or techniques used.

Leadership issues should be considered (including use of co-therapists).

The content of group sessions may be described although not in excessive detail.

Evaluation should be made of the group in terms of group processes, dependent on the theoretical perspective used, individual participants and the context.

o If appropriate, results of repeated psychometric or baseline measures should be included, together with participant feedback.

There should be a review of the group, together with a review of the strengths and weaknesses of the clinical work.

It is essential to show reflection and awareness of diversity in all pieces of academic work.

2.2. Additional guidelines on writing up consultancy/teaching

1. Referral/Establishing the ContractA clear statement should be made about the reasons for undertaking the piece of work. This could be a statement about referral (if a referral was made) or identified service needs and how you learnt of these. In consultancy, this would involve identifying the client and roles and responsibilities of the consultant.

2. Assessment PhaseA description should be provided of methods of gathering information and sources of information eg. discussion with service manager, staff team, observation etc. Consent issues should be discussed.

3. Formulation of Problem/Service needIf possible, use theory of consultation/adult learning or appropriate psychological model to structure formulation. Alternatively, describe the use relevant published work guiding your undertaking. Demonstrate how the problem is conceptualised following the assessment phase. This may lead on to a further gathering of information.

4. Action PlanA plan of intervention should follow logically from the assessment and formulation. This should cover aims and objectives for teaching/consultation and an outline of the teaching/consultation plan. In a consultation you may wish to discuss issues of legitimacy and resources.

5. Intervention/Implementation phaseProvide a description of what you have done and the methods used, related to any relevant models/evidence

6. OutcomeDescribe what was achieved in relation to the original aims and objectives. In teaching there may be an assessment of learning needs before and after the intervention, or as a minimum feedback on teaching. In a consultation there

should be an exploration of how the ending was agreed and what implementation plan or follow-up has been arranged. Feedback from the consultation and closure of the contract should be discussed.

7. ReviewDiscuss strengths and weaknesses of the work and any ethical professional issues, along with any lessons learned and alternative options for interventions.

2.3. Additional guidelines on writing up psychometric assessments

2.3. 1. Content of a psychometric assessment CPROf the required four written Clinical Practice Reports one may be a report of a psychometric assessment (for example as often performed in neuropsychological/rehabilitation settings but not limited to this). See section 1.2. for requirements regarding joint work.

The Report submitted should enable the assessors to have a clear idea of the problem to which the Report refers and of the way in which it was approached. Assessors will be looking for a systematic approach to the problem which integrates theory with practice and addresses the issue of outcome. The assessors will attach particular importance to the application of psychological knowledge in the formulation of the problem and the candidate’s demonstrated ability to evaluate the assessment work critically and to learn from it.

USE THESE GUIDELINES FLEXIBLYClinical Practice Reports could be structured using a logical framework. A

structure is suggested below. Candidates should use the structure flexibly to present the clinical practice work as efficiently and simply as possible. The

structure should support, rather than constrain, the presentation of the CPR. Whatever structure is chosen, candidates should endeavour to take into

account points 2(i) to 2(ix).

2.3.2. Structure of a psychometric assessment CPR

(i) Referral - A brief statement of how and/or why the problem came to the candidate or their supervisor, who referred (agency, profession), for what presenting problem or to answer what questions. An CPR should contain a clear statement of the purpose of the assessment;

(ii) Pre assessment thinking – This information may be partly available from the referral and should be generated by the trainee in his or her thinking about the referral. It should indicate the broad classes or types of likely or possible causes of the problem for which the client has been referred for assessment.

For example:

Physical illness (e.g. tumour, infection) Iatrogenic (caused by treatment) Developmental delay (e.g. autism, Down’s syndrome) Organic (e.g. degenerative condition or conditions)

Malingering (i.e. the individual may benefit from claiming or exaggerating deficits, either deliberately or without awareness)

Psychogenic (e.g. due to depression, grief or anxiety) Multiple (a combination of the above)

Alternatively, if the client is being referred for assessment for rehabilitation or management, it may include your pre-assessment thinking about the likely cognitive and emotional impact of the disorder and how you may go about assessing these. It might also include your thinking about ethical issues, the reason for the referral and what you will need to find out in order to be able to respond to it.

(iii) Initial assessment – This must set the scene of the problem, and should describe the client’s and family’s concerns. Ideally, it should contain a sense of the client’s own speech or the client’s own thoughts about the problem, and should stress the multiplicity of concerns expressed by the client. For example, the client complains that they ‘feel embarrassed when going to the pub’. When this is unpicked through interview the following symptoms are elicited: a) he can’t remember the order, b) he can’t name the drinks, and/or c) he can’t calculate the cost of the round. All of these problems (memory, expressive language and calculation deficits) lead him to avoid the pub because he is afraid he will embarrass himself or his friends (social anxiety).

An initial assessment might include information from interviews, clinical case notes, meetings, telephone calls, observations or daily diaries, past medical history, previous assessments, screening measures conducted during the initial assessment or by other colleagues. Make sure you note previous diagnoses or major treatment (such as inpatient psychiatric hospitalisation). Include placements (e.g. group home or day activity) if relevant for the assessment. Such assessment should form the basis for subsequent action including assessment of outcome.

a) Background information on the client

Date of birth, age, gender, and handedness. For children and young people with suspected learning disabilities: family, parents’ age, social and educational history, job functioning, marital history, health, siblings age, school performance, family history, medical or developmental history (for children this may include pregnancy, birth, perinatal incidents, hospitalisations-overnight), neurological history (blows to the head, seizures), milestones (first unsupported steps, first words other than mum/dad, toileting), current treatment/medication, school (academic progress – reading, writing and numeracy, socialising with peers, compliance with routines).

For adults and older adults: family history, age and cause of parents’ deaths, social and educational history, job functioning, hobbies or interests, marital history, health, siblings age and health status, medical history, neurological history (blows to the head, seizures, stroke etc), current treatment/medication.

b) Presenting Complaint

Be behavioural and descriptive. How long has there been a problem, how severe is it, when did it start, what is the frequency/duration of the difficulties, does it vary, have there been previous attempts at intervention and how successful were they.

c) Clinical impression

Observe and comment briefly on grooming and clothes appearance, language and social presentation, affect, response to you, response to testing (is it therefore valid or representative of their actual abilities?).

The CPR should contain a clear statement of what the client was like and how much assessment was possible;

(iv) Initial formulation - An initial formulation consists of a statement about how the problem was understood after the Initial Assessment. Such an initial formulation could turn out to be wrong but should lead coherently to the Action Plan.

If the clinical practice work is a complex one, then the initial formulation might be a mixture of the causes outlined in (ii) or some other factors may be at play. This section should describe the overall formulation of the presenting problem/s, but then may focus on some areas in more detail. This will allow generation of an action plan that leads coherently to the assessments used;

(v) Action plan - following logically from the initial assessment and formulation of the problem. This action plan should specify what assessments you have decided to use and how you decided on them. For example, your assessment may be part of a multidisciplinary assessment which included: neuroradiological scans, laboratory analyses (bloods), observations, diary records, further interview and psychometric testing.

If so, and the trainee is focussing on only one aspect, the action plan needs to provide an overview of the assessments that are indicated by the initial formulation. The focus should then be placed on the trainee’s own planned assessment.

Where relevant it should refer to the professional and ethical issues raised;

(vi) Further assessment - A description of how the assessment was implemented. Although not a verbatim account, this should provide enough detail and/or examples to enable the assessors to have a clear picture of which procedures were adopted. It is important to demonstrate the link between theory and practice in this section and relate procedures to established research findings:

a) Assessment process – briefly describe the assessment process, how you clarified the aims of assessment with the client and explicitly gained consent for assessment. If a child or an individuals who is not capable of giving informed consent is involved, described how you handled this issue (e.g. seeking assent from relative in the clinical practice work of an older adult with suspected dementia, or consent from the parent of a child);

b) Sessions – briefly describe how many sessions were required, how long they were (e.g. the client was seen for assessment at home on three occasions. Each testing session took an hour). Depending on the clinical practice work you may wish to describe what you did at each session and why, although this is not always necessary (e.g. session 2 was curtailed due to fatigue/anxiety);

c) Assessment results – summarise the assessment results, giving the reader a clear structure for interpreting and assimilating information, e.g. group together information on similar functions or aspects of the client’s presentation (for example, general intellectual function, attention, executive function, motor function, verbal abilities, visuo-spatial and visuo-constructive abilities, memory, affect/personality) rather than going through results test by test without a framework. Give test results in a table. This table should include: the test name (maximum score), raw scores, scaled scores, and percentile ranks. Where necessary, describe the client=s performance in test terminology not using impressionistic labels. Many manuals provide a verbal description of performance such as ‘borderline normal’, use these as well;

d) Observations – describe the client’s reactions to assessment and their performance during assessment, including any problems noted during testing (e.g. lack of insight, expressive difficulties, poor motivation, difficulty sustaining attention, tearful, self-derogatory, etc.);

e) Interpretation – summarise the strengths and weaknesses identified and the likely brain regions or cognitive modules/operations which may be compromised. Good interpretations contain opinions based on objective evidence not subjective impressions (objective evidence includes clinical opinion based on observation, however). Provide a source of normative data if a test is not widely used or there could be doubt about its interpretation. Explain statistics if necessary;

(vii) Re-formulation of the problem - This should initially focus on the trainee’s own input, and should then lead to an overall reformulation. Synthesise all the information you have gathered about the client’s presenting problems. The re-formulation may be the same as the initial formulation but with more detail and more evidence, or it may be different as a result of the information gathered during further assessment. Summarise details about the client, the cognitive difficulties, the effect on his or her life, mood etc.

Re-formulations can be seen as the summary section of a clinical report. That is they should finish by making a statement about what the presenting problems suggest in terms of the likely causes outlined in (ii), e.g. “the cognitive difficulties Mr S is experiencing were consistent with the injury sustained and these difficulties are addressed in the recommendations outlined below”.

Reformulations should contain your opinion.

The reformulation may also contain detail about recommended or planned rehabilitation;

(viii) Intervention/Recommendations section - Some psychometric assessments lead to rehabilitation interventions, some lead to recommendations or feedback to the client, the client’s family and/or the referring agent, some lead to both.

If you undertook rehabilitation with the client, you should provide enough detail and/or examples to enable the assessors to have a clear picture of which procedures were adopted. It is important to demonstrate the link between theory and practice in this section and relate procedures to established research findings.

If the clinical practice work resulted in advice or care planning, please describe plans, advice, or recommendations made on the basis of your assessment (e.g. rehab planning and sessions carried out, need for support, competence, follow-up services, need for re-evaluation). Describe how the information was shared with the client, their family (if relevant) and the referring agent. Describe the impact of this information on the individuals/systems concerned. Describe how this information was used as a collaborative working tool with the client and/or family; (ix) Outcome - A description of what was achieved. This might include accounts and/or measures of change in neuropsychological, social, behavioural or occupational functioning, skills, settings, management practice, and so on.

Follow-up details should be described in this section. If the clinical case is a complex one, or if others were involved in taking forward clinical care then the focus should be on the trainee’s own input, but could also include a brief update on overall progress, if appropriate / available;

Critical review - This should focus on the strengths and weaknesses of the trainee’s assessment. If the CPR reports a complex case, the critical review should show an awareness of the strengths and weaknesses of the assessment as a whole. This might include the trainee’s view on the adequacy of the assessment, the tests used, whether additional assessments might have been helpful, which ones and why, the length of assessment, the degree to which the client engaged with the assessment, the degree to which the initial formulation needed reworking and what the trainee learned from that, the degree to which recommendations from the assessment were adhered to by others, or the pragmatic constraints of the service. It might also include ideas about what clinical issues need addressing next for this client.