Psychological Testing and Assessment
Abstract and Keywords
Psychological evaluations are commonly conducted within psychiatric settings with the goal of informing treatment decisions that are intended to benefit the patient. In addition to a clinical interview and review of records, the evaluation includes the selection, administration, scoring, and interpretation of psychological testing. Guided by the question(s) from the referring party, this multifaceted process occurs within a setting of existing care that requires clarification of the roles/duties of the professionals and organizations relative to each other and the patient. Additionally, psychological testing involves unique ethical considerations (e.g., psychometrics) not typically encountered during psychotherapy or psychiatric care. A variety of standards, provided in the form of rules that require or prohibit specific behaviors, has been created by governing organizations in order to inform the ethical decision-making process while conducting psychological assessments. These standards are understood within the broader framework of aspirational principles of ethics (e.g., nonmaleficence) universal to biomedical practice.
Psychological testing is the general term for the selection, administration, scoring, and interpretation of measures designed to address questions related to intellectual ability, diagnoses, neurocognitive functioning, and level of ego development, among others. Psychological testing is one component of a psychological evaluation which typically includes a review of records, clinical interview, behavioral observation, and communication with others, including the referring party (e.g., the treating psychiatrist). An assessment typically results in a written report that is intended to inform the treatment process. Guidance for ethical decision-making in psychological assessment is provided both in the form of aspirational principles (e.g., patient autonomy) that are applicable across a variety of medical settings, as well as specific standards established by organizations that oversee the training and licensure of psychologists.
Ethical Considerations Relevant to Psychological Evaluation
Psychological testing is an important component of complex psychiatric evaluations, and prudent psychiatrists often seek them. At the same time, psychiatrists are not required to know, and are seldom familiar with, the ethical standards surrounding the use of psychological tests. The purpose of this chapter is to provide an overview and practical guide for the reader regarding best practices when utilizing psychological assessment services.
(p. 1092) First, we will review the basic principles of biomedical ethics that govern the practice of medicine and psychology and their application to psychological evaluations. Second, we address some of the specific standards that have been established by various professional organizations. In the third section, we address practical issues such as the question of who is the patient, the context of evaluation, and various constraints that may arise. The fourth section addresses matters of informed consent as well as the responsibilities of psychologists regarding matters such as choice of test instruments, scoring, and interpretive procedures. In this section we also address various technical problems such as assessing malingering and the challenges of evaluation in a multicultural context. We conclude with a discussion of how and to whom results should be delivered.
This chapter is an overview and guide specific to psychological evaluations; a discussion of overarching ethical problems common to psychiatric practice (e.g., potential harm to patients secondary to diagnoses/test findings such as personality disorders, intellectual disability, or a dementing process) will be discussed on a limited basis to avoid duplication of such material found elsewhere within this Handbook.
Psychiatrists, as all physicians, are bound by the Principles of Biomedical Ethics (Beauchamp and Childress 2009). This is true for psychologists as well and may be found, albeit in altered form, in the American Psychological Association’s (APA) Ethical Principles of Psychologists and Code of Conduct (2010). Here we briefly review these principles and how they may be relevant in psychological assessment.
This principle encompasses both liberty, the freedom from the controlling influences of others, and agency, the capacity for independent action (Beauchamp and Childress 2009, p. 100).
Respect for autonomy means that we acknowledge the rights of others to hold views, make choices, and take actions based on their personal values and beliefs (Beauchamp and Childress 2009, p. 103). From this principle certain general moral rules can be deduced such as truth-telling, respect for privacy, and protection of confidential information (Beauchamp and Childress 2009, p. 104). Principle E of the APA Ethics Code (2010, p. 4) states in part that psychologists are to respect the worth and dignity of others, protect those whose autonomy is impaired, and respect individual and cultural differences. Two aspects of autonomy most relevant to psychological assessment are informed consent and competence.
The APA Ethics Code (2010, p. 3) states that: “Psychologists strive to benefit those with whom they work and take care to do no harm … (They) seek to safeguard the welfare and (p. 1093) rights of those with whom they interact … (and) they are alert to … factors that might lead to misuse of their influence (Principle A).” More specifically, beneficence entails not only promoting the welfare of patients but also balancing benefits against risk to produce the best overall result (Beauchamp and Childress 2009, p. 197).
Psychologists are not neurosurgeons; our errors will never paralyze a patient, but the practice of psychological assessment is not benign. Not only are we to avoid harm but we are also to avoid engaging in actions that would risk harm (Kitchener 1984). Since the APA Ethics Code does not define harm (Kitchener 1984), we are left to determine how much discomfort is justifiable. A second aspect of nonmaleficence is more precise, viz. being negligent and failing to maintain appropriate standards of care. We discuss various aspects of this issue below.
This term usually refers to distributive justice or the “fair, equitable, and appropriate distribution (of services) determined by justified norms that structure the terms of social cooperation” (Beauchamp and Childress 2009, p. 241). For further reading see Rawls (1971). In this regard, Principle D states: “Psychologists exercise reasonable judgment and take precautions to ensure that their potential biases, boundaries of their competence, and limitations of their expertise do not lead to or condone unjust practices.” The philosophical and policy questions that derive from this principle are beyond the scope of this chapter, but relevant issues include the concepts of competence, its boundaries, and concerns regarding bias.
Historically, the four principles listed above constituted the basic principles of biomedical ethics. Recently the principle of professional–patient relationships has been added to emphasize the importance of veracity, privacy, confidentiality, and fidelity. Karen Kitchener (1984) argues that these obligations are especially critical to mental health treatment where trust is such a vital part of practice.
While psychologists perform assessments of their own patients, they also do so as consultants. When playing a consulting role, psychologists do not have the same fiduciary obligations as they would to their own patients. Nevertheless, some of these issues remain relevant to those who provide consulting services.
Laws and Organizational Rules
The five principles of biomedical ethics serve as aspirational guidelines for all the fields of medicine, and they have been adapted in various ways by organizational bodies tasked with (p. 1094) determining the training and clinical goals of their members. These organizations, which function within national, state, or provincial boundaries, derive enforceable standards from these principles that must be adhered to in order to maintain membership in good standing and avoid sanction.
Considerations beyond Standards
Regardless of location, psychologists must consider how a state, province, or nation’s laws may conflict with professional standards. The APA Ethics Code (2010, p. 4) states:
If psychologists’ ethical responsibilities conflict with law, regulations, or other governing legal authority, psychologists clarify the nature of the conflict, make known their commitment to the Ethics Code, and take reasonable steps to resolve the conflict consistent with the General Principles and Ethical Standards of the Ethics Code. Under no circumstances may this standard be used to justify or defend violating human rights.
Professional organizations and regulatory bodies typically allow psychologists to defer to the legal system on matters where a conflict may arise between professional standards and the law, while clearly communicating the need for the psychologist’s actions to be guided by the generally more demanding ethical code (e.g., see Knapp et al. 2007). In the context of psychological assessment, for example, the situation may arise in which a court issues an order for the release of test data that the psychologist deems potentially harmful to the client. Here, psychologists would fulfill their ethical duty by explaining their concerns regarding potential negative consequences, communicating their responsibility to adhere to the principle of nonmaleficence, and attempting to resolve the matter by providing alternative information that would satisfy the court’s needs. If the court orders the release of the test data nonetheless, and psychologists comply, it is unlikely they would face organizational or regulatory sanction.
In addition to the legal context in which ethical standards are applied, one must consider the unique and often complex set of factors which can affect their application. The introduction to the British Psychological Society’s (BPS) Code of Ethics and Conduct states:
Psychologists are likely to need to make decisions in difficult, changing, and unclear situations. The Society expects that the code will be used to form a basis for consideration of ethical questions, with the principles in this code being taken into account in the process of making decisions, together with the needs of the client and the individual circumstances of the case. However, no code can replace the need for psychologists to use their professional and ethical judgment.
(BPS 2009, p. 4)
The emphasis placed on the need for individual judgment based on professional training demonstrates the inadequacy of standards as a comprehensive guide. Relative to general principles such as justice, standards offer more specificity regarding ethical behavior. However, they should be viewed only as an organizing structure for ethical decision-making since they cannot account for all possibilities. The APA Ethics Code (2010) communicates this point by stating that conduct “not specifically addressed by an Ethical Standard does not mean that it is necessarily either ethical or unethical” (p. 2).
(p. 1095) Standards are not only limited in their ability to inform ethical behaviors in all situations, but could serve as an impediment to psychologists who would otherwise aspire to an even higher level of ethical excellence in their absence (for further reading see Handelsman et al. 2009). Standards are often presented in the context of what one should not do and the potential sanctions that could follow if the standard were violated. From this perspective, psychologists may disregard or overlook personal beliefs based on the totality of their life experience, including religious and/or philosophical principles, which would otherwise inform their behaviors. An alternative way of addressing such issues is offered by the concept of positive ethics which has been proposed as a way of maintaining a comprehensive outlook on ethical decision-making, including self-care, self-awareness, ongoing peer consultation, and the identification and promotion of beneficial behaviors that result in the highest ethical position possible (Handelsman et al. 2009).
Extensive training is required to competently administer, score, and interpret psychological tests. Unlike physicians who are typically required to obtain board certification within a specialty area as a prerequisite for employment and access to medical privileges, psychologists are not required to participate in a formal specialization process, and most do not. Board certification is offered by organizations such as the American Board of Professional Psychology (ABPP) which designates areas of specialization including clinical neuropsychology, clinical health psychology, and forensic psychology. Some employers place an emphasis on acquiring such certification, but relatively few psychologists hold board certification for various reasons and the lack of it does not indicate a lack of competence. Responsibility for maintaining competence within the area of psychological testing falls to the professional organizations that provide educational standards and accredit academic programs, the regulatory agencies that review complaints against psychologists, as well as individual psychologists who must adhere to standards and familiarize themselves with recommendations by various organizations whose focus is testing.
Standards regarding competence are typically general in nature and often do not comment directly on psychological testing. For example, the APA Ethics Code (2010, p. 4) states: “Psychologists provide services … based on their education, training, supervised experience, consultation, study, or professional experience” (Standard 2.01). Standard 2.3 within the BPS Code of Ethics (2009, pp. 16–17) references the need for psychologists to engage in continued professional development, remain aware of relevant innovations within their realm of professional activity, consult and receive supervision when their professional expertise may be insufficient for the circumstances, receive adequate education and training, remain aware of and acknowledge the limitations of their methods and conclusions across various settings, and help ensure that supervisees adequately comply with these standards and do not work beyond their level of competence.
(Krishnamurthy et al. 2004, pp. 732–733)
This relative lack of guidance regarding standards for competence in the form of enforceable rules makes it difficult for practitioners and students to determine what training and experience is needed to attain competence. The absence of a single system of rules is due in part to the wide variety of settings (e.g., academic, forensic) in which testing is conducted along with the numerous assessment instruments that exist. Although enforceable standards (p. 1096) do not exist for establishing competence in the area of psychological testing, guidelines do exist to help inform the process. The Association of Psychology Postdoctoral and Internship Centers organized a conference (co-sponsored by the APA and others) on competencies that led to a report by Krishnamurthy et al. (2004). Eight core competencies in psychological assessment were identified (Box 74.1) along with four recommendations for training (Box 74.2) and three principles for evaluating competency. Similar guidelines specific to personality (Society for Personality Assessment 2006) and neuropsychological assessment (Hannay et al. 1998) have also been proposed.
Focus of Content
(Krishnamurthy et al. 2004, p. 734)
Psychological testing is the general term for the selection, administration, scoring, and interpretation of measures designed to address questions related to intellectual ability, diagnosis, neurocognitive functioning, and level of ego development, among others. A variety of specializations exist that employ testing including educational, forensic, child, occupational, neuropsychological, and health psychology. We do not attempt to cover all specialties but instead focus on ethical issues within psychological evaluations most relevant to psychiatric settings. (p. 1097)
The Roles and Context of the Referral
Who Is the Client?
If a psychologist in private practice were to be contacted by an individual desiring a psychological evaluation, there would be no question as to who the client is and to whom the psychologist owes his or her professional obligation. However, the identification of roles and issues of fidelity are more complicated in many of the settings in which psychological evaluations are provided. For instance, who is the client when an institutionalized patient with multiple providers is referred for testing within a hospital system? Is it the referring psychiatrist, the primary care physician, the patient, the patient’s representative, the funding insurance carrier, or the institution in which the evaluation is conducted? Psychologists are expected to cooperate with other professionals when “indicated” in order to “serve their clients/patients effectively and appropriately” (APA Ethics Code 2010, Standard 3.09, p. 6), but psychologists must first identify who their client is and with whom the professional relationship and accompanying obligations exist. Unfortunately, a standard that specifies the appropriate course of action in all instances does not exist. The primary means by which a psychologist maintains fidelity to the patient is by determining their role with respect to all parties involved and disclosing potential conflicts that may arise.
Forms of Testing
Numerous psychological tests exist to assess diverse populations in a variety of settings, including health and rehabilitation psychology; however, the two primary types of evaluations used in psychiatric settings are personality assessment and neuropsychological testing. A particular referral question may be addressed most appropriately using one form of testing to the exclusion of the other, but it may require both. All forms of psychological (p. 1098) testing materials (e.g., manuals, instruments, protocols, test questions or stimuli) are not to be released, as psychologists are required to protect their integrity and security (APA 2010, Standard 9.11, p. 13). However, rules differ regarding the release of test data, which include raw and scaled scores along with the patient’s responses. The APA Ethics Code (2010, Standard 9.04, pp. 12–13) allows for the distribution of this material to parties identified by the patient in release of information documentation but other regulatory bodies may not. In addition, a psychologist “may refrain from releasing test data to protect a client/patient or others from substantial harm or misuse or misrepresentation of the data of the test.” In the event that a psychologist is concerned about the possibility of substantial harm, the principles of nonmaleficence and beneficence would have to be weighed against the principles of respect for autonomy since the patient’s wishes would be denied.
Neuropsychological evaluations assess a patient’s performance on a variety of neurocognitive tasks including global intellectual ability, academic functioning, memory, attention, executive functioning, visuospatial skills, language, processing speed, and motor skills. This form of evaluation is effective for informing referral questions related to ADHD, dementia, traumatic brain injuries, and other conditions associated with brain functioning (e.g., to what extent might executive functioning problems be contributing to poor medication compliance?). Referrals for neuropsychological testing often come from the patient’s primary care physician, psychiatrist, or neurologist, requiring coordination of care and clarification of roles to avoid potential harm and maximize benefit to the patient.
Personality assessment is a form of psychological assessment used to identify particular states and traits in order to describe their character and psychological functioning. This may include the identification of specific symptoms and their severity, tolerance for distress, coping mechanisms, risk for self-harm, interpersonal functioning, self-view, quality of thinking, and emotional regulation. Personality assessment is subdivided into two types of measures: self-report inventories and performance-based measures. Self-report inventories, including the Minnesota Multiphasic Personality Inventory, second edition (MMPI-2) (Butcher et al. 1989), MMPI-2 Restructured Format (MMPI-2-RF) (Ben-Porath and Tellegen 2008), and the Personality Assessment Inventory (PAI) (Morey 1991), consist of standardized questions to be answered by the patient based on how well they feel an item applies to them. Performance-based testing, including the Rorschach Inkblot Method (Rorschach 1964; Meyer et al. 2011), assesses personality characteristics based on actual behavior when presented with a moderately ambiguous task. Due to the unique contributions of self-report and performance-based measures, it is often recommended they be administered in combination when personality characteristics are the primary focus of the referral question and particularly when a formal thought disorder or problems with reality testing are suspected.
Adjustments to the Referral
Ideally, the relationship between the referral source and the psychologist is a collaborative one in which concerns and ideas are communicated throughout the evaluation process. Such collaboration requires psychologists to play an active role in the process well beyond test selection. For example, based on a review of records, psychologists may develop additional questions of their own; this also frequently happens during the process of interviewing and testing the patient. Most importantly, the patient may provide information that informs (p. 1099) the process and adjusts the focus of testing. Finally, collaboration involves the patient. As a means of developing rapport and honoring the ethical principle of autonomy, all psychological evaluations should begin with an inquiry regarding what questions and concerns are most relevant to the patient. Doing so may reveal additional concerns and symptoms that will further inform testing and treatment planning.
In order to keep all parties informed, any major adjustments to the referral question(s) should be communicated to the referring psychiatrist in a timely manner. The situation may even arise in which the psychologist concludes that psychological testing is either incapable of or is an inappropriate means by which to answer the referral question. For instance, a referral for evaluation requested that the psychologist determine if the patient would act on their homicidal thoughts. The psychologist can provide additive information about the context in which the patient’s impulsivity, anger, or depression is experienced, but would have to communicate the inability of a psychological evaluation to precisely predict specific behaviors such as violence to self or others.
When psychologists conduct an assessment, they obtain the informed consent of the patient (APA 2010, Standard 9.03, p. 12). Informed consent is a process by which a patient’s autonomous authorization for assessment or treatment is obtained. Since psychological testing is generally a voluntary process, efforts should be made to ensure that the patient is fully informed about the testing process, including its risks and benefits. The informed consent process also should provide the patient enough information about the evaluation and its intended uses for him or her to reach an informed decision about participating.
Informed consent involves providing the patient with an explanation of the purpose of the evaluation (e.g., pre-surgical planning, differential diagnosis, monitor the effect of treatment, etc.), the role of the psychological consultant, his or her relationship with other health professionals treating the patient, the likely use of the testing data, and the limits of confidentiality (APA 2010, Standard 3.11, p. 7). Additional information should include a general description of the assessment process, including procedural issues such the expected length of the evaluation, as well as how and to whom the results will be communicated. Engaging the patient in an interactive discussion of all pertinent information prior to the evaluation honors the principles of autonomy, beneficence, and nonmaleficence within the framework of existing ethical principles, laws, and institutional rules and has the added practical benefit of gaining the patient’s cooperation and improving performance.
Informed consent should never be assumed simply because the patient presented for a scheduled assessment, whether in an outpatient setting or a locked inpatient unit. It is possible that a patient may feel pressured to comply with a mental health professional or even coerced by a family member (for further reading see, Gottlieb et al. under review). Therefore, it is important to elicit the patient’s understanding of why the assessment was recommended by their health care practitioner in order to identify potential misconceptions, clarify the purpose of the evaluation, and ensure the patient is voluntarily (p. 1100) consenting. In situations when the patient has questionable capacity to consent, or the patient is clearly incapable of doing so, such as in the case of a minor, the psychologist nonetheless provides an appropriate explanation, seeks the patient’s assent, considers the patient’s best interests, and obtains permission from a legally authorized person, if applicable (APA 2010, Standard 9.03, p. 12). Even young children and adults with limited cognitive ability can usually understand a simple and straightforward explanation of the reason for the evaluation.
General Assessment Process
The nature and duration of the evaluation will vary based on the referral question, selected test battery, documents to be reviewed, and patient characteristics. After the assessment is completed, the psychologist scores and interprets the test data, integrates it with collateral sources, and writes a report for the referral source. This process varies by setting and practitioner, but typically it requires at least one to two weeks. The assessment typically yields a written report in which the referral question(s) is addressed. The report may vary in structure but generally includes a patient’s identifying information, the sources of information, a list of procedures followed, results, conclusions, and recommendations. Although the impetus for evaluation is often some concern regarding pathology, all patients have unique strengths and weaknesses that are discovered during the course of a psychological assessment, and it is important for both to be presented and integrated into conclusions and recommendations. Any reservations or limitations about the test results and conclusions should also be explained. For example, if the patient complained of having slept poorly the night before the evaluation, the psychologist may comment that fatigue may have negatively impacted performance and affected the results.
There are no official standards that dictate test selection for any particular psychological assessment; rather, practitioners are trained in the various philosophies, theories, and psychometric properties underlying assessment instruments to make professional judgments. Psychologists may have equally legitimate reasons for choosing different tests or techniques for the task at hand. One way or another, psychologists are required to base their opinions on techniques sufficient to substantiate their findings (APA 2010, Standard 9.01, p. 12). For example, if the referral question involves the determination of the presence or severity of dementia, measures designed to assess memory and language would be included in the test battery rather than the Rorschach technique, which is not designed for this purpose.
In addition to formal testing, psychological assessment typically involves conducting a clinical interview and reviewing multiple sources of information, including available records and collateral sources, all of which are integrated to arrive at a coherent case conceptualization, conclusions, and recommendations. Psychologists do not base their assessment decisions or recommendations on tests that are outdated for their current purpose (APA 2010, Standard 9.08, p. 13), but there is no unambiguous rule for determining if a test is obsolete. (p. 1101) For example, an older version of a test may be used when performing a re-evaluation or when the previous version’s normative data is a better match for the patient.
Psychologists are wise to use only those instruments that are based on sound psychometric principles such as appropriate standardization, reliability, validity, and adequate normative data. Psychometrics, or the theory and technique of psychological measurement, involves the construction, validation, and refinement of test instruments and procedures. A thorough review of this field is beyond the scope of this chapter; below we provide a brief overview. For further information on this topic, we suggest Kaplan and Saccuzzo’s text, Psychological Testing: Principles, Applications, and Issues (2013).
Reliability refers to the consistency of a measure. That is, a test would have no value if it were inconsistent and produced different results every time. There are different ways of measuring reliability, and these will vary depending on the assessment context. For example, test-retest reliability, or the consistency of test results over time, is often important in clinical assessment, particularly when measuring stable constructs such as intelligence. When a test taps a fluctuating state, such as symptoms of depression, it is desirable that test items be sensitive to more transient emotional states in order to detect change such as improved mood in response to treatment, but in these cases, test results will vary more widely and are inherently less reliable.
In the case of repeated assessments, it is important to consider the likelihood and potential magnitude of practice effects, or the influence of past experience with the same instrument. Practice effects are most pronounced when the interval between the tests is short and the effect is typically greatest between the first and second evaluation. Practice effects and other effects of prior exposure typically plateau in subsequent retest situations. For example, in the case of a patient with suspected neurodegenerative disease who is being monitored with serial cognitive testing to gauge disease progression, stable or improved test scores at the second evaluation may reflect a temporary practice effect rather than actual disease stability or improvement. Concerns about potential effects stemming from repeated administrations are primarily a concern when conducting cognitive and academic testing. As a result, neuropsychological evaluations often make use of alternative forms for measures as a means of acquiring more accurate results.
Validity represents the degree to which a test actually measures what it is intended to measure. Similar to reliability, there are different ways to measure and determine validity. It is worth noting that just because a test is reliable does not mean that it is valid. Reliability can be conceptualized as an indicator of precision while validity may be thought of as a measure of accuracy; hence a test can be precise without being accurate. Standardization procedures for test administration are a critical element that allows for consistent and accurate results. Intellectual ability and personality characteristics are constructs that are inherently difficult to measure, resulting in limitations to validity. However, the reliability and validity of psychological and neuropsychological tests have been established over extended periods of time in various clinical populations, and many compare favorably to medical tests regarding validity (Meyer et al. 2001).
(p. 1102) An important aspect of formal psychological testing is that it uses normative data, which allows for a improved understanding of the test results. For example, a raw or total score on a particular test is interpreted, or given meaning, by comparing it to the normative sample. Normative data provide precise characterization of the study population, clear definition and measurement of phenomena, and allow for appropriate interpretation and generalization of results. The overall performance of a normative sample determines the relative standing of the individual patient in relationship to that group. For example, Mrs. X, a 54-year-old female, obtains a raw score of 33 on a test of verbal memory. This datum alone provides no meaningful information, but when it is compared to a normative sample of 300 women between the ages of 50 and 55 with a mean score of 35 and standard deviation of 4 points, it becomes clear that her performance is within normal limits and unlikely to represent abnormal verbal memory function. But the extent to which a normative sample is representative of Mrs. X is critical for making a valid interpretation of the test data. For example, if the test was normed on 95% Caucasian Americans with an average educational level of 15 years and Mrs. X is a first-generation Hispanic female with eight years of schooling, the psychologist would be better served by selecting a verbal memory task with normative data that more closely resembled Mrs. X’s culture and educational level.
Reliance on normative data is also important for understanding the prevalence of atypical scores. It is common and even expected for a healthy individual to obtain a low score in the course of a psychological assessment. For example, over 40% of healthy older adults have at least one low memory score on formal testing (Brooks et al. 2007). Similarly, a single mild elevation on the MMPI-2 Scale 2 may not necessarily be clinically significant given that minor depressive symptoms are relatively common in the general population. Failure to consider fundamental psychometric principles in the context of frequency when interpreting multiple test scores can result in both false positive and false negative mental health diagnoses.
Effort and Symptom Validity Testing
In general clinical settings, it is assumed that patients are invested in the assessment, provide a complete and accurate portrayal of symptoms, and are motivated to perform to the best of their ability in order to obtain maximal benefit from the evaluation. However, the intentional exaggeration of symptoms and/or intentional presentation of diminished emotional or cognitive capacity does occur. At times concern about secondary gain (i.e. external motivators) and its accompanying exaggerated symptoms may constitute a primary reason for referral for psychological assessment (e.g. in criminal, civil, or disability cases). In such circumstances, it is important that psychological assessment accurately detect these phenomena since poor effort can undermine the validity of the entire examination. For example, if the objective is to assess for ADHD in a college student, the patient may inflate various symptoms as well as underperform on other cognitive tests in an effort to obtain formal academic accommodations he or she would otherwise not be entitled to. There is a broad scientific literature relevant to the measurement of effort, response bias (e.g., tendency to over-endorse items), and malingering; here we summarize the pertinent points.
(p. 1103) Psychological assessment typically employs formal measures known as effort tests to quantify questionable effort. Effort tests are considered a category of measures that evaluate the validity of symptoms, termed symptom validity tests (SVTs). Many psychological measures, both personality and cognitive, often have effort indicators designed into the test itself. Alternatively, the psychologist may administer effort tests that were specifically designed to evaluate the validity of one’s responses or performance regarding memory, cognitive impairment and symptoms of serious mental illness. The incorporation of effort testing, either through embedded or independent measures, may be particularly indicated in contexts involving litigation of various sorts such as worker’s compensation, disability claims, criminal matters, or discharge from military service. Interestingly, effort tests require little to no actual effort on the part of the patient. A hallmark of effort tests is that even patients with severe neurologic impairment, or developmental problems can generally perform normally and without error. Hence, underperformance on such tests may represent inadequate effort or additional effort to perform poorly. For example, below-chance performance indicates that the patient performed worse than would be expected if a person were to simply have guessed. The likelihood of non-credible performance increases with each failed effort indicator (Victor et al. 2009).
During the course of an evaluation, if the psychologist develops concerns about the patient’s effort, the situation may be approached in different ways. In some instances, the psychologist may broach the issue by reminding the patient of the importance of giving their best effort and attempting to elicit any factors that might be impeding the patient’s engagement such as fatigue, displeasure with the evaluation process, side effects of medications, or misunderstood instructions. After such a discussion, some patients demonstrate improved task engagement, in which case the evaluation may continue. On the other hand, if performance does not improve, practitioners may decide to truncate the test battery (e.g., move from comprehensive neuropsychological testing to a cognitive screening measure) in order to provide some preliminary information to the referral source without exposing the patient to further tests which could affect the validity of future results due to practice effects. If a patient is fatigued for example, a psychologist may opt to discontinue the evaluation and ask the patient to return when he or she is more able to fully engage. In any case, when symptom validity is an issue, the psychologist reports the test results and notes that the data may represent an underestimate of the patient’s current functioning. Finally, we should note that genuine psychopathology and symptom fabrication may coexist. In such cases, differential diagnosis becomes more difficult and may require further investigation.
Finally, psychologists may use a number of phrases in their report to convey problems with effort, including “suboptimal effort,” “inadequate effort,” or “poor effort.” It is important to understand that poor effort is not synonymous with malingering, a rare diagnosis that refers to intentional alteration of performance in the context of known external gain. External gain can be monetary, non-monetary (e.g., drug seeking, time away from work), or represent efforts to avoid responsibility or legal consequences. In the DSM-5 (American Psychiatric Association 2013), malingering is assigned a V-code. Behaviors involving poor effort or exaggeration may be volitional or nonvolitional and may be motivated by external or internal factors. Malingering must be differentiated from other sources of poor effort or exaggeration, such as factitious disorder (deliberate feigning for psychological gain), conversion disorder, and somatoform disorder.
(p. 1104) Whether the question of patient effort/exaggeration is stated in the referral or becomes apparent during the course of testing, the psychologist may be in a difficult position. This is particularly true when test results are ambiguous, or it seems likely that legitimate symptoms underlie a disingenuous presentation. Determinations regarding symptom validity could affect a patient’s disability compensation, current treatment course, and their reputation with providers throughout the health care system for years to come. A diagnosis of malingering carries such a risk of harm and offense that significant evidence is required to give it, including the presence of secondary gain (e.g., financial compensation). However, the principle of integrity requires that psychologists carry out their duties in a way that promotes truth; and delivery of resources to a nonsuffering patient contradicts the principles of justice and nonmaleficence in that patients with legitimate illness may be harmed by this misdirection of resources.
The ability to generalize from normative data is important for drawing conclusions from psychological assessment. Basic demographic information must be used for appropriate test selection, but there are additional factors that may need to be considered including age, gender, race, ethnicity and acculturation, socioeconomic status, sexual orientation, religion, and disability. For example, differences have been reported among varying ethnic groups in cognitive test performance that have been shown to be better accounted for by differences in education level and/or socioeconomic status. Furthermore, potential heterogeneity within minority groups must also be considered; for example, a Mexican-American patient who is highly acculturated into an urban, professional occupation differs significantly from a Mexican-American patient who is from a small Mexican town, only went through third grade, speaks limited English, and is employed as a migrant worker. Psychologists take these personal, linguistic, cultural, and situational differences into account, as well as any other test factors or patient characteristics that may affect test results, their clinical judgment, or the accuracy of their conclusions (APA 2010, Standard 9.06, p. 13).
Special attention is needed when an assessment must be conducted in a person’s non-native language. Attempts to locate professionally trained bilingual examiners represent the best practice, but such a resource is often unavailable, particularly in non-urban settings. An acceptable alternative is to use a fully qualified translator rather than a patient’s family member. But even this approach can carry threats to the integrity of the assessment when examinees and translators speak different dialects of the same language. For example, the utility of a Spanish version of test or a Spanish-speaking translator will vary when the patient is from one Spanish speaking country and the test was normed, or the translator is from another, where dialect, pronunciation, expressions, and vocabulary may be quite different. In such cases screening measures may be helpful to estimate the patient’s level of reading comprehension and bilingual ability; this is particularly important if the psychologist intends to utilize personality measures such as the MMPI-2 or the PAI, both of which have specific (p. 1105) reading level requirements. Another common approach, where possible, is to select tasks without a heavy language demand. For example, the psychologist may employ standardized tests that allow the psychologist to administer the instrument non-verbally and the patient to point to a pictorial answer rather than having to respond verbally. While this strategy often restricts the scope of the assessment, it may provide some useful information with which to address the referral question.
Accommodations for Disabilities
Patients may have any number of physical conditions or illnesses that may impact engagement or performance during assessment. In these situations, the examiner should adjust the assessment process where needed to accommodate the disability and elicit the patient’s best performance while maintaining the standardization process to the extent possible. An accommodation may include modification of test administration processes or test content. A test that requires the use of sensory, motor, or language skills that are affected by the patient’s disability may not be appropriate or may need significant modification. For example, patients with low vision may require large-print test materials, magnification tools, or Braille test versions, if available. Oftentimes, the disability renders assessment of a particular construct impossible; for example, there is no appropriate modification to evaluate visuospatial abilities in a patient who is completely blind.
Some disabling conditions may be temporary; for example, in the case of a patient with cancer referred to assess for mild cognitive impairment or to help determine the best approach to psychotherapy, it may be preferable to conduct the evaluation after completion of chemotherapy since it can affect cognitive functioning in some patients. Similarly, chronic fatigue is a common problem that the psychologist may choose to address by conducting the evaluation over the course of two morning sessions, rather than one longer day. As another example, the treating psychiatrist of a 64-year-old man with schizophrenia may be concerned about the potential presence of comorbid Alzheimer’s disease. If so, it would be preferable to conduct the neuropsychological evaluation during a period in which the patient is adherent with medication recommendations and is relatively free from active psychosis.
The principle of justice promotes the idea that all individuals should have access to psychological services regardless of characteristics that make them unique. When conducting psychological evaluations with special groups including non-English speakers, diverse populations, and individuals with disabilities, the psychologist must make an effort to accommodate appropriately, judge the limitations of accommodation, and qualify test results to effectively communicate such limitations.
Communicating Assessment Results
Feedback to the Referral Source
Written reports provide a clear and concise interpretation of the various sources of data in a manner that is understandable and useful to the reader. Diagnostic considerations are typically included in addition to potential treatment interventions in the form of (p. 1106) recommendations. Recommendations are offered to the treating psychiatrist as considerations, with the understanding that the physician will determine which options are clinically indicated. The psychological assessment may reveal a need for additional medical interventions or consultations such as speech or physical therapy. When recommendations of this nature are made by the psychologist, he or she must be cautious not to overstep the boundaries of their expertise into territories of related disciplines.
Suggestions for psychological intervention are routinely offered. These recommendations may be general in nature, such as simply highlighting that brief supportive psychotherapy may be beneficial to address a mild adjustment disorder, or specific, such as recommending intensive outpatient therapy for an eating disorder or dialectical behavior therapy for borderline personality disorder. Additionally, the psychologist may provide information about the patient’s readiness for or openness to treatment and whether the patient is best suited for insight-oriented, interpersonal, or goal-oriented cognitive behavioral approaches. The psychologist may also offer resources (e.g., support groups, helpful websites, reading material) and suggest consultation with a social worker if warranted. School or work accommodations may also be outlined. Recommendations for follow-up evaluations to assess for change over time or response to treatment are common. Finally, the psychologist should be responsive to questions from the referral source for clarification or additional details as needed to collaboratively approach the case and provide optimum patient care.
Feedback to the Patient
The provision of feedback is an important, and sometimes neglected, component of a psychological evaluation and may take a variety of forms depending on the setting. This typically 30–60-minute follow-up visit routinely involves the spouse, other family members, or anyone else the patient would like present. The appropriate authorization would have been obtained to provide information to the patient’s treatment team. For children, results are communicated to the parents or legal guardian. The APA Ethics Code (2010) states: “psychologists take reasonable steps to ensure that explanations of results are given to the individual or designated representative unless the nature of the relationship precludes provision of an explanation of results (such as in some organizational consulting, pre-employment or security screenings, and forensic evaluations), and this fact has been clearly explained to the person being assessed in advance” (Standard 9.10).
Providing feedback to the patient is not only consistent with the principles of respect for autonomy and the professional–patient relationship but can be a critical means by which the treatment process is advanced. The term “feedback,” which implies the movement of information in a single direction, does not accurately reflect the process which should occur between clinician and patient. Instead, the communication that takes place should be bidirectional and collaborative. This approach demonstrates respect for the patient by avoiding a judgmental or superior tone and reduces the inherent power differential in the relationship and the likelihood of defensiveness. By discussing the results of the psychological assessment, both assessor and patient can gain a more complete understanding of how the findings relate to symptom presentation and the referral question(s). In allowing the patient to respond to, and even challenge, components of the test findings, the psychologist reduces the likelihood of harm that can result from unnecessary offense or confusion about the meaning (p. 1107) of the results. In addition to verbal feedback, the psychologist must also be sensitive to how the written report is received by the patient. Although the psychologist has a duty to present test information in a format that accurately reflects the findings, the wording should not unnecessarily disparage the patient (e.g., “The patient is likely to express anger indirectly” is preferable to “The patient demonstrates passive-aggressive tendencies”) or confuse the patient with specialized language.
Psychiatrists are often the referral source within psychiatric settings and have varying familiarity with personality and neuropsychological testing. While some can provide an explanation of psychological test results to the patient, others may not. As a result, psychologists remain available and willing to address any questions or concerns that may arise. Test results can be provided to the patient by phone, but face-to-face feedback is preferred, especially in situations involving particularly sensitive (e.g., dementing process indicated) or complex information. For those who want more detailed information, the psychologist should be prepared to discuss the psychometric properties associated with the tests administered, including their limitations (e.g., confidence intervals, validity, reliability), as well as any sources which were used in the interpretation of raw data.
Psychological evaluation is an integral part of mental health care and can play a vital role in providing maximum benefit to patients, especially those with more complex presentations. As treatment becomes more team-based and collaborative we see the role of psychologists, both as providers and consultants, increasing and resulting in more effective health care delivery. The ethical issues associated with interdisciplinary care and the process of psychological testing require a knowledgeable and thoughtful approach. Biomedical principles and the standards of psychological organizations are helpful in that they provide a basis and rationale for specific determinations. However, the psychologist must ultimately weigh the relative importance of sometimes competing principles and determine how best to serve the patient.
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