Therapeutic Assessment: Basic Concepts and Techniques
Stephen E. Finn, Ph.D.
Center for Therapeutic, Austin, TX
As some readers of this newsletter may have seen, Therapeutic Assessment was featured in the January 2006 issue of the APA Monitor. In this article, I briefly describe the background and format of Therapeutic Assessment.
Background and Theory
Therapeutic Assessment (TA) is a relatively new assessment paradigm where psychological tests are used as the centerpiece of a brief psychotherapeutic intervention. TA grew out of the tradition of collaborative and humanistic psychological assessment introduced by Constance Fischer (1986/1994) and others, and was developed by me and my colleagues in Austin after we noticed that many clients seemed to undergo profound psychological changes after taking part in a psychological assessment. When I was a faculty member at the University of Texas at Austin, my students and I studied why and how psychological assessment could be therapeutic (e.g., Finn & Tonsager, 1992) and eventually developed a theory of how this happens. Briefly, TA seems to work by producing changes in clients’ “stories” about themselves and the world. The assessor uses psychological tests to gain empathy for clients’ dilemmas and problems in living, then helps clients develop more accurate and compassionate stories about themselves (Finn & Tonsager, 1997). For example a client who believes he is “lazy” because he lacks motivation and drive, may learn through an assessment that he is depressed. This new “story” is not only more accurate and less negative, it points towards concrete steps the client may take to address his lack of passion and motivation (i.e., therapy and medication). Independent studies confirm that TA can lead to decreases in symptomatology, increases in self-esteem and hope, and better compliance with treatment recommendations (Newman & Greenway, 1997; Ackerman, Hilsenroth, Baity, & Blagys, 2000).
Format of a Therapeutic Assessment
Although every evaluation is unique, there is a common structure to many therapeutic assessments.
Step 1: Initial Session
In the initial session, the client and assessor meet to discuss the goals and context of the assessment. If the client has been referred by another professional, the assessor reveals (with that person’s permission) the questions the referring professional hopes will be addressed in the assessment process. In addition, the assessor and the client work together to delineate questions the client has concerning him or herself or concerning the client’s life circumstances, about which the assessment may be able to provide insights. Subsequently, the assessor collects background information relevant to each of the client’s questions, and practical aspects of the assessment are discussed (e.g., cost, number of subsequent sessions, who will receive information about the client’s assessment results). The client has an opportunity to ask questions about the assessment process and voice his or her concerns or fears.
By centering on client’s personal concerns, questions, and agendas, TA: 1) helps motivate clients to respond to the psychological measures in an open and honest fashion, 2) identifies “open doors” through which difficult-to-hear test findings may be presented at the end of the evaluation, and 3) assesses and engages client’s curiosity and observing ego, which alone can decrease distress and set the stage for therapeutic change.
In TA, assessors pay close attention to how the various psychological measures are introduced to clients and administered. Generally, it is important to begin by explaining that the tests are widely used in many different settings and yield information about a range of strengths, problems, and personality traits. Then the assessor should explain how a particular test is relevant to the client’s questions for the assessment. For example, a client who has asked, “How depressed am I?” may be told that the MMPI-2 and the Rorschach have been used in research to measure severity of depression. A client who has asked about having trouble concentrating and completing assignments at work may be told that the Wechsler Intelligence Scale for Adults-III (WAIS-III) may help understand the nature of client’s difficulties.
The assessor administers the tests (typically one per session) following standard instructions and administration procedures; however, a substantial effort is made to make the administration setting as comfortable for clients as possible. If clients express reservations about taking a particular test, they are encouraged to discuss their concerns with the assessor and unless resolved and reassured, clients are never asked to participate in or finish (if concerns are voiced during an administration) any measures with which they are not comfortable. From my experience, this approach provides both clients and assessors with possible insights into clients’ dilemmas. For example, a client who dislikes the Rorschach because of “all the dark cards that look scary” may have an opportunity to connect to dark feelings inside him- or herself and with the fear of falling into a depression. In TA, after standardized administration of the measures, clients are asked to reflect on their experience of taking each test, process their feelings about it, and are encouraged to share thoughts, interpretations, or insights about their specific responses.
By referencing client’s personal goals for the assessment, explaining how the various tests are relevant, and inviting the client to share his or her insights about the test, the assessor; 1) elicits the client’s cooperation and best effort, 2) communicates respect for the client by letting him/her “in” to the assessor’s thinking, 3) utilizes a client’s insight about their test results and process, and 4) supports the client in integrating new information he/she may learn in the process of completing the tests.
This approach is also extremely helpful in working with clients from other cultural backgrounds, as the assessor and client may discuss unique cultural meanings of clients’ various responses, which if misunderstood might lead to misinterpretations on the part of the assessor. For example, several years ago a Native American client I was assessing saw a number of “wolves” on the Rorschach. Normally, these would have been scored as “aggressive content,” but in discussing these responses later, the client explained that wolves were considered “wise” and “holy” in his tribe. This helped me understand the personal meaning of these responses to the client and avoid attributing an erroneous meaning to them.
Step 3: Tests are Scored and Interpreted
In TA, there is great respect for the nomothetically based hypotheses that can be derived from standardized tests; thus, the next step is to score and interpret the test results and profiles as if they were the sole source of information about the client. That is, assessors first interpret the assessment results as if they were blind to the client’s assessment questions, and then seek a coherent integration of all the various test results and collateral information available for consideration. Next, assessors review the results again, holding the client’s questions in mind. At this stage, assessors begin to sketch out tentative answers to a client’s questions and to anticipate which of these answers will be most challenging for the client to hear and understand.
One of the later developments in TA is the use of a separate assessment intervention session – prior to the summary/discussion (feedback) session – for assessors to introduce and explore hypotheses with clients that they have derived from the assessment data. Assessment intervention sessions are not necessary or advisable for all clients.
Basically, in an assessment intervention session, an assessor uses non-standardized tests or other techniques – such as psychodrama, role-playing, or art projects – to create vivid experiences for clients that may help them understand their main questions for the assessment. Alternatively, standardized tests may be administered following individualized, nonstandardized instructions. Prepared with a set of hypothesis derived from the assessment results about the client’s conflicts, defenses, and core issues, the assessor attempts to elicit in the assessment session actual instances of the client’s problems in living. If such efforts are successful, the client and assessor may then observe, analyze, and discuss those problems as they occur in the assessment setting and then try to generalize any insights to the client’s outside life.
As an example, let’s say a client has a question: “Why am I so tired all the time and can’t enjoy life the way I used to?” Imagine this client’s Rorschach scores suggest a substantial underlying depression (e.g., DEPI=6), but the MMPI-2 profile reveals no self-reported depression (Scale 2 = 50T) and suggests the heavy use of use of repression and denial to manage painful affect (e.g., Scale 3 = 75T). The assessor may ask the client to tell stories to selected TAT cards with a clear dysphoric content. If the client told stories related to painful events and consistently ended them by saying: “But, things will turn out just fine,” or “In the end, she will brush it off and will go on with her everyday life” -- the assessor could ask the client to tell a story without a happy ending. The assessor could then lead the client in observing and discussing the client’s coping mechanisms, their role in keeping the client’s painful affect out of awareness, and the costs paid in tiredness, lack of drive, and decreased enjoyment. If appropriate, the client and the assessor could then discuss other ways of handling and processing difficult feelings.
In general, assessment intervention sessions are centered on psychological issues that could be difficult for the client to grasp from an explanation of the test results alone. In our clinical experience, many clients describe these sessions as having impacted them greatly.
Step 5: Assessor Plans the Summary/Discussion Session
Following the assessment intervention session, the assessor takes time to carefully plan the summary/discussion session with the client. Based on our clinical work and supported by research, clients appear to find assessment information most useful when it is presented according to how closely it matches their existing ideas or the story they have about themselves (Schroeder, Hahn, Finn, & Swann, 1993). Early in a summary/ discussion session, assessors should relate information that is very close to clients’ existing self-conceptions. After this, assessors can proceed to information that is slightly new and different and, finally to ideas that are likely to conflict with clients’ current understandings of their situations. If one begins with this more difficult material, typically clients will react defensively or with anxiety or will get overwhelmed early in the session. On the other hand, if one never broaches difficult topics, the client may decide the assessment tools or the assessor are incompetent or that the information they revealed in the assessment is too shameful to discuss.
Another guideline for preparing the summary/discussion session has to do with the process and tone of the session. As I have written about elsewhere (Finn, 1996), an assessor can use the assessment results as an empathic window into a client’s experience and ask, “If I were this person, what would be the best way to tell me about my test results?” For example, clients with high F scale on the MMPI-2, multiple elevations on the clinical scales, and DEPI = 6 on the Rorschach are in a state of general overwhelm, and assessors should plan for shorter summary-discussion sessions, structured, with a few major points. While giving feedback to clients with an elevation on the MMPI-2 Scale 4 (70T), and T = 0 and Human Content = 1 on the Rorschach, assessors should take care to present the test findings in a rather blunt, matter-of-fact manner rather than too “sympathetic” or “touchy feely” way, which makes these clients more likely to lose respect for assessors and the assessment process.
Finally, most clients (not all) seem to appreciate some recognition from the assessor that psychological assessment is a vulnerable experience and that they showed some trust by agreeing to participate. Such comments fit naturally into the discussion of the test results (especially when interpreting unguarded and honest test protocols) or an assessor may choose to begin or end the summary/discussion session by expressing such appreciations.
Step 6: Summary/Discussion Session
If there has been an assessment intervention session, the assessor typically begins the summary/discussion session by inquiring about the client’s reactions to that session and discussing those. Then the assessor reviews the plan for the session with the client- typically, to discuss and answer the client’s questions posed at the beginning of the assessment – and invites the client to interrupt, agree, disagree, ask questions, and share any reactions during the session. With many clients, it is useful to start by showing the WAIS-III or the MMPI-2 profile, and orient the client to it. Then, the assessor begins to review the major test findings of the assessment and how they relate to the client’s questions.
Research confirms the experience of me and my colleagues by showing that the best method for reviewing test findings with clients is an interactive one (Hanson, Claiborn, & Kerr, 1997). For this reason we now call these types of sessions summary/discussion, rather than feedback sessions, for the latter term implies a unilateral flow of information from assessor to client.
I suggest that assessors share one piece of information, all the while carefully watching a client’s demeanor to judge his/her reactions. If the client agrees with the finding, the assessor asks for a example of how it is borne out in the client’s life and then listens carefully to the example to make sure the client is not simply blindly agreeing to the assessor’s interpretation. If a client disagrees, one may ask the client to help modify the finding so it fits with the client’s experience. If a client totally rejects a hypothesis derived from the testing, an assessor has several options. Sometimes, it is useful to restate the finding using different language; at other times one asks the client if any part of what one has said seems correct. And other times, it is better to simply back off and agree that the test could be wrong. I believe an assessor should never argue with a client about the validity of the assessment results.
As outlined earlier, the assessors tries to present information in order of how well is matches client’s existing self-concepts, all while looking for signs of overwhelm or defensiveness from the client. (It is best to stop and come back later to review the results, should clients become too overwhelmed to process the information). If all pertinent information is covered, the assessor moves toward ending the session by inviting other questions or reactions from the client, thanking the client for participating, mentioning that a letter will follow, and inviting the client to attend a follow session in 4 to 6 weeks. I also encourage assessors to share some way with clients that they felt moved or learned something through working with the client.
Step 7: Written Feedback Given to the Client
In TA, the assessor sends a letter to the client shortly after the summary/discussion session, reviewing the major points from the session and incorporating the client’s modifications and examples (noted during the summary/ discussion session.) In this way, the client sees his or her own impact on the assessment findings. With the client’s permission, a copy of the letter is also sent to the referring professional.
Assessment feedback forms are included with the letter, providing clients with an opportunity to reflect on the assessment process and provide the assessors with feedback about strengths and weaknesses of the assessment.
Step 8: Follow- Up Session(s) (Optional)
At the summary/discussion session, clients are invited to return at some later date (typically 4-6 weeks later) to talk about their later reactions to the assessment and any new questions they have. In my clinical experience, such meetings serve as “booster sessions” in enhancing the beneficial aspects of TA. A similar invitation is extended to the referring professionals, who often use the assessment as a base for consultation in their ongoing work with the client.
Billing for Therapeutic Assessment
Many third-party payers permit and encourage assessors to bill some parts of a therapeutic assessment as psychotherapy. It is best to consult with each company about how it wishes to handle such sessions. It may also be useful to remind payers that the current APA ethics code requires assessors to offer feedback to clients about their assessment results, except in certain forensic and employment screening situations.
Ackerman, S. J., Hilsenroth, M. J., Baity, M. R., & Blagys, M. D. (2000). Interaction of therapeutic process and alliance during psychological assessment. Journal of Personality Assessment, 75, 82-109.
Finn, S. E., & Tonsager, M. E. (1992). Therapeutic effects of providing MMPI-2
test feedback to college students awaiting therapy. Psychological
Assessment, 4, 278-287.
Finn, S. E., & Tonsager, M. E. (1997). Information-gathering and therapeutic models of assessment: Complementary paradigms. Psychological Assessment, 9, 374-385.
Fischer, C. T. (1985/1994). Individualizing psychological assessment. Mahwah, NJ: Erlbaum.
Hanson, W. E., Claiborn, C. D., & Kerr, B. (1997). Differential effects of two test-interpretation styles in counseling: A field study. Journal of Counseling Psychology, 44, 400-405.
Newman, M. L., & Greenway, P. (1997). Therapeutic effects of providing MMPI-2 test feedback to clients at a university counseling service. Psychological Assessment, 9, 122-131.
Schroeder, D. G., Hahn, E. D., Finn, S. E., & Swann, W. B., Jr. (1993, June). Personality feedback has more impact when mildly discrepant from self views. Paper presented at the fifth annual convention of the American Psychological Society, Chicago, IL.