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Society’s need for behavioral health care services provides an opportunity for trained providers of mental health and substance abuse services to become part of the solution to a major health care problem. Each of the behavioral health professions has the potential to make a particular contribution to this solution. Not the least of these contributions are those that can be made by clinical psychologists. The use of psychological tests in the assessment of the human condition is one of the hallmarks of clinical psychology. The training and acquired level of expertise in psychological testing distinguishes the clinical psychologist from other behavioral health care professionals. Indeed, expertise in test-based psychological assessment can be said to be the unique contribution that clinical psychologists make to the behavioral health care field.
For decades, clinical psychologists and other behavioral health care providers have come to rely on psychological assessment as a standard tool to be used with other sources of information for diagnostic and treatment planning purposes. However, changes that have taken place during the past several years in the delivery of health care in general, and behavioral health care services in particular, have led to changes in the way in which third-party payers and clinical psychologists themselves think about and use psychological assessment in day-to-day clinical practice. Some question the value of psychological assessment in the current time-limited, capitated service delivery arena, where the focus has changed from clinical priorities to fiscal priorities (Sederer, Dickey,&Hermann, 1996). Others argue that it is in just such an arena that the benefits of psychological assessment can be most fully realized and contribute significantly to the delivery of cost-effective treatment for behavioral health disorders (Maruish, 1999a). Consequently, psychological assessment could assist the health care industry in appropriately controlling or reducing the utilization and cost of health care over the long term.
In developing this research paper, I intended to provide students and practitioners of clinical psychology with an overview of how psychological assessment can be used in the treatment of behavioral health problems. In doing so, I present a discussion of how psychological assessment in currently being used in the therapeutic environment and the many ways in which it might be used to the ultimate benefit of patients.
As a final introductory note, it is important for the reader to understand that the term psychological assessment, as it is used in this research paper, refers to the evaluation of a patient’s mental health status using psychological tests or related instrumentation. Implicit here is the use of additional information from patient or collateral interviews, review of medical or other records, or other sources of relevant information about the patient as part of this evaluation.
Psychological Assessment as a Treatment Adjunct: An Overview
Traditionally, the role of psychological assessment in therapeutic settings has been quite limited. Those who did not receive their clinical training within the past few years were probably taught that the value of psychological assessment is found only at the front end of treatment. That is, they were probably instructed in the power and utility of psychological assessment as a means of assisting in the identification of symptoms and their severity, personality characteristics, and other aspects of the individual (e.g., intelligence, vocational interests) that are important in understanding and describing the patient at a specific point in time. Based on these data and information obtained from patient and collateral interviews, medical records, and the individual’s stated goals for treatment, a diagnostic impression was given and a treatment plan was formulated and placed in the patient’s chart, to be reviewed, it is hoped, at various points during the course of treatment. In some cases, the patient was assigned to another practitioner within the same organization or referred out, never to be seen or contacted again, much less be reassessed by the one who performed the original assessment.
Fortunately, during the past few years psychological assessment has come to be recognized for more than just its usefulness at the beginning of treatment. Consequently, its utility has been extended beyond being a mere tool for describing an individual’s current state, to a means of facilitating the treatment and understanding behavioral health care problems throughout and beyond the episode of care. There are now many commercially available and public domain measures that can be employed as tools to assist in clinical decisionmaking and outcomes assessment, and, more directly, as a treatment technique in and of itself. Each of these uses contributes value to the therapeutic process.
Psychological Assessment for Clinical Decision-Making
Traditionally, psychological assessment has been used to assist psychologists and other behavioral health care clinicians in making important clinical decisions. The types of decisionmaking for which it has been used include those related to screening, diagnosis, treatment planning, and monitoring of treatment progress. Generally, screening may be undertaken to assist in either (a) identifying the patient’s need for a particular service or (b) determining the likely presence of a particular disorder or other behavioral/emotional problems. More often than not, a positive finding on screening leads to a more extensive evaluation of the patient in order to confirm with greater certainty the existence of the problem or to further delineate the nature of the problem. The value of screening lies in the fact that it permits the clinician to quickly identify, with a fairly high degree of confidence, those who are likely to need care or at least require further evaluation.
Psychological assessment has long been used to obtain information necessary to determine the diagnoses of mental health patients. It may be used routinely for diagnostic purposes or to obtain information that can assist in differentiating one possible diagnosis from another in cases that present particularly complicated pictures. Indeed, even under current restrictions, managed care companies are likely to authorize payment for psychological assessment when a diagnostic question impedes the development of an appropriate treatment plan for one of its so-called covered lives.
In many instances, psychological assessment is performed in order to obtain information that is deemed useful in the development of a patient-specific treatment plan. Typically, this type of information is not easily (if at all) accessible through other means or sources. When combined with other information about the patient, information obtained from a psychological assessment can aid in understanding the patient, identifying the most important problems and issues that need to be addressed, and formulating recommendations about the best means of addressing them.
Another way psychological assessment plays a valuable role in clinical decision-making is through treatment monitoring. Repeated assessment of the patient at regular intervals during the treatment episode can provide the clinician with valuable feedback regarding therapeutic progress. Depending on the findings, the therapist will be encouraged either to continue with the original therapeutic approach or, in the case of no change or exacerbation of the problem, to modify or abandon the approach in favor of an alternate one.
Psychological Assessment for Outcomes Assessment
Currently, one of the most common reasons for conducting psychological assessment in the United States is to assess the outcomes of behavioral health care treatment. The interest in and focus on outcomes assessment can probably be traced to the continuous quality improvement (CQI) movement that was initially implemented in business and industrial settings. The impetus for the movement was a desire to produce quality products in the most efficient manner, resulting in increased revenues and decreased costs.
In health care, outcomes assessment has multiple purposes, not the least of which is as a tool for marketing the organization’s services. Those provider organizations vying for lucrative contracts from third-party payers frequently must present outcomes data demonstrating the effectiveness of their services. Equally important are data that demonstrate patient satisfaction with the services they have received. However, perhaps the most important potential use of outcomes data within provider organizations (although it is not always recognized as such) is the knowledge it can yield about what works and what does not. In this regard, outcomes data can serve as a means for ongoing program evaluation. It is the knowledge obtained from outcomes data that, if acted upon, can lead to improvement in the services the organization offers. When used in this manner, outcomes assessment can become an integral component of the organization’s CQI initiative.
More importantly, for the individual patient, outcomes assessment provides a means of objectively measuring how much improvement he or she has made from the time of treatment initiation to the time of treatment termination, and in some cases extending to some time after termination. Feedback to this effect may serve to instill in the patient greater self-confidence and self-esteem, or a more realistic view of where he or she is (from a psychological standpoint) at that point in time. It also may serve as an objective indicator to the patient of the need for continued treatment.
Psychological Assessment as a Treatment Technique
The degree to which the patient is involved in the assessment process has changed. One reason for this is the relatively recent revision of the ethical standards of the American Psychological Association (1992). This revision includes a mandate for psychologists to provide feedback to clients whom they assess. According to ethical standard 2.09, “psychologists ensure that an explanation of the results is provided using language that is reasonably understandable to the person assessed or to another legally authorized person on behalf of the client” (p. 8).
Finn and Tonsager (1992) offer other reasons for the recent interest in providing patients with assessment feedback. These include the recognition of patients’ right to see their medical and psychiatric health care records, as well as clinically and research-based findings and impressions that suggest that therapeutic assessment (described below) facilitates patient care. Finn and Tonsager also refer to Finn and Butcher’s (1991) summary of potential benefits that may accrue from providing test results feedback to patients about their results. These include increased feelings of self-esteem and hope, reduced symptomatology and feelings of isolation, increased self-understanding and self-awareness, and increased motivation to seek or be more actively involved in their mental health treatment. In addition, Finn and Martin (1997) note that the therapeutic assessment process provides a model for relationships that can result in increased mutual respect, lead to increased feelings of mastery and control, and decrease feelings of alienation.
Therapeutic use of assessment generally involves a presentation of assessment results (including assessment materials such as test protocols, profile forms, and other assessment summary materials) directly to the patient; an elicitation of the patient’s reactions to them; and an in-depth discussion of the meaning of the results in terms of patient-defined assessment goals. In essence, assessment data can serve as a catalyst for the therapeutic encounter via (a) the objective feedback that is provided to the patient, (b) the patient self-assessment that is stimulated, and (c) the opportunity for patient and therapist to arrive at mutually agreed-upon therapeutic goals.
The purpose of the foregoing was to present a broad overview of psychological assessment as a multipurpose behavioral health care tool. Depending on the individual clinician or provider organization, it may be employed for one or more of the purposes just described. The preceding overview should provide a context for better understanding the more indepth and detailed discussion about each of these applications that follows.
Psychological Assessment as a Tool for Screening and Diagnosis
One of the most apparent ways in which psychological assessment can contribute to the development of an economical and efficient behavioral health care delivery system is by using it to screen potential patients for need for behavioral health care services and to determine the likelihood that the problem identified is a particular disorder or problem of interest. Probably the most concise, informative treatment of the topic of the use of psychological tests in screening for behavioral health care disorders is provided by Derogatis and Lynn (1999). They clarify the nature and the use of screening procedures, stating that the screening process represents a relatively unrefined sieve that is designed to segregate the cohort under assessment into “positives,” who presumably have the condition, and “negatives,” who are ostensibly free of the disorder. Screening is not a diagnostic procedure per se. Rather, it represents a preliminary filtering operation that identifies those individuals with the highest probability of having the disorder in question for subsequent specific diagnostic evaluation. Individuals found negative by the screening process are not evaluated further (p. 42).
The most important aspect of any screening procedure is the efficiency with which it can provide information useful to clinical decision-making. In the area of clinical psychology, the most efficient and thoroughly investigated screening procedures involve the use of psychological assessment instruments. As implied by the foregoing, the power or utility of a psychological screener lies in its ability to determine, with a high level of probability, whether the respondent is or is not a member of a group with clearly defined characteristics. In daily clinical practice, the most commonly used screeners are those designed specifically to identify some aspect of psychological functioning or disturbance or provide a broad overview of the respondent’s point-in-time mental status. Examples of screeners include the Beck Depression Inventory-II (BDI-II; Beck, Steer, & Brown, 1996) and the Brief Symptom Inventory (BSI; Derogatis, 1992).
The establishment of a system for screening for a particular disorder or condition involves determining what it is one wants to screen in or screen out, at what level of probability one feels comfortable about making that decision, and how many incorrect classifications or what percentage of errors one is willing to tolerate. Once one decides what one wishes to screen for, one must then turn to the instrument’s classification efficiency statistics—sensitivity, specificity, positive predictive power (PPP), negative predictive power (NPP), and receiver operating characteristic (ROC) curves—for the information necessary to determine if a given instrument is suitable for the intended purpose(s).
Anote of caution is warranted when evaluating sensitivity, specificity, and the two predictive powers of a test. First, the cutoff score, index value, or other criterion used for classification can be adjusted to maximize either sensitivity or specificity. However, maximization of one will necessarily result in a decrease in the other, thus increasing the percentage of false positives (with maximized sensitivity) or false negatives (with maximized specificity). Second, unlike sensitivity and specificity, both PPP and NPP are affected and change according to the prevalence or base rate at which the condition or characteristic of interest (i.e., that which is being screened by the test) occurs within a given setting. As Elwood (1993) reports, the lowering of base rates results in lower PPPs, whereas increasing base rates results in higher PPPs. The opposite trend is true for NPPs. He notes that this is an important consideration because clinical tests are frequently validated using samples in which the prevalence rate is .50, or 50%. Thus, it is not surprising to see a test’s PPP drop in real-life applications where the prevalence is lower.
Key to the development of any effective plan of treatment for mental health and substance abuse patients is the ascertainment of an accurate diagnosis of the problem(s) for which the patient is seeking intervention. As in the past, assisting in the differential diagnosis of psychiatric disorders continues to be one of the major functions of psychological assessment (Meyer et al., 1998). In fact, managed behavioral health care organizations (MBHOs) are more likely to authorize reimbursement of testing for this purpose than for most other reasons (Maruish, 2002). Assessment with well-validated, reliable psychological test instruments can provide information that might otherwise be difficult (if not impossible) to obtain through psychiatric or collateral interviews, medical record reviews, or other clinical means.This is generally made possible through the inclusion of (a) test items representing diagnostic criteria from an accepted diagnostic classification system, such as the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) or (b) scales that either alone or in combination with other scales have been empirically tied (directly or indirectly) to specific diagnoses or diagnostic groups.
In most respects, considerations related to the use of psychological testing for diagnostic purposes are the same as those related to their use for screening. In fact, information obtained from screening can be used to help determine the correct diagnosis for a given patient. As well, information from either source should be used only in conjunction with other clinical information to arrive at a diagnosis. The major differentiation between the two functions is that screening generally involves the use of a relatively brief instrument for the identification of patients with a specific diagnosis, a problem that falls within a specific diagnostic grouping (e.g., affective disorders), or a level of impairment that falls within a problematic range. Moreover, it represents the first step in a process designed to separate those who do not exhibit indications of the problem being screened for from those with a higher probability of experiencing the target problem and thus warrant further evaluation for its presence. Diagnostic instruments such as those just mentioned generally tend to be lengthier, differentiate among multiple disorders or broad diagnostic groups (e.g., anxiety disorders vs. affective disorders), or are administered further along in the evaluation process than is the case with screeners. In many cases, these instruments also allow for a formulation of description of personality functioning.
There are many instruments available that have been specifically designed to help identify individuals with disorders that meet a diagnostic classification system’s criteria for the disorder(s). In the vast majority of the cases, these types of tests will be designed to detect individuals meeting the diagnostic criteria of DSM-IV or the 10th edition of the International Classification of Diseases (ICD-10; World Health Organization, 1992). Excellent examples of such instruments include the Millon Clinical Multiaxial Inventory-III (MCMI-III; Millon, 1994), the Primary Care Evaluation of Mental Disorders (PRIME-MD; Spitzer et al., 1994), the Patient Health Questionnaire (PHQ, the self-report version of the PRIME-MD; Spitzer, Kroenke, Williams, & Patient Health Questionnaire Primary Care Study Group, 1999); the Mini-International Neuropsychiatric Interview (MINI; Sheehan et al., 1998).
Like many of the instruments developed for screening purposes, most diagnostic instruments are accompanied by research-based diagnostic efficiency statistics—sensitivity, specificity, PPP, NPP, and overall classification rates—that provide the user with estimates of the probability of accurate classification of those having or not having one or more specific disorders. One typically finds classification rates of the various disorders assessed by any of these types of instrument to vary considerably. For example, the PPPs for those disorders assessed by the PRIME-MD (Spitzer et al., 1999) range from 19% for minor depressive disorder to 80% for major depressive disorder. For the self-report version of the MINI (Sheehan et al., 1998), the PPPs ranged from 11% for dysthymia to 75% for major depressive disorder. Generally, NPPs and overall classification rates are found to be relatively high and show a lot less variability across diagnostic groups. For the PRIME-MD, overall accuracy rates ranged from 84% for anxiety not otherwise specified to 96% for panic disorder, whereas MINI NPPs ranged from 81% for major depressive disorder to 99% for anorexia. Thus, it would appear that one can feel more confident in the results from these instruments when they indicate that the patient does not have a particular disorder. This, of course, is going to vary from instrument to instrument and disorder to disorder. For diagnostic instruments such as these, it is therefore important for the user to be aware of what the research has demonstrated as far the instrument’s classification accuracy for each individual disorder, since this may vary within and between measures.
Personality Measures and Symptom Surveys
There are a number of instruments that, although not specifically designed to arrive at a diagnosis, can provide information that is suggestive of a diagnosis or diagnostic group (e.g., affective disorders) or can assist in the differential diagnosis of complicated cases. These include multiscale instruments that list symptoms and other aspects of psychiatric disorders and ask respondents to indicate if or how much they are bothered by each of these, or whether certain statements are true or false as they apply to them. Generally, research on these instruments has found elevated scores on individual scales, or patterns or profiles of multiple elevated scores, to be associated with specific disorders or diagnostic groups. Thus, when present, these score profiles are suggestive of the presence of the associated type of pathology and bear further investigation. This information can be used either as a starting place in the diagnostic process or as additional information to support an already suspected problem.
Probably the best known of this type of instrument is the Minnesota Multiphasic Personality Inventory–2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989). It has a substantial body of research indicating that certain elevated scale and subscale profiles or code types are strongly associated with specific diagnoses or groups of diagnoses (see Graham, 2000, and Greene, 2000). For example, an 8-9/9-8 highpoint code type (Sc and Ma scales being the highest among the significantly elevated scales) is associated with schizophrenia, whereas the 4-9/9-4 code type is commonly associated with a diagnosis of antisocial personality disorder. Similarly, research on the Personality Assessment Inventory (PAI; Morey, 1991, 1999) has demonstrated typical patterns of PAI individual and multiple-scale configurations that also are diagnostically related. For one PAI profile cluster—prominent elevations on the DEP and SUI scales with additional elevations on the SCZ, STR, NON, BOR, SOM, ANX, and ARD scales— the most frequently associated diagnoses were major depression (20%), dysthymia (23%), and anxiety disorder (23%). Sixty-two percent of those with a profile cluster consisting of prominent elevations onALC and SOM with additional elevations on DEP, STR, and ANX were diagnosed with alcohol abuse or dependence.
In addition, there are other well-validated, single- or multiscale symptom checklists that can also be useful for diagnostic purposes. They provide means of identifying symptom domains (e.g., anxiety, depression, somatization) that are problematic for the patient, thus providing diagnostic clues and guidance for further exploration to the assessing psychologist. The BDI-II and STAI are good examples of well validated, single-scale symptom measures. Multiscale instruments include measures such as the Symptom Checklist-90-Revised (SCL-90-R; Derogatis, 1983) and the Symptom Assessment-45 Questionnaire (SA-45; StrategicAdvantage, Inc., 1996).
Regardless of the psychometric property of any given instrument for any disorder or symptom domain evaluated by that instrument, or whether it was developed for diagnostic purposes or not, one should never rely on test findings alone when assigning a diagnosis. As with any other psychological test instruments, diagnosis should be based on findings from the test and from other sources, including findings from other instruments, patient and collateral interviews, reviews of psychiatric and medical records (when available), and other pertinent documents.
Psychological Assessment as a Tool for Treatment Planning
Psychological assessment can provide information that can greatly facilitate and enhance the planning of a specific therapeutic intervention for the individual patient. It is through the implementation of a tailored treatment plan that the patient’s chances of problem resolution are maximized. The importance of treatment planning has received significant attention during recent years. The reasons for this recognition include
concerted efforts to make psychotherapy more efficient and cost effective, the growing influence of “third parties” (insurance companies and the federal government) that are called upon to foot the bill for psychological as well as medical treatments, and society’s disenchantment with open-ended forms of psychotherapy without clearly defined goals. (Maruish, 1990, p. iii)
The role that psychological assessment can play in planning a course of treatment for behavioral health care problems is significant. Butcher (1990) indicated that information available from instruments such as the MMPI-2 not only can assist in identifying problems and establishing communication with the patient, but can also help ensure that the plan for treatment is consistent with the patient’s personality and external resources. In addition, psychological assessment may reveal potential obstacles to therapy, areas of potential growth, and problems that the patient may not be consciously aware of. Moreover, both Butcher (1990) and Appelbaum (1990) viewed testing as a means of quickly obtaining a second opinion. Other benefits of the results of psychological assessment identified by Appelbaum include assistance in identifying patient strengths and weaknesses, identification of the complexity of the patient’s personality, and establishment of a reference point during the therapeutic episode. And as Strupp (cited in Butcher, 1990) has noted, “It will predictably save money and avoid misplaced therapeutic effort; it can also enhance the likelihood of favorable treatment outcomes for suitable patients” (pp. v–vi).
The Benefits of Psychological Assessment for Treatment Planning
As has already been touched upon, there are several ways in which psychological assessment can assist in the planning of treatment for behavioral health care patients. The more common and evident contributions can be organized into four general categories: problem identification, problem clarification, identification of important patient characteristics, and prediction of treatment outcomes.
Probably the most common use of psychological assessment in the service of treatment planning is for problem identification. Often, the use of psychological testing per se is not needed to identify what problems the patient is experiencing. He or she will either tell the clinician directly without questioning or admit his or her problem(s) while being questioned during a clinical interview. However, this is not always the case.
The value of psychological testing becomes apparent in those cases in which the patient is hesitant or unable to identify the nature of his or her problems. In addition, the nature of some of the more commonly used psychological test instruments allows for the identification of secondary, but significant, problems that might otherwise be overlooked. Note that the type of problem identification described here is different from that conducted during screening (see earlier discussion). Whereas screening is commonly focused on determining the presence or absence of a single problem, problem identification generally takes a broader view and investigates the possibility of the presence of multiple problem areas. At the same time, there also is an attempt to determine problem severity and the extent to which the problem area(s) affect the patient’s ability to function.
Psychological testing can often assist in the clarification of a known problem. Through tests designed for use with populations presenting problems similar to those of the patient, aspects of identified problems can be elucidated. Information gained from these tests can both improve the patient’s and clinician’s understanding of the problem and lead to the development of a better treatment plan. The three most important types of information that can be gleaned for this purpose are the severity of the problem, the complexity of the problem, and the degree to which the problem impairsthe patient’s ability to function in one or more life roles.
Identification of Important Patient Characteristics
The identification and clarification of the patient’s problems is of key importance in planning a course of treatment. However, there are numerous other types of patient information not specific to the identified problem that can be useful in planning treatment and that may be easily identified through the use of psychological assessment instruments. The vast majority of treatment plans are developed or modified with consideration to at least some of these nonpathological characteristics. The exceptions are generally found with clinicians or programs that take a one-size-fits-all approach to treatment.
Probably the most useful type of information that is not specific to the identified problem but can be gleaned from psychological assessment is the identification of patient characteristics that can serve as assets or areas of strength for the patient in working to achieve his or her therapeutic goals. For example, Morey and Henry (1994) point to the utility of the PAI’s Nonsupport scale in identifying whether the patient perceives an adequate social support network, which is a predictor of positive therapeutic change.
Similarly, knowledge of the patient’s weaknesses or deficits may also affect the type of treatment plan that is devised. Greene and Clopton (1999) provided numerous types of deficit-relevant information from the MMPI-2 content scales that have implications for treatment planning. For example, a clinically significant score (T > 64) on the Anger scale should lead one to consider the inclusion of training in assertiveness or anger control techniques as part of the patient’s treatment. On the other hand, uneasiness in social situations, as suggested by a significantly elevated score on either the Low Self-Esteem or Social Discomfort scale, suggests that a supportive approach to the intervention would be beneficial, at least initially.
Moreover, use of specially designed scales and procedures can provide information related to the patient’s ability to become engaged in the therapeutic process. For example, the Therapeutic Reactance Scale (Dowd, Milne, & Wise, 1991) and the MMPI-2 Negative Treatment Indicators content scale developed by Butcher and his colleagues (Butcher, Graham, Williams, & Ben-Porath, 1989) may be useful in determining whether the patient is likely to resist therapeutic intervention.
Other types of patient characteristics that can be identified through psychological assessment have implications for selecting the best therapeutic approach for a given patient and thus can contribute significantly to the treatment planning process. Moreland (1996), for example, pointed out how psychological assessment can assist in determining whether the patient deals with problems through internalizing or externalizing behaviors. He noted that, all other things being equal, internalizers would probably profit more from an insightoriented approach than a behaviorally oriented approach. The reverse would be true for externalizers. Through their work over the years, Beutler and his colleagues (Beutler & Clarkin, 1990; Beutler, Wakefield, & Williams, 1994) have identified several other patient characteristics that are important to matching patients and treatment approaches for maximized therapeutic effectiveness.
Prediction of Treatment Outcomes
An important consideration in the development of a treatment plan has to do with the likely outcome of treatment. In other words, how likely is it that a given patient with a given set of problems or level of dysfunction will benefit from any of the treatment options that are available? In some cases, the question is, what is the probability that the patient will significantly benefit from any type of treatment? In many cases, psychological test results can yield empirically based predictions that can assist in answering these questions. In doing so, the most effective treatment can be implemented immediately, saving time, health care benefits, and potential exacerbation of problems that might result from implementation of a less than optimal course of care.
The ability to predict outcomes is going to vary from test to test and even within individual tests, depending on the population being assessed and what one would like to predict. For example, Chambless, Renneberg, Goldstein, and Gracely (1992) were able to detect predictive differences in MCMI-IIidentified (Millon, 1987) personality disorder patients seeking treatment for agoraphobia and panicattacks.Patientsclassified as having an MCMI-II avoidant disorder were more likely to have poorer outcomes on measures of depression, avoidance, and social phobia than those identified as having dependent or histrionic personality disorders. Also, paranoid personality disorder patients were likely to drop out before receiving 10 sessions of treatment. In another study, Chisholm, Crowther, and Ben-Porath (1997) did not find any of the seven MMPI-2 scales they investigated to be particularly good predictors of early termination in a sample of university clinic outpatients. They did find that the Depression (DEP) andAnxiety (ANX) content scales were predictive of other treatment outcomes. Both were shown to be positively associated with therapist-rated improvement in current functioning and global psychopathology, with ANX scores also being related to therapist- rated progress toward therapy goals.
The reader is referred to Meyer et al. (1998) for an excellent overview of the research supporting the use of objective and projective test results for outcomes prediction as well as for other clinical decision-making purposes. Moreover, the use of patient profiling for the prediction of treatment outcome is discussed later in this research paper.
Psychological Assessment as a Treatment Intervention
The use of psychological assessment as an adjunct to or means of therapeutic intervention in and of itself has received more than passing attention during the past several years (e.g., Butcher, 1990; Clair & Prendergast, 1994). Therapeutic assessment with the MMPI-2 has received particular attention primarily through the work of Finn and his associates (Finn, 1996a, 1996b; Finn & Martin, 1997; Finn & Tonsager, 1992). Finn’s approach appears to be applicable with instruments or batteries of instruments that provide multidimensional information relevant to the concerns of patients seeking answers to questions related to their mental health status. The approach espoused by Finn will thus be presented here as a model for deriving direct therapeutic benefits from the psychological assessment experience.
What Is Therapeutic Assessment?
In discussing the use of the MMPI-2 as a therapeutic intervention, Finn (1996b) describes an assessment procedure whose goal is to “gather accurate information about clients . . . and then use this information to help clients understand themselves and make positive changes in their lives” (p. 3). Simply stated, therapeutic assessment may be considered an approach to the assessment of mental health patients in which the patient is not only the primary provider of information needed to answer questions but also actively involved in formulating the questions that are to be answered by the assessment. Feedback regarding the results of the assessment is provided to the patient and is considered a primary, if not the primary, element of the assessment process.Thus, the patient becomes a partner in the assessment process; as a result, therapeutic and other benefits accrue.
The Therapeutic Assessment Process
Finn (1996b) has outlined a three-step procedure for therapeutic assessment using the MMPI-2 in those situations in which the patient is seen only for assessment. It should work equally well with other multidimensional instruments and with patients the clinician later treats.
Step 1: The Initial Interview
According to Finn (1996b), the initial interview with the patient serves multiple purposes. It provides an opportunity to build rapport, or to increase rapport if a patient-therapist relationship already exists. The assessment task is presented as a collaborative one. The therapist gathers background information, addresses concerns, and gives the patient the opportunity to identify questions that he or she would like answered using the assessment data. Step 1 is completed as the instrumentation and its administration are clearly defined and the particulars (e.g., time of testing) are agreed upon.
Step 2: Preparing for the Feedback Session
Upon the completion of the administration and scoring of the instrumentation used during the assessment, the clinician first outlines all results obtained from the assessment, including those not directly related to the patient’s previously stated questions. This is followed by a determination of how to present the results to the patient (Finn, 1996b). The clinician must also determine the best way to present the information to the patient so that he or she can accept and integrate it while maintaining his or her sense of identity and self-esteem.
Step 3: The Feedback Session
As Finn (1996b) states, “The overriding goal of feedback sessions is to have a therapeutic interaction with clients” (p. 44). This begins with the setting of the stage for this type of encounter before the clinician answers the questions posed by the patient during Step 1. Beginning with a positive finding from the assessment, the clinician proceeds first to address those questions whose answers the patient is most likely to accept. He or she then carefully moves to the findings that are more likely to be anxiety-arousing for the patient or challenge his or her self-concept. A key element to this step is to have the patient verify the accuracy of each finding and provide a reallife example of the interpretation that is offered. Alternately, the clinician asks the patient to modify the interpretation to make it more in line with how the patient sees him- or herself and the situation. Throughout the session, the clinician maintains a supportive stance with regard to any affective reactions to the findings.
Finn and Martin (1997) indicate two additional steps that may be added to the therapeutic assessment process. The purpose of the first additional step, referred to as an assessment intervention session, is essentially to clarify initial test findings through the administration of additional instruments. The other additional step discussed by Finn and Martin (1997) is the provision of a written report of the findings to the patient.
Empirical Support for Therapeutic Assessment
Noting the lack of direct empirical support for the therapeutic effects of sharing test results with patients, Finn and Tonsager (1992) investigated the benefits of providing feedback to university counseling center clients regarding their MMPI-2 results. Thirty-two participants underwent therapeutic assessment and feedback procedures similar to those described above while on the counseling center’s waiting list. Another 28 participants were recruited from the same waiting list to serve as a control group. Instead of receiving feedback, Finn and Tonsager’s (1992) control group received nontherapeutic attention from the examiner. However, they were administered the same dependent measures as the feedback group at the same time that the experimental group received feedback. They were also administered the same dependent measures as the experimental group two weeks later (i.e., two weeks after the experimental group received the feedback) in order to determine if there were differences between the two groups on those dependent measures. These measures included a selfesteem questionnaire, a symptom checklist (the SCL-90-R), a measure of private and public self-consciousness, and a questionnaire assessing the subjects’subjective impressions of the feedback session.
The results of Finn and Tonsager’s (1992) study indicated that compared to the control group, the feedback group demonstrated significantly less distress at the two-week postfeedback follow-up and significantly higher levels of self-esteem and hope at both the time of feedback and the two-week postfeedback follow-up. In other findings, feelings about the feedback sessions were positively and significantly correlated with changes in self-esteem from testing to feedback, both from feedback to follow-up and from testing to follow-up among those who were administered the MMPI-2. In addition, change in level of distress from feedback to follow-up correlated significantly with private self-consciousness (i.e., the tendency to focus on the internal aspects of oneself) but not with public self-consciousness.
- L. Newman and Greenway (1997) provided support for Finn and Tonsager’s findings in their study of 60 Australian college students. Clients given MMPI-2 feedback reported an increase in self-esteem and a decrease in psychological distress that could not be accounted for by their merely completing the MMPI-2. At the same time, changes in self-esteem or symptomatology were not found to be related to either the level or type of symptomatology at the time of the first assessment.Also, the clients’attitudes toward mental health professionals (as measured by the MMPI-2 TRT scale) were not found to be related to level of distress or self-esteem. Their results differed from those of Finn and Tonsager in that general satisfaction scores were not associated with change in self-esteem or change in symptomatology, nor was private self-consciousness found to be related to changes in symptomatology. Recognizing the limitations of their study, Newman and Greenway’s recommendations for future research in this area included examination of the components of therapeutic assessment separately and the use of different patient populations and different means of assessing therapeutic change (i.e., use of both patient and therapist/third party report).
Overall, the research on the benefits of therapeutic assessment is limited but promising. The work of Finn and others should be extended to include other patient populations with more severe forms of psychological disturbance and to reassess study participants over longer periods of follow-up. Moreover, the value of the technique when used with instrumentation other than the MMPI-2 warrants investigation.
Monitoring treatment progress with psychological assessment instruments can prove to be quite valuable, especially with patients who are seen over relatively long periods of time. If the treatment is inefficient, inappropriate or otherwise not resulting in the expected effects, changes in the treatment plan can be formulated and deployed. These adjustments may reflect the need for (a) more intensive or aggressive treatment (e.g., increased number of psychotherapeutic sessions each week, addition of a medication adjunct); (b) less intensive treatment (e.g., reduction or discontinuation of medication, transfer from inpatient to outpatient care); or (c) a different therapeutic approach (e.g., a change from humanistic therapy to cognitivebehavioral therapy). Regardless, any modifications require later reassessment of the patient to determine if the treatment revisions have affected patient progress in the expected direction.This process may be repeated any number of times.These in-treatment reassessments also can provide information relevant to the decision of when to terminate treatment.
Methods for determining if statistically and clinically significant change has occurred from one point in time to another have been developed and can be used for treatment monitoring. Many of these methods are the same as those that can be used for outcomes assessment and are discussed later in this research paper. In addition, the reader is also referred to an excellent discussion of analyzing individual and group change data in F. L. Newman and Dakof (1999) and F. L. Newman andTejeda (1999).
Patient profiling is yet another approach to monitoring therapeutic change that can prove to be more valuable than looking at simple changes in test scores from one point in time to another. Patient profiling involves the generation of an expected curve of recovery over the course of psychotherapy based on the observed recovery of similar patients (Howard, Moras, Brill, Martinovich, & Lutz, 1996; Leon, Kopta, Howard, & Lutz, 1999).An individual recovery curve is generated from selected clinical characteristics (e.g., severity and chronicity of the problem, attitudes toward treatment, scores on treatment-relevant measures) present at the time of treatment onset. This curve will enable the clinician to determine if the patient is on the expected track for recovery through the episode of care. Multiple measurements of the clinical characteristics during the course of treatment allow a comparison of the patient’s actual score with that which would be expected from similar individuals after the same number of treatment sessions. The therapist thus knows when the treatment is working and when it is not working so that any necessary adjustments in the treatment strategy can be made.
Other Uses for Patient Profiling
Aside from its obvious treatment value, treatment monitoring data can support decisions regarding the need for continued treatment. This holds true whether the data are nothing more than a set of scores from a relevant measure (e.g., a symptom inventory) administered at various points during treatment, or are actual and expected recovery curves obtained by the Howard et al. (1996) patient profiling method. Expected and actual data obtained from patient profiling can easily point to the likelihood that additional sessions are needed or would be significantly beneficial for the patient. Combined with clinician impressions, these data can make a powerful case for the patient’s need for additional treatment sessions or, conversely, for treatment termination.
As well as the need for supporting decisions regarding additional treatment sessions for patients already in treatment, there are indications that patient profiling may also be useful in making initial treatment-related decisions. Leon et al. (1999) sought to determine whether patients whose actual response curve matched or exceeded (i.e., performed better than) the expectancy curve could be differentiated from those whose actual curve failed to match their expectancy curve on the basis of pretreatment clinical characteristics. They first generated patient profiles for 821 active outpatients and found a correlation of .57 (p < .001) between the actual and expected slopes. They then used half of the original sample to develop a discriminate function that was able to significantly discriminate (p < .001) patients whose recovery was predictable (i.e., those with consistent actual and expected curves) from those whose recovery was not predictable (i.e., those with inconsistent curves). The discriminant function was based on 15 pretreatment clinical characteristics (including the subscales and items of the Mental Health Index, or MHI; Howard, Brill, Lueger, O’Mahoney, & Grissom, 1993) and was cross-validated with the other half of the original sample. In both subsamples, lower levels of symptomatology and higher levels of functioning were associated with those in the predictable group of patients.
The implications of these findings are quite powerful. According to Leon et al. (1999),
The patient profiling-discriminant approach provides promise for moving toward the reliable identification of patients who will respond more rapidly in psychotherapy, who will respond more slowly in psychotherapy, or who will demonstrate a low likelihood of benefiting from this type of treatment.
The implications of these possibilities for managed mental health care are compelling. . . . [A] reliable prediction system— even for a proportion of patients—would improve efficiency, thereby reducing costs in the allocation and use of resources for mental health care. For instance, patients who would be likely to drain individual psychotherapeutic resources while achieving little or no benefit could be identified at intake and moved into more promising therapeutic endeavors (e.g., medication or group psychotherapy). Others, who are expected to succeed but are struggling could have their treatment reviewed and then modified in order to get them back on track. . . . Patients who need longer term treatment could justifiably get it because the need would be validated by a reliable, empirical methodology. (p. 703)
The Effects of Providing Feedback to the Therapist
Intuitively, one would expect that patient profiling information would result in positive outcomes for the patient. Is this really the case, though? Lambert et al. (1999) sought to answer this question by conducting a study to determine if patients whose therapists receive feedback about their progress (experimental group) would have better outcomes and better treatment attendance (an indicator of cost-effective psychotherapy) than those patients whose therapists did not receive this type of feedback (control group). The feedback provided to the experimental group’s therapists came in the form of a weekly updated numerical and color-coded report based on the baseline and current total scores of the Outcome Questionnaire (OQ-45; Lambert et al., 1996) and the number of sessions that the patient had completed. The feedback report also contained one of four possible interpretations of the patient’s progress (not making expected level of progress, may have negative outcome or drop out of treatment, consider revised or new treatment plan, reassess readiness for change).
The Lambert et al. (1999) findings from this study were mixed and lend only partial support for benefits accruing from the use of assessment-based feedback to therapists. They also suggested that information provided in a feedback report alone is not sufficient to maximize its impact on the quality of care provided to a patient; that is, the information must be put to use. The use of feedback to therapists appears to be beneficial, but further research in this area is called for.
Notwithstanding whether it is used as fodder for generating complex statistical predictions or for simple point-in-time comparisons, psychological test data obtained for treatment monitoring can provide an empirically based means of determining the effectiveness of mental health and substance abuse treatment during an episode of care. Its value lies in its ability to support ongoing treatment decisions that must be made using objective data. Consequently, it allows for improved patient care while supporting efforts to demonstrate accountability to the patient and interested third parties.
The 1990s witnessed accelerating growth in the level of interest and development of behavioral health care outcomes programs. The interest in and necessity for outcomes measurement and accountability in this era of managed care provide a unique opportunity for psychologists to use their training and skills in assessment (Maruish, 1999a). However, the extent to which psychologists and other trained professionals become a key and successful contributor to an organization’s outcomes initiative will depend on their understanding of what outcomes and their measurement and applications are all about.
What Are Outcomes?
Outcomes is a term that refers to the results of the specific treatment that was rendered to a patient or group of patients. Along with structure and process, outcomes is one component ofwhatDonabedian(1980,1982,1985)referstoas“qualityof care.” The first component is structure. This refers to various aspects of the organization providing the care, including how the organization is organized, the physical facilities and equipment, and the number and professional qualifications of its staff. Process refers to the specific types of services that are provided to a given patient (or group of patients) during a specific episode of care.These might include various tests and assessments (e.g., psychological tests, lab tests, magnetic resonance imaging), therapeutic interventions (e.g., group psychotherapy, medication), and discharge planning activities. Outcomes, on the other hand, refers to the results of the specific treatment that was rendered.
In considering the types of outcomes that might be assessed in behavioral health care settings, a substantial number of clinicians would probably identify symptomatic change in psychological status as being the most important. However, no matter how important change in symptom status may have been in the past, psychologists and other behavioral health care providers have come to realize that change in many other aspects of functioning identified by Stewart and Ware (1992) are equally important indicators of treatment effectiveness. As Sederer et al. (1996) have noted,
Outcome for patients, families, employers, and payers is not simply confined to symptomatic change. Equally important to those affected by the care rendered is the patient’s capacity to function within a family, community, or work environment or to exist independently, without undue burden to the family and social welfare system. Also important is the patient’s ability to show improvement in any concurrent medical and psychiatric disorder. . . . Finally, not only do patients seek symptomatic improvement, but they want to experience a subjective sense of health and well being. (p. 2)
The Use of Outcomes Assessment in Treatment
Following are considerations and recommendations for the development and implementation of outcomes assessment by psychologists. Although space limitations do not allow a comprehensive review of all issues and solutions, the information that follows touches upon matters that are most important to psychologists who wish to incorporate outcomes assessment into their standard therapeutic routine.
The specific aspects or dimensions of patient functioning that are measured as part of outcomes assessment will depend on the purpose for which the assessment is being conducted. Probably the most frequently measured variable is that of symptomatology or psychological/mental health status. After all, disturbance or disruption in this dimension is probably the most common reason why people seek behavioral health care services in the first place. However, there are other reasons for seeking help. Common examples include difficulties in coping with various types of life transitions (e.g., a new job, a recent marriage or divorce, other changes in the work or home environment), an inability to deal with the behavior of others (e.g., spouse, children), or general dissatisfaction with life. Additional assessment of related variables may therefore be necessary or even take precedence over the assessment of symptoms or other indicators.
For some patients, measures of one or more specific psychological disorders or symptom clusters are at least as important as, if not more important than, overall symptom or mental health status. Here, if interest is in only one disorder or symptom cluster (e.g., depression), one may choose to measure only that particular set of symptoms using an instrument designed specifically for that purpose (e.g., the BDI-II would be used with depressed patients). For those interested in assessing the outcomes of treatment relative to multiple psychological dimensions, the administration of more than one disorder-specific instrument or a single, multiscale instrument that assesses all or most of the dimensions of interest (e.g., BSI) would be required. Again, instruments such as the SA-45 or the BSI can provide a quick, broad assessment of several symptom domains.
It is not always a simple matter to determine exactly what should be measured. However, careful consideration of the following questions should greatly facilitate the decision: Why did the patient seek services? What does the patient hope to gain from treatment? What are the patient’s criteria for successful treatment? What are the clinician’s criteria for the successful completion of the current therapeutic episode? What, if any, are the outcomes initiatives within the provider organization? Note that the selection of the variables to be assessed may address more than one of the above issues. Ideally, this is what should happen. However, one needs to ensure that the task of gathering outcomes data does not become too burdensome. The key is to identify the point at which the amount of data that can be obtained from a patient or collaterals and the ease at which they can be gathered are optimized.
Once the decision of what to measure has been made, one must then decide how it should be measured. In many cases, the most important data will be those that areobtained directly from the patient using self-report instruments. Underlying this assertion is the assumption that valid and reliable instrumentation, appropriate to the needs of the patient, is available to the clinician; the patient can read at the level required by the instruments; and the patient is motivated to respond honestly to the questions asked. Barring one or more of these conditions, other options should be considered.
Other types of data-gathering tools may be substituted for self-report measures. Rating scales completed by the clinician or other members of the treatment staff may provide information that is as useful as that elicited directly from the patient. In those cases in which the patient is severely disturbed, unable to give valid and reliable answers (as in the case of younger children), unable to read, or otherwise an inappropriate candidate for a self-report measure, clinical rating scales, such as the Brief Psychiatric Rating Scale (BPRS; Faustman & Overall, 1999; Overall & Gorham, 1962) and the Child and Adolescent Functional Assessment Scale (CAFAS; Hodges, 1994), can serve as a valuable substitute for gathering information about the patient. Related to these instruments are parent-completed instruments for child and adolescent patients, such as the Child Behavior Checklist (CBCL; Achenbach, 1991) and the Personality Inventory for Children-2 (PIC-2; Lachar & Gruber, 2001). Collateral rating instruments and parent-report instruments can also be used to gather information in addition to that obtained from self-report measures. When used in this manner, these instruments provide a mechanism by which the clinician, other treatment staff, and parents, guardians, or other collaterals can contribute data to the outcomes assessment endeavor.
When to Measure
There are no hard and fast rules or widely accepted conventions related to when outcomes should be assessed. The common practice is to assess the patient at least at treatment initiation and again at termination or discharge. Additional assessment of the patient on the variables of interest can take place at other points as part of postdischarge follow-up.
Many would argue that postdischarge or posttermination follow-up assessment provides the best or most important indication of the outcomes of therapeutic intervention. In general, postdischarge outcomes assessment should probably take place no sooner than 1 month after treatment has ended.When feasible, waiting 3–6 months to assess the variables of interest is preferred. Alonger interval between discharge and postdischarge follow-up should provide a more valid indication of the lasting effects of treatment. Comparison of the patient’s status on the variables of interest at the time of follow-up with that found at the time of either treatment initiation or termination will provide an indication of the more lasting effects of the intervention. Generally, the variables of interest for this type of comparison include symptom presence and intensity, feeling of well-being, frequency of substance use, and social or role functioning.
Although it provides what is arguably the best and most useful outcomes information, a program of postdischarge follow-up assessment is also the most difficult to successfully implement. There must be a commitment of staff and other resources to track terminated patients; contact them at the appropriate times to schedule a reassessment; and process, analyze, report, and store the follow-up data. The task is made more difficult by frequently noted difficulties in locating terminated patients whose contact information has changed, or convincing those who can be located to complete a task from which they will not directly benefit. However, those organizations and individual clinicians who are able to overcome the barriers will find the fruits of their efforts quite rewarding.
Analysis of Outcomes Data
There are two general approaches to the analysis of treatment outcomes data. The first is by determining whether changes in patient scores on outcomes measures are statistically significant. The other is by establishing whether these changes are clinically significant. Use of standard tests of statistical significance is important in the analysis of group or population change data. Clinical significance is more relevant to change in the individual patient’s scores.
The issue of clinical significance has received a great deal of attention in psychotherapy research during the past several years. This is at least partially owing to the work of Jacobson and his colleagues (Jacobson, Follette, & Revenstorf, 1984, 1986; Jacobson & Truax, 1991) and others (e.g., Christensen & Mendoza, 1986; Speer, 1992; Wampold & Jenson, 1986). Their work came at a time when researchers began to recognize that traditional statistical comparisons do not reveal a great deal about the efficacy of therapy. In discussing the topic, Jacobson and Truax broadly define the clinical significance of treatment as “its ability to meet standards of efficacy set by consumers, clinicians, and researchers” (p. 12).
From their perspective, Jacobson and his colleagues (Jacobson et al., 1984; Jacobson & Truax, 1991) felt that clinically significant change could be conceptualized in one of three ways. Thus, for clinically significant change to have occurred, the measured level of functioning following the therapeutic episode would either (a) fall outside the range of the dysfunctional population by at least 2 standard deviations from the mean of that population, in the direction of functionality; (b) fall within 2 standard deviations of the mean for the normal or functional population; or (c) be closer to the mean of the functional population than to that of the dysfunctional population. Jacobson and Truax viewed option (c) as being the least arbitrary, and they provided different recommendations for determining cutoffs for clinically significant change, depending upon the availability of normative data.
At the same time, these investigators noted the importance of considering the change in the measured variables of interest from pre- to posttreatment in addition to the patient’s functional status at the end of therapy. To this end, Jacobson et al. (1984) proposed the concomitant use of a reliable change (RC) index to determine whether change is clinically significant. This index, modified on the recommendation of Christensen and Mendoza (1986), is nothing more than the pretest score minus the posttest score divided by the standard error of the difference of the two scores.
The demand to demonstrate the outcomes of treatment is pervasive throughout the health care industry. Regulatory and accreditation bodies are requiring that providers and provider organizations show that their services are having a positive impact on the people they treat. Beyond that, the behavioral health care provider also needs to know whether what he or she does works. Outcomes information derived from psychological assessment of individual patients allows the provider to know the extent to which he or she has helped each patient. At the same time, in aggregate, this information can offer insight about what works best for whom under what circumstances, thus facilitating the treatment of future patients.
Psychologic Alassessment in the Era of Managed Behavioral Health Care
Numerous articles (e.g., Ficken, 1995) have commented on how the advent of managed care has limited the reimbursement for (and therefore the use of) psychological assessment. Certainly, no one would argue with this assertion. In an era of capitated behavioral health care coverage, the amount of money available for behavioral health care treatment is limited. Managed behavioral health care organizations therefore require a demonstration that the amount of money spent for testing will result in a greater amount of treatment cost savings.As of this writing, this author is unaware of any published research that can provide this demonstration. Moreover, Ficken asserts that much of the information obtained from psychological assessment is not relevant to the treatment of patients within a managed care environment. If this indeed is how MBHOsview psychological assessment information, it is not surprising that MBHOsare reluctant to pay for gathering it.
Where does psychological assessment currently fit into the daily scope of activities for practicing psychologists in this age of managed care? In a survey conducted in 1995 by the American Psychological Association’s Committee for the Advancement of Professional Practice (Phelps, Eisman, & Kohut, 1998), almost 16,000 psychological practitioners responded to questions related to workplace settings, areas of practice concerns, and range of activities. Even though there were not any real surprises, there were several interesting findings. The principal professional activity reported by the respondents was psychotherapy, with 44% of the sample acknowledging involvement in this service. Assessment was the second most prevalent activity, with only 16% reporting this activity. In addition, the results showed that 29% were involved in outcomes assessment.
Taking a closer look at the impact that managed care has had on assessment, Piotrowski, Belter, and Keller (1998) surveyed 500 psychologists randomly selected from that year’s National Register of Health Service Providers in Psychology in the fall of 1996 to investigate how managed care has affected assessment practices. One hundred thirty-seven usable surveys (32%) were returned. Sixty-one percent of the respondents saw no positive impact of managed care; and, consistent with the CAPP survey findings, 70% saw managed care as negatively affecting clinicians or patients.The testing practices of 72% of the respondents were affected by managed care, as reflected in their performing less testing, using fewer instruments when they did test patients, and having lower reimbursement rates. Overall, they reported less reliance on those tests requiring much clinician time—such as the Weschler scales, Rorschach, and Thematic Apperception Test—along with a move to briefer, problem-focused tests. The results of their study led Piotrowski et al. to describe many possible scenarios for the future of assessment, including providers relying on briefer tests or briefer test batteries, changing the focus of their practice to more lucrative types of assessment activities (e.g., forensic assessment), using computer-based testing, or, in some cases, referring testing out to another psychologist.
In yet another survey, Stout and Cook (1999) contacted 40 managed care companies regarding their viewpoints concerning reimbursement for psychological assessment. The good news is that the majority (70%) of these companies reported that they did reimburse for these services. At the same time, the authors pointed to the possible negative implications for the covered lives of those other 12 or so companies that do not reimburse for psychological assessment. That is, these people may not be receiving the services they need because of missing information that might have been revealed through the assessment.
Piotrowski (1999) summed up the current state of psychological assessment by stating,
Admittedly, the emphasis on the standard personality battery over the past decade has declined due to the impact of brief therapeutic approaches with a focus on diagnostics, symptomatology, and treatment outcome. That is, the clinical emphasis has been on addressing referral questions and not psychodynamic, defenses, character structure, and object relations. Perhaps the managed care environment has brought this issue to the forefront. Either way, the role of clinical assessment has, for the most part, changed. To the dismay of proponents of clinical methods, the future is likely to focus more on specific domain-based rather than comprehensive assessment. (p. 793)
Opportunities for Psychological Assessment
The foregoing representations of the current state of psychological assessment in behavioral health care delivery could be viewed as an omen of worse things to come. In my opinion, they are not. Rather, the limitations that are being imposed on psychological assessment and the demand for justification of its use in clinical practice represent part of health care customers’ dissatisfaction with the way things were done in the past. In general, this author views the tightening of the purse strings as a positive move for both behavioral health care and the profession of psychology. It is a wake-up call to those who have contributed to the health care crisis by uncritically performing costly psychological assessments, being unaccountable to the payers and recipients of those services, and generally not performing assessment services in the most responsible, cost-effective way possible. Psychologists need to evaluate how they have used psychological assessment in the past and then determine the best way to use it in the future.
Consequently, this is an opportunity for psychologists to reestablish the value of the contributions they can make to improve the quality of care delivery through their knowledge and skills in the area of psychological assessment. As has been shown throughout this research paper, there are many ways in which the value of psychological assessment can be demonstrated in traditional mental health settings during this era of managed behavioral health care. However, the health care industry is now beginning to recognize the value of psychological assessment in the more traditional medical arenas. This is where potential opportunities are just now beginning to be realized.
Psychological Assessment in Primary Care Settings
The past three decades have witnessed a significant increase in the number of psychologists who work in general health care settings (Groth-Marnat & Edkins, 1996). This can be attributed to several factors, including the realization that psychologists can improve a patient’s physical health by helping to reduce overutilization of medical services and prevent stress-related disorders, offering alternatives to traditional medical interventions, and enhancing the outcomes of patient care. The recognition of the financial and patient-care benefits that can accrue from the integration of primary medical care and behavioral health care has resulted in the implementation of various types of integrated behavioral health programs in primary care settings. Regardless of the extent to which these services are merged, these efforts attest to the belief that any steps toward integrating behavioral health care services—including psychological testing and assessment— in primary care settings represents an improvement over the more traditional model of segregated service delivery.
The alliance of primary and behavioral health care providers is not a new phenomenon; it has existed in one form or another for decades. Thus, it is not difficult to demonstrate that clinical psychologists and other trained behavioral health care professionals can uniquely contribute to efforts to fully integrate their services in primary care settings through the establishment and use of psychological assessment services. Information obtained from psychometrically sound selfreport tests and other assessment instruments (e.g., clinician rating scales, parent-completed instruments) can assist the primary care provider in several types of clinical decisionmaking activities, including screening for the presence of mental health or substance abuse problems, planning a course of treatment, and monitoring patient progress. Testing can also be used to assess the outcome of treatment that has been provided to patients with mental health or substance abuse problems, thus assisting in determining what works for whom.
Psychological Assessment in Disease Management Programs
Beyond the primary care setting, the medical populations for which psychological assessment can be useful are quite varied and may even be surprising to some. Todd (1999) observed that “Today, it is difficult to find any organization in the healthcare industry that isn’t in some way involved in disease management. . . . This concept has quickly evolved from a marketing strategy of the pharmaceutical industry to an entrenched discipline among many managed care organizations” (p. xi). It is here that opportunities for the application of psychological screening and other assessment activities are just beginning to be realized.
What is disease management, or (as some prefer) disease state management? Gurnee and DaSilva (1999, p. 12) described it as “an integrated system of interventions, measurements, and refinements of health care delivery designed to optimize clinical and economic outcomes within a specific population. . . . [S]uch a program relies on aggressive prevention of complications as well as treatment of chronic conditions.” The focus of these programs is on a systems approach that treats the entire disease rather than its individual components, such as is the case in the more traditional practice of medicine. The payoff comes in improvement in the quality of care offered to participants in the program as well as real cost savings.
Where can psychological assessment fit into these programs? In some MBHOs, for example, there is a drive to work closer with health plan customers in their disease management programs for patients facing diabetes, asthma, and recovery from cardiovascular diseases. This has resulted in a recognition on the part of the health plans of the value that MBHOs can bring to their programs, including the expertise in selecting or developing assessment instruments and developing an implementation plan that can help identify and monitor medical patients with comorbid behavioral health problems. These and other medical disorders are frequently accompanied by depression and anxiety that can significantly affect quality of life, morbidity, and, in some cases, mortality. Early identification and treatment of comorbid behavioral health problems in patients with chronic medical diseases can thus dramatically affect the course of the disease and the toll it takes on the patient. In addition, periodic (e.g., annual) monitoring of the patient can be incorporated into the disease management process to help ensure that there has been no recurrence of the problem or development of a different behavioral health problem over time.
A Concluding Note
It is difficult to imagine that any behavioral health care organization—managed or otherwise—would not find value in at least one or two of the previously described applications. The issue becomes whether there are funds for these applications. These might include funds for assessment materials, reimbursing network providers or other third-party contractors (e.g., disease management companies) for their assessment work, an in-house staff position to conduct or oversee the implementation of this work, or any combination of the three. Regardless, it is highly unlikely that any MBHO is going to spend money on any service that is not considered essential for the proper care of patients unless that service can demonstrate value in short-term or long-term money savings or offset costs in other ways. Th ecurrent restrictions for authorizing assessment are a reflection of this fact. As Dorfman (2000) succinctly put it,
Until the value of testing can be shown unequivocally, support and reimbursement for evaluation and testing will be uneven with [MBHOs] and frequently based on the psychologist’s personal credibility and competence in justifying such expenditures. In the interim, it is incumbent on each psychologist to be aware of the goals and philosophy of the managed care industry, and to understand how the use of evaluation and testing with his or her patients not only is consistent with, but also helps to further, those goals. To the extent that these procedures can be shown to enhance the value of the managed care product by ensuring quality of care and positive treatment outcome, to reduce treatment length without sacrificing that quality, to prevent overutilization of limited resources and services, and to enhance patient satisfaction with care, psychologists can expect to gain greater support for their unique testing skill from the managed care company. (pp. 24–25)
The ways in which psychologists and other behavioral health care clinicians conduct the types of psychological assessment described in this research paper have undergone dramatic changes during the 1990s, and they will continue to change in this new millennium. Some of those involved in the delivery of psychological assessment services may wonder (with some fear and trepidation) where the health care revolution is leading the behavioral health care industry and, in particular, how their ability to practice will be affected in the twenty-first century. At the same time, others are eagerly awaiting the inevitable advances in technology and other resources that will come with the passage of time. What ultimately will occur is open to speculation. However, close observation of the practice of psychological assessment and the various industries that support it has led this author to arrive at a few predictions as to where the field of psychological assessment is headed and the implications they have for patients, clinicians, and provider organizations.
What the Field Is Moving Away From
One way of discussing what the field is moving toward is to first talk about what it is moving away from. In the case of psychological assessment, two trends are becoming quite clear. First, as just noted, the use of (and reimbursement for) psychological assessment has gradually been curtailed. In particular, this has been the case with regard to indiscriminate administration of lengthy and expensive psychological test batteries. Payers began to demand evidence that the knowledge gained from the administration of these instruments in fact contributes to the delivery of cost-effective, efficient care to patients. This author sees no indications that this trend will stop.
Second,asthePiotrowskietal.(1998)findingssuggest,the form of assessment commonly used is moving away from lengthy, multidimensional objective instruments (e.g., MMPI) or time-consuming projective techniques (e.g., Rorschach) that previously represented the standard in practice. The type of assessment authorized now usually involves the use of brief, inexpensive, problem-oriented instruments that have demonstrated validity for the purpose for which they will be used. This reflects modern behavioral health care’s timelimited, problem-oriented approach to treatment. Today, the clinician can no longer afford to spend a great deal of time in assessment when the patient is only allowed a limited number of payer-authorized sessions. Thus, brief instruments will become more commonly employed for problem identification, progress monitoring, and outcomes assessment in the foreseeable future.
Trends in Instrumentation
In addition to the move toward the use of brief, problemoriented instruments, another trend in the selection of instrumentation is the increasing use of public domain tests, questionnaires, rating scales, and other measurement tools. In the past, these free-use instruments were not developed with the same rigor that is applied by commercial test publishers in the development of psychometrically sound instruments. Consequently, they commonly lacked the validity and reliability data that are necessary to judge their psychometric integrity.
Recently, however, there has been significant improvement in the quality and documentation of the public domain, freeuse, and nominal cost tests that are available. Instrumentssuch as the SF-36 Health Survey (SF-36; Ware, Snow, Kosinski, & Gandek, 1993) and the SF-12 Health Survey (SF-12; Ware, Kosinski, & Keller, 1995) health measures are good examples of such tools. These and instruments such as the Behavior and Symptom Identification Scale (BASIS-32; Eisen, Grob, & Klein, 1986) and the Outcome Questionnaire (OQ45; Lambert, Lunnen, Umphress, Hansen, & Burlingame, 1994) have undergone psychometric scrutiny and have gained widespread acceptance. Although copyrighted, these instruments may be used for a nominal one-time or annual licensing fee; thus, they generally are treated much like public domain assessment tools. In the future, one can expect that other high quality, useful instruments will be made available for use at little or no cost.
As for the types of instrumentation that will be needed and developed, one can probably expect some changes. Accompanying the increasing focus on outcomes assessment is a recognition by payers and patients that positive change in several areas of functioning is at least as important as change in level of symptom severity when evaluating treatment effectiveness. For example, employers are interested in the patient’s ability to resume the functions of his or her job, whereas family members are probably concerned with the patient’s ability to resume his or her role as spouse or parent. Increasingly, measurement of the patient’s functioning in areas other than psychological or mental status has come to be included as part of behavioral health care outcomes systems. Probably the most visible indication of this is the incorporation of the SF-36 or SF-12 in various behavioral health care studies. One will likely see other public domain and commercially available, non-symptom-oriented instruments, especially those emphasizing social and occupational role functioning, in increasing numbers over the next several years.
Other types of instrumentation will also become prominent. These may well include measures of variables that support outcomes and other assessment initiatives undertaken by provider organizations. What one organization or provider believes is important, or what payers determine is important for reimbursement or other purposes, will dictate what is measured. Instrumentation may also include measures that will be useful in predicting outcomes for individuals seeking specific psychotherapeutic services from those organizations.
Trends in Technology
Looking back to the mid-1980s and early 1990s, the cuttingedge technology for psychological testing at that time included optical mark reader (OMR) scanning technologies. Also, there were those little black boxes that facilitated the per-use sale and security of test administration, scoring, and interpretations for test publishers while making computerbased testing convenient and available to practitioners. As has always been the case, someone has had the foresight to develop applications of several current technological advances that we use every day to the practice of psychological testing. Just as at one time the personal computer held the power of facilitating the testing and assessment process, the Internet, the fax, and interactive voice response, technologies are being developed to make the assessment process easier, quicker, and more cost effective.
The Internet has changed the way we do many things, so that the possibility of using it for the administration, scoring, and interpretation of psychological instruments should not be a surprise to anyone. The process here is straightforward. The clinician accesses the Web site on which the desired instrumentation resides. The desired test is selected for administration, and then the patient completes the test online. There may also be an option of having the patient complete a paper-andpencil version of the instrument and then having administrative staff key the responses into the program. The data are scored and entered into theWeb site’s database, and a report is generated and transmitted back to the clinician through the Web. Turnaround time on receiving the report will be only a matter of minutes. The archived data can later be used for any of a number of purposes. The most obvious, ofcourse, is to develop scheduled reporting of aggregated data on a regular basis. Data from repeated testing can be used for treatment monitoring and report card generation. These data can also be used for psychometric test development or other statistical purposes.
The advantages of an Internet-based assessment system are rather clear-cut. This system allows for online administration of tests that include branching logic for item selection. Any instruments available through a Web site can be easily updated and made available to users, which is not the case with diskdistributed software, for which updates and fixes are sometimes long in coming. The results of a test administration can be made available almost immediately. In addition, data from multiple sites can be aggregated and used for normative comparisons, test validation and risk adjustment purposes, generation of recovery curves, and any number of other statistically based activities that require large data sets.
There are only a couple of major disadvantages to an Internet-based system. The first and most obvious is the fact that it requires access to the Internet. Not all clinicians have Internet access. The second disadvantage has to do with the general Internet data security issue. With time, the access and security issues will likely become of less concern as the use of the Internet in the workplace becomes more of the standard and advances in Internet security software and procedures continue to take place.
The development of facsimile and faxback technology that has taken place over the past decade has opened an important application for psychological testing. It has dealt a huge blow to the optical scanning industry’s low-volume customer base while not affecting sales to their high-volume scanning customers.
The process for implementing faxback technology is fairly simple. Paper-and-pencil answer sheets for those tests available through the faxback system are completed by the patient. The answer sheet for a given test contains numbers or other types of code that tell the scoring and reporting software which test is being submitted. When the answer sheet is completed, it is faxed in—usually through a toll-free number that the scoring service has provided—to the central scoring facility, where the data are entered into a database and then scored. A report is generated and faxed back to the clinician within about 5 minutes, depending on the number of phone lines that the vendor has made available and the volume of submissions at that particular time. At the scoring end of the process, the whole system remains paperless. Later, the stored data can be used in the same ways as those gathered by an Internet-based system.
Like Internet-based systems, faxback systems allow for immediate access to software updates and fixes. As is the case with the PC-based testing products that are offered through most test publishers, its paper-and-pencil administration format allows for more flexibility as to where and when a patient can be tested. In addition to the types of security issues that come with Internet-based testing, the biggest disadvantage of or problem with faxback testing centers around the identification and linking data. Separate answer sheets are required for each instrument that can be scored through the faxback system.
Another disadvantage is that of developing the ability to link data from multiple tests or multiple administrations of the same test to a single patient. At first glance, this may not seem to be a very challenging task. However, there are issues related to the sometimes conflicting needs of maintaining confidentiality while at the same time ensuring the accuracy of patient identifiers that link data over an episode or multiple episodes of care. Overcoming this challenge may be the key to the success of any faxback system. If a clinician cannot link data, then the data will be limited in its usefulness.
One of the more recent applications of new technology to the administration, scoring, and reporting of results of psychological tests can be found in the use of interactive voice response, or IVR, systems.Almost everyone is familiar with the IVR technology. When we place a phone call to order products, address billing problems, or find out what the balance is in our checking accounts, we are often asked to provide information to an automated system in order to facilitate the meeting of our requests. This is IVR, and its applicability to test administration, data processing, and data storage should be obvious. What may not be obvious is how the data can be accessed and used.
Interactive voice response technology is attractive from many standpoints. It requires no extra equipment beyond a touch-tone telephone for administration. It is available for use 24 hours a day, 7 days a week. One does not have to be concerned about the patient’s reading ability, although oral comprehension levels need to be taken into account when determining which instruments are appropriate for administration via IVR or any audio administration format. As with fax- and Internet-based assessment, the system is such that branching logic can be used in the administration of the instrument. Updates and fixes are easily implemented systemwide. Also, the ability to store data allows for comparison of results from previous testings, aggregation of data for statistical analyses, and all the other data analytic capabilities available through fax- and Internet-based assessment. As for the down side of IVR assessment, probably the biggest issue is that in many instances the patient must be the one to initiate the testing. Control of the testing is turned over to a party that may or may not be amenable to assessment. With less cooperative patients, this may mean costly follow-up efforts to encourage full participation in the process.
Overall, the developments in instrumentation and technology that have taken place over the past several years suggest two major trends. First, there will always be a need for the commercially published, multidimensional assessment instruments in which most psychologists received training. These instruments can efficiently provide the type of information that is critical in forensic, employment, or other evaluations that generally do not involve ongoing treatment-related decisionmaking. However, use of these types of instruments will become the exception rather than the rule in day-to-day, in-the-trenches clinical practice. Instead, brief, valid, problemoriented instruments whose development and availability were made possible by public or other grant money will gain prominence in the psychologist’s armamentarium of assessment tools.As for the second trend, it appears that the Internet will eventually become the primary medium for automated test administration, scoring, and reporting.Access to the Internet will soon become universal, expanding the possibilities for in-office and off-site assessment and making test administration simple, convenient, and cost effective for patients and psychologists.
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