Unfortunately, many people use the terms testing and assessment synonymously, but actually these terms mean quite different things. Testing refers to the process of administering, scoring, and perhaps interpreting individual test scores by applying a descriptive meaning based on normative, nomothetic data. The focus here is on the individual test itself. Assessment, on the other hand, consists of a process in which a number of tests, obtained from the use of multiple methods, are administered and the results of these tests are integrated among themselves, along with data obtained from observations, history, information from other professionals, and information from other sources—friends, relatives, legal sources, and so on. All of these data are integrated to produce, typically, an in-depth understanding of the individual, focused on the reasons the person was referred for assessment. This process is person focused or problem issue focused (Handler & Meyer, 1998). The issue is not, for example, what the person scored on the Minnesota Multiphasic Personality Inventory-2 (MMPI-2), or what the Rorschach Structural Summary yielded, but, rather, what we can say about the patient's symptomatology, personality structure, and dynamics, and how we can answer the referral questions. Tests are typically employed in the assessment process, but much more information and much more complexity are involved in the assessment process than in the simple act of testing itself.
Many training programs teach testing but describe it as assessment. The product produced with this focus is typically a report that presents data from each test, separately, with little or no integration or interpretation. There are often no valid clear-cut conclusions one can make from interpreting tests individually, because the results of other test and nontest data often modify interpretations or conclusions concerning the meaning of specific test signs or results on individual tests. In fact, the data indicate that a clinician who uses a single method will develop an incomplete or biased understanding of the patient (Meyer et al., 2000).
WHY TEACH AND LEARN PERSONALITY ASSESSMENT?
When one considers the many advantages offered by learning personality assessment, its emphasis in many settings becomes quite obvious. Therefore, we have documented the many reasons personality assessment should be taught in doctoral training programs and highlighted as an important and respected area of study.
Learning Assessment Teaches Critical Thinking and Integrative Skills
The best reason, we believe, to highlight personality assessment courses in the doctoral training curriculum concerns the importance of teaching critical thinking skills through the process of learning to integrate various types of data. Typically, in most training programs until this point, students have amassed a great deal of information from discrete courses by reading, by attending lectures, and from discussion. However, in order to learn to do competent assessment work students must now learn to organize and integrate information from many diverse courses. They are now asked to bring these and other skills to bear in transversing the scientist-practitioner bridge, linking nomothetic and ideographic data. These critical thinking skills, systematically applied to the huge task of data integration, provide students with a template that can be used in other areas of psychological functioning (e.g., psychotherapy, or research application).
Assessment Allows the Illumination of a Person's Experience
Sometimes assessment data allow us to observe a person's experience as he or she is being assessed. This issue is important because it is possible to generalize from these experiences to similar situations in psychotherapy and to the patient's environment. For example, when a 40-year-old man first viewed Card II of the Rorschach, he produced a response that was somewhat dysphoric and poorly defined, suggesting possible problems with emotional control, because Card II is the first card containing color that the patient encounters. He made a sound that indicated his discomfort and said, "A bloody wound." After a minute he said, "A rocket, with red flames, blasting off." This response, in contrast to the first one, was of good form quality. These responses illuminate the man's style of dealing with troubling emotions: He becomes angry and quickly and aggressively leaves the scene with a dramatic show of power and force. Next the patient gave the following response: "Two people, face to face, talking to each other, discussing." One could picture the sequence of intrapsychic and interpersonal events in the series of these responses. First, it is probable that the person's underlying depression is close to the surface and is poorly controlled. With little pressure it breaks through and causes him immediate but transitory disorganization in his thinking and in the ability to manage his emotions. He probably recovers very quickly and is quite capable, after an unfortunate release of anger and removing himself from the situation, of reestablishing an interpersonal connection. Later in therapy this man enacted just such a pattern of action in his work situation and in his relationships with family members and with the therapist, who was able to understand the pattern of behavior and could help the patient understand it.
A skilled assessor can explore and describe with empathic attunement painful conflicts as well as the ebb and flow of dynamic, perhaps conflictual forces being cautiously contained. The good assessor also attends to the facilitating and creative aspects of personality, and the harmonious interplay of intrapsychic and external forces, as the individual copes with day-to-day life issues (Handler & Meyer, 1998). It is possible to generate examples that provide moving portraits of a person's experience, such as the woman who saw "a tattered, torn butterfly, slowly dying" on Card I of the Rorschach, or a reclusive, schizoid man whom the first author had been seeing for some time, who saw "a mushroom" on the same card. When the therapist asked, "If this mushroom could talk, what would it say?" the patient answered, "Don't step on me. Everyone likes to step on them and break them." This response allowed the therapist to understand this reserved and quiet man's experience of the therapist, who quickly altered his approach and became more supportive and affiliative.
Responses to assessment stimuli allow us to look beyond a person's pattern of self-presentation, possibly concealing underlying emotional problems. For example, a 21-year-old male did not demonstrate any overt signs of gross pathology in his initial intake interview. His Rorschach record was also unremarkable for any difficulties, until Card IX, to which he gave the following response: "The skull of a really decayed or decaying body ... with some noxious fumes or odor coming out of it. It looks like blood and other body fluids are dripping down on the bones of the upper torso and the eyes are glowing, kind of an orange, purplish glow." To Card X he responded, "It looks like someone crying for help, all bruised and scarred, with blood running down their face." The student who was doing the assessment quickly changed her stance with this young man, providing him with rapid access to treatment.
Treatment planning can focus and shorten treatment, resulting in benefits to the patient and to third-party payors. Informed treatment planning can also prevent hospitalization, and provide more efficient and effective treatment for the patient. Assessment can enhance the likelihood of a favorable treatment outcome and can serve as a guide during the course of treatment (Applebaum, 1990).
The establishment of the initial relationship between the patient and the therapist is often fraught with difficulty. It is important to sensitize students to this difficult interaction because many patients drop out of treatment prematurely. Although asking the new patient to participate in an assessment before beginning treatment would seem to result in greater dropout than would a simple intake interview because it may seem to be just another bothersome hurdle the patient must jump over to receive services, recent data indicate that the situation is just the opposite (Ackerman, Hilsenroth, Baity, & Blagys, 2000). Perhaps the assessment procedure allows clients to slide into therapy in a less personal manner, desensitizing them to the stresses of the therapy setting.
An example of an assessment approach that facilitates the initial relationship between patient and therapist is the recent research and clinical application of the Early Memories Procedure. Fowler, Hilsenroth, and Handler (1995, 1996) have provided data that illustrate the power of specific early memories to predict the patient's transference reaction to the therapist.
Several psychologists have recently provided data that demonstrate the therapeutic effects of the assessment process itself, when it is conducted in a facilitative manner. The work of Finn (1996; Finn & Tonsager, 1992) and Fischer (1994) have indicated that assessment, done in a facilitative manner, will typically result in the production of therapeutic results. The first author has developed a therapeutic assessment approach that is ongoing in the treatment process with children and adolescents to determine whether therapeutic assessment changes are long-lasting.
There are many mental health specialists who do psychotherapy (e.g., psychologists, psychiatrists, social workers, marriage and family counselors, ministers), but only psychologists are trained to do assessment. Possession of this skill allows us to be called upon by other professionals in the mental health area, as well as by school personnel, physicians, attorneys, the court, government, and even by business and industry, to provide evaluations.
Assessment Reflects Patients' Relationship Problems
More and more attention has been placed on the need for assessment devices to evaluate couples and families. New measures have been developed, and several traditional measures have been used in unique ways, to illuminate relational patterns for therapists and couples. Measures range from pencil-and-paper tests of marital satisfaction to projective measures of relational patterns that include an analysis of a person's interest in, feelings about, and cognitive conceptualizations of relationships, as well as measures of the quality of relationships established.
The Rorschach and several selected Wechsler verbal subtests have been used in a unique manner to illustrate the pattern and style of the interaction between or among participants. The Rorschach or the WAIS subtests are given to each person separately. The participants are then asked to retake the test together, but this time they are asked to produce an answer (on the WAIS; e.g., Handler & Sheinbein, 1987) or responses on the Rorschach (e.g., Handler, 1997) upon which they both agree. The quality of the interaction and the outcome of the collaboration are evaluated. People taking the test can get a realistic picture of their interaction and its consequences, which they often report are similar to their interactions in everyday relationships.
Personality Assessment Helps Psychologists Arrive at a Diagnosis
Assessment provides information to make a variety of diagnostic statements, including a Diagnostic and Statistical Manual (DSM) diagnosis. Whether the diagnosis includes descriptive factors, cognitive and affective factors, interaction patterns, level of ego functions, process aspects, object relations factors, or other dynamic aspects of functioning, it is an informed and comprehensive diagnosis, with or without a diagnostic label.
There is a huge literature on the use of personality assessment in the workplace. Many studies deal with vocational choice or preference, using personality assessment instruments (e.g., Krakowski, 1984; Muhlenkamp & Parsons, 1972; Rezler & Buckley, 1977), and there is a large literature in which personality assessment is used as an integral part of the study of individuals in work-related settings and in the selection and promotion of workers (Barrick & Mount, 1991; Tett, Jackson, & Rothstein, 1991).
Psychologists are frequently asked to evaluate people for a wide variety of domestic, legal, or medical problems. Readers should see the chapters in this volume by Ogloff and Douglas and by Sweet, Tovian, and Suchy, which discuss assessment in forensic and medical settings, respectively.
Assessments are often used in criminal cases to determine the person's ability to understand the charges brought against him or her, or to determine whether the person is competent to stand trial or is malingering to avoid criminal responsibility.
Assessments are also requested by physicians and insurance company representatives to determine the emotional correlates of various physical disease processes or to help differentiate between symptoms caused by medical or by emotional disorders. There is now an emphasis on the biopsy-chosocial approach, in which personality assessment can target emotional factors along with the physical problems that are involved in the person's total functioning. In addition, psychoneuroimmunology, a term that focuses on complex mind-body relationships, has spawned new psychological assessment instruments. There has been a significant increase in the psychological aspects of various health-related issues (e.g., smoking cessation, medical compliance, chronic pain, recovery from surgery). Personality assessment has become an integral part of this health psychology movement (Handler & Meyer, 1998).
Assessment techniques are used to test a variety of theories or hypothesized relationships. Psychologists search among a large array of available tests for assessment tools to quantify the variables of interest to them. There are now at least three excellent journals in the United States as well as some excellent journals published abroad that are devoted to research in assessment.
Assessment Is Used to Evaluate the Effectiveness of Psychotherapy
In the future, assessment procedures will be important to insure continuous improvement of psychotherapy through more adequate treatment planning and outcome assessment. Maruish (1999) discusses the application of test-based assessment in Continuous Quality Improvement, a movement to plan treatment and systematically measure improvement. Psychologists can play a major role in the future delivery of mental health services because their assessment instruments can quickly and economically highlight problems that require attention and can assist in selecting the most cost-effective, appropriate treatment (Maruish, 1990). Such evidence will also be necessary to convince legislators that psychotherapy services are effective. Maruish believes that our psychometri-cally sound measures, which are sensitive to changes in symptomatology and are administered pre- and posttreatment, can help psychology demonstrate treatment effectiveness. In addition, F. Newman (1991) described a way in which personality assessment data, initially used to determine progress or outcome, "can be related to treatment approach, costs, or reimbursement criteria, and can provide objective support for decisions regarding continuation of treatment, discharge, or referral to another type of treatment" (Maruish, 1999, p. 15). The chapter by Maruish in this volume discusses the topic of assessment and treatment in more detail.
Assessment can substantially reduce many of the potential legal liabilities involved in the provision of psychological services (Bennet, Bryan, VandenBos, & Greenwood, 1990; Schutz, 1982) in which providers might perform routine baseline assessments of their psychotherapy patients' initial level of distress and of personality functioning (Meyer et al., 2000).
PROBLEMS OF LEARNING PERSONALITY ASSESSMENT: THE STUDENT SPEAKS
The first assessment course typically focuses on teaching students to give a confusing array of tests. Advanced courses are either didactic or are taught by the use of a group process model in which hypothesis generation and data integration are learned. With this model, depression, anxiety, ambivalence, and similar words take on new meaning for students when they are faced with the task of integrating personality assessment data. These words not only define symptoms seen in patients, but they also define students' experiences.
Early in their training, students are often amazed at the unique responses given to the most obvious test stimuli. Training in assessment is about experiencing for oneself what it is like to be with patients in a variety of situations, both fascinating and unpleasant, and what it is like to get a glimpse of someone else's inner world. Fowler (1998) describes students' early experience in learning assessment with the metaphor of being in a "psychic nudist colony." With this metaphor he is referring to the realization of the students that much of what they say or do reveals to others and to themselves otherwise private features of their personality. No further description was necessary in order for the second author (Clemence) to realize that she and Fowler shared a common experience during their assessment training. However, despite the feeling that one can no longer insure the privacy of one's inner world, or perhaps because of this, the first few years of training in personality assessment can become an incredibly profound educational experience. If nothing else, students can learn something many of them could perhaps learn nowhere else—what it is like to feel examined and assessed from all angles, often against their will. This approach to learning certainly allows students to become more empathic and sensitive to their patients' insecurities throughout the assessment procedure. Likewise, training in assessment has the potential to greatly enrich one's ability to be with clients during psychotherapy. Trainees learn how to observe subtleties in behavior, how to sit through uncomfortable moments with their patients, and how to endure scrutiny by them as well.
Such learning is enhanced if students learn assessment in a safe environment, such as a group learning class, to be described later in this chapter. However, with the use of this model there is the strange sense that our interpretation of the data may also say something about ourselves and our competence in relation to our peers. Are we revealing part of our inner experience that we would prefer to keep hidden, or at least would like to have some control over revealing?
Although initially one cannot escape scrutiny, eventually there is no need to do so. With proper training, students will develop the ability to separate their personal concerns and feelings from those of their patients, which is an important step in becoming a competent clinician. Much of their ignorance melts away as they develop increased ability to be excited about their work in assessment. This then frees students to wonder about their own contributions to the assessment experience. They wonder what they are projecting onto the data that might not belong there. Fortunately, in the group learning model, students have others to help keep them in check. Hearing different views of the data helps to keep projections at a minimum and helps students recognize the many different levels at which the data can be understood. It is certainly a more enriching experience when students are allowed to learn from different perspectives than it is when one is left on one's own to digest material taught in a lecture.
The didactic approach leaves much room for erroneous interpretation of the material once students are on their own and are trying to make sense of the techniques discussed in class. This style of learning encourages students to be more dependent on the instructor's method of interpretation, whereas group learning fosters the interpretative abilities of individual students by giving each a chance to confirm or to disconfirm the adequacy of his or her own hypothesis building process. This is an important step in the development of students' personal assessment styles, which is missed in the didactic learning model. Furthermore, in the didactic learning model it is more difficult for the instructor to know if the pace of teaching or the material being taught is appropriate for the skill level of the students, whereas the group learning model allows the instructor to set a pace matched to their abilities and expectations for learning.
During my (Clemence) experience in a group learning environment, what became increasingly more important over time was the support we received from learning as a group. Some students seemed to be more comfortable consulting with peers than risking the instructor's criticism upon revealing a lack of understanding. We also had the skills to continue our training when the instructor was not available. Someone from the group was often nearby for consultation and discussion, and this proved quite valuable during times when one of us had doubts about our approach or our responsibilities.
After several classes in personality assessment and after doing six or seven practice assessments, students typically feel they are beginning to acquire the skills necessary to complete an assessment, until their supervisor asks them to schedule a feedback session with the patient. Suddenly, newfound feelings of triumph and mastery turn again into fear and confusion because students find it awkward and discomforting to be put in a position of having to reveal to the patient negative aspects of his or her functioning. How do new students communicate such disturbing and seemingly unsettling information to another person? How can the patient ever understand what it has taken the student 2-3 years to even begin to understand? Students fear that it will surely devastate someone to hear he or she has a thought disorder or inadequate reality testing. However, when the emphasis of assessment (as in a therapeutic assessment approach) is on the facilitation of the client's questions about him- or herself, in addition to the referral question(s), this seemingly hopeless bind becomes much less of a problem. This approach makes the patient an active participant in the feedback process.
PROBLEMS OF TEACHING PERSONALITY ASSESSMENT: THE INSTRUCTOR SPEAKS
The problems encountered in teaching the initial assessment course, in which the emphasis is on learning the administration and scoring of various instruments, are different from those involved in teaching an advanced course, in which assessment of patients is the focus and the primary issue is integration of data. It must be made clear that the eventual goal is to master the integration of diverse data.
The instructor should provide information about many tests, while still giving students enough practice with each instrument. However, there may only be time to demonstrate some tests or have the student read about others. The instructor should introduce each new test by describing its relevance to an assessment battery, discussing what it offers that other tests do not offer. Instructors should resist students' efforts to ask for cookbook interpretations. Students often ask what each variable means. The response to the question of meaning is a point where the instructor can begin shifting from a test-based approach to one in which each variable is seen in context with many others.
Learning to do assessment is inherently more difficult for students than learning to do psychotherapy, because the former activity does not allow for continued evaluation of hypotheses. In contrast, the therapeutic process allows for continued discussion, clarification, and reformulation of hypotheses, over time, with the collaboration of the patient. This problem is frightening to students, because they fear making interpretive errors in this brief contact with the patient. More than anything else they are concerned that their inexperience will cause them to harm the patient. Their task is monumental: They must master test administration while also being empathic to patient needs, and their learning curve must be rapid. At the same time they must also master test interpretation and data integration, report writing, and the feedback process.
Sometimes students feel an allegiance to the patient, and the instructor might be seen as callous because he or she does not feel this personal allegiance or identification. Students' attitudes in this regard must be explored, in a patient, non-confrontational manner. Otherwise, the students might struggle to maintain their allegiance with the patient and might turn against learning assessment.
Not unlike some experienced clinicians who advocate for an actuarial process, many students also resist learning assessment because of the requirement to rely on intuitive processes, albeit those of disciplined intuition, and the fear of expressing their own conflicts in this process, rather than explaining those of the patient. The students' list of newfound responsibilities of evaluating, diagnosing, and committing themselves to paper concerning the patients they see is frightening. As one former student put it, "Self-doubt, anxiety, fear, and misguided optimism are but a few defenses that cropped up during our personality assessment seminar" (Fowler, 1998, p. 34).
Typically, students avoid committing themselves to sharply crafted, specific interpretations, even though they are told by the instructor that these are only hypotheses to try out. Instead, they resort to vague Barnum statements, statements true of most human beings (e.g., "This patient typically becomes anxious when under stress"). Students also often refuse to recognize pathology, even when it is blatantly apparent in the test data, ignoring it or reinterpreting it in a much less serious manner. They feel the instructor is overpathologizing the patient. The instructor should not challenge these defenses directly but instead should explore them in a patient, supportive manner, helping to provide additional clarifying data and trying to understand the source of the resistance. There is a large body of literature concerning these resistances in learning assessment (e.g., Berg, 1984; Schafer, 1967; Sugarman, 1981, 1991). Time must also be made available outside the classroom for consultation with the instructor, as well as making use of assessment supervisors. Most of all, students who are just learning to integrate test data need a great deal of encouragement and support of their efforts. They also find it helpful when the instructor verbalizes an awareness of the difficulties involved in this type of learning.
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