Diagnosis-Specific Instruments 123 Personality Measures and Symptom Surveys 123 PSYCHOLOGICAL ASSESSMENT AS A TOOL FOR TREATMENT PLANNING 124 The Benefits of Psychological Assessment for Treatment Planning 124 PSYCHOLOGICAL ASSESSMENT AS A TREATMENT INTERVENTION 126 What Is Therapeutic Assessment? 126 The Therapeutic Assessment Process 126 Empirical Support for Therapeutic Assessment 127
TREATMENT MONITORING 127 Monitoring Change 128 Other Uses for Patient Profiling 128 The Effects of Providing Feedback to the Therapist 128
OUTCOMES ASSESSMENT 129 What Are Outcomes? 129
The Use of Outcomes Assessment in Treatment 129
PSYCHOLOGICAL ASSESSMENT IN THE ERA OF MANAGED BEHAVIORAL HEALTH CARE 131 Current Status 132
Opportunities for Psychological Assessment 132 A Concluding Note 133 FUTURE DIRECTIONS 134
What the Field Is Moving Away From 134 Trends in Instrumentation 134 Trends in Technology 135 REFERENCES 136
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.
Portions adapted from M. E. Maruish (1999a) with permission from Erlbaum. Portions adapted from M. E. Maruish (1999b) with permission from Elsevier Science. Portions adapted from M. E. Maruish (2002) with permission from Erlbaum.
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 chapter, 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 chapter, 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 decision-making 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 decision-making 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 as a Tool for Screening and Diagnosis 121
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.
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 in-depth and detailed discussion about each of these applications that follows.
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