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.
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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 impairs the patient's ability to function in one or more life roles.
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 insight-oriented 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.
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-II-identified (Millon, 1987) personality disorder patients seeking treatment for agoraphobia and panic attacks. Patients classified 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) and Anxiety (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 chapter.
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