For many years there has been very active debate, and sometimes even animosity and expressions of derision, between those who preferred a more objective approach to personality assessment (read self-report and MMPI) and those who preferred a more subjective approach (read projective tests and Rorschach). This schism was fueled by researchers and teachers of assessment. Each group disparaged the other's instruments, viewing them as irrelevant at best and essentially useless, while championing the superiority of its own instruments (e.g., Holt, 1970; Meehl, 1954, 1956).
This debate seems foolish and ill-advised to us, and it should be described in this way to students, in order to bring assessment integration practices to the forefront. These misleading attitudes have unfortunately been transmitted to graduate students by their instructors and supervisors over many years. Gradually, however, the gulf between the two seemingly opposite approaches has narrowed. Clinicians have come to use both types of tests, but there is still a great deal of misperception about each type, which interferes with productive integration of the two types of measures and impairs clinicians' efforts to do assessment rather than testing. Perhaps in the future teachers of personality assessment will make fewer and fewer pejorative remarks about each other's preferred instruments and will concentrate more and more on the focal issue of test integration.
Another issue is the place of assessment in the clinical psychology curriculum. For many years graduate curricula contained many courses in assessment. The number of courses has gradually been reduced, in part because the curricula have become crowded with important courses mandated by the APA, such as professional ethics, biological bases of behavior, cognitive and affective aspects of behavior, social aspects of behavior, history and systems, psychological measurement, research methodology, techniques of data analysis, individual differences, human development, and psychopathology, as well as courses in psychotherapy and in cultural and individual diversity (Committee on Accreditation, Education Directorate, & American Psychological Association, 1996). Courses have also been added because they have become important for clinical training (e.g., child therapy, marital therapy, health psychology, neu-ropsychology, hypnosis). Therefore, there is sometimes little room for assessment courses. To complicate matters even more, some instructors question the necessity of teaching assessment at all. Despite the published survey data, we know of programs that have no identified courses in assessment, and programs in which only one type of measure (e.g., self-report, interview, or projective measures) is taught. While most programs do have courses in assessment, the content of some courses does not prepare students to do effective assessment. Sometimes the courses offered are merely survey courses, or courses in which the student administers and scores one of each type of test. Unfortunately, with this type of inadequate training students do poor applied work and even poorer research, both of which reflect poorly on the discipline of personality assessment.
With the impact of cognitive therapy there have been radical changes in the ways in which some training programs teach assessment, seemingly without knowledge of the significant improvements in assessment research and practice that have taken place in the last 15 years or so. There seems to be a "Throw the baby out with the bathwater" approach, whereby traditional instruments are derided and replaced primarily with self-report measures. This is an important issue because it has major implications for teaching assessment in graduate school and in internship settings.
For example, Wetzler (1989) describes a hospital-based assessment approach in which a general broadly focused assessment has been replaced with a so-called focal approach, using self-report instruments. These changes, he indicates, have come about because of shorter hospitalization stays, and because what he calls "the standard battery" (Rapaport, Gill, & Schafer, 1968) "is no longer appropriate." He believes the questions that need to be answered in this acute problem setting cannot be adequately addressed using the "traditional" assessment approach: "What was well-suited to the psychiatric community of the 1930s, 1940s, and 1950s is no longer appropriate" (p. 5). "No matter what the referral question, they administer the standard battery," he states (p. 7). He lists a number of reported dissatisfactions with "traditional assessment" procedures, which include the problem that "test findings do not respond to [the] referral questions." His solution is to replace "traditional assessment" with "focal assessment," which includes the use of observer rating scales, self-report inventories, and a number of questionnaires derived from psychological research rather than from clinical observation or theory. He describes focal tests as specialized instruments considering specific areas of psychopathology, which have a much narrower focus and are "more concrete and descriptive, focused on surface symptoms and behavior, with clearly defined criteria for scoring, and with normative data available."
Wetzler concludes that "In light of [its] scientific foundation focal assessment is frequently more valid and therefore more effective than projective testing and/or informal interviewing" and that "focal assessment is more appropriate to the parameters of contemporary treatment than is traditional assessment" (p. 9), especially because in his setting assessment findings and clinical decisions must be made within 72 hours.
We do not agree with Wetzler in a number of his conclusions; we believe the approach he described comes closer to the definition we used earlier of testing than it does to assessment, since only self-report measures are employed, and test scores are emphasized rather than the development of integrated findings. The overemphasis on the validity of test scores does not take into account the validity of their use in a particular clinical setting without the concomitant understanding of the patient's feelings and his or her experience of being hospitalized, as well as other important issues that would make these disembodied test scores more meaningful. What is lacking is an understanding of and an appreciation for the patient's contextual world, which we emphasize in our teaching. We have no way of knowing whether the patient responded to these instruments in a meaningful manner. The reduction in personal contact with the patient and its replacement with standardized self-report instruments does not seem to us to be an improvement in the assessment process. Validity of the instrument may be only an illusion in many cases, in which patients take a test with perhaps questionable motivation and a nonfacilitative orientation.
This approach to assessment is a prototype of other similar approaches that are convenience-driven, test-driven, and technician-driven; it is a most dangerous approach, in which the role of the assessor is primarily to choose the right test, and the test scores are said to provide the appropriate answers.
Earlier in this chapter we emphasized that psychologists should be well trained in the area of psychometrics and in the limitations of tests, especially problems of reliability and validity. In testing, one seeks the assistance of confidence limits of the results, but in assessment one determines the validity of the results of the test scores by taking into account a host of variables determined from interview data, from observations of the patient during the assessment, and the similarities and differences among the various assessment findings. In the focused approach it is doubtful whether the proper evaluation of the test scores can be accomplished. More to the point, however, is the criticism that there is actually a rigid adherence to a traditional battery. Our survey of test use in internship settings suggests otherwise; internship directors reported that a wide variety of tests are employed in assessment in their setting. We do not recommend or teach adherence to a traditional test battery, although these assessment devices are among those recommended for use, for reasons discussed in this chapter. We believe innovations in assessment should be employed to improve the validity of the assessment procedure and to improve the delivery of assessment services to those who request them. If the referral questions are not answered in an assessment it is the fault of the assessor, who has not paid attention to the referral issue or who has not sufficiently clarified the referral issue with the person requesting the assessment.
To describe an approach we believe is more typical of assessment rather than testing, also in a hospital setting, we will review the approaches of Blais and Eby (1998), in which psychologists have even more stringent demands on them to provide focal answers, often within a day. Blais and Eby train their internship students to assist the referring physician in clarifying referral questions. After a brief discussion with the nurse in charge of the patient, a review of the patient's chart, or both, the student selects the appropriate tests and procedures to answer the referral questions, taking into account the necessary turnaround time and both the physical and psychological limitations of the patient.
In a training case example in which the turnaround time was less than a day, Blais and Eby describe a battery that included a seven-subtest short form of the WAIS-R, the Rorschach, four TAT cards, and the PAI. The brief WAIS-R took less than 30 minutes to administer. Since the patient was described by the staff as extremely guarded, projective testing was viewed as crucial. The Rorschach and the TAT were chosen, the latter to identify the patient's object relations and core interpersonal themes, and both tests served to determine the degree of suicidal ideation. The PAI was chosen rather than the MMPI-2 because it is significantly shorter and the patient had poor physical stamina, and because it can be scored as a short form, using only 199 of its 344 items. It also contained several treatment planning scales that could possibly provide important information relevant to a referral question about treatment.
Although the battery described for this individual patient did include the traditional tests, batteries designed for other patients might not include any of the traditional tests. In addition, these traditional tests were employed not because they were traditional but, rather, because each offered something that the other measures did not offer. Also, the manner in which they are scored is directly tied to a large body of research, including, in the case of the Rorschach, extensive normative findings and reliability and validity data. The Rorschach was scored using the Comprehensive System (Exner, 1993), which includes a well-validated suicide constellation measure along with a host of other scores of importance to the referral issue, and with the P. Lerner and H. Lerner Defense Scale (1980). The TAT was scored as well, using the Social Cognition and Object Relations Scale (SCORS) system, a research-based interpretive system that measures eight aspects of object relations (Westen, 1991a, 1991b). The data were integrated into a picture of the patient's current psychological functioning and categorized according to thought quality, affect, defenses, and relationship to self and others, all issues directly related to the referral questions. Verbal report was given to the referring psychiatrist by telephone well before rounds the next morning, along with treatment recommendations.
The assessment approach designed by Blais and Eby is an example of a hospital-based assessment that demonstrates that traditional tests can be employed with quite rapid turnaround time and that a test battery that includes traditional tests need not be rigidly fixed. In Blais and Eby's approach the clinicians responded flexibly and actively in the assessment process, integrating data from several different sources and responding in an efficient and rapid manner to focalized referral issues generated from several sources. In Wetzler's approach, the response was to develop a test-focused approach rather than a person-focused approach. Sharing the information in this section of our chapter with students helps to impress them with the importance of taking a person-focused approach to personality assessment.
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