Psychological assessment has been defined in various ways. Sometimes the term is mistakenly used interchangeably with "psychological testing." Specifically, psychological testing is a part of the psychological assessment, and is defined as the procedure by which one or more psychological instruments are administered to one person or a group of people to examine a specific area(s) of functioning. This involves administering tests, inventories and/or checklists in accordance with their particular procedures, scoring these instruments and presenting the results.
In contrast, the psychological assessment involves not only psychological testing, but also includes a clinical interview, interpretation of test results, review of patient documents, conclusion, diagnosis and recommendations for treatment. The type and number of psychological tests employed, the clinical interview format and the focus of the psychological assessment is determined by the referral source. For example, the questions to be answered and information desired will be quite different when the referral for assessment is made by an addictions treatment program versus that made by the criminal/civil court (forensic), school personnel (scholastic), career counselors (aptitude/career), or business and industry (personnel/ability).
The psychological assessment attempts to provide a clinical treatment staff with current information regarding the patient's ability to function in and benefit from treatment. Expedient information regarding a patient's addiction disorder, whether it be alcohol, cocaine, food, sex, gambling, etc., is most important to help understand the patient's weaknesses and strengths, allowing the clinical staff to provide the most appropriate addiction treatment. This process involves gathering information on the patient's medical, educational, social, legal, family, occupational, developmental and mental health histories. This data provides the treatment team with an overview of the patient within the context in which the addiction process has developed and persists. In addition, specific information is needed regarding the patient's current level of functioning. This requires an assessment of the patient's intellectual abilities, personality dynamics and emotional/behavioral stability, including questions such as:
The clinical staff needs answers to these questions at the onset of treatment to determine whether this program is appropriate for the patient, and to develop an individualized treatment plan which meets the patient's needs.
During the clinical interview, the patient's overall responding and relating style emerges out of the interaction between the psychologist and the patient. This sample of interpersonal patterns is used to develop hypotheses about symptoms, personality and diagnosis. To obtain this patient information, the clinical interview assesses the following:
In assessing affect, the patient's reported mood and his/her expression of emotion is evaluated during the interview and compared with "normal" expression. In order to evaluate this expressed emotion, the psychologist assesses the patient's mood, modulation of affect, appropriateness of affect and degree of emotional liability.
The nature and degree of anxiety expressed in the interview must be assessed to determine the extent to which anxiety may, at least initially, interfere with the patient's ability to function adequately in the treatment program. Moderate to high levels of anxiety can interfere with the patient's memory, concentration and comprehension abilities.
The patient's ambivalence, i.e., indecisiveness, fear of directness, or doubt, is also assessed to ascertain the patient's ability to make decisions and to express him/herself. Ambivalence may reflect problems in self-esteem and may indicate dependency problems. Fear of directness may reflect the patient's reluctance to express a clear choice. Such ambivalence suggests the patient is likely to encounter difficulty making a commitment, and may be at risk for leaving treatment prior to completion.
The psychologist assesses cognition, or thinking patterns, to determine whether any significant disassociation is occurring which may interfere with the patient's ability to be logical, clear and relevant. The patient's language construction and coherence is assessed to rule out disturbance/confusion about the essence of reality that would interfere with the patient's ability to express him/herself in a reasonable and coherent manner. During the clinical interview, the extent to which reality orientation is intact can be inferred from the patient's questions, mannerisms and response to the examiner's inquiry.
At this point, the patient's relationship to reality and elements of time, place and person are assessed to ascertain the patient's current state of consciousness, stability and reality testing. Questions regarding the patient's knowledge of specific dates, years and current times provide data to evaluate the patient's awareness of time. To evaluate place orientation, the patient is questioned in regard to where and why the interview is taking place, thereby providing a means to assess reality contact. Finally, the patient's self-identity is assessed to rule out cognitive dysfunction of personal identification due to projections and hallucinations.
The second portion of the psychological assessment involves psychological testing. At the Illinois Institute for Addiction Recovery, the psychological tests given fall into one of two categories: intellectual abilities and personality. The patient's intellectual abilities are assessed by at least one of the following psychological tests:
Personality dynamics are assessed by means of the following:
The WAIS-III is administered to patient's 16 to 74 years of age, and the WISC-III is administered to adolescents under 16 years of age. The test results provide the clinician with an I.Q. score and information on the patient's verbal and performance abilities. This information determines whether the patient possesses minimal intellectual skills to function adequately. In some cases, due to the lack of academic training or deficits in reading and writing, the patient will require a simplified treatment program. Assessed deficits in vocabulary, fund of knowledge, memory, etc., may require the patient to be provided with audio tapes as a substitute for reading assignments, a discussion group and/or video tapes, as well as periodic reviews to determine the extent and accuracy of information retained.
The Shipley-Hartford test takes as little as 20 minutes to administer, and five minutes to evaluate the results. It provides a quick screening for organic brain dysfunction and a general level of intelligence (vocabulary and abstract reasoning). The WISC-III or WAIS-III works in all cases involving adolescent patients and, in special cases, the WAIS-III is used for some adult patients. Analysis of comprehension and picture arrangement subtests of the WISC-III or WAIS-III helps the clinician identify patients -- particularly adolescents -- who may require special attention to improve their social judgment, use of their past experiences, and the ability to make plans and anticipate consequences. Also, patients who attempt to malinger and report they lack the academic ability to complete assignments, or who attempt to mask passive resistance and uncooperativeness by reporting they are academically slow, can be identified and treated.
The MMPI and MMPI-A are used to assess personality dynamics, including:
Information obtained from the MMPI validity scale elevations assist the clinician in assessing the patient's motivation for treatment. Also, these scales provide information regarding the extent of patient denial, minimization and guardedness.
The degree to which a patient is depressed, or whether depression exists at all, is an important factor when assessing the addict. It is reasonable to believe that when an addict voluntarily enters treatment, he or she has most likely "hit bottom," and has lost -- or is in the process of losing -- their family, job, freedom and/or health. The extent of depression and other factors help determine the risk of suicide and assist in making decisions on whether the patient is appropriate for addictions treatment.
From time to time, the treatment team encounters an addict who is "too good to be true." This addict is verbally adroit, appears highly motivated, interacts well with peers and staff, provides feedback to peers in group therapy, finishes assignments prior to deadlines, etc. However, the psychological assessment often penetrates this façade and uncovers an intellectually bright, verbally manipulative addict with excellent verbal skills and sociopathic personality features.
Treatment is facilitated when rapport is established and trust built between the addict and the primary counselor and treatment peers. When personality features such as suspiciousness, distrust and paranoid ideation influence the establishment of rapport and trust, these features need to be identified and dealt with in order for treatment to be effective. MMPI clinical scales provide data regarding the presence of these personality traits and can thereby alert the treatment team. A review of confidentiality laws may be all that is necessary to assure some addicts who are involved with legal charges that their signature is required in order to release treatment information, and that only treatment information is recorded in the patient chart. In other cases, MMPI data may verify information obtained in the clinical interview indicating the presence of a thought disorder. A psychiatric evaluation and medication review may be ordered to assist in determining the most appropriate treatment for such patients.
Interaction between the addict and treatment peers is basic to addiction treatment programs. Addicts who withdraw from their peers, spend much of their free time alone and minimally participate in group therapy may be mistakenly identified as treatment resistant and uncooperative. MMPI profile data may support this conclusion or may propose an alternative explanation for these patients' social withdrawal, and thereby suggest a different treatment approach. For example, the patient may be socially inhibited due to social anxiety, poor social skills or low self-esteem. In either case, the psychological assessment provides the treatment team with additional information to use in reviewing their initial conclusions.
The MacAndrew Alcoholism Scale, which is embedded within the MMPI, is one of many supplementary scales developed over the years through thousands of MMPI research studies. Extensive research with the MacAndrew Alcoholism Scale reveals that it correctly identifies 84 to 96 percent of the patients who are addicted to alcohol. In addition, the MacAndrew also appears to be effective in identifying people who are at high risk for alcohol addiction. At the Illinois Institute for Addiction Recovery, more than 10,000 MMPIs and MacAndrew Alcoholism Scales have been administered over the past 19 years. It has been our experience that the MacAndrew has also been as effective in identifying cocaine and cannabis addicted patients as it is with alcoholics. The MacAndrew, with its robust predictive ability, is also very helpful in identifying patients who are extremely defensive, and with confronting patients who are in deep denial or are significantly minimizing their drug dependency.
To complete the psychological assessment, all available patient information needs to be reviewed -- including the patient's medical chart, the initial and any past admission assessments, communication from significant others, etc. -- to enhance accuracy and produce a complete report. Furthermore, obtained data needs to be integrated in a meaningful, comprehensive and relevant manner in order to be read and used by the addiction treatment team. Terminology should be adjusted to ensure clear communication. Psychological assessment content needs to be concise and avoid unnecessary bulk.
Finally, it is most important to keep in mind that the psychological assessment describes the addict at the initial stages of treatment. Expect the assessment to be outdated and inaccurate as the patient progresses and experiences the first steps of recovery and treatment success.
Don
Legan is a licensed clinical psychologist. He is a member of the
medical faculty at the University of Illinois College of Medicine at
Peoria, maintains a private practice and has been the clinical
psychologist for the Illinois Institute for Addiction Recovery at
Proctor Hospital since 1979.