Are psychological assessments a piece of history or a new growth area for psychological practice? Both, according to many observers. The growing acceptance of psychological assessments, including insurance reimbursements, has helped propel an early foundation of psychological practice into a growing niche for some.
Recent research has prompted new recognition of assessment's value among consumers and health professionals, and psychology's advocacy efforts have helped insurers recognize assessment's value as well. Meanwhile, psychologists are moving into new areas of assessment and developing new techniques.
"In large measure, the public understands the value of psychological testing," says Bruce L. Smith, PhD, assessment advocacy coordinator for the Society for Personality Assessment (SPA) and a private practitioner in Berkeley, Calif. "People have the sense that this is science, not someone's opinion."
A valuable resource
Whether they focus on personality, intelligence or some other characteristic, psychological assessments are far more than tests.
"Testing implies something like a blood test, where you just give a test and get a number," explains Smith, also a member of the clinical faculty at the University of California, Berkeley. "Assessment is a much more complex enterprise where you integrate data points from various places to get a more comprehensive understanding."
While psychological assessments can require considerable interpretation, researchers have found that they are just as valid as medical tests.
In a 2001 study published in the American Psychologist (Vol. 56, No. 2, pages 128-165), APA's Psychological Assessment Work Group compared psychological tests with medical tests like magnetic resonance imaging, Pap smears and electrocardiograms. The researchers discovered that psychological tests generally predict outcomes just as well as medical tests do. The power of psychological assessment surprised even some leaders in the field.
"It was really quite eye-opening," says study co-author Gregory J. Meyer, PhD, editor of the Journal of Personality Assessment and a University of Toledo associate psychology professor. "I'd been under the impression that psychological tests were in a different league than medical or dental tests-that our instruments would be lower on the totem pole."
That research, along with psychology's advocacy efforts, is prompting changes by managed care and other payers, says David W. Ballard, PsyD, assistant executive director for corporate relations and business strategy in APA's Practice Directorate. In January, new Current Procedural Terminology (CPT) codes related to psychological and neuropsychological testing go into effect (see "Revised codes, higher payments for testing services in 2006" and "Medicare milestone follows a long road"). For the first time, the CPT codes give psychologists a more accurate way to bill for the time and effort they spend administering and interpreting tests and reporting results. The codes also allow psychologists to bill for tests administered by a technician or a computer.
"That change reflects a growing understanding of assessment's value," says Ballard.
Once used primarily to help diagnose clients and guide their treatment, assessment has now branched into settings including neuropsychology labs, schools and business settings.
One area in especially high demand is forensic assessment, says private practitioner Alan J. Lee, PsyD, of Hamilton, N.J.
Long fascinated by "what makes people tick," Lee started his career as a professional fire investigator and later became a psychologist in the federal prison system. Today he and his practice's other psychologists focus exclusively on forensic and clinical assessment.
The field has moved far beyond its traditional use in cases where defendants' sanity or competency to stand trial are in question, says Lee. On a typical day, he might assess whether a defendant truly understood the Miranda warning before confessing; whether a troubled adolescent is likely to set fires or sexually assault other treatment center residents; or whether a parent is fit to retain custody of a child.
No matter what the subject, says Lee, assessment provides crucial information not available through interviews and observations. Tests such as the Rorschach that tap into variables outside of an individual's awareness can be especially helpful in forensic cases, he adds.
"There are high stakes at risk here," says Lee, citing conviction, sentencing and loss of custody as examples. "Oftentimes people will underreport things on self-reports or interviews that would be more apparent on projective measures, where the person is less able to distort his or her presentation."
Forensic assessment isn't just limited to criminal cases, notes Smith, who has conducted assessments in civil cases involving discrimination, harassment, wrongful termination and petitions for political asylum.
"Any time a litigant's mental or emotional state is at issue, assessment is a crucial aspect of the evaluation process," he explains.
Another area in demand from consumers is therapeutic assessment, in which the process of assessment becomes a therapeutic intervention in its own right. When Stephen E. Finn, PhD, started the Center for Therapeutic Assessment in Austin in 1993, the center had one other therapist. Within a year, there were seven full-time staffers and a steady stream of clients.
Growing out of the movement toward greater psychologist/client collaboration, the technique that Finn pioneered begins with the client posing questions about issues they want to explore. These questions guide the psychologist's choice of assessment instruments and the feedback provided once results are in.
Throughout, the psychologist encourages the client to examine the assessment process itself. "I liken it to asking the client to stand with you on an observation deck overlooking the assessment session," explains Finn, an adjunct assistant clinical professor at the University of Texas.
"People will come in for therapeutic assessment who wouldn't set foot in the door for psychotherapy," says Finn, noting that interventions typically last for six to eight weeks. "They see this as a time-limited, problem-solving process they can take and do whatever they want with."
And while research is still ongoing, evidence suggests that Finn's approach is helpful. In a 1992 study published in Psychological Assessment (Vol. 4, No. 3, pages 278-287) Finn found that simply sharing results of the Minnesota Multiphasic Personality Inventory-2 with clients decreased their distress, increased their self-esteem and left them more hopeful about their situations.
The next generation
But not all graduate students may be receiving the training they need to take full advantage of such careers in assessment, says SPA Board of Trustees' Secretary Radhika Krishnamurthy, PsyD, chair and director of clinical training at Florida Institute of Technology's PsyD program.
A 2001 survey in the Journal of Clinical Psychology (Vol. 57, No. 6, pages 717-726) found some erosion in assessment training, she says, largely in the teaching of projective assessment. Several other recent surveys have found that students' graduate assessment training is insufficient to meet internship directors' expectations, she adds.
In a 2004 paper in the Journal of Clinical Psychology (Vol. 60, No. 7, pages 725-739), Krishnamurthy and co-authors laid out eight core assessment competencies all psychologists should know. They range from understanding the theoretical and empirical bases of assessment to knowing how to conduct cognitive, affective, behavioral and personality assessments. They also include psychometric knowledge, technical assessment skills and the ability to collaborate and communicate effectively.
But assessment training teaches students more than just how to use tests and what to do with results, says Krishnamurthy. It also teaches them how to be precise and to think critically, she says.
"I think of it as training students not to rely only on clinical intuition," she says, "but to be able to back that up with research-based information."Rebecca A. Clay is a writer in Washington, D.C.
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