When a doctor or therapist sees a client with psychological symptoms or (non-symptomatic) other concerns, it is not always obvious what the problem is, and rarely obvious why. Because of the limitations of observation and the clinical interview method, it can often be unnecessarily time-consuming, difficult and sometimes impossible to get a clear “fix” on what is wrong, as well as how and why a specific client became susceptible to their particular problems. This is where a psychological evaluation (or “psychological assessment”) can make valuable contributions.
Psychology has developed tests and methods of psychological assessment to objectively, accurately and sensitively assess numerous domains of psychological functioning.
Dr. Crowhurst offers psychological evaluations that assist in three areas:
• Diagnosis – Psychological assessment aids in making psychiatric diagnoses, such as Major Depression or Post Traumatic Stress Disorder. It is often very helpful in differentiating between conditions that can look similar, but have very different treatment requirements (e.g., Bipolar Affective Disorder versus Borderline personality, or Schizotypal personality versus Schizophrenia or Schizoaffective Disorder).
• Formulation– A formulation is a client-specific theory about what is wrong and why. It incorporates relevant current circumstances, individual personality traits, and ones developmental as well as relationship histories in order explain how and why they are struggling with the issues that are troubling to them.
• Treatment Planning – A diagnosis, where applicable, as well as a case formulation usually form the basis for treatment planning. Psychological assessment, however, has much more to contribute than just these vital pieces to the treatment planning puzzle. Psychological assessment helps identify important issues to focus on that were not apparent by other means. It often flags specific treatment approaches that are likely to be effective or ineffective for particular clients. Finally, it identifies obstacles to therapeutic progress (e.g., difficulty building trust, resentment of authority) that, if not identified, often derail a course of therapy.
For the above purposes, Dr. Crowhurst uses:
• The Minnesota Multiphasic Personality Inventory (MMPI-2)
• The Rorschach Inkblot Method
• The Millon Clinical Multiaxial Inventory (MCMI-III and IV)
• The Personality Assessment Inventory (PAI)
• The Thematic Apperception Test (TAT)
Psychological assessments are often sought by other professionals (e.g., family doctors, lawyers, other therapists) or organizations (prospective employers, insurance companies). Many of Dr. Crowhurst’s therapy clients elect to complete a psychological assessment at the beginning of treatment in order to aid the process of psychotherapy.
What to Expect in a Psychological Evaluation
The process of a psychological assessment or evaluation typically begins with one to two interviews in order to get “the story” from the client’s point of view. The interview is semi-structured, organizing around an agenda to hear the client’s experiences and thoughts about specific topics including:
• The present complaint or concern (e.g., symptoms of panic, conflict in personal relationships, failure to achieve a sense of purpose or direction in life), and the history of this concern.
• The history of other problem concerns or symptoms, and an account of previous treatments, if any.
• An overview of work and school history.
• The history of intimate and other close relationships.
• An overview of relevant family history, the client’s relationships with, and the relationships between other family members.
A Case Illustration of a Psychological Assessment
Illustrating the assessment process with the “fictitious” case of “Chet” (a blend of several actual cases with specifics changed to protect anonymity):
Chet was a 26 year-old engineer who moved to Calgary from England at 19 for university, and was now working in his first career job. He was referred by his family doctor for assessment and treatment. For many unspecified months, Chet had experienced abdominal symptoms, which, over the last two months, had gone from intermittent discomfort to near constant pain. Numerous medical investigations had been carried out and found normal, so a psychological basis for the symptoms was suspected.
Chet reported no history of similar complaints, nor any history of psychological problems or treatment. He viewed himself, apart from concerns about the pain, to be a happy and well-adjusted individual, satisfied in his 3-year common-law relationship, and glad to be working in his chosen profession. He was the 4th child in the sibling line, with a father who was a politician and his mother a lawyer. He described an unproblematic family life, though remarked on the importance of maintaining the very British “stiff upper lip.”
The interview is often as important for what it doesn’t say as for what it does say. The interview summary above is somewhat unusual in being quite unrevealing. This observation, in combination with a few hints in what was said (e.g., “unproblematic” family life, “stiff upper lip”) imply some problems of which the client is probably unaware. Drawing upon these observations, it is very tempting to develop certain clinical impressions of the case (i.e., a fairly obvious “white wash” perception of a happy, problem-free life).
The following statements will seem contradictory, because they are: clinical impressions that are developed from interviews and observations are vital to case conceptualization and formulation. That said, clinical impressions are notoriously unreliable. In cases like this one, where the client’s statements are unrevealing, and, furthermore, there is reason to believe what was provided is inaccurate, the problems of interview-based clinical impressions are compounded. For these reasons, a full, formal psychological assessment is called for, using psychological tests that are of unique value owing not only to their objectivity and sensitivity, but also to their built in validity scales designed to measure response biases.
Following the interview, the psychologist will choose relevant psychological tests to confirm, clarify and elaborate on what has been learned (and not learned) from the interview.
Chet was asked to complete a measure of symptoms, problems and personality traits (MMPI-2)–a true-or-false format questionnaire taking an hour and 30 minutes to complete. The results of the test were valid, despite some tendency to suppress complaints, as well as to respond in the obvious “socially desirable” manner to many items. This bias was not a deliberate attempt to “fake good,” but resulted from self-deception based on the need to see himself as he (somewhat inaccurately) portrayed things.
The clinical scales reflect excessive tendencies to use repressive defenses to ward off anything more than minimal levels of emotional activation. This, no doubt, accounts for his “see no evil” response bias noted above. On the symptoms scales, there were elevations on scales related to physical symptom complaints, particularly gastro-intestinal symptoms. The level of concern (i.e., scale elevation) was beyond what is seen among patients with actual medical problems, and reflects “somatization,” or the diversion of psychological distress that is channeled into physical symptom expressions. In addition to this pattern of somatization, there were indications of atypical depression involving the lack of normal interest and desire, as well low energy, but no feelings of sadness or the “blues” typically seen with depression.
The Rorschach Inkblot test was administered, was also valid, and confirmed the MMPI-2 signs of depression, inordinate preoccupation with physical concerns as well as the inability to tolerate high levels of emotional activation. It showed a strong tendency to avoid situations that stir up feelings, but, in addition, there were indications of significant anger, hostility or resentment associated with his perceptions of interpersonal situations. As with the MMPI-2, patients who obtain the scores seen here are known to disavow strong emotional experience, especially negative feelings, and divert them elsewhere: negative emotional experience of which they are, to some extent, aware is diverted into depression, while the portion of emotional activation that is more thoroughly disavowed is blocked from consciousness and diverted into physical symptom expressions.
In addition to the foregoing, Chet has a personality profile emphasizing characteristics including a heightened need for acceptance and to get along well with others. Individuals like this are bothered by fears of rejection more than most, and avoid asserting demands for themselves, complaining, or reporting negative feelings or impulses that risk disapproval by others. Clients like this usually have a history of parents who were unresponsive to their emotional needs. Often times, parents who are unresponsive, even negligent of their childrens’ emotional needs become more responsive in times of physical illness. These characteristics, some of them hypothetical, based on known characteristics of other cases, form part of the formulation.
Integrating the interview with test findings along with personal characteristics and historical similarities that most patients with similar test profiles exhibit, a working formulation begins to take shape:
Chet is probably experiencing significant stresses in the interpersonal domain, probably at work (since this is where things have recently changed), but perhaps in his personal relationships too. He appears to be an individual who responds to stress and anger by channeling them into somatic symptom equivalents and, to some extent, depression. This is likely the result of a developmental history involving parents whose “stiff upper lip” values extended to being overly concerned about appearances, uncomfortable with emotional expression, and communicating a strong message to their children that the expression of strong emotions, especially negative ones, will not be well received, and would be better to be inhibited. Internalizing these early messages would account for shaping a personality style that organizes around getting along by always being positive, never being assuming or demanding, and inhibiting (consciously) or suppressing (unconsciously) any direct expressions of negative emotion.
Clients who fit this description tend to be strangers to their inner world of feelings, and a primary goal of therapy is to facilitate their opening up to their unfelt feelings. Easier said than done, this is likely to be a lengthy process, but once accomplished, there will no longer be a problem of “disavowed” emotion to be “diverted” into somatic (or atypical) depressive symptom expressions.
Therapy with clients like Chet is not as straight forward as it seems from the succinct statement of treatment goals. There are significant pitfalls the assessment recognizes that could preclude Chet’s engagement in therapy, or lead to premature termination.
Telling clients like Chet that their symptoms are “all in their head” has exactly the same effect as telling paranoid patients “it’s not them, it’s you.” Clients like Chet experience their distress physically because they can’t experience it emotionally. Consequently, they see their problems as primarily medical in nature, and early psychological interpretations guarantee an immediate termination of treatment. While making the emotional connections will take time and care, a meaningful early goal might involve exploring stresses at work, and then the factors at work that might make “other people” angry if they were dealing with the same circumstances. Gradually, it may be seen that there is a relationship between stress and the physical symptoms experienced (while not yet challenging the assumption of a medical mechanism). As therapy progresses, learning ways to better handle stresses is likely to relieve the pressure to develop symptoms, but without altering the psychological mechanism that creates them. Over time, repeatedly seeing the connection between increases in stress and the subsequent worsening of symptoms, the client may begin to develop insight into the psychological mechanism behind symptom formation. Developing an accurate and deeper understanding of feelings is expected not only to resolve his symptom problems, but to bring the personal satisfaction of being open to a wider range of emotional experience and expression. In turn, this is likely to add a rewarding dimension of depth to his personal relationships, too.