Personality Assessment and Health Care Reform

When most people think of health care reform, they think in terms of insurance mandates, cost-containment strategies, or even “death panels.” Rarely does psychological assessment enter the discussion.  Yet, it is clear from the scientific literature that psychological assessment in general–and personality assessment in particular–has much to contribute to reforming our bloated healthcare system.

As we have discussed earlier, personality assessment should be a vital aspect of psychological and psychiatric treatment.  Not only can assessment be a therapeutic modality in its own right (Therapeutic Assessment), but it can contribute to accurate psychiatric diagnosis, and thus more effectively targeted treatment decisions.  Take, for example, the case of a patient presenting with mild psychotic symptoms.  These could reflect an underlying schizophrenic disorder, the early phase of a manic episode in a bipolar disorder, or perhaps the onset of a major depressive disorder with psychotic features.  Often times it is difficult to disentangle these possibilities from interviews alone.  Without an accurate diagnosis, the only recourse a treating psychiatrist has is “trial and error.” This can lead t multiple different medications being tried. Not only are these medication trials expensive in their own right, but they can cause significant delays in effective treatment. The literature is clear that the earlier an effective treatment is begun, the greater the chance of success. If a competent assessment is done, however, it may be possible to establish the correct diagnosis initially, and thus select the best treatment approach the first time.

Most interesting, however, is the role that assessment may play in the delivery of non-psychiatric medical care.  It is well known that psychological factors play a crucial role in disease and identifying these factors (e.g., stress) and directing treatment at reducing them can go a long way toward improving overall treatment outcome.  In addition, psychological interventions are often important in improving compliance with treatment regimens.  Many of the highest “utilizers” of medical services are individuals who have frequent medical crises precisely because they fail to adhere to treatment protocols (e.g., diabetics who don’t control their sugar intake or insulin properly or patients with multiple medical problems who can’t follow complex medication regimens). Identifying the cognitive or emotional reasons that might cause this “non-compliance” can be crucial in improving outcome and reducing unnecessary services.  A recent study at Massachusetts General Hospital, for example, looked at the factors contributing to non-compliance in patients with the highest utilization of services.  Using psychological assessment techniques they were able to identify cognitive and emotional factors (e.g., patient who were too confused to follow complex instructions, or too depressed to remember appointments) that led to failures to follow recommendations and consequent emergency room visits or hospitalizations.  By addressing these specific factors, they were able to improve patient outcomes and achieve cost savings in the millions of dollars.

Personality Assessment and Mass Murder

OK, the title of this post was admittedly a bit over the top to catch your attention. But there is an important connection here that I would like to explore in this post.

The alleged shooter in the Aurora, CO mass shooting, James Holmes, made a startling presentation at his arraignment. As you may recall, he appeared in court with his hair dyed flame red contending that he had no recollection of the shooting and even doubted that he was responsible. Meanwhile, subsequently, his attorney has offered statements that suggest that he may be laying the groundwork for an insanity defense. While most of the high-profile killers in recent memory have died at the time of killings, some of them survive and are captured. Holmes, Jared Loughner, the accused assailant of Congresswoman Gabrielle Giffords, and Nidal Hasan, the accused Ft. Hood shooter are all currently facing trial, and all will likely offer a defense based upon mental illness of some sort. Thus, personality assessment becomes an integral part of the criminal proceedings.

High-stakes forensic cases–especially criminal–are notoriously difficult to evaluate. Defendants have a powerful incentive to feign mental illness or at the least to exaggerate their symptoms. At the same time, there is an equally high index of suspicion such that prosecutors (and usually juries) are loathe to attribute the crimes to psychiatric illness. Research has shown that interviews alone are notoriously unreliable at determining real from feigned symptoms. Kenneth Bianchi, the notorious Hillside Strangler, was able to convince several psychiatrists that he suffered from Multiple Personality Disorder (now known as Dissociative Identity Disorder) until exposed by Dr. Martin Orne. Personality testing can be invaluable in helping make the differential diagnosis between malingering and genuine symptoms.

Several personality tests have been developed to ferret out attempts to malinger (fake) psychiatric symptoms. Most of these have been fairly well-validated, and can contribute to the assessment of defendants in high stakes cases such as the ones mentioned above. At the same time, more broad-spectrum instruments can help paint a picture of the defendant’s personality and psychopathology that can aid the forensic examiner in understanding the motivation for the crime. John Hinkley, the man who attempted to assassinate Ronald Reagan out of an obsession with the actress Jodie Foster, was found not guilty by reason of insanity largely because of the psychological assessment performed by psychologist, Ernst Prelinger. On the other hand, often it is the testimony of psychologists who have tested the defendant that has punctured claims of insanity by demonstrating that the psychological tests either show no significant disorder or a strong likelihood of faking.

As the current batch of high-profile defendants work their way through the criminal justice system, it will be interesting to watch if and how psychological assessment is used to help determine the defendants’ state of mind and ultimately their criminal culpability.

The Rorschach

Sooner or later, any discussion of psychological assessment or psychological testing comes around to the Rorschach. Probably no technique in the field of psychology has attracted more interest, more curiosity, or more misinformation than this assessment technique now nearing its second century. To some, the Rorschach Inkblot Method is an almost magical method for probing the “murky depths of the psyche,” as one practitioner put it.  To others, it is nothing more than pseudo-science, a technique akin to phrenology or astrology–and with the same accuracy.  Indeed, in the vernacular, the term Rorschach has come to mean something that provokes different interpretations from different individuals.  The test itself, then, might be considered a “Rorschach.” There continue to be  references to the Rorschach in the popular media, including a recent BBC radio program discussing the method and its current status in the field.

Firstly, a bit of history: The Rorschach Test (now more commonly referred to as the Rorschach Inkblot Method) was developed by a young Swiss psychiatrist, Hermann Rorschach.  Rorschach was an interesting man.  The son of an avant garde artist, he had a fascination with inkblots and a child’s game called “klecksen” (meaning inkspot) as a child. As a psychiatrist, he was searching for a method of evaluating some of his more disturbed patients who weren’t easily reachable through interviews alone.  Rorschach initially saw the method primarily as a diagnostic instrument, useful in differentiating schizophrenics from manic-depressives or “feeble-minded.” The test was published in 1921, but Rorschach died shortly thereafter at the age of 37, before he could conduct much further research.  Soon after, however, the test became closely identified with psychoanalysis, and it was seen as a “projective” method–patients were thought to project their unconscious fantasies onto the blots.  While use of the instrument in this manner often proved clinically useful, the lack of a consistent method for interpretation as well as the lack of solid empirical research led many to call for its abandonment.  In the 1970’s, however, a psychologist named John Exner sought to bring order to the chaos and developed a “comprehensive” system for coding and interpreting Rorschach data that was based on empirical research.  For a time, it seemed that the “Rorschach wars” were over.  However, those who were skeptical of the method (and they tended to be the same psychologists who were skeptical of any “depth” theory or method in psychology) continued their criticisms, culminating in the book “What’s Wrong with the Rorschach?” by James Wood and his colleagues.  Since that publication, there have been numerous discussions about the reliability, validity, and utility of the Rorschach, and while the critics certainly have not been silenced, the Rorschach continues to be used frequently by psychologists for the purposes of assessment.

The Rorschach is classed as a “performance-based” instrument.  That is, the subject performs a task (in this case interpreting an inkblot), and that performance is analyzed both quantitatively and qualitatively.  It can be an effective addition to a test battery because, unlike self-report inventories, it is not a function of how the subject views him or herself.  Nor is it easily influenced by attempts to present oneself as “healthy” or “sick.” At the same time, it is not an “x-ray of the mind,” as some have insisted.  It can best be seen as an important part of the psychological assessor’s armamentarium.  No psychologist should base her or his conclusions on a single method, and the Rorschach in conjunction with other instruments can provide meaningful information about individuals in both clinical and non-clinical settings.

You’ve been referred for an assessment

Perhaps you’ve been referred for a psychological assessment.  What can you expect? What should you look for? What do you hope to gain from the experience?

Assessments are recommended by psychotherapists in order to aid in treatment planning or to help when the therapy appears “stuck.” If this is the case, you should discuss this with your therapist; often an assessment can get things moving again and can point to overlooked areas for therapeutic exploration.

Sometimes a psychiatrist will recommend an assessment to clarify the diagnosis before initiating drug treatment.  This can be very valuable and can eliminate many false starts by pointing in the direction of the correct medication the first time.

Perhaps you have been having trouble concentrating and your doctor wonders if you have Attention Deficit Disorder.  This is a classic indication for psychological assessment.  Although there are many self-rating scales for ADHD, these are based solely on a person’s self report, and cannot distinguish among the various causes of problems in attention.  Anxiety, depression, stress, are all potential reasons other than ADHD for someone having difficulties with attention and concentration. An assessment can pinpoint where the problem lies, identify the likely cause(s), and lead to the most effective treatment strategy.

So now you’ve decided to go ahead with an assessment.  What can you expect?

First of all, the assessment should be conducted by a licensed psychologist who is proficient in personality assessment.  The American Psychological Association has designated personality assessment as a proficiency, and psychologists who are trained and experienced in this modality are designated as proficient.

The psychologist will likely take a history.  In order to choose the appropriate tests to answer the questions that you and your referring doctor have and to interpret them in the light of your unique situation, she will need to know about you and your life.  She will want to know the important events, something about your relationships, your concerns, etc.  It is important to be frank; remember, assessment psychologists operate under the same rules of confidentiality as do psychotherapists.

At this time, it is also important that you let the assessor know what your questions for the assessment are.  These may be different from those of the doctor who referred you.  It is important that your questions be addressed as well as those of the referrer.

You will likely do a number of different tests; this may extend over several days.  Some may be paper-and-pencil questionnaires, others more like puzzles, still others–such as the Rorschach Inkblot Method–may seem strange.  You should feel free to ask about the purpose of the specific tests, although the psychologist may choose to answer you after having first completed it.

Finally, you should expect to receive both verbal feedback on the assessment as well as a written report.  In addition, a written report is likely to go to the referring doctor as well.  In times past, it was thought that the results of psychological testing was too “sensitive” to share with the patients themselves.  We now know this to be untrue.  A competent psychological assessment involves the active collaboration of the person being assessed and culminates in full and complete disclosure of the findings.  Many patients find this to be one of the most enlightening experiences of their lives.

Psychological assessment can be time-consuming and costly, but it can be highly cost-effective if it shortens the course of subsequent treatment and makes it more effective.

Personality Assessment methods

Psychologists use a variety of methods in order to conduct assessments and arrive at recommendations.  The key to competent evaluation of individuals is what is referred to as multi-modal assessment. Multi-modal assessment involves the use of different methods from different domains (e.g,, different classes of tests, interviews, review of records, collateral sources such as family members).  Only this approach ensures that the most valid conclusions are drawn.  As Professor Gregory Meyer of the University of Toledo has stated, “The evidence indicates that clinicians who use a single method to obtain patient information regularly draw faulty conclusions.” This is because of what psychologists refer to as “method variance,” that fact that individuals can appear differently when different methods are used to gather information.  Thus, for example, a patient who seems quite untroubled during an interview, may appear to have significant pathology on a personality inventory.  This may happen, for instance, when an individual is reluctant to admit to certain symptoms or disturbing thoughts in a face-to-face encounter, but is more self-revealing when filling out a paper-and-pencil test. Patients may even have different results on different tests; an individual who is highly defensive on a true-false inventory may reveal much about himself on a free response test such as the Rorschach.  Of course, the converse is also often true as well.  When we gather information from multiple sources and then integrate this information into a comprehensive formulation, we are much more likely to draw appropriate conclusions and to make recommendations that referrers (other clinicians, courts, schools, etc.) will find most helpful. Below are descriptions of some of the common methods that psychologists use to conduct assessments:

Interview

The most basic information-gathering tool is, of course, the interview.  Psychologists are trained to conduct interviews in a manner that encourages honesty, forthrightness, and self-reflection.  Interviews may be structured (a set list of questions that doesn’t vary), semi-structured (similar to structured interviews, but with more leeway for follow-up questions, etc.) or unstructured (open-ended interviews in which the subject’s own associations often dictate the direction the interview takes).  Which of these techniques is used typically depends upon the purpose of the assessment.  In so-called “high-stakes assessments” (e.g,, criminal cases, public safety employee screening), a more structured approach may be used in order to reduce the possibility of bias.  On the other hand, in clinical cases, a more unstructured approach is frequently indicated in order to foster a more therapeutic relationship and encourage the patient to reflect upon him or herself.

Self-Report Tests

These paper-and-pencil tests, sometimes referred to as forced-choice instruments because the subject must choose between a limited number of possible answers (e.g., true-false, or a scale of 1-3, etc.), contain questions or statements that the individual rates as true or not about themselves.  Some of these  are single issue tests, such as those designed to rate the level of depression or anxiety that a person is experiencing.  Others are comprehensive inventories that yield scores on multiple scales measuring different aspects of an individual’s personality.  These inventories have been developed empirically, meaning that the various scales have been found to differentiate different groups of patients (e.g., depressed from schizophrenic) or predict certain behavior patterns.  Typically, interpretation involves the analysis of profiles, that is not only the scores on individual scales, but the relationship between the scores on the various scales.  Although there are computer programs that do some of the work of interpretation, only highly trained assessment psychologists can properly interpret the profile of an inventory such as the MMPI-2 (Minnesota Multiphasic Personality Inventory-2) or the PAI (Personality Assessment Inventory).  In addition, most of these inventories have sophisticated validity scales, which are indicators designed to reveal over or under reporting of symptoms or conscious attempts at impression management.

Performance-Based Tests

The other main class of psychological instruments are called performance-based tests or free-response tests.  These are distinguished from self-report inventories in that the subject is typically asked to perform a task (e.g., interpret an inkblot, tell a story to a picture, complete a sentence).  Various inferences about the individual’s personality may be drawn from the way in which s/he engages in this task.  The tests are “free-response,” in that there are no constraints placed on what the person may say in response to the task.  These tests used to be called “projective,” because it was thought that the person projected his or her personality into their responses.  This term has fallen out of favor, however, because recent research has demonstrated that the response process is more complex than simply a projection of one’s personality.  In addition, there is little agreement among psychologists as to the definition of the term projection.

The most well-known of these tests is the Rorschach (usually referred to as the Rorschach Inkblot Method).  In recent years, there has been some controversy about the Rorschach that has made its way into the popular press.  Although there are some psychologists who are skeptical about it, the vast majority of assessment psychologists find it to be a valid and useful method of personality assessment.  Because it is not a self-report inventory, it is not subject to some of the same kinds of manipulation.  Research has demonstrated that inferences drawn from the Rorschach have about the same validity as those drawn from well-validated inventories.  It appears that the Rorschach is more valid for certain kinds of questions and self-report inventories for others.  A comprehensive assessment that utilizes instruments from both classes of tests is most likely to yield reliable information.

Personality Assessment: some facts

To most people–including many psychologists–psychological assessment is synonymous with testing.  Experienced assessors, however, see a significant distinction between the two terms: assessment and testing.  Testing refers to the use of a standardized instrument to obtain a specific interpretation about a person.  In this way, it can be seen as analogous to medical tests, in which a laboratory analyzes a sample of urine or blood and obtains a value that has a more or less invariant meaning (e.g., a blood glucose level above 100 means the person is at risk for Type 2 Diabetes).  The Hamilton Depression Scale, a self-report instrument that is often used by psychiatrists who treat depression, is an example of this.

Assessment, on the other hand, involves the use of psychological tests, but as a part of an integrated evaluation of multiple data sources (e.g., interviews, school records, observer ratings, etc.).  The interpretation of the tests themselves is frequently contextual; that is a particular test finding might have a different meaning depending upon the circumstances of the individual’s life.  To give a simple example, an elevated depression scale on the MMPI-2 (Minnesota Multiphasic Personality Inventory-2), a commonly used personality inventory, would be interpreted differently for an individual who recently lost a spouse than for someone with no history of recent trauma.  Comprehensive personality assessment requires a sophisticated set of skills, including familiarity with the administration and interpretation of many different tests, interviewing, clinical intuition, empathy, and the ability to integrate data from multiple different sources into a coherent whole.  For this reason, the American Psychological Association recently declared personality assessment to be a specific proficiency in psychology, i.e., a unique set of skills that requires specific training.

So, why do we bother? After all, if this is a labor-intensive, highly specialized activity, is it really necessary?  The short answer is yes.  Clinicians–and others who are charged with evaluating individuals–frequently make errors in judgment when relying upon a single source of information.  In the context of mental health treatment, a competent personality assessment can:

  • improve treatment efficiency by quantifying key aspects of patient functioning that then become the target of treatment
  • identify intentional or unintentional response styles in which patients systematically underreport or overstate their symptoms and difficulties, and
  • identify treatment-related information about patients that they may be unable or unwilling to communicate directly.

As a result, efficient use of assessment can lead to cost containment by minimizing diagnostic errors, identifying patient strengths that may be utilized in treatment, or conversely alerting clinicians to hidden impediments to effective treatment, and by providing patients with information that may enable them to make changes that obviate the need for further professional intervention.

In subsequent posts, I will be discussing some of the specifics about assessment as well as some of the arenas outside of mental health treatment in which it can be important.