Context of Clinical Assessment

Chapter 1

that may occur during the course of therapy, capacity for insight, diagnosis, coping style, level of resistance, degree of functional impairment, and problem complexity.

If a referral is made during therapy, however, a number of problem areas may exist that are not readily apparent from the referral question. The evaluator must investigate these complicating factors, along with potential decisions that may flow from the assessment information. An area of potential conflict arises when psychiatrists are attempting to fulfill roles of both administrator (caretaker) and psychotherapist and yet have not clearly defined these roles either for themselves or for their patients. The resulting ambiguity may cause the patient to feel defensive and resistant and the psychiatrist to feel that the patient is not living up to the therapist's expectations. Elaboration of a specific trait or need in the patient cannot resolve this conflict but must occur in the context of interactions between the therapist and the patient. A standard psychological evaluation investigating the internal structure of the patient will not address this issue.

A second possible problem area for clients referred in the midst of therapy can be the result of personal anxiety and discomfort on the therapist's part. Thus, issues such as therapist bias and possible unreasonable expectations may be equally or even more important than looking at a patient's characteristics. If role ambiguity, countertransference, bias, or unreasonable expectations are discovered, they must be elaborated and communicated in a sensitive manner.

When psychiatrists are acting in the role of physician, they and the psychologist may have different conceptual models for describing a patient's disorder. Whereas psychiatrists function primarily from a disease or medical model, psychologists may speak in terms of difficulties in living with people and society. In effectively communicating the results of psychological evaluations, examiners must bridge this conceptual difference. For example, a psychiatrist may ask whether a patient has a dissociative disorder, whereas a psychologist may not believe that the label dissociative disorder is useful or even a scientifically valid concept. The larger issue, however, is that the psychiatrist is still faced with some practical decisions. In fact, the psychiatrist may share some of the same concerns regarding dissociative disorders, but this conceptual issue may not be particularly relevant in dealing with the patient. Legal requirements or hospital policies might require that the patient be given a traditional diagnosis. The psychiatrist may also have to decide whether to give antipsychotic medication, electroconvulsive therapy, or psychotherapy. An effective examiner should be able to see beyond possible conceptual differences and instead address practical considerations. A psychiatrist may refer a defensive patient who cannot or will not verbalize his or her concerns and ask whether this person has schizophrenia. Beyond this diagnosis are factors such as the quality of the patient's thought processes and whether the person poses a danger to him- or herself or to others. Thus, the effective examiner must translate his or her findings into a conceptual model that is both understandable by a psychiatrist and useful from a task-oriented point of view.

General Medical Setting

It has been estimated that as many as two-thirds of patients seen by physicians have primarily psychosocial difficulties, and of those with clearly established medical diagnoses, between twenty-five percent and fifty percent have psychological disorders in addition to medical ones. Most of these psychological difficulties are neither diagnosed nor referred for treatment. In addition, many traditionally "medical" disorders, such as coronary heart disease, asthma, allergies, rheumatoid arthritis, ulcers, and headaches, have been found to possess a significant psychosocial component. Not only are psychological factors related to disease; of equal importance, they are related to the development and maintenance of health. In addition, the treatment and prevention of psychosocial aspects of "medical" complaints have been demonstrated to be cost-effective for areas such as preparation for surgery, smoking cessation, rehabilitation of chronic pain patients, obesity, interventions for coronary heart disease, and patients who are somatizing psychosocial difficulties. A complete approach to the patient, then, involves an awareness of the interaction among physical, psychological, and social variables. Thus, psychologists have the potential to make an extremely important contribution. To adequately work in general medical settings, psychologists must become familiar with medical descriptions, which often means learning a complex and extensive vocabulary. Another issue is that, even though they often draw information from several sources to aid in decision making, physicians must take ultimate responsibility for their decisions.

The most frequent situations in which physicians might use the services of a psychologist involve the presence of an underlying psychological disorder, possible emotional factors associated with medical complaints, assessment for neuropsychological deficit, psychological treatment for chronic pain, the treatment of chemical dependency, patient management, and case consultation. Regardless of whether a medical exam uncovers any physical basis for a patient's complaints, the physician still has to devise some form of treatment or at least an appropriate referral. This process is crucial in that a significant portion of patients referred to physicians do not have any detectable physical difficulties, and their central complaint is likely to be psychological. The psychologist can then elaborate and specify how a patient can be treated for possible psychosocial difficulties. Doing this may require using not only the standard assessment instruments, but also more specialized ones, such as the Millon Behavioral Health Inventory or the Millon Behavioral Medicine Diagnostic.

Another area that has greatly increased in importance is the psychological assessment of a patient's neuropsychological status. Whereas physicians attempt to detect physical lesions in the nervous system, the neuropsychologist has traditionally been more concerned with the status of higher cortical functions. Another way of stating this is that physicians evaluate how the brain is functioning, while neuropsychologists evaluate how the person is functioning as a result of possible brain abnormalities. The typical areas of assessment focus primarily on the presence of possible intellectual deterioration in areas such as memory, sequencing, abstract reasoning, spatial organization, and executive abilities. Such referrals, or at least screening for neuropsychological deficit, typically account for approximately one-third of all psychological referrals in psychiatric and medical settings. In the past, neuropsychologists have been asked to help determine whether a patient's complaints were "functional" or "organic." The focus now is more on whether the person has neuropsychological deficits that may contribute to or account for observed behavioral difficulties than on either/or distinctions. Physicians often want to know whether a test profile suggests a specific diagnosis, particularly malingering, conversion disorder, hypochondriasis, organic brain syndrome, or depression with pseudoneurological features. Further issues that neuropsychologists often address include the nature and extent of identified lesions, localization of lesions, emotional status of neurologically impaired patients, extent of disability, and suggestions for treatment planning such as recommendations for cognitive rehabilitation, vocational training, and readjustment to family and friends.

A physician might also request a psychologist to conduct a presurgical evaluation to assess the likelihood of a serious stress reaction to surgery. Finally, physicians-particularly pediatricians-are often concerned with detecting early signs of serious psychological disorder, which may have been brought to their attention by parents, other family members, or teachers. In such situations, the psychologist's evaluation should assess not only the patient's current psychological condition but also the contributing factors in his or her environment and should provide a prediction of the patient's status during the next few months or years. When the patient's current condition, current environment, and future prospects have been evaluated, the examiner can then recommend the next phase in the intervention process. A psychologist may also consult with physicians to assist them in effectively discussing the results of an examination with the patient or the patient's family.