Introduction to Part I

THE HYPOTHESIS TESTING MODEL

Psychological assessment has long been a mysterious, intuited process, taught to psychologists in training test by test, with components of conceptualization, integration, and report writing somewhat tacked onto the end of the process. While psychologists seem to unconsciously agree on the purpose of psychological assessment, its utility has been debated in the literature. At its most basic, psychological assessment provides a catalog of an individual's cognitive, emotional, behavioral, and psychological strengths, weaknesses and vulnerabilities, deficits, and resources. At its best, it provides dynamic insights into the inner workings of an individual, yielding invaluable information for diagnosis, potential intervention, and prognosis.

Claims for the utility of assessment have ranged significantly from merely categorizing an individual's strengths and weaknesses to clarifying diagnosis and prognosis to describing a person's personality in its entirety. While these all may be effective approaches to assessment, it is most practical and pragmatic to talk about why and how psychological assessment can be useful to the mental health field (and to related fields, such as medicine) in general. This book presents a model of psychological assessment designed to ensure that assessors provide ethical and competent services and make useful contributions to the lives of the individuals they assess.

Psychological assessment should be used to help answer whatever referral questions are present and to make clear and specific recommendations to help the individual being assessed function better in their life. While this may include an analysis of strengths and weaknesses, a diagnosis, and a description of personality structure, the central goal of making useful (and realistic) recommendations should never be forgotten. This important concept is revisited throughout this text, as it is easy to lose sight of the importance of this seemingly simple goal: determining what will be most useful to the individual being assessed in the current situation.

A few examples can illustrate how psychological assessment can be useful to different people. First, consider a high-level executive who is trying to get a promotion at work. While an assessment may include her level of cognitive and intellectual functioning and details of her personality dynamics, the ultimate goal should be to inform what would likely help her grow in such a way that she can successfully get the promotion, if possible. Some possible findings from an assessment with such an individual may relate to her interpersonal style or decision-making skills. These are areas extremely important to executives' growth, and recommendations on how to improve them can be explicitly made.

Next, consider a child presenting disruptive behavior at school (or consider the child's parents at their wits' end). An assessment can help identify what is likely underlying the disruptive behavior, which could include anything from attention deficit hyperactivity disorder (ADHD) to depression to an adjustment disorder. Recommendations for each of these problems would look very different. A child with depression would likely not benefit from psychostimulant medication, just as a child with ADHD would not benefit from antidepressant medication. An assessment can help the parents clarify what is likely going on and recommend to other service providers what type of treatment would likely succeed.

This text is a primer for the process of psychological assessment and testing rather than a guide to using any single test. Six major processes make up any psychological assessment:

1. conducting a clinical interview
2. choosing a battery of tests
3. administering, coding, scoring, and interpreting tests
4. integrating and conceptualizing information gathered from test results, the clinical interview, behavioral observations, and other sources
5. writing a psychological assessment report
6. providing feedback to the individual assessed or the referral source

While most psychological assessment texts focus on test administration, coding, scoring, and interpretation (see Groth-Marnat & Wright, 2016; Lezak, Howieson, Bigler, & Tranel, 2020; Sattler, 2018; Weiner & Greene, 2017) and while there are many works on clinical interviewing (see MacKinnon, Michels, & Buckley, 2015; McConaughy, 2013; Sommers-Flanagan & Sommers-Flanagan, 2017; Sullivan, 1970), few have focused specifically on the fourth step: the use of all data collected throughout the assessment to come up with a fully integrated, coherent picture of the individual being tested that will support clear, specific, and useful recommendations. Similarly, sample reports can be extremely useful in formatting the structure of a psychological assessment report, but few texts have focused on the conceptual content of good reports.

THE HYPOTHESIS TESTING MODEL

The importance of psychological assessment lies in the fundamental assumption that there are aspects of our functioning that we are not entirely aware of or cannot effectively articulate. If every person had a clear and accurate understanding of what was going on for them, the only form of assessment necessary would be clinical interviews. An even more efficient method would be to administer surveys that rely on individuals' self-reporting. However, because there is not a single person who is entirely aware of all aspects of their functioning, we combine multiple methods of evaluation—including self-report, collateral reports, “objective” measures, clinical observation, and performance-based measures (including, perhaps both most controversially and most intriguingly, projective measures)—to develop a more accurate impression of current functioning. It is important to note (as most texts on psychological assessment do) that testing and assessment provide a picture of how the individual being assessed is currently functioning. While inferences about past functioning and future prognosis can be made, the tests themselves are measuring individuals at that particular moment in time, at that particular point in history. Many people not in the mental health field confuse psychologists with psychics, and it should be made clear that assessment results cannot predict the future with 100% accuracy.

There is no perfect measure. No self-report is made without bias and blind spots, no test has perfect reliability and validity, and no single method of measurement should be taken as gospel. The validity of every single test in existence has been challenged. (Some specific criticisms are addressed in the chapter on testing.) For this reason, a humble approach to using tests is necessary to build a consumer's confidence in the assertions made in the final report. The hypothesis testing model uses the strengths of each individual test, as well as clinical acumen, while assuming that each individual measure is flawed. Each individual assessment can be treated as a research study by (a) making hypotheses, (b) testing them to rule out possibilities and incorporate others, and (b) using multiple tests, multiple methods, and at times even multiple informants, which provide more solid data and allow the assessor to be much more confident in their findings. The basics of the hypothesis testing model follow.

Step 1: Initial Clinical Assessment

The first step of the hypothesis testing model is to conduct a thorough clinical interview whenever possible. You will then use the results of this interview, together with background information collected from various sources, to create hypotheses. Clinical interviews can vary dramatically from assessor to assessor (see MacKinnon, Michels, & Buckley, 2015; McConaughy, 2013; Sommers-Flanagan & Sommers-Flanagan, 2017; Sullivan, 1970 for theories on clinical interviewing). While some scholars advocate the use of structured clinical interviews (which can be especially useful for diagnostic clarity), others advocate the use of open-ended, unstructured, conversationally based interviews. One model for the process of conducting—and, more importantly, using—a clinical interview is discussed in more detail in Chapter 1. The initial clinical assessment is a combination of the information gathered from the clinical interview and other sources of report, such as referral parties, previous records, and collateral interviews. This clinical assessment has three goals: (1) assessing impairment in functioning; (2) understanding the current and developmental context and course of functioning; and (3) generating hypotheses.

The first goal of the initial clinical assessment is to assess specifically what, if any, is the impairment in functioning. Most assessments are conducted because there is some sort of impairment in the functioning of the individual being assessed. Individuals usually come for an assessment with a presenting problem or a specific difficulty they are having. These presenting problems may be reported by the individuals themselves, or they may be defined by whoever refers the individual for the assessment, perhaps a treating clinician, a primary care physician, a teacher, or any other person who knows the individual being assessed. For example, social and interpersonal functioning, emotional well-being, or behavioral problems may be affecting how well the individual can function on a day-to-day basis.

While some impairments may be overtly evident,...