Stephen E
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Seba LannooIn Our Clients’ Shoes
eory and Te nicjues of erapeutic Assessment
COUNSELING AND PSYCHOTHERAPY INVESTIGATING
PRACTICE FROM SCIENTIFIC, HISTORICAL, AND CULTURAL
PERSPECTIVES
A Lawrence Erlbaum Associates, Inc. Series
Editor, Bruce E. Wampold, University of Wisconsin
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In Our Clients’ Shoes
eory and Teniques of erapeutic Assessment
Stephen E. Finn
Psyology Press Psyology Press
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Contents
Foreword
Constance T. Fischer
Preface
Anowledgments
Part I
e History and Development of erapeutic Assessment
1
Introduction: What Is erapeutic Assessment?
2
Appreciating the Power and Potential of Psyological Assessment
3
erapeutic Assessment: Would Harry Approve?
4
How erapeutic Assessment Became Humanistic (written with Mary E.
Tonsager)
Part II
Specific Teniques of erapeutic Assessment
5
Testing One’s Own Clients Mid-erapy With the Rorsa
6
Giving Clients Feedba About “Defensive” Test Protocols
7
Assessment Feedba Integrating MMPI—2 and Rorsa Findings
8
Assessment Intervention Sessions: Using “Soer” Tests to Demonstrate
“Harder” Test Findings With Clients
9
One-Up, One-Down, and In-Between: A Collaborative Model of Assessment
Consultation
10
erapeutic Assessment of a Man With “ADD”
11
Collaborative Sequence Analysis of the Rorsa
12
Using the Consensus Rorsa as an Assessment Intervention With
Couples
13
“But I Was Only Trying to Help!”: Failure of a erapeutic Assessment
14
Collaborative Child Assessment as a Family Systems Intervention
15
Teaing erapeutic Assessment in a Required Graduate Course
Part III
eoretical Developments
16
Please Tell Me at I’m Not Who I Fear I Am: Control-Mastery eory and
erapeutic Assessment
17
Challenges and Lessons of Intersubjectivity eory for Psyological
Assessment
18
How Psyological Assessment Taught Me Compassion and Firmness
19
Conclusion: Practicing erapeutic Assessment
References
Author Index
Subject Index
Descriptive Contents
Foreword
Constance T. Fischer
Preface
Anowledgments
Part I
e History and Development of erapeutic Assessment
1
Introduction: What Is erapeutic Assessment?
The basic concepts and procedures of Therapeutic Assessment are
introduced.
2
Appreciating the Power and Potential of Psyological Assessment
Psychologists are challenged to acknowledge the life-changing power of
psychological assessment. The author tells about his first clinical
assessment as a psychology graduate student, through which he became
convinced that assessment could affect clients in profound ways.
3
erapeutic Assessment: Would Harry Approve?
Links are drawn between the interpersonal theories of Harry Stack
Sullivan and the procedures of Therapeutic Assessment. The author’s
study of Sullivan helped shape Therapeutic Assessment.
4
How erapeutic Assessment Became Humanistic (written with Mary E.
Tonsager)
The overlap is described between Therapeutic Assessment and Humanistic
Psychology. Humanistic procedures were incorporated into Therapeutic
Assessment because they proved to benefit clients.
Part II
Specific Teniques of erapeutic Assessment
5
Testing One’s Own Clients Mid-erapy With the Rorsa
Traditionally, assessors have been cautioned against giving the Rorschach
to their own psychotherapy clients. The author talks about instances when
this practice can be useful and provides four case examples.
6
Giving Clients Feedba About “Defensive” Test Protocols
Therapeutic Assessment views guarded or “defensive” test protocols as
signs that clients have conflicting motivations regarding an assessment.
Specific guidelines are presented about how to talk to such clients about
their test results.
7
Assessment Feedba Integrating MMPI—2 and Rorsa Findings
The MMPI—2 and Rorschach tap different levels of clients’ experience, and
this fact is important in understanding patterns of agreement and
disagreement between the two tests. Guidelines are presented for giving
feedback to clients with different patterns of scores and the author
illustrates these guidelines with a detailed case example.
8
Assessment Intervention Sessions: Using “Soer” Tests to Demonstrate
“Harder” Test Findings With Clients
This chapter details the steps in “assessment intervention sessions” in
Therapeutic Assessment, in which psychological tests are used in non-
standardized ways to help clients discover new insights suggested by
standardized testing. Several case examples are discussed.
9
One-Up, One-Down, and In-Between: A Collaborative Model of Assessment
Consultation
Therapeutic Assessment can be a useful way to consult to other clinicians
about clients they find puzzling or difficult. The author discusses ways to
structure such consultations to make the most impact on the client-
therapist system.
10
erapeutic Assessment of a Man With “ADD”
This is a detailed case study of an adult therapeutic assessment, with
partial transcripts of a number of sessions. The case illustrates how to help
clients discover new insights about themselves that might otherwise be
rejected at the end of an assessment.
11
Collaborative Sequence Analysis of the Rorsa
A case is presented illustrating the usefulness of a collaborative extended
inquiry following a standardized Rorschach administration. The session
described was a turning point in a difficult couples assessment.
12
Using the Consensus Rorsa as an Assessement Intervention With
Couples
The Consensus Rorschach has a long and venerable history. In therapeutic
assessments of couples, a modified version of this procedure is used to help
partners become aware of their individual and joint contributions to
u
problematic relationship dances. ”
13
“But I Was Only Trying to Help!”: Failure of a erapeutic Assessment
Therapeutic Assessment defines “failed” assessments as those after which
clients feel diminished or traumatized. The author recounts one such
assessment in detail and draws lessons for psychological assessment in
general.
14
Collaborative Child Assessment as a Family Systems Intervention
In Therapeutic Assessment, psychological assessments of children and
adolescents are seen as potential therapeutic interventions on a whole
family system. The author discusses 10 ways for assessors to collaborate
with parents and their potential effects on a family system.
15
Teaing erapeutic Assessment in a Required Graduate Course
The principles and techniques of Therapeutic Assessment are applied to
working with graduate students in a required course on psychological
assessment. By structuring the course as a chance for students to learn
about themselves as new clinicians, the author helps them experience a
therapeutic assessment first hand.
Part III
eoretical Developments
16
Please Tell Me at I’m Not Who I Fear I Am: Control-Masteryeory and
erapeutic Assessment
Control-Mastery theory is a relatively new psychodynamic theory that
helps understand the process through which clients change in
psychotherapy. This theory helps us understand why clients benefit from a
therapeutic assessment.
17
Challenges and Lessons of Intersubjectivity eory for Psyological
Assessment
Links are drawn between Therapeutic Assessment and the psychodynamic
theory of intersubjectivity. Constance Fischer’s phenomenological
approach to collaborative assessment addresses major challenges of
intersubjectivity theory for psychological assessment.
18
How Psyological Assessment Taught Me Compassion and Firmness
Psychological assessment, especially when it is collaborative, challenges
assessors to grow personally in order to better understand their clients.
The author shares several life lessons from his years practicing
Therapeutic Assessment.
19
Conclusion: Practicing erapeutic Assessment
This chapter concerns practical matters involved in conducting therapeutic
assessments: When are they appropriate? How does one bill? How does one
get referrals? How does one learn the method and get ongoing support?
References
Author Index
Subject Index
Foreword
Some 15 years ago, as I read and reread the in-thi handout that Steve
Finn had given me from his Society for Personality Assessment workshop,
tears eased their way down my face. ey were the tears that accompany
being in tou with shared core but vulnerable values. is man whom I had
just met had explicitly incorporated aspects of my Individualizing
Psychological Assessment into his independently developed practices. I
found throughout the handout that aer Steve had reflected thoroughly on
test paerns, theory, resear, and what he already knew of the person’s
situation, he posed his impressions to the client in that person’s terms. He
collaborated respectfully, so as to truly individualize his descriptions, all the
while helping the person to realize greater possibilities. I was moved by the
openness and depth of his care for and faith in his clients, and by their
profound experiences while working with Steve. I had always thought that
collaborative/individualized assessment was necessarily growthful for
clients as well as immediately helpful to readers of assessment reports. But
Steve oen went further, planning for clients to experience therapeutic
insights—lived as well as understood. at workshop handout presaged what
Steve soon named “erapeutic Assessment.”
I’ve oen been asked whether erapeutic Assessment is appropriate for
when clients have been referred by professionals who are unfamiliar with it.
I reply that even when clients are referred more traditionally, therapeutic
insights are not only helpful to the clients but provide the referring party
with understandings of the clients’ openness to new experience. Many
persons self-refer and many professionals do refer their clients for this
service.
e title of this book, “In Our Clients’ Shoes,” evokes for me the
collaborative assessor’s practice of exploring the client’s world by traveling
with that person, through tests and talk, cating glimpses of his or her
goals, horizons, hopes, and perceived dangers and obstacles. e therapeutic
assessor accompanies and guides clients into test-related experiences
through whi they come to personal discoveries that are comprehended
both affectively and conceptually. Clients grasp connections with the
questions that were presented for the assessment, and also apprehend
personally viable means of altering course to their goals. e assessor has
not unilaterally presented clients with “feedba” nor told them what to do.
Indeed, Steve’s quiet, receptive presence to clients, evident in the case
excerpts in this book, oen has reminded me of Buber’s “encounter” with
the other—a profound respect for the other’s being and for the intangible
“between.”
I am appreciative of and grateful for Steve’s brave, creative, enthusiastic,
unstinting, and effective outrea—giving national and international
workshops, making his erapeutic Assessment approa accessible through
filmed excerpts, invitational writings, symposia, and extensive supportive
consultation with students and colleagues. He has developed arts showing
concrete steps for conducting erapeutic Assessment, published articles
that integrate diverse theories into collaborative practices, provided a broad
range of clinical examples, and published and encouraged resear on the
outcomes of collaborating with assessment clients. Steve regularly seeks
consultation with colleagues on theory and on clinical cases, always
evolving his own understandings and practices. Due primarily to Steve’s
dedicated efforts, collaborative and erapeutic Assessment practices are
being adopted, adapted, and advanced by practitioners across the country
and in many international seings.
In Our Clients’ Shoes illustrates Steve’s steady development of
erapeutic Assessment’s approa and practices. Every apter is readily
understood and helps the reader to imagine undertaking erapeutic
Assessment practices in his or her own way.
Constance T. Fischer
Duquesne University
Preface
I coined the term Therapeutic Assessment in the late 1980s to describe an
approa to psyological assessment that I was developing with the help of
my colleagues in Austin, Texas. As the clinical methods and theory of
erapeutic Assessment evolved, and as my colleagues and I gained
experience working with diverse groups of clients, I became convinced that
we had found a powerful way to impact clients’ lives and help them with
their persistent problems in living. I also witnessed (and knew from my own
experience) that practicing psyological assessment in this way enhanced
the wisdom, compassion, and personal and professional development of
most clinicians. I felt a strong urge to share with others what I had learned.
us, I began to travel and speak about erapeutic Assessment to
different groups of psyologists around the world. I oen showed videotape
excerpts from my assessment sessions with various clients, who altruistically
waived their rights to confidentiality so that other psyologists could learn
a new approa that had proved helpful to them. Other clients generously
consented to be assessed “live” before a group of psyologists, so that those
clinicians could observe and collaborate in the assessments. e response to
these various workshops has been tremendous, and at this point I estimate
that over 3,000 clinicians have aended one or more of my training sessions
in erapeutic Assessment. I know that many others have learned about
erapeutic Assessment in their graduate training, or have read something
that explicated or referred to its principles and teniques. Now, every week
I receive inquiries about erapeutic Assessment, with requests for readings,
training workshops, consultation, or help with resear proposals.
I am excited and somewhat humbled by this growing interest; excited
because of the number of clients who may be having positive experiences
with psyological assessment, and humbled because my own writing and
formal resear on erapeutic Assessment has not kept pace with my
thinking, clinical work, or training workshops. I conceived of this book as a
way to partially remedy that situation, by assembling—in one place—a
number of my papers on erapeutic Assessment that jointly explicate some
of its history, theory, teniques, and impact on clients and assessors. Most
of the apters in this volume are based on my presentations at various
conferences over the past 13 years—especially at the annual meetings of my
beloved professional home, the Society for Personality Assessment—and
many have been disseminated as unpublished papers up until now. Several
other apters were published previously but are reprinted here because
they explicate central points about erapeutic Assessment and/or are now
difficult to obtain.
e book is organized into three sections. Part I describes the history and
development of erapeutic Assessment, including personal experiences that
led me to focus on psyological assessment as a potential therapeutic
intervention. A major principle of phenomenological psyology is that you
must understand a person’s context to fully understand their view of the
world; I hope these apters are useful in explaining mine. e longer
section of the book, Part II, contains a variety of apters that illustrate
particular teniques of collaborative and erapeutic Assessment. If you
are aempting to learn the “nuts and bolts” of erapeutic Assessment—for
example, (a) how to integrate test findings, (b) how to engage clients in
discussing their experiences of a test, (c) how to conduct assessment
intervention sessions, or (d) tea erapeutic Assessment to graduate
students—these papers should help you a great deal. In Part III, I draw links
between erapeutic Assessment and two major sools of psyotherapy:
intersubjectivity theory and Control-Mastery theory. If time and space
permied, I would also have wrien about links between erapeutic
Assessment and other psyotherapeutic approaes that influenced me,
su as cognitive-behavioral psyotherapy, narrative therapy, systems-
centered group therapy (Agazarian, 1997), and self psyology. In the
penultimate piece in the book, I explore one of the theoretical claims of
erapeutic Assessment: that assessors also grow and ange as a result of
practicing psyological assessment. e final apter deals with important
practical maers: (a) when erapeutic Assessment is and is not called for,
(b) how to bill for erapeutic Assessment sessions, (c) how to market this
type of psyological assessment, and (d) where to find professional support
for this kind of work.
Obviously, my thinking about erapeutic Assessment has continued to
evolve over the years. us, some of the apters I ose reflect more current
conceptualizations than do others. I have resisted the urge to radically
“update” older pieces, believing that readers will find it interesting to see
how certain concepts and practices developed over time. However, I have
standardized my terminology and eliminated certain redundancies between
papers to make the experience of reading them in sequence more enjoyable.
Also, in hopes of conveying some of the spontaneity and excitement I felt at
the time, I have retained mu of the informal language of those papers I
first presented in oral form.
My greatest hope for this book is that it will help you “get in your clients’
shoes” more completely so that you and your clients may tou ea other’s
lives. A warning label seems appropriate, however: erapeutic Assessment
is not for the faint of heart! As one of my favorite aker authors has
wrien:
For the listener who knows what he is about, there is a realization that there is no withdrawal
halfway. ere is every prospect that he will not return unscathed. ere is no lead apron that can
protect his own life from being irradiated by the unconscious level of the one he engages with…
ea act of listening that is not purely meanical is a personal ordeal. Listening is never eap.
(Steere, 1955/1985, p. 13).
Most days, I consider what Steere wrote as a allenging but amazing
personal benefit of my work with clients. But if you do not wish to ange
and grow, put this book down immediately and run for cover!
Anowledgments
Many people contributed directly or indirectly to this book. Barton Evans
encouraged me to begin “steering the ocean liner” of my life to a place
where I could do more writing. Steve Ruer, my editor at LEA, believed in
me and encouraged me to assemble this book; Nicole Bumann at LEA
patiently kept me on tra through numerous deadlines. My colleagues at
the Center for erapeutic Assessment listened to early versions of many of
these papers, supported me emotionally and professionally, and helped me
develop my ideas; I am extremely grateful to them all for their ongoing
collaboration: Jennifer Chapman, Marita Fraowiak, Bey Peterson, Dale
Rudin, Terry Parsons Smith, and Judith Zamorsky. Millie Smith and Ri
Armington held me up with their friendship and love. And above all, this
book would not exist without Jim Durkel, who held my hand, read early
dras, and kept our home life together as I spent many hours traveling or in
front of the computer.
Many other individuals contributed to the development of erapeutic
Assessment. Connie Fiser, Leonard Handler, and Caroline Purves paved
the way with their courage, creativity, and unwavering humanism. Mary
Tonsager and Hale Martin helped me test and fine tune many of the
methods, and Mary spearheaded the early resear. Mary McCarthy added
to the theory, took erapeutic Assessment into new seings, and
enthusiastically helped spread the word. Carol Middelberg and Deborah
aringer added to and improved erapeutic Assessment teniques for
couples and ildren. Jan Kamphuis helped analyze and make sense of the
recent resear. e following individuals also worked with me in Austin
conducting psyological assessments and were part of the supportive
community from whi erapeutic Assessment evolved: Patricia Altenburg,
Rosemary Ellmer, Beatrice Gerry, and LaNae Jaimez.
is book is dedicated to my colleagues in the Society for Personality
Assessment, who continue to inspire me, tea me, and support me as both a
person and a psyologist.
In Our Clients’ Shoes
eory and Te nicjues of erapeutic Assessment
Part I
e History and Development of erapeutic
Assessment
1
Introduction: What Is erapeutic Assessment?
Definitions and Distinctions
As erapeutic Assessment has become more accepted in recent years,
people are starting to use this and related terms in different ways. For this
reason, I find it useful to define my terms and make certain conceptual and
practical distinctions. I do this humbly—realizing that my definitions may be
different from those of other people who think, write, and practice in this
area, and that the distinctions I make are “fuzzy” and do not map precisely
onto real life.
Traditional Assessment
In 1997, Mary Tonsager and I published a paper in whi we contrasted
traditional “information-gathering” psyological assessment and
erapeutic Assessment on a number of dimensions (Finn & Tonsager, 1997).
at detailed analysis is still useful, but for my purposes here let me simply
define traditional assessment as that model where psyological tests are
administered to clients primarily for the purposes of diagnosis, treatment
planning, treatment evaluation, and/or increased understanding. e main
emphasis in traditional assessment is typically on the standard- ized data
that is carefully collected by the “expert” assessor (or an assistant), who then
compares test scores to nomothetic norms in order to derive conclusions that
will be useful in understanding, communicating about, and treating a certain
“patient,” or in monitoring the progress of treatment.
EXHIBIT 1-1 Types of Psyological Assessment
“therapeutic assessment”
Next, let me define therapeutic assessment (lowercase). Mainly, I consider
this to be an aitude about psyological assessment—where the goal of the
assessor is more than collecting information that will be useful in
understanding and treating the patient. In therapeutic assessment, in
addition, assessors hope to make the assessment experience a positive one
and to help create positive anges in patients and in those individuals who
have a stake in their lives (su as family, therapists, and employers).
erapeutic assessment is based on the intent to use psyological
assessment to help patients directly, rather than just indirectly, as with
traditional assessment. Apart from this intent, from my observations,
therapeutic assessment is not tied to any particular set of procedures, clinical
teniques, or philosophy. It is practiced in a variety of ways, and I further
believe that many clinicians are conducting therapeutic assessments without
even claiming to do so! An example of a gied psyologist who positively
impacted clients through his assessments—without ever asserting that they
were explicitly therapeutic—was Paul Lerner (2005a, 2005b).
Collaborative Assessment
I also find it useful to distinguish between collaborative and noncollaborative
therapeutic assessment. One thing probably common to all therapeutic
assessment is that assessors generally have some thoughtful way that they
communicate information derived from an assessment directly to patients.
In my mind, collaborative assessment goes beyond the practice of giving
feedba, even if that is done in an interactive way. It involves a
comprehensive effort to engage the client in multiple phases of the
assessment process—including (a) framing the reasons for the assessment, (b)
observing test responses and behaviors, (c) discovering the significance of
those responses and behaviors, (d) coming up with useful recommendations,
and (e) draing summary documents at the end.
Collaborative psyological assessment is probably almost always
beneficial to clients, and as su I consider it a subset of therapeutic
assessment. But collaborative assessment may not always start with the
explicit intent to produce positive ange. For example, three pioneers of
collaborative assessment—Connie Fiser (1985/1994), Len Handler (1995),
and Caroline Purves (1997)—were all practicing collaborative assessment for
years before they openly anowledged that their assessments were
therapeutic to clients. All three developed their approaes by trying to
make the assessment process more humane, respectful, and understandable
to clients, or, as Fiser (1985/1994) wrote, by gradually eliminating those
aspects of psyological assessment that were dehumanizing or potentially
harmful to clients.
Fiser also articulated a coherent philosophy of science, based in
phenomenological psyology, whi grounds and extends collaborative
assessment teniques. My brief summary of this intersubjective model is as
follows: “We can never know some external reality in its own right. We
inevitably participate in what we see, always using our perspectives,
bagrounds, and interests to assign meaning to our observations.” (See ap.
17 for a more extensive discussion of Fiser’s theory.) is point of view
establishes an aitude about psyological test scores and their relationship
to real-life events that permeates many aspects of collaborative assessment.
If you grasp and believe Fiser’s model, you will never, for example, find
yourself arguing with a client over the meaning of a test score (e.g., “What
do you mean, you aren’t depressed? Your MMPI-2 Scale 2 score is 98!”). Also
you will be intrigued, naturally, about the client’s own thoughts about that
MMPI-2 score and the mat between what psyologists call “depression”
and that client’s own experiences. If you believe in phenomenological
psyology, no one will have to tell you to discuss these maers with the
client; you will just do so! For these reasons, I believe that Fiser’s human—
science framework encourages greater consistency in and expansion of
collaborative assessment teniques, and it therefore underlies mu of my
own work on erapeutic Assessment, to whi I now turn.
erapeutic Assessment
I reserve the term Therapeutic Assessment (uppercase) for the
semistructured collaborative assessment approa—grounded in Fiser’s
human—science philosophy—that has been developed by me and my
colleagues at the Center for erapeutic Assessment in Austin, Texas. I call
Fiser’s, Handler’s, and Purves’s approaes “loosely structured”
collaborative assessment because there is a systematic method to their work
—but it’s not spelled out as explicitly as in erapeutic Assessment. I do not
claim that our method produces greater benefits to clients than the less
structured forms of collaborative or therapeutic (lowercase t) assessment.
However, I do believe it is somewhat easier to tea and to resear and that
its organization helps guide assessors through the many complex oice
points that arise in a collaborative assessment. I’ve oen said—and I’m only
half jesting—that erapeutic Assessment is for those of us who are not as
creative, intuitive, and qui on our feet as are Fiser, Handler, and Purves.
If you follow the structure of erapeutic Assessment for a period of time,
gradually you will know when it is appropriate to deviate from this format
and feel confident doing so. I’m reminded of the promise of my ildhood
piano teaer, who told me that if I practiced my scales diligently, someday I
would be able to play jazz. Recently I see the truth of this statement in the
assessments I do with my clients.
EXHIBIT 1–2 General Flow Chart of a erapeutic Assessment
Flow Chart and Brief History of erapeutic
Assessment
So let me review the general structure of a erapeutic Assessment,
explaining, as I proceed, how the different steps developed and were
incorporated into the model. us, rather than presenting the steps in the
order they appear in an assessment, I discuss them in the order in whi
they found their way into erapeutic Assessment.
Step 4—Summary andlor Discussion Sessions
I first became convinced of the potential therapeutic value of psyological
assessment during my graduate training. During this period, I had several
moving and powerful experiences discussing assessment results with clients,
and they reported aerwards that their lives were anged. (I relate some of
these experiences in ap. 2.) Not surprisingly then, as I became interested in
understanding how assessment could be therapeutic and in discovering
ways to make it more so, I initially focused on what I then called “feedba
sessions” with clients.
One of the things I explored in my early resear concerned how to order
the information we present in feedba sessions to make those sessions the
most useful and beneficial to clients. At first, most clinicians I consulted
suggested that one should start by telling clients something positive about
themselves. It turns out that this is not always the best practice, especially
with clients who have very negative self-images. Instead, my colleague Bill
Swann and I demonstrated (Sroeder, Hahn, Finn, & Swann, 1993) that
clients are most able to integrate and make use of assessment information
when it is presented in the following order:
(1) Begin with what I call Level 1 findings—those that map onto the way
clients already think about themselves. An example would be telling a
self-labeled extrovert that his very low score on Scale 0 of the MMPI—2
suggests that he enjoys meeting new people, is comfortable in large
groups, and would not do well in a job where he worked mainly on his
own.
(2) Next, introduce Level 2 findings from the assessment, whi reframe
or amplify clients’ usual ways of thinking about themselves. is might
involve telling a client who is concerned about lethargy, la of
motivation, and poor focus, that his Rorsa D score of −4 suggests
he is emotionally overwhelmed, rather than just “lazy” as he fears.
(3) Last, if all is still going well, you may introduce Level 3 findings to
clients—those that conflict in some major way with their usual
conceptions of themselves. Resear has shown that in many instances
clients continue to consider and assimilate su information long aer
an assessment is completed.
EXHIBIT 1–3 Ordering Resuts Presented to Clints from a Psyological Assessment
Besides collaborating with me on the resear that supported this way of
discussing assessment results with clients, Swann’s own work helped
provide an explanation for why this approa works best (Swann, 1996,
1997; Swann, Stein-Seroussi, & Giesler, 1992). His self-verification theory
posits that people have a drive to maintain the current “stories” or “semas”
they have about themselves and will oen discount or push aside
information that conflicts with these stories. is is true even if a person’s
existing self-story is primarily negative, as anybody knows who has tried to
pay a compliment to a person with low self-esteem (Swann, Wenzlaff, Krull,
& Pelham, 1992). By starting an assessment feedba session with self-
verifying information and gradually moving to findings that are less self-
verifying, one creates the optimal condition for clients to incorporate new
information into the ways they think about themselves and the world.
Once I understood self-verification theory, I began to clarify the most
appropriate focus of intervention in a psyological assessment—that is,
clients’ existing conceptualizations of themselves and other people. I realized
that if we could assist clients in anging these stories—whi oen are
vague, inaccurate, and laing in self-compassion—we could profoundly
impact their lives. Around this time, I also had two other insights about
feedba sessions. First, I knew that people do not ange their beliefs about
themselves easily, and that I would need to support people emotionally—in a
tangible way—to help them assimilate and accommodate to new
information. is spurred me to work on and improve my ability to mirror
and connect with clients deeply in a short period of time. Second, experience
told me that I could best help clients ange their stories by dialoguing with
them about the assessment findings and explicitly asking them to agree,
disagree, revise, and give real-life examples of what I was saying. Resear
by Hanson and others has since confirmed that this interactive style of
discussing assessment results benefits clients more than a unilateral,
assessor-driven presentation of test findings (e.g., Hanson, Claiborn, & Kerr,
1997). For this reason, I no longer talk about conducting “Feedba Sessions”
at the end of an assessment, preferring now to call them
“Summary/Discussion Sessions.”
Step 1 —Initial Sessions
e next set of developments in erapeutic Assessment concerned initial
sessions. In listening to clients who voluntarily agreed to participate in
psyological assessments, I realized that certain aspects of their self-
semas were more open to ange than others. And sometimes, clients
themselves were actively searing for new ways of thinking about
themselves and the world. is led to the practice of asking clients—in the
initial assessment sessions—what puzzles, questions, or quandaries they had
about themselves, and then making these questions the focus of the
assessment. My initial thought was that su questions would signal me
where clients’ stories were most flexible, serving as “open doors” through
whi one could send assessment information during the feedba session.
is proved to be true, and my colleagues and I found that Level-3 findings
were mu more likely to be accepted by clients if they could be related to
the clients’ own puzzles about themselves. Also, clients’ assessment
questions oen revealed a lot of information about their existing self-
semas, and one could oen discover what was Level-1 information by
asking clients in the initial session for their best guesses—before any testing
was done—about the answers to their questions. Finally, by focusing
psyological assessments on clients’ personal agendas, we made the whole
assessment process mu more client-centered, whi seemed to lower
clients’ anxiety, enlist them in the assessment in an active way, and engage
their curiosity.
All of these factors seemed to enhance the therapeutic impact of our
assessments, but as time has gone on I have become more convinced of the
value of helping clients get curious about their problems. By assisting clients
in forming questions, we invite them to “climb up” with us, if you will, on
an “observation de” overlooking their lives where we may begin to look
jointly for answers. Many clients report that they feel relief immediately
aer an initial assessment session simply from having translated their inner
turmoil into concrete questions. Some clinicians would say the procedure
helps engage the observing ego. I believe developmental affective
neurobiologists like Sore (1994) and Siegel (1999) would tell us that we are
actually helping people engage a different part of their brains, and that this
helps them grow and develop.
Step 5—Written Feedba Is Provided
Clients’ assessment questions also gave an innovative way to structure
wrien feedba to clients. Rather than provide them with copies of formal
psyological reports, we wrote them leers that addressed their questions
and that reflected their input during summary/discussion sessions. Although
I anowledge that su leers are time consuming to write, I firmly believe
in their value. For example, recent resear by Lance and Krishnamurthy
(2003) demonstrated that a combination of oral and wrien assessment
feedba was superior to oral feedba alone. We also adopted the process
first modeled by Fiser (1985/1994) of inviting clients to comment on or
modify dras of su leers, whi again, clearly involves them in co-
editing the new story that emerged from the assessment. Sample leers to
clients are included in apters 7 and 10.
Step 2—Standardized Testing Session (s)
In erapeutic Assessment, in contrast to some types of collaborative
assessment, the initial session is followed by one or more sessions in whi
standardized tests are administered according to standardized procedures. In
keeping with Fiser’s idea of individualized psyological assessment, there
is no predetermined baery of tests. Whi tests are administered is
determined primarily by the nature of the client’s (and/or the referring
professionals’) questions for the assessment, although, to some extent, they
also depend on an assessor’s training, experience, and personal preference.
For example, clients who ask if they have a learning disability will be given
intellectual and aievement testing. A client who asks why he is so angry
at his mother may be given the MMPI-2 and the Rorsa.
If you were a fly on the wall wating me during these standardized
testing sessions, you’d see very few differences compared to an assessor
practicing traditional psyological assessment. e exceptions would be
that:
(1) I follow specific guidelines about the order in whi tests are
administered. I try to administer first those tests that are closest—in
their face validity—to the client’s central assessment questions. is
lowers clients’ anxiety by showing them that I am not just a voyeur,
but am collecting information that is relevant to our agreed-upon
contract. For example, if a client wants to know if he has aention
deficit disorder (ADD), I first ask that he complete one of the face-valid
screening inventories for adult ADD. Next I might administer cognitive
tests of aention and memory. Only aer these are completed would I
move on to other tests—like the Rorsa or MMPI—2—that are less
obviously tied to the client’s presenting concerns.
(2) I introduce ea test according to its relevance to the client’s
assessment questions, making a special effort to comment on those tests
whose purpose is hard to decipher, for example, “is long
questionnaire, the MMPI-2, is a widely used psyological test that will
give us information about your anger and a host of other things, like
depression and anxiety. I believe it could help us understand why you
are so angry at your mother.”
(3) Aer I have completed the standardized administration of ea test, I
inquire about the client’s experience of the task, paying special
aention to assessment events that seem related to the client’s
questions for the assessment. For example, with the client who
wondered about ADD, I would likely administer the WAIS—III
(Wesler, 1997) according to standardized procedures, but talk with
the man aerwards about his concentration and aention during the
test, and whether it seemed beer, worse, or different from his
functioning outside the assessment situation. If I gave the man who
was angry at his mother the Rorsa, I might ask him to reflect
aerwards on his percepts to Card VII: “ice pi,” “nutcraer,” and
“tundra,” telling him of the old lore that responses to this card might
tell something about a person’s relationship with his mother.
Alternatively, I might use one of Handler’s (2006) teniques for an
extended inquiry and ask the client, “If this ice pi could talk, what
might it say?” e use of extended inquiries with clients is
demonstrated in apters 10 and 11.
As you can imagine, su opportunities for dialogue during an assessment
are useful in helping assessors to understand clients’ behavior and test
scores. Also, they provide opportunities for clients and assessors to gradually
“coedit” the clients’ existing stories, rather than trying to make big anges
all at once at the end of an assessment. For this reason, in erapeutic
Assessment, we tend to meet with clients once or twice a week for 1—1/2 to
2 hours, rather than administering all the standardized tests in one day in a
marathon testing session. We find clients are generally less overwhelmed
with this sedule, are more able to participate as active collaborators, and
are able to gradually shi their stories, while dealing in small bates with
the emotions this brings up.
Step 3—Assessment Intervention Sessions
Assessment intervention sessions were one of the last additions to the
erapeutic Assessment process, and were developed to address several
concerns at once. First, in some assessments there seemed to be few clear
events or opportunities for meaningful discussions with clients about their
standardized testing. For example, for a while, I did a number of assessments
using the MMPI-2 as the only standardized test. As you can imagine there
are a limited number of relevant things one can explore with clients about
their experience of responding to 567 True—False questions, even if those
questions are sometimes odd or thought provoking. Second, in spite of our
best efforts to “bring clients along” during an assessment, sometimes—when
planning feedba—we would find that most of the important findings were
Level-3 information that was likely to be quite threatening to clients. ird, I
had become firmly convinced by this time that it was mu more
therapeutic to “midwife” a new story into being for a client than to present it
fully formed in a summary/discussion session. Assessment intervention
sessions deal with these and other issues.
e main idea behind assessment intervention sessions is relatively
simple, that is, to bring into the room those problems-in-living of the client
that are the focus of the assessment, where they may be observed, explored,
and addressed with various therapeutic interventions. Because these sessions
take place aer the standardized testing is complete, the assessor can use the
results of su testing to help “get in the client’s shoes” when imagining how
to evoke and then help with the difficult experiences that are targeted. And
the assessor has a range of assessment materials and other teniques to use
in order to evoke different emotional states in clients that are related to their
problems in living. is is the “gestalt therapy” step in erapeutic
Assessment, and I gladly confess that most of the teniques were borrowed
from the “Assessment of Process” section of Fiser’s (1985/1994) book. I still
remember staying up all night the first day I read that book, and in
particular being inspired and fascinated by Fiser’s creative methods for
bringing test scores alive for clients. Assessment intervention sessions are
my aempt to “standardize” Fiser’s creativity and make it teaable; still,
they are the most difficult part of erapeutic Assessment to learn. us, I
provide detailed instructions for conducting assessment intervention
sessions in apter 8 and several case examples with different types of clients
in apters 10 and 12.
Step 5—Follow-Up Sessions
Postassessment follow-up sessions were the latest addition to the
erapeutic Assessment model, and quite frankly, my colleagues and I first
began doing them because clients asked for them. We now routinely tell
clients at their summary/discussion sessions that many people find it useful
to meet again in 2 to 3 months, to talk more about their assessment and
discuss any questions or developments that have come up. Su an
opportunity seems especially valuable for self-referred clients who do not go
into ongoing psyotherapy at the end of an assessment. In fact, I now have
a number of individuals I tested over the years who come to see me for a
few sessions once or twice a year to discuss their progress and clarify their
next steps. At first I was skeptical about the value of su an arrangement,
but I have become convinced that this model—of an intense assessment,
followed by periodic consultations—is a good therapeutic model for some
people, and that it provides a reasonable option for those individuals who do
not wish to engage in ongoing psyotherapy, for whatever reason.
Conclusion
is then is an overview of erapeutic Assessment as practiced at our
Center in Austin. As you read through the remaining apters of this book,
you will see how the format in Exhibit 1–2 informed my experiences with
clients, and how these interactions reciprocally influenced the theory and
structure of erapeutic Assessment. is process is ongoing, and I am
certain that in 10 years we will know even more about how to make
psyological assessment a transformative experience.
In the meantime, it feels important also to state that every assessment I do
is slightly different, and oen my colleagues and I find it is necessary to
modify the plan I have described to best serve a particular client. For some
clients, assessment intervention sessions seem unnecessary or too dangerous
(Zamorsky, 2002), and for others it is best to discuss test results as you go
along, right aer ea test is administered. We have even discovered that
some clients don’t reveal their most important questions about themselves
until the very end, when the assessment is nearly completed (T. P Smith,
2002). So as you read through the remaining apters, I encourage you to see
the structure of erapeutic Assessment as a heuristic tool that will help
organize your thinking, and as an aid to training people how to do
collaborative assessment. You may also find that in your own seing—for
various reasons—you are not able to implement all the steps of erapeutic
Assessment. Please do not feel bad about this; I encourage you to take what
you can and adapt our ideas and teniques to your own clients and
personality. Above all, it is important to maintain the therapeutic aitude
discussed earlier, to treat clients with kindness and respect, and to remember
that we can never know some absolute truth about a client from our test
scores. If you keep those things in mind, it is likely that you too will be
practicing therapeutic assessment, and your clients and you will benefit.
Note
Portions of this apter are drawn from a Master Lecture I presented to the Society for Personality
Assessment (Finn, 2006).
2
Appreciating tke Power and Potential of
Psyological Assessment
When I first began speaking to groups of psyologists about the power of
psyological assessment, I feared I would be “preaing to the oir.” To be
sure, I did find that every time I talked, several people in the room had a
knowing glint in their eyes and they nodded as I recounted various moving
experiences with clients. However, I also learned that many psyological
assessors had never thought about psyological assessment as anything
beyond a tool for diagnosis and treatment planning.
I now believe that most of us still don’t yet fully appreciate the power and
potential of psyological assessment. I know this personally, because I keep
being surprised—even aer all this time—by the mystery and transformative
impact of our assessments. I confess that I oen begin an assessment
thinking, “Oh no, how am I going to help this person?” en later, as the
assessment progresses, I’m amazed at the difficult, meaningful shis both of
us have made. I also know that we don’t fully understand psyological
assessment when I read our scientific journals, see assessment reports from
other psyologists, and aend presentations at professional meetings. Even
among groups of experienced and commied psyological assessors I
sometimes get the sense that we’re groping in a darkened room for a
treasure we only see a hint of now and then. And this worries me, for if we
don’t fully understand the nature of our work, how can we expect those
who are skeptical about personality assessment to do so?
I clearly remember the first time I got a peek at the treasure that is
psyological assessment. It was at the end of my first year of clinical
psyology training at the University of Minnesota, when I did my very first
practicum on the adult inpatient unit of Hennipen County Medical Center in
Minneapolis. To set the stage, I had just completed a year of assessment
training with some incredibly good instructors. We learned the MMPI from
James Buter and Auke Tellegen, intellectual testing from a prominent
neuropsyologist, and the Comprehensive System for the Rorsa and
the TAT from some excellent adjunct faculty. I had found these courses
extremely interesting and arrived at this first practicum with a lot of
intellectual curiosity about how psyological tests would be useful in an
applied clinical seing.
My primary supervisor, Dr. Glenna Sroeder, took one look at the green
and rather intellectualizing graduate student I was, and decided that I
should have my first assessment experience with a rather harmless patient, a
sizophrenic man named Joe, who was in residence at that time on the unit.
Joe was a middle-aged, semihomeless man who was well known to the
entire psyology and psyiatry staff. I learned later that he was somewhat
legendary for appearing twice a year, exactly 6 months apart, in the hospital
emergency room in the middle of an acute psyotic episode. Ea time, Joe
would be admied to inpatient psyiatry where he would be stabilized on
antipsyotic medication. Aer about 3 weeks, he would disarge himself
and refuse to be involved in aercare, only to appear again when 6 months
had passed.
I saw Joe rather late in his stay, about 1 week before he planned to leave
the hospital. He may even have hung around a bit longer then he had
planned to help me get some assessment experience. I know I gave Joe the
WAIS and the MMPI, but it was the Rorsa that stands out for me now I
think this was the first client Rorsa I ever gave outside the course I had,
and I remember Joe rejected Cards II, III, VIII, IX, and X. I came prepared
with my memorized instructions for Rorsa administration and assured
Joe that if he just kept looking, he would see something. He didn’t. I even
stopped at one point to ask if he had reservations about doing the testing,
and he assured me that he did not, he just couldn’t see things on any of
those “ugly” cards—only the ones to whi he had already given responses. I
returned to my supervisor feeling that I had failed my first real Rorsa
administration.
Luily, Dr. Sroeder was a very skilled clinician. She assured me that I
had done just fine and told me to go ahead and score what I could of the
Rorsa and to come see her in the morning. Joe actually had given a fair
number of responses to the cards he hadn’t rejected, although the majority
of them used pure form. As Dr. Sroeder and I sat with the Rorsa the
next morning, she asked me consider what Cards II, III, VIII, IX, and X had
in common. “Chromatic color,” I offered. “Good,” said she. “And what does
Rorsa theory tell us about color cards?” “ey stir up emotions.” “And
what might it mean that Joe called the cards ugly?” “He didn’t like the
emotions they stirred up?” “Exactly! And how did Joe deal with emotions he
didn’t like facing?” Here, I was stu. “He denies them,” Dr. Sroeder
explained. “Joe is ready to leave the hospital again, but he gets there ea
time by pushing aside a bun of unpleasant feelings that he can only ignore
for so long. Eventually they burst through again, and he ends up ba in the
hospital.”
I remember being amazed at how Dr. Sroeder’s interpretation made
sense, but the real cliner was when I went to talk about the testing with
Joe. Tears rolled down his weather-beaten face as we talked about the
Rorsa, and he told me not to worry, it was just that nobody had ever
understood him so well before. We talked about what he might do to face
the “ugly” feelings that were so hard, and he agreed to e out a few of the
aercare programs that were available. We shook hands briefly, looking
deep into ea other’s eyes (a first for me and perhaps for Joe) and parted.
I le that session deeply moved (and a convinced Rorsaer), but there’s
more to the story. irteen months later, I began my psyology internship
in that same inpatient psyiatry ward. It wasn’t too long before I heard that
Joe had come into the emergency room again, but this time the staff seemed
relieved. For as it turned out, Joe hadn’t been admied since that last time I
had seen him, and a lot of the nurses were afraid that something bad had
happened to him on the streets. Eventually, Joe made it up to unit and when
he saw me, he ran across the room, shook my hand, and asked, “Can we do
those inkblots again? at was one of the most important things that ever
happened to me in my life‼” I was a bit surprised, but assured him that we
could, and I asked him how he’d been doing since I last saw him. It came out
that he had indeed followed up on the aercare we had talked about, had
been aending a group, had an apartment, and had been taking his
medication. He told me he had been working hard to face the feelings he’d
been avoiding, and it had helped—he’d just had a setba recently aer a
friend died. He hoped we could “e out his psye” while he was there to
see if he’d been making progress. And the next week he gave me a
Rorsa with responses to all 10 cards.
is experience was so significant to me, in part, because nothing I had
learned in my assessment courses had prepared me for it. I remember
quizzing my professors and supervisors aerwards. Yes our tests were valid
and reliable and interesting, but why had nobody told me that psyological
assessment can ange peoples lives? Was there anything wrien about this?
Had it ever been studied? And why was this being kept su a big secret?
So let’s seriously consider that question: If psyological assessment has
the potential to be a truly powerful and life-anging event for clients and
assessors both, why don’t more people know about that fact? And let’s start,
as is always good, by turning our focus towards home—on the profession of
psyology.
I submit to you that most of psyology bought into a paradigm long ago
where psyological assessment is seen as something like a glorified blood
test. We have these tools, called psyological tests, whi can be used to
“extract” information from a semicooperative “patient.” Once that is done,
we can put our data into a computer, whi will analyze it and spit out an
interpretation that then can be used to make decisions or direct treatment.
And oh, by the way, someone along the way might want to tell the patient
what we found, but that isn’t really necessary.
is is a harsh aracterization, especially of the many gied, artful
clinicians who practice a humanized, nonmeanical form of psyological
assessment. But I believe they are largely exceptions! How many assessors
do you know who never give assessment feedba to clients, or who mail
them a long, boiler-plate report full of tenical jargon and other
meaningless phrases? How mu effort are we puing into developing beer
and beer validity scales—important, to be sure—but instead of researing
what things one can do at the beginning of an assessment so that clients
want to reveal all they can to a psyologist? And how can we as a
profession sit by quietly and continue to let shoddy psyological
assessment practices take place that are dehumanizing and even damaging
to clients? As best I can tell—this is possible only if we ourselves don’t fully
appreciate the true power and potential of psyological assessment. And if
I’m right here, we need not wonder when so few students want to learn
about psyological assessment, or when critical articles get published about
us in The New York Times, or when managed-care gatekeepers balk at
paying for psyological assessment.
I believe we’re at a crucial time in the history of psyological assessment
and that it’s important that we take active steps to get out the secret of what
psyological assessment can be. Here are just a few ideas of how we might
do this.
First, we have to rid ourselves and our profession of the view of
psyological assessment as a semiskilled tenical enterprise conducted by
slightly sizoid people who would have been therapists if only they liked
humans as mu as numbers. To do this, we have to stop fooling ourselves—
and to realize that every time we give someone an MMPI—2, a Rorsa, or
a Be Depression Inventory, it is an interpersonal event that has the
potential to impact that person—for beer or worse. Sometimes we want to
ignore this, to simplify our jobs, and so we can administer more tests, get
more money, and make our bosses happy. But we give both others and
ourselves a false message about psyological assessment ea time we fail
to recognize the import of our work and treat it like drawing blood.
Second, every ance we get, we have to tell people what psyological
assessment really can be, and encourage our satisfied clients to spread the
word. Do you know that at our group practice in Austin, where we
specialize in erapeutic Assessment, almost half of our referrals now come
through word-of-mouth—from people who have heard through other clients
how helpful an assessment can be? And, at least in my case, lots of people—
middle-class people—pay a fair bit of money for those assessments.
Spreading the word is also why, at least once a year, I run a workshop where
I do an assessment live—while other psyologists and mental health
professionals wat and give me advice. Aer they have seen what an
assessment can do—they never forget. In fact, aer one of these assessments
I usually get four or five workshop participants calling me to ask if they can
do an assessment themselves! I’m delighted that the Journal of Personality
Assessment is now publishing more case studies of psyological
assessment. I hope we can read some examples of how assessment
transformed peoples’ lives, and perhaps some other exam-pies—where it did
not—so we can continue to learn how to improve our methods. For I really
don’t feel we’re anywhere near realizing the true potential of psyological
assessment.
To aieve this, I think it’s crucial that we shi our focus from researing
exclusively test construction and validity, to learning more about what
factors make psyological assessment useful and therapeutic for those
involved. In 1996 through 1997, I aired an APA task force, the
Psyological Assessment Work Group, whose arge was to review the
existing literature on the validity and utility of psyological assessment.
You may have read some of our reports about psyological test validity—
whi were very encouraging (Meyer, Finn, Eyde, Kay, Kubisyn, Moreland,
Eisman, & Dies, 1998; Meyer et al., 2001). Regarding test utility, we had
disappointing news. Almost no studies existed that had investigated the
utility or therapeutic value of psyological assessment. As others had done
before us, we issued an urgent call for su studies to be initiated
immediately. ere still is a great need for su resear.1
1 Almost a decade later, it is clear that very few researers heeded our call. ere still are very few
published studies of this type.
In closing, let me go ba to where I started. I love personality assessment.
I personally can’t think of work that is more interesting, moving, and
allenging. I believe that many of you feel the same way too. Now, please
join me in leing the world know about the power and potential of
psyological assessment.
Notes
is apter is adapted from my first presidential address to the Society for Personality Assessment
(Finn, 2002b).
3
erapeutic Assessment: Would Harry Approve?
In this apter I discuss one aspect of my professional development: Harry
Sta Sullivan’s influence on me and on the evolution and practice of
erapeutic Assessment. en I point out specific features of erapeutic
Assessment that are consonant with Sullivan’s thought. I conclude by
discussing how Sullivan’s vision of the therapeutic process can inform
psyological assessment in general.1
1 As far as I know, Sullivan never mentioned psyological testing directly in his lectures or
writings. However, he did make the points “Diagnosis and prognosis cannot be dissociated from
therapeutic considerations” (1940/1953, p. 180) and that even history taking is inevitably an
interpersonal enterprise.
My Contacts with Sullivan and Sullivan’s Writings
I may be rare in having been exposed to Sullivan’s work while I was an
undergraduate. My advisor at Haverford College was Douglas A. Davis, a
personality psyologist who was quite interested in Sullivan. I remember
Davis mentioning Sullivan to me in several discussions while I was a
freshman. Two years later, in his Abnormal Psyology course, I read
sections of Schizophrenia as a Human Process (Sullivan, 1962), while visiting
weekly (as part of the course) with a young sizophrenic man hospitalized
at the Haverford State Hospital. I recall being amazed at the time at the
applicability of Sullivan’s insights to my experience. Also, as a newly
convinced aker, I was moved by Sullivan’s obvious, profound respect for
individuals with sizophrenia, whi fit so well with aker ideas of the
“inner light” shared by all humanity.
When I entered graduate sool at the University of Minnesota, we were
assigned The Psychiatric Interview (Sullivan, 1954) during my first semester.
I was stru by Sullivan’s statement that a good interview leaves the client
anged and “with some measure of increased clarity about himself and his
living with other people” (1954, pp. 18–19)—a theme that would become
important to me later. I also hungrily read Perry’s (1982) biography of
Sullivan as soon as it was published; this strengthened my positive
identification with Sullivan as I learned that he was probably gay or bisexual
and—also like me—came from a poor family in upstate New York.
A crucial phase in my conversion to Sullivanian thought occurred during
my internship and fellowship years at Hennepin County Medical Center in
Minneapolis. My primary supervisors were Dr. Ada Hegion and Dr. Kenneth
Hampton, both of whom practiced psyotherapy and psyological
assessment according to interpersonal principles. rough my contacts with
these expert clinicians, I learned firsthand the power of authentic
relationship between therapist and client, and saw vivid examples of the
therapeutic value of psyological assessment with hospitalized
sizophrenic clients. Also, through Dr. Hampton and Dr. Hegion, I was
exposed to the writings of Frieda Fromm Reimann (1950), who was, as you
may know, one of the core members of the Washington Sool of Psyiatry.
A final step in my exposure to Sullivan came during my first years as an
assistant professor at the University of Texas at Austin (1984—1985). I
decided to have clinical psyology students read The Psychiatric Interview
in their first assessment course. To help me tea this book, I immersed
myself in other Sullivan works to develop a broader understanding,
primarily Conceptions of Modern Psychiatry (1940/1953), The Interpersonal
Theory of Psychiatry (1953), and The Fusion of Psychiatry and Social Science
(1964). is was the same period during whi I was developing my model
of erapeutic Assessment and beginning to resear its efficacy. erefore,
it is no accident that many of the concepts and terms used in erapeutic
Assessment are highly Sullivanian in nature, or that Sullivan features
prominently in the discussion of the first empirical study of erapeutic
Assessment (Finn & Tonsager, 1992), done while I was at the University of
Texas.
Parallels Between Sullivan and erapeutic
Assessment
ere are many direct parallels between Sullivan’s approa to treatment
and the principles and practice of erapeutic Assessment. I was conscious
of many of these correlations at the time I developed my approa to
assessment; others I discovered later, for example while reading Evans’s
(1996) excellent tribute to Sullivan. Let me explicitly highlight these
similarities.
e Importance of Clients’ Goals
In many of his writings, Sullivan stressed that the aim of all extended
clinical contacts with clients is to help them meet their specific
individualized goals. He felt this context was essential to enlisting clients’
trust, gathering necessary information, and justifying the whole enterprise
of psyotherapeutic treatment. If clients do not expect to benefit from their
interactions with the clinician, then—from Sullivan’s point of view—one can
only address “certain limited objectives” (1954, p. 17).
Because psyological testing has traditionally been conceptualized as
separate from treatment, psyologists have not tended to emphasize clients’
goals, and have instead focused on referral questions from outside sources. I
believe this is unfortunate and that it has led to many abuses. In erapeutic
Assessment, I have aempted to reaffirm Sullivan’s thinking and emphasize
that the primary goal of psyological testing is to help the individual being
tested (i.e., the client). In practice, helping the client is accomplished by the
assessor and client working to form individualized questions the client
wishes to explore during the assessment; these goals then shape all
subsequent assessment sessions. By contracting to address clients’ personal
goals, we enlist them as collaborators in the assessment, and give them a
reason, as Sullivan says, to try to be “foursquare and straightforward about
{their} most lamentable failures and …most agrining mistakes” (1954, p.
16). Contrast this approa with traditional assessment’s focus on
developing beer and beer validity indicators for psyological tests, to tell
us whether clients are telling us the “Truth” about themselves. (See ap. 6.)
Respect for Clients’ Privacy
In The Psychiatric Interview, Sullivan (1954) emphasizes the need to
distinguish between relevant and irrelevant data, and cautions the clinician
against asking about “maers into whi there is no tenical reason to
inquire” out of habit or simply to satisfy personal curiosity (e.g., see p. 34).
Sullivan says that clients appreciate su constraint and that this helps them
trust the clinician as an expert working on their behalf.
Unfortunately, su reticence is another factor not emphasized in
traditional psyological assessment. It is oen assumed that clients should
willingly participate in hours of testing or respond—without being given any
explanation—to numerous personal questions that have lile obvious
connection to their goals for the assessment. (e use of large fixed baeries
of tests, regardless of the referral question, is a prime example of
insensitivity to issues of privacy.) In erapeutic Assessment, we take
respect for clients’ privacy even beyond the point suggested by Sullivan, and
are wary of asking any questions that are not overtly related to clients’
questions for the assessment. I oen use the metaphor of the client and
assessor agreeing on the blueprints of an “observation de” to be built over
a certain area of the client’s life, in order to meet the client’s goals for the
assessment (Finn, 1996b). All tests and inquiries are connected to this
blueprint, especially if their link to the client’s goals is not likely to be
obvious. For example, recently I asked a client to complete the MMPI-2, and
warned him that it contained a lot of questions that appeared unrelated to
his assessment questions. I then explained that this test would give me a
good sense of his overall personality and emotional condition, whi would
help address his question, “Why do I have su a hard time meeting
people?” As the assessment proceeds, the assessor may suggest that the
observation de be extended, in order to follow up on results that were not
anticipated. However, like a good carpenter, the assessor asks the client’s
permission before altering the blueprints or extending the de!
e Assessor as a Participant—Observer
Handler (2000) did a beautiful job of elucidating Sullivan’s concept of the
clinician as participant—observer. Again I would like to contrast this to the
logical—positivist view behind mu traditional assessment, where a goal is
set of the assessors being a “completely objective” observer. is is why
standardized data collection procedures are highly emphasized in this
model, so that (in analogy to collecting a blood sample), we don’t get “germs
in the test tube” by introducing any of our stimulus value as a person.
My stance in this area has been influenced not only by Sullivan, but also
by Fiser (1985/1994) and other writers in phenomenological psyology
and intersubjectivity (e.g., Stolorow & Atwood, 1992). In erapeutic
Assessment, we do not believe in the possibility of complete objectivity in
the human sciences, nor do we believe it is advisable if it could be aieved.
As Handler so amply demonstrated, the judicious use of our own reactions
with clients can greatly further the assessment process. Also, take this
wonderfully gruff statement from Sullivan (1954): “…the psyiatrist has an
inescapable, inextricable involvement in all that goes on in an interview; and
to the extent that he is unconscious or unwiing of his participation in the
interview, to that extent he does not know what is happening” (p. 19). If we
apply this to psyological assessment, we begin to anowledge that we are
an inevitable part of the context of the client’s behavior in sessions. e
Rorsa I take from a client is invariably different from that collected by
another clinician, and I ignore su factors at my peril.
For this reason, following Fiser’s (1985/1994) lead, my colleagues and I
write all our assessment reports in the first person and aempt to
anowledge our part in the interpersonal field of the assessment. Here’s a
quote from a summary leer to a sool about an adolescent boy referred
because of sexually inappropriate behavior:
As we went through the Rorsa, Jeff gave more and more explicit sexual responses to the cards,
and I was aware of his glancing at me out of the comer of his eye, as if to gauge my reaction.
When I later asked about this, he admied that he wondered if I was “shoed” by his responses.
When I said, “No, only curious,” I thought he looked a bit disappointed. I inquired and Jeff denied
this at first, but then agreed that it was somewhat “fun” to sho people. He then went on to
explain how he normally felt that people rarely noticed him. Shoing people felt good because he
could see his impact on them and know that he “maered.”
Although su passages appear to deal only with the assessor—client
interaction, you can see how they also could be helpful to a referral source.
e Primacy of Careful Listening and Observation
One thread that weaves throughout Sullivan’s writings is his emphasis on
careful listening and observation as the primary method of psyiatric
inquiry. Sullivan himself was a masterful clinician who learned to pay
aention to subtle nuances in language, tone, and body language in part
through his groundbreaking work with sizophrenics.
In my view, traditional training in psyological assessment places too
mu aention on test “scores” and too lile on observing how those scores
come into being. As we all know, any particular test score can be aieved in
numerous ways, and important information is lost if one focuses on the end
product of a test to the exclusion of process. In erapeutic Assessment, we
see participant observation in the interpersonal process of the assessment as
the primary method of understanding clients’ problems in living.
Nomothetic test scores are certainly valued as a way of organizing
observations and generating hypotheses about clients’ problems in living.
However, they are not seen as indices of “Truth” about who the client “really
is,” but as a starting point for discussion with the client. Following Sullivan,
we esew the sear for “Truth” and instead seek what he calls “consensual
validation”; hypotheses derived from test scores are subjected to
“continuous, or recurrent, test and correction” (Sullivan, 1954, p. 121) by
both assessor and client.
Skepticism About Standard Psyiatric Terminology
As Evans (1996, 2000) wrote, Sullivan (1954) maintained a firm skepticism
about both standard psyiatric terminology (su as diagnoses) and less
formalized psyiatric jargon (su as the term, mother fixation), whi he
referred to as “psyiatric banalities” (p. 35). He criticized su language in
part because it was vague, easily misunderstood, and not communicative of
relevant information about clients. Also, however, he felt that diagnostic
labels tend to imply a static, immutable state to clients’ problems in living,
and to direct the clinician away from what is most interesting: those
contextual or situational variables that ameliorate or exacerbate those
difficulties.
In erapeutic Assessment, we follow in Sullivan’s steps, aempt to avoid
jargon in our discussions with or about clients, and aim to present in wrien
summaries vivid, first-person accounts of our experiences interacting with
clients. In this regard, I was influenced not only by Sullivan but also by
Fiser’s (1984/1994) excellent book on assessment, in whi she provides
detailed examples of how to replace pseudoscientific terminology with
evocative description. Also, like Sullivan and Fiser, I avoid diagnostic
labels not just to increase clarity of communication, but because this
practice reflects the focus of my aention. I certainly believe in genetically
or biologically influenced psyological traits and conditions. However, my
goal in an assessment is to identify the necessary and sufficient contextual
factors for clients’ problem behaviors to occur. If the client and I can discern
and label su elements, we can imagine what conditions are necessary to
avoid the difficulties troubling the client, and even test out this hypothesis in
the assessment sessions. Later, in a report, I record our hypotheses and the
results of our experiments, as both a reminder to the client and an aid to
other professionals involved in the treatment. Over time, su professionals
come to appreciate my focus on context, as they see that it oen leads
directly to practical interventions aer an assessment. For example, I was
quite pleased recently when a psyiatrist I have worked with for years
asked the following question about a man he was referring for an
assessment: “When does Mr. Smith act more sizophrenic and when does
he act less so?” Some years ago, this referring professional never would have
posed su contextually informed questions.
Far-Reaing Change Occurs rough Changes in the “Self”
One of Sullivan’s most famous concepts is what he calls the self-system—
those thoughts and conceptions that define our identity and protect our self-
esteem. Sullivan believed that all of us have an implicit goal of maintaining
our self-system (and thereby avoiding anxiety); this then leads to various
types of problems, as outmoded conceptions of the self fail to ange with
shiing life circumstances. For those of you familiar with Self Psyology,
you can hear that this theory of Sullivan foreshadowed that of Kohut (1977,
1984). Like Kohut, Sullivan (1953) also had explicit ideas about how the
clinician can facilitate ange in the client’s self-system. is occurs through
an experience of “closeness” and “good will” between therapist and client, in
whi the therapist “spreads a larger context before” the client, “whereupon,
in spite of anxiety…the self-system can be modified” (p. 302).
Sullivan’s theory has been integral to my thinking about why assessment
can produce lasting and far-reaing ange in clients (an idea that some
people initially felt was outlandish). You see, in my mind, although
psyological assessment is a short-term clinical interaction, it has the
potential to directly influence the self-system of the client. By enlisting
clients as participant observers in their own assessment and collaboratively
discussing our hypotheses and test findings, our goal is to help them modify
the existing stories they tell themselves about themselves (i.e., their self-
system) so as to more effectively operate in the world. If we are successful at
intervening on this level with a client, ange occurs across contexts and the
client’s whole outlook and approa to life is different. I also totally agree
with Sullivan’s ideas about how to foster su shis: e client must feel
supported enough and safe enough with the assessor and/or therapist to
tolerate the anxiety that accompanies su shis in identity. Or to offer a
Sullivanian paraphrase of a recent election slogan: “It’s [about] the
relationship, stupid!”
Sullivan’s “One-Genus” Hypothesis and ‘Psyological
Assessment
e one-genus hypothesis is Sullivan’s elegant postulate, that “everyone is
mu more simply human than otherwise” (1953, p. 32). I believe that this
simple and profound assumption has far-reaing implications for the
practice of psyological assessment.
If we adopt Sullivan’s point of view, that there is more commonality than
difference between our clients and us, it leads to a basic optimism about our
work as psyological assessors. We start with the faith the even the most
complex and apparently incomprehensible behaviors of our clients can be
understood by us because, in fact, we are not so different as to prevent
empathic understanding. Also, if we believe Sullivan’s statement, it cannot
help but bring humility and respect to our interactions with clients because
we are aware that “there but for the grace of God go I.” Some of the
psyological assessment practices I personally find most questionable, su
as the failure to provide informed consent or feedba to clients, become
almost unthinkable in this Sullivanian framework. For when we are aware
of our shared humanity with clients, we find ourselves wanting to treat
clients as we would like to be treated.
Sullivan’s one-genus hypothesis also leads directly to a allenge that, for
me, makes psyological assessment so rewarding and interesting. To fully
understand our clients’ problems, we must first overcome what Sullivan
calls our own “security operations” to find our personal version of their
inner struggles, conflicts, and dilemmas. Only then can we effectively help
clients or other professionals rea a new level of understanding about their
problems in living. For example, in working with Jeff, the sexually
provocative adolescent I wrote about earlier, I was required to find that part
of me that would rather sho people and bring punishment on myself
rather than live with the feeling that I was powerless and did not exist. Once
I had identified this set of feelings in myself (and remembered my own
version of acting them out), I was able to convey my understanding to Jeff
and to those adults in his life who were bewildered and angered by his
behavior. From this common framework, we were all able to think of other
ways Jeff could feel anowledged and powerful, and to see if those other
ways could successfully replace the solution he had previously aieved
through trying to sho others.
Of course, as clients’ behaviors become less usual, more shoing, and
more socially rejected, we as assessors must work harder to find the parts of
us that are more similar to those clients than different. is is what I call the
“personal and spiritual growth side effect” of interpersonal assessment and
therapy. rough our clients, we come to reclaim parts of ourselves we
might otherwise never have anowledged, increasing our depth,
compassion, and vitality as human beings. Or as Sullivan (1962) so aptly
said, “ere is always interaction between interviewer and interviewed,
between analyst and analysand, and from it, both must invariably learn if
sound knowledge of the [client’s personality] is to result” (pp. 297–298).
In closing, I assert that if one puts Sullivan’s “one-genus” hypothesis into
practice in assessment, one inevitably ends up with the teniques of
collaborative assessment. On this basis, I believe that Harry would be greatly
pleased with the development and increasing interest in erapeutic
Assessment.
Note
is apter is drawn from a paper I presented to the Society for Personality Assessment (Finn,
2000). I am grateful to Leonard Handler and David Niols for their comments on an earlier dra.
4
How erapeutic Assessment Became Humanistic
(written with Mary E. Tonsager)
is apter describes the links between erapeutic Assessment and
humanistic psyology, detailing how humanistic practices were gradually
incorporated into the methods of erapeutic Assessment and highlighting
those aspects that are clearly compatible with humanistic principles.
e Development of erapeutic Assessment
e seed of erapeutic Assessment was Steve’s noticing during his
graduate training that some clients appeared to have positive life-anging
experiences via psyological assessment (see ap. 2.) He became quite
curious about how this happened and whether it was possible to enhance
the beneficial effects of psyological assessment and increase the proportion
of clients experiencing su benefits. In the 1980s, as a faculty member at the
University of Texas, Steve began experimenting with different ways of
conducting assessments and noticing their results with clients. In the early
1990s, Mary conducted—for her master’s thesis—the first controlled study
demonstrating the beneficial aspects of psyological assessment for clients
(Finn & Tonsager, 1992). At this point in the development of erapeutic
Assessment, our focus was largely on how to make “feedba sessions”
about psyological test results therapeutic for clients.
Looking ba now, we see that our methods at that time were largely
humanistic in that we emphasized showing respect for clients, reducing the
power imbalance between client and assessor, and dialoguing with clients
about test results—instead of insisting that test findings were “true” in some
objective sense. However, neither of us was highly familiar with humanistic
psyology at that point in our professional development, even though to
some extent we had both read Maslow, Rogers, May, and other self-
identified humanistic psyologists. us, it has been interesting for ea of
us in writing this apter to muse about the origins of our early humanistic
leanings. Clearly, Steve was strongly influenced by being a aker and by
that group’s belief in the “inner light” in every person. Also, Steve felt a
great kinship with Harry Sta Sullivan and his view of the psyologist as a
consultant and participant observer in the clinical process (see ap. 3).
Furthermore, Steve’s clinical training at Hennepin County Medical Center in
Minneapolis emphasized showing respect for clients’ dignity and being open
to what they had to tea. Mary had been influenced by her study and
clinical supervision in Kohut’s Self Psyology and Stolorow’s theory of
Intersubjectivity (e.g., Atwood & Stolorow, 1984; Stolorow, Branda, &
Atwood, 1987). ese approaes helped us realize the importance of
“accurate mirroring” and empathic aunement, and highlighted the healing
power for clients of feeling understood.
In addition to our affinity for humanistic psyology, during the early
1990s we became aware of the writings of psyologists who practiced
psyological assessment within an explicitly human science of humanistic
framework, primarily Fiser (1970, 1972, 1978, 1979, 1982, 1985/1994;
Craddi, 1972, 1975; also Dana, 1982, 1984a, 1984b; Dana & Graham, 1976;
Dana & Lee, 1974) and others. Contact with these thinkers helped us
develop a philosophical underpinning for what we were doing already in
assessment. Also, we began to borrow and systematize humanistic practices
from these other clinicians—not just because they fit our values and our
developing theory of what potentially makes assessment therapeutic—but
also because these practices got results. Rather quily we learned that the
more we conducted assessments from a model where clients were integral
participants in a collaborative process whose goal was jointly observing,
understanding, and rethinking their problems, the more profoundly those
clients were affected. To tell the truth, we’re not sure that erapeutic
Assessment would be so thoroughly compatible with humanistic psyology
today if we had not be so impressed with the positive results of
incorporating humanistic principals in our work with clients.
Some specific examples might be helpful. As mentioned earlier, our initial
focus was on the process of giving feedba to clients. One initial difficulty
we encountered was how to discuss those test results with clients that
conflicted with their typical views of themselves. Early on, we found that if
clients were first given information that seemed to confirm their self-views,
they oen were then more open to information that seemed to conflict with
those views (Sroeder et al., 1993). Although this insight might be
considered empathic, it is not necessarily humanistic. We also learned not to
insist upon the validity of a test result, but rather to present it as theory that
could be modified, accepted, or rejected by a client. is practice is more in
line with a human science view of psyological assessment (cf. Fiser,
2001); however, for us it was more a useful strategy than an expression of an
underlying phenomenological point of view.
A next discovery in the development of erapeutic Assessment was that
clients were more accepting of test information that could be tied to their
personal goals or “puzzles” about themselves. us, we started the practice
of asking clients at the beginning of an assessment to form questions about
themselves that they wished to explore through psyological testing. At the
end of the assessment, these questions provided “open doors” through whi
to present information that clients might otherwise find overwhelming or
difficult to hear. If we could explain how what we were saying was relevant
to clients’ personal agendas, they seemed to incorporate allenging
information more easily and to make bigger life anges aer an assessment.
is even seemed to work with clients who were referred against their will
for an assessment, as is the case for many forensic evaluations.
In hindsight, this simple shi to a client-centered assessment model from
a more test-centered model had a profound impact on our view of
assessment. As we collected clients’ questions and joined them in
elucidating their goals, we found our focus shiing from test feedba to the
entire assessment process. We became more empathic to clients’ dilemmas
of ange and more auned to the contextual aspects of behavior. Test
results were still important, but we became more interested in how they
could help clarify daily problems in living. Finally some of Fiser’s
emphasis on “life-centered assessment” (e.g., Fiser, 2001) began to make
experiential sense.
A next step in the growth of erapeutic Assessment was our developing
“assessment intervention sessions” (see ap. 8). ese sessions are a
standardized version of what Fiser (1985/1994) called “assessment of
process.” e assessor elicits—oen using test materials—in vivo analogs of
clients’ problems in living and works collaboratively with clients to observe,
understand, and shi those problematic thoughts, behaviors, or emotions.
For example, a client who is in trouble for “working too slowly” at a job, and
who is excessively careful due to a fear of making mistakes, is invited to do
the Digit Symbol test of the WAIS—III. e assessor helps the client notice
his or her slow pace, name it (e.g., “being careful”), notice the similarity to
the job situation, and then experiment with various ways of working faster.
Once some success is aieved in the assessment situation (i.e., a quier
pace with the Digit Symbol task) the client is asked to test out similar
solutions in the work context itself and report ba at the next assessment
situation how this went.
Although we have not yet conducted a formal resear study on
assessment intervention sessions, our clinical experiences have shown us
that they oen lead to profound, positive shis on the part of clients. We
have even developed a set of interventions that are useful for clients with
different types of presenting issues, for example, those clients who believe
that they have ADD and are reluctant to consider other alternatives (see
ap. 10). And although, once again, our procedures were driven by a desire
to impact our clients therapeutically, the end result was a set of practices
that allowed us to explore “experiaction” (Fiser, 2001) and that fit
extremely well with a human-science model of psyological testing. ese
and other developments have now led to our articulating an explicit human
science basis for erapeutic Assessment (see ap. 17).
Next we describe some principles and practices of erapeutic
Assessment and how they relate to humanistic psyology and lead to
therapeutic benefit for clients.
Some Humanistic Elements of erapeutic
Assessment
Enlisting Clients in Setting Goals for the Assessment
Historically, the goals of psyological assessment have been directed
towards meeting the needs of mental health professionals—whether to
clarify a client’s diagnosis or mental health status, to aid in treatment
planning, or to evaluate the effectiveness of interventions that have already
taken place. Finn and Tonsager (1997) called this approa the “information-
gathering model” of psyological assessment. In contrast, a primary goal of
erapeutic Assessment is to meet the individual goals and/or needs of
clients. Typically, this involves identifying, exploring, and answering clients’
questions about themselves and/or their relationships with others.
As mentioned earlier, we now typically devote the initial session of an
assessment to helping clients formulate these questions and to gathering
baground information relevant to the questions. In some ways, this
process is akin to a first meeting with an aritect (the assessor) to discuss
plans for an observation de (the assessment) that will be built over some
area of the client’s property (life). e two parties decide how large an area
the de will cover and where it will be placed; that is, those aspects of the
client’s life that are to be examined and in what depth. For example, a recent
client asked, “Why do I avoid any situation involving confrontation?” and
“Why do I react so negatively to any criticism?” When Steve inquired how it
would be helpful to have answers to these questions, the client added the
question “How can I become more comfortable with other people’s
displeasure?”
In assessments of ildren and adolescents, we gather questions both from
parents and the ildren. For most ildren and young adults, this is a
unique opportunity to have their own goals, frustrations, and concerns
addressed and responded to in a meaningful way. Recently, we have been
asked the following questions by ildren we tested: “Who do I get so mad at
my mom?”; “How come it’s hard for me to fall asleep?”; “Am I good at
anything?” Furthermore, with adolescents, we negotiate that the ild’s
questions may be kept private from the parents, although the adolescent will
be informed of the parents’ questions about him or her.
is practice of working collaboratively with clients to define the goals
for an assessment obviously fits with C. R. Rogers’s (1951) client-centered
psyotherapy and Jourard’s (1968) “psyology of invitation” as a means to
help people understand themselves beer. As theorized by many humanistic
writers, we find that collaborative goal seing (a) gives clients a sense of
power,(b) heightens their own curiosity and engagement in the assessment
process, and (c) ultimately reduces their anxiety during and aer an
assessment. As su, this practice prepares the ground for clients to
undertake revisions in their views of themselves and sets the stage for
therapeutic ange.
Using Psyological Tests as “Empathy Magnifiers”
In erapeutic Assessment, psyological tests are not viewed as indicators
of some objective “Truth” about clients, even though standardized
procedures and nomothetic norms are used as starting points in a dialogue
between clients and assessors. Rather, tests are viewed as “empathy
magnifiers” that are useful in helping assessors get in clients’ shoes (Finn &
Tonsager, 1997). In this way, erapeutic Assessment is in accord with
humanistic psyology’s goals of “reconciling” the objective and the
subjective (Bugental & Sapienza, 1994).
For example, during a recent therapeutic assessment, a client’s
standardized scores on the Rorsa indicated a tendency to avoid or flee
highly emotional situations (Afr = .16, CF + C = 0). (is is the client
mentioned earlier who asked, “Why do I avoid any situation involving
confrontation?”) Immediately aer the Rorsa administration, Steve
invited the client to reflect on one of his responses to Card VIII: “ese two
creatures are scurrying away from a bad situation…It looks like an explosion
could happen at any minute and they’re running like hell to save their lives.”
e following dialogue ensued:
Steve: Do you identify with those creatures at all?
Client: (Smiling) I sure do! at’s what I’m doing all day long at work. I
guess I think I’ll get killed if I sti around. e explosion these two
are running from is a bad one.
Steve: And is that true for you?
Client: Not that bad, really. But I never really realized before that it
feels like I’ll die.
Steve: Yes, that seems like an important insight into why you avoid
confrontation.
Client: 111 say. No wonder I’ve had su a hard time with all this.
As Fiser (2001) noted, this is essentially a hermeneutic approa. e
assessor cycles (in a disciplined way) between the client’s goals, the
nomothetic test data, the assessor’s own associations, and the client’s
interpretation of his test response. Gradually, a deeper understanding of the
client’s dilemma emerges—for both client and assessor—yielding a moment
of greater self-awareness and self-compassion on the part of the client. is
fits our experience of the therapeutic benefit of a successful psyological
assessment: Both assessor and client come away with a deeper
understanding of the client’s dilemmas of ange, an understanding that
heals shame and points towards new ways of being for the client.
Sharing Our Reactions With Clients—Including What We
Learned
In erapeutic Assessment, we anowledge the contextual basis of all
knowing, and reject the positivist goal of being “objective observers.”
roughout an assessment, when relevant, we share our reactions and
personal context with clients, anowledging our biases so that they may
take them into account in forming their own opinions. For example, here is
an excerpt from Steve’s final session with the client who avoids
confrontation, when the two of them were discussing ways the client could
become more comfortable with “other people’s displeasure” (one of his
assessment questions).
Steve: So from what we’ve discussed so far, do you see any way to get
more comfortable confronting other people?
Client: I guess I just need to learn that I won’t die if other people are
mad at me.
Steve: at sounds right to me. Any ideas how to help yourself with
that?
Client: Perhaps I could start with some people who aren’t that
important to me. at would make it less scary.
Steve: Great idea! I remember starting with store clerks and people like
that when I was working on this same issue.
Client: Oh, did you have problems with this same thing?
Steve: Oh, yes. I used do to all kinds of things to keep people from
geing mad at me. You should have seen me!
Client: And now it’s beer?
Steve: Yes. I’m not so scared of confrontation anymore.
Client: at makes me feel beer—like there’s hope for me too.
Steve: I’m having a similar reaction—that both of us are geing beer
at this anger stuff, and it’s going to make our lives a whole lot
beer.
We believe su interanges are in keeping with humanistic principles of
authenticity, modeled so powerfully by Peris and others (cf. Barton, 1994). In
their feedba to us at the end of our assessments, many clients have
referred to su moments as turning points in their regaining hope for
themselves. Also, many clients feel enlivened when they feel they have
impacted the assessor. For this reason, we make it a practice to tell clients at
the end of an assessment specific ways that we have been toued or have
grown through working with them.
Believing in an Innate Healing Potential
When we lecture about erapeutic Assessment, one frequent question we
are asked is “Do you really believe that su a brief procedure has the
potential to ange someone’s life?” We do, and typically we explain how
psyological assessment potentially can have lasting impact because it
addresses the “story” individuals tell themselves about themselves and the
world. In preparing this apter, we came to see the humanistic thread in
our optimism, for we too view human beings as “resourceful, free,
imaginative, creative, integrative, symbolic, perspectively gied, {and}
temporally flexible person[s}…” (Barton, 1994, p. 228).
In contrast to traditional relational psyotherapies, whi aempt to
bring out su qualities in clients through an ongoing relationship with a
therapist who is more “self-actualized,” erapeutic Assessment operates in
a more incisive way. By engaging clients in an intense process of self-
exploration and using psyological tests to quily gain empathy for
clients’ problems in living, we aempt to decrease shame and assist clients
in seeing and testing out new ways of being. Clinical experience and
controlled resear now bear out the healing potential of this approa.
One client recently reflected this aspect of erapeutic Assessment in her
wrien feedba at the end of an assessment:
I realize now that I started this not really thinking it could help since 4—5 therapists had already
given up on me. But part way through, your constantly asking me to think about what I was
saying and doing hit me. If you thought I could ange, maybe I could if I just started paying
aention to my assumpshuns [sic}. Now I know there are different ways to see things and its [sic]
already starting to work.
In closing, we are pleased and bemused to report that by searing for
ways to conduct psyological assessments in ways that are helpful to
clients, we ended up with practices and principles that are clearly
humanistic. is provides fresh validation for the principles of humanistic
psyology and speaks to common truths that may be discovered by any
open-minded clinician through deeply listening to clients.
Note
is apter is excerpted from an article that was first published in The Humanistic Psychologist
(Finn & Tonsager, 2002). I am grateful to Mary Tonsager for her collaboration and friendship over the
years.
Part II
Specific Teniques of erapeutic Assessment
5
Testing One’s Own Clients Mid-erapy With the
Rorsa
During my training, I was taught, as most psyologists were, that seeing a
client in therapy whom one had previously assessed was an iffy enterprise,
at best. Su an arrangement was said to distort the transference in the
therapy, and I was encouraged to refer all clients I had assessed to someone
else for treatment. Even more flawed, my instructors and colleagues told me,
is the procedure of testing one’s own clients in the middle of ongoing
psyotherapy, for it (a) produces skewed test results that are impossible to
interpret and (b) can be destructive to the psyotherapy relationship. I
would like to set this second issue—the effects of testing on the therapy
relationship—aside for a moment, to focus on the first issue: the question of
test validity.
A well-known study by Exner, Armbruster, and Miman (1978) directly
examined how Rorsa protocols of clients are affected if the clients are
tested by their own psyotherapists. Two groups of clients were randomly
assigned to be administered the Rorsa either by their own therapists or
by therapists previously unknown to them. e laer arrangement
resembles most clinical assessment situations and also parallels the
procedures by whi the normative data for the Comprehensive System
(Exner, 1993) were collected. All clients had participated in 20 to 40 sessions
of psyotherapy when they were tested.
Exner and his colleagues found that clients tested by their own therapists
gave longer protocols with more Blends and more color and human
movement (M) responses than did clients tested by clinicians with whom
they had no previous relationship. Clients tested by their own therapists also
gave more sex responses (Sx), fewer popular responses (P), and responses of
lower form quality ese results suggest that clients tested midtherapy by
their own therapists do produce different, perhaps more revealing, protocols
and that an assessor could possibly overpathologize when interpreting one
of these protocols by comparing it to either formal or subjective normative
data alone.
ese data impressed me the first time I saw them and let me know that
the cautions of my supervisors were not without some empirical baing.
But they were not enough to convince me that it would never be wise to
give the Rorsa to a client of my own during psyotherapy. First I was
greatly influenced by Fiser’s (1985/1994) writings on individualized
assessment and by her arguments that standardized test procedures could be
departed from when nomothetic scores were not necessary for individual
classification. Second, I felt one might even be encouraged by Exner et al.’s
(1978) results. If my client’s protocol were “more revealing” if I administered
the Rorsa, might I learn even more about the client than if I referred to
another clinician? And although there might be alterations in the client’s
Rorsa due to our relationship, couldn’t I adjust my interpretation of the
Structural Summary based on the significant differences reported by Exner
and his colleagues? Finally, in my own thinking I was coming to believe that
assessment is a possible therapeutic intervention with clients, as well as an
information-gathering procedure (cf. Finn & Tonsager, 1997). If this were
true for the Rorsa, I did not want to miss the opportunity to use it with
my own clients.
On the basis of these thoughts, I was ready to go ahead and give several
of my own clients the Rorsa but I was given pause by the other,
previously mentioned admonition—that by doing so I could damage a well-
functioning therapy relationship. I carefully thought through the concerns of
my instructors and colleagues. As best as I could understand, the gist of
these was that the assessment situation oen pulls for transference
projections from clients. Most commonly clients will aribute to assessors
what Shafer (1954) called voyeuristic, autocratic, oracular, or saintly traits.
e introduction or exaggeration of su transference elements in an
ongoing therapy could derail the normal development of the therapy
relationship, I was told, and lead to therapeutic impasses or premature
terminations. is seemed possible to me, but I am a person who wishes to
learn from my own mistakes. us, I decided to go ahead and see what it
was like to give the Rorsa to some of my own clients midtherapy. I have
now done this approximately 75 times over the course of 20 years, and I’m
going to share with you four brief case histories that illustrate what I have
learned. All the clients I discuss had never taken the Rorsa before I
administered it and many were asked to complete the MMPI-2 at about the
same time. All had completed at least 25 sessions of individual,
psyodynamically oriented psyotherapy with me before the testing.
Case 1—Chad: Using the Rorsa to Introduce
Material into Psyotherapy
Chad was an aractive intelligent 26-year-old man who sought
psyotherapy because of difficulties with his studies at a prestigious
medical sool. He had previously done well at an elite liberal arts sool
where he had majored in philosophy and literature, but was failing several
courses in medical sool. At first, I believed that Chad’s academic
difficulties were mainly due to intense performance anxiety based on his
need to gain respect in a family that had always beliled him. As the
therapy continued, however, I became impressed with what appeared to be a
subtle thought disorder, whi grew more obvious when Chad was anxious.
I came to believe that disrupted thinking was interfering with Chad’s
cognitive performance and I sought for a way to introduce this hypothesis
into the psyotherapy. I decided to ask Chad to take the Rorsa with me.
Chad produced a long (R = 43) protocol with many Blends and few
popular responses (P = 4), just as Exner et al. (1978) found. In addition to
numerous shading responses (Sum Shading = 24), Chad’s protocol had
significant indicators of thought disorder (WSUM6 = 62) including two
contamination responses (CONTAM = 2) and three Level-2 fabulized
combinations (FABCOM2 = 3). As there was no evidence in the Exner et al.
(1978) study that increased familiarity with the assessor leads to higher
scores on indicators of ideational disturbance, I felt comfortable that my
informal observation of Chad’s thought disorder had been confirmed.
It took several weeks before I felt ready to discuss Chad’s test results with
him and during that period, he experienced intense anxiety about what I
had “found out about” him. It appeared that the oracular aspects of the
transference had indeed intensified, as my supervisors and colleagues
predicted. Although this period of the therapy was intense, it certainly was
not impossible to manage. I told Chad that I knew he had revealed a great
deal of himself in the Rorsa and that I was taking time to be clear about
the results. When I finally told him in the feedba session that it appeared
that his thinking style was quite different from others, and I wondered if it
interfered with his academic performance, he became quite tearful at first.
Aer a few moments of sobbing, he then expressed relief, saying this was a
aracteristic he recognized about himself and that he had been working
hard in therapy for months to hide his “different thinking” from me. In the
next several sessions, Chad told me that his father had the same type of
“different thinking” as he. We also began to explore under what
circumstances Chad came up with a thought that was unique or unusual.
Chad stayed in therapy for 28 months aer the testing, and we continued to
mark the Rorsa administration as a turning point in our relationship. He
showed an appropriate idealized transference to me, but this transference
did not continue longer than usual or interfere with termination.
Case 2—Barry: Taking Advantage of the Regressive
Pull of the Rorsa
Barry was a 41-year-old African American man who had seen me weekly in
psyotherapy for about 2 years when we decided to do the Rorsa
together. Barry’s presenting issue was his failure to ever have a successful
heterosexual relationship. He had had few interpersonal sexual experiences
at all and was quite frustrated that he was so successful in his career and so
unsuccessful in the social and/or sexual realm of his life. In the first several
sessions, Barry revealed that his mother was diagnosed with bipolar disorder
and had regularly been hospitalized throughout his life. Over the next 2
years we periodically explored her erratic temper and occasional severe
beatings of Barry and his siblings. We came to understand that these
beatings were in part connected with the anxiety Barry suffered when he
considered approaing women for a date. Still Barry seemed unable to take
behavioral steps towards confronting his anxiety. Finally during one session,
Barry almost casually reported an early memory of his mother standing over
his crib and fondling his penis until he got an erection. He had no other
memories of sexual contact with his mother. Several sessions later I asked
Barry if he would take the Rorsa with me.
Barry’s opening response was of two wolves in the D7 area of Card I. In
the inquiry he commented on the texture of the wolves’ fur and their eyes.
In sequence, his following responses were (2) “two hands reaing up to the
sky” (Dl). [Inquiry: “ey’re in miens—you can’t see the fingers—they’re
reaing for help.”} en, (3) “two breasts” (Dd22). {Inquiry: “ey’re here.
I’m looking down at them from above.”} (4) “e more I look at it I see a
whole body with a waist and a skirt. e first thought I have is maybe this is
my mother with a skirt here. She’s lunging at me. It gets more ominous as I
look at it. If that whole figure is a woman, this light spot (Dd27) is the
womb. It’s a lile high, but that’s what it is.”
e Card II content seemed even more significant: 5) “Two elephants sort
of joining together” (the Popular), 6) “blood stains (D2) because of the red,”
7) “a roet ship blasting off” (DS5+D3), and 8) “bloody finger prints” (D2
again). Here is the inquiry for the laer response: “ey’re here and here.
Somebody just put finger prints down there.” {Me: What makes they look
like finger prints?} “It’s all messy, like somebody put their fingers in blood
and put them down again. I have a recollection of the one and only time I
had my house broken in. ey cut themselves. I saw blood on the door and
was nauseated that not only did they violate my house, they le their blood
behind.”
Barry went on to give 14 responses with sexual content, most of whi
were percepts of vaginas or anuses involving a Vista determinant. Even
adjusting for the increase in Sx responses found by Exner et al. (1978), I felt
this was a highly significant finding, and it made me wonder if Barry had
been sexually traumatized. Of course, I was careful not to suggest this
possibility to Barry. Even more significant than the test feedba session was
a series of dreams Barry began to have even before test feedba was given.
e first of these occurred several nights aer the Rorsa administration.
In the dream Barry had an image of his mother punishing him by rubbing
his face in a soiled sanitary napkin. When Barry got the nerve to ask his
older brother about this image, the brother confirmed that this incident had
in fact happened. Over the subsequent months of therapy Barry began to
recover more images of sexual traumas, many of whi were confirmed by
his brother. To my best understanding, the regressive pull of the Rorsa
had opened a door for Barry that proved very important in his healing from
his sexual difficulties. I don’t know if the same series of events would have
occurred if I had referred Barry to a consulting psyologist for his
Rorsa, but I tend to believe that the trusting relationship we had built
prior to the Rorsa was important to what happened.
Case 3—Stephanie: Transference Crisis Following
the Rorsa
e next case also concerns sexual abuse and recovered experience. I share it
because it temporarily shook my confidence and taught me a great deal
about the power of administering the Rorsa to one of my own clients.
Stephanie was a 23-year-old woman who came to see me aer she
completed the allowed number of sessions at her university counseling
center. Stephanie’s history was significant in that she had been sexually and
physically abused by her father from ages 7—11, until one day she reported
the abuse to a teaer at sool, who notified authorities. Stephanie was
removed from the home while the case was investigated, her father spent
some time in jail, and the family was reunited aer Stephanie’s mother
pressured her to say that all was forgiven and that she wanted to go home
with her father. Stephanie came to therapy with her memories of the abuse
intact, but with a noticeable la of emotion about any of the events. She
was quite loyal to her family and even to her father, and she mentioned
quite frequently that she felt she was responsible for the abuse. One year
into the therapy, I asked Stephanie to participate in the Rorsa.
Stephanie gave an extremely ri protocol containing mu useful
information, but I mainly want to focus on the events aer the test
administration. Let me explain first that I administered Stephanie’s
Rorsa in the standard side-by-side seating format. Also, she gave su a
lengthy protocol (64 responses) that I had only a few minutes to talk with
her aer the test, because I had another client waiting to meet with me. e
morning aer the Rorsa administration, Stephanie called to say she
urgently needed to see me. When we met several hours later, she tearfully
reported being furious at me ever since the Rorsa. She said that I had
treated her badly, barely spoken to her or looked at her during the test
administration, and then le her alone aerwards. She said she felt angry,
dirty, used, and hurt. She had thought I was a kind man who was interested
in her well-being, but now she saw I was evil and uncaring and she never
wanted to see me again.
Although I was greatly taken aba at first, I listened quietly to Stephanie
until I understood what was occurring. I then told her that I had
inadvertently recreated a situation that felt like the many times her father
had sex with her. She now was experiencing many of the feelings that she
had previously been unable to remember. Stephanie recognized almost
immediately that what I said was true and became calmer. She was then
able to listen as I apologized for not telling her beforehand about the seating
arrangement used with the Rorsa administration and for not making
sure that we had time to talk aer the test administration. Stephanie and I
were able to work together over the next several months on the parallels
between her experience during the Rorsa and the abuse by her father.
One day she told me she said she saw the painful experience of the
Rorsa as serendipitous and as crucial for her in opening up to the
emotions surrounding her sexual abuse. I learned how important it is for the
therapy relationship to be strong enough to handle any transference
disruptions if I continued to administer the Rorsa to my own clients.
Case 4—Robert: An Example of Projective
Counseling
In a now overlooked paper, Harrower (1956) described a tenique in whi
projective test results are shared with clients aer an assessment, and clients
are invited to share associations with the therapist, mu as might be done
with a dream fragment. Harrower called this method “projective counseling”
and I used it with Robert, a 43-year-old psyotherapy client. Robert was a
gay man who sought psyotherapy to explore recent difficulties
establishing lasting intimate relationships. He had been in several long term
relationships in his twenties and thirties, but these had ended and he
currently reported lile lu geing beyond the first or second date with
potential boyfriends. Aer 14 months of psyotherapy, I was convinced
that Robert had a deep ambivalence about intimacy. He seemed consciously
aware only of the part of him that longed to be in a close relationship. He
rejected my suggestion that there might be ways he was inadvertently
pushing potential lovers away. We were able to broa this hypothesis in a
new way during the Rorsa feedba session.
For example, Robert and I reviewed all his pair (2) and human movement
(M) responses, as I suggested that these might tell us something about his
perceptions of relationships. We started with Robert’s opening response to
Card III: “two people in formal clothes facing ea other and bowing while
tipping their hats” (Dl). As we discussed this percept, Robert recognized his
own somewhat formal interpersonal style and his desire to “look good” for
others. He realized that sometimes this might make him seem distant to men
in whom he was interested. We then moved on to Card IV, to whi Robert
had reported, “Some sort of scary monster coming out at you. He’s about to
come out and stomp you…It’s a big figure. You are seeing it from a worm’s
eye view. It looks like it’s about to land on you” (W). I guided Robert slightly
by telling him there was old clinical lore that people’s responses to Card IV
reflected their feelings about men. With this help he associated to times
neighborhood bullies had taunted him as a ild and the fear he still
sometimes felt around groups of loud men. We wondered together if some
remaining fear of being taunted or humiliated made him anxious when he
approaed a potential boyfriend.
On Card IX, Robert had seen, in sequence: “…two lile pink babies lying
there with their feeding hands up” (D6) and then “…a guy riding on a motor
cycle with exhaust coming out of the ba” (Dd99). At this point in our
discussion Robert was on to himself, looked up at me and grinned, saying: “I
guess I’d sure like to leave the baby part of me behind in the dust.” is led
to a fruitful discussion of how uncomfortable Robert was with his longing
and need for closeness and how he worked hard to hide this part of him
from others. For weeks aerwards, Robert and I continued to review his
Rorsa responses and he raved about the insights he received about his
approa to relationships. Some time later, Robert started dating a man who
seemed quite suitable for an intimate relationship, and years later they are
still together.
Conclusions
In summary I have learned that it is possible and useful to give the
Rorsa to my own clients mid-therapy. e findings of Exner et al. (1978)
seem to be confirmed in that I get longer, more revealing, and more
disturbed looking protocols from my long-term clients than from clients
who are in the beginning stages of a relationship with me. For this reason, I
would not administer the Rorsa to a client of mine who needed testing
to appear in court or for the purposes of employment screening. However, as
part of the ongoing exploration of therapy, it can be useful to administer the
Rorsa to one’s own clients. As I have illustrated, the Rorsa can
confirm impressions that a clinician has already begun to form in a therapy
relationship and then provide a way to introduce su impressions into the
therapy. e regressive pull of the Rorsa testing situation can also
unearth unconscious material that then emerges either in clients’
associations or dreams. In some cases, a mid-therapy Rorsa
administration can temporarily intensify transference from the client and
perhaps even present a crisis in the therapy Although I have never again
experienced as big a disruption as I did with Stephanie, I have had clients
temporarily go through increased fear that I will judge them or try to hurt
them with test findings. However, I have found that su crises can be
managed and even harnessed to produce significant breakthroughs in
therapy. Last, the Rorsa may be used mid-therapy in the collaborative
enterprise of projective counseling, where the client not only learns new
insights but also discovers the power of the Rorsa. For these and other
reasons, I suggest that we continue to explore the uses of the Rorsa mid-
therapy and that we stop condemning the testing of one’s own long-term
clients. A more reasonable admonition is that assessors should also consider
the context of an assessment whenever interpreting test data. is principle
applies not only to testing one’s own clients, but to every other assessment
situation as well.
Notes
is apter is drawn from a paper I presented to the Society for Personality Assessment (Finn,
1994). I was amused at the time that my presentation was placed in a session called “Misuses of
Psyological Testing.” I am pleased that collaborative assessment practices are now more accepted.
I am grateful to Constance Fiser for her comments on an earlier dra of this paper.
6
Giving Feedba to Clients About “Defensive” Test
Protocols
I believe that, in many ways, how we think about and deal with clients who
have MMPI-2 L, S, or K scores over 65 or Rorsas with less than 14
responses reveals a great deal about how we view the assessment process in
general and our role as assessors specifically. In addition, this topic
highlights a number of conundrums we encounter in the practice of clinical
assessment as a result of the different internal and external pressures we
face.
In this apter, I highlight the complex context of clinical assessment by
proposing five different guidelines regarding guarded or “defensive” test
protocols. ese suggestions also apply to protocols that are possibly
exaggerated or malingered, but I focus most of my examples on guarded
protocols. Although I focus on how to talk about “defensive” protocols with
clients, I also discuss how I think about su assessment events; as you
know, how we interpret an event greatly influences how we respond to it. A
final caveat is that these guidelines are from my personal experiences
interacting with clients who produced “defensive” or invalid protocols. I
have no illusions that these guidelines apply to all assessments seings.
GUIDELINE # 1: DON’T believe that a guarded test protocol means you have no information
about the client with whi to address the goals of the assessment. DO realize that a guarded test
protocol is an important assessment event that can contribute to your understanding of clients’
problems in living, dilemmas of ange,1 and of how others react to them.
1 Dilemmas of change is a term used by family therapists (e.g., Papp, 1983) to describe those
situations in whi clients are “stu” in a certain paern, because they perceive all their options as
leading to painful, undesirable outcomes.
In making this point, I’m thinking of one of my first assessment
experiences, whi involved a client on an adult inpatient unit, recently
admied aer a serious suicide aempt. As I remember, the nursing staff
and team psyiatrist found the client close-mouthed and quite puzzling and
had asked for an MMPI to clarify the diagnosis. I was looking forward to
practicing my newly learned MMPI interpretive skills and also had
fantasized about making an incisive contribution to the case. erefore, I
was quite dismayed when the client produced an MMPI with elevations on
the validity scales L and K, and no elevations on any of the clinical scales.
Aer scoring the profile, I confirmed—through reading my MMPI books—
that it was “invalid” and “uninterpretable,” and I complained to my
supervisor, “Now I’ll never be able to address the referral questions!” He
smiled and patiently asked, “Is that so?” He then helped me get curious
about how the “defensiveness” on the client’s MMPI might relate to the staff
s confusion about the client—whi of course was the case. As the
assessment unfolded, I gradually learned that the client was in great distress,
but feared telling anyone about his concerns because he believed that the
CIA was involved in a plot against him. e MMPI accurately reflected the
dilemma he found himself in, of wanting help, but not knowing whom to
trust.
I now realize that my error—of viewing a “defensive” test protocol as
conveying no information about the client—is a common one and reflects
the logical—positivist, information-gathering model of assessment (Finn &
Tonsager, 1997) in whi I was trained. An invalid MMPI was the same as a
dirty test tube in a blood test; it precluded finding out what was “really”
wrong with the client. My disappointment also reflected the pressures I felt
to fulfill what Shafer (1954) called the “oracular” role of the assessor. Once I
realized that my job was not to “scoop” the other members of the treatment
team, I relaxed and set about forming a relationship with the client. As he
got comfortable on the unit, he gradually revealed his fears to me and to
others, and even eventually retook the MMPI, producing a valid profile.
GUIDELINE #2: DON’T think that you can interpret a single validity indicator as always meaning
the same thing. DO remember that—as with any test result—validity indicators must be
interpreted in light of other test scores, the client’s history, and the context of the assessment.
Here I’m thinking about a custody situation I was involved in some years
ago, where another psyologist had concluded—almost entirely on the basis
of an MMPI-2 K score of 70T—that a father was “unable to admit to faults,”
“highly defensive,” and “personality disordered.” Clearly this
conceptualization was faulty, for the psyologist seemed unaware that
elevated MMPI—2 K scores are almost typical in custody assessments (Ben-
Porath, Graham, Nagayama Hall, & Hirsman, 1995). e psyologist’s
error reminds us, however, that how clients understand the purpose of an
evaluation may greatly influence their test performance. is general point
is sometimes easy to forget.
Likewise, an MMPI-2 F score of 100T will mean different things for an
inpatient than for an outpatient, and there are many factors that can
contribute to a low R or a high Lambda on the Rorsa. Any good assessor
knows that there are no guaranteed, fixed rules about interpreting single test
scores. But we don’t always remember this when interacting with clients
whose test protocols deviate from traditional guidelines for test validity.
With the guideline I’ve given in mind, we can stay humble and curious in
discussing supposedly “defensive” test responses with clients. Su
assessment events may not indicate defensiveness in the usual sense at all.
Again, I suspect that our desperate sear for fixed rules to interpret test
scores reflects a way to deal with the anxiety of the clinical assessment
situation. e pressure on the psyologist in the information-gathering
model of assessment—to interpret test results unilaterally (i.e., without input
from clients or others) in a way that yields the “Truth” about the client—is
so great that we long for simple rules that help us appear “scientific” and
“hard-minded.” Unfortunately, when these rules are used rigidly, they oen
result in conclusions that are less valid and reliable than do other methods
that are more practical and based in common sense. For example, in
collaborative or erapeutic Assessment, we are likely to discuss with clients
any test score whose meaning is ambiguous, thereby enlisting them as “co-
investigators” in the assessment and keeping us from reaing erroneous
conclusions.
GUIDELINE #3: DON’T take clients’ “defensive” or “invalid” test responding “just personally,” that
is, as necessarily indicating their distrust of you or as a sign that they are unwilling to collaborate
with you during the evaluation. DO, in su situations, consider whether you adequately
developed a relationship with a client before beginning testing and/or whether you fully
appreciated the dilemmas facing the client in the evaluation.
In coming up with these suggestions, I’m grateful to another supervisor
who patiently helped me sort through my narcissistic injury as a beginning
assessor when a client—with whom I thought I was working well—gave me
a Rorsa record with R = 12 and Lambda = 2.4. I believed that if the client
trusted me, as I had thought, surely she would have given a longer, less
“defensive” protocol. I later discovered that the client’s constriction on the
Rorsa had more to do with her terror of interpersonal situations where
she didn’t “know the rules” than it had to do with anything about me.
However, at the time, I felt embarrassed and insecure about my abilities as a
clinician, and was angry at the client for “fooling me” into thinking we were
geing along well together. Despite whatever my reaction says about my
own personality struggles at the time, it also relates to the context in whi I
was operating.
I had been taught that a good assessor establishes enough “rapport” with a
client to ensure an unguarded test protocol. (In other respects, one’s
relationship with the client wasn’t really emphasized during my early
training; it simply had to be adequate to get good “data.”) When this
woman’s Rorsa appeared “defensive,” I believed there either had to be
something wrong with her or with me. Given these two options, I did what
many of us do—I blamed her! I submit to you that this kind of self-protective
externalization is oen at work when we label our clients as “defensive,”
“deceptive,” “uncooperative,” “resistant,” or “uninsightful.” I believe this
process also explains what the psyologist did in the custody evaluation I
mentioned earlier, when she labeled the father with high MMPI-2 K score as
“personality disordered.”
Besides taking the client’s test responses just personally, we also can make
the other mistake—of never examining whether we contributed to a
constricted or guarded test result. is is why I use the phrase “just
personally”—we should always consider our personal contribution to the
field of assessment. I remember a number of years ago when the ief
psyologist of a private psyiatric hospital asked me to consult about the
high number of invalid MMPIs being generated by the facility’s psyiatric
inpatients. e first thing I did was to wat how the MMPI was being
administered to patients. I discovered that the nursing staff or a
psyometrist would approa clients, give them an MMPI booklet, answer
sheet, and a pencil and say, “Your doctor wants you to do this.” en clients
would complete the MMPI in the middle of the day room, while other
clients were siing near them and milling about. e number of invalid and
defensive protocols dropped drastically as soon as clients were allowed to
complete the MMPI in their rooms, and when the nurses and psyometrists
were trained to spend time with clients discussing the reason for testing and
answering their questions.
is solution may seem obvious, but again, I don’t view the hospital
psyologists as having been stupid, poorly trained, or laing in common
sense. Rather, they had simply learned a way of thinking about assessment
that emphasized “geing the data” over establishing a relationship with
clients. When we all realize that psyological testing is more than a “blood
test” in medicine, we will automatically put most of our aention on helping
clients feel safe and trusted during an assessment, rather than on their
simply completing certain tests. As I discuss later, those of us practicing
erapeutic Assessment have developed a number of ways to enlist clients’
cooperation.
GUIDELINE #4: DON’T accuse clients who produce invalid test protocols during feedba
sessions of “not cooperating,” “holding ba,” “lying,” “exaggerating,” or “faking bad.” DO, instead
explore with clients any dilemmas or “Cat-22s” they faced regarding the assessment, and
whether these dilemmas were recognized and adequately discussed prior to testing.
Perhaps some of you, like me, have encountered clients who have been
criticized during previous evaluations for not cooperating adequately or for
aempting to influence the results of the assessment. I’ve been stru by
how deeply su criticisms are felt and how damaging they can be to clients’
aitudes about psyological assessment. For example, I remember a client
we once worked with at our Center who was reluctant to take the MMPI—2.
On further inquiry, we discovered that his memory of a previous MMPI
feedba session was of being told that he himself was “invalid.” I’ve always
wondered if this was his distortion or an accurate reading of the aitude of
the previous assessor!
But if we’re not going to target clients who produce guarded or invalid
test protocols, and also not target ourselves (although we may consider our
contribution to the interpersonal field of the assessment), what are we to do
instead? I believe that what is called for in many of these situations is
empathy about the client’s “dilemma-of-ange” (Papp, 1983) as reflected in
the assessment, that is, those apparently unresolvable conflicts or Cat-2 2s
that manifest sometimes in elevated scores on validity indicators.
Unfortunately, if we assessors are in what Agazarian (1997) called a “barrier
experience”—of taking clients’ test behaviors just personally or blaming
them for not responding as we wished—it’s very difficult to be empathic or
curious about an invalid or guarded test result.
As one example of how we can conduct an assessment differently, let me
return to the custody assessment I mentioned earlier. When I discussed with
the father his high K score on his MMPI—2, he told me about his approa
as he filled out the test. He felt it was important to cooperate fully with
whatever he was asked to do by the court-appointed assessor, as he
recognized that she could play a major part in whether he had future
contact with his daughter. On the other hand, he wanted to put his best foot
forward during the evaluation because his ex-wife was accusing him of
many things he felt were distorted, unfair, or just not true. When confronted
with the MMPI-2, with all its socially undesirable items, the man did what
seemed reasonable to him in the situation, that is, to emphasize his strengths
as a person and as a father and downplay those factors that would leave him
open to his wife’s accusations. As he explained to me, “When I apply for a
job, I tell them what I do best and in what areas I’m trying to improve. I
don’t give them a long list of every difficulty I’ve had with jobs in the past.
Here I was being interviewed for a job as a father, and I approaed it the
same way.”
When I told the client I thought his strategy was reasonable, but that it
le him open to accusations of having covered up deep-seated problems, he
asked if he could take the MMPI—2 again or whether there was another test
that was less vulnerable to these kinds of interpretations. We agreed to do
the Rorsa together—whi had not been administered in the previous
evaluation—and he produced a very unguarded protocol with some
indications of oppositional tendencies, but no other deviations from the
general norms. In my court testimony, I suggested that rather than
indicating a personality disorder, the father’s MMPI-2 K score might reflect
his good judgment and his desire for continuing involvement with his
daughter. Aer all, what we would think of a parent who deliberately
revealed all his faults during a custody evaluation? I also anowledged the
man’s tendency to “dig in his heels” when he felt unfairly blamed, and said
that although I didn’t see this as a major personality flaw, the client and I
agreed that it had certainly affected his ability to deal with his ex-wife. e
client was quite happy with my testimony, and the jury concluded that he
should have ongoing contact with his young daughter.
Client conflicts of interest are quite easy to understand in assessments
where clients are being tested in part against their will, for example, in
forensic situations, disability evaluations, assessments done as part of the
treatment of another family member, or in inpatient seings where clients’
personal desires to be admied or released from a hospital sometimes are in
conflict with those of staff or of their larger interpersonal system. However,
it is my experience that similar dilemmas of ange oen are involved when
clients who are being tested voluntarily produce invalid or guarded test
protocols. Once, I assessed a 15-year-old girl who had voluntarily asked for
psyotherapy for severe depression. Her symptoms had goen no beer
aer a year of treatment by an excellent psyologist and following several
trials of different antidepressant medications. e treating therapist was
quite puzzled and suggested an assessment, to whi the client readily
agreed.
During the assessment, the young woman generally was quite open and
forthcoming with me, except when I asked about her family situation, when
she appeared more anxious and reserved. Her therapist reported that the girl
had refused repeatedly to involve her parents in her therapy, and when I
contacted the parents during the evaluation, they seemed reluctant to come
in for an interview as part of the assessment. I grew even more intrigued
when the client produced an extremely guarded MMPI-A protocol, and a
Rorsa with R = 14 and Lambda = 1.2. Her last response on the Rorsa
was this: “Here’s a person who has been caught in an awful situation. He
doesn’t know what to do because if he moves one way or the other, someone
will get hurt. Finally, out of desperation, he jumps off this cliff. He may die,
but at least he’ll be free from trying to decide what to do.”
In a subsequent session, with her therapist present, I told the girl that I
wondered if this response reflected some way she felt trapped in her own
life. Aer first saying “No,” she eventually broke down crying, and told her
therapist and me that her father had been sexually abusing her for 4 to 5
years. Understandably, she was depressed miserably but also terrified of
telling anyone about the abuse because she feared her mother’s anger and
worried that her father would be put in jail. Her “defensive” test protocols
were a perfect expression of the Cat—22 she found herself in her life and
in the assessment.
GUIDELINE #5: DON’T think that the final solution to defensive testing responding is for
psyologists to develop beer validity scales or statistical corrections to compensate for response
styles or response sets. DO recognize that there’s no beer way to get reliable and valid test data
than to enlist our clients’ curiosity, motivation, and willingness to explore their problems in living
during an assessment.
I want to be careful here, in that I don’t mean to disparage the work of
my talented colleagues who continue to do excellent work on the
development and interpretation of test validity indicators. Su resear is
extremely valuable, especially to psyologists working in seings where
clients are assessed routinely assessed without their full consent. However, I
continue to believe that the best solution to the problem of test invalidity is
for assessors to mitigate the dilemmas of ange facing clients in typical
assessment situations.
In erapeutic Assessment we work to reduce clients’ reservations about
the assessment process in various ways. Before we begin an assessment, we
give them detailed information about psyological assessment in general
and about their evaluations in particular and then aempt to answer all
their questions. We solicit clients’ goals for the assessment—even if the
clients are referred to us by another mental health professional, the court, or
an insurance company—and promise to make those goals a primary focus of
our evaluation and to give clients feedba at the end of the assessment. We
also inquire whether clients have encountered psyological assessment in
the past, and if so, how they felt about those experiences. If the previous
experiences were negative, we aempt to negotiate with clients an
assessment contract with specific terms that preclude our repeating the
previous trauma. As the assessment takes place, we explain the purpose of
ea test in terms of its relevance to the clients’ goals, and we involve clients
in making sense of their test behaviors and experiences during the
evaluation. Finally, we e our assessment findings with clients during the
feedba session, ask them to comment on early dras of wrien reports,
and offer a follow-up meeting 2 to 3 months aer the assessment for them to
ask further questions and give us additional feedba.
It is our experience that the combination of these various steps—many of
whi are based in common sense or basic rules of respectful relationships—
greatly decreases the number of guarded or invalid test protocols we
encounter. When guarded or invalid test protocols show up, whi they do, I
now find it easier to be curious and nondefensive myself, and to trust that
this assessment finding—like all others—is a useful and important
communication from the client. If I am surprised by this communication or
am unable to imagine what it might mean, I ask clients to help me
understand it and to tell me what I still have not grasped about their lives or
their view of the assessment.
ere is a corollary to this last guideline that may seem provocative, but I
mention it because I believe it deserves serious discussion as we think
together about the future of psyological assessment. If a client’s full
cooperation and motivation cannot be gained during an assessment, because
of inevitable Cat—22s embedded in the assessment process, perhaps we
should think twice about whether it is appropriate to conduct the assessment
at all. Just as clients have the right to not incriminate themselves in court,
perhaps they also should have the right to not participate in any
psyological assessment whose findings could be used against them and to
know about this danger beforehand. is consideration would require us to
give serious scrutiny to some types of forensic assessment, to
preemployment evaluations, and to other evaluations where it seems
unlikely that one can obtain unambiguous informed consent, su as
assessments of adolescents who are referred against their will.
I have done all these types of evaluations myself, and I do not mean to say
that they cannot be conducted in ways that are respectful to clients. I am
heartened greatly by the serious aention given to client informed consent
by many forensic examiners. Also, at our Center we are experimenting with
ways to modify assessments containing inherent conflicts of interest for
clients, to see if they can be made less problematic and more therapeutic. For
example, we have developed a protocol for “therapeutic custody
evaluations” that so far has resulted in a large number of out-of-court
selements in extremely polarized postdivorce situations.
Nevertheless, I believe many psyologists are not trained adequately to
discuss the pros and cons of “involuntary” assessments fully with clients
before they begin testing. Or, the complex pressures we feel to fulfill our
roles and make a living lead us to gloss over the intricacies of geing
informed consent from clients. Again, I think these problems stem from our
emphasis on the traditional model of assessment, whi views psyological
testing as a neutral, objective way to gain information about a client, rather
than as a vulnerable and potentially profound relational experience that can
deeply affect—for beer or worse—clients’ lives. Perhaps as we begin to
appreciate the true power of psyological assessment—as I think is now
happening—we will find that invalid and guarded test protocols become less
frequent.
Notes
is apter is drawn from a paper I presented to the Society for Personality Assessment (Finn,
1999). I am grateful to Ronald Ganellen for encouraging me to write about this topic.
7
Assessment Feedba Integrating MMPI—2 and
Rorsa Findings
Recently, there has been increased interest in the process of giving feedba
to clients about personality assessment results, and a number of excellent
resources exist to guide clinicians in sharing results with clients about their
MMPI-2 profiles (e.g., Buter, 1990; Finn, 1996b; Lewak, Marks, & Nelson,
1990). Although many clinicians oen use a baery of tests rather than a
single assessment instrument, to date lile has been wrien about how to
talk with clients about findings from multiple personality tests. is void in
the literature is significant for several reasons. First, the current ethical
principles of the American Psyological Association (1992) make it clear
that clients should be given feedba—in language they can understand—
about tests that are administered to them. Presumably, if multiple
instruments are used, clients should be given feedba about all of them.
Second, recent resear suggests that clients therapeutically benefit from
hearing about their MMPI-2 results when su feedba is presented in an
empathic, collaborative way (Finn & Tonsager, 1992). If a method can be
developed to provide feedba to clients about both self-report and
performance-based personality tests, it is possible that even greater
therapeutic benefits could be aieved.
In this apter, I first propose a model for integrating results from the
MMPI—2 and Rorsa, depending on the paern of clients’ MMPI—2 and
Rorsa scores. I have developed this model over years of conjoint use of
the two tests with clients and have come to believe that the two instruments
complement ea other extremely well in applied clinical situations. Next, I
use this conceptual model to suggest ways of discussing findings from these
two tests with clients. e guidelines I present have proven to work well
with many clients and were developed with the goal of providing
therapeutic feedba to clients about their MMPI-2 and Rorsa results.
Last, I illustrate this feedba approa with a single case example.
Understanding MMPI-2 and Rorsa Results
Before we can discuss test findings with clients, we must first understand
them ourselves. Unfortunately for the practicing clinician, there is still
considerable disagreement among experts about how to integrate results
from the MMPI and Rorsa (e.g., Arer & Krishnamurthy, 1993a, 1993b;
Exner, 1996; Meyer, 1997). Based on my clinical work, I have come to believe
that both the MMPI—2 and Rorsa provide reliable, valid, and clinically
useful information. In many cases, the two tests largely confirm ea other,
and this is useful in giving me more confidence about the assessment results
and hence making me more sure-footed in my interactions with clients. I
believe that in other cases, the MMPI-2 and Rorsa should be expected to
disagree, and I use a model that has been in part articulated by others
(Ganellen, Wasyliw, Haywood, & Grossman, 1996;Lovi, 1993; Meyer, 1997;
Weiner, 1993) to resolve those apparent contradictions. is model bases
conjoint interpretation of the MMPI—2 and Rorsa on the different
aracteristics of the two tests.
e MMPI-2 is a highly structured test that is typically administered in a
noninteractive fashion. Its response format draws on intellectual
meanisms, su as reading and filling in dots on an answer sheet or
pushing buons on a computer keyboard—tasks that are now fairly familiar
to a large number of adults in the United States. e MMPI-2 has the
potential—because of the empirical correlates of its test scores—to reveal
traits and problems of whi clients are not fully aware. In general, however,
its scores reflect clients’ self-presentations and their conscious views of
themselves at the time of testing. Also, clients who use intellectual defenses
and who function well in structured, noninterpersonal situations can easily
produce benign MMPI—2 profiles, without significant elevations on its
validity scales.
In contrast, the Rorsa administration takes place in an interpersonal,
relatively unstructured situation. e nature of the task is largely unfamiliar
to most clients and thereby generally produces more anxiety for clients than
does the MMPI—2, in part because it is harder for them to know what they
are revealing about themselves. As is well known, the shadings and colors of
the Rorsa blots oen stir up emotional responses in clients. In general,
then, the test excels at revealing problems in cognition, perception, and
affect that arise in unstructured, interpersonal, emotionally arousing
situations. Some clients excel at avoiding su situations in their day-to-day
lives; hence Rorsa results can be especially important in predicting the
kinds of difficulties clients will encounter in unusually stressful situations,
su as during the middle of a long-term uncovering psyotherapy.
Patterns of MMPI—2 and Rorsa Responses
Exhibit 7–1 shows a sema for broadly classifying combinations of
Rorsa and MMPI—2 results into five paerns, according to (a) the level
of disturbance revealed on the MMPI—2, (b) the level of disturbance
revealed on the Rorsa, and (c) the level of engagement of the client in
the Rorsa. e two convergent cells (Cells A and D), where both the
MMPI—2 and the Rorsa show either high or low levels of disturbance,
are relatively easy to interpret. e two discrepant cells (Cells B and C),
where the MMPI-2 and Rorsa appear to disagree on the level of the
client’s disturbance, are more complex. Let us now consider the meaning of
ea of these test paerns.
EXHIBIT 7–1 Paerns of MMPI-2 and Rorsa Results
Note. MMPI-2 profiles in all cases are considered to be consistent (i.e., VRIN and TRIN
within normal limits), valid, and unguarded (i.e., with no significant elevations on L, K,
Fp, and S).
aRorsa protocols in these cells show adequate engagement on the part of the
client (i.e., R is average or above and Lambda is < 1.0); bese Rorsa protocols are
constricted (with low Rs and/or Lambdas greater than 1.0).
Cell A—High Disturbance on Both the MMPI—2 and Rorsa
In this cell fall clients whose psyological functioning is disrupted in both
structured and unstructured situations. e MMPI-2 and Rorsa agree
because there is no hidden “underlying” disturbance; that is, the clients’
problems in living are quite evident in their day-to-day functioning, they are
aware of these problems, and are willing and able to report them on the
MMPI—2. is paern of test results is common among inpatients and
outpatients who are voluntarily seeking help because of an emotional crisis.
In my experience, clients with this paern of test results have histories that
are consistent with their test results. Su clients are not surprised by
feedba about the assessment findings.
Cell B—Low Disturbance on the MMPI—2, High Disturbance
on the Rorsa
When the Rorsa and MMPI disagree, this is the most frequent type of
discrepancy. In clinical seings, clients with this paern have underlying
pathology that emerges in emotionally arousing, regressive, interpersonal,
unstructured situations (su as the Rorsa administration). However,
they function relatively well in familiar, structured situations when they can
use intellectual resources to deal with anxiety (su as when taking the
MMPI-2). Su clients are oen unaware of the full nature of their
difficulties and hence, are unable to report them on the MMPI—2. ey oen
present for mental health services puzzling over certain problems in living
that do not fit with their usual self-concepts. In my experience, this paern
of test results is most common in outpatient seings, especially those
seings where clients have been preselected for a certain level of adaptive
functioning (e.g., university counseling centers, employee assistance
programs.) In our outpatient clinic, su clients are oen referred by
therapists who are puzzled at their la of progress in treatment, or who are
concerned because the clients have begun to exhibit disturbing, atypical
behaviors or aracteristics in the middle of a long-term uncovering
psyotherapy. In my experience, a careful history oen reveals several
unusual events in these clients’ pasts that seem out of aracter, and that
occurred when the clients were under severe stress. Giving assessment
feedba to su clients is complex, for they may be surprised when an
assessor talks about their underlying pathology. Su clients have the
potential to become flooded, confused, or defensive when the full extent of
their problems is discussed.
Cell C—High Disturbance on the MMPI—2, Low Disturbance
on the Rorsa
is is the least frequent discrepancy between the MMPI—2 and Rorsa
in inpatient and outpatient seings; this paern is most frequently found
among clients applying for psyiatric disability or being tested for forensic
purposes. Two distinct interpretations are possible:
Case 1—Client Shows Adequate Engagement on the Rorschach. In this
instance, clients are adequately engaged in both the MMPI-2 and Rorsa,
and the disagreement between the two sets of test findings reflects the
greater control clients have over their self-presentations on the MMPI-2 as
compared to the Rorsa (Ganellen, Wasyliw, Haywood, & Grossman,
1996). e disturbance shown on the MMPI-2 represents a conscious aempt
on part of clients to endorse psyopathology, whereas the la of
disturbance on the Rorsa is inconsistent with this presentation and
raises the possibility of malingering, exaggeration, or a “cry for help.” In su
instances, clients typically produce a very high score on Scale F of the
MMPI-2, and the F(p) scale developed by Arbisi and Ben-Porath (1996) may
be useful in distinguishing conscious malingering from more
aracterologically based symptom exaggeration.1 Malingering should also
be considered when this test paern occurs in assessment situations where
clients are clearly motivated to present themselves as more psyologically
disturbed than they actually are (e.g., when applying for psyiatric
disability or claiming “insanity” in a legal proceeding). As might be
expected, assessment feedba with clients in this cell is oen anxiety
provoking for assessors, as it involves discussing the possibility of clients
overreporting symptoms.
1 Meyer (1997) referred to these two response styles as “Style 4-M” and “Style 5-M,” respectively.
Case 2—“Constricted” Rorschach. e paern of a highly disturbed MMPI
—2 and a relatively “normal” Rorsa also occurs in situations where
clients have no motivation to feign psyopathology (e.g., in outpatient and
inpatient seings where clients are voluntarily seeking treatment). In su
instances, this paern results from a defensive reaction of emotional
withdrawal or constriction on the part of clients in response to the
regressive pull of the Rorsa administration. ese clients are able to
reveal their problems in living on the MMPI-2 because it is impersonal, less
arousing, and less overwhelming. However, during the Rorsa, these
clients “shut down” because they are overstimulated and confused by the
interpersonal, emotionally arousing test situation. An assessor will typically
sense that su clients have made a sincere aempt to cooperate with the
Rorsa; nevertheless, their protocols typically show a high Lambda
and/or low R. Meyer (1997) labeled this response style as “Style 2-R,” and
reminded us of another term, “coarctated,” used by Rapaport, Gill, and
Safer (1968) to describe su Rorsas. Feedba with su clients can be
disastrous if an assessor mistakenly asserts that they have overreported
symptomatology on the MMPI—2.
Cell D—Low Disturbance on the MMPI—2, Low Disturbance on
the Rorsa
Clients in this cell function well in both structured and unstructured
situations. is paern of test results is rarely seen in clinical seings and is
more common when assessments are performed for employment screening
or resear.
Feedba to Clients
Exhibit 7–2 takes these understandings about MMPI—2 and Rorsa
paerns and applies them to the task of giving feedba to clients. As you
can see, when the Rorsa and MMPI-2 agree in their assessments, it is
relatively easy to discuss them with clients (Cells A & D). In su situations,
I generally tell the client that the two tests largely agree in their conclusions,
and that I will use the MMPI—2 profile to illustrate the assessment findings.
I structure my feedba around the MMPI—2 because its dimensional scales
are quite understandable to clients and the profile provides a beer visual
aid than does the Structural Summary. I then explicate the general absence
or presence of different traits or problems in living, making modifications
from the Rorsa results whenever appropriate.
EXHIBIT 7–2 Sample Feedba Stastement to Clients With Different Paerns of
MMPI-2 and Rorsa Results
In su situations, the Rorsa is still extremely valuable in the
feedba, by providing a metaphorical language in whi to word
assessment findings. For example, a client may have a score of 80T on Scale
4 of the MMPI-2, as well as a significant elevation on the Anger Content
Scale. e Rorsa Structural Summary shows an elevated number of S
and AG responses, and the content includes five percepts of volcanoes ready
to explode. When discussing Scale 4 with this client, I would label it an
“anger scale,” and tell the client that he appears to be so angry that he feels
like a “volcano ready to explode.” Although the MMPI—2 has provided the
visual aid, the Rorsa gives me the exact words to use with the client in
describing his subjective experience.
Similarly, a recent client with an MMPI—2 F score of 80T, the Anxiety
content scale at 9IT, and a D of-4 on the Structural Summary gave the
following as her last percept on Card X of the Rorsa:
“ese pink things are cliffs and you can see these lile creatures hanging on, trying not to fall off.
ere’s been a terrible earthquake, or a storm or something, and this one in the middle couldn’t
hang on and is dropping. But these ones are still holding on for dear life.”
Without the Rorsa content, I might have told this woman that the
testing revealed that she was under a great deal of emotional stress. Instead,
during the feedba session I told her that the recent events of her life had so
upset her that she seemed to feel as if she were “hanging on for dear life”
and might “fall off the edge of a cliff any moment.” My words resonated
with her deeply and she seemed to feel profoundly understood. (Incidentally,
like most clients, she appeared not to realize that the wording of my
feedba came from her own Rorsa response.) Alternatively, I could
have read this woman’s final response to her so that we could discuss it
together, in the style of Molly Harrower’s (1956) “projective counseling” or
Constance Fiser’s (1985/1994) “individualized assessment.”
Giving feedba is most difficult when the Rorsa and MMPI—2
diverge, that is, when one of the tests shows mu more disturbance or
distress than the other. When the Rorsa shows more distress and/or
disturbance than the MMPI-2 (Cell B), I typically invoke the concept of
levels of personality—telling clients that the MMPI-2 depicts the way they
typically think of themselves and are usually seen by others. I then explain
that the Rorsa taps a “different level” of personality functioning, that is
not as visible in day-to-day life, and that is revealed in unfamiliar, stressful,
emotionally arousing situations. Clients typically readily understand and
accept this explanation, and we then go on to discuss how their coping
meanisms help them manage the stresses of everyday living. Aer this
groundwork has been laid, I suggest to clients that more serious difficulties
tend to get put aside but may arise to plague them and confuse them from
time to time. With these clients, I think it is important that I interpret the
MMPI—2 as reflecting real strengths, and do not try to insist that the
Rorsa findings are more “real” or “important.” In this way clients feel
affirmed, rather than shamed, for the ways in whi they have managed
underlying problems.
When the MMPI-2 depicts more distress and/or disturbance than the
Rorsa (Cell C), I talk with clients about how they clearly want help or
anowledgment and have used the MMPI-2 to communicate this message
to me. Again, by seeing both sets of test results as “real,” I avoid accusing
clients of exaggerating or lying for primary or secondary gains. In Case 2,
where the la of disturbance on the Rorsa is the result of the client’s
constricting during the performance-based test situation, I talk with clients
about how difficult it may be at times for others to see how mu inner
turmoil they are experiencing.
In both divergent situations, I again compile the test findings first and
then look through the Rorsa for metaphors to use in wording feedba
statements for clients. Especially in the case of Cell B—where clients are
sometimes unaware of underlying levels of distress—using metaphors will
oen allow clients to resonate with what I am saying.
Case Example—Harry 2
2 e client’s name and other identifying information have been anged to protect confidentiality.
As an illustration of some of these principles, let us consider the case of a 56-
year-old man, Harry. Harry was an aractive, successful businessman who
had recently divorced and fairly quily begun a romantic relationship with
another woman. He was puzzled by feedba he got from this woman, close
friends, and his ex-wife that he was “emotionally unavailable.” In contrast,
he was quite proud of his fierce independence and emotional resilience. At
the suggestion of his new girlfriend, he sought a personality assessment to
get “an outside opinion” on himself. He posed two main questions to be
answered by the assessment:
(1) Others say I’m closed and don’t open up emotionally. I think I am very
self-sufficient and self-controlled. Am I just a pompous ass?
Am I really controlling and closed, or are others so insecure that it
makes them uncomfortable that I have my dus in a row?
(2) Why am I so ambivalent about geing close to people?
MMPI—2 and Rorsa Results
Exhibit 7–3 shows Harry’s basic MMPI-2 profile (Welsh Code 136/0897:425#
FKL/). As you can see, there were no significant elevations on the validity
scales, and only one mild elevation on the clinical scales—on Scale 1 (T = 59).
Consistent with my impressions of him in the interview, Harry presented
himself as free from any significant emotional problems. e physical
distress on Scale 1 appeared in line with Harry’s reports of joint and
muscular pains, whi he aributed to injuries suffered while he was a
Green Beret in Vietnam.
EXHIBIT 7–3 Harry’s K-Corrected MMPI-2 Profile
Notes. VRIN = Variable Response Inconsistency Scale; TRIN = True-Response
Inconsistency Scale; F = Infrequency; Fb = Infrequency Ba Page; Fp = Infrequency
Psyopathology; S = Superlative Self-Presentation; Hs = Scale 1, Hypoondriasis; D =
Scale 2, Depression; Hy = Scale 3, Hysteria; Pd = Scale 4, Psyopathic Deviate; Mf =
Scale 5, Masculinity—Femininity; Pa = Scale 6, Paranoia; Pt = Scale 7, Psyasthenia; Sc =
Scale 8, Sizophrenia; Ma = Scale 9, Hypomania; Si = Scale 0, Social Introversion.
Source. is figure is excerpted from the MMPI-2™ (Minnesota Multiphasic
Personality Inventory-2™) Manual for Administration, Scoring, and Interpretation,
Revised Edition, Copyright © 2001 by the Regents of the University of Minnesota Press.
All rights reserved. Used by permission of the University of Minnesota Press. “MMPI-2”
and “Minnesota Multiphasic Personality-2” are trademarks owned by the Regents of the
University of Minnesota.
Exhibit 7–4 shows the Structural Summary from Harry’s Rorsa.3 As
you can see, this revealed a great deal of distress and disturbance that was
not visible on the MMPI—2, including ideational difficulties, depression,
strong needs for affection, and a great deal of underlying anger. us,
Harry’s test results are a good example of the paern found in Cell B of
Exhibit 7–1. e Rorsa also illustrated Harry’s overreliance on
intellectualization as a coping meanism [2AB + (Art + Ay) = 22}, whi, as
mentioned earlier, is typical of someone with his paern of discrepancy
between the MMPI-2 and Rorsa. Note also that Harry had an elevated
score (.30) on Armstrong and Lowenstein’s (1990) Trauma Content Index.
3 I am presenting the fourth edition of the Structural Summary (Exner, 1995), as this is what was
available at the time I was working with Harry.
EXHIBIT 7–4 e Structural Summary for Harry’s Rorsa
One of Harry’s responses to Card V is illustrative of the complex and
highly informative content of his Rorsa protocol. Referring to the whole
blot, he said:
“is looks like a bat. Here is the tail, head, wings… I guess it’s possible that there is a significant
growth on the wings that’s not normal. It’s carrying fungus, dust, or something instead of being
fluffy. I don’t see it as a burden, but it could be. A bat struggling along in spite of gradually
accumulating stuff. It needs to be cleaned away or it will follow a natural process and slow down.
I sense a hesitance in me to accept this idea that this bat might be in trouble, or be overburdened,
or have developed a cancer that will overcome it. But I have this realization that it may not be as
good as it looks like. It’s more sad.”
Assessment Summary/Discussion Session
When I discussed the assessment results with Harry, I first showed him the
MMPI—2 and praised him for his emotional resilience and general good
coping. I enumerated his many strengths and said that I thought that in
many ways, he did have his “dus in a row.” He seemed relieved and proud
as I confirmed the ways that he thought about himself. I then told Harry
that I thought more was going on in him than met the eye and I talked about
the underlying difficulties revealed on the Rorsa—the depression,
powerlessness, neediness, and thinking problems. As I continued, Harry
began to weep silently, and slowly a story emerged of the multiple severe
traumas he had suffered in Vietnam, including one mission where all the
men in his company had been killed, except for him. Harry had never
discussed these experiences with anyone, and had coped by pushing them
out of his mind. It also came out that Harry had been physically abused
severely as a ild by his father. Again, he had never discussed this abuse
with anyone, but had coped as a ild by excelling both academically and in
sports at sool. Harry seemed to feel toued and grateful at the end of the
feedba session.
Feedba Letter
e following are excerpts from the leer I sent Harry aer our feedba
session, summarizing the assessment results and answering his questions.
ese comments are very like those I used with Harry during the
summary/discussion session:
Dear Harry,
is letter is to summarize the results of your psyological assessment, whi we
reviewed in our feedba session last week….
One of the major findings of the assessment was that you have extremely strong and
varied coping meanisms that allow you to function under circumstances that would
emotionally disable a majority of people. One of these coping meanisms is your ability to
push painful feelings to the side and keep on going…. ree other very useful coping
meanisms that you have are:
(1) Self-reliance: a strong ability to take care of yourself if need be. e testing indicates
that you do enjoy being around people, but you have learned to meet your own needs
and survive on your own. is ability allows you to exit from bad situations and
relationships if you need to, instead of being stu there because of fears of being
alone.
(2) Rationality, a strong ability to analyze and rationally approa problems, putting
feelings aside so that you can think clearly and not get overwhelmed by emotions.
(3) Forgetting: an ability to forget painful events from the past so they don’t continue to
bother you.
e Rorsa test allows us to look “below” your coping meanisms to see what is going
on at a deeper level of your personality. e results from this test suggest that more is
happening in you emotionally than at first meets the eye. ere may even be a level of
emotional experience in you that you are not fully aware of and that is burdening you. Some
of these feelings, whi are nearly invisible to others, include depression, powerlessness,
intense longings for affection and nurturance, and anger….
Your strong coping meanisms have allowed you to function well in catastrophic
situations in the past and to escape the worst consequences of those traumas in the present.
However, using those meanisms to the extent that you do probably slows you down and is
psyologically costly….
e biggest cost of your unresolved distress may be the effects it has on your intimate
relationships. Your test scores predict that you will have strong ambivalence about getting
close to others. You are likely to worry about getting hurt and getting in over your head.
is fear is not unreasonable, since…getting too close could open up a Pandora’s box of
feelings inside you and leave you overwhelmed, distressed, and feeling crazy.
Harry, we now have enough information to understand your “dilemma of ange”—the
costs and benefits you have to weigh in deciding whether to keep your life as it is now, or
try to ange it.
Your dilemma begins with the strong hunger inside you to be close to others and your
obvious desire to continue to open up and grow emotionally. Opposing this is the reality
that your level of closeness with others is currently limited by the need to protect your
inner distress. On the one hand, the major traumas in your life are now past and it is mu
safer to explore your feelings about these situations. However, to do so would be painful
and you may decide that it’s better to leave things the way they are, especially since you are
functioning quite well and learning to open up some on your own. Trying to go faster in
your opening-up process would require quite an investment in yourself to get through it
safely. You would need to work with a psyotherapist who is highly skilled in working on
trauma and who can support you as you explore “beneath” your strong coping meanisms
and work through some of the pain that has been accumulating gradually….
Let me now answer the questions you posed for the assessment:
(1) Others say I’m closed and don’t open up emotionally. I think I am very self-
sufficient and self-controlled. Am I just a pompous ass? Am I really controlling and
closed, or are others so insecure that it makes them uncomfortable that I have my dus
in a row?
Some of both appears to be true. You do appear on the outside to be self-sufficient and
self-controlled and to have no needs for other people. We know the latter is not true from
the Rorsa testing, but your appearance may make others feel insecure and
uncomfortable about their own needs. Another thing that may be happening (whi is
common to most people) is that your coping meanisms may become a bit harsher and
more exaggerated when you feel threatened by internal emotions or by others’ demands or
criticism. When this happens, you may have a tendency to look like you’re full of yourself
and insensitive to others. Clearly, from our assessment, the opposite is true.
(2) Why am I so ambivalent about getting close to people?”
As described, the testing indicates that you do want to be close to others and that you
have a strong desire for affection and companionship. But intimacy is going to be a mixed
bag for you right now. As you get closer to others, you will probably fear getting in over
your head. As of yet, you still aren’t able to set secure limits when you sense that other
people want things from you. Also, getting closer to others could bring up a lot of painful
feelings in you. For the time being, you’ll probably feel both pulled towards others and like
you want to run away.
e reader will note how I incorporated the language of Harry’s
Rorsa responses into many of my comments.
Harry’s Response
Shortly aer I sent my leer, I received a note from Harry, from whi I
quote:
ank you for your perceptiveness and gentleness during our last session. I realize now that
I have been carrying a lot of junk around with me that is slowing me down and that I better
do something about it before it’s too late….I have made an appointment with a psyologist
near where I live. He has some experience with Vietnam himself and seemed to understand
what you and I discovered in the testing.
Conclusion
e MMPI-2 and Rorsa are sometimes difficult to integrate in an
assessment, and there is still controversy about their conjoint interpretation.
However, I believe that the two tests tap important and potentially different
aspects of clients’ life experiences and that apparent contradictions can oen
be resolved by a conceptual understanding of the inner workings of the two
instruments. Further resear needs to be done to investigate the interpretive
model proposed in this article. In the meantime, my colleagues and I at the
Center for erapeutic Assessment have found this model to enri our
understandings of clients. By using the Rorsa and MMPI-2 in
conjunction, we find that we have beer empathy for our clients’ subjective
experience and can reflect their inner worlds ba to them more accurately.
Our clients feel more understood and “held” in the assessor-client
relationship, whi oen allows them to explore new alternatives to their
familiar problems in living. In the current discussions of whether the MMPI-
2 and Rorsa are worth using together—based on incremental validity
and diagnostic efficiency—psyologists should also consider whether the
two tests have incremental therapeutic utility.
Note
is paper was originally published in the Journal of Personality Assessment (Finn, 1996a).
8
Assessment Intervention Sessions: Using “Soer”
Tests to Explore “Harder” Test Findings With
Clients
Sometimes, as in the case of Harry in apter 7, it is possible to go directly
from standardized testing to an effective collaborative summary/discussion
session with a client. Resear has shown that summary/discussion sessions
—when they are conducted according to the principles of collaborative and
therapeutic assessment—can produce significant decreases in clients’ self-
reported distress and symptomatology, increases in self-esteem and hope
about the future, and improved treatment compliance (Aerman,
Hilsenroth, Baity, & Blagys, 2000; Finn & Tonsager, 1992; Newman &
Greenway, 1997).
In other instances, however, an assessor realizes that in spite of his or her
best efforts to “bring a client along” through the early stages of an
assessment, particular allenges are presented by a summary/discussion
session. It may be that there were few opportunities for collaborative
discussion during the standardized testing, perhaps because of time
constraints or the nature of the tests used (su as paper-and-pencil
inventories). Or, the client may not have been very open to new ways of
viewing himself or herself and the world. Whatever the reason, sometimes
an assessor approaes a summary/discussion session with the sense that
“the bulk of what I want to talk about with the client is probably Level 3
information!”—that is, “Most of my hunes and tentative answers to the
client’s questions are very different from how the client already conceives of
things, and are likely to produce a lot of anxiety and/or be rejected by the
client.” As explained in apter 1, my colleagues and I developed a set of
procedures that we call “assessment intervention sessions” to address su
situations and to help clients get the most out of an assessment.
Goals of Assessment Intervention Sessions
To borrow a phrase from psyodynamic psyotherapy, in part, assessment
intervention sessions help avoid the dangers of “premature interpretations”
by giving clients the opportunity to discover assessment findings on their
own that assessors have formulated from standardized tests. In this way,
su sessions help clients become aware of and explore findings that might
otherwise be rejected in a summary/discussion session, and they help clients
“rewrite” their own stories about themselves and the world—rather than
having revisions suggested entirely by the assessor at the end of the
assessment. Also, assessment interventions help the client and assessor
explore and test out hypotheses the assessor has derived from the
standardized testing. Concepts and hunes that might come across as dry
when tied to formal test scores can become vivid and alive when enacted in
an assessment intervention session. Su enactments help clients understand
and hold onto new understandings aieved through the assessment process
and provide memorable, shared moments that assessors and clients can refer
to throughout the rest of the assessment. Finally, because assessment
intervention sessions aempt to bring clients’ problems in living into the
assessment seing and then solve them in that context, they help assessors
and clients develop empathy for clients’ dilemmas of ange, and also
provide opportunities to more adaptively address su problems in the
outside world.
Basic Steps in Conducting Assessment
Interventions
As discussed in apter 1, assessment intervention sessions take place aer
the assessor and client have completed the standardized testing that is
relevant to the client’s questions for the assessment, and before the
summary/discussion session. Exhibit 8–1 summarizes the basic steps in
planning and conducting assessment intervention sessions with clients. I
discuss ea step in detail and then illustrate it using the example of Jim, a
24-year-old man I assessed several years ago. As mentioned in apter 1,
these steps are derived from Fiser’s (1985/1994) procedures for “assessment
of process.”
EXHIBIT 8–1 Basic Steps in Conducting Assessment Intervention Sessions
Step 1 —Plan Beforehand
Select a Focus. is is the most important step. You will want to oose
one major focus for ea assessment intervention. (You can do several
interventions if you wish, ea targeting a different problem behavior.) And
it is best to select a focus that is related to one of the client’s assessment
questions. First, ask yourself, “What are the most important things I think I
know from the standardized testing about this client’s problems in living?”
en ask, “Would I like to explore any of these hypotheses further with the
client?” and “Whi of these points is going to be most difficult for the client
to accept or understand?” Finally, “Whi of the client’s questions can I
relate to this issue?”
Case Example. Jim was a shy, gentle man with a long history of
aievement difficulties. His major question for the assessment was “Why
can’t I succeed at anything?” and he explained that he had barely graduated
from high sool due to poor grades and spoy aendance. Since high
sool, he had lived at home with his parents and had been unable to hold a
steady job or finish a single course at the local community college. He had
registered for and dropped different courses numerous times.
Intellectual and aievement testing confirmed that Jim had a severe
verbal learning disability, whi had been diagnosed when he was 7 years
old. His Performance IQ on the Wesler Adult Intelligence Scale-Ill (WAIS-
III; Wesler, 1997) was 124, but his Verbal IQ was only 92. His composite
scores on the Wesler Individual Aievement Test-II (WIAT-II;
Psyological Corporation, 2002) were as follows: Reading = 88,
Mathematics = 89, Wrien Language = 87, and Oral Language = 99- What
stru me most in administering these tests was Jim’s constant stream of
self-denigration, for example, “I won’t be any good at this one,” “I can’t
write well,” “Stupid, stupid, stupid!” (when he made a calculation error
during the WAIS-III Arithmetic subtest). is self-targeting took place even
when Jim was doing well on a subtest. For example, aer earning a scaled
score of 14 on Blo Design, Jim said, “at was prey hopeless, wasn’t it?”
When I countered that in fact he had done quite well, he seemed to brush off
my comment. Not surprisingly, Jim also had a tendency to give up easily
and would have earned mu lower scores on many of the WAIS—III
subtests if I had not encouraged him to “keep trying.”
Jim’s basic MMPI-2 profile had a 2-7-8-0 code type (with all elevations
close to 90T), and I was stru once more by the evidence of his extremely
low self-esteem. For example, his score on the Low Self-Esteem (LSE)
Content scale was 97T—the highest possible—and suggested that he saw
himself as inept, defective, and unable to succeed. I knew that Jim would not
be surprised by interpretations of his depression and anxiety, or of his
learning disability, all of whi were certainly contributing to his inability to
aieve. I also had important things to say to him about his enmeshed
relationship with his parents, and how I thought that prevented him from
“launing.” Again, I thought this fact would be no surprise to Jim. What I
believed would be more difficult for Jim to see and accept was how he
unconsciously sabotaged any ances of succeeding in his areas of strength,
by giving up or not even leing himself try things because he was so very
certain that he would fail. I knew I would have to present Jim with a vivid
example of this phenomenon for him to grasp it, and I had the “open door”
of his assessment question (“Why can’t I succeed…?”) to help set the stage.
us, I ose Jim’s pervasive tendency to give up before he started as the
focus of my assessment intervention.
How Can You Elicit the Problem Behavior In Vivo? Once you have a
focus, the next task is to use your empathy, and a deep understanding of the
standardized test results, to “get in the client’s shoes” and strategize how to
evoke—right there in the assessment room—the problem behavior you are
interested in exploring. At this stage, you might ask yourself, “What are the
necessary and sufficient contextual cues to produce the problem behavior I
want to focus on?” and “What test materials or other activities can I use that
will provide these cues?” Your options are to use (a) standardized tests you
haven’t yet used (perhaps in unstandardized ways); (b) role plays, art
projects, psyodrama, or other less-structured activities; or (c)
nonstandardized, or even out-of-date assessment materials that you will not
score or aempt to interpret by comparison to nomothetic norms. Many of
my assessment interventions use this third strategy, and for this reason I
titled this apter “Using ‘Soer’ Tests to Explore ‘Harder’ Test Findings
With Clients.”
Case Example. I knew from the WAIS-III that Jim would likely judge
himself inept at any cognitive or performance task I asked him to do. I also
knew from his high Performance IQ that he was skilled at tasks involving
visual memory and visuospatial integration. My plan was to present Jim
with some su task and elicit the self-denigration and desire to quit that he
showed during the WAIS—III, then confront him with irrefutable evidence
of his success to help him realize how distorted his self-perceptions were. I
considered various tests and opted to use the Bender Visual Motor Gestalt
Test (BVMGT; Bender, 1938), because it is so face valid and easy to
administer. I was also thinking of the many creative ways Fiser
(1985/1994) uses the Bender- Gestalt in her interactions with clients. To
highlight Jim’s negative self-views, I decided I would not only use the copy
procedure, but also the immediate recall for the BVMGT.
Step 2—Introduce the Session to the Client
As in the standardized testing sessions, you should begin an assessment
intervention session by eing in with clients (e.g., “How are you today?”)
and asking about their reactions to the previous session. en, introduce the
current session by telling clients whi of their assessment questions you
hope to address that day. is helps lower clients’ anxiety and reminds them
that your main goal is to meet their personal agenda for the assessment. By
mentioning one or more specific questions, you also “prime” the client to be
thinking along certain lines as you conduct the intervention.
Case Example. Jim had completed the MMPI-2 in the previous session
and said he had not thought about it since we last met. He looked even more
down than usual on the day of the assessment intervention, and said his
father had been “hassling” him that morning about not having found a job. I
listened and reflected that su interactions seemed to make him feel more
hopeless. He agreed and said he didn’t know why he couldn’t get himself to
apply for jobs. I said maybe what we did that day would help shed some
light, and told him that I hoped to explore his question, “Why can’t I
succeed at anything?” He said that would be helpful and that he was ready.
Step 3—Elicit, Observe, and Name the Problem Behavior
Elicit the Problem Behavior Several Times. Next, conduct your
planned experiment and see if your osen strategy elicits the problem
behavior you want to explore with the client. If it does, try to get a large
enough sample of the problem behavior so that the client will have a ance
to observe it and connect it to contextual variables.
Case Example. When I gave Jim the standard instructions for the
Bender-Gestalt copy, he immediately said, “I’m no good at drawing.” I
encouraged him to do what he could, and as I expected, he then proceeded
to copy all nine of the figures almost perfectly, sighing throughout, and
erasing several times to get them “just so.” He looked prey miserable and
ashamed the whole time. When he finished, I asked how he was doing and
he said he was “angry at himself” that he had so mu difficulty with
something that “simple.” I then took away his sheet of copied designs, gave
him a blank piece of paper, and told him that I wanted him to draw as many
of the Bender designs as he could from memory. He looked quite panied
and said he was sure he wouldn’t be able to remember any. I told him to do
the best he could, and aer a few minutes, he drew excellent versions of the
last four designs presented, then pushed the paper towards me and said that
was all he could remember. I thanked him and told him that was fine, then
asked if he would take just a few more minutes to see if he could remember
any more. I thought he would refuse, but he did not, and as he sat there he
remembered two more designs, again tried to bail out, and then with my
encouragement remembered and drew two more, recalling a total of 8 out of
9 of the designs.
I thanked Jim and looked over, expecting to see some relief or satisfaction
on his face, but to my surprise he still looked miserable. I wasn’t sure what
was happening, but was inspired to ask, “Well, how do you think you did?”
Jim replied with real anguish, “Terrible! I’m so stupid I couldn’t remember
any of them.” It began to dawn on me that I had underestimated the extent
of Jim’s distorted self-appraisal, and I asked him, “How many do you think
there were?” “I don’t know,” he replied, “14 or 15.” Again, I was quite
surprised and had to pause for a minute. “No, Jim,” I said, laying the cards
out on the table, “there were only 9 cards, and you got almost all of them.
Most people only remember 6 or 7, and you got 8. And your copies of the
cards are also excellent—mu, mu beer than most people’s. Really! I’m
telling you the truth.”
Jim looked shoed and confused and sat there immobile and speeless. I
began to talk in a so voice,
You see, Jim, you feel so negatively about yourself that you can’t tell what you’re good at or what
you’re not. Like most of us, you don’t want to aempt anything you think you’ll fail at, but you
don’t believe you can do anything well—even when you can. is is partly the answer to your
question, “Why can’t I succeed at anything?” You can, but you don’t believe in yourself, so
understandably you don’t even try. If I hadn’t encouraged you, you would have given up aer
four designs, but I was prey sure you could do this, so I asked you to keep going. Also, even
when you do something well, you’ll see it negatively. So that just reinforces that idea that you
can’t do anything well.
At this point, Jim was weeping, and put his head in his hands to hide his
face. I put a hand on his shoulder and kept quiet, handed him some tissues,
and then got up to get him a glass of water, whi he accepted and drank.
Invite the Client to Observe the Problem Behavior and Adopt the
Client’s Words. Draw Connections to Versions Outside the
Assessment Setting. Once the problem behavior is in the assessment room,
your next step is to bring it to the aention of the client. Ask the client what
he or she calls that way of acting, and if possible, see if the client recognizes
versions of the behavior in other contexts. I try to adopt the client’s
language from that point on, although sometimes I will offer alternate
wordings if I think they will lead to a more useful understanding of the
client’s problem. To return to the metaphor used in apter 1, all of this is a
way of inviting clients to climb up with you on an “observation de” over
agreed-on aspects of their lives. From there, you can collaboratively discuss
what you both see and come to beer understand clients’ dilemmas of
ange.
Case Example. It might have been useful if I had stopped to discuss the
Bender-Gestalt with Jim before I showed him how well he did on the recall
portion of the test. is would have allowed us an opportunity to talk about
its similarity to other types of aievement situations and for me to hear
Jim’s thoughts about what I viewed as his tendency to give up. Instead, once
Jim calmed down, I asked him if we could talk about what had happened
and what he was feeling. He said yes, and I gestured for him to start. He
then explained, “I was crying because nobody has ever told me that I did
something good. I just couldn’t believe it at first, but then you explained
how I don’t know what I can do anymore, and I saw that it is true. I started
wondering what else I can do that I don’t know about.” I said I was thinking
the same thing and I wondered what we might call Jim’s tendency to
undersell himself He said he didn’t know. I said it was almost like he saw
himself through a distorted “lens.” He agreed and said he saw himself as
“loser.” We then began to talk about his “loser lens” and how it influenced a
lot of his behavior. He agreed it kept him from looking for jobs, led him to
give up easily—as on the Bender-Gestalt—and made him really self-critical
about anything he did. I pointed out how he had been seriously “off” in his
estimation of the number of designs he had failed to recall. I asked if there
were other times he could think that he had really underestimated himself to
that extent. He told of going away to camp when he was 9 years old and of a
counselor who had taught him how to toss horseshoes. At first Jim hadn’t
wanted to try and was sure he couldn’t learn the game. By the end of the
week of camp, he was beating everyone—even the counselor who had
encouraged him. He glowed as he told me about this series of events.
Step 4—Explore the Context Leading to the Problem Behavior
Sometimes it is enough to elicit, name, and connect a problem behavior to
the outside world, and you should stop an assessment intervention at that
point. Mainly, I aempt to judge whether the client is emotionally
overwhelmed aer we do that work or can take part in further discussion. If
the client can proceed, my next step is to learn more about the context of the
problem behavior. What factors are necessary and sufficient to elicit it?
What is its history? What reinforces or maintains it? Clients typically are
not at all aware of su contextual cues, so it can take careful questioning by
the assessor to get this information.
Case Example. I asked Jim if there were any situations where he didn’t
have the “loser lens” on, and he took a few minutes to think about this.
Eventually he replied, “When I’m playing my guitar in my room all by
myself. en I don’t worry about how I am doing and I just play for myself
and for the fun of it.” So would that ange if he knew someone was
listening to him? “Oh sure. at would ruin the whole thing. I wouldn’t be
able to play at all. ” And did he ever think he played well? He admied that
sometimes he played OK, and gave a small smile. Jim then spontaneously
recalled his father siing with him in elementary sool at the kiten table,
aempting to tutor him on various subjects and ending up berating Jim
instead. I said that sounded really awful and I wondered if those events were
part of how he developed the “loser lens.” Jim said that might be true, but
that it was still going on, like that morning when his father criticized him
for not looking for jobs. I asked if he thought the morning’s events had
influenced his approa to the Bender-Gestalt. He said he wasn’t sure, but
admied he had arrived feeling prey “hopeless.” “So,” I said, “these lectures
from your parents—whi they may see as trying to motivate you—actually
make it less likely that you’ll succeed.” Jim agreed that was true. He then
suggested we should find a way to tell them that, and I said that seemed like
a very good idea.
Last I asked Jim if there was anything he got out of “giving up” early—
some way it helped him, even though it made him feel ashamed of himself.
“Sure,” he said, “I don’t have to feel scared about how I’m doing.” “So shame
is preferable to anxiety in your book?” I asked. Jim paused, and slowly said,
“Nooo…1 guess I just never thought it through before.” I said I was sure that
was true and that many of us seemed to prefer pain that was familiar (like
shame) rather than pain that was new and unknown (like anxiety).
Step 5—Imagine Solutions to the Problem Behavior and Test
em Out In Vivo. Keep Revising Proposed Solutions Until the
Client Peels Some Success
Once the problem behavior is in the room and you and the client have some
understanding of what evokes it and reinforces it, you can begin to imagine
what might blo it or keep it from occurring. You then can run lile
“experiments” together to see if you can make it go away. In keeping with
the collaborative approa, I’m careful to let clients generate solutions first,
then I make additions or completely new suggestions if necessary. I draw on
my knowledge of different therapeutic strategies in imagining possible
solutions.
Case Example. At that point, I eed in with Jim to see if he needed a
break or could keep on talking. He assured me that he was doing well and
was very interested in what we were discussing. We then had the following
interaction:
Steve: I wonder if you’re willing to do a lile experiment with me?
Jim: What’s that?
Steve: I’d like to give you another aievement task that would
normally pull for the loser lens, and see if we can keep it from
happening.
Jim: OK. How would we do that?
Steve: Do you have any ideas based on what we talked about?
Jim: Well, I guess first I should just keep going, no maer how badly I
think I’m doing.
Steve: Good idea. And what might that be like?
Jim: I guess I’ll feel anxious.
We then discussed how to deal with the anxiety and Jim suggested he just
try to “ignore it.” I seconded the idea and proposed that he try to remember
there was nothing to fear; we were just doing a lile experiment.
I then asked Jim to try one more time to draw the Bender-Gestalt figures
from memory. I told him this would give us a measure of his long-term
recall. (At this point, it was about 40 min since the immediate recall.) Jim
started to say that he wasn’t sure he could remember any, caught himself,
stopped, and deliberately said, “I’ll do the best I can.” He then started to
draw. Aer several figures, he said he didn’t want to stop but was having a
difficult time ignoring the anxiety he was feeling. I asked if he could
approa the task like he was playing his guitar. He pondered this, and then
he asked if I would be willing not to look at him while he drew. I said I
would, and suggested that I step outside the office for a minute, whi he
agreed to.
When I returned aer refilling my water glass, Jim was siing at the table
beaming. He looked so different from the man who had walked in my office
earlier and met my eyes, smiling. “How did you do?” I asked. “Good,” he
said, and proudly showed me his paper on whi he had drawn all nine of
the original BVMGT figures. I said, “at’s great, Jim,” and asked him to tell
me about his experience. Jim then told of doubting himself and almost
stopping several times, but geing himself to “just take a few more minutes
to see if {he} could remember any others” (as I had coaed him previously).
He was clearly overjoyed with how well he had done, and also with his
success at holding off the “loser lens.” I mirrored his excitement and said I
was really impressed at what a “qui study” he was. I asked if he could now
answer his question of why he couldn’t succeed at things, and he said,
“Because I don’t believe in myself and give up too easily!” I affirmed that
was the biggest reason, and that we could talk about more possibilities when
we met next week to go over all the test results.
Step 6—Discuss How to Export Successful Solutions to the
Outside World
Over the years I have learned that some clients become easily deflated when
they try to implement solutions we have discovered in assessment
intervention sessions in their daily lives. Clearly, different contexts have a
host of different cues and demands, and without the presence of the
assessor/coa, it can be difficult for clients to successfully remember and
export adaptive strategies they have experienced one time. For this reason,
before ending an assessment intervention session, I oen ask clients to join
me in doing “thought experiments” about what it will be like to take the
strategies we explored and try to use them in their lives outside the
assessment office. As clients and I envision and discuss this possibility,
sometimes we can then make further refinements to the solutions we have
discovered so they will be more generalizeable. I also suggest clients “see
what they can do” with what we have learned and report ba to me at our
next meeting. As discussed in apter 1,1 believe su instructions help
reinforce clients’ curiosity, whi sets the stage for therapeutic ange to
occur.
Case Example. Towards the end of our session, I asked Jim, “What do
you think it would be like to try some of what we learned today when you
go home and want to look for a job?” He said it would be “interesting” and
“different,” and I proposed that we think about what things would be similar
and what would be different so we could plan for any difficulties. We agreed
that job hunting was hard because it pulled for the “loser lens” and that Jim
had trouble even geing started because he was sure he was going to fail. He
suggested that he would have less performance anxiety if his parents didn’t
know he was making applications, because otherwise they asked lots of
questions and it would be harder, like when I was wating him do the
Bender-Gestalt drawings. I wondered if he could just try to ignore the
anxiety that would inevitably come up—as he had done in our session—and
just consider the next week “a lile experiment.” He smiled with recognition
at that phrase and said he would see if he could fill out four applications
before we met next week. I offered that he could call if had any questions
before then, or if he wanted to share the results of his efforts. He said he
might, shook my hand, and thanked me for the session saying it had been
very useful. Aer he le, I made detailed notes and began to think more
about my plan for the summary/discussion session the following week.
Conclusion
As I hope you see from this case example, assessment intervention sessions
are powerful tools for impacting clients’ stories about themselves and the
world and helping them begin to see previously bloed solutions to their
ronic problems in living. Su sessions work because they illuminate for
clients how they (like all of us) actively participate in constructing their own
worlds, thereby limiting themselves unintentionally. By making new sense
of aracteristic behaviors, assessment intervention sessions help clients see
new options and move beyond learned helplessness to thoughtful action.
Assessment intervention sessions also help assessors become more
empathic to clients’ dilemmas of ange and really grasp the idiographic
meaning of nomothetic test results. For example, I thought I understood the
degree of negative distortion in Jim’s self-concept from his MMPI-2 profile,
yet I was quite surprised when he said he had done “terribly” on the Bender-
Gestalt recall and that there were “14 or 15” designs in total. is brought to
life Jim’s score of 97T on the MMPI-2 LSE scale, and I will never see a score
like that again without remembering Jim and his view of the Bender-Gestalt.
Last, I must anowledge that assessment intervention sessions can seem
a lile “magic” when you first start hearing about them or wating
videotaped examples. In this apter, I have aempted to demonstrate that
in fact, they are logically and systematically structured, and can be done
even by clinicians who are new to erapeutic Assessment. I have taught
first-year clinical psyology graduate students to do successful assessment
interventions (see ap. 15). And my colleagues and I have now developed a
number of “standard” assessment interventions for different types of
problem behaviors. e following references provide detailed examples of
some of these interventions: Finn and Martin (1997); Finn and Kamphuis
(2006); Finn (2003, in press); aringer, Finn, Wilkinson, and Saber (in
press). Clearly, assessment interventions are one of the most “artful” pieces
of erapeutic Assessment, and you will benefit from reading about then,
practicing them, and geing supervision over time. For now, however, I
encourage you to “give them a try” and “see what you find.” en feel free to
let me know how it goes.
Note
is apter is based on a paper presented at the 28th Annual Symposium on Recent Developments
in the Use of the MMPI, MMPI-2, and MMPI-A (Finn, 1993).
9
One-Up, One-Down, and In-Between: A
Collaborative Model of Assessment Consultation
Over the years, I have come to appreciate that it is quite complicated to
assess a client already in treatment with another mental health professional
or with a team of professionals. Relatively lile has been wrien about this
topic, although there are some notable exceptions (e.g., Allen, 1981; Berg,
1986, 1988; Cohen, 1980, Shafer, 1954). In apter 9, I present a detailed
account of my consulting with a client and therapist via erapeutic
Assessment. In this apter, I discuss assessment consultation more generally
and outline the collaborative principles and teniques that my colleagues
and I employ
In fact, in our practice at the Center for erapeutic Assessment, about
half of the assessments we do are of clients whose treaters find them to be
puzzling, frustrating, frightening, and/or boring. Typically, we are asked to
test su clients to help understand them and aid in their therapy.
Sometimes, the referring professional (henceforth referred to as the RP) has
just started to work with the client. At other times, the treatment has gone
on for some time but is in some kind of crisis at the time of the referral. In
many instances, we are asked to address important referral questions, su
as: “Should I refer this client to another therapist?,” “Does this client need a
higher level of care?,” “Have we done all we can do for this person and
should we terminate therapy?,” or “Why are the client and I so stu in
therapy?” Other times, the RP isn’t explicit about su questions and instead
simply refers for “diagnosis and treatment planning.”
My experience and the existing literature show that there are many
potential pitfalls in su assessments. Let me start by mentioning just a few.
e Referring Professional Doesn’t ink
Systemically About Treatment Impasses
Aer years of consulting to other mental health professionals and also
treating my own clients I have come to the following conclusion: In most
instances, when a treatment is stu, or a client or therapist feels anxious,
frustrated, confused, or despairing about their interactions, both individuals
play a part in that predicament. I say this humbly, and with the advantage of
hindsight about the many times I have goen into conundrums with clients
because of my own “stuff.” Now if you think systemically or
intersubjectively about your relationships with clients, my statement will
seem completely self-evident. However, the fact is that many mental health
professionals do not think about treatment as an interpersonal enterprise
that inevitably affects both people. And even those of us who generally do
can lose that perspective when we are in the middle of a difficult impasse
with a client.
A nonsystemic view is oen reflected in the referral questions one
receives from the RP at the beginning of an assessment. For example,
contrast these two questions (actually given by RPs in recent assessments):
“Why do I feel so disgusted with John in our sessions over the last two
months?” versus “Why won’t Sara do what I tell her and what she knows is
good for her?” In the first instance, the referring therapist was quite open to
considering her role in the treatment difficulties; in the second, the treater
blamed the client for the la of progress and seemed closed to the idea that
he {the treater] might be part of the problem. As Cohen (1980) noted, in
some su instances, the RP simply sends the client for a diagnostic
assessment, and never anowledges at all to the assessor that the treatment
is in trouble.
We have found that when RPs are open to thinking systemically about
treatment impasses, assessment consultation is easier and more effective.
Assessors are then able to use an assessment to “get in clients’ shoes” and
then help treating clinicians become more empathic to those clients’
dilemmas of ange. Oen, this then helps RPs understand how and/or why
they were bloed in their understandings, and whi factors had more to do
with them than with the client. As mentioned earlier, sometimes a RP
normally thinks quite systemically, but loses that view temporarily in the
middle of treatment; an assessment can help the person shi from blaming
the client to a more complex understanding.
Unhelpful Triangulations
Related to the aforementioned point: When an RP and a client are at an
impasse, and when neither of them has a systemic view of the situation, the
potential for the assessor to get triangulated in an unhelpful way is quite
high. Sometimes, in these instances, both the RP and the client hope
(consciously or not) that the assessment will show that the other is at fault.
ere is a pull for the assessor to “take sides” and put the other person in
their place. In extreme situations, if the assessor avoids taking sides, the RP
and/or client may feel betrayed and furious! Luily, this level of spliing is
rare, in my experience.
More frequent is the situation where the client and RP both seem to agree
that the client is the sole problem. For example, the client, Sara, I referred to
earlier—whose therapist wanted to know why she wouldn’t do what he “told
her”—began her assessment completely eoing her therapist’s framing of
the therapy, for example, “I know I should do what my therapist tells me; he
has my best interests in mind, but I always screw things up and don’t know
why.” Assessors can have different reactions to this kind of referral, but one
common one—especially when the assessor is aware of shortcomings in the
treatment—is to feel protective of the client and frustrated with the RP is
kind of experience can be intensified by the fact that psyological
assessment is different in many ways from (especially long-term) therapy. In
collaborative assessment, it is easy for clients to develop idealizing
transferences towards assessors, and for assessors to feel more
compassionate toward clients than toward RPs. en, if the assessor
experiences the RP as blaming or failing to understand the client, it is easy
to be pulled towards “rescuing” the client.
Not infrequently, in these situations, assessors will fantasize “I could do
beer with this client,” and clients will think, “Maybe I should ange
therapists and work with the assessor instead.” I have seen instances where
these fantasies were carried out (sometimes with the cooperation of the RP),
the assessor and client start psyotherapy together, and before too long
they too are at a therapeutic impasse that resembles the original one
between the client and RP!
I do not mean to imply that there never are times when it is appropriate
for an assessor to assume treatment of a client referred for assessment by
another clinician. However, I believe that these are very rare. As I discuss
later, in most instances, the RP, client, and assessor will all benefit the most
if the assessor can use the triangular format of the assessment to help the RP
and client repair their relationship and move on with a deeper
understanding of why they were stu.
e Vulnerability of the RP
I don’t think I’m just projecting my own issues in believing that most mental
health professionals are not great at asking for help. Many of us in
caregiving professions are more comfortable giving than receiving, and this
has a number of important implications for our work with clients. One thing
I’ve noticed over the years is that many of us will wait until we are
completely stumped, confused, or exasperated by a client until we ask for a
consultation from a colleague. And then, when we do finally admit that we
can’t figure out and resolve a difficult treatment situation on our own, we
have to bale shame and a loss of face. For these reasons, I always
appreciate the courage of any RP who refers a client for an assessment,
especially if that person has been working with the client for some time.
A related place of vulnerability for most clinicians is that we all base at
least some of our self-esteem on our skill and ability to be helpful to clients.
With some RPs, this leads to a “Cat—22” about assessment consultation:
ey want the assessor’s help, but also fear being exposed or “shown up” by
the assessor. As Allen (1981) noted, su competitive feelings can produce a
dilemma for assessors: If they learn new things about the client, the RP feels
diminished; if the assessment confirms what the RP originally thought, it
may be dismissed as “not really that helpful.” As I discuss later, if assessors
are blind to this dilemma, they may become competitive themselves and
make maers worse. Or in extreme cases, they may not realize that the RP
actually wants the assessment to fail and is subtly sabotaging it from behind
the scenes.
Oracular Transference in the Referring
Professional
e anxiety of RPs may also be heightened if they are a nonpsyologist, or
otherwise not very familiar with psyological assessment. is can lead to
a number of misconceptions about the purposes of psyological testing, for
example, the belief that psyological testing will reveal the final “Truth”
about the client. is idea is an example of what Shafer (1954) called the
“oracular” view of assessment. Although this misconception may initially
generate referrals for assessment, my experience is that assessors who play
into it (or believe it themselves) will eventually be hurting for business!
Typically some RPs will be disappointed that psyological assessment did
not give them what they hoped and will stop referring. In other cases, RPs
will feel intimidated by psyological assessment and will only refer in dire
circumstances. In erapeutic Assessment, we try to remember that there is
no absolute “Truth” in the human sciences; rather, we look for overlapping
insights that ea are shaped by the context in whi they were drawn, for
example, assessment versus long-term therapy. In my experience, this
aitude leads to more successful assessments.
Hidden Agendas
Sometimes, it becomes clear that an RP wants to use an assessment to make
a point to the client, rather than to genuinely explore some set of questions.
is is oen apparent in the initial consultation between assessor and RP,
when the laer—either openly or subtly—seems to be dictating the
assessment results the assessor should “find.” Sometimes this is rather
blatant, as in the case of the therapist who made it clear that I was to use an
assessment to prove to his client Sara that what he said about the cause of
her depression “was really true.”
Another type of hidden agenda occurs when difficult things need to be
said to clients—and this is already patently clear to everyone involved—but
the clients are referred for an assessment in hopes of “passing the bu” to
the assessor. For example, some years ago I was asked to evaluate a mother
of two—who was extremely psyotic and depressed—to see if she was
“capable of caring for her ildren on her own.” My sense was that everyone
involved in the treatment already knew the answer to this question; they
just didn’t want to make the decision! Along these lines, I have learned to
pay special aention when an RP poses a referral issue that seems totally
obvious, simply on the basis of the client’s history. I don’t immediately
assume the RP is trying to shi responsibility to me; sometimes he or she is
truly confused. But I always ask the RP why an assessment is needed to
address that particular question. Also, I firmly believe that even when some
maer is already fairly clear, an assessment can be helpful in preparing a
client to accept difficult information. e important distinction here is
whether this reasonable goal is on the table at the beginning of the
assessment, and whether both the RP and assessor are responsible for
helping the client assimilate emotionally arged material.
Splitting Among a Treatment Team
Yet another kind of hidden agenda occurs when a client is involved with
multiple professionals who have very different views of the client and
disagree about what approa to take in treatment. In some instances, the
different treaters agree to refer the client for assessment in order to find out
“who is right.” A classic example of this is mentioned by Berg (1988), where
a client with borderline traits was being assessed on an inpatient unit to
determine appropriate treatment, and the staff split into two major groups:
one that advocated for a “tough love” approa, and another that felt the
client needed more “compassion 2nd support.” I have seen this kind of
situation develop in outpatient treatment also, when a client is involved
with multiple professionals, for example, a psyiatrist, individual therapist,
family or couples therapist, and/or group therapist.
In private practice situations, spliing in a treatment team can be even
more difficult to navigate if the treaters involved do not know or rarely have
contact with ea other. I find this situation is all too common among busy
mental health professionals who are not reimbursed for time to talk with
ea other. Another complication in su situations is that one professional
(typically the individual therapist) sometimes refers a client for assessment
without consulting with or even leing the other treaters know this is
happening. Naive assessors can find themselves caught in the middle of
major power struggles within a treatment team, especially if they don’t
make an effort to talk to all the professionals working with the client.
Anxiety in the Assessor Leads to Role Enactments
Given what I’ve already discussed, is it any wonder that assessors may also
feel anxious about consultative assessments? Su assessments oen are
very delicate situations that pose great allenges for assessors. In a
relatively short period of time, assessors are called on to (a) connect with
clients, (b) establish a collegial relationship with one or more RPs, (c) be
honest with ea individual, and (d) try to make the consultation a useful,
positive experience for people who may not be geing along very well with
ea other!
We all have our own habitual ways of dealing with su anxiety, but my
experience is that there are two major troublesome paerns of responding
on the part of assessors and RPs. Both occur when—out of their anxiety—
assessors and RPs go into stereotyped, hierarical role relationships, where
either: (a) the assessor goes “one-up” to the RP (e.g, “I am the expert who
will tell you the Truth about your client”) and/or the RP goes “one-down”
(e.g., “Please look in the crystal ball of your testing and tell me what to do
with this difficult client”), or (b) the assessor goes one-down to the RP (“I
will do your bidding; all your ideas about the client are perfectly accurate;
what do you want me to say to the client to support you?” and/or the RP
goes one-up (“You are a minor tenician whose job is to do what I tell you,
soothe my anxiety, and mirror my brilliance to me and the client”).
Of course, I’ve exaggerated these positions in describing them here. My
experience is that one rarely gets full-blown role-enactments like this; and
clearly, when they happen it is not good for clients, RPs, or assessors. I do
think, however, that some flavor of these roles may be present in many
consultative assessments, and su paerns—even when subtle—interfere
with the usefulness of psyological assessments in facilitating therapy. is
brings us to the following questions: How can we assessors avoid su
hierarical roles—not take sides, or go “one-up” or “one-down” to an RP or
treatment team? How can we stay “in-between,” if you will, during a
consultative assessment and maintain the most relational, effective, way of
being?
Suggestions
e following proposals are based in my experience conducting, supervising,
and receiving consultative assessments:
Maintain Empathy for the Referring Professional
First, when I am in the role of the assessor, I make a conscious effort to be
empathic to the RP, as well as to the client. I try to remember how scary it
can be when I refer my own clients for consultation to let another
professional see the details of my work, especially when a therapy is not
going well. I also review in my mind all the clients I have struggled with in
treatment, and how difficult it was for me to ask for help. Finally, when
siing with a client that another professional has found difficult, I try to
“feel my way into” those difficulties, for example, in what ways do I find the
client frustrating, confusing, or difficult? And if I don’t feel this way towards
the client during the assessment, can I imagine how I might if I saw the
client in another context, su as long-term treatment?
When the experience I have with the client parallels in some way the
difficulties experienced by the RP, I am qui to share that fact with the RP,
for example, “Dr. Smith, I sure see what you mean about Ms. Atkins’s
guardedness! In an hour interview, I wasn’t able to get her to do more than
answer Yes or No questions!” I find that RPs greatly appreciate this kind of
joining, and typically feel relieved to know “it is not all them.” I then can
help lead them away from blaming the client by asking su questions as,
“What have you noticed about when Ms. Atkins seems more or less
guarded?” I have also found that RPs who began an assessment scapegoating
a client, sometimes become more willing to examine their own part in
treatment difficulties once I have affirmed the allenges presented in
working with the client.
Be Aware of Your Own Anxiety
I find I am less likely to get triangulated or to get caught in unhelpful role
enactments if I am aware of my own anxiety and take steps to deal with it
directly (through a variety of ways I have learned over the years). Also, I
know now—as the result of my own therapy, self-observation, and feedba
from others—the kinds of behaviors I’m likely to exhibit when I’m anxious
and overwhelmed. (My personal favorite is to go “one-up” and become an
“authority.”) is self-knowledge helps me to keep a lookout for su
behaviors during an assessment and to interrupt them in myself (hopefully)
before they get out of hand. If I find myself wanting to quote resear and
give books to an RP to get the person “up to speed,” I realize I am more allied
with the client than the RFJ and I work hard to get ba to an equidistant
place. I also accept that there are limits to self-awareness. For example, in
apter 13,1 tell about a couples assessment I did that ended badly. In
retrospect, one major factor that contributed to the outcome was that I was
unaware of how anxious I felt about various aspects of the assessment. I
have come to accept that I did the best I could at the time.
Build a Collegial Relationship From the Beginning
In most instances, the success of a consultative assessment relates directly to
the strength of the relationship between an assessor and a RP (and also, of
course, between the assessor and client). For these reasons I extend myself
with RPs I haven’t worked with before; for example, going to their office to
discuss a referral and inquiring about their training, treatment philosophy,
and even (if appropriate) their personal lives. Over time, as the RP and I
work together on more assessments and come to know one another beer,
su contacts can be shortened and/or may take place over the phone. But
initially, I find it helps to have face-to-face contact with a RP before an
assessment gets too far along. Also, in our beginning contacts, I try to
inform the RP about my particular approa to assessment, the ways I think
I can help, and how they can assist during the assessment. I also have
developed an information sheet for RPs about erapeutic Assessment,
whi I send them when they first inquire about a consultation. (See Exhibit
9–1.)
EXHIBIT 9–1 Information Sheet for Referring Profesionals
Forestall Triangulation
I find that there are a number of ways I can prevent triangulating with
clients and RPs to minimize the possibility of “spliing.” For example, I make
it clear to clients that I will be communicating with the RP throughout the
assessment and I ask the client to sign a permission form (if this has not
already taken place) for me and the RP to talk freely. Occasionally, clients
balk at this request, saying that they came to me for an “independent second
opinion.” I assure clients that my job is to do just that but th&t it will be
helpful for me to talk about their treatment with the RP So far, this has
always resulted in the client allowing the RP and me to collaborate.
Also, typically I let clients know early in an assessment that my job is to
facilitate their treatment with the RP and that I will not be available for
treatment aer the assessment, although I will be open to future
consultation. And although I accept that clients oen develop very positive
transferences to me during an assessment, and I try not to interfere with this
process (believing it facilitates—in many instances—the therapeutic outcome
of an assessment), I also make an aempt to avoid taking clients’
idealization of me “just personally.” By this I mean that I take pride in my
ability to comprehend the dilemmas of allenging clients and to help them
feel understood; but, I am also aware of the particular features of the
assessment situation that allow clients and me to develop a very positive
alliance.
As mentioned earlier, I generally consider it disadvantageous for an
assessment to end with the client’s transferring from the RP to the assessor
for ongoing treatment. Not only is this is a good way for an assessor to lose
sources of referrals, it also can be destructive for all the parties involved.
Clients may feel rejected by the RP and as if they “failed” the previous
treatment. RPs may feel relieved at first, but also inadequate that they were
not able to work through an impasse with their client. And assessors, I
believe, are likely to be enacting omnipotent rescue fantasies that will only
get them into trouble later!
In addition, I believe that clients and therapists learn the most and make
the most progress in their work by repairing breaes or empathic breaks in
their treatment relationship. I believe the best outcome of an assessment is
for the assessment to facilitate su repairs and help the RP and client
understand the context of any struggles they have had together. And if it
becomes clear that a RP las some expertise or skill that would benefit the
client (e.g., Eye Movement Desensitization and Reprocessing (EMDR), sex
therapy, Dialectical Behavior erapy) I find it oentimes works to involve
other professionals as “auxiliary therapists” aer the assessment, rather than
for the client and RP to terminate their relationship entirely.
If continuing treatment is not possible—because of limitations in the RP or
the client, or because irreparable harm has already occurred to their
relationship—it is important for the assessor to anowledge this reality and
discuss it with both client and therapist. In su instances, if the two parties
decide to terminate their treatment relationship and the client wishes to
continue therapy, I recommend the client be referred to someone else than
the assessor. e assessor—if asked—can help find the new therapist and
share with that person what was learned through the assessment.
One other—fortunately infrequent—scenario is when the assessor realizes
that a treatment impasse is related to unethical practices of the RJ^ su as a
dual relationship, or sexual misconduct with the client. I imagine that
generally, RPs who take part in su behaviors are unlikely to seek
consultation; however, I have found myself in this situation several times.
Once I was asked to test an adolescent boy who had grown very
noncommunicative in therapy. Before long, I discovered that the therapist
was a close friend of the boy’s parents, and the client understandably didn’t
feel safe talking to him! I recommended that the boy have a different
therapist, but again, resisted the invitation to see him in treatment myself. A
allenge in su situations is for the assessor to confront su ethical lapses
—and in some cases go as far as facilitating a report to the RPs licensing
agency—while still not going into a “one-up” judgmental place. I’m happy to
say that I was able to maintain a relationship with the therapist I just
mentioned and that he continued periodically to seek consultation from me
aer that initial assessment.
Collaborate With the RP
Perhaps the most important thing a consulting assessor can do to ensure a
positive outcome is to involve the RP—as mu as possible—as an active
collaborator in the assessment. is can be done in a number of ways:
Work With RPs to Clarify eir Goals. I collect specific referral
questions from RPs and share with them assessment questions posed by the
client. rough this process, I educate RPs about what an assessment can
and cannot do. For example, the referring therapist in the case in apter 9
wanted an assessment to know if her client had been sexually abused. I told
her that psyological assessment could not definitively answer su a
question, but that I would be happy to explore this issue as part of the
assessment. Also, I never accept a referral simply for “diagnosis and
treatment planning/’ Fiser (1985/1995) details ways to help a RP expand
su referral questions. For example, if a RP says he mainly wants a
diagnosis, the assessor can ask, “What diagnoses are you considering, and
how will it affect your treatment plan if the assessment supports one
diagnosis over the others?”
As mentioned earlier, RPs’ assessment questions also provide information
about whether they are scapegoating or overpathologizing a client. If I
believe this to be true, I “test the waters” in an initial meeting, to see if the
RP can regain empathy for the client. For example, aer listening to one RP
complain for 20 min about his client, I gently asked, “What’s your sense of
how your client views the difficulties the two of you are having?” is led
the therapist to immediately shi to thinking more compassionately about
the client, whi helped the two of us work together as the assessment
proceeded.
Ask the RP to Help Prepare the Client for the Assessment.
Unfortunately, many RPs say lile to their clients about their reasons for
requesting an assessment consultation. If this happens, clients oen arrive
for their initial assessment session with a variety of fantasies of what
prompted the assessment, for example, “My therapist is really si of me and
is geing ready to fire me,” “I’m so crazy that even my therapist can’t figure
me out,” or “I’m hurting my therapist with my anger.” Sometimes there is
some truth to what the client is thinking, but even then, there are helpful
ways for RPs to discuss su maers with clients. When RPs call me to make
a referral, I oen ask if they have already discussed the assessment with
their clients. If not, I tell them it would facilitate the assessment if they
would explain to clients their reasons for making a referral and tell them
what is entailed in an assessment. I offer to send RPs an information sheet
about my assessments that they can share with their clients. Some RPs will
then ask for help framing what they will say, and I’m able to coa them in
wording their rationale systemically, for example, “I want help
undemanding why our work hasn’t been more helpful to you” versus “We
need to figure out why you won’t do what I tell you.” I mention to RPs that
clients oen need to discuss a possible assessment several times before they
are ready to call me. Again, many of these details can be skipped if the RP
and I have worked together on a number of assessments.
Besides revealing their own reasons for requesting an assessment, it can
also help for RPs to work with their clients before my initial assessment
session to help identify those clients’ own questions for the assessment. I
oen learn a great deal about the relationship between an RP and client by
how su efforts fare. Some clients arrive at their first session with a number
of questions that seem to have been dictated by the RP and that they clearly
don’t understand. is sets the stage for me to explore the clients’ confusions
and questions about treatment, and to share those with the RP aer the
initial assessment session.
Stay in Contact With the RP During the Assessment. Given that I
typically assess outpatient clients over a number of weeks, rather than just
on 1 day, I give RPs periodic updates—oen in the form of short messages on
their answering maines. I make a special effort to talk with RPs aer
particularly significant sessions with clients, and I ask them to share
information with me about how their clients are experiencing the
assessment. (Most clients continue to meet with the RP during an
assessment.) As mentioned earlier, if I find myself struggling with a client, I
share su experiences with the RP, and I ask for advice from the RP about
how to handle difficult interactions. is approa reinforces the idea that I
am not an expert with all the answers and that the RP and I can best help
the client by working together.
Involve the RP in Interpreting Test Data and Planning Feedba to
the Client. I make it my practice, whenever possible, to meet with RPs to
review assessment findings and answer their questions before they meet
with me to discuss the assessment findings with clients. is is beneficial in
several ways. First, RPs are oen quite helpful in interpreting test data, and I
generally seek their associations to clients’ Rorsa responses, MMPI-2
scores, and ematic Apperception Test (TAT) stories (among other
assessment information). Nonpsyologist RPs oen seem especially
gratified that I would share su information with them and are very
interested in how psyological tests work. “Demystifying” the assessment
process seems to facilitate our collaboration. Second, I find that RPs have
excellent insights as to how I should present certain assessment findings to
clients. ey and I can work together to identify Level 1,2, and 3 information
(see ap. 1), oose specific words that will be most useful to a client (e.g.,
should we use the term depression or simply talk about “painful feelings”),
and make decisions about how mu to say. Given that it is never possible to
tell clients everything I have learned from an assessment, it helps me to have
another person hold information that must be “contained.” Last, in our
meeting, the RP and I can discuss what our respective roles will be in the
summary/discussion session with the client. I typically ask RPs to help tra
clients’ emotional reactions, slow me down if necessary, and intervene if
they think clients are confused about what I am saying. ey can also help
clients tie assessment findings to real life examples, for example, “John, I
think what Dr. Finn just described from your MMPI is what happens
between you and your boss at work. Do you agree?”
Help RPs “Depersonalize” the Helpfulness of an Assessment. As
discussed earlier, some RPs tend to feel “shown up” by an assessment, or will
blame themselves for “not having figured things out” earlier on their own. In
truth, sometimes a consultation does highlight an area of deficit for the RP
(e.g., a la of knowledge about a certain condition), and if so, I do not
minimize that fact, nor do I draw inordinate aention to it. Generally,
however, I see su reactions as reflecting the shame (I mentioned earlier)
that many mental health professionals seem to feel about ever needing help.
erefore, I try to assist RPs in not taking the usefulness of an assessment
“just personally.” I might say to them (if I believe it’s true) that this was a
complex client who was difficult to understand without testing, or I might
join RPs in lamenting the inevitable truth that none of us can know
everything! Again, I do all this not just to be kind, but because I believe if
the RP goes “one-down” that it will interfere with our collaboration.
Treat Differing Views of Clients as Opportunities for Synthesis,
Discovery, and New Understanding. Given my belief that there is no
absolute “Truth” about a client, and that all insights are perspectival, I see
differences in how RPs and I experience clients as interesting puzzles to be
understood. For example, one client I assessed was quite sadistic with his
female therapist, but gentle and kind with me. When the RP and I discussed
this with the client, he admied that he “had a lot of anger at women”—a
conclusion that was supported by his Rorsa and TAT responses.
Identifying su “interaction effects” is oen key to aieving a deep
understanding of clients, and in helping them overcome problems in living.
For example, with the aforementioned client, the RP and I recommended
that he shi from his female work supervisor to a male one; this ange
almost completely eliminated the work problems that had prompted the
assessment referral.
Clearly, I would never argue with an RP about an assessment finding or
insist that my view of a client is “beer” or “right.” If an RP and I cannot
aieve a consensual integration of our perceptions, I generally ba down,
or suggest that we “agree to disagree,” or propose that we bring up our
different understandings with the client. Berg (1986) suggested that the
nature of the relationship between an assessor and RP may be highly
informative about the client. us, when I find myself wanting to argue with
an RP, I ask myself (or the two of us) what this might tell me about the
client. Even if I felt that a RP had a seriously distorted view of a client—and
was not open at all to alternative conceptualizations—I most likely would
not push my own perceptions—unless I felt the client was being harmed.
Instead, I try to calmly raise my differing point of view and then let it go,
hoping that if the RP feels respected, he or she may be open to further
discussion at some later date.
Ask the RP to Attend the Client’s Summary/Discussion Session. As
you will have surmised, whenever possible I conduct my
summary/discussion sessions with the client with the RP present; in fact, I
like to do these at the RP’s office. (Some RPs arge clients for these sessions;
others do not.) Su sessions are a ance for real healing if the client and
RP have been at odds, as the three of us discuss the previous treatment
difficulties and put words to a common understanding. Also, if the client
and RP have been working well together, the RP’s presence helps the client
feel “held” during su sessions, whi typically are somewhat
overwhelming and anxiety provoking for clients. Finally, as clients see the
RP and me working together, they typically feel safer—sensing that there
now are multiple individuals who have their best interests in mind. I oen
suggest to RPs that they book a lile extra time to sit with a client aer I
have completed my work and le. is arrangement signals to all of us that I
am “handing things ba over” to the client-RP dyad—although I make it
clear that I am available for future consultation and/or sessions. Also, in
most instances, I remind the client and RP that I will be sending a wrien
summary of the assessment findings.
Ask the RP to Review the Written Summary Before It Is Sent to the
Client. Regarding the wrien report or leer to the client, I oen ask RPs if
they are willing to review and comment on an early dra before I send it to
the client or collateral professionals. Again, I do this not only to help RPs
feel included, but because I have found their insights and comments about
su documents to be invaluable!
Follow-up With the RP Aer the Assessment. I typically talk with RPs
soon aer ea summary/discussion session—or exange phone messages—
to compare notes and thank them again for their referral. I also seek
feedba from RPs in several ways about my work—for example, during our
discussions before or aer the summary/discussion sessions, or by asking
them to fill out and return a simple feedba form aer the assessment. is
form consists of six open-ended questions:
(1) “Briefly, what were your hopes and expectations when you referred
this client for a psyological assessment?”;
(2) “Did the assessment meet your expectations?”;
(3) “What part(s) of the assessment were most useful to you and your
client?”;
(4) “What parts were least useful?”;
(5) “What would have made the assessment more useful?”; and
(6) “What would you tell a colleague who was considering referring a
client to me and/or us for this type of assessment?”
I provide a self-addressed stamped envelope when I send this form to
theRP.
A Few Caveats
I have two remaining caveats before closing. First, some RPs do not seem
interested in close collaboration with assessors. is may be because they
are busy and do not want to devote the time to discussing assessment
results, aending summary/discussion sessions, and/or reviewing leers to
clients. If this is the case, in some instances, I suggest the RP discuss with the
client the possibility of billing for su professional time. Also, some RPs are
simply unfamiliar with the collaborative model of assessment, especially if
this is the first time we have worked together. eir previous experiences led
them to believe they would simply “send” the client to me for testing, and I
would then simply mail ba a report at some later date. As mentioned
earlier, I handle su situations by educating new RPs about how I approa
psyological assessment; then we jointly decide if my approa will meet
their needs and those of the client. Yet other RPs resist collaboration because
they aren’t interested in being affected by the assessment themselves or
don’t think they have anything to learn. ey may not view psyological
assessment as a potential form of consultation, but rather as something akin
to ordering a blood test, and this is the way they want to keep things. It is up
to ea assessor to decide whether they wish to work with RPs who
maintain this kind of stance.
is leads to my second piece of advice: If possible, be thoughtful about
whi RPs you oose to work with. (I realize that many assessors work in
seings where they have no oice about su maers.) I myself don’t enjoy
doing assessments for RPs who won’t work together with me—whatever the
reason for their la of collaboration. And I tend to decline assessments
where I sense a potent hidden agenda on the part of the RP or treatment
team, although I may confront that agenda first to see if it shis. Remember
also, if you believe in intersubjectivity, it follows that we assessors will be
personally and professionally affected by our interactions with RPs. When
su relationships function well, they involve no small degree of
professional intimacy. Hence, I tend to turn down referrals from people I
don’t care to know, and accept those from people who interest me or who I
think have something to tea me. And I recognize that I must limit the
number of RPs I can work with because I only have so mu time and
emotional energy. Again, I must anowledge that not every assessor has
this type of freedom.
Conclusion
In closing I want to recognize that a collaborative model of assessment
consultation can also feel daunting to assessors. In some ways, things may
seem easier if we consider (a) our psyological tests as ways to uncover
absolute truths, (b) clients as objects of scientific study, and (c) RPs as
consumers who simply need us to provide them with factual information.
Also, who wouldn’t feel good about being an infallible oracle? So given all
this, why adopt an interpersonal, collaborative model in your work? First, I
think it is a more humble way of viewing psyological assessment, and
more accurate. Second, a collaborative approa will lead you to be more
helpful to clients and RPs. I just don’t believe it is possible to help decipher
complicated treatment situations without developing relationships with all
those involved. ird, you’ll learn more about psyological tests, yourself,
and the world. And last, perhaps it’s not so bad to trade in our reputation
and identity as oracles for those of experts whose job it is to facilitate
healing relationships between people! Most of us could feel prey good
about doing that kind of work.
Note
is apter is adapted from a paper I presented to the Society for Personality Assessment (Finn,
1997b). I am grateful to Jim Durkel and Steve Smith for their comments on an earlier dra.
10
erapeutic Assessment of a Man With “ADD”
is apter represents the first complete published case study of a
psyological assessment conducted by the methods of erapeutic
Assessment. I hope that a detailed, comprehensive example of erapeutic
Assessment in action will help those psyologists aempting to use this
approa on their own. I’ve osen this case because it represents a common
scenario in my practice whereby I use psyological assessment to consult to
a therapist-client pair who are feeling “stu” in psyotherapy (see ap. 9).
Also, I believe this particular case illustrates certain strengths of
collaborative psyological assessment.
Case Study
Referral
Elizabeth S, a master’s-level therapist who had been in private practice for 4
years, initiated the assessment aer hearing about my work from a
colleague. She called and explained that she had been working in art therapy
for several years with David, a 28-year-old man, primarily focusing on his
desire to be more successful at work and in his romantic relationships with
women. Both David and Ms. S felt that therapy had helped him but that
recently it laed a clear focus. Ms. S said that sessions oen “meandered”
and covered many topics. She reported that David had been diagnosed with
aention deficit disorder (ADD) when he was a ild but that privately she
wondered if he had bipolar affective disorder or a dissociative disorder or
had been sexually abused. She asked if a psyological assessment could
address these issues and give direction to the floundering therapy.
I replied that no test could say for certain whether someone had been
abused or had bipolar disorder but that I could investigate these issues as
part of an assessment. I also told Ms. S that oen a midtherapy psyological
assessment helps document progress to date and define new goals. We
agreed that she would ask David to call me to discuss the assessment and
that I would get ba in tou with her if he called. I said I would mail her
two information sheets about erapeutic Assessment—one for referring
professionals (see Exhibit 9–1) and one for adult clients—and asked her to
pass the laer on to David when she talked to him about doing the
assessment. Last, I asked if she had shared her questions for the assessment
with David; she said that she had and would do so again when discussing
the referral with him.
David called about a week later saying that Ms. S had given him the
information sheet and that he was very interested in pursuing the
assessment. I asked about his goals for the assessment, and he told a similar
story to Ms. S. He had been in therapy for over 2 years, felt it had helped
him get to know himself, but he was still struggling with two major issues:
relationships with women and disorganization. He aributed the laer to his
ADD, diagnosed when he was a ild. He wondered why he had never
responded well to Ritalin™ or other psyostimulant medications and asked
if the assessment could help explore that question. I said I believed it could.
We discussed the cost of the assessment and set a time for an initial meeting.
I asked David to think about specific questions he wanted the assessment to
address; he agreed to do this and said he would bring them to our meeting. I
then called and le a message for Ms. S, leing her know that David had
contacted me and promising to call her aer his and my initial meeting.
First Session
When I greeted David in the waiting room the first time, he bounced up
quily from his seat and shook my hand vigorously. I was stru by his
youthful appearance and his high energy We walked ba to my office
where he threw himself on the cou. He said he was looking forward to the
assessment, and he talked quily and animatedly throughout the first 15
min of the 90-min session. During the meeting, we worked together to
develop questions he wished to address in the assessment, and I collected
baground information relevant to ea of his questions:
(1) Do I really have ADD and if not, why do I have trouble concentrating
and remembering things?
(2) Why can’t I break up with girlfriends when they’re treating me badly?
What in me is too weak to do this?
(3) Why is it so hard for me to be alone?
Regarding the first question, David explained that he had been diagnosed
with ADD at age 10 aer his teaers complained that he didn’t pay
aention in sool and or complete homework assignments. He also
mentioned being tested at age 14 because of his “complete disorganization”
but knew nothing about the results or the person who evaluated him. David
now experienced similar organizational difficulties in his work as a
computer tenician and had been denied promotions because he was not as
productive as his co-workers. When I asked for an example of how his ADD
showed up, he said he struggled to remember instructions from his
supervisors. Typically, aer meeting with one of them, he couldn’t
remember what they had told him. When I first inquired, David could
identify no contexts under whi his memory and aention problems were
beer or worse. When I urged him to think more, he concluded that on days
when he felt “agitated,” he had more trouble paying aention, but he did not
know what caused him to feel agitated. David’s doubts about the ADD
diagnosis—reflected in his first assessment question—stemmed from
comments Ms. S had made in therapy and from his own recognition that the
medications he took for ADD “rarely did any good.” However, if ADD was
not responsible for his aention problems, he did not know what was. He
explained that currently he was not taking any psyostimulants; his current
psyiatrist had prescribed Luvox™, but he said he oen forgot to take it
and did not know if it helped.
Regarding his romantic relationships, David explained that he had a series
of girlfriends who treated him badly, yet he hung on to the relationships
because he “was in love with them” and felt “it was beer than being alone.”
He described a common paern. Initially he would start dating a woman to
whom he was not that aracted thinking, “It’s not the greatest thing in the
world, but I can leave her if I meet someone beer.” en, within several
months he would find himself feeling insecure and possessive and would
accuse his girlfriend of being unfaithful. Eventually he would discover he
was unable to break off the relationship even if the girlfriend were treating
him terribly. For example, his most recent girlfriend had been sexual with
David’s best friend and then told him about it. He forgave her for this; then
she went on to have sex with yet another of his friends. Once again, David
was willing to continue the relationship, but the girlfriend ended it, saying
that she was tired of David’s being “so needy.”
Although this comment stung, David said he recognized the truth of it—
hence his third assessment question, “Why is it so hard for me to be alone?”
He explained that typically he worked hard to find a new romantic
relationship as soon as one ended. At the time of the assessment, he had not
dated for 2 weeks—his longest period since age 18—mainly at the urging of
Ms. S. He found this situation near intolerable in that the “pursuit of a
woman” distracted him and kept him “out of bad feelings.” He said he hated
being alone because he always felt “lost and empty.” He coped by (a)
planning activities that involved others, (b) wating television, and (c)
frequently moving to new cities where he would get caught up in the
excitement of meeting new people. In fact, recently he had been considering
another move. I asked David what he would feel if he didn’t do these things.
He replied, “Chaos, lost, blaness, panic.” I remember thinking at this point
in the session that he looked like a lost, small boy. Finally, I asked David
how he would answer his own assessment question (about being alone) if he
had to make his best guess before we did any testing. In reply, he told me
about his early history.
When David was 7 years old, his parents divorced. He had no idea at the
time that his parents were having marital problems and was extremely
surprised by the separation. Following the breakup, David lived first with his
father and saw his mother 1 day ea month. His father was quite depressed
during this period, had severe financial problems, dated a lot of women, and
smoked marijuana a great deal. Because of these issues, David eventually
went to live with his mother, who also was “very confused and sleeping
around.” When he was 10 years old, David’s mother married his stepfather, a
“very strict man” who “didn’t like ildren.” When he was 11, David began
experimenting with marijuana and got in trouble for stealing liquor from his
parents. In high sool, he “calmed down” and was able to graduate both
high sool and college.
David explained that Ms. S thought all he had gone through as a ild
made it hard for him to be alone. He said this was possible, but he was not
sure what the exact connection was. He did wonder if he was “always
expecting girlfriends to break up with him because his parents had goen a
divorce.” We also discussed Ms. S’s question about whether he had been
sexually abused as a ild. He said he himself had no inkling of this but that
Ms. S had come up with this idea from some drawings he had done during
therapy. We agreed to keep his ildhood experiences in mind as we
explored his questions for the assessment.
At the end of the session, I read aloud the questions David and I had
developed together. He said he liked them and that he was excited about the
assessment. He agreed to help me tra down the professional who had
tested him at age 14, saying that he would ask his mother for her name. He
also signed a release for me to talk with his current psyiatrist and gave me
permission to talk more with Ms. S about him and his therapy. Finally, we
set up several appointments over the next several weeks for David to come
in for testing.
Contacts With Collateral Sources
Prior to my next meeting with David, I worked to gather baground
information from other health professionals who had worked with him.
First, I seduled an appointment to meet Ms. S at her office. I oen do this
when consulting with therapists I have not worked with before, finding that
it helps the two of us work as collaborators rather than as competitors
during the assessment (see ap. 9). Ms. S served me tea and seemed to
appreciate the opportunity to talk about her work with David. It was clear to
me that she cared about him a great deal and was concerned about whether
she was helping him. She worried that she was “missing something” ajnd
confessed that she was not very sophisticated in psyodiagnosis. I asked for
more information about her three questions: (a) Does David have bipolar
disorder? (b) Does he have a dissociative disorder?, and (c) Was he sexually
abused as a ild? She explained that the first question came from talking to
David’s current psyiatrist, Dr. K, who had mentioned this possibility. Ms.
S wondered about the dissociative disorder because David so oen had
trouble remembering things. I asked if she had ever seen him in a
dissociative state or whether he ever reported depersonalization, dere
alization, amnesia, or evidence of separate identities. Ms. S said that he did
not, nor had she witnessed any of these phenomena. Finally, she showed me
several drawings David had produced in therapy sessions and explained
how the colors and placements of various objects in the drawings fit with art
therapy theories about sexual abuse. I listened respectfully and asked if
anything else had made her wonder about abuse. Again, she said she was
concerned that she was missing something with David and that she was
confused why he let girlfriends “abuse” him so. We parted with a good
feeling between us, agreeing to stay in contact as the assessment progressed
and to meet again when I had completed the testing with David.
Next, I called Dr. K, the psyiatrist who was treating David, and learned
that he had seen David only two times. He explained that various physicians
had prescribed a number of psyostimulants over the years for David, with
lile positive result. Dr. K said David was “hard to get a read on” and that he
wondered if the ADD symptoms weren’t due more to a bipolar or
cyclothymic process. Dr. K had prescribed Luvox™, an antidepressant
known to decrease anxiety, but David had not been on it long enough at
their last meeting to know if it was helping. Dr. K said David was due for a
follow-up appointment very soon in whi he would assess the success of
the Luvox. He asked me to let him know the results of the assessment as
soon as I could.
Several days aer our initial session, David called to say that his mother
had located a copy of the report from his evaluation at age 14. He said it was
interesting and that he would drop it by my office. e report described an
aievement and language evaluation done by a PhD spee-language
pathologist. At the time, David’s individual aievement test scores were
high in math and reading, both at the level of a high sool senior. However,
his spelling and wrien language skills were mu weaker and the report
concluded “David’s ability to organize his wrien work… is quite poor. It is
quite likely that many of David’s behaviors whi are aracterized as
‘irresponsible’ are actually a result of his difficulties in the area of
organization.”
Standardized Testing Sessions
Second Session. When David returned for his next session, I noticed
immediately that he seemed calmer. He said it had been good for him to ask
his mother about the earlier assessment and that she had expressed guilt
about ways her parenting might have affected him. He had not known how
to respond and he expressed hope that Ms. S and I could help him think this
through. I said I would be glad to help. We looked at the report from the
assessment together and agreed that it supported his belief that his problems
with organization went way ba. I asked if the evaluation had made mu
difference in the way his teaers responded to him; he remembered geing
some coaing on study skills but said he felt teaers still thought his poor
sool performance was his “fault/’
In erapeutic Assessment, the assessor begins standardized testing with
those instruments that seem most related—on the basis of face validity—to
the client’s main concerns (see ap. 1). us, I asked David to complete a
self-rating scale (the Aention Deficit Scales for Adults; Triolo & Murphy,
1996) for adults regarding ADD symptoms. When he finished, I quily
scored and ploed the results, and David and I examined them together. His
scores indicated that he saw himself as having long-standing problems with
aention, concentration, organization, and short-term memory, and that
these problems caused him distress and affected him negatively in his social
and work relationships. I explained to David that although these results
were consistent with ADD, they did not prove it. I then showed him a
diagram I had copied from a professional article (Forness, Kavale, King, &
Kasari, 1994), depicting how aention and concentration problems can have
many sources other than ADD. David found this quite interesting, and our
discussion provided a good segue to the next part of the session in whi I
interviewed him about symptoms of bipolar spectrum disorders, asked about
his current drug and alcohol use, and had him complete the Dissociative
Experiences Scale (Bernstein & Putnam, 1986).
David did describe some discrete periods of hypomanic mood, oen
lasting several days, when he felt “on top of the world” and that he could
“do anything.” During su times, he would sleep 4 to 5 hours a night,
engage in some impulsive buying, and contact old friends around the world.
However, none of these behaviors was ever severe enough to cause him
social or financial difficulties. Typically, these periods would end with a
“crash” aer 2 to 3 days, but David said he had never had a prolonged
episode of depression because he always “got {himself} out of them” by
being busy or hanging around people. As far as he knew, no one in his
extended family had highs like he described or had ever been treated for
bipolar disorder. He believed his mother had been on and off
antidepressants, but he had never discussed this with her. Interestingly,
David said he believed his aention and concentration were actually beer
than usual during his “highs.” On this basis, I hypothesized that su periods
were unlikely to be the major cause of his memory problems.
Regarding drug and alcohol use, David said that at the time of the
assessment he drank two to four beers a week but several times a year
would “tie one on.” He no longer smoked marijuana, in part because his job
required periodic drug screens. On the Dissociative Experiences Scale, David
scored very low and we discussed the few items he endorsed at all—one
indicating occasional memory difficulties and one in whi he said he could
occasionally do things with ease that were typically difficult for him. When I
asked about the laer item, David explained that when he felt on top of the
world, it was easier for him to approa women at parties. At the end of the
session, David and I discussed what we had learned so far that day: He had
long-standing problems with aention, concentration, and organization, but
those problems were not due to drug and alcohol use nor to “phasing out”
(the words we used for dissociation). He did have some periods of
hypomanic mood, had never had a major depression, and at least by his
report, the hypomania didn’t account for his ADD-like symptoms. At the
end of the session, David seemed thoughtful and grateful for my having
included him in my thinking. We set up a time for him to complete the
Minnesota Multiphasic Personality Inventory-2 (MMPI—2; Buter,
Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) under the supervision of
my testing assistant, then reaffirmed our next appointment together.
Following the session, I called Ms. S and le a message on her phone
maine describing the session and what I thought David and I had learned.
ird Session. At the beginning of our next session, David talked about
his experience of the MMPI—2. He joked about being aracted to my female
testing assistant, then described doing the MMPI-2 in one siing with no
breaks, saying he found it remarkably easy to concentrate while he was
doing it. I asked what he thought made the difference; he said he felt calmer
and more aentive since we began the assessment but could not say why. I
told him I had not scored his MMPI-2 yet and wanted to do another test that
day that would provide information about his relationship difficulties. He
agreed and I then administered the Rorsa, using the standard
administration from the Comprehensive System (Exner, 1995).
In erapeutic Assessment, one oen follows standardized test
administration by engaging clients in targeted, collaborative discussions of
their experience of a test or of their responses. Aer the Rorsa, I asked
David about the personal meanings of what he had seen on the cards, mu
as in Harrower’s (1956) projective counseling tenique. First, I explained
that there were several ways to use the Rorsa to understand someone. I
would be carefully scoring David’s responses and referring to the wide base
of available resear to compare his responses to those of other people.
However, another way was to look at his responses as possible symbols or
metaphors of how he experienced himself and the world. I asked if David
would be willing to look over the cards again to see if any of his responses
stru him as meaningful in that way. As we reviewed the cards, he
immediately brought up his first response to Card I (“Maybe two winged
creatures holding onto a middle pole. [Inquiry] e middle core is here.
ese are the two creatures on either side, the legs, arms holding on, wings,
heads”).
David: Sometimes I’ve felt like this. I see them holding on for dear life.
If they let go, they’re likely to get blown away or fall.
Steve: And you relate to that type of situation?
David: Yes, that’s what I feel if I don’t keep busy. Like I’m going to fall
into an abyss.
Steve: And what’s in the abyss?
David: [oughtfully] I don’t know…. Terrible feelings, I guess. I don’t
know any more than that.
Steve: And when you look at these creatures on the card, how do you
see them? Are they likely to fall, or will they make it? David: I think
right now they’re holding on, but if they let down their guard, they
could slip and fall.
Steve: And does that feel like you also?
David: [Long pause] I’m not sure. I mean, I guess I act that way…like I
have to hold on hard or something terrible will happen.
Steve: And is that why it’s so difficult to be alone?
David: Yes, ‘cause that’s when the abyss feels closer. I don’t want to
fall.
Steve: And how about right now? Does it feel the same?
David: [Pause] Again, I’m not sure. But it somehow doesn’t seem as
scary.
Steve: What doesn’t?
David: Leing go. Like I can imagine these creatures loosening up a
lile and nothing awful happening.
Steve: Any sense why it doesn’t seem so scary right now?
David: [Laughs] Perhaps because I’m not alone. You’re here too. Steve:
Yes, perhaps that’s it.
David and I also discussed two responses that were very similar to ea
other on Cards III and VII. e laer response was:
It also looks like it could be one of those oil derris. It reminds me of the other one [on Card III].
You can see where they lit it on fire and it’s burning, with the large flame coming out of the top.
[Inquiry] It’s like the other one. It kind of reminds me of those pictures from Kuwait in the Gulf
War. Here is the oil derri coming out of the ground; the white part is the fire. It’s being
destroyed.
At first David’s only thoughts about these responses concerned the TV
news of the Gulf War. “It reminds me of the Kuwait oil situation. I saw it on
TV Some friends of mine were firefighters. We were interested in Red Adair,
a specialist who puts these kinds of fires out.” I then asked for any symbolic
interpretations, whi led to the following discussion:
David: I know sometimes I feel like that—like a fire that’s difficult to
put out.
Steve: How so?
David: It’s those times I told you about, when I feel agitated. It’s like
there’s something hot and dark boiling in me and I don’t know
what to do about it. It’s so out of my control, just like those fires.
No one knew how to handle them. Steve: Except for Red Adair?
David: [Smiling] Yep. Perhaps I’m looking for an expert like that who
knows how to handle me and can tell the other people what to do.
As I smiled in return, I imagined David might be hoping I could play that
role.
Standardized Test Results
David’s basic MMPI-2 profile is presented in Exhibit 10–1, the Content
Scales are presented in Exhibit 10–2, and the Harris-Lingoes subscales are
listed in Exhibit 10–3. As I have come to expect in a collaborative
assessment in whi the client’s goals are being addressed, David produced
an unguarded MMPI-2 profile (L = 39T, K = 47T). e MMPI-2 code type
(7”948’) suggested severe anxiety (A = 75T, ANX = 77T) and some cognitive
disruption (Scale 8 = 70T Sc3 = 78T) that David was handling by keeping
busy, being very social, and engaging in occasional impulsive, defiant
behaviors (Pd2 = 61T). e MMPI—2 also suggested that he was a very
sensitive man (Pa2 = 69T; Mf2 = 69T) who was gregarious and probably had
lots of superficial friendships but that he would find it difficult to trust
people enough to form intimate, lasting relationships. Several scores
suggested that under David’s autonomous, energetic exterior (Ma4 = 76T),
he might feel discouraged, insecure, and somewhat depressed (D1 = 69% D5
= 7 AT). I took special notice of the elevation on Scale 9, given Dr. K’s
concern about bipolar disorder. A “Caldwellian” (Caldwell, 2001)
interpretation of David’s profile suggested that David’s anxiety, busyness,
and defiance were adaptations to a ildhood in whi adult caretakers were
unpredictable, unreliable, and oen critical. By keeping busy, failing to meet
responsibilities, and worrying, David would distract himself from feelings of
emptiness, grief, and terror (Caldwell, 2001). Caldwell also posited that
elevations on Scale 7 (and the anxious worrying they depict) are the result of
clients’ being traumatized by shoing, unpredictable occurrences. I found
this interesting given David’s report that he was caught quite off guard by
his parents’ divorce.
EXHIBIT 10–1 David’s Basic MMPI-2 Profile
Note. VRIN = Variable Response Inconsistency Scale; TRIN = True-Response
Inconsistency Scale; F = Infrequency; Fb = Infrequency Ba Page; Fp = Infrequency
Psyopathology; S = Superlative Self-Presentation; Hs = Scale 1, Hypoondriasis; D =
Scale 2, Depression; Hy = Scale 3, Hysteria; Pd = Scale 4, Psyopathic Deviate; Mf =
Scale 5, Masculinity—Femininity; Pa = Scale 6, Paranoia; Pt = Scale 7, Psyasthenia; Sc =
Scale 8, Sizophrenia; Ma = Scale 9, Hypomania; Si = Scale 0, Social Introversion.
Source. is and other MMPI-2 profiles are excerpted from the MMPI-2™ (.Minnesota
Multiphasic Personality Inventory-2™) Manual for Administration, Scoring, and
Interpretation, Revised Edition,Copyright © 2001 by the Regents of the University of
Minnesota Press. All rights reserved. Used by permission of the University of Minnesota
Press. “MMPI-2” and “Minnesota Multiphasic Personality-2” are trademarks owned by
the Regents of the University of Minnesota.
EXHIBIT 10–2 David’s MMPI-2 Scale Profile
Note. ANX = Anxiety; FRS = Fears; OBS = Obsessiveness; DEP = Depression; HEA =
Health Concerns; BIZ = Bizarre Mentation; ANG = Anger; CYN = Cynicism; ASP =
Antisocial Practices; TPA = TypeA; LSE = Low Self-Esteem; SOD = Social Discomfort;
FAM = Family Problems; WRK = Work Interference; TRT = Negative Treatment
Indicators.
EXHIBIT 10–3 David’s Scores on the MMPI–2 Harris–Lingoes Subscales
Subscales T Score
Depression
Subjective Depression (DI) 69
Psyomotor Retardation (D2) 48
Physical Malfunctioning (D3) 43
Mental Dullness (D4) 58
Brooding (D5) 74
Hysteria
Denial of Social Anxiety (Hy 1) 45
Need for Affection (Hy2) 51
Lassitude–Malaise (Hy4) 66
Somatic Complaints (Hy4) 67
Inhibition of Aggression (Hy5) 48
Psyopathic Deviate
Familial Discord (Pdl) 51
Authority Problems (Pd2) 61
Social Imperturbability (Pd3) 52
Social Alienation (Pd4) 62
Self Alienation (Pd5) 72
Paranoia
Persecutory Ideas (Pal) 52
Poignancy (Pa2) 69
Naivete (Pa3) 60
Sizophrenia
Social Alienation (Scl) 59
Emotional Alienation (Sc2) 50
La of Ego Mastery, Cognitive (Sc3) 78
La of Ego Mastery, Conative (Sc4) 61
La of Ego Mastery, Defective Inhibition (Sc5) 51
Subscales T Score
Hypomania
Amorality (Mai) 50
Psyomotor Acceleration (Ma2) 58
Imperturbability (Ma3) 59
Ego Inflation (Ma4) 76
Note. MMPI–2 – Minnesota Multiphasic Personality Inventory–2.
David’s Rorsa results are presented in Exhibits 10–4 and 10–5.1 In
contrast to the MMPI—2, the Structural Summary suggested a severe
underlying depression (DEPI = 6, S—CON = 9) that most likely was long-
standing (CDI = 5) and that was overwhelming David’s coping meanisms
at the time of the assessment (Lambda = .13, D = −2). I have previously
described this kind of discrepancy between the MMPI—2 and Rorsa,
seen so frequently in situations like this in whi a client is referred for
evaluation by a therapist who is puzzled and concerned about a la of
progress in therapy (Finn, 1996a; see ap. 7).
1 I am presenting the fourth edition of the Structural Summary (Exner, 1995), as this is what was
available at the time I was working with David.
EXHIBIT 10–4 e Sequence of Scores for David’s Rorsa
Card and hoc Determinant(s)
Special
Response and and Form (2) Content(s) P Z
Scores
Number DQ Quality
I 1 W+ Ma+ 2 (H), Hh 4.0
2 WSo FMao Ad 3.5 AG
II 3 WSo F– Ad 4.5
4 WS+ ma.CF.C’o Sc, Fi, Na 4.5
III 5 D+ Mao 2 H, Hh P 3.0
Card and hoc Determinant(s)
Special
Response and and Form (2) Content(s) P Z
Scores
Number DQ Quality
6 DS+ ma.C’F– Sc, Fi, Na 4.5
IV 7 Wo FDo (H) P 2.0
V 8 Wo FMao A P 1.0
VI 9 W+ FY.FC’o Art, Ad P 2.5
PER,
10 D+ ma.C’Fu Sc, Fi 4.0
MOR
VII 11 WS+ ma Sc, Fi 4.0
VIII 12 W+ Mau 2 A, Na, Art P 2.5 COP
13 Wo Fu Art, Sc 4.5
IX 14 Wv CFu (Ad) AB
X 15 Wo FC– 2 A P 5.5
EXHIBIT 10–5 e Structural Summary for David’s Rorsa
Unlike some clients I have seen requesting evaluation for ADD, David
showed no ideational disturbance (WSum6 = 0) on the Rorsa. However,
his mediation scores suggested that he viewed the world quite differently
from most people (X + % = .47;X-% = .27;Xu% = .27). Most likely, his
emotional difficulties were affecting his ability to accurately perceive the
world around him. is hypothesis is strengthened if one examines the
Sequence of Scores, as there is an interesting interaction of affect regulation
and cognitive interference in David’s responses. David gave relatively few
responses to the last three cards of the Rorsa, suggesting that he was
baing away from the emotionally arousing aspects of those cards (Afr =
.36). Nevertheless, his perceptual accuracy on Cards VIII to X was
significantly less than on the first seven cards (X + % for Cards I through VII
= .64; X + % for Cards VIII through X = .00). Also, David’s FQ responses
tended to co-occur with S (S–% = .75). All this suggested that although he
was most likely a bright man (DQ+ = 8), David’s ability to think clearly was
compromised when he was emotionally aroused and especially when he was
angry. Given this, it was not surprising that one of his main coping
meanisms was to avoid emotions.
Further examination of the interpersonal aspects of the Structural
Summary helped explain David’s quandary around emotions. In short, it
appeared that David had never learned to use others as supports in
managing difficult emotions (T = 0; COP = 1; Isolate/R = .40; Pure H = 1).
Le to his own resources, David had few options other than to avoid and
shut down emotions, for when he let himself experience emotion, it more
oen overcame his ability to structure it cognitively (FC:CF + C = 1:2). Until
he could get beer at regulating affect, David desperately needed others to
help him contain and process strong feelings. I was reminded of David’s
telling me aer the Rorsa that the “abyss” seemed less close because I
was there with him.
In summary, although it was still possible that David’s aentional
problems were due to ADD, a more parsimonious explanation was that
anxiety and a severe underlying depression were affecting his ability to
aend and concentrate. David may have been depressed for so long—for
example, since early ildhood—that he failed to recognize that he was
depressed. It was also likely that David had developed a kind of perceptual
screening to cope with emotionally arousing situations and that this further
interfered with his ability to remember and focus on the world around him.
David’s fear of being alone and his tendency to stay with uncaring
girlfriends seemed related to this same emotional quandary. Staying busy
and highly social and always being in a relationship were ways David
worked to hold off his underlying painful emotional states. Probably he
knew what it was like to be overwhelmed by su feelings and worked hard
to avoid su an experience. Unfortunately, the things he did to help himself
contributed further to his already shaky self-esteem (3r + (2)/R = .27). In the
absence of other evidence, there was no need to invoke repressed sexual
trauma to explain David’s behavior in relationships; his Rorsa gave
ample evidence of why he would let himself be treated badly by girlfriends.
Furthermore, although no test can accurately indicate whether a client has
been sexually abused, neither David’s MMPI—2 profile nor his Rorsa
showed paerns associated with past abuse (e.g., Kamphuis, Kugeares, &
Finn, 2000).
Last, regarding the question of a bipolar spectrum disorder, I viewed
David’s test results as equivocal. He did have an elevation on Scale 9 of the
MMPI—2, and his Structural Summary showed some features common to
individuals with bipolar disorder (H. K. Singer & Brabender, 1993). However,
the Rorsa showed no signs of severe bipolar disorder (e.g., WSUM6 = 0).
As was clear from my interview with him, David did have some hypomanic
periods, but the testing suggested no psyotic process was present at the
time that I tested him.
Assessment Intervention Session
In erapeutic Assessment, assessment intervention sessions are special
testing sessions sometimes conducted aer standardized testing is completed
to explore working hypotheses about clients’ problems in living and give
them a ance to collaboratively rea new understandings (see ap. 8).
When David and I met next, I set out to explore my hun that emotional
flooding was largely responsible for his aentional problems. I also
hypothesized that quite oen, David was close to painful feelings of grief
connected to his ildhood experiences. With these thoughts in mind, I
prepared four or five alternate number recall tasks, similar to the Digit Span
subtest on the Wesler Adult Intelligence Scale-Ill (Wesler, 1997). I also
reviewed and selected several ematic Apperception Test (TAT; Murray,
1943) cards for us to do.
David arrived looking very upset; he confided that he had just had a fight
over the phone with his ex-girlfriend and was still very angry. I listened
while he vented for a short time then interrupted and said I wanted to use
this opportunity to e out some things I thought I understood about his
problems with aention and memory. Was that OK? He said it was, so I first
asked him to rate how agitated he felt at that moment on a scale ranging
from 0 to 10, with 0 being not agitated at all and 10 being the most agitated
he’d ever felt. He rated his agitation at 10.1 then administered the first
number recall task. David did quite poorly, being able to remember only
four digits forward and three digits baward. He agreed this was no
surprise, as he had said previously that he could not remember things at
times he felt agitated. We then worked to find out what would decrease his
agitation. First, we tried simply talking more about the situation with his
girlfriend, with me listening carefully and mirroring ba what he said. is
brought his agitation down to a 7.1 then led him in a short relaxation and
breathing exercise, aer whi he rated his agitation as 5. We then did
another digit recall task; this time he did beer and remembered seven digits
forward and five baward. Aer we finished, we talked:
Steve: Well, what did you notice?
David: I could remember more that time. I wasn’t so distracted. How
well did I do?
Steve: at was a normal average score. David: Really? at’s good to
know.
Steve: And perhaps we’ve also learned something about what’s going
on when you’re agitated, and what helps to calm you down.
David: You mean like when I feel agitated, I might be angry, and I need
to talk and get over it and maybe slow down and breathe?
Steve: at seems like one possibility Does that fit for you?
David: Yes … [Tentatively]. Although I’m not sure I’m angry all that
mu.
Steve: I believe you, let’s try one other thing.
I then pulled out the TAT cards I had selected and asked David to tell a
story to card 3BM (using the standard instructions). His story was as
follows:
is looks like a woman who is so confused that she’s dropped to the ground where she was
standing and had a mental shutdown. She looks very distraught and grief strien. Before she was
geing ready to go somewhere. She was all dressed up. But then she got some news of some kind
—a phone call or a leer—horrible news. She dropped everything, fell to the ground, and her mind
stopped. [Steve: Aer?] She came ba to reality and the reality of it hit her again. But then she
cried for an hour until she fell asleep.
Following the story, David rated his level of agitation at 7 and we did yet
another digit recall test. is time he could only remember six digits
forward and five baward. We noted this and he took a moment to tell me,
“is picture is what happens to me when I get a big sho. My brain has a
meltdown.” I asked for times when he might have felt like this, and he told
of a ildhood incident aer his parents divorced. His father and he were
going out to dinner and David got angry over something. His father said he
could not go because he was mad and then le him. He eventually came
ba and got David, but David had been near hysterical with fear in the
meantime. I then selected another TAT card (13B) and asked David to tell me
a story to fit that picture:
It looks like a lile boy who’s got more on his mind than a boy his age should have on his mind….
He’s thinking hard and emotions are flying around his head. He almost looks adultlike, but he’s a
ild. It looks like maybe his parents are ildren as well as him. e adults in the family are
acting like ildren and the ildren are being forced to act like adults without wanting to. He’s
being forced to be alone. e family doesn’t know what’s going on. Feelings are washing over
him. [Steve: What does he need?} He needs parents that are actually adults and that have wisdom.
He needs someone to treat him like he’s a ild, so he doesn’t have to be so self-reliant.
At that point David began to cry. We talked quietly together as he
explained that this picture reminded him of himself as a ild. He said that
he and Ms. S had talked about this period of his life, but that he never let
himself really feel what it was like. We agreed that he had been a tough kid
who had tried hard to act like a grownup and that this paern was hard to
break. David slowly calmed, then sat up, turned to me, and anged topics:
David: I don’t think I have ADD aer all. Steve: Tell me more.
David: I think this is all about feelings. I can’t concentrate when I have
too many feelings. My brain melts down and I can’t think. And
there are so many things I have stored up inside—that I’ve never
goen to—and it’s bad for me. I’ve been holding all this in for too
long and I’ve got to stop running.
Steve: I think you might be right. And it’s like you said last time—you
can loosen up a bit and you don’t die.
David: You’re right. I actually feel good geing into this. is is what I
need to do with Elizabeth. Can you tell her?
I told David I would be glad to help and I reminded him that our next
meeting was a joint one with Ms. S to review the results of the assessment. I
also said I would be talking with her before that meeting and would
certainly pass on what we had discovered.
Consultation With Ms. S
Shortly aer this session with David, I arranged to meet with Ms. S another
time at her office. I had explained that I wanted her thoughts about the
results and her help thinking about how to discuss them with David. I began
by telling Ms. S that I could see why she had been puzzled about David. His
testing suggested he was quite a complicated young man and that it was not
easy to figure out the best way to approa his therapy. Immediately Ms. S
seemed relieved. I also told her it was clear to me that she and David had
formed quite an aament and that I thought she should be proud of this,
as his testing suggested this was not easy for him to do. Again, Ms. S seemed
pleased to have me validate her experience.
en I slowly went through ea of the tests, showing Ms. S the results,
explaining how I interpreted them, and describing in detail my interactions
with David during our sessions. Ms. S was particularly interested in the
projective testing, never having seen how it actually worked, and she gave
additional associations to David’s Rorsa responses based on her therapy
with him. Finally, I summarized my tentative answers to some of Ms. S’s
questions: David did not appear to have a dissociative disorder, might have
hypomanic tendencies, and, as she suspected, his aention problems did not
appear to be due to ADD per se. I was carefully broaing Ms. S’s theory
about David’s having been sexually abused when she broke in:
Ms. S: Oh, I see now that I was way off in that.
Steve: You’ve anged your mind?
Ms. S: Yes. I think I was just grasping for something to explain David’s
la of progress. But you’ve already explained what was going on,
don’t you think?
I concurred, and then Ms. S and I discussed ways she and David could
work differently in therapy to slowly and gently access more of his
underlying painful affect. I explained that while doing this, Ms. S would
need to tea David how to lean on her more as an emotional support.
Without learning this in tandem, he could easily become overwhelmed,
whi would only reinforce the need for him to continue avoiding his
feelings. Ms. S asked me specifically how she could support him and asked
me to discuss this directly with David in our next session.
Summary/Discussion Session
In erapeutic Assessment, we no longer call the sessions at the end of an
assessment “feedba sessions,” as this name implies a unidirectional flow of
information from assessor to client. In fact, when I arrived at Ms. S’s office
for our meeting with David, he was already there and he quily took the
lead in explaining his new insights about how “old feelings” were causing
his “brain to melt down.” I filled in how these same feelings made it difficult
for him to be alone and kept him stu in bad relationships. David then told
Ms. S that the two of them needed to “get at these feelings” and how good
he had felt aer crying during the TAT with me. Ms. S said she was
commied to doing this kind of work with David and asked me to describe
how to make it safe. I then talked with them both about the relationship
between affective management and object relations:
Steve:Imagine that when we’re born, we have a lile container inside
to hold emotions. At first this is the size of a thimble. When it gets
“full” it overflows, and the baby will feel distressed and cry…. If all
goes well, an adult caregiver, usually the mother, then comes and
acts like a “saucer” under the infant’s “cup.” She holds and soothes
the baby, “cating the overflow” of emotion. When this happens
consistently, the cup grows, say from a thimble size to the espresso-
sized cup of a 1-year-old, the coffee cup size of a 2-year-old, and so
forth. If we’ve had enough good emotional saucers, when we get to
be adults we have big “buet-sized” containers inside that let us
hold lots of emotion without being anxious, losing our ability to
think clearly, acting out in self-destructive ways, or geing
depressed__ Of course, we still need emotional saucers, and will
our whole lives. But…we can handle those situations where support
isn’t immediately available. David, from your testing it looks like
you didn’t have reliable saucers growing up and were faced with
emotions no kid could handle on his own. … Now, your job is to
learn to use Elizabeth as a saucer, or you’ll just repeat your
ildhood experience of being flooded by feelings you can’t handle
and feeling all alone with them.
David: So what does that look like to use someone as a saucer? Steve: It
means staying in contact with them and leing then “hold you”
with their eyes and their heart. I bet, if you think about that, you’ve
already had some experiences like that with Elizabeth.
David: [Tentatively] I guess I have. But the whole idea is really prey
strange.
David then asked me directly if I thought the Luvox might help him; I
said it might, explaining it was another way to help manage overwhelming
emotions. He confessed that actually he had not been forgeing to take it,
but that it was incompatible with his “tough guy” aspirations to be on an
antidepressant. I said this was understandable; growing up he had been
treated as if he should be able to handle difficult emotions on his own. is
expectation was unreasonable, and he must have developed shame about
wanting or needing help with his feelings. I then mentioned that David
might even consider some other medications that could help reduce his
agitation and that Dr. K would be the real authority on these. We all agreed
that I would call Dr. K to discuss the assessment and that David and Ms. S
would follow up with him shortly.
Toward the end of the session, David asked about the advisability of
discussing his ildhood experiences with his parents. Ms. S and I concurred
in suggesting he go slowly with that also. I explained that su interactions
might also stir up a lot of emotion for David and that he and Ms. S would
want to prepare for that eventuality. In addition, I recommended that he
think carefully about what he hoped to get out of su discussions. Shortly
aer this, I le, giving David and Ms. S time to discuss the assessment alone
together. ey both thanked me and said my work with them had been
extremely valuable. I offered to be available to either of them in the future,
and David and I talked about the possibility of our having a follow-up
session in about a month. I le feeling quite optimistic that the assessment
had helped the two of them get “unstu” in the therapy and that I could be
a resource if they ran into further problems.
Written Feedba and Immediate Follow-Up
Approximately 2 weeks aer our final session, I sent David a leer
summarizing what we had learned in the assessment (see Appendix). I asked
Ms. S to review a dra of this leer before I mailed it, and I made several
anges based on her suggestions. I also asked David to complete two forms
used in our practice for clients to give feedba aer an assessment: a
questionnaire consisting of a series of open-ended inquiries and the
Assessment estionnaire-2 (AQ-2; Finn, Sroeder, & Tonsager, 1994), a
standardized instrument of clients’ satisfaction with different aspects of a
psyological assessment. I also asked Ms. S to fill out an open-ended
questionnaire concerning her impressions of the assessment.
On the AQ-2, David rated himself as highly satisfied with the assessment
(Total Satisfaction = 60T) relative to a sample of clients who had been
evaluated previously at the Center for erapeutic Assessment.2 His AQ-2
component scores showed that his high satisfaction was based fairly equally
on (a) feeling he had learned new things about himself, (b) feeling more
secure about who he was aer the assessment, (c) liking me and feeling liked
by me, and (d) having few negative emotions during the assessment
sessions. In the open-ended feedba questionnaire, David explained his
feelings in his own words (responses are in italics):
How well did the assessment meet your expectations?
It was far better. I did this mainly because Elizabeth thought it would be helpful. I had no idea it
would help so much.
What part(s) of the assessment did you find most valuable?
The whole thing, but especially crying during the stories. I saw how much I’ve been avoiding my
past and how it affects my memory and ability to think.
What suggestions do you have for improving the way we do assessments?
Can’t think of any.
What would you tell a friend who was considering geing an assessment from us?
Do it! Dr. Finn is a really nice man and you’ll learn a lot about yourself.
Please give any other comments.
I really appreciated the way you included me from the beginning. I didn’t realize you would
listen so much to my ideas and this helped a lot.
2 e standardization sample for the AQ—2 tended to be quite satisfied with their assessments;
thus, the T scores exhibit a ceiling effect.
Interestingly, Ms. S reported similar feelings in some of her wrien
feedba:
How well did the assessment meet your expectations?
Far exceeded. I had heard good things about your work but frankly had no idea the assessment
would be so useful.
What part(s) of the assessment did you find most valuable?
Having the testing validate some of my ideas, while showing others to be red herrings. I now feel
much more secure about how to proceed in the treatment.
What suggestions do you have for improving the way we do assessments?
None, just publicize more what you do!!
Please give any other comments.
Thank you for the respect you showed me during the assessment. I was afraid a psychologist
would come in as the “big expert” and look down on me, but you never made me feel that way
Long-Term Follow-Ups
Approximately 6 months aer the assessment, I got a call from Ms. S asking
if she could consult with me again about David. I said I would be happy to
talk with her and noted the worried tone in her voice. When we met, Ms. S
reported that right aer the assessment her therapy with David had seemed
to have new purpose and clarity. e two of them had begun to talk in more
detail about David’s early experiences in his family and how these related to
his adult relationships. As predicted, David had begun to experience strong
feelings of sadness and anger, and Ms. S had reminded him to use her as a
support. During this time, David had increased his therapy sessions to twice
a week and was taking the Luvox Dr. K had prescribed. About 4 weeks prior
to Ms. S’s calling me, however, David had a particularly emotional session
with her right before she le on a brief vacation. en, while Ms. S was
away, David had rather impulsively and angrily confronted his mother
about his “terrible” ildhood, and she had reacted defensively, blaming him
for being su a difficult ild. By the time Ms. S returned, David was
severely depressed, had been drinking heavily, and was furious at her for
being away He talked alternately about quiing therapy and leaving town
or about commiing suicide. Ms. S had reacted by insisting that David make
a suicide contract with her; he refused and they had spent two very difficult
sessions in a power struggle about this. Finally, the two of them had agreed
that Ms. S would consult with me about what to do.
I sympathized with Ms. S about how scary it was to hear a client talking
about suicide and how frustrating it must have been to have David “jump
the gun” in talking to his mother about his ildhood. I asked Ms. S if she
felt guilty at all about taking her vacation and she confessed that she did. In
retrospect, she wished she had reminded David in that last session she was
leaving so they could have slowed down their work before she went away.
We agreed that might have been good, and that possibly David’s “plunging
in” was his way of acting out his various feelings about her going. Last, I
asked if Ms. S felt she could be a good saucer for David’s feelings of wanting
to hurt himself or flee. She seemed startled when I asked this, then quily
saw that she had been so intent on preventing his acting out, she had not
mirrored at all his desperation, fury, and fears of being hurt all over again.
She told me that at times she was scared by the intensity of some of David’s
emotions. I said I could see why, given what had showed up on his
Rorsa, and I asked if she had enough saucers to hold her while she was
busy holding David. Ms. S laughed and mentioned he was not the only one
who tried to manage difficulties all alone. I said I related to this and
commended her on calling me when she needed help. Two weeks later, Ms.
S called to say that she and David were out of their power struggle and ba
on tra. In fact, the crisis had led to several breakthroughs: David had
anowledged how mu he needed her and how terrified he was of geing
abandoned. Also, his mother had called him, contrite, and asked for a joint
session with him and his therapist. Ms. S and David were carefully planning
how to approa that meeting.
ese events all took place over 6 years ago. Ms. S and I talked briefly
during this period, but in preparing this article, I got quite curious about
what had happened to David. us, I called Ms. S to ask for an update. She
related that she and David continued to work hard in twice-a-week therapy
for about 5 years aer the assessment. David periodically experienced bouts
of serious depression; however, ea time these came up, the two of them
had worked together to help him manage the feelings. Also, aer the crisis I
had heard about, David joined a weekly therapy group to get additional
support when Ms. S was si or out of town. Gradually, David’s moods
stabilized and his romantic relationships improved. In fact, Ms. S told me
that about 1 year ago, David got married to a lovely woman and relocated
because of his wife’s job. ey had a touing and good termination, with
David’s being able to feel sad and anowledge how important the therapy
had been to him. Recently Ms. S had a card from him saying that he and his
wife were expecting their first ild and that if it was a girl, he wanted to
call her “Elizabeth.” Ms. S and I laughed together and talked about our
therapy “ildren” and “grandildren.”
Summary and Conclusions
Admiedly, not every instance of erapeutic Assessment has su an
unequivocally positive outcome as the one I have presented here. However, I
ose this case not only to demonstrate the effectiveness of erapeutic
Assessment, but because it illustrates several important points.
Collaborative Assessment Helps Clients Change eir Life
Stories
How can su a relatively brief procedure as a erapeutic Assessment help
foster su important and long-lasting outcomes for a client? Psyologists
know that normally, people do not ange that easily! As my work with
David shows, collaborative assessment teniques are powerful because they
focus on helping clients “rewrite” the stories they tell themselves about
themselves (whi psyologists usually call identity) when those stories
have become problematic or incomplete in important ways. My purpose
with David was to discover his existing stories, use psyological tests as
“empathy magnifiers” to come up with new possibilities (Finn & Tonsager,
1997), and then provide David with a set of memorable events (su as my
TAT intervention), that would help him revise his self-concept. In this
instance, David’s old story (“I have ADD”) shied to a new story (“I have
too many emotions I’ve never dealt with that are overwhelming my
thinking”), whi led to a new set of actions that gradually anged his
experience of the world. I also had the advantage in this assessment that a
significant figure in David’s life (Ms. S) was able to support his new views
and ways of being and follow up with him as he integrated his new story
into his life.
Compared to other forms of therapeutic intervention, psyological
assessment has the advantage of quily gathering detailed specific
information about clients’ self-semas and interpersonal semas.
Furthermore, when erapeutic Assessment teniques are applied, clients
are enlisted as active participants—in everything from specifying the goals
of the assessment, to collecting collateral information, to helping interpret
test results. I believe traditional assessment approaes—in whi results are
either never shared with clients or are shared as a fait accompli at the end of
the assessment—do not work as well for anging a client’s life story is is
because to all of us as humans, our identities are like precious works of art,
whi we have constructed on the basis of innumerable life experiences and
in whi we have a great deal of ownership, investment, and pride. Resear
has demonstrated that in most cases people will distort or discount
perceptions and information that allenges their existing self-semas to
verify and maintain those semas (Swann, 1997).
It is mainly by presenting clients with significant experiences during an
assessment, whi we as assessors then help to reframe or label in new
ways, that we can assist them in authoring new identities. is type of
collaboration allenges us as psyologists to contain our hypotheses and
insights longer and to give more thought about how to assist our clients in
developing new insights. Psyologists may feel less important and more
like midwives than parents. However, I am convinced that what is lost in
grandiose self-esteem through this process is gained in effectiveness with
clients.
Collaborative Psyological Assessment Is a Powerful,
Nonthreatening Way to Consult to Colleagues
is case also illustrates the potential utility of psyological assessment in
consulting to treating professionals. Others have recognized that assessment
is useful in this way, especially in clarifying diagnostic uncertainties about a
client (e.g., Allen, 1981). However, with the exception of Fiser (1985/1994),
few people have noted how oen diagnostic referral questions actually
reflect more complex treatment quandaries based on the relationship
between client and treating clinician. In my experience, this is no less true
with highly experienced treaters than with therapists like Ms. S, who are
early in their careers. When this fact is fully appreciated, a different view of
assessment as consultation emerges: It is a systemic intervention affecting a
client, therapist, and their relationship (see ap. 9). us, assessors must be
highly skilled in managing complex systems to avoid spliing or becoming
triangulated in an unhealthy way with the therapist—client pair.
In erapeutic Assessment, su pitfalls are avoided by treating both
client and referring therapist as essential collaborators in the assessment. As
already noted, clients are enlisted as co-participant observers throughout the
assessment. is case also demonstrates how the same end is aieved with
referring professionals. I involved Ms. S in ea step of the assessment: (a)
explaining the purpose of the assessment to David, (b) supporting him as the
assessment unfolded, (c) interpreting his test responses, (d) discussing the
assessment results with him, and (e) constructing the wrien summary at
the end of the assessment. At ea stage, I endeavored to take neither a one-
up nor a one-down stance towards Ms. S, to respect her vulnerability in
seeking my assistance, and to openly join her in anowledging the
difficulties of becoming intimately involved with clients like David. As
sometimes happens, this led to her feeling free to consult me again when she
and David reaed another crisis later in their treatment relationship. I
suspect that if more assessors approaed referring professionals in this
collaborative manner, there would soon be even more call for assessment as
consultation to client—therapist pairs in difficulty.
APPENDIX
Excerpts From Feedba Letter to David
Dear David:
As promised, I’m writing to summarize the information we went over in
your assessment feedba session with Elizabeth Smith on June 27,19—. My
hope is that you and Elizabeth will then have a wrien document to refer to
as you proceed in your therapy.
I’ll structure this leer by addressing the questions we came up with for
the assessment. Before doing this, however, let me say again how mu I
respect the way you put yourself into the assessment, David. I am well
aware that psyological testing is a vulnerable and difficult thing for
anyone to do, and I know from your test results that it is not always easy for
you to trust others. I saw the real effort you made to let me see who you are,
David, even when that was a bit uncomfortable. I appreciate the courage
and trust you showed. Also, thank you again for allowing me to videotape
our sessions to use in training other psyologists.
Now to your questions:
—Why can’t I break up with girlfriends when they’re treating me badly?
—What in me is too weak to do this?
—Why is it so hard for me to be alone?
David, your personality test results showed that you are trying to manage
a lot of overwhelming emotions, whi have been around for a long time.
Underneath your energetic and optimistic exterior, you are struggling with a
great deal of depression and sadness, anger (especially at authority figures),
feelings of worthlessness, and a sense of powerlessness. Although you are an
extremely intelligent guy with a lot of varied coping meanisms, this inner
pain has currently exceeded your ability to manage it, with the result that
you are experiencing severe anxiety and periodic bouts of depression. As
you told me, at times it feels that if you let down your guard, you will fall
into an abyss. When you rea this type of situation, you always have the
option of making a large geographic move—as you have in the past—whi
distracts you and provides you new and exciting people to interact with.
Another past option has been to become immersed in a romantic
relationship where you can lose yourself and gain some temporary relief
from your inner pain.
In short, it is your unresolved inner pain that makes it difficult for you to
be alone and that sets you up for geing caught in bad relationships. Until
you can explore and resolve some of the depression and anger you are
carrying, it will be difficult for you to (a) oose good partners for romantic
relationships, (b) set appropriate limits so you don’t get abused by your
partners, (c) feel secure that others are telling you the truth, and (d) stop
from re-creating relationships where you get emotionally abandoned.
As I mentioned in our last session, your longing to be connected to
someone is a good sign—and shows that you haven’t totally given up on
other people. However, until you have resolved more of the issues from your
past, it may be wisest to avoid geing involved romantically and to use
therapy and nonromantic friends for your social and emotional support.
—Do I really have ADD and if not, why do I have trouble concentrating
and remembering things?
As we discussed in our last session, this is a difficult question that we
cannot answer with total certainty at this time. It is clear that you are
distractible and highly active, David, and you have many of the symptoms
of Aention Deficit Disorder. However, as you yourself decided in our next-
to-last session, it is quite possible that your aentional problems are caused
mainly by your anxiety and depression and by your aempts to cope by
staying highly active, “up,” and distracted from your negative moods.
I am fairly certain from the testing and from the stories you told that the
events of your ildhood had a detrimental impact on you. Your parents’
divorce and their inability to help you process your anger and sadness about
their separation probably le you with a lot of confusing and overwhelming
feelings. One of the stories you told to the picture cards seems a good
description of what you probably experienced at the time:
It’s a lile boy who’s got more on his mind than a boy his age should have on his mind. He’s
thinking hard about a turn of events. It looks like he’s not looking at anything. He’s thinking hard
—with lots of emotions flying around in his head. He almost looks adultlike, but he’s a ild. It
looks maybe like his parents are ildren as well as him. e adults in the family are acting like
ildren, and the ildren are being forced to act like adults without wanting to. He’s being forced
to be alone. e family doesn’t know what’s going on. Feelings are washing over him. He needs
parents that are actually adults…that have wisdom. He needs someone to treat him like he’s a
ild, so he doesn’t have to be so self-reliant. (TAT 13B)
If this story is an accurate description of a period in your ildhood, David,
it helps to explain a lot of the problems you are having now. e divorce and
separation were probably quite traumatic for you, in part because you didn’t
have adequate “saucers” to help hold and process the painful emotions you
were experiencing. us, you had to “cut off” whole parts of your emotional
experience and develop ways to manage on your own. ose protected
emotions still exist, as you said, “in deep storage,” and you add to them still
because you continue to manage difficult feelings by avoiding them if you
can.
For now, I recommend that you seek treatment for your anxiety, depression,
and anger—with psyotherapy and medication—and see if this makes an
impact on your aentional problems. If you make significant progress in
addressing these underlying issues and still find yourself highly distractible,
further testing could help identify other neurologically based causes to your
aentional problems.
David, these are the recommendations we discussed in the last session:
(1) ink seriously about your impulse to leave town, as it may represent
an old way of coping with your anxiety and depression. I know you are
unhappy with your current job, but a move will only temporarily
postpone the inner pain you are feeling. It might be best to stay put and
work hard in therapy to resolve your emotional issues.
(2) Keep resisting the urge to get into a romantic relationship, and learn to
rely on Elizabeth and on friends more. I know that you don’t really
know how to do this, as you don’t have mu experience leing others
support you. But keep asking Elizabeth what it would look like to use
her as a “saucer.”
(3) It might be wise to increase your individual sessions with Elizabeth
right now, or to add other supports (su as a therapy group). In either
case, your work in therapy right now is to access your inner pain—lile
by lile—while geing support from others so it doesn’t overwhelm
you. As we discussed, you may find yourself distrusting whether
Elizabeth (or others) can handle your emotions; if so, su feelings also
should be discussed. By alternately exploring your distrust and your
inner pain, you should find yourself less anxious and depressed and
more able to tolerate aloneness.
(4) Your idea of discussing your ildhood with your parents is a good
one. But take time to work with Elizabeth about how to handle the
feelings that could result and to clarify your goals for su discussions.
(5) Work with Dr. K to find an antidepressant that works for you. e
Luvox may or may not be a good drug for you; he and you may also
want to discuss adding a mood stabilizer (su as Depakote™) to help
with your overactivity and agitation.
ank you again, David, for leing me get to know you. I admire your
many strengths and was impressed by how well you manage some very
difficult emotions. If you have any questions or comments about this leer—
or if you would like to sedule the follow-up session we discussed—feel free
to contact me.
One last request: Would you be willing to complete the enclosed forms
about your experience of the assessment and return them to me? Your
feedba will help me work in the future with people in situations similar to
yours.
Best wishes,
Steve Finn
Note
is apter is excerpted from a paper previously published in the Journal of Personality
(Finn, 2003b).
Assessment
11
Collaborative Sequence Analysis of the Rorsa
In this Chapter, I describe how it provid helpful—and perheps essential—
during an assessment to involve a client in jointly interpreting the sequence
of his responses to one Rorsa card. Collaborative sequence analysis is
one of many extended inquiry teniques used in collaborative and
erapeutic Assessment (see ap.l).
Case Study
Baground Information
e client was a middle-aged man, Jeff, who came with his wife, Ann, for a
couples’ assessment several years ago. e couple had been in marital
therapy for over 3 years, aempting to deal with Ann’s long history of
severe depression and Jeff s increasing exasperation that she wasn’t geing
well. Ann had been hospitalized several times, but ea time she wasn’t
good at following through with the aercare that was prescribed when she
was released (taking medication, exercising, etc.). Recently, the couple had
been increasingly distant from one another—with Ann feeling Jeff was less
and less sympathetic about her depression, and Jeff being frustrated when he
came home from work to find that Ann had slept all day, hadn’t cooked or
cleaned, or paid mu aention to the ildren. e couple and their
therapist felt “stu” in the marital treatment, and hoped that a
psyological assessment might shed some light on next steps to take.
Procedures
Exhibit 11–1 shows the general flow art for erapeutic Assessment of a
couple. As you can see, I meet with the couple first to gather questions they
hope to have answered, then perform individual assessments on ea
partner (including the Rorsa and a variety of other tests.) I then
typically follow the individual testing with a Consensus Rorsa (see ap.
12), whi I discuss with the couple, and with 4 to 5 hours of feedba,
where I discuss the individual test results and how these fit together to make
sense of the couple’s problems.
EXHIBIT 11–1 Flow Chart of a erapeutic Assessment
Assessment estions
Exhibit 11–2 shows some of the questions Ann and Jeff came up with at the
beginning of the assessment. As you can see, Ann was puzzled about her
depression, Jeff was trying to manage his frustration and find out how to be
helpful, and both were struggling to know how to relate to one another
other in a more intimate way. Incidentally, in gathering questions from
members of a couple, I discourage those of the form “Why does my partner
do X?”—whi are primarily about the other person. Instead I ask the
individuals to frame questions about themselves or that “include
themselves,” for example, “When my partner does X, why do I feel Y?” My
intent here is to disrupt the projections the two partners put on ea other,
whi I believe sets the stage for therapeutic ange.
EXHIBIT 11–2 Sample estions Posed by Jeff and Ann to Guide the Assessment
Standardized Testing
e events I describe took place during Jeff s individual Rorsa in the
early part of the assessment. I should mention that at this point in the
process, Jeff had produced an MMPI-2 profile that fit his presentation as a
person with no emotional problems, as there were no significant elevations
on any clinical scale. ere was, however, a very low score on Scale 9
(Hypomania), suggesting that Jeff was tired and had very low energy.
While I was giving the Rorsa, I noticed early on a paern in Jeff s
responses that continued throughout the Rorsa: He repeatedly gave
what I saw as “depressive” responses (e.g., including MOR, C, or V) that
were immediately followed by various “defensive” responses, typically
involving intellectualization (i.e., scored AB, Art, Ay, or Sc), sizoid
withdrawal (scored Bt or Ls or Na), or narcissistic defense (Fr). Exhibit 11–3
shows the sequence of Jeff s responses and scores to Cards II, III, and IV Ive
omied the inquiry to simplify the table.
EXHIBIT 11–3 Sequence of Responses and Scoring from Jeff’s Individual Rorsa
Card Free Association Scoring
W+ Ma.FCo 2
II 2 clowns playing pay cake
H, Cg 4.5 COP
Wo FC.V—A,
A smashed bug
B1 4.5 MOR
A buerfly hovering above a creek with WS+ FMp.CFu
trees on the side A, Bt 4.5
DdS99+
III A ripped tuxedo FC’.FCu Cg 5.5
MOR
A picture from National Geographic—2 W+ Mp.mpo 2
native women doing laundry Art, H, Cg P 5.5
Wo FMp.FC’o
IV An upside down bat, hanging by its feet
A 2.0
One of those pictures from the 60s, a “Keep W+ Mp.Fru
on Truing” guy leaning against a mirror (H),Art 2.5 PER
As you can see, on Card II, Jeff saw: (a) two clowns playing pay cake (a
somewhat manic response); (b) a smashed bug (a depressive response that
included both MOR and V); and (c) a buerfly hovering above a creek (a
more sizoid response involving botanical content). On Card III he saw: (a)
a ripped tuxedo (a depressive response emphasizing the aromatic
coloring); and (b) a picture from National Geographic showing two native
women doing laundry (an intellectualized response). His responses to Card
IV were: (a) an upside-down bat, hanging by its feet (that I saw as rather
passive); and (b) one of those pictures from the 1960s, a “Keep on Truing”
guy, leaning against a mirror (another intellectualized picture with
significant metaphorical content). I began to develop a hypothesis that Ann
wasn’t the only member of the couple who was depressed, but that Jeff
warded off his depression with a variety of coping meanisms and “kept on
truing.” As you can see in Exhibit 11–4, Jeff s Structural Summary
confirmed my impression that he was depressed, although I didn’t know
that for sure at the time.
EXHIBIT 11–4 Lower Portion of the Structural Summary for Jeff’s Rorsa
By the way, at the time I had never seen the Robert Crumb “Keep on
Truing” poster Jeff alluded to, but aer looking it up on the internet, I
scored that response to Card IV as unusual form quality because it was rare,
but fit the contours of the blot.
Extended Inquiry
Following my standardized administration and inquiry of the Rorsa, my
next goal was to discuss my hunes with Jeff. I pulled my air around and
asked him, “What was that test like for you?” and “Did you notice anything
in particular about your responses?” He didn’t. I then asked if he would
listen to me read some of his responses and give me his impression. I ose
and read together all the responses that would receive a depressive score. I
asked Jeff what he thought of them. He said they seemed “upseing and
gloomy.” I agreed and told him that all of them would be scored in a way
that indicated depression. He said he wasn’t surprised, and that if he let
himself, he could feel really depressed about the situation at home. I then
asked Jeff how he kept from feeling depressed. He said in his German family,
people didn’t get depressed. One just put one foot in front the other and
went to work ea day. “Oh,” I said, pulling out Card IV, “at explains the
order of your responses on this card.” Jeff asked me to explain. “Your first
response—the bat hanging upside down—gets a score for depression,” I said.
He could see that. “Do you remember your next response?” “e ‘Keep on
Truing’ guy,” said Jeff, with dawning recognition. “at’s what I do! When
I’m depressed, I just keep on truing. And I don’t understand why Ann
can’t do that too.” We then talked about how different people have different
coping defenses, and that Ann might not be able to push her depression to
the side the way he could. Jeff said he could imagine this, and that he had
always appreciated her emotional sensitivity, as contrasted with his family’s
denial of emotions. I asked Jeff if Ann knew that he struggled not to be
depressed too. He said he had never told her because he didn’t want to
burden her. “You mean the way you are burdened by her depression?” I
asked. Jeff smiled and said he could see what I meant.
It’s difficult to describe the wonder and relief that showed on Jeff s face at
that point, as he recognized his own depression, found a framework for his
frustration with Ann, saw that he was being unfair to himself by not talking
to Ann about his depression, and realized that his own mind had given the
key for understanding all this through what he saw on the Rorsa. I felt
excited and good about the session as we said good-bye and Jeff went home.
Ripple Effect in the Couple
What I was not prepared for was the almost immediate systemic shi that
began to take place in the couple. At our next joint session, Ann said that
Jeff had told her that he was depressed too, but just wasn’t leing it show.
She asked if this was true. I had scored Jeffs Rorsa at that point, and was
able to confirm that fact, and Jeff asked that we show her the sequence of his
responses on Card IV We reviewed those responses and also looked at Cards
II and III. (Ann had already completed her individual Rorsa.) Ann
quily saw the paern Jeff and I had seen and agreed with our
interpretation. She said she hadn’t realized that Jeff was depressed too, and
that it made her sad that she hadn’t been trying harder to help around the
house. Jeff said he hadn’t realized that Ann couldn’t just “keep on truing”
the way that he could, and he was sorry that he had been so frustrated with
her lately. ese understandings continued to deepen and be incorporated as
we finished the assessment over the next several weeks, and as Ann and Jeff
returned to their couples therapist, who aended the final assessment
summary/discussion session.
Follow-Up
When I saw the couple for follow-up a month aer the assessment, I was
amazed at the anges that had taken place. Ann was mu less depressed
and was keeping the household together, and Jeff was pushing himself less
and asking Ann for help with various things. I’m still not sure what
happened, but I believe that Ann’s learning about Jeff s depression helped
her access a nurturing, caretaking side of herself that pulled her out of her
depression. As Ann gave Jeff more aention, he felt less frustrated and was
able to be more empathic to her. Also, we might hypothesize that Ann was
“holding” depression for both of them, and that as Jeff anowledged his
own depression, Ann no longer had to be depressed for him. I saw the
couple one more time, 18 months aer the assessment, and they were doing
fairly well. Ann was ba at work and had had no more hospitalizations,
and Jeff reported that he “had [his] wife ba.”
Conclusion
ere were several memorable moments in this couples assessment, but one
of the most important, I think, was the collaborative sequence analysis of
Jeff s individual Rorsa. is case shows the usefulness of the extended
inquiry procedure following standardized testing, and how both the actual
test scores and collaborative discussion come together to illuminate
important paerns in clients’ behavior. is case also shows how in couples’
assessments, one partner’s testing can help the other partner become
empathic to that person’s dilemmas of ange. is by itself can produce far-
reaing systemic anges.
In the following apter I discuss another potentially powerful tool in
erapeutic Assessment of couples: the use of the Consensus Rorsa as a
couples’ assessment intervention.
Note
is apter is based on a paper presented at the XVIII International Congress of the Rorsa and
Projective Methods (Finn, 2005a).
12
Using the Consensus Rorsa as an Assessment
Intervention With Couples
As mentioned in apter 11, my colleagues and I oen use the Consensus
Rorsa—in whi multiple individuals are asked to view the cards and
come up with joint responses—as an assessment intervention in couple and
family assessments. is procedure is extremely useful in exploring systemic
paerns in couples and families, including roles or power struggles, and in
seeing how family members respond to ea other’s emotions and conflicts—
conscious and unconscious—in ways that produce vicious behavioral cycles.
Also, the clinician can assess the flexibility of the family system and its
individual members by aempting to intervene in problematic behaviors.
When su interventions succeed, the couple or family may be able to
generalize what they have learned to the world outside the assessment
office. As su, the Consensus Rorsa can serve as a kind of brief couples’
or family therapy.
e Consensus Rorsa has a venerable history as a group interaction
assessment tenique. As reported by Aranow, Reznikoff, and Moreland
(1994) and Handler (1997), over the years su eminent individuals as
Blanard (1959, 1968), Roman and Bauman (I960), M. Singer and Wynne
(1963), Loveland (1967), Klopfer (1969), Dorr (1981), and Nakamura and
Nakamura (1987) described the use of the Consensus Rorsa with
couples, families, groups of sool ildren, incarcerated youth, and groups
of co-workers. More recently, Aranow et al. (1994), Handler (1997), and Noy-
Sharav (2006) detailed their own variations on the tenique and provided
useful case examples.
As an assessment intervention with couples, the Consensus Rorsa is
used primarily to help a couple become aware of assessment findings that
would be difficult to grasp in a summary/discussion session. I find that the
most difficult Level 3 information for many couples involves systemic or
intersubjective aspects of their “dance” together, that is, how “the behavior
of one partner maintains and provokes the behavior of the other” (H. G.
Lerner, 1985, p. 56). Because most of us develop our “stories” about the world
and ourselves primarily from our subjective experience, we la the data
necessary to fully understand interactional phenomena. For example, we
know that (a) we have trouble communicating about sex with our current
partner, (b) we never had this trouble with previous partners, and
understandably conclude that (c) our partner has a hang-up about sex! We
are unable to see that we may be part of the problem, it’s just that none of
our previous partners have elicited this difficulty from us before in talking
about sex. e Consensus Rorsa as described in this apter can help
illuminate su relational phenomena and help couples move beyond
blaming ea other for problematic interactions.
If you refer ba to the flow art of a couples assessment in the previous
apter (see Exhibit 11–1), you see that I typically administer the Consensus
Rorsa towards the end of a couple’s assessment, aer ea partner has
completed standardized individual testing and individual assessment
intervention sessions and just before the summary/discussion sessions.1 As
you may remember from apter 8, this is the typical placement of
assessment intervention sessions. Very oen, ea member of the couple has
taken the Rorsa alone at this point, but this is not always the case and it
is not necessary. For example, to keep the costs of an assessment down, I
have sometimes met for an initial session where I gathered assessment
questions, gave ea person the MMPI-2, then proceeded at a subsequent
meeting with the Consensus Rorsa, and followed up later with a
conjoint summary/discussion session. I encourage you to adapt this method
to your practice and the needs of your clients.
1 I have on occasion administered the Consensus Rorsa as a stand-alone assessment tenique,
for example in consulting to a marital therapy that is at an impasse. It has seemed to be quite useful in
that context also.
I now go through the steps for using the Consensus Rorsa as an
assessment intervention, and then present several brief case examples.
Procedure
Preparation
Before the couple arrives for the session, review their questions for the
assessment and any individual test results. ink about hypotheses you have
for how these two people “come together,” that is, how do their individual
strengths and struggles contribute to their interactions as a couple? What do
you already know about the type of couple “dance” they tend to do? Does
one person pursue and the other avoid? Is one overresponsible and the other
underresponsible? How would you expect these paerns to be reflected in
the joint Rorsa task? Also, ponder what would be difficult to say to the
couple if you did a summary/discussion session at this point.
en oose one or more of the couple’s assessment questions as useful
foci for the assessment intervention. When the couple arrives, e in with
them so you know any important context. (ey may have had a fight on
the way to the session!) en explain to them that you will be doing a task
you hope will help illuminate the assessment questions you have osen.
Seating
Sit across from the couple—with them next to one another so they can view
ea card at the same time. If possible, videotape the couple as they perform
the first part of the assessment intervention. It is not necessary to have
yourself on camera.
Part 1
Step 1
Let the couple know that you will be asking them to do the “inkblot test.” (If
individual Rorsas have been administered previously, tell them you will
be doing the test again but in a different way.) Give the directions for the
Consensus Rorsa:
I have a series of cards here that have inkblots on them. As I show you ea card, I want you to
talk out loud together about what you see. Your task is to come up with responses that both of you
can see and both of you agree upon reporting. When you agree, let me know and I will write
down your response and ask you some questions about it. Any questions before we begin?
Answer most questions (e.g., Can we take turns? Do we have to say what
we saw before? Can we give more than one response per card?) with the
usual phrase: “It’s up to you.” If the couple tries to report separate responses,
remind them, “Look for things you both can see and both agree upon
reporting.”
Administer—in Order—Cards I, II, IV, VII, and X. is card set was
investigated by Nakamura and Nakamura (1987) and found to be productive
and evocative when used with families. It is possible to use the entire set of
10 cards, and there are some advantages to this, but su a procedure results
in a lengthy (3 to 4) hour session, unless you limit the number of responses
to ea card. For the purposes of the assessment intervention, we have found
this subset of cards to be sufficient and quite useful.2
2 One advantage to using the full set of cards is that the assessor can score the consensus protocol
and compare the scores to those obtained by ea partner on their individual Rorsas.
Noy-Sharav (2006) wrote about this option and about other innovative ways to score consensus
protocols.
Step 2
Observe the couple as they interact, making notes about significant events
and paerns that you see. Intervene in the interactions only if one person
aempts to report a percept that the other has not agreed to. en gently
remind the couple of the instructions: “Did both of you agree on this one?”
or “Do both of you agree on this part of the response?”
Record the responses as they are given and inquire aer ea response
about location, determinants, and so forth. Be alert for pseudo-agreements,
where the partners appear to agree, but in fact are using different areas of
the blot or different determinants. Highlight su discrepancies if necessary
by asking, for example, “Are you sure you’re using the same area of the
blot?” or “Mary, are you seeing it the same way as John?”
Step 3
Aer Card X is completed, let the couple know that you will be giving them
a short break (15 to 20 min). Ask them not to talk with one another about
the Rorsa during this break.
While the couple is on break, review your notes and observations. What
aracteristic paerns or significant events did you witness during the
administration? How might these behaviors be connected to the couple’s
presenting problems and goals for the assessment? See if you can think of
another way that the couple could have approaed the Consensus
Rorsa so as to avoid or mitigate the problems you observed. What did
the couple do well on in the interaction? Choose whi of these paerns and
events you wish to discuss with the couple and cue up the videotape to
illustrative points in the administration. It is particularly helpful if the
excerpts you show clearly relate to one or more of the couples’ assessment
questions.
Part 2
Step 4
Have the couple come ba in the testing room and begin by asking them
about their experiences during the Consensus Rorsa. Be cautious about
sharing your observations at this point; instead inquire about their feelings,
thoughts, and observations—listening for any experiences that seem to fit
with your previous hypotheses or any that seem highly discrepant.
Remember, in collaborative assessment, we prefer to build on clients’
observations and insights if at all possible before we introduce our own.
Step 5 (Eliminate this step if you have not videotaped the
administration.)
Show the couple the section(s) of the videotape you previously selected as
being illustrative. en ask them to comment on what they experienced or
observed wating the tape. I typically start with an open-ended question
like, “What did you notice?”
Step 6
Aer the partners have shared their thoughts, you may decide to share
yours and help the couple draw connections between what happened during
the Rorsa and what happens at other times (e.g., “Is this what happens
when you have to cooperate on a task at home?” “Now I see what you
meant by your communication difficulties!” “John, is this an example on
Card V of what you meant about Mary’s indecisiveness?”). Continue these
discussions until you and the couple understand more about the
interactional paerns you witnessed. You may want to slowly wat
portions of the videotape again, stopping frequently to discuss and share
observations. Try to highlight especially systemic aspects of the interactions,
for example, “Do you see how you both play a part in the paern we saw?”
‘John, what did you notice about your response when Mary did X?” “Mary,
did you notice what you did right aer that?”
Step 7
Ask the couple to think of another approa to the Rorsa task that
would eliminate or alter the problem sequences. Adopt the couple’s
proposed solution or suggest a modification or alternative. en—using any
of Cards III, X VI, VIII, or IX (whi were not administered initially)—have
the couple try out the new approa and observe and/or comment on their
experience. Keep shaping the interaction until the couple feels some success
modifying the problematic paern.
Step 8
If the new approa is successful, explicitly draw a parallel to outside
problem situations, for example, “Do you think you can do the same thing
when you find yourselves arguing at home?” “Mary, what would it take for
you to express your anger like that when you are alone with Joe?” If there is
to be a next session, ask the couple to try out what they learned during the
week, and to report ba at that time.
Alternate Procedures
Sometimes couples who typically have extremely problematic and
conflictual interactions in their daily lives surprise themselves and the
assessor by working together extremely well during the Consensus
Rorsa. In su instances in Part 2, you may cue up videotape excerpts of
especially nice interactions, and initiate a discussion of what allowed those
interactions to take place and what it would take to “export” them to the
couple’s life outside the testing room. If you can, identify specific factors
that made a positive difference and helped “set up” the couple for success.
Another option I have used is to intervene when handing Card X to the
couple in the first part of the administration. I have given the following
instructions: “Now I want the two of you to think about an instance when
you were at your worst together. Can you think of a time together?” I wait
until the couple agrees on a particularly difficult situation they had, then
continue: “Now I want you to do this last card together as if you were in
that situation again. Try to treat ea other the same way and get the same
feelings, but this time while doing the Rorsa task.” Most couples I have
tried this approa with have been able to reenact their problematic paerns
when given these instructions. en I have proceeded with Part 2 of the
Consensus Rorsa, contrasting the partners’ experience before and aer
Card X.
Case Examples
Case 1 —Kathy andJohn
Baground. Kathy and John were in their mid—40s and had been
married 7 years when they were referred by their couples therapist for an
assessment. It was a second marriage for ea. eir major question for the
assessment was “How can we avoid the terrible scenes we get into?” and
they explained that they periodically found themselves in violent physical
fights, oen when they had been drinking, and oen beginning (they said)
with some irrational outburst on Kathy’s part. e implication at the
beginning of the assessment was that Kathy was more of the problem, and
the referring couples therapist confessed to me that she thought Kathy had
borderline personality disorder. Kathy, for her part, was struggling with
shame and regret over her outbursts, but persisted in trying to understand
why she acted this way. One of her assessment questions was “Why am I
acting like su a nut in this marriage when I’ve never acted this way
before?” John seemed quite happy with the idea that Kathy was “the crazy
one,” although he admied that he was quite reactive and cruel once things
started to deteriorate between them.
Individual Test Results. e MMPI-2 profiles I obtained fit with the idea
that Kathy was more emotionally disturbed than was John. Her basic profile
was quite unguarded and had multiple elevations on Scales 2 (797), 3
(7070,4(817),6 (747), 7 (77 7), and 8 (727). To me, the MMPI-2 suggested
significant problems with emotional regulation in a sensitive woman who
felt anxious, depressed, and alienated. I knew from the couples’ therapist
that Kathy came from a family that was quite neglectful and aotic, and I
saw this profile as fiing with that baground. I did remember, however,
that Kathy’s work and relationship history had been extremely stable
(before John) and that she was responsible and well liked at her job. ese
facts puzzled me, as su aracteristics generally do not accompany the
kind of MMPI—2 profile Kathy produced.
John’s MMPI-2 was somewhat guarded and suggested that he, by nature,
tended to keep his “cards close to his est” and “put his best foot forward”
(K = 68T, F = 42T, S = 70T). As might be expected, John had no significant
elevations on the MMPI—2 Clinical scales. He did, however, have a low
score (38T) on Scale 9, whi made me wonder about an underlying
depression.
Given these findings, John’s and Kathy’s Rorsas surprised me, and I
must confess that when I first saw the Structural Summaries, I thought that I
had inadvertently mixed them up. Kathy’s protocol did show significant
indications of problems with emotion management (Afr. = .78; FC/CF + C =
2/5; Pure C = 2) and a great amount of painful longing (T = 3). Also, her
mediation scores suggested that she sometimes had significant difficulties
making sense of the world and of relationships (XA% = .68, M- = 3),
especially when she was caught up in emotionally arousing situations
(almost all her FQ- responses occurred on Cards VIII, IX, and X). However,
Kathy showed less depression, anxiety, and emotional distress on the
Rorsa than would have been expected from her MMPI-2 (DEPI = 3, Y =
1, D = +1, AdjD = +2). Her protocol was not “coarctated” (see ap. 7; R = 31,
Lambda = .39), and I saw no reason why she would feign or exaggerate
psyopathology on the MMPI-2. I could only wonder if she had somehow
come to see herself as more disturbed than she actually was.
John’s testing fit the paern of “good MMPI, bad Rorsa” described in
apter 7. His Structural Summary suggested he had a significant underlying
depression, low self-esteem, and emotional distress (DEPI = 6; 3r+(2)/R = .26,
V = 4; D = −3), that he managed primarily through emotional constriction
and withdrawal (FC/CF + C = 2/0; Afr. = .32; SumC’/SumC = 6/1), and
intellectualization (2AB + Art + Ay = 8). And his mediation and ideation
scores suggested that if anyone in the couple was crazy, it might be him
(XA% = .35, WSUM6 = 34)!
From the integration of the couple’s MMPI—2s and Rorsas, I
developed the hypothesis that the terrible scenes the couple fell into were
actually an example of projective identification in action. John was carrying
a level of pain and disintegration that he kept tightly under wraps; but it
was pushing for expression. I wondered if somehow, he got Kathy to “act
this out” for him, and that she was vulnerable to this dynamic because of
her sensitivity, difficulties with emotion management, and longing to be
accepted. To the extent that the projective identification succeeded, Kathy
ended up feeling ashamed, and John “exported” his shame and “craziness”
and got to feel superior. Kathy, for her part, longed to be taken care of, and
unconsciously benefited from John’s appearing stable and strong mu of
the time. She had grown up in a aotic family and wanted someone who
could protect her. By accepting the role of the “nut” in the marriage, she
helped John appear saner than herself and thereby felt safer. I hoped if my
hypotheses were useful, that the Consensus Rorsa would help me
illuminate these paerns.
Consensus Rorsa, Part 1. Kathy and John said they were a lile
nervous when I eed in, but could not say more about that. When I told
them that we would be using the “couples Rorsa” to explore their
question of why they got into bad scenes together, J ohn rolled his eyes and
groaned. He had greatly disliked the experience of his individual Rorsa,
and he and I had talked extensively about that fact. I got their permission to
videotape, gave them the instructions I laid out earlier, and held out Card I,
whi John took. e following is a transcript of the first part of the
administration:
(e couple looks at Card I and then at ea other.)
John: What did you see?
Kathy: One thing I saw was a buerfly.
John: Hmmm…what else?
Kathy: I also saw a bat with its wings spread.
John: Anything else?
Kathy: Uh huh. A woman…right here in the middle. She’s held prisoner
by these two creatures on the side. I don’t know what they are,
griffins or something. She’s struggling to get away from them but
they have a tight hold on her.
John: Griffins? (skeptically)
Kathy: Yes! (defensively) It’s a mythical creature that’s half eagle and
half lion. Haven’t you ever heard of them? You can see the wings
here, but they also have the tail and fur of a lion on their legs.
John: at one’s too weird for me. (Looks at me and rolls his eyes.) But
I can see the other ones.
Kathy: (looks deflated) OK, let’s use those…unless you saw something
else entirely.
From this interaction, I felt confirmed in my hypothesis about how this
couple functioned intrapsyically. John, as predicted by his MMPI-2, “held
his cards close to his est” and seemed noncommial about Kathy’s first
two highly conventional responses. By not agreeing or disagreeing with
these, he played to Kathy’s desire to be accepted, then got her to “climb out
on a limb” and reveal a mu more vulnerable response. At that point, he
rejected the response, implied that Kathy was crazy, and le her feeling
ashamed and one-down. By accepting this frame and going one-down,
rather than standing up for herself, Kathy helped John stay stable, whi
helped fulfill her fantasy of a calm, reasonable partner. is same type of
paern was repeated on Cards II, IX and VII, with Kathy looking more and
more frustrated and demoralized as the task went on, but seeming unable to
figure out a way to ange the paern.
On Card X, things seemed to come to a head. Kathy started off appearing
to try something different, by asking John to go first, but he easily got her off
tra by using humor and appealing to her care-taking impulses:
Kathy: You go first on this one. What did you see?
John: I don’t remember. I hated these colored ones especially. I can’t
remember what I said. I guess I’ve just bloed it all out. (He smiles
cutely and we all laugh at his pun.) Honey, you know I’m not good
at these things. What did you see?
Kathy: I thought this was a bun of bugs at a party. See here’s two
ants, and a couple of beetles waving party favors. And these are
two crabs…
John: Crabs aren’t bugs.
Kathy: I know, but they’re at the party too.
John: If you say so.
Kathy: What the hell is that supposed to mean! (angrily)
John: Nothing! (innocently) I was just trying see what you saw, but it
doesn’t make sense to me.
Kathy: No you weren’t. You were puing me down.
John: Honey, don’t be so sensitive. See (turns to me)…this is the kind of
thing that happens at home all the time.
Steve: Yes, I know. Kathy, how are you feeling right now? Kathy: Like I
just want to throw the cards at him.
Steve: And can you say why?
Kathy: No I can’t. And even if I could it wouldn’t help.
Steve: Well, I think this is a good time to take a break. I’m going to ask
the two of you to leave me alone for 15 to 20 minutes. I’ll cue up
some portions of the videotape, and when you come ba we’ll see
if we can make sense of what just happened.
Consensus Rorsa, Part 2. When Kathy and John came ba in the
office aer the break, Kathy apologized for losing her temper and John
looked a bit smug. I asked them their impressions of what had happened,
and at first, the “old story” came out, with whi I was familiar:
Kathy: I guess I’m just too sensitive and emotional some times. I don’t
know what comes over me, but I lose my temper. And then, quite
understandably, John gets angry in return, and we get in those big
scenes.
John: I’m glad you got to see this, because this is what happens at
home. And then when we’ve been drinking, it just snowballs until
we’re at ea other’s throats.
I nodded and said I was sure the drinking made it worse. But I thought we
could understand beer what set Kathy off. Would the couple be willing to
wat the videotape with me and see if we could figure that out? Kathy
eagerly said yes. John agreed also, but looked less than thrilled. I showed
them their interactions over Card I, then stopped the videotape and asked,
“What did y’all see?”
Both seemed confused at this point. Kathy commented that John seemed
to be “deferring to her,” whi she said he oen did on maers relating to
“art or emotions or relationships.” John repeated again that he could see two
of the things Kathy saw, but not the third one, explaining that he didn’t even
know what a griffin was. I asked Kathy what she had been feeling when
John rejected her third response, and she admied, “Rejected. It was one of
my favorite responses.” I asked if either had noticed that John never put
forward one of his own responses (they hadn’t) and I showed them Card II
to illustrate what I meant. Kathy looked excited at this point and we all had
the following interange:
Kathy: I see what’s going on. He never has to face rejection. He lures
me out, then shoots me down, and he never runs the same risk.
John: But I didn’t remember what I said, I already told you. And you’re
beer at this kind of thing than I am. You always have been.
Steve: Kathy, do you buy that?
Kathy: No, not really.
Steve: And John, I don’t think you’re doing this intentionally, but I
think something else is going on. You saw some prey gory things
on the Rorsa when you took it yourself, and it was hard…it was
a prey unpleasant experience, as we talked about. You told me
that it was maddening not knowing what a good response was and
that you worried that I would think you were crazy. Remember?
John: Yeah.
Steve: So I wonder if this paern I’m seeing is a way you unconsciously
protect yourself from feeling insecure and vulnerable. And Kathy,
do you know why you play into it?
Kathy: Because I’m so mu hoping that he’ll be able to see what I see.
Steve: Exactly! And also, I wonder if you don’t want John to get off
balance, because that would be scary for you. If that seems right,
let’s see if what we’re seeing here is at all similar to what happens
when you get into those big scenes at home.
ey both agreed that my interpretations might be true, and we went over
a recent fight and tried to apply what we had learned. I then asked them to
think of a different way to do the Rorsa task.
Kathy: Well, I guess I should ask him to go first. Steve: Good idea. Or at
least take turns.
John: But what if I can’t remember what I said?
Steve: Well, you could just look and see what the card looks like today.
Or if you want, you could ask me and I’ll remind you of your other
responses.
John: OK. (I hand him Card III.) I remember this one. I saw two people
whose hearts are being ripped out of their bodies. ey’re in love,
but are involved in a real painful interaction. It’s a painting and the
red symbolizes the broken hearts.
Kathy: at must be how you feel about us.
John: I never thought of it that way.
Steve: And Kathy, can you see what John saw?
Kathy: Yes, clearly, and I feel really sad for John. Steve: John, what is
that like for you?
John: Uncomfortable. I don’t like feeling those things and I don’t like
other people seeing me feel them.
Steve: And can you feel the support in what Kathy’s saying?
John: I guess so.
Steve: And what is that like?
John: I’d really prefer it if I could just leave the room. I feel like you
both have the goods on me now.
John and I then had a long discussion about how sadness and other
“tender” feelings were not considered manly when he was growing up in his
German family. I then was able to make a more compassionate
interpretation, based on Middelberg’s (2001) guidelines, of the dance
between him and Kathy. I hoped this would address his shame:
Steve: And John, I want to say explicitly that I don’t think you got
Kathy to go first with the Rorsa and then rejected her responses
in order to be mean. I don’t think you were even conscious of what
you were doing. As I’ll talk about more next week when we go over
your test results, I think you have a lot of painful feelings inside—
like shame and rejection—that you don’t know what to do with and
that are really overwhelming. You just found a way to have Kathy
hold some of those feelings for you until you could find another
option. And Kathy, you were all too willing to do so, so that you
could have a partner who didn’t appear to struggle with difficult
emotions. Does this make sense?
ey both agreed that it did, and I felt I had prepared them well for the
summary/discussion the next week. In this instance, the assessment
intervention had worked beautifully to help the couple see an interactional
dance that would have been very difficult to explain otherwise. It had also
confirmed a hypothesis I had derived from the standardized testing, and
gave a potent memorable example that all of us could refer to in the work
ahead.
Case 2—Tom and Kirk
Baground. Tom and Kirk were a gay male couple in their late 30s who
sought me out for counseling aer reading a book I co-wrote about gay
relationships (Driggs & Finn, 1990). ey had met 2 years earlier at an
Alcoholics Anonymous (AA) meeting, and had been living together for
about 9 months at the time I saw them. Although they hadn’t requested any
psyological testing, both men seemed to have difficulties puing their
feelings into words, and I suggested a brief couples assessment very early in
our work to “get more information that would help with therapy.” ey were
amenable and had generated questions and ea completed an MMPI—2 by
the time we met for the Consensus Rorsa. eir major presenting issue
was how to manage a pronounced pursuer—avoider dance (Middelberg,
2001) that recurred every time they had a significant disagreement. At su
times, Kirk would push to “talk the issue through” and Tom, aer a few
moments, would grow silent and/or retreat physically. is had resulted in
several scenes where Tom had loed himself in the bathroom and Kirk had
pounded on the door and entreated him to come out for over 30 min.
At the time we did the assessment, I knew just a lile about ea man’s
baground. Both had had serious problems with drug and alcohol abuse,
but were sober at the time, Tom for 4 years and Kirk for 2 years. Both had
histories of trauma and neglect. Kirk had been sexually abused as a ild by
an uncle, and Tom told me that he spent ages 10 to 12 living with his mother
in an abandoned car. So far, I hadn’t collected a lot of information about
su topics, as both men seemed reluctant to talk about their pasts. Neither
had been in individual or couples therapy before coming to see me, but both
were working hard in their 12-step recovery programs. I really admired both
men for the strides they had made and for the support and caring they
showed towards ea other in my office.
Individual Test Results. Tom’s basic MMPI-2 profile is shown in Exhibit
12–1 and Kirk’s in Exhibit 12–2. As you can see, the profiles were
remarkably similar to one another.
EXHIBIT 12–1 Tom’s Basic MMPI-2 Profile
Note. VRIN = Variable Response Inconsistency Scale; TRIN = True-Response
Inconsistency Scale; F = Infrequency; Fb = Infrequency Ba Page; Fp = Infrequency
Psyopathology; S = Superlative Self-Presentation; Hs = Scale 1, Hypoondriasis; D =
Scale 2, Depression; Hy = Scale 3, Hysteria; Pd = Scale 4, Psyopathic Deviate; Mf =
Scale 5, Masculinity—Femininity; Pa = Scale 6, Paranoia; Pt = Scale 7, Psyasthenia; Sc =
Scale 8, Sizophrenia; Ma = Scale 9, Hypomania; Si = Scale 0, Social Introversion.
Source: is and other MMPI-2 profiles are excerpted from the MMPI-2™ (Minnesota
Multiphasic Personality Inventory-2™) Manual for Administration, Scoring, and
Interpretation, Revised Edition,Copyright © 2001 by the Regents of the University of
Minnesota Press. All rights reserved. Used by permission of the University of Minnesota
Press. “MMPI-2” and “Minnesota Multiphasic Personality-2” are trademarks owned by
the Regents of the University of Minnesota.
EXHIBIT 12–2 Kirk’s Basic MMPI-2 Profile
Note. VRIN = Variable Response Inconsistency Scale; TRIN = True-Response
Inconsistency Scale; F = Infrequency; Fb = Infrequency Ba Page; Fp = Infrequency
Psyopathology; S = Superlative Self-Presentation; Hs = Scale 1, Hypoondriasis; D =
Scale 2, Depression; Hy = Scale 3, Hysteria; Pd = Scale 4, Psyopathic Deviate; Mf =
Scale 5, Masculinity—Femininity; Pa = Scale 6, Paranoia; Pt = Scale 7, Psyasthenia; Sc =
Scale 8, Sizophrenia; Ma = Scale 9, Hypomania; Si = Scale 0, Social Introversion.
Both were essentially 2—4—7—8 profiles, consistent with the trauma and
neglect in ea man’s baground. Kirk appeared to be more emotionally
expressive and gregarious than Tom, as indicated by his elevation on Scale 3
(667) and his low score on Scale 0 (42T). Tom was a bit more guarded (Scale
6 = 64T) and reserved (Scale 0 = 64T) as a person. But apart from these
differences, both profiles suggested that the men struggled with mild to
moderate depression, anxiety, and impulse control. I hypothesized that ea
could get emotionally overwhelmed rather quily, but that Kirk was more
likely to move forward in su a state, while Tom was more likely to
withdraw. Neither was likely to be able to step aside at su times to find a
more adaptive solution.
Consensus Rorsa, Part 1. On the day we met for the Consensus
Rorsa, Tom and Kirk said they were doing well together and had just
goen ba from a science fiction convention, an interest they shared. I had
explained that we would be doing a task that might shine more light on
their strengths and struggles as a couple, and as neither had taken the
Rorsa before, I asked if they had heard about the Rorsa inkblots.
Both had, and were excited about geing to take the test. I got their
permission to turn on the video camera, gave them the instructions for the
Consensus Rorsa, and handed them Card I. Without a pause, Kirk
jumped right in:
Kirk: Ooo, this is cool. I see a person being tortured. Here he is strapped
to the table, and these figures on the side are some sort of torture
masters. ey have on big robes and are standing over him
supervising the procedure.
Tom: Neat! And maybe they’ve cut of his head already, or no, let’s say
it’s bent way ba, so you can’t see it. at’s part of how they’re
tormenting him. And he’s either crying…or he’s passed out. What
do you think?
Kirk: Passed out. And would that be the kind of shi they have him in
that you can see through? It’s really flimsy so that he shivers down
there in the dungeon.
Tom: I hadn’t noticed that before. at’s a nice detail.
Kirk: (Pause) Do you see anything else?
Tom: It could also be a damaged bat—the whole thing. ese are holes
in his wings where he’s been shot or something. And these are lile
pieces falling off. Do you see that?
Kirk: Yeah, I like that. And the fact that it’s bla really helps with the
“bat-ness” or should I say “bainess” too. (Both laugh.) Shall we tell
him those two now since we both agree?
Tom: Sure. Good idea. Do you want to or shall I?
Kirk: Why don’t you do one and I’ll do other, and we can help ea
other.
I must say I was fascinated and somewhat astonished as we proceeded
with Cards II, IV, and VII in a very similar manner. e interaction between
the two men could not have been nicer. ey collaborated beautifully, taking
turns, modifying ea other’s responses, and showing openness and
curiosity about what the other saw. And almost every response they came
up with had morbid, aggressive, or traumatic content. Many had FQ-scoring,
but both men could see every one, and they seemed to get great pleasure
from sharing their percepts with ea other.
I felt somewhat guilty as I modified the instructions for the last card, Card
X:
Steve: Good job. Now I want to give you different instructions for this
one. I want you to do the same task, but this time I want you to do
it as if you were in your very worst place together. Let’s think ba
to a recent bad time that you had. Can you think of one?
Kirk: You mean like that last fight we had? When Tom loed himself
in the bathroom?
Steve: Yes. at’s a good one. Tom, do you remember that scene? (Tom
nods tentatively.) I want the two of you to do this card together
with the same feelings you had that day that you fought. OK? Are
you willing? (Both nod; I hand them Card X.)
Tom: (Looking scared.) I saw two spiders, here and here.
Kirk: (Sounding angry.) Well that’s the sorriest, dumb-ass thing I ever
heard! Can’t you come up with something beer than that, you
moron?
At that point, Tom fell silent, his face went white, and he seemed to sink
into the cou. I stopped what we were doing and asked what he was
feeling. He couldn’t talk at first, then said he felt paralyzed and that he
couldn’t think clearly. Kirk was immediately concerned, put his hand on
Tom’s knee, and said that he had only been “play-acting.” Tom said he knew
that, but that it had still affected him. I asked Tom to stand up and walk
around a bit, and I got him a glass of water. Gradually, he got more color in
his face, and I suggested we take a 15-min break. Both men agreed and went
out to walk around the park near my office. I had some water myself and
considered what to do.
Consensus Rorsa, Part 2. When Tom and Kirk returned from the
break, they both seemed fine, and Tom said he was glad “we did that last
part” so I could see what happens between them. I agreed that it was useful
and asked him if he had any words for the state he had been in. “Frozen
sho,” he said, and I agreed that it seemed to be a kind of “sho” state
associated with being “flooded with emotions.” Tom said that made sense,
and I asked Kirk if he ever got like that when he was emotionally
overwhelmed. He said that he used to, but now he was more likely to lose
his temper and “go on the warpath.” I asked if Kirk went on the warpath
when Tom went into “frozen sho” and Kirk admied that he did because
he felt Tom was “ignoring” him. Tom jumped in to say that he wasn’t trying
to reject Kirk, and Kirk said he saw that, but that it was hard to keep in
mind. Kirk started to tear up, and Tom looked guilty, so I decided to talk to
them both about what I thought had happened.
Steve:Guys, none of this is anybody’s fault, and I think what we’re
seeing here is the flip side of a strength you have in your
relationship. (ey look interested.) Did you notice how ea of you
were able to see anything the other one saw on the Rorsa?
(ey did.) at is very unusual in itself and what was even more
remarkable was that ea of you saw some prey difficult things.
(ey asked how.) Well a lot of those responses you gave were
fairly gory and painful in their content. Do you see that? (ey
did.) ose are the kinds of things people see who have had prey
hard things happen to them in the past, like sexual abuse, or living
in a car. (at made sense to them.) Well, I think a strength of your
relationship is that the two of you can relate to the pain ea other
has been through, whi means you understand things that other
people don’t get and can keep ea other company in some very
difficult places. Does that seem right? In a way, you’re very
compatible with one another. (ey agreed.) But the fact that you
both had su painful ildhoods also means that sometimes you
get triggered by one another, and go into what we call a
retraumatized place. When any of us is traumatized, we’re
biologically wired to do one of three things—fight, flee, or freeze.
Unfortunately, when you freeze, Tom, you Kirk are likely to aa.
And when you fight, Kirk, you’re likely to freeze, Tom. At the
moment, neither of you can stop this paern when it gets going, in
spite of how mu you care about one another. It’s just not possible
until you know how to keep from going into a retraumatized place.
I then let both men respond and ask questions. Both seemed to get the
major concepts involved in what I had said and to agree with the gist of my
interpretation. Given that I knew I would be working with them in ongoing
psyotherapy, I felt it was wise to stop the session where we were, rather
than try to practice some kind of method of interrupting their downward
spiral. I knew we would have plenty more opportunities to discuss ways to
interrupt the pursuer—avoider dance, and frankly I was exhausted and I
sensed they were too.
is case demonstrates how the Consensus Rorsa can be used in
ongoing psyotherapy and how it is useful even if the partners in a couple
haven’t taken individual Rorsas beforehand. It also shows an example of
the modified instructions I gave earlier.
Conclusion
ere are several different methods that can be used as assessment
interventions in couples assessments: family sculpting, projective drawings,
explicit role enactments, and so forth. In this apter, I presented one
tenique, the Consensus Rorsa, and illustrated its usefulness with two
different types of couples. e goal of the Consensus Rorsa, like other
assessment interventions, is to get a couple to bring their problematic
“dance” into the office where they and the assessor can begin to observe the
roles ea play and imagine and begin to practice other responses. If a
couple feels some success in breaking their typical paern of interaction
with the assessor’s support and guidance, it can give them hope and provide
practical strategies for modifying su paerns in their daily lives.
As with other assessment intervention teniques, many assessors are
initially intimidated by the Consensus Rorsa. Admiedly, it can be
difficult at first to manage the complex, multileveled interactions that take
place in the Consensus Rorsa. Also, if you are just learning the
tenique, you may doubt whether you’ll actually be able to see any useful
paerns. I encourage you to simply start giving the Consensus Rorsa to
couples (and families) and see what happens. I predict that over time, you’ll
come to recognize common ways that couples approa this task, and also
be able to see unique and meaningful aspects of ea couple’s interactions.
Note
is apter is based on a paper presented to the Society for Personality Assessment (Finn, 1996c). I
am grateful to Carol V Middelberg for her comments on an earlier dra.
13
“But I Was Only Trying to Help!”: Failure of a
Tlierapeutic Assessment
Finn and Tonsager (1997) defined one instance of failure in erapeutic
Assessment as when the client feels “less capable, demoralized, and even
abused aer the assessment” (p. 380). Because I have devoted mu of my
professional career to studying how psyological assessments can be
therapeutic for clients, I was very concerned several years ago when a
couples’ assessment I conducted resulted in one member of the couple
feeling highly traumatized. Since that time, I have reflected a great deal on
that particular assessment. In this apter I share what I have learned so far.
Summary of the Assessment
e flow art for a therapeutic couples’ assessment was presented in an
earlier apter. (See Exhibit 11–1).
Referral. Ted and Nancy, as I’ll call them, had been married 13 years
when they were jointly referred to me by their family/couples therapist,
Sara, and by Nancy’s individual therapist, Louis, both of whom were
longtime friends of mine. Both clinicians said that they felt stu in their
work with these clients, but this was especially true of my friend, Sara.
When making the referral, Sara explained how upset she was that Nancy
and Ted set few limits on their 12-year-old son, Sam, who in turn was
becoming increasingly aggressive at home and at sool (see Exhibit 13–1).
Sara thought that Ted wanted to be firmer with Sam, but that Nancy had
convinced him that firm limits were unreasonable. Sara also believed that
Nancy was seing Sam up to be abusive and physically violent, and that this
was part of Nancy’s desire to play the “ victim,” while geing Sam to act out
her anger. Sara was clearly frustrated with Ted’s passivity and inactivity, but
less so, in retrospect, than with Nancy’s subtle control over the family. Sara
believed that individual and marital issues were geing routed through Sam,
and had tried to get the couple to work on their own relationship, but she
reported that conjoint sessions almost always got waylaid to talking about
Sam. When the couple’s issues did get discussed, Nancy would aracterize
Ted as “harsh” and “uncaring,” a picture that Sara said did not fit with her
experience of him. In fact, Sara saw Nancy as being quite “mean” towards
Ted, who “just took it.” Sara hoped the assessment would help highlight the
couple’s issues for Ted and Nancy and help correct what she saw as Nancy’s
“distortions” of Ted.
EXHIBIT 13–1 Sociogra of Ralationship at the Begining of Assessment
Nancy’s individual therapist, my friend Louis, was in contact with Sara
and was aware of her experience of the couple. Louis complained that he
had to “walk on eggshells” in his work with Nancy. If Louis didn’t mirror
her exactly in their sessions, Nancy would get quite defensive or “crater”
into deep sobbing. Louis believed Nancy hadn’t really worked through a
number of issues from her family of origin, but Louis hadn’t been able to say
this to her directly as Nancy strongly believed she had “been there and done
that.” Louis hoped the assessment would help Nancy come closer to facing
her unresolved issues and to understanding her own part in the problems
with Sam and with Ted.
Initial Contacts. Nancy called me to initiate the assessment;
unfortunately, due to my sedule, I was not able to see the couple for about
4 months. At our initial meeting, Nancy opened the session by thanking me
for seeing them and saying that she was excited about the assessment. It
soon became clear that Ted did not exactly share this sentiment. He claimed
not to have seen the information sheet I had mailed them months earlier,
clearly was quite skeptical about the process aer I explained it, and said
bluntly that he was not sure the assessment would be worth the money it
cost. I was a bit taken aba at his flat-footedness. Nancy also caught me
completely off guard by saying she had arranged for their insurance
company to mail me an application to be a preferred provider; as soon as I
filled that out, everything would be finalized for them to proceed. When I
made it clear I had no intention of completing the 50-page application,
Nancy said she was sure that I had agreed to this over the phone. I knew I
had not and said so. At this point, Ted got even more upset and said he
would have to think the whole idea over more. I thought this was an
excellent idea. We talked more about what the assessment would be like if
they proceeded, and I asked them to call me when they had made up their
minds. To my surprise, a month later Ted called to say they would go ahead
and I set up the individual meetings that form the first part of the couples’
assessment.
Early Assessment Sessions. e initial assessment meetings seemed to
go quite well. Nancy—who had once trained to be a mental health
professional—approaed her assessment sessions with eagerness and
dedication, asking a number of sophisticated questions about herself and the
couple relationship (see Exhibit 13–2).
EXHIBIT 13–2 Tad and Nancy’s estions for the Assessment
I was impressed by Nancy’s systemic thinking and the willingness to
“own her part” that seemed to be reflected in her questions. Early on, Nancy
also brought me in numerous pages of material she hoped would help me
understand her—including a genogram of her family with detailed notes
about how family relationships had affected her, as well as journals and
other writings from significant periods of her life. Ted—a computer designer
—was somewhat harder to engage and posed many fewer questions to be
addressed by the assessment. He clearly was less comfortable with the
language of emotions and admied he was skeptical about many of Sara’s
ideas about Sam’s problems. But, he seemed genuinely puzzled by why
Nancy was so unhappy in the relationship and what he could do to make
things beer. He warmed up and showed real passion when he talked about
his work and how competent and comfortable he felt in that venue. I came
to admire his willingness to keep working in therapy and to do the
assessment with Nancy, although it clearly was very unfamiliar territory.
e early testing sessions—where I administer standardized tests to ea
member of the couple—seemed to go quite well. Again, Nancy was quite
forthcoming. She quily completed the MMPI-2, journaled long entries to
the Early Memory Procedure (EMP; Bruhn, 1992) and produced a 31-
response Rorsa protocol. She also broke down crying at numerous
points when we discussed the painful humiliation she had received from her
parents, a difficult first marriage, and how lonely she felt in her relationship
with Ted. And although she seemed ashamed of her emotionality, saying
that she had been sure she had resolved all the pain from her ildhood, I
thought I was able to support her in accepting her feelings by saying that I
too was oen caught off guard by finding unresolved feelings I had
previously worked on in therapy.
Ted worked quite hard on all the tests, but was more taciturn and less
psyologically minded when we discussed them. He admied there were
some similarities between his deferential approa to his controlling mother
and his stance towards Nancy, but otherwise he had lile reactions to the
EMP He had trouble remembering any incidents before age 10. His
Rorsa was shorter than Nancy’s (R = 22), but had mu more color and
a lower Lambda than did hers. (His Lambda was .16 and hers was 1.38.)
Overall, I felt good about the assessment at that point, and both referring
therapists reported that the couple had said they were enjoying the process.
us, I took a week off from meeting with Ted and Nancy to analyze the test
results and plan the assessment intervention and the eventual feedba to
the couple.
Reviewing the Standardized Testing. In retrospect, I think it was at this
point that I made my first significant mistake. Typically, when conducting
complex assessments, my colleagues and I at the Center for erapeutic
Assessment present our work in a group meeting and assist ea other in
understanding the clients and planning the later stages of those assessments.
Unfortunately, I was unable to do this with my assessment of Ted and
Nancy, as several members of our group had a previous relationship with
Nancy. I have a second group of experienced colleagues where I regularly
get consultation; but members of this group also knew Nancy from another
seing, so I decided, with some regret to “go it on my own,” rather than look
farther for someone with whom to talk things over.
I especially regreed the la of collegial support in this case because as I
looked at the results of the testing, it appeared to me that Nancy’s protocols
suggested many more aracter difficulties and mu more underlying
distress than did Ted’s. Her MMPI-2 was fairly guarded (L = 62T, K = 78T,
and S = 757), but nonetheless revealed a spike of 7 IT on Scale 4. I realized
that this elevation reflected in part the spunk and determination Nancy had
used to survive a difficult ildhood (Caldwell, 2001); but to me it also fit my
experience of Nancy as being somewhat of a bully. Her Rorsa scores
gave further evidence of an externalizing and somewhat obsessional
aracter adaptation (HVI and OBS were both positive). However, the
Rorsa also suggested that this aracter armor protected a great deal of
unresolved pain and anger, as indicated by DEPI = 5, S = 5, Fd = 1, and a
Trauma Content Index (Armstrong & Lowenstein, 1990) of .16. Apparently,
Nancy’s self-view—that she had worked through all her major issues—did
not appear to be accurate, and the evidence suggested she was prone to
project her unresolved issues onto others.
Ted’s MMPI-2 was just slightly guarded (K = 60T, S = 707) and had only
one minor elevation, on Scale 0 (607). Taken together, these scores seemed to
reflect his reserved and somewhat constrained aracter. I also noted with
some interest his score of 62T on the MMPI-2 Overcontrolled Hostility scale,
whi did not surprise me as I suspected he was full of resentment towards
Nancy and other people whom he “let get their way.” I was surprised,
however, by the amount of romatic color on his Rorsa. His Weighted
SumC was 4.5. (He had 9 M, so was solidly introversive as I had expected.)
And his FC/CF + C ratio was 3/3—suggesting to me that he was mu more
emotionally responsive than he appeared. Ted’s protocol also had a number
of shading responses, including two Texture responses and a Vista response,
although his EA was so large that he had a D of 0 and an Adjusted D of 0,
whi fit his report that he was not experiencing mu distress. e
Rorsa also suggested that Ted leaned towards withdrawal and self-
involvement in his aracter defenses, for he had two reflection responses
and his Isolation Index was .27.
In sum, I could see how Ted’s emotional awkwardness, withdrawal, and
narcissistic self-involvement could rub salt in Nancy’s wounds. I could even
see him as being passive—aggressive at times. But I found no evidence in the
testing or in my interactions with him that he was severely depressed, full of
anger, or incapable of feeling for others as Nancy suggested and as was
reflected in her questions. In fact, Nancy—who believed her years of therapy
had resolved her emotional issues satisfactorily—appeared to be projecting
some of her own aracteristics on Ted. In turn, Ted, who wasn’t confident
or skilled enough to counter su projections—instead was withdrawing,
pulling inward, and overcontrolling his anger, thereby acting in ways that
appeared to confirm Nancy’s aributions.
As I pondered these thoughts, I felt anxious. By that point in the
assessment, I knew Nancy was not ready to entertain su hypotheses from
me, and I suspected Ted wasn’t either. Most of what I wanted to say seemed
like Level 3 (or Level 7!) information. us, I put a great deal of hope on the
assessment intervention session, believing that we could begin talking about
some of these issues at that time.
Consensus Rorsa. As described in apter 12, in couples’
assessments I oen employ a modified form of the Consensus Rorsa as
an assessment intervention. I hoped this task would give Ted, Nancy, and me
an in vivo example of their problematic interactions, so that we could
observe them, discuss them, and collaborate in reaing new
understandings. As sometimes happens with this procedure, however, Ted
and Nancy worked together beautifully in reaing conjoint Rorsa
responses to the five cards I gave them. ere was almost no tension as they
discussed their individual responses, negotiated “win—win” compromises,
and reported their joint decisions to me to write down. At the midpoint of
the procedure, I asked them to take a 15-min break, while I cued up portions
of the videotape for us to wat and discuss (see ap. 12). I planned to show
these excerpts and to ask them about the contextual factors that made this
joint task so easy for them, compared to their aempts to work together at
home. I urged them not to talk to one another about the task until we could
do so together aer the break.
However, when I went out to the waiting room, I found Nancy in tears,
and Ted looking shut down and siing across the room from her. I invited
them ba into my office and gently asked what had happened. Apparently,
they had started off the break reading magazines, until Nancy asked if Ted
wanted to talk. He (thinking of my admonition not to discuss the Consensus
Rorsa) had quipped, “What shall we talk about, the abject misery of our
lives?” Nancy had felt very hurt by this comment, and had crumpled. Ted
explained to me that he had been trying to make a joke and had told Nancy
so. Nancy did not believe this, however, and said this was the kind of
“sadistic” remark Ted always made, and that he had intended to humiliate
her about being unhappy with their relationship. Ted tried to defend himself,
at whi point Nancy accused him of not caring about her feelings. He had
then retreated, whi is when I had found them in the waiting room.
As I listened, I thought I might understand what had happened and I
asked Ted if he had been feeling unsure of himself when Nancy asked if they
might talk together. He said that he had, and agreed that his “joke” had been
an aempt to deal with his awkwardness about not knowing what to say. I
asked Nancy if she could believe that Ted hadn’t intended to hurt her, and
she said no, she was sure he had meant to “stab her in the heart.” I then
baed up and asked Ted if he could “feel for Nancy’s pain,” even if he
hadn’t intentionally caused it. He said he did. I asked if he knew from
previous experience that Nancy didn’t react well to jokes with any hint of
sarcasm in them. He agreed he should have remembered this, and said again
that he hadn’t meant to hurt her. I then wondered aloud if it had been at all
scary for them to get along so beautifully during the Consensus Rorsa.
ey both said they had been very surprised at how well it went. At this
point, Nancy stopped crying. I said that sometimes, when things go really
well for a couple, when previously there has been a lot of disappointment,
the partners find it hard to tolerate the good period, and unconsciously find
ways to create more distance so as to not get their hopes up and get hurt
again.
Ted said he could see how that would work and perhaps his comment had
been his way of “geing ba to familiar territory.” Nancy countered that
these things happened all the time, even when they were geing along
terribly, and that she wasn’t afraid of being close to Ted; it was what she
most longed for. I asked her what would happen if she let herself entertain
the possibility that Ted hadn’t been malicious when he made his comment.
She said she would have to completely ange her conception of things, that
she didn’t trust him to know what he was feeling, and that she was really
good at telling what was going on with people.
I think at that point I was frustrated myself and also felt protective of Ted.
My intent was to help Nancy see the systemic aspects of her and Ted’s
difficulties, but in retrospect, I went “one-up” and proceeded to give Nancy a
lile lecture. I told her I thought both she and Ted had had parents who
were controlling and critical, but that the two of them had reacted to this in
very different ways. I said she had learned to scan the environment carefully
and to be very distrustful of other people’s motives. Ted, in contrast, had
learned to withdraw and put up a thi barrier. e result, I explained, was
kind of like the marriage between a “bull in a ina shop” (i.e., a seemingly
insensitive person) and the “princess and the pea” (an overly sensitive
person). is was at times a disastrous pairing, but I believed neither person
consciously intended to hurt the other.
Summary/Discussion Sessions. Again, in retrospect, I now see that I
“lost” Nancy at that point in the assessment. I remember her somewhat
dazed look as she and Ted le that evening. ey did return several weeks
later for two long summary/discussion sessions (whi Sara and Louis were
unable to aend), where I tried my best to present a balanced systemic
picture of the difficulties in their relationship. Nancy cried through most of
the feedba about her individual test results, but insisted that we continue
even when I expressed my strong reservations that the information clearly
was overwhelming her. I asked her at numerous points what she thought of
my hunes—that her ildhood had been even more neglectful and abusive
than she had previously realized and that she still had more “unprocessed”
feelings from those events than she had recognized. She said that she
guessed this was in fact true. When I reviewed Ted’s test results and asked
her reactions to these, she meekly said that she guessed she had been
distorting him. When we discussed their questions about the couple
relationship, she again appeared to agree with my formulations, but there
was very lile energy in her statements.
Postassessment Feedba. Still, it wasn’t until aer I sent my summary
leer that I learned how traumatic the assessment was for Nancy. I heard
from my friend Louis, Nancy’s individual therapist, that Nancy had taken to
bed for a week aer receiving the leer. Nancy complained to Louis that I
was mu “harder” on her than on Ted in the leer and had blamed her for
all the couple’s problems and the difficulties with Sam. Incidentally, at first I
didn’t think this was at all true, and Louis and Sara reassured me that it was
not. However, recently I reviewed the leer again with a different colleague,
who pointed out several places where the leer came across as imbalanced.
Around this time, Nancy told Louis that she was considering filing a
formal complaint about me with the Texas psyology licensing board. She
never did this, but she did—according to Louis—spend months in her
individual therapy energetically refuting the various statements I had made
about her in the leer. Ted reportedly had initially felt fine about the
assessment, but then baed Nancy up in her huge disappointment, saying
that he never had believed the assessment would be worth the money it cost.
e couple did follow my recommendation to find a new couples therapist,
who would work with them separately from the family therapy with Sara,
and Ted even contacted me at several points to get referrals. I sent word
through Louis that I would be willing to meet with Nancy or with the
couple, free of arge, to discuss their experience of the assessment, but they
never took me up on this. Recently, I learned that Ted, Nancy, and Sam le
town due to a ange in Ted’s job, so I imagine I will never get the ance to
meet directly with Nancy
Lessons Learned
In the months since this assessment, I have spent considerable time
rehashing it with Louis and Sara, and various outside consultants, including
Dr. Paul Lerner. Here are a few of the things I’ve learned so far:
Beware of “Oracular” Transferences
In his classic book, Shafer (1954) elegantly described the various
transferences pulled for by the assessment situation and cautioned against
clients’ tendency to see the assessor as an “oracle.” I now believe that
Nancy’s hurt at the end of the assessment was magnified by her idealization
of me at the beginning (whi was fed, in part, by Louis and Sara), and that
Nancy genuinely hoped and expected me to help her by “geing the goods”
on Ted in the assessment and then scolding him resoundingly for being
callous towards her. Nancy’s puing me on su a high pedestal not only
le more room for me to fall, but it also meant that hypotheses I put forward
were harder for her to reject and therefore more painful.
In retrospect, I didn’t do as mu as I could have to dispel Nancy’s (as
well as Sara’s and Louis’s) idealized view of me and of the assessment
situation. I could have said plainly at the beginning that I didn’t know if the
assessment would be helpful, although I hoped it would. In the
summary/discussion sessions, I could have made it clear that I don’t view
test scores as “Truth” about an individual, whi might have made it easier
for Nancy to reject statements I made that were not useful for her to hear at
that point in time.
Karpman’s Triangle Is Hard to Avoid
Some of you may be familiar with Karpman’s (1968) “drama triangle,”
describing the reciprocal roles of victim, persecutor, and rescuer (see Exhibit
13–3). Karpman describes the power that these internalized “scripts” of
relationships have over us, and how difficult it is for most of us to avoid
these roles as they become activated. In retrospect, both Nancy and Ted
came into the assessment presenting themselves as victims, and to some
extent so did the therapists, Sara and Louis, although both professionals also
admied to struggling with impulses to act out as persecutors. I was initially
invited in as an idealized rescuer, and willingly took on this role, thinking I
could maintain an equidistant stance. However, as Karpman predicts, all our
roles were unstable and by the end of the assessment, I had fallen, subtly,
into the persecutor role by aempting to “set Nancy straight” about her part
in things—whi in retrospect was the hidden agenda of Ted, Sara, Nancy,
and perhaps even Louis. I don’t mean to deny my own responsibility here; I
had my own reasons stemming from my own psyology for having fallen
into the persecutor role. Still, at the point that I acted out as a persecutor,
Nancy was confirmed in her victim role, she and Ted pulled together more
closely together, and when she threatened to report me, I got a ance to feel
like a victim, just like Nancy. It was at that point, when I found myself
protesting, “But I was only trying to help!” (a direct quote from Karpman’s
account of the rescuer-turned-persecutor-turned-victim) that I realized I was
in the drama triangle script, and I was able to take another step ba and
analyze what happened.
EXHIBIT 13–3 Karpman’s (1968) “Drama Triamgle’
e Payoff of Masoism
Before this assessment, I thought I understood from my work with
traumatized clients the kind of sadism that can be expressed through the
victim role. But it was Paul Lerner who helped me realize that I hadn’t fully
appreciated another payoff of masoism—the sense of omnipotent control
over others. When I discussed this case with Lerner, he pointed out that
Nancy’s many questions about herself—for example, “Where are my blind
spots?” “How am I participating in projective identification?”—although
sophisticated, were most likely not questions that she wanted me to help her
answer through the assessment. As Lerner explained, these were in fact,
invitations for me to “beat her up” by presenting her with conclusions she
was in no way ready to consider. Depending on your theory, you can believe
that Nancy unconsciously (a) wanted me to accept her invitation to
traumatize her, as object relations theory might posit; or (b) secretly hoped I
would pass the test by turning down her invitation, as control mastery
theory would suggest (Weiss, 1993). In either case, if I fell into confirming
Nancy’s beliefs that others were out to harm her, she would have the
decidedly biersweet relief of knowing that her “story” still seemed to fit the
relational terrain she found herself in, and that she, as she said, “was really
good at knowing what was going on with people.”
e Multiple Motives Behind Assessment estions
is leads to another conclusion that in retrospect seems really obvious. In
erapeutic Assessment, when we invite clients to pose questions to be
addressed by the assessment, we should not assume that they are open to all
possible answers to su questions. In retrospect, I should have known this,
as I have wrien before about the need to carefully adapt assessment
feedba to people’s existing conceptions of themselves. But I don’t believe I
have ever understood so clearly before this assessment how difficult it can
be for us assessors to “contain” certain ideas we have when a larger system
is pushing for us to express them. I have started a new practice of asking—
early in an assessment—not only about people’s “best guesses” to the
answers to their assessment questions, but what would be “the worst
possible thing” they could be told about themselves through the assessment.
If I had done this with Nancy, I fantasize that I would have been even more
prepared for the possible trauma that could result from the assessment
(assuming, of course, that she would have been able to honestly answer this
question).
Be Careful of Taking on the Agendas of Referring erapists
As I mentioned earlier, I now suspect that the two referring therapists—Sara
and Louis—secretly hoped the assessment would confront Nancy with
information about herself that they were finding it difficult to manage—that
is, how she could come across as fragile and controlling at the same time,
and how difficult it was to relate to her because of her tendency to feel
wounded by anything but absolute agreement with her point of view. I have
long been aware of the complexity of managing referring professionals’
hidden agendas in an assessment (see ap. 9). However, I now suspect that I
was even more at risk to “take on” Sara’s and Louis’s frustrations because
they were dear and trusted friends of mine. And I probably was more
anxious than I was aware of because I wanted to impress my friends and
help them in a touy situation. is awareness will make me more cautious
in the future when assessing clients for referring professionals who are also
friends.
erapeutic Assessment Is Oen Too Difficult to Do Alone
Finally, I am humbled to be reminded of something I have wrien about
before: erapeutic Assessment, because of the brief and powerful
connections formed between assessors and clients, is oen too difficult to do
without the assessor having the baing and collaboration of a community
of skilled and savvy colleagues (Finn, 2002a). e transferences,
countertransferences, and aaments formed in these encounters are
extremely intense; it is partly due to this fact that erapeutic Assessment
can be so powerfully beneficial. But for these same reasons, the teniques
of erapeutic Assessment are also potentially harmful, and should be
practiced in certain instances only with the support and assistance of others.
I fantasize that if I had pushed myself to obtain consultation before the final
stages of the assessment—perhaps by calling Dr. Lerner or someone else—
that I might have avoided this assessment failure and helped Ted and Nancy
aieve a new point of view. I oen struggle to recognize that I need help
and to ask for it when I do. is experience was a powerful reminder of the
potential costs of that kind of hubris.
Note
is apter is drawn from a paper I presented to the Society for Personality Assessment (Finn,
2004). I am grateful to Gregory J. Meyer for his comments on an earlier dra.
14
Collaborative Child Assessment as a Family
Systems Intervention
In sools and inpatient hospitals, it is still fairly common that young
ildren undergo psyological assessments with minimal involvement of
parents or other family members. In outpatient clinical practice, parental
involvement is more feasible and also typically necessary to promote
parents’ cooperating with a ild’s assessment (e.g., their giving consent,
bringing the ild to appointments, and paying the bill). us, most
assessors involve parents in outpatient ild evaluations in certain basic
ways, for example by: (a) interviewing them at the beginning of the
assessment about a ild’s problems; (b) asking them to complete rating
scales, su as the Child Behavior Che List (Aenba, 1991) or the
Parenting Stress Inventory (Abidin, 1995); and (c) giving parents some
feedba at the end of the assessment about the ild’s test results.
In this apter, I argue that whenever possible, it is extremely useful to
involve parents and other custodial guardians (e.g., stepparents,
grandparents) as full collaborators in a ild’s assessment. Su involvement
can take many forms; however, the basic principle is that parents are treated
as essential participant-observers, who work with the assessor to jointly
construct an understanding of the ild’s problems in living. I have come to
believe that the best way to help ildren through assessment is by assisting
their parents and caregivers in developing more accurate, empathic, and
useful “stories” about why those ildren have problems. When parents are
involved as active collaborators in an assessment, the assessor has more of a
ance to influence the current story. Also, the assessor gains ri
information about a ild’s interpersonal network and the contribution of
family dynamics to the ild’s problems in living. Last, the assessor is
presented with numerous opportunities to make systemic interventions that
address the ild’s or family’s presenting issues. As su this approa fits
with the idea that psyological assessment of a ild is potentially a potent
family systems intervention (Fulmer, Cohen, & Monaco, 1985; Ziffer, 1985).
I now discuss ten instances of parent-assessor collaboration and illustrate
their usefulness as systemic interventions (see Exhibit 14–1).
EXHIBIT 14–1 Ten Ways to Make Child Assessment Collaborative
1. Work with Parents to Define the Goals of the
Psyological Assessment
As explained in apter 1, in erapeutic Assessment, we begin an
evaluation by asking clients to pose questions that they wish to address with
psyological assessment. When I assess young ildren, I typically invite
parents alone to an initial meeting, where I work with them to define their
questions and goals.1 I listen carefully and compassionately to their concerns
and gather information about the presenting issues. is practice serves
many systemic purposes. First, by anowledging the parents’ right to
specify the parameters of the assessment, I support them as heads of the
family and as the people who can have the most impact on a ild. Even if a
sool, therapist, or other professional have requested the assessment, I
reinforce the idea that parents are the most important people in a ild’s life.
Second, by asking parents to leave the ild at home for the initial session, I
reinforce an appropriate generational boundary that is not always kept in
some families. I remember one mother who insisted that it would be fine for
her 6-year-old son to aend the initial session with her and her husband.2
“Oh, we talk with him about anything,” she told me. “He already knows
everything we think.” I requested that we meet alone, and was pleased at the
end of the initial meeting when she spontaneously commented that it was
“probably good” to have le the boy at home, so we all could talk more
freely.
1 use the word “parents” throughout the apter, but recognize that many ildren are raised by
grandparents, aunts and uncles, foster parents, and other caregivers.
2 I had already verified that this was not a maer of the family not having ild care and therefore
needing to bring the ild along.
Whom one invites to the initial session can also impact a family system. It
is not unusual that a mother sets the appointment and asks if her husband
“really needs to be there” as “he has to work.” I do everything I can to get
both parents to aend significant portions of the psyological assessment
and have found that this alone seems to have an impact, for example, by
geing an emotionally distant parent reinvolved, or seing the stage to
discover that the parents disagree about the best way to handle the ild’s
problems. In the case of divorced parents, even if only one has initiated the
assessment, I inquire whether they would be comfortable meeting together
for the initial session. And I almost never undertake a ild assessment
without the consent and full cooperation of both parents. is stance sends
the message that I consider both parents important to understanding the
ild and also that it will be best for the ild if the parents have a cordial
enough postdivorce relationship that they can cooperate on maers
involving the ild’s mental health care.
e questions parents generate are themselves ri sources of information
about the family system. Contrast these two sets of questions: (a) “Why does
Johnny lie and fail to take responsibility for things?” and “Would a boy’s
ran be the best place for him?” versus (b) “How can we bring out the best
in Aaron?” and “Is there anything we are doing that is contributing to
Aaron’s problems?” As you see, su questions not only provide information
about a ild, but also about the parents, and potentially, important family
dynamics that might relate to the ild’s problems. When the grandparents
who posed the first set of questions told me that Johnny had always been
difficult and was “just like his father” (their son), I wondered if they were
scapegoating Johnny to avoid personal or marital difficulties, or grief about
their shortcomings as parents. In the second instance, I suspected that
Aaron’s parents were open to feedba about their overprotective style and I
was able to gear the assessment to help them coddle him less.
Of course, it is not only the content of parents’ questions but the process
through whi they are generated that is informative and potentially
therapeutic. I have had parents who never could agree on a single
assessment question, and had to give separate lists of questions. As you
might suspect, the parents’ inability to “get on the same page” was part of
the ild’s problems, and I made it a goal of the assessment to help the
parents rea a common understanding of the ild that would be acceptable
to ea. I’m also very interested when one parent dominates the initial
session, posing lots of questions, while the other sits passively by. Again, this
makes me wonder if the ild’s issues pertain in part to one overinvolved
and one underinvolved parent.
Last, I believe that the process of gathering assessment questions from
parents can promote their curiosity, lessen their anxiety, enlist their
observing egos, and help disrupt projections they may have on a ild. More
than one couple has commented to me that they felt beer about their ild
just from having put their concerns into words and knowing that those
concerns would be explored and addressed in an assessment.
2. Negotiate with Parents to Allow an Adolescent
Child to Have Private estions for the
Assessment
Typically, when a ild is older (e.g., age 13 and above), I ask parents
beforehand if they will allow the ild to pose his or her own questions for
the assessment, whi I answer to the ild, and that will remain private
from the parents unless the ild opts to share them aer feedba. ite
frankly, I started this practice as a way to get adolescents to cooperate with
psyological assessment, and then discovered that it was a potential family
systems intervention in itself. Obviously, this approa promotes
differentiation and separation—individuation in a family, and I have had
several instances where enmeshed parents initially objected to the idea of
their ild’s having any privacy. By talking with them about adolescent
development and the need for teenagers to have some autonomy, I
eventually got these parents to agree to my plan. Interestingly, in all the
families, the ildren immediately became more cooperative and less
rebellious, whi by itself made quite an impression on the family.3
3 In adolescent assessments, my initial meeting involves both parents and ild. Following this, I
have separate meetings with the adolescent and the parents. Typically, I share parents’ assessment
questions with the adolescent, but not vice versa. is is my way of anowledging that the
adolescent is in the more vulnerable position, especially if the parents are not being tested.
3. Ask Parents to Prepare a Child for the First
Meeting With the Assessor
With young ildren, my second session is with the parents and ild
together. In preparation, at the prior meeting, I ask parents to talk to their
ild about the purpose of the assessment before we all meet. I also ask if
they know what they will say, or if they would like guidance from me. If
appropriate, I then coa parents on how to handle this discussion with their
ild.
Clearly, this practice gives additional information about the family system
and about potential targets of intervention. I have had several families who
didn’t want to say anything to their ild about the real purpose of the
assessment for fear the ild would feel badly, and one family who asked if I
would come to their house and pretend to be a family friend so the ild
“wouldn’t have to feel ashamed” about seeing a psyologist. (As you might
imagine, I concluded it was the parents who were struggling with intense
shame about their ild’s difficulties.) In other families, this discussion
highlighted unhealthy triangulations within the family system, for example,
the father who said he would tell his son, “Your mother thinks you have a
learning disability. I don’t, but we’re going to have you tested anyway.” In
one other case, my coaing led to our seeing that an assessment was not
really necessary. e parents told their daughter they wanted to have her
assessed because they were afraid she was using drugs, something they had
been afraid to say before. rough their discussions with her, the parents
discovered that they had been misinterpreting a lot of her normal adolescent
behaviors, in part because of their own drug use as teenagers. Trust was
restored once they all started talking.
In general, by asking parents to discuss the assessment with their ild, I
am sending the message that “nothing is too bad to talk about.” Also, I am
modeling respect and empathy for the ild, as if to say, “It may be scary
and confusing for your ild to come for an assessment without being given
some explanation first. Your ild has a right to be told something about
why she is being asked to do the testing.” Last, if I do coa parents on what
to say, I generally suggest that they frame the intent of the assessment
systemically, for example, “We’re hoping the psyologist can help us all
figure out why you’re depressed and how the family can help with this,”
rather than, “We want to know why you’re depressed all the time.” Clearly, a
single communication will not ange a family system, but su statements
reflect a whole philosophy that I aempt to impart to families throughout an
assessment.
4. Ask Parents to Observe a Child’s Testing
Sessions and Discuss eir Observations
Aerwards With the Assessor
is is a tactic I borrowed from Fiser (1985/1994). Although not always
feasible or advisable (e.g., with adolescents, or with overinvolved parents), it
sometimes can be extremely useful to have parents observe assessment
sessions. When possible, it seems best to have parents observe unobtrusively,
through a two-way mirror, over a video hook-up, or with the parent(s)
behind the ild’s ba, off to the side of the room. If the parent is out of
room, I always let the ild know he or she is being observed. Aerwards,
the parents and I compare notes and ask ea other questions about what we
observed. If the ild is not old enough to be alone while the parents and I
talk, I usually call aer the session and talk with the parent(s) over the
phone.4
4 A not unreasonable concern is that if a ild knows parents are observing, it will inhibit the ild
so mu that the assessment is hampered. If I believed this was happening in a particular case, I would
discontinue the parental observation. However, my experience with young ildren is that they either
seem unphased by their parents’ wating, or they use the opportunity to send the parents “messages”
they want the parents to hear and that I can help make sure the parents grasp.
I find that having parents observe testing sessions empowers them and
demystifies the psyological assessment process, as well as giving parents a
ance to discover answers to their own questions about their ild.
(Remember, in collaborative assessment, we consider it more useful for
clients to rea their own insights with our guidance than for us to offer
interpretations they have not yet considered.) When parents observe
assessment sessions, it also provides a ance for the assessor to intervene on
a “perceptual level” with parents who are projecting on their ildren. I
remember one parent who wated me give the Bender Visual Motor Gestalt
Test (Bender, 1938) to her depressed 12-year-old son. e boy was very self-
critical and kept saying that he didn’t think he could do the task. Aer the
session, the mother and I had the following exange:
Mother: Did you see how manipulative he was? at’s the way he is at
home all the time!
Steve: I’m not sure. What did he do that looked manipulative to you?
Mother: Why, when he kept saying he couldn’t draw those designs. He
was just being lazy! It’s like at home when I ask him to do ores
and he doesn’t want to do them. He just expects to be waited on!
Steve: Oh, is that how you saw it? I had a different idea at the time: that
he felt insecure and afraid that he would fail, so he kept trying to
get out of performing. He seemed like he doubted his own abilities.
Mother: Really? I never thought of it that way!
Steve: Well, I’m not sure that I’m right. But I also wondered if he might
be depressed. Does he always look so sad and tired?
Mother: I’m not sure. at just seems normal to me.
As you can see, in su interactions I’m careful not to insist on being
right, because I may not be. But just comparing different interpretations of
events oen helps parents start to see their ild differently and more
compassionately
Another marvelous possibility is that parents will feel less inadequate
when they see the assessor struggling with the same problems they
encounter with their ild. Some years ago, a mother wated me try to
handle her 5-year-old daughter as she threw a major temper tantrum when I
wouldn’t let her do whatever she wanted in our assessment session.
Aerwards, the mother told me she was so relieved to see that it “wasn’t
just her,” and she and I compared notes about what did and did not work
when her daughter was in su a state. Mu later, the mother told me that
event was “worth all the money” paid for the assessment, because her
relatives and the girl’s teaers had been implying that the girl’s tantrums
were entirely the mother’s fault. Eventually, with the mother’s input, I found
a way of handling the 5-year-old’s meltdowns by stating firm limits
beforehand, stiing to them, and ignoring her when she had a tantrum.
Even beer, the mother was able to successfully adopt this approa at
home.
Finally, when parents observe assessment sessions, it provides an
opportunity to help them think contextually and to disrupt global
aributions they have of their ild. For example, aer several sessions with
a ild who was well-behaved with me but rebellious at home, the parents
admied, “We can’t believe he’s so good with you. ey’ve told us he’s an
angel at sool, but we haven’t believed them. I wonder if we’re doing
something wrong at home?” I was able to lead them in thinking about what
was different about the assessment and sool context, and to see if we
could export any of those elements to the home.
5. Enlist Parents in Collecting Historical
Information or Systematic Data About a Problem
Behavior, Either by emselves or With the Help
of Other Family Members
When there is a problem behavior that occurs within the family context and
is not likely to be so visible in sessions with the assessor, it can be very
useful to train parents and other family members to be objective observers
of the behavior and to contribute data to the assessment. For example,
parents might be asked to tra a ild’s temper tantrums, what happens
right before they occur, how the parents respond, and what happens
aerwards. Alternatively, parents may be asked to contact collateral sources
and other informants to collect information that is relevant to their
assessment questions. When parents are enlisted as “co-investigators” in
su ways, I find they have increased curiosity, are less reactive to their
ild’s behavior, and oen have insights that they can readily put to use in
addressing their own presenting concerns.
is approa also provides an indirect way of assessing a family’s
readiness to ange. For example, I kept asking a set of parents to contact
their pediatrician for records pertaining to their ild’s early history. ey
kept “forgeing” to do so. Eventually, it became clear that the parents were
so overwhelmed with various responsibilities that they found even this
simple task impossible. We then were able to discuss how lile energy they
had to make substantial anges in their lives. It became clear that any
suggestions I came up with would have to take account of this reality Yet
another family made it clear that they didn’t want to “do any work” to
understand what was going on with their son; they preferred to just “drop
him off” and let me deal with the problem. When I questioned this approa,
I found that both parents came from wealthy families and had been raised
by hired caregivers. Although they were trying to be more involved with
their son than their parents had been with them, clearly they hadn’t yet
shed all the aitudes their parents had modeled for them.
By enlisting parents as data gatherers, one can sometimes “alter
proximity” (i.e., shi interpersonal closeness) within a family. For example,
some years ago I assessed a 10-year-old girl with inconsistent enuresis. I
asked her parents to art the ild’s fluid intake during and aer dinner and
to keep tra of her bedweing. To do this, the parents had to pay more
aention to their daughter in the evenings. To our surprise, the enuresis
decreased. It later came out through the testing that the girl felt neglected by
how tired and uninvolved the parents were at night aer working all day.
Her enuresis seemed to be one way of drawing their aention.
In another instance, I was asked to see a 6-year-old boy with severe
temper outbursts and his mother. Due to the mother’s drug abuse, the boy
been raised by his maternal grandparents during the first 4 years of his life.
At the time of the assessment, ild and mother had lile contact with his
grandparents. I asked the mother if she would be willing contact her parents
to get information about the boy’s early developmental milestones. Her
phone call brought them all ba into contact and eventually provided the
mother and ild with greatly needed support. I don’t think this would have
happened if I had been the one to call and talk with the grandparents.
6. Ask Parents if ey Are Willing to Be Tested as
Part of eir Child’s Evaluation
Some assessors routinely do this whenever parents will cooperate. I don’t
always test parents, but try to judge whether they are likely to feel
threatened by su a request. One way to gauge this is to look at parents’
questions for the assessment. If the questions are totally ild focused and/or
scapegoating, it probably is too big a jump to suggest that the parents’
personalities have any import for addressing the ild’s problems. Some
parents, however, ask a question like, “Are there any things we can do for
Amy that we are not doing?” Su questions show the parents are open to
looking at their role in the ild’s problems. With su families, I suggest
that it might be helpful to get a formal measure of the parents’ personalities,
strengths, and struggles. I remind parents of their relevant assessment
questions and then present my rationale in more or less systemic terms: “In
thinking about what else you can do, it will be useful to see how your
personalities interact with that of your ild” or “I’d like to see how your
ild’s problems have been impacting you.” I might also help the parents
take my request less personally by saying that parental testing is a routine
part of many ild assessments.
Obviously, how parents react to a request to be tested provides excellent
information about whether they are ready to accept systemic formulations
of their ild’s problems. If a parent asks, “How the he would my MMPI-2
tell us anything about Johnny’s frequent headaes?” I try to explain my
request in as nonthreatening terms as possible, or I may simply ba down
and realize that the new “story” I offer that parent about their son cannot be
centered on a systemic view of the ild’s headaes. As you might guess, it
is good to know su things before a summary/discussion session!
If parents will participate in testing, it shis the focus of the assessment
off of the ild to some degree, whi some ildren find relieving. I have
seen several ildren become less symptomatic aer learning that “Mommy
and Daddy are doing testing too.” Obviously, parental test results also allow
an assessor to think about interface issues, or ways that parents are engaged
in projection or projective identification with the ild. For example, several
years ago I assessed a mild-mannered single father and his 8-year-old
acting-out son. e father had four percepts of exploding volcanoes on his
Rorsa, and I developed the hypothesis that the son was acting out anger
for the father. In another instance, a mother was very concerned that her
low-aieving son was depressed; the testing indicated that he wasn’t, but
her MMPI-2 showed that she was struggling with severe depression. When
confronted with her MMPI-2 profile, the mother realized that she needed
help herself. When she started to see a psyotherapist, her son immediately
started doing beer in sool.
7. Sedule One or More Family Sessions or
Parent-Child Sessions as Part of a Child’s
Assessment
is is something I do in almost all ild assessments, except again in those
instances where parents need to see a ild as the sole source of problems.
Su family sessions are in addition to the conjoint session that typically
takes place at the beginning of the assessment. Typically, I try to involve all
family members living in the home—including siblings, grandparents, and
other relatives. I may give the family a task to do together su as the
Consensus Rorsa (see ap. 12), planning a family vacation, or a family
art project. Or I may ask them to play together or simply talk about the
presenting issues. In some instances, I simply want to “see what happens”
when I get the family together. At other times, I have a more focused
assessment intervention in mind.
Whatever the structure, family sessions provide a very useful opportunity
to observe family dynamics and sometimes lead to major breakthroughs in
assessments. For example, not long ago I assessed a ild who was having
frequent nightmares, and whose Trauma Content Index (Armstrong &
Lowenstein, 1990; Kamphuis et al., 2000) on the Rorsa was quite high,
whi made me wonder if he had experienced some emotionally
overwhelming events. e parents were at a loss as to what could have
happened. It wasn’t until I observed some disturbing interactions in the
waiting room and asked more questions that it came out that he was being
severely tormented at home by his older siblings when the parents were
away. e parents were clueless to this dynamic, and horrified once they
found out what was happening.
Family sessions also provide an opportunity to identify and explore those
ild problems that are limited to the family context and to help parents see
family influences. Here I remember an assessment where parents
complained that their son was sleepy all the time. eir physician had
assured them that there was no medical reason for the boy’s problem. e
boy’s teaers said he was alert at sool, and I found him lively and
focused with me in the testing sessions (whi the parents observed).
However, the boy fell asleep during the family session. Eventually it came
out that there was tremendous tension in the parents’ marital relationship,
whi I believe the boy was clued into. He “slept through” most family
interactions to keep himself from becoming aware of what he unconsciously
knew.
Last, as mentioned earlier, family sessions can be used in the later stages
of a ild assessment to explore and highlight systemic issues in an
assessment intervention session. One useful tenique is simply to ask
family members to reenact problematic scenes from home, and then get
them to swit roles and play ea other. When doing this, I typically ask
parents to role-play the ild, in hopes it will give them more empathy for
the ild’s perspective. en, one can get the family to think of and try out
possible solutions to problematic behaviors. Like other assessment
interventions, this works best if the assessor and family keep revising the
new strategy until the clients feel some success.
In one memorable assessment, a 10-year-old boy, James, got into terrible
“spells” at home when he was angry, in whi he would rage and destroy
furniture and other family members’ erished property (e.g., an heirloom
clo from his mother’s family). e father oen got so overwhelmed during
su scenes that he would barricade himself in the bedroom, leaving it to the
mother to try to cope. I asked the family to role-play the scene for me, and
then asked the father and son to play ea other’s parts. When the boy
(playing his father) was in the bedroom with a pillow over his head, I asked
him “What are you thinking?” e boy replied, “at I wish James had never
been born. en I wouldn’t have had to get married. I hate my life!” I knew
this in fact to be true of the father, but when it came out of the boy’s mouth,
everyone was stunned into silence. I then asked the father (playing James)
what he needed from his father. Without thinking he said, “To know that my
father really loves me.” James and his father then started crying and hugged
ea other. is was the beginning of substantial positive anges in the
family system.
8. Ask Parents to Corroborate and Modify
Assessment Findings Presented in the
Summary/Discussion Session
I give assessment feedba to all parents and ildren. Typically, I meet with
the parents first, then with the ild and parents together. e exception is
with adolescents; I discuss the findings with them alone first and answer
their own assessment questions. en I meet with their parents and give the
adolescent the option of aending this session. As with all
summary/discussion sessions in erapeutic Assessment (see ap.l), I
present my thoughts as hypotheses, order them according to how mu they
agree with the parents’ existing story about their ild, and I ask parents to
corroborate, modify, or reject what I am saying. e parents and I refer ba
to things they observed during the assessment and to real-world events that
support the new story. We then talk about what this new story suggests
about the family’s next steps.
Here is an excerpt from the summary/discussion session with James’s
parents, the boy who raged and destroyed personal property.
Steve: {reviewing the Rorsa] So as we talked about before, James
scores suggest that he is severely depressed, and that he feels prey
terrible about himself. You might remember that we talked about
all the dead and damaged things he saw on the inkblots.
Father: So what does that have to do with his rages?
Steve: Do you remember that article I gave you several weeks ago,
whi explained that depression in ildren oen comes out as
angry behavior?
Father: Oh yes, I remember now. at’s confusing because he doesn’t
look depressed, he looks angry.
Steve: I know what you mean.
Mother: And if I understand what we learned last week, he feels
terrible because he knows we didn’t really want him at first. I
almost had an abortion, but then we decided to get married.
Father: I don’t think he knows all that, do you?
Steve: He may not know about the abortion, but I think the family play
we did showed that he knows you [father] sometimes wish you
never had him, and that makes him think that you don’t love him.
Father: I know I haven’t been very good about showing that lately.
Mother: But you’ve been trying hard this week. Steve: And how has it
been working?
Mother: It’s been the best week we’ve had with James in months.
Steve: I wonder if he’s been blaming himself for your [father’s]
unhappiness?
As Fiser (1985/1994) wrote, this is essentially a hermeneutic approa to
assessment feedba. Hypotheses are considered, revised, and tied to
examples. All participants offer information from their own perspectives,
resulting in a new understanding of the ild that is more complete,
accurate, and useful. As parents “get on the same page” and develop a
coherent and similar story about the ild’s problems, the ances of their
being able to implement next steps increases.
Also, this approa is respectful of parents and of any cultural differences
that exist between them and the assessor. Parents are able to explain how
they—from their own bagrounds—view different aspects of the family and
ild system, while the assessor is able to listen, ask questions, and suggest
different points of view. I’m reminded of a boy I assessed with strong cross-
gender interests whose parents were divorced. e Caucasian mother was
quite concerned about the boy’s desire to dress in girl’s clothes and about
the vicious taunting he got from other boys at sool. e Native American
father was less concerned about the boy’s behavior and explained that in his
tribe, boys and men with feminine interests are considered “special” because
they are “in between” and therefore closer to the spirit world. Gradually,
with mu discussion among the three of us, both parents agreed that the
bullying at sool was the boy’s major problem. is led us to strategize an
intervention with the teaers and principal and helped the parents work
together in implementing this intervention.
9. Ask Parents to Review Reports for Sools,
erapists, or Other Referral Sources and to Help
Present Assessment Findings
is brings up another collaborative, potentially therapeutic tenique. I
always ask parents to review and comment on any report I write for a
sool, physician, or other referral source. Normally, I keep revising the
report until the parents and I are comfortable with the way things are
worded. I then ask parents to work with me in presenting the assessment
results to the sool or other party.
is tactic can be a way of unobtrusively coaing parents to be seasoned
advocates for their ild in other systems. For example, I might ask, “How
do you think we should word this recommendation so your ild’s teaer is
most likely to accept it?” or “Since we’ve agreed that these would be good
goals for your ild’s therapy, should we think of a way to know if these
goals are being met?”
is kind of collaboration can also facilitate (sometimes strained)
relationships between parents and other members of the ild’s system. For
example, aer one meeting where parents and I shared assessment findings
with sool personnel, the principal told me, “I’ve never liked them before,
but today I really did.” Also, parents can wat how I interact with teaers,
therapists, and other important people and learn to adopt a similar approa.
10. Involve Parents in Giving Oral or Written
Feedba to the Child About the Assessment
Results
As stated earlier, I always offer feedba to ildren about their assessment
results. For very young ildren, I oen write a story that captures the
assessment feedba in metaphor and then invite the ildren to modify, and
illustrate the story. (See Fiser, 1985/1994, and Beer, Gohara, Marizilda, &
Santiago, 2002, for examples of this approa.) Oen I ask parents to
collaborate in writing the story or to make comments and anges on my
dra before it is presented to ild. Alternatively, they may aend the
session where the story is read to the ild or even be the ones to read the
story aloud.
Again, by involving parents in this way, I anowledge that they are the
most important people in their ild’s life and can have more impact on the
ild than a therapist ever can. Also, when parents assist in writing the
ild’s feedba story, it provides an opportunity for them and me to help
ea other “get in the ild’s shoes.” For example, a mother might say, “I
think we should make the leopard in the story a eetah. She has a favorite
book about eetahs.” Or I might explain—in response to a parent’s
suggestion—why I don’t think we should put a happy ending on a story: “I
think Johnny will see that ending as ignoring his reasonable anxiety about
how things are going to turn out. Can we think of a way to give him hope
while also recognizing that there are some big unknowns ahead?” Last,
when the ild senses that the feedba story is a joint product and that the
parents endorse it, he or she is more likely to accept the therapeutic
messages contained in the story.
Conclusion
As discussed in apter 4, there are many reasons to engage in collaborative
assessment practices. One may do so for humanistic or philosophic reasons
or because it facilitates clients’ cooperation with assessment. But in ild
assessment, I believe there is one overaring reason to involve parents as
active collaborators: Only by doing so can we understand the full context of
a ild’s problems in living, and only by working with the ild’s family
system can we produce substantial, lasting therapeutic ange. e
teniques outlined in this apter are basic steps in practicing erapeutic
Assessment with ildren and families. In the near future, I hope to write
more about the complexities and allenges of this type of assessment.
Note
is apter is based on a paper presented to the Society for Personality Assessment (Finn, 1997a).
15
Teaing erapeutic Assessment in a Required
Graduate Course
As a member of the psyology faculty at the University of Texas at
Austin from 1984 to 1992,1 routinely taught the theory and teniques of
erapeutic Assessment to first-year clinical psyology graduate students
in their required course on personality assessment. is course involved a
theoretical and/or factual component as well as a practical and/or hands-on
component. Students read resear and theory about the major personality
tests, learned the administration and scoring of ea test, and conducted a
number of practice assessments while being closely supervised. Early on it
became clear to me that students in this course were not only learning how
to assess clients; they themselves were also going through an important
assessment—of their knowledge of psyological testing and their suitability
to be clinical psyologists. Furthermore, the assessment to whi my
students were subjected was analogous to the most difficult of clinical
assessment situations—in whi clients are tested in part against their will,
are ambivalent about self-disclosure, and are aware that assessment results
will be used by others to make major decisions affecting their lives.
To be more specific, my observations about students’ personality traits,
clinical skills, and knowledge of assessment were oen weighed heavily by
the clinical psyology faculty in deciding whether to retain a student at the
end of the first year. Students were well aware of this and felt great pressure
to do well in my course. is pressure, in turn, had the potential to inhibit
greatly students’ comments in class and their willingness to take risks while
practicing assessment. In effect, the evaluation component of the course
tended to set up a transference situation where I was seen as a feared,
omnipotent authority rather than as a benevolent, human instructor. I soon
realized that I might best address this stressful assessment situation by
applying the same principles and teniques to my teaing that I was
educating my students to use in their clinical interactions with clients. In
this way I would be “practicing what I preaed,” and students would have
the benefit of experiencing erapeutic Assessment at the same time that
they were learning to do it themselves. I describe the course in its final form,
even though different elements were anged and added over the years.
Principles of erapeutic Assessment as Applied to
the Graduate Course in Personality Assessment
e underlying principles of erapeutic Assessment in clinical assessment
situations are articulated elsewhere (Finn, 1996b; Finn & Tonsager, 1997). A
modified set of these principles as applied to a required graduate course in
personality assessment guided my teaing:
(1) A required graduate course in personality assessment is an unseling
and personally allenging experience for students. It demands
interpersonal and emotional skills and ways of thinking that have not
typically been required in other academic courses; also the instructor’s
ratings of students are used by others to make major decisions
regarding the students’ lives. ese factors can cause considerable
anxiety for students.
(2) A graduate course in personality assessment is also an interpersonally
allenging situation for an instructor. It involves (a) providing factual
information, (b) giving feedba to students about clinically relevant
personality aracteristics, (c) modeling interactions with clients, and
(d) supporting students through their first interactions with clients. is
multifaceted role has the potential to generate considerable anxiety in
the instructor.
(3) When students and instructors are anxious, they are prone to enact
highly stereotyped roles in whi instructors play all-knowing experts
and students act the part of deferential, passive novices. Su roles
interfere with active learning on the part of both students and
instructors.
(4) Students have the right to know, at the beginning of the course, what
aspects of their performance will be evaluated, the procedures used to
assess their performance, and how the results may affect them when
the course is completed. Providing su information may decrease
students’ feelings of powerlessness and lower their anxiety.
(5) e instructor has the responsibility of clarifying with the students the
goals, purpose, and requirements of the course.
(6) Students become most engaged in and benefit most from a course
when they are treated as collaborators whose ideas and cooperation are
essential to the learning process.
(7) Students become most invested in a course when it addresses, in part,
their own personal and professional goals.
(8) When a course addresses students’ goals and students are treated as
collaborators, their anxiety is lower and their motivation is higher;
thus, their course performance is more likely to reflect accurately their
abilities and personal potential.
(9) Giving students feedba about their course performance in a
collaborative manner can help them understand and address any
performance deficits.
(10) When instructors discuss course ratings with students in an
emotionally supportive manner, students oen feel affirmed, less
distressed, and more hopeful, even if the feedba is initially difficult
for them to hear.
(11) A course on personality assessment can have a lasting impact—both
personally and professionally—on students’ lives.
(12) A collaborative approa to teaing personality assessment also
creates opportunities for instructors to learn, hone clinical skills, and be
allenged by their teaing.
Flow Chart of a Course in erapeutic Assessment
Exhibit 15–1 represents a flow art of my course in erapeutic
Assessment. Let me explain the steps in detail here.
EXHIBIT 15–1 Flow Chart of a Cource in erapeutic Assessment
Step 1: Assessment estions Are Specified and Gathered
In erapeutic Assessment, the assessor engages clients as collaborators at
the beginning of the assessment by helping them identify personal goals and
form questions to be addressed during the assessment (Finn, 1996; Finn &
Tonsager, 1997). In involuntary assessments (su as court-ordered
assessments, disability evaluations, and personnel-screening evaluations),
clients typically are reluctant to frame personal goals for an assessment; they
may even feel that posing assessment questions is dangerous in that su
information may be used against them. In su situations, assessors can
oen gain clients’ cooperation by first sharing the referring persons’
assessment questions with clients, and negotiating beforehand with the
referring person for permission to keep the client’s own questions
confidential (Finn & Tonsager, 1997).
In my graduate course, I followed the protocol for involuntary
assessments by reviewing at the first class meeting the questions the clinical
psyology faculty members would ask me to answer about ea student at
the end of the course. ese questions were:
(1) Does the student have an adequate knowledge of the theory and
resear related to personality assessment?
(2) How well was the student able to conceptualize clinical case material?
(3) Has the student adequately mastered the administration and scoring of
major personality tests?
(4) How well did the student write assessment reports?
(5) At what level are the student’s basic clinical skills—for example,
empathy, active listening, and ability to maintain appropriate
boundaries?
(6) How did the student respond to supervisory feedba?
(7) Did the student demonstrate any behavior that raises concern about
her or his suitability to be a clinical psyologist?
(8) Is the student ready to participate in a clinical practicum?
I promised students that I would discuss my answers to these questions
with ea of them at the end of the semester before I gave my report to the
clinical psyology faculty. I also stated that I would be very interested in
their ideas and reactions to my answers and would incorporate their ideas in
my report. I then invited students to pose additional individual questions
that might be useful to them for me to address during and at the end of the
semester. I assured them that these questions (and my answers) would not
be shared with the clinical-training commiee without their permission and
that their course evaluation would not be influenced by whether they came
up with additional questions, or by the content of these questions. I gave
examples of questions students had posed in previous years (e.g., “Why do I
find it hard to talk about sex with clients?” “Am I too shy to be a good
therapist?” “I’ve been told I need to be warmer with clients. How can I do
this?”). Last, I let students know that they could offer these questions at any
point during the semester by discussing them with me or joing them down
and puing them in my mailbox.
Step 2: Course Contract Is Finalized
During the first class meeting, I also handed out a detailed syllabus of the
course requirements, including information about how ea assignment
would be graded. For example, as part of the course, students were required
to learn the administration of the Rorsa according to the
Comprehensive System (Exner, 1995). e course information specified
when students would be tested on administration and included a rating
sheet I used to grade the observed administration. Last, I answered any
questions students had about the course structure and requirements until
they and I were satisfied that we had a mutual understanding of the course
contract.
e majority of the syllabus was structured to follow the flow of a
standard erapeutic Assessment of a client, that is, initial interview,
standardized testing, assessment intervention session, summary/discussion
session, and wrien report (Finn & Tonsager, 1997). For ea of these tasks, I
would repeat the following steps (3 through 10) during the course.
Step 3: e Assessment Task Is Explained and Conceptualized
First, I provided readings about ea task, and students and I discussed the
teniques and underlying principles involved. For example, we thoroughly
explored the purpose of the initial interview of a erapeutic Assessment,
the types of problems that can arise, and how to handle these various
complications.
Step 4: e Assessment Task Is Demonstrated by the Instructor
Before the course began, I invited colleagues in the community to refer
clients to be assessed by the students and me as part of the course. (It was
not difficult to find clients who would agree to su an arrangement in
return for a free assessment.) I would select one of these clients for me to
assess myself. en, I demonstrated ea assessment task in front of the
class, before the students performed the task on their own. For example,
aer the students and I had discussed the initial session of a erapeutic
Assessment, I interviewed a volunteer client while students observed during
a class meeting. Later, I worked with this same client to demonstrate other
parts of the assessment. I videotaped some lengthy tasks, for example, the
Rorsa administration, outside of class sessions. I then showed portions
of the videotape during class periods and/or asked students to wat the
tape on their own before we met. I openly discussed any anxiety I felt about
su demonstrations, in order to normalize the students’ anxiety about being
observed. I also modeled steps I took to deal with my anxiety.
Step 5: Students Kate and Give Feedba to the Instructor
While I demonstrated ea assessment task, students rated me on the same
form the teaing assistants (TAs) and I would later use to rate them. Aer I
completed ea task, I would also rate myself. en the students and I would
discuss our observations and ratings of my performance. I would try to
model a nondefensive receptivity to their feedba and to be open to
learning from the students’ observations. is was rarely difficult, as
students generally made sensitive, accurate, and insightful comments.
Repeatedly my students told me that my willingness to demonstrate ea
assessment task was extremely valuable and greatly appreciated. It was also
an important way to embody the collaborative principles underlying
erapeutic Assessment. By making myself vulnerable and openly
anowledging my anxiety, mistakes, and learning, I reduced the power
imbalance between students and myself and helped to alleviate their
anxiety. One can never completely eliminate this power imbalance, nor is it
the goal of erapeutic Assessment to do so. e instructor and/or assessor
is still seen as an expert on assessment, but one who recognizes that no one
person has the entire truth about any interpersonal situation and who is
willing to learn from the student and/or client. By demonstrating my work, I
also managed to engage the students as co-assessors and collaborators in the
course and in the observed assessment and thereby increased their
excitement and motivation to learn. Last, my actions communicated my
respect for students as individuals and as a group, and seemed to empower
them to believe that they too could become skilled assessors.
Step 6: Students Role-Play Ea Assessment Task
Following the observed demonstration, students would practice ea task
(e.g., the initial interview) in pairs or small groups—with myself, the TAs, or
other students role-playing clients. I tried to encourage students to give ea
other feedba, based on their subjective experience of playing assessors or
clients. By leing students supervise ea other, I again tried to resist being
viewed as the only expert.
Step 7: Students Perform Ea Assessment Task With a Client
Next, students were individually observed while performing ea
assessment task (initial interview, Rorsa administration,
summary/discussion session, etc.) with a volunteer client. e TAs or I
would observe these sessions and rate students on the appropriate rating
form. Students would rate themselves on the same form aer completing the
task.
Step 8: Students Are Given Feedba on Ea Task
e TAs and I compared our ratings and observations of the students’
performance on ea task with the students’ own ratings. Both strengths and
weaknesses were brought up for discussion, and we asked students to
respond to our comments, rather than passively accept them as “ultimate
truths.” We paid special aention to issues students had identified in their
individualized assessment questions (posed at the beginning of the course).
is approa parallels the feedba process in erapeutic Assessment, in
whi clinicians tie assessment findings to clients’ individual goals and
engage clients in discussing the accuracy and meaning of test findings,
rather than acting as if su results represent absolute reality.
Step 9: Students Try Out Modifications of Ea Task
In the assessment intervention stage of erapeutic Assessment, clients and
assessors use test behaviors as analogs of extra-test problems in living. en
they sear for new solutions to external problems by identifying new ways
for the client to approa test materials (see ap. 8). For example, a client
who has posed the question, “Why do I have trouble completing my
assignments at work?” may copy the Bender-Gestalt figures in an obsessive,
painstakingly slow manner. Aer discussing with the client the similarities
between his behavior in the two situations, the assessor might ask the client
to draw the figures again, but more rapidly. By trying different ways to
speed up the Bender-Gestalt copy, the client and assessor may identify ways
that the client can complete more assignments at work.
In the assessment course, aer students and I noticed problems in their
performance of any assessment task, we would role-play the task again and
again, identifying possible solutions and/or blos to behavior ange. For
example, a student and I might discover that she failed to do an adequate
Rorsa inquiry because she was afraid of annoying the irritable, easily
offended client she had been assigned. e student and I would discuss ways
to deal with su clients’ annoyance, and would try out these strategies
together until we were both reasonably confident that she could handle su
situations in the future. In class, I would explicitly state my belief that su
problems arise for all beginning assessors and that the purpose of the
practice assessments was to identify su difficulties and address them
before students went on to practicum placements. In rare instances, students
and I found that they were unable to modify easily problem behaviors that
showed up during their assessments. In su cases, if the problems were
significant, I sometimes suggested to students that they consider geing
psyotherapy.
Step 10: Students Repeat the Assessment Task With Another
Client
By the end of the course, students observed me many times, and they, too,
were observed many times, as they honed or modified their assessment
skills, and repeated ea assessment task with another client. Students
generally completed two to three full personality assessments as part of the
course requirements. Although I had no illusions that this amount of
experience would identify and address all potential problems students might
encounter, I felt fairly confident that students would have the ance to
address most major clinical and aracterological issues.
Step 11: End of Course Feedba Session Is Given to Student
When all course requirements were completed, I offered an individual
summary/discussion session to ea student, whi I conducted according to
the teniques of erapeutic Assessment, for example, addressing students’
individualized goals, offering balanced (both positive and negative)
feedba, beginning with feedba that was likely to fit students’ self-
concepts, allowing students to allenge my comments (see ap.l). As with
earlier supervisory sessions, I tried to engage ea student in a dialogue
about my observations and I carefully listened to any disagreements or
modifications of my feedba. Before the session ended, I told ea student
her or his grade and I invited feedba about the course and/or about me as
an instructor. I let students know they would have another opportunity to
give me feedba anonymously.
Step 12: Written Report Is Prepared and Student Has Option of
Commenting
In erapeutic Assessment, reports are wrien in language that clients can
understand and are virtually always shared with clients. In addition, clients
are given the ance to respond in writing to their reports (Finn & Tonsager,
1997). In my course, I followed this approa with students. Shortly aer the
summary/discussion session, I prepared my wrien report about ea
student for the clinical psyology faculty, including modifications that
came out of my discussions with students. I gave students copies of their
reports and I invited them to put any reactions or disagreements in writing
and give them to me. I promised to present su comments to the clinical
psyology faculty at the same time I gave my own report. I believe that my
commitment to showing students my reports helped keep my assessments
precise and balanced. I avoided impressions and comments that I could not
adequately support. Also, as in a clinical assessment, students’ comments on
my reports were oen illustrative of my impressions, and were thereby
useful to the other faculty.
Step 13: Students Anonymously Give Feedba to the
Instructor
In my practice, all clients are invited to rate their assessment experiences on
a standardized form (the Assessment estionnaire—2; Finn, Sroeder, &
Tonsager, 1994) at the end of an assessment. My department routinely
required students to anonymously complete course evaluations at the end of
the semester. I always let students know that I paid careful aention to their
ratings and comments in designing the course for the following year. I
sometimes found that students were more forthcoming in their feedba on
the anonymous course ratings than they were when discussing the course
with me in their feedba sessions. I see this as an inevitable result of the
distrust inherent in involuntary assessment situations.
Step 14: Report and Student Comments Are Presented to
Faculty
Finally, I shared my report about ea student, along with any comments
she or he had wrien, with the clinical psyology faculty. My observations
were integrated with those of other faculty members to make
recommendations about commendation, remediation, or dismissal of
students from the department.
Case Example—Elizabeth
Let me now illustrate the approa I have described with the case of one
student, a 23-year-old woman whom I name Elizabeth.
First Impressions
In the initial class session, Elizabeth impressed me as a bright, nervous
woman. She asked several excellent clarifying questions about the course
syllabus, but spoke in a rapid, breathless voice, sometimes stumbling over
words. She repeatedly twisted a bead nelace that she wore throughout the
class meeting, and several times I had a vision of its breaking and spilling all
over the floor. I vaguely remembered meeting Elizabeth 4 months earlier, at
the departmental party at the beginning of the first semester, where we
aed about our mutual interest in horseba riding. I also recalled Dr.
Smith, the first-semester assessment instructor, telling me that Elizabeth
seemed quite “anxious/’ In keeping with these experiences, I received the
following note in my department mailbox the day aer the class session:
Dr. Finn,
I have one additional question for us to consider during the course. Dr. Smith told me that
I talk too mu with clients and I haven’t been able to stop this. I hope you and I can figure
out why I do this and how to help me stop.
Elizabeth
I was impressed by Elizabeth’s awareness of a problem and her
willingness to disclose it to me. I was also encouraged by the “you and I”
phrasing in her note, whi seemed to indicate her acceptance of the
collaborative frame of the course.
Initial Session
I briefly anowledged Elizabeth’s note at the beginning of the next class
session, and she appeared calmer in this and the next several class meetings.
She continued to ask excellent questions in class and made insightful
comments about the readings I had assigned. I began to see her as a bright
and very dedicated student who worked hard and prepared carefully for
class sessions. She and I had a short meeting before her first client session,
aer I interviewed the client I was assessing in class. I took the opportunity
to ask Elizabeth more about her “talking too mu” with clients. I found out
that Dr. Smith’s observation reminded her of comments several friends had
recently made—that she seemed “wound up.” She confessed that this
feedba had surprised her at first because she had oen been told she was
“too quiet” in college. When I asked Elizabeth what she thought about this
discrepancy, she said it might be because she “tried too hard” with new
things, but then calmed down aer a while. I sympathized with the anxiety
of doing new things and of overdoing as a result, and we agreed that
Elizabeth should “do her best” but not “try too hard” in her first client
interview. She also agreed to role-play an initial interview with one of the
TA supervisors prior to meeting with her client. At the end of our meeting,
Elizabeth also asked me how I felt when the client I had interviewed in class
began to cry.
Early Assessment Sessions
Elizabeth’s first assessment client was a subdued, apparently ronically
depressed young man who sought psyological testing to explore why he
had so mu trouble keeping friends. As I wated her initial interview I
was stru by Elizabeth’s calm, firm demeanor with the client, and I
wondered if Dr. Smith or Elizabeth’s friends had misperceived her, or if she
had simply corrected her tendency to “talk too mu” and “try too hard.”
Aer the interview, we both agreed that the session had gone quite well and
that Elizabeth had done a good job of both directing the client and leing
him talk. I commended her for her poise; she said that she had felt in the
interview as she did when riding a “good horse”: “comfortable and not at all
afraid.” We sketed out the next steps in the assessment and seduled a
time for me to wat Elizabeth administer the Rorsa to her client several
days hence. She had already wated me administer the Rorsa and had
passed a trial administration during whi one of the TAs played a client.
Partway into the observed Rorsa session, I noticed a marked ange
in Elizabeth’s comportment, compared to the beginning of the Rorsa or
the initial interview. She began to fidget in her seat, several times cut-off the
client in midsentence with questions, and her spee became rapid and
breathy, as I had noted in the first class session. As I wated, I remembered
that Elizabeth asked me about my experience of the client I had interviewed,
and I developed a hypothesis about her apparent rise in anxiety. e young
man Elizabeth was testing had become noticeably distressed on Card V of
the Rorsa, aer seeing “a bat flying home over a balefield. His wings
are burned and torn. He’s been through something terrible and is just trying
to make it through—to make it ba to his cave.” is response was followed
by numerous morbid percepts, and the client’s general flat affect became
more and more depressed until, on Card IX, he began to cry.
Elizabeth reacted by becoming more and more directive and by speaking
very rapidly, especially during the Inquiry. is seemed to confuse the client,
and there was a rather tense ending to the Rorsa administration. Aer
the session, Elizabeth herself was upset, and she commented that she was
aware she had “talked too mu.” When I asked if she knew why, she said
she had been anxious because this was her first Rorsa, and she felt she
had once again “tried too hard.” When I shared my hypothesis that she had
goen more active as her client got more distressed, Elizabeth paused to
consider and then quily agreed that this was so. She said she had been
afraid the client was going to “fall apart” and she had no idea “how to put
him ba together again.” is led to a fruitful dialogue, where I noticed that
Elizabeth had seemed calmer in the initial interview, where the client was
somewhat withdrawn and depressed, but not overtly upset. Elizabeth agreed
and spontaneously noted that both of the clients she had tested in the
previous semester (under Dr. Smith’s supervision) had been highly
emotional and very distressed. We hypothesized that Elizabeth got
uncomfortable when clients showed painful emotions, and she tended to
react by talking too mu and becoming controlling. I reminded her of her
question about how I felt when the client I interviewed began to cry, and we
spent some time discussing my reactions and ways to handle su situations.
Assessment Intervention
e next day, Elizabeth and I met to role-play ways to handle distressed
clients. I modeled simply anowledging clients’ pain, without trying to fix
or control it. Elizabeth confessed that this was a novel idea for her; she
tended to feel responsible for others’ distress. At first, as I role-played a
weeping client she reacted by trying to eer me up. I drew an analogy to
horseba riding, and we discussed how a rider must stay calm and
unruffled if a horse is frightened by a sudden noise or event. At this point,
Elizabeth seemed to cat on and she successfully handled several other
situations that I presented to her. Last, we reviewed how she could have
responded to her client when he began to cry during the Rorsa. Later
that week, Elizabeth met with her client again to conduct the assessment
intervention session for his assessment.
I had asked Elizabeth to begin by asking the client about his experience of
the Rorsa administration. Not surprisingly, the client seemed even more
subdued and withdrawn at the beginning of the session. However, he was
able, with Elizabeth’s help, to say that he felt upset aer their previous
meeting. I was pleased as Elizabeth calmly asked questions about his
perception of her. en, to my surprise, the client spontaneously offered,
“You know, what happened with us happens with me and my friends all the
time. at’s part of the problem I’ve been having.” e client went on to
relate how his friends couldn’t handle his depression, and how
misunderstood he felt when they offered suggestions, told him to “stop
moping,” or suggested he “just go out and have fun.” Elizabeth participated
in this discussion beautifully, and was able to incorporate the client’s
observations later in the TAT testing we had planned. Aer the session, she
and I joyfully discussed the client’s learning and her ability to react well to
his distress.
Later Assessment Sessions
For Elizabeth’s second assessment, we both agreed that she would work
with a middle-aged woman who was described by the referring therapist as
“prone to fits of hysterical crying.” I did not personally supervise this
assessment, but the TA reported that Elizabeth handled the initial interview
and early testing sessions quite well, even though the client became
markedly distressed at several points. en, during the summary/discussion
session, Elizabeth again became rather anxious and strident, and insisted on
the rightness of several of her interpretations. Aerward, both she and the
TA were puzzled about her [Elizabeth’s] behavior, because the client had not
been markedly distressed during the feedba, and in fact, had seemed
pleased and appreciative of the assessment.
I was concerned when Elizabeth came to see me during my office hours
the next day, for she looked disheartened and a bit haggard. Once again, she
was rather breathless as she talked about the summary/discussion session
with her client, speaking rapidly and stumbling over words. I gently probed
about what might have made her anxious during that session, until
Elizabeth broke down and began to cry. I remembered my advice to her and
stayed calm and inquisitive, as Elizabeth finally disclosed another piece of
the puzzle: Her mother had been diagnosed recently with ovarian cancer. In
fact, Elizabeth had found out about her mother’s illness only the morning
before the first assessment class meeting. (No wonder she had been so
anxious that day!) e day of the summary/discussion session with her
second client, Elizabeth had learned that her mother’s cancer was not
responding to emotherapy. Furthermore, it came out that Elizabeth was
extremely close to her mother, who was a highly emotional woman who had
always looked to Elizabeth to help contain her depressed feelings.
I sympathized with Elizabeth’s situation, recommended that she seek
support during su a difficult time, and gave her the name of several good
psyotherapists in the community. is event demonstrates the fine line
that oen exists between supervision and therapy. I do not inquire about
students’ personal issues during supervision unless there is an impasse in
their ability to work with clients. Once personal issues are identified, I
generally refer students to an outside therapist to explore the personal issues
further.
Elizabeth calmed down considerably and appeared to leave my office with
renewed hope and determination. I was le musing about how I too tend to
avoid seeking help when I need it, and I realized that I had never discussed
with students the impact that personal emergencies can have on an
assessor’s ability to be with clients. I resolved to add su a discussion to my
course in the future.
In the following weeks, Elizabeth appeared calmer and happier in class
sessions. She did an excellent third assessment on a difficult client, and
showed no disabling anxiety or controlling behavior during that assessment.
Her reports were well craed and insightful. She also aieved the highest
grade in the class on the wrien final exam.
Summary/Discussion Session
My summary/discussion session with Elizabeth, held jointly with the TA
supervisor, was smooth and productive. We reviewed Elizabeth’s
considerable strengths as an assessor and again discussed the difficulties she
had shown earlier in the semester. I commended Elizabeth for her ability to
improve her clinical skills, and Elizabeth thanked me for my support and
responded briefly to my inquiries about her mother’s health. She also
shared, in an appropriate way, some additional insights she had discovered
in therapy about her reactions to others’ distress. e TA and I said a few
words about our own learning process in this area and we all parted with
warm feelings.
Written Report
My wrien report on Elizabeth’s course performance (Exhibit 15–2) was
given to the clinical psyology faculty. I shared this report with Elizabeth
several days before the faculty met to discuss her performance.
EXHIBIT 15–2 Wrien Report Comcerning Elizabeth’s Cource Perfomance
Elizabeth’s Comments on the Report
Elizabeth wrote a brief response to my report, whi I also shared with the
clinical faculty:
I agree with Dr. Finn’s report and feel that I learned a lot about myself and about assessment
through his course. Dr. Finn discreetly mentioned “family issues” that were troubling me during
the semester. I want to clarify this. My mother was diagnosed with cancer earlier this year and her
health is going downhill quily. is has been quite upseing for me and my family, but I think
that I am handling it as well as can be expected and I have lots of support. I will be spending the
summer with my mother and I plan to return to my studies in the fall.
Summary and Conclusions
In this apter, I highlighted the similarities between a required graduate
course in personality assessment and the clinical assessment of clients who
are involuntarily referred for psyological testing. I aempted to
demonstrate how the same principles underlying clinical erapeutic
Assessment may also be applied to the educational seing. By (a)
minimizing any unnecessary power differential between themselves and
students; (b) addressing students’ personal goals in course evaluations; (c)
modeling vulnerability and openness to feedba; and (d) treating students
as collaborators in the learning process, instructors of personality
assessment may increase the professional and personal impact of their
courses on students. Su an approa is allenging to instructors in that it
requires them to be aware of their own anxiety and to minimize defensive
reactions to it. However, the rewards of this method are great. Over the
years, I have had the pleasure of receiving feedba from former students
that my course in personality assessment was one of the most important in
their graduate training. I am also very aware of how mu I have learned
about myself, about teaing, and about personality assessment from
instructing others in erapeutic Assessment.
Notes
is apter is excerpted from one (Finn, 1998) previously published in the book, Teaching and
(Handler & Hilsenroth, 1998).
Learning Personality Assessment
I am grateful to Jim Durkel for his comments on an earlier dra and to the many students who
instructed me in how to tea psyological assessment.
Part III
eoretical Developments
16
Please Tell Me at I’m Not Wko I Fear I Am:
Control-Mastery eory and erapeutic
Assessment
I am always searing for new “lenses” to use in looking at the complex
process of psyological assessment. us, it was with some excitement that
I joined a study group in Austin several years ago run by Dr. Elayne
Lansford, an expert on Control-Mastery theory. I already knew a bit about
this theory and suspected that some of its insights into human nature and
psyotherapy would be useful in my practice of erapeutic Assessment. I
was right, and in this apter I review the major concepts in Control
Mastery theory and illustrate their applicability to erapeutic Assessment
through several case examples. I then discuss how Control Mastery theory
helps us understand the phenomenon of “failed” assessments, in whi
clients feel less capable or even traumatized following a psyological
assessment. Finally, I offer some general thoughts on the role of theory in
psyological assessment.
A Brief Introduction to Control-Mastery eory
Control-Mastery theory is a relatively new psyodynamic theory, first
articulated by Joseph Weiss, M.D. in the 1960s. In 1972, Weiss and his
colleague Harold Sampson, PhD, co-founded the San Francisco (formerly
Mt. Zion) Psyotherapy Resear Group, and although Weiss died in 2004,
this group continues to theorize, tea, and conduct resear about
psyotherapy. In fact, Control-Mastery theory is the only psyodynamic
theory that I know of supported by a wide body of quantitative resear.
e basic tenets of Control-Mastery theory are relatively simple at first
glance, although they have far-reaing implications. First, it is assumed
that clients’ problems in living derive from unconscious pathogenic beliefs
they developed from early traumatic experiences (Weiss, 1993). For example,
a gay man I see for psyotherapy was rejected as a ild by his father for
being a “sissy”; he clearly came to believe that he was weak and unaractive
and could never be accepted or loved by another man. Another client
witnessed her father emotionally and physically abusing her mother, who
never stood up to her husband or said a bad word about him aerwards.
is client acquired a strong belief that “One must silently accept any kind
of treatment from important others, no maer how terrible.” Although su
conclusions helped these individuals make sense of their early life
experiences and adapt to them, they now get in the way of their pursuing
normal developmental goals that would help them aieve happiness. As
you can see, this first part of Control-Mastery theory is not that dissimilar
from other post-Freudian psyodynamic theories, su as ego psyology,
object relations, or self psyology.
Where Weiss’s theory is unique is in his assumption that clients seeking
psyotherapy are powerfully motivated to “disconfiirm” their pathogenic
beliefs about themselves and the world in order to become more
independent, happy, and aieve more satisfying relationships. Weiss says
that when clients seek treatment, they have an unconscious “plan” to seek
evidence—through the relationship with the therapist—that their pathogenic
beliefs are inaccurate and that it is safe to begin acting as if they were
untrue. In Weiss’s theory, all clients “test” therapists in several ways to see if
they will disprove their pathogenic beliefs.
First, there are what Weiss called transference tests, in whi the client
may see if the therapist accepts and goes along with their pathogenic beliefs,
in the same way as early caregivers did. For example, my gay male client
was quite confused early in treatment when I asked him why he wasn’t
trying to date men he found aractive. He said he assumed none of them
would ever want to be with him, and he grew notably interested and
relieved when I said that I doubted that to be the case. Another kind of test—
calledpassive-into-active testing—occurs when clients treat therapists as they
themselves were treated as ildren, to see if the therapists can demonstrate
a more effective way of responding. Hence, I was not surprised when the
second client I mentioned—who had witnessed her mother silently accepting
abuse—one day became unfairly critical and derisive towards me in a
session. I had the presence of mind to stand up for myself, and I said
explicitly that I did not deserve to be treated that way; at that point the
woman calmed down, apologized, and anged the topic. Most importantly,
in the following weeks she began to be more assertive with her highly
irresponsible boyfriend, who was misusing her terribly, and she started to
trust me with more details about their relationship.
One interesting footnote is Weiss’s assertion that oen, clients reveal their
pathogenic beliefs and unconscious plan for ange very early in treatment,
and more oen than not in the first few sessions. Weiss said that sometimes
clients will state their unconscious beliefs and plans directly; more oen, one
must listen “in between the lines” to deduce clients’ unconscious agendas.
Control-Mastery eory and erapeutic
Assessment
As far as I know, no one in the San Francisco Psyotherapy Resear Group
has yet applied the concepts of Control-Mastery theory to formal
psyological assessment. Most likely, this is partly due to the traditional
diotomization of assessment and psyotherapy. Hence, it may only be
when one considers erapeutic Assessment—with its explicit goal of
helping clients developing new, more accurate and useful understandings of
themselves and the world—that the utility of this theory for psyological
assessment becomes evident.
Clients’ Unconscious Plans and eir estions for an
Assessment
I have found it useful to consider clients’ pathogenic beliefs and unconscious
plans in listening to the questions and goals they pose at the beginning of a
therapeutic assessment. Sometimes, clients seem to lay out their worst fears
or beliefs about themselves directly, with the overt goal of using the
psyological test results to prove or disprove them. For example, some
clients will ask questions like “Are all my problems really the result of an
awful ildhood, or am I just using that as an excuse, like my family tells
me?” or “Am I really angry, like my probation officer says, or just more
honest than most people [as I think]?” I never assume before I see the
assessment results exactly how I will end up answering the client’s questions
by the end of the assessment; but, I generally assume that the client is
testing me to say ba directly what he or she has revealed through the
testing. I might end up telling the first client that she has been severely
traumatized, and that her family’s expectations for her are completely
unreasonable. Or, her test responses might suggest the opposite, that her
baground wasn’t that dysfunctional and that she overplays her
baground for sympathy because she is terrified of succeeding. In either
case, I believe the client is using the assessment to disconfirm some worst
fear about herself, for example, that she really is a whiny complainer who
simply needs to pull herself up by her bootstraps, or alternatively, that she is
so severely damaged that she can never succeed and deserves pity and
sympathy from others. And again, I assume that clients will tell me whi
fears to disconfirm through their responses to the MMPI-2, Rorsa, and
so forth.
Like Weiss, I find it rare that clients lay out their pathogenic beliefs for
testing so explicitly; I am more used to situations where depressed and
traumatized clients pose assessment questions like “Why am I so lazy?” or
“Why am I so unreasonably distrustful of everyone?” In su instances, it is
usually fairly easy to disprove the pathogenic beliefs embodied in these
questions by explaining to clients how the labels they have for themselves
are inaccurate, or la compassion, even if they have a grain of truth. I will
show the person who thinks he is “lazy” his elevated Depression scale score
on the MMPI—2, and explain to him how ronic depression can lead to
poor work habits, underaievement, and la of motivation. I might talk to
the woman who views her distrust as a aracter flaw about her elevated
Trauma Content Index on the Rorsa. If she can anowledge that awful
things were done to her early in life by people who should have been
trustworthy, then possibly she can come to see her interpersonal vigilance as
an outmoded coping meanism, and gradually focus on learning when it is
smart to be wary and when it is safe to trust.
ere is another more striking client presentation I have seen, where the
stated goals for the assessment seem unreasonable or clearly contradict
information revealed during the assessment. As Weiss (1993) suggested, this
can be a clue that the client is unconsciously asking the assessor to refute a
pathogenic belief. For example, a colleague and I recently assessed a man
who was demoralized aer being berated by his wife for years about his
“la of feeling” and “inability to be intimate.” One of the questions he posed
for his assessment was “How can I come to be satisfied living totally on my
own without any intimate relationships?” However, the client’s Rorsa
was full of color determinants and whole human percepts, and he rated
himself on the MMPI-2 as gregarious and highly invested in spending time
with others. We told him at the end of the assessment that he wouldn’t be
happy living the life of a hermit, and that one of his problems was a high
degree of emotional sensitivity su that he easily got overwhelmed and
sometimes shut down completely. His wife’s emotional harangues were the
worst possible environment for him to connect to his feelings, but during the
safe context of the assessment, he showed that he could be quite tender and
emotional. e client seemed visibly relieved at this feedba and agreed to
his wife’s moving out—something he had been reluctant to consider
beforehand.
Similarly, some couples present for conjoint assessment with stated goals
that contradict almost everything they reveal during the course of the
assessment. Several years ago, I assessed a man and wife who said their
main question was “How can we come to forgive ea other for past hurts
and be happy together again?” ey had been vindictively aaing and
counteraaing ea other for over 20 years. During the individual portions
of the assessment, ea confessed that she or he no longer loved the other
and fantasized constantly about divorce. When I asked, in the assessment
intervention session, whether there was simply “too mu salt in the soup”
for the relationship ever to recover, they both seemed shoed. But when we
met a week later to review all the test results, they had already discussed
ending the marriage, and reported they had had their best week together in
years.
In contrast, another couple I helped assess seemed on the verge of divorce
aer a number of terrible traumas, including, 2 years earlier, the kidnapping,
rape, and murder of their 10-year-old daughter. ey had already separated
when the assessment began and posed questions like “Is there any hope?”
and “What is the best way to tell our families if we divorce?” During the
assessment, ea shared tender memories of the other, and they both spoke
of still being very mu in love. I wondered why they were considering
divorce, and now think that they had developed a pathogenic belief that
they were cursed as a couple. As the assessment progressed, it became clear
that they had pulled ba from ea other aer their daughter’s death, and
had very lile support from others to deal with this tragedy. en, they had
projected their guilt and anger on one another, and both secretly feared their
spouse blamed them for what had happened. I told them in the final
summary/discussion session that I had hope for the marriage if they could
get the support they needed to face their collective grief, and that ea
needed to hear from the other that they were not at fault for their daughter’s
death. I said I knew talking about all this would take a lot of courage, but
that the testing showed that ea was a strong person who was up to the
allenge. ey both began to cry and when I saw them for follow-up a
month later, they had moved ba in together and were starting to rebuild
their marriage.
Behavioral Tests of the Assessor
Sometimes, it seems that clients test assessors behaviorally, mu as Weiss
said happens during psyotherapy. For example, my colleagues and I rather
frequently assess young adults whose high-aieving, successful parents are
very concerned about their being underresponsible and failing to
individuate. ere oen are surprised looks all around when—in the first
session of su an assessment—I suggest that things will work beer if the
young man or woman is responsible for geing himself or herself to our
sessions. Sometimes, the young adult comes quite reliably—whi in itself is
interesting—but, in most cases there is at least one missed session. I have
come to see these missed sessions as a transference test, and I try to respond
according to what I have deduced up to that point about the client’s
underlying pathogenic beliefs. One young man clearly believed “I am a
constant disappointment to others and deserve severe criticism.” He seemed
shoed when I was fairly nonalant about the missed appointment and
when I casually asked if we should ange our meeting time to late
aernoons, as I knew that he oen stayed up late. He declined my offer and
never again missed one of our 10 a.m. meetings. Yet another young woman
was clearly overindulged by her parents, who never set limits on her and
only brought her for testing at the insistence of her high sool counselor.
When I recommended to her parents that the girl be asked to pay out of her
allowance for her second missed session, she threw a temper tantrum and
stormed out of my office. But in a later meeting, she told me that I had
earned her respect and she too never missed another appointment. Mu
later, the young woman confessed that she feared she was incapable of
living on her own, but that paying for the missed session had raised her
confidence.
Passive-to-Active Tests. e most common passive-to-active tests I have
seen during assessment are those where clients who have been abused in the
past turn the tables and try to disparage the assessor or the assessment
methods. For example, a young man I helped assess once was seen at the
request of his parents because he had virtually cut off all contact with them
except for taking their money to pay for college. e young man was very
tall, muscular, and emotionally closed off, and the parents were concerned
because he had told the mother’s therapist that he sometimes thought about
“pulling a Colombine.” One of the parents’ assessment questions was
whether they should worry about his killing them. At first this concern
seemed outlandish, but as the assessment proceeded, my postdoctoral
assistant and I were shoed by how malicious and abusive the boy’s parents
had been to him as he grew up. For example, when he was 7, his father had
insisted that he learn to water ski, and had kept him in the water, sobbing
uncontrollably, for over 5 hours until he was finally able to get up on the
skis for a brief period of time. e mother sat in the boat with the father the
whole time this was happening and did not intervene.
e young man agreed to the assessment but was openly skeptical about
whether our psyological tests could tell him anything he didn’t know. He
was somewhat hostile, but kept this fairly under wraps while I was in the
room. en he had two very significant assessment sessions alone with my
postdoctoral assistant. In the first, they talked about his early ildhood and
he soened considerably as she expressed her horror and sadness about his
abuse. At the second session, they did the Rorsa, and aerwards he was
so openly disparaging and hostile that he reduced this sturdy young
psyologist to tears.
Fortunately, she and I consulted immediately aer, and I explained
Weiss’s idea that the client was hoping that she could demonstrate a way of
handling abuse that he had never been able to discover. Apparently, the
client’s pathogenic belief was that one either had to accept ill treatment, cut
off all contact with one’s abuser, or become a violent person oneself. At their
next meeting, my assistant confronted the client directly about how awfully
he had treated her. She did this, of course, without becoming abusive
towards him. Later, he also heard me confront his parents when giving
assessment feedba about their horrific treatment of him. Like my assistant,
I was direct and blunt and forceful, but I never crossed the line to become
sadistic or cruel. ere were many complicated outcomes to this assessment,
but one was that the young man was able to resume contact with his
parents, while standing up to them in appropriate ways. By passing his tests,
my assistant and I had apparently disconfirmed his pathogenic beliefs and
modeled a new way of being.
Failed Assessments
Over the years, I have become quite interested in failed assessments, whi
are defined in erapeutic Assessment as those assessments that result in
clients’ feeling diminished or traumatized by the process (Finn & Tonsager,
1997). Aer reading Weiss and his colleagues, I now hypothesize that certain
assessments fail—in the sense of hurting rather than helping clients—because
they confirm, in the clients’ minds, some key pathogenic belief they hold
about themselves. For example, recall the case I discussed in apter 13, of
the woman who experienced her passive, withdrawn husband as abusing
her (mu as her humiliating and narcissistic father had done). Some of her
major questions for the assessment were “Where are my blind spots?”
“Where is my ‘bad stuff and what I don’t want to see about myself?” and
“How am I participating in projective identification in {my marriage]?” I was
impressed at the time by the client’s psyological sophistication and
openness, and I rather naively set myself the task of helping her learn about
her part in the dysfunctional marital dance she and her husband were doing.
In the summary/discussion session, I talked to the client about her
misperceptions of and projections on her husband. I told her I saw no
evidence that he was being hostile to her when he shut down emotionally;
rather, he simply had no other way of handling his anxiety. I suggested that
she had not fully confronted the reality of how sadistic her father had been
to her when she was young. Furthermore, her own testing showed a great
deal of underlying anger that she was not aware of. I knew these things
would be allenging for her to hear, but I was confused and surprised when
I learned later that she had been highly traumatized by the feedba session.
Aer learning more about Control-Mastery theory, I have come to see that
my feedba must have confirmed—in her mind—some of her deepest held
pathogenic beliefs from her ildhood: that she was bad, solely responsible
for her unhappiness, and did not deserve any sympathy from others.
As mentioned in apter 13, as a result of my rethinking of this case and
other “failed” assessments, I have made a slight, but important modification
in the procedures of the first session of a therapeutic assessment. Now, aer
helping clients to form individualized questions to be addressed by an
assessment, I always ask at some point, “What is the worst possible thing I
could tell you as a result of our work together?” I have been surprised by
how useful clients’ answers to this question have been, and I have
remembered Weiss’s idea that clients are oen amazingly insightful in initial
sessions about otherwise unconscious pathogenic beliefs. You may want to
experiment with asking this question at the beginning of an assessment.
e Role of eory in Psyological Assessment
is is one of several apters in this book relating erapeutic Assessment
to various theories of human behavior and psyopathology. Previously I
discussed Sullivan’s interpersonal theory (ap. 3), humanistic psyology
(ap. 4), and family systems theory (ap. 14). In apter 17, I write about
intersubjectivity theory and phenomenology, and elsewhere I have related
erapeutic Assessment—albeit more briefly—to object relations and self
psyology (Finn & Tonsager, 1997). Now that I have added another
perspective—Control-Mastery theory—to the list, I feel the need to comment
on how I use theory in my day-to-day work with clients. is seems
important because in the past, aer disseminating various papers, I have
read some comment later where someone has wrien “erapeutic
Assessment is based on Sullivanian principles” or “erapeutic Assessment
derives from humanistic psyology” or “erapeutic Assessment applies
family systems theory to psyological assessment.” Ea of these statements
is true, in part, but they all miss the mark in a similar way.
My goal in thinking about a set of test data, or about the process of
psyological assessment, in general, is to flexibly consider a variety of
theoretical perspectives, and then compare the different insights that result. I
find that with one client, object relations theory helps me the most, with
another, family systems theory, and with yet another, intersubjectivity
theory. But what is most important, I believe, is avoiding the “one size fits
all” interpretations I see in so many of the psyological assessment reports I
receive from other assessors. Hence I present this exposition of Control-
Mastery theory, not because I believe it is the definitive way to understand
the complex work we do as assessors, but to provide another lens to aid us in
geing in our clients’ shoes, helping them find compassion for themselves,
and discovering new, more adaptive ways of being in the world.
Note
is apter is drawn from a paper I presented to the Society for Personality Assessment (Finn,
2005c).
17
Challenges and Lessons of Intersubjectivity
eory for Psyological Assessment
Inter subjectivity theory is a psyoanalytic perspective developed by Robert
Stolorow and his colleagues, George Atwood and Bernard Branda, in a
series of seminal books published over the last 20 years (Atwood & Stolorow,
1984, 1996; Stolorow & Atwood, 1992; Stolorow, Atwood, & Branda, 1994;
Stolorow, Branda, & Atwood, 1987). Some people have seen
intersubjectivity theory as an outgrowth of Kohut’s self psyology because
both use empathy and introspection as basic guiding principles; however,
this is incorrect and there are important differences between the two
theories (cf. Trop, 1994). Stolorow (1996) said that intersubjectivity is more
closely allied with the personology of Henry Murray, and indeed like
Murray’s theory, its basic tenets are idiographic, phenomenological, and
systemic in nature.
As far as I know, Stolorow and his colleagues have not wrien mu
about psyological testing or formal personality assessment, although
Stolorow (1994) mentioned learning idiographic personality assessment at
Harvard from Irving Alexander, a protege of Silvan Tomkins. Likewise, with
a few notable exceptions (e.g., P. M. Lerner, 1990; Silverstein, 1999; B. L.
Smith, 2005), few psyological assessors seem aware of intersubjectivity
theory. is may be because at first glance, intersubjectivity theory and
traditional psyological assessment appear highly incompatible.
You see, according to intersubjectivity theory, the “self” is not a separate
stable aracteristic of an individual—in fact, it cannot be described fully
independent of the interpersonal system in whi it is observed and/or
measured. Objective measures of “self-esteem,” “depression,” and “borderline
personality traits” are quite limited, an intersubjectivist would say, for
several reasons. First, behavior always occurs within a certain context,
meaning that a client who displays borderline aracteristics with one
assessor might not display borderline aracteristics with a different
assessor. Second, there is no su thing as a completely objective measure;
assessors can never escape the influence of their own subjective views on
their perceptions of clients. My personal history and implicit organizing
principles inevitably shape my interpretation that a set of test materials
indicates “depression,” and this would be true of any other psyologist as
well. ird, one can never fully know the extent or nature of one’s
contribution to an interpersonal context, although one can be open to and
curious about su factors. I remember when my friend and colleague, Anna
Maria Carlsson, reported at the annual Society for Personality Assessment
meeting that different assessors in the large Stoholm Comparative
Psyotherapy Study tended to collect different types of Rorsas
(Carlsson & Bihlar, 2000). Some assessors tended to get higher Rs, others
more space responses, and yet others lower Lambdas. I remember that many
people were troubled by these findings when they were presented, but they
are no surprise to an intersubjectivist. In any enterprise that involves human
relationships (as psyological assessment certainly does), there is no way to
completely remove the influence of the observer and/or assessor. What is
unique in the Swedish study is the opportunity to learn about su effects,
because usually we don’t have the data that permits su comparisons.
To help you grasp these ideas more concretely, let me relate a personal
incident that taught me a great deal about intersubjectivity and the
importance of perspective. My partner, Jim, and I frequently travel for work.
Some years ago, I noticed an interesting correlation between our travel and
the state of our queen-sized bed in the morning. When Jim was out of town,
I typically woke up to find the sheets and blankets neatly ordered. I could
hop out of the bed and make it up in a minute, by simply folding ba the
corner of the bedclothes where I had slept. In contrast, when Jim was in
town, the sheets and blankets were generally in disarray the next morning.
(And, I should add, this was not for the reasons you might be thinking.) It
might take 3 to 4 minutes to make the bed, requiring one to carefully
separate and tu in ea sheet and blanket. Aer a number of instances of
observing this paern, over some months, I reaed a reasonable conclusion:
“Jim musses up the bed.” I confess I even felt a bit virtuous that my calmer
temperament and/or clearer conscience led me to sleep so soundly in
contrast to him.
is glowing self-appraisal remained unallenged until one day when
Jim and I were making up an especially disorderly bed together. As we
tued in sheets and blankets on our respective sides, I looked across and
asked playfully, “What is that you do to the sheets in the middle of the night,
anyway?” “Me?” he replied. “It’s you that makes su a mess of them!” “Not
me!” I protested. “When you’re not here, I simply have to fold ba a corner
of the sheets in the morning.” “But that’s what happens to me when you’re
out of town,” Jim retorted. And then we both began to laugh. For we
realized, it was neither he nor I who was responsible, but we who
mysteriously entangled the bed. In statistical terms we might say that the
tendency to mess up sheets resided in the interaction term of the analysis of
variance (ANOVA), while ea of us had thought it was a main effect. And
su mistakes are common, an intersubjectivist would say, because typically
we don’t have the data we need to see su interactions in two-person
systems—ea of us has only our personal subjective point of view.
Furthermore, we tend to view behaviors or personal aracteristics as
residing solely in one person or the other because it is so difficult to think
systemically and interactionally. If you meditate about it, it really is very
complex trying to imagine the exact process through whi the sheets on
our various beds go awry!
Again, returning to psyological assessment, you can see how difficult it
is to apply an intersubjective model to the types of referral questions we
traditionally are asked to address. Other professionals ask us, “Is this client
borderline?” or “What causes this client to behave so oddly?” or “Will this
client be helped by group psyotherapy?” e first two of these questions
imply that the source of psyopathology resides in individuals, and that
there are people who have borderline aracteristics and those who do not.
e second question assumes that behavior is linearly determined, and that
the purpose of assessment is to discover some “Truth” about people that can
then be used to guide treatment. And the third question acts as if some
people respond well to group therapy and others do not, without mu
regard for the type of group, the aracteristics of the leader, or the client’s
aitude towards su a referral. If we adopt an intersubjective perspective,
must we be content to answer “It depends,” “It’s complex,” and “I don’t
know” to su referral questions?
Luily, another option exists. In 1985, Constance Fiser published a
groundbreaking book, called Individualizing Psychological Assessment, in
whi she laid out a coherent view of psyological assessment compatible
with intersubjectivity theory, and then derived a set of practical guidelines
for psyological assessment. Interestingly, Fiser came to her approa
from existential—phenomenological psyology, yet reaed a conclusion
about psyological inquiry that is remarkably similar to that articulated by
Stolorow and his colleagues: Although we can never escape our own
subjectivity, we can anowledge this fact to ourselves and others, and
constantly investigate how our internal organizing principles influence our
perceptions and conclusions. For reasons I’ll explain later, this basic principle
led Fiser quite naturally to the practice of collaborative psyological
assessment. As described in apter 1, my colleagues and I later formalized
Fiser’s methods into the structured approa we call erapeutic
Assessment, emphasizing the fact that su assessments have been shown to
be beneficial to clients (Aerman, Hilsenroth, Baity, & Blagys, 2000; Finn &
Tonsager, 1992; Newman & Greenway, 1997).
Next, I want to elucidate for you how intersubjectivity theory fits with
the practices of collaborative, phenomenological, therapeutic psyological
assessment. I’ll organize this section by referencing “lessons” I think
intersubjectivity has for psyological assessors.
Lesson # 1: Focus on Context
In collaborative assessment, we do not ignore the fact that there are
individual influences on behavior; to return to my ANOVA example, we
believe in main effects as well as interactions. We even accept that there are
potent genetic and biological influences on behavior. However, as Fiser
says in her book, we reject conceptions that “trait = fate.” We collaborative
assessors focus mu of our aention on the contextual factors influencing
behavior because this is where things get interesting if you’re trying to help
people overcome problems in living. When a referring professional asks us
to determine whether or not a client is “borderline,” we might get curious
about his or her uncertainty and ask questions like, “Under what
circumstances does the client act in a way that makes you think this, and
when does he not?” If we can, we assist the referral source in reframing the
original question to something like “Sometimes, Bob expresses himself in
highly emotional, self-destructive ways and makes sudden decisions in
whi he doesn’t anticipate potential negative consequences. Other times, he
is emotionally controlled and thoughtful. How can we understand su
behavior paerns?”
Su contextualized referral questions pave the way for what we hope
will be the outcome of the assessment—an understanding of the conditions
that are necessary and sufficient for a problem behavior to occur, including
su things as clients’ perceptions or interpretations of events around them.
For if we can determine this, we can begin to imagine contexts where the
problem behavior might disappear and then, as described in apter 8, run
“experiments” during the assessment where we set up su contexts and see
what happens. If these experiments succeed, they lead directly to
recommendations of how to alter the client’s context outside of the
assessment room to minimize the likelihood of a problem behavior
occurring.
Lesson #2: Attend to the Frame of the Assessment
Another place where we pay a great deal of aention to context in
collaborative and/or therapeutic assessment is in the framing of the
assessment itself. We believe it greatly affects our test results how a client
views the purposes of the assessment and whether the client and assessor
succeed in forming a mutually respectful relationship where they work
together to understand “puzzles” the client brings to the assessment. For
example, in apter 6, I’ve wrien about my view of “defensive” test
protocols, whi traditional assessors tend to see as indicative of resistance
or la of cooperation in a client. In erapeutic Assessment, when we get
an MMPI-2 protocol with high L and K and low F, or a Rorsa with a
high Lambda and less than 14 responses, we ask ourselves immediately, “Did
the client and I adequately discuss her thoughts about the assessment before
beginning testing?” and/or “Do I fully appreciate the dilemmas facing the
client in the evaluation?”
For example, I recently conducted a couples assessment where both
partners produced normal range MMPI—2 profiles, with very high elevations
on L, K, and S. is result surprised me at first because (a) the couple was
paying a great deal of money for the assessment, (b) the results would go
only to them and their couples therapist, and (c) they genuinely seemed to
want help understanding their relational stalemate. However, as I explored
the MMPI-2 findings with them in a session, I came to understand a piece of
the clients’ context I had missed. Ea very mu wanted to cooperate with
the assessment, but also was afraid that the testing would show that he or
she individually was the main cause of the marital conflicts. So, both of
them downplayed their problems and emphasized their strengths when
completing the MMPI-2. Once we all understood this, we were able to
discuss their fears openly, and I shared my belief that “It takes two to tango.”
ey agreed, and aer more discussion vowed that no maer what they
learned about ea other through the assessment, they would try not to use
it as ammunition. We agreed it would be helpful if ea focused on his or
her part in the couple’s difficulties. ey asked to retake the MMPI-2, I
agreed, and both produced very different unguarded profiles. Also, at our
next session, they reported they’d had their best week together in 5 years!
Lesson #3: Involve Clients in Co-Interpreting
Assessment Data
If you are interested in the practice of discussing test data with clients, you
should know that Fiser made it a routine procedure to involve clients in
interpreting their own test behaviors. is makes sense to an
intersubjectivist because we recognize that we look through our own “lens”
in understanding any test behavior, test score, or statement of a client. us,
we can never really know what a certain piece of assessment data “means.”
is does not mean that we give up our own point of view entirely; it too
conveys an important aspect of what is occurring in the assessment room.
However, we do not believe our interpretation reflects some abstract
“reality” and we are curious about others’ points of view (especially that of
the client).
For example, several years ago I tested a highly successful and educated
businessman, John, who was curious about his tendency to hook up with
women who were far less accomplished than him. John explained that these
relationships eventually all failed because of a basic incompatibility in
interests; however, he still found himself aracted to this type of woman.
John’s MMPI-2 was unremarkable, except for a slight elevation on Scale 9,
whi seemed to reflect his high-driving, busy lifestyle. On the Rorsa,
John surprised me by producing eight Morbid responses, and when I asked
him to comment on the test right aer taking it, he said, “I sure saw a lot of
damaged things, didn’t I?” I concurred and invited him to speculate on this.
He drew a blank. I then suggested that sometimes su responses reflect
feelings a person has about himself—that he himself is defective. He
considered for a moment and asked, “Could that be from long ago?”
John then revealed that he had spent the first 6 years of his life in a
complete body cast because of a congenital spinal rotation. He had never
really reflected on the effects this experience had on him, especially as he
had completely healed physically and was now an accomplished athlete. As
we continued to talk, John remembered feeling different from other kids in
the neighborhood and anxious and insecure when he finally was able to
aend sool. He drew a connection I had not made between su insecurity
and the feelings he experienced in the presence of women he considered
“highly eligible.” Rather quily, we drew a link to John’s selecting women
he considered “beneath him” and he le the session highly satisfied. Our
joint exploration took us to an understanding of his morbid responses that
was based on an integration of our two subjectivities and that neither of us
could have reaed alone.
Lesson #4: Consider Other Points of View
In Fiser’s book, she comes up with numerous pragmatic ways of dealing
with the subjectivity problem in psyological assessment. One of my
favorites is this: Aer you have looked at a set of test scores and developed a
tentative understanding, force yourself to look at the data again, while
trying on different theoretical “hats.” Ask yourself, “How would a cognitive
behaviorist understand this data, or a family systems therapist, or a social
learning theorist?” Obviously, it helps to be widely read and to have training
in different personality theories. Even aending roundtables and symposia
at professional meetings can assist with this exercise because they help us
personify the different points of view. Even if the next Monday morning you
can’t remember the intricacies of the different presenters’ papers, you might
ask yourself as you look at some test data, “What would presenter A,
presenter B, and presenter C say about this particular person?” Or if you
work in a seing with other psyologists, you can share cases and allenge
ea other to look at assessment results from different perspectives. One of
the best reasons I can think to be part of an assessment consultation group is
to become more aware of the biases and organizing principles with whi
we all perceive the world and our clients.
Lesson #5: Anowledge Your Influence on the
Assessment When Reporting Results
Next, I’d like to say a word about collaborative, intersubjective assessment
reports. If you have not seen any, Fiser has numerous examples in her
book or you can read those examples I’ve included in apter 7 and apter
10. One of the first things you notice if you were trained to write traditional
reports is our liberal use of first person to refer to the assessor. You see if we
can’t escape our own influence on the field of the assessment, why not
anowledge it, document it, and put it out there so other readers can take it
into account?
e following is an excerpt from a report Fiser wrote about her
assessment of a boy with academic difficulties:
When I asked Robbie to copy some geometric designs freehand (the Bender-Gestalt), he started
right away and then had to erase part of the first design. Similarly, he scaered the designs on his
paper without regard for the total number that would have to go on the page. Midway I
interrupted to identify this continuing paern. Robbie agreed that starting withoutplanning is
what leads to the messy papers that are so dissatisfying to his teaers. We explored the possibility
that he could stop and think before beginning. For example, he could have counted the dots
beforehand instead of midway as he had done. I suggested that he also could have made ea
figure smaller. en he enthusiastically volunteered to start over. is time he numbered the
figures, arranged then sequentially, corrected an error from the original sheet, and pronounced
that the second sheet was mu beer (as it indeed was, although both were adequate for a 10-
year-old. (Fiser, 1985/1994, p. 32)
Do you see how there’s no aempt on Fiser’s part to pretend she was a
detaed, objective “examiner”? In fact, as one reads through the complete
report, one gets a sense of what Fiser herself is like and how her way of
being influences and in turn responds to this young boy. Other readers, su
as Robbie’s teaers, could read this report and begin to imagine their own
contribution to the “interaction effect” with Robbie, whi resulted in their
being frustrated with him and his hating sool.
e Challenge of inking Intersubjectively
In closing, I wish to anowledge how allenging it is to think
intersubjectively and to practice collaborative psyological assessment. Part
of this difficulty lies in the fact that we live in a world that is dominated by
logical positivism and what intersubjectivists call the “Myth of the Isolated
Mind” (Stolorow & Atwood, 1992)—the view that ea of us is independent
from the world and people around us and that our perceptions represent
objective views of reality. Additionally, although this philosophy is
increasingly rejected in physics and botany, it continues to dominate most
psyology and psyiatry training programs in the United States. We need
only pi up a copy of the Diagnostic and Statistical Manual of Mental
th
Disorders (4 ed. [DSM—IV}; American Psyiatric Association, 1994) to see
why traditional, logical—positivist psyological assessment continues to
direct our profession.
Second, you will notice that an intersubjective or phenomenologic point
of view is difficult to maintain psyologically, as it leads to a sense of being
more vulnerable, less in control, and less sure of oneself. We become aware
of what Stolorow and Atwood (1992) call the unbearable embeddedness of
being, and sometimes this awareness seems too mu to handle. If I really
remember the lesson of the bed-sheet incident with my partner Jim, I must
constantly realize that there is an impossible-to-quantify interaction term in
all of my experiences of self, friends, and clients. I feel less sure of where I
stop and another person begins. e Rorsa I recorded yesterday might
say important things about me, as well as about the client. at MMPI-2
profile I scored this morning has no fixed, invariant interpretation. e client
I’m struggling to treat in psyotherapy might do beer with my colleague
down the hall. To the extent that my security depends on seeing my world
and me as separate, defined, and unanging, su thoughts can generate a
great deal of anxiety.
So what are the benefits of thinking intersubjectively? I believe that it
helps us cultivate a realistic humility that benefits our work. You see,
although many of us are learned and wise, and our psyological
instruments are wonderful, our tests don’t reveal some fundamental “Truth”
about our clients. What we have to offer through assessment is a unique and
rare perspective, a new “story” if you will, about how to understand a
particular person. And if we use our tests for what they are—as empathy
“magnifiers” to beer understand a client’s subjectivity—the story we jointly
construct with that person through the assessment will lead to increased
compassion, envisioning new possibilities, and an increased sense of
connection.
On my good days, I find the intersubjective perspective fascinating and
invigorating. What an amazing and wonderful puzzle it is to try to
understand how my perceptions of and reactions to clients intersect with
their perceptions of and reactions to me to create a set of events that are
reflected in test scores and other events during an assessment! And as I work
with more and more clients, I think I’m learning about some of my “main
effects.” (Another time I may write about the types of Rorsas / tend to
collect.) Of course, this too is constantly shiing, as I ange and am
influenced by my clients.
For this is one last implication of intersubjectivity theory: Assessments
have the potential to ange not only clients, but also assessors. If we are
open to clients’ ideas and impressions of us and to their differing
interpretations of test scores, us, and themselves, we will be affected—no
doubt about it. (is idea is explored further in ap. 18.) To me, the main
benefit of collaborative, intersubjective assessment is that it helps us grow as
psyologists and as human beings. Really, not bad wages at all when you
think about it!
Note
is apter is adapted from a paper presented to the Society for Personality Assessment (Finn,
2002a).
18
How Psyological Assessment Taught Me
Compassion and Firmness
I began practicing psyological assessment in 1979 as a 23-year-old
graduate student. When I look ba on myself at that time, I see a bright,
energetic, and rather insecure young man who was concerned about people
and who covered up his self-doubts and anxieties with an air of self-
importance and accomplishment. Many things have happened in the
intervening 28 years that have helped me become who I am today—a wiser
and somewhat more secure middle-aged man who sometimes covers up his
anxieties with an air of self-importance and accomplishment. Among the
things that have shaped me the most, I count my work as a practitioner,
teaer, and researer of psyological assessment. My goal in this apter
is to illuminate several ways that I think practicing assessment has affected
me and to reflect on how this happened.
My title focuses on learning compassion and firmness because these are
two of the most important ways assessment has anged me. I want to start
with a story about learning compassion that happened in 1982 when I was a
psyology intern at Hennepin County Medical Center in Minneapolis. As
part of my usual duties, I was assigned to do a personality assessment with a
male client about my same age who had been admied recently to the
inpatient psyiatry ward following a suicide aempt. is client, whom I’ll
call John, was memorable in that in just a few days, he had managed to
alienate a good deal of the highly experienced nursing staff—not to mention
the rest of the people being treated on the ward—with his condescending
and disdainful demeanor. In the treatment groups, John called the other
patients “idiots” and offered penetrating but harsh comments on why they
had the problems they did. One day he reduced a well-liked occupational
therapist to tears with his biting remarks about her suggested cra project.
And John and I got off to a bad start in our first meeting when he made it
clear how impossible it was that a psyology trainee like myself could tea
him anything about himself that he did not already know. I le that session
with a major dose of negative countertransference, and my supervisor, Dr.
Ken Hampton, patiently listened to me rant about why I should even “waste
my time” on someone who obviously did not want to be helped when there
were so many other deserving people needing assessments. I think Dr.
Hampton knew this could be an important assessment for me, and he calmly
and firmly instructed me to do the best I could with John, explaining that if
we could understand John’s off-puing behavior beer, it would be of
considerable help to the other staff.
John’s Minnesota Multiphasic Personality Inventory (MMPI; Hathaway &
McKinley, 1943) profile was extremely guarded and had no significant
elevations on any of the clinical scales. In my mind at the time, this just
confirmed the futility of my doing any further testing with John. Again, Dr.
Hampton insisted that I persevere, and I gave John a Rorsa (Exner,
1993). is was quite a different experience. John produced five reflection
responses in his average length protocol, confirming my impressions of his
narcissism. He also gave a series of extremely depressive percepts, including
a number of morbid images su as people with “empty” insides and a
poignant final response about a person who had fallen apart into pieces.
Furthermore, John seemed quite undone by the process of the Rorsa,
and for the first time, I felt some sympathy for him. When I inquired gently
about how he was doing, he turned on me viciously, saying I might truly be
the biggest fool he had ever met in all his contacts with the mental health
system and that I needn’t bother talking to him about the results of the
assessment. He then stormed out of the testing room, got a nurse to let him
ba in the loed ward, and then refused to talk to me when I followed a
few minutes later. To my embarrassment, the nurses and other staff observed
all this and couldn’t hide their knowing grins.
As a 26-year-old psyology intern, I took this all quite personally, and I
stormed off myself to my supervisor’s office, where I too had a temper
tantrum, although it was slightly more intellectualized than John’s. Again,
Dr. Hampton listened patiently and asked me to show him the MMPI and
read him the Rorsa. I’ve since come to understand a great deal about the
types of MMPI—Rorsa discrepancies represented in John’s testing (see
ap. 7), but at the time, I needed help resolving the apparent contradictions.
Could I see, asked Dr. Hampton, how John’s offensive interpersonal tactics
and defensiveness on the MMPI were so strong because of the extreme inner
pain and emptiness he was trying to protect? I thought I could, but why
wouldn’t John just admit to this pain and let us help him when it obviously
troubled him enough to make a serious suicide aempt? Dr. Hampton
nodded slowly, looked me in the eye, and asked if I could find no empathy
for a person who would rather hide his pain and insecurity with an air of
competence and self-sufficiency rather than face the shame of admiing that
he needed help. I nodded slowly, starting to “get it.” Dr. Hampton wated
me closely and then explained projective identification to me in simple
language. In fact, he said, what I was now experiencing—in terms of rage
and embarrassment and the desire to retaliate—was a version of the feelings
John struggled with daily. And for this to have happened, it must mean that
I was vulnerable to some of the same dynamics as John.
at interpretation was quite a allenge for me at that point in my
personal development, and I needed quite a bit of support in supervision and
my own therapy to “metabolize” it over time. Dr. Hampton’s timing was
perfect in that I was able, fairly quily, to shi my view of John to that of a
fellow human being rather than someone who was totally different from me.
Also, as I completed the assessment with my supervisor’s help, writing the
report, and eventually giving feedba to John and the staff working with
him, I found more compassion, not only for John, but also for the part of
myself that was so like him.
Over the years, I’ve come to see this experience as representative of one of
the most allenging and exciting parts of being an assessor. To really be
empathic to the clients we assess—and I’m using the word “empathy” in the
Kohutian sense, as the ability to “put ourselves in our clients’ shoes”—we are
allenged repeatedly to find in ourselves a personal version of the conflicts,
dynamics, and feelings troubling the people we assess. And although it’s
certainly possible to conduct psyological assessments without engaging in
su personal exploration, I believe that if you do so, your reports will be
wooden, your clients will not really feel moved and understood when you
talk about their test results, referring professionals won’t feel enlightened,
and aer a while, you’ll feel bored with psyological assessment.
Of course, psyotherapists face a similar allenge to identify on some
level with their clients. If you do a lot of assessment, it’s even more
allenging for a number of reasons. First, we assessors get asked to
comprehend and explain the clients that no one else can understand, oen
because those clients exhibit qualities that even experienced mental health
professionals prefer to deny in themselves. Over my years of doing
assessments, I’ve streted myself to empathize with how one might commit
murder, perpetrate sexual abuse, repeatedly set oneself up to be victimized,
engage in all kinds of compulsions, really truly wish to die, and use every
known aracter defense and mind-altering emical to ward off inner pain.
Recently, I was really struggling with an assessment I was doing, so I sought
consultation with Dr. Paul Lerner, who helped me see that I didn’t really
understand my own or other’s capacity for sadistically holding other people
hostage by being a martyr (see ap. 14).
ere is another way that doing personality testing allenges us
differently than doing nonassessment-based psyotherapy. Our tests are
powerful tools that give us access to clients’ inner worlds in ways we don’t
have otherwise (except perhaps through clients’ dreams). I have wrien
elsewhere about my view of psyological tests as “empathy magnifiers”
(Finn & Tonsager, 1997, 2002). Well, sometimes we see things clearly through
magnifying glasses that we might not otherwise oose to see. For example,
to go ba to my assessment with John, aer talking about his Rorsa
with Dr. Hampton, I found myself quite haunted by some of the images John
reported. is was heightened aer my psyotherapist at the time pointed
out the similarities to some of my own Rorsa responses, from a protocol
administered 2 years earlier just before my first Rorsa course. Open-
response tests are not the only tests that can have these types of effects. I
think we can have similar strong emotional reactions just by reading slowly
and thoughtfully through the MMPI-2 (Buter et al., 1989) critical items
endorsed by a highly distressed or disturbed client.
Now, I implied in my title that assessment has taught me firmness as well
as compassion, and I want to relate one more, briefer personal story that
illustrates this second point. Early in my clinical practice, I became aware of
a particular “blind spot” I had by doing an exercise that Alex Caldwell (2003)
talked about during his Klopfer award acceptance spee to the Society for
Personality Assessment. I used to allenge myself aer interviewing clients
I was assessing to sket my best guess of their MMPI profiles before the
answer sheets were scored. Over time, I saw a glaring paern: I consistently
failed to predict elevations on Scale 4 or both Scale 4 and Scale 9. And
although the hypothesis Di Rogers (2003) mentioned in his Master Lecture
is intriguing—that we will tend not to see people as psyopathic unless they
surpass our own level of psyopathy—in fact, I’m prey sure the opposite
was true in my case. At that time in my life I had so clamped down on my
own “inner psyopath” that I simply kept expecting other people to be as
nice as I thought myself to be.
I knew something was off about this and was grateful to have the MMPI
to “wat my ba.” Still, fairly quily, another problem became glaringly
apparent. Even when I knew from my assessment materials that clients
tended to act out in antisocial ways, I tended to be rather ineffective with
them during assessments. I would talk with them about their impulsivity,
excitement seeking, and ability to be coldhearted, but I remember feeling at
the end of su assessments that I had missed something and that the clients
were vaguely disappointed. Similarly, when I saw su clients in therapy,
they would tend to leave aer four or five sessions. At first, I consoled
myself with the maxim that antisocial clients don’t respond well in general
to mental health interventions. e only problem was, the clients I was
seeing weren’t hard-core psyopaths at all but simply people who tended to
act out as a coping meanism. Also I was acutely aware that some of my
colleagues had mu beer tra records than I did with this type of client.
In this case, it was a client and an assessment workshop that helped me
make the personal shi required. I was assessing a young woman named
Mary who had goen into some legal trouble for threatening a man at a
party with a knife because he refused to have sex with her when the bash
was done. At one point, I was talking with Mary about her MMPI (a 4—9—2
—7 profile for those of you who are interested) and she looked at me and
said, “I wish you wouldn’t be so damn nice all the time!” When I looked
confused she said, “You always try not to hurt peopie’s feelings. But
sometimes it’s not good. It would work beer if you’d just call a spade a
spade!” is impressed me, in part because I had just aended an MMPI
workshop with Alex Caldwell where he had discussed his hypothesis about
Scale-4 elevations being related to a combination of overly harsh and overly
permissive parenting in ildhood. I suddenly realized that I was repeating
history by acting like an overprotective parent and failing to provide what
self psyologists call an “adversarial transference” experience (Wolf, 1998)
for these individuals where they could bump up against a firm, savvy, and
yet benevolent authority figure. Years later, Carl Gacono explained to me
that antisocial clients can’t idealize us if they feel that they can outsmart us
and get away with things in the therapy and/or assessment relationship.
True to form, Mary appeared for our assessment feedba session with a
beer in her hand and a glint in her eye that seemed to say, “So what are you
going to do about this?” I calmly pointed at the small kiten off the waiting
room and said firmly, “You can put that in the refrigerator and pi it up
when we’re done.” We then went over the assessment results together, whi
I had worked hard to put into no-nonsense, direct, blunt language. Mary
listened respectfully, asked a few questions, and said at the end, “You really
got me!” I remember feeling that tremendous excitement of having risen to
an occasion and knowing that I would never be quite the same aerwards.
As it turned out, I ended up working in psyotherapy with Mary aer
the assessment, and years later, she told me how relieved she had been when
I made her put up her beer, because in her words, “Mom always let me play
in the middle of the highway.” e lesson I learned from Mary helped me
not only in that assessment but in almost every assessment I’ve done since
then. For I’ve come to see that our job is not only to find compassion for our
clients and to understand the psyological dilemmas underlying their
problems in living but also to talk with clients about these issues in clear,
forceful language. For many clients, an assessment may be the first time that
someone respected them enough to bring up su topics, and our doing so
conveys a certain faith in the part of them that wants to grow and ange.
We do no one any good by constructing excessively sympathetic apologias
for clients’ psyological “shortcuts.” As Mary said, most times it’s best just
to “call a spade a spade.” Our reluctance to do this is, I believe, is in fact due
to a common empathic error: We project our own shame on clients and
assume they will be devastated if we speak frankly about the less savory
aspects of their personalities. In fact, some part of them is longing to get
su things out in the open and to beer understand why they behave in
self-destructive or cruel ways and how to begin to make anges.
In conclusion, I believe that the work of an assessor is not for the faint of
heart. To do our jobs well, we must continuously confront our inner
shadows and courageously say things to people that no one has said before.
is work takes energy, lots of support from others, and an ability to
appreciate and even be amused by life’s individualized, “remedial
classroom”—by whi I mean our tendency to create and encounter the
same life lessons over and over until we master them sufficiently to move on
to the next. Perhaps because—rather than in spite of—these very allenges, I
count myself luy to be a psyological assessor.
Note
is paper was previously published in the Journal of Personality Assessment (Finn, 2005b).
19
Conclusion: Practicing erapeutic Assessment
By this point in this book, I hope to have inspired you, convinced you about
the potential of psyological assessment as a life-anging experience, and
have interested you in erapeutic Assessment in particular. us, in this
final apter, I address certain practical maers regarding the practice of
erapeutic Assessment: When is this approa not appropriate? Who pays
for an assessment conducted in this manner? How does one get referrals?
What kind of support is needed to learn and practice erapeutic
Assessment?
Possible Contraindications for erapeutic
Assessment
Are there times when erapeutic Assessment is not the best approa and
it may be beer to use a traditional, noncollaborative format? ite
possibly, there may be situations when this is true. Here are four instances
that come to mind:
An Assessment is Being Done for Selection and! or
Classification Purposes Only
Occasionally, at our clinic, we receive requests for psyological testing that
are solely for the purpose of qualifying an individual for some psyological
or educational service. A common example would be a parent who requests
that a ild be given an IQ test to see if the ild qualifies for a sool
program for “gied and talented” ildren. Oen, the only assessment
question is whether the ild has a documented IQ score of 135 or greater. I
typically talk with these parents to make sure there are no other issues that
should be explored through an assessment. If there are not, I arrange for the
IQ test and for a brief summary/discussion session where I talk with the
parents about their ild’s intellectual functioning. Occasionally, something
arises in the IQ testing that warrants further discussion, and I may suggest
to the parents that it could be helpful to expand the focus of the assessment.
Typically, however, a full erapeutic Assessment would be “overkill” for
this kind of referral question and others like it.
A Client Is in Acute Crisis or Severe Emotional Distress but an
Assessment Is Still Needed
When clients are in severe acute distress, most types of psyological testing
are inadvisable, and some clients with whom I have worked have expressed
resentment about being tested under su circumstances in the past. Imagine
being asked to participate in a WAIS—III when you were severely suicidal,
or being told while acutely psyotic that you could only have visitors to the
inpatient ward aer you completed an MMPI-2! ese are events clients told
me that actually happened to them. Psyological assessment may still be
appropriate at su times, and may involve observing and interviewing the
client, talking to family members and collateral professionals, and reviewing
records from past evaluations. But the client may have diminished capacity
to engage in full collaboration, and if so, aempts to engage the client as a
participant observer may miss the mark. Some acutely distressed clients may
not even be able to give true informed consent. Under su circumstances, I
would still try to collaborate with family members of the client and other
members of the treatment team, and I would treat the client as respectfully
as possible, for example, explaining everything I was doing and offering to
answer any questions. However, I would freely deviate from the erapeutic
Assessment flow art (see ap.l), and hope that I might involve the client
more fully at a later point in time.
Involuntary Assessments
When clients are referred against their will for a psyological assessment,
collaborative assessment teniques may be somewhat useful in gaining the
clients’ cooperation. For example, Purves (1997, 2002) wrote moving
accounts of collaborative assessments of incarcerated adolescents and of
mothers referred for possible termination of their parental rights. Again, I
would do everything I could in su instances to treat the client respectfully,
give informed consent, share my thoughts about the test findings, and listen
to the client’s explanations, modifications, and corrections. But clearly, in
those instances where client confidentiality is limited and mu is at stake, it
may not be in clients’ best interests to generate questions about themselves,
share reactions to assessment feedba, and so forth. My goal in su
situations is to incorporate enough of the spirit of erapeutic Assessment
that the clients do not feel abused by the assessment process; but rarely is it
possible to adhere to the complete collaborative model.
You may remember from apter 14 that I have a particular way of
handling the assessment of adolescents who are brought for assessment
against their will by their parents. I ask parents to put their questions
concerning those adolescents “on the table” for their ildren to know, and
to allow the adolescents to have their own private assessment questions, to
whi they will receive answers before their parents get feedba at the end
of the assessment. If the adolescent is still uncomfortable and unwilling to
be assessed, I am likely to suggest to the parents that we wait and do the
assessment at some point in the future. (I may or may not continue working
with the adolescent during this interval to build more of a relationship.) I
realize that even when parents do agree to my proposal, legally they have
the right to full access to my records. But in all my years of assessing
adolescents, I have never yet had parents renege on their promise of privacy
for their ild regarding an assessment.
An Assessment Is Likely to Be Used to Harm the Client
Rarely, at the beginning of an assessment, I have sensed that one part of a
client’s interpersonal system is likely to use assessment results to try to
humiliate or punish the client. For example, I wrote in apter 9 about a
referring therapist who wanted an assessment of his client to “prove” that an
interpretation the therapist made was “actually correct.” In another instance,
two parents were intent on using assessment results concerning their ild
as ammunition in an escalating marital bale, and I could see no way to
protect the ild’s best interests. Clearly, in su situations, an assessor can
first try to confront the parties whose agendas would be harmful to the
client. If this tactic were unsuccessful, I myself would decline to conduct the
assessment. But if I did not have that kind of freedom, I would either inform
the client of my suspicions (if I could do so without puing the client in a
bad spot), or conduct a routine traditional assessment that did not ask the
client to be a vulnerable collaborator.
Billing for a erapeutic Assessment
Two questions I am asked frequently are: “How do you bill for a erapeutic
Assessment?” and “Do insurance companies pay for this type of
assessment?” ere are no fixed answers to these questions, but I gladly
share my experience. Also, a colleague and I addressed these two questions
in a apter published elsewhere (Finn & Martin, 1997). In general, however,
I caution you that questions of billing and appropriate arges vary to some
extent by state, third-party payor, and the particular client. erefore, it is
always good to e with your own licensing board, professional society,
aorney, or contract provider if you are unsure of whether your billing
practices are appropriate.
Because erapeutic Assessment is a mixture of psyological testing and
psyotherapy, when I am asked to provide an itemized bill for an insurance
provider, I oen bill some of the sessions as diagnostic interview, some as
psyological testing, and some as psyotherapy.1 I am as transparent about
this practice as possible, and have sometimes sent an accompanying leer
explaining this breakdown. Exhibit 19—1 gives an example of a bill from a
recent assessment of a 50-year-old woman, Barbara Jones. At the first
session, Mrs. Jones and I met for 60 min to develop questions for the
assessment and discuss baground information, and I billed for 1 hour of
diagnostic interview. At the next session, Mrs. Jones spent 1.5 hours
completing the MMPI—2 (for whi I did not arge) but then we spent 1
hour discussing her experience of taking the test, and I spent 30 min scoring
and interpreting the test, so I billed for 1.5 hours of psyological testing.
e following week, Mrs. Jones and I completed and discussed her
experience of the Rorsa together (2 hours), and I spent an hour scoring
and interpreting it, so I billed for 3 hours of psyological testing. Our next
session was a 90-min assessment intervention session, whi I billed as
psyotherapy. I then spent 2 hours interpreting and integrating the testing
and writing a detailed script for the summary/discussion session (billed as
psyological testing). Mrs. Jones and I then met for 1.5 hours for a
summary/discussion session (billed as psyotherapy), and subsequently I
spent 4 hours writing a report about the assessment that Mrs. Jones needed
for her work, whi I billed as psyological testing. I was not under
contract with Mrs. Jones’s insurance provider, so in this instance she paid
me and then submied the bill on her own for reimbursement. erefore, I
am unaware of how her company processed the bill and how mu was
paid.2
1 Again, some third-party payors may object to this kind of breakdown, and may ask you to bill all
the sessions as psyological testing. I suggest you clarify this with companies with whi you have
service contracts.
2 I find that even middle-class clients will pay these kinds of fees for a psyological assessment
and feel that they got their money’s worth! Currently, I also do a portion of my assessments gratis or
on a sliding-fee scale for clients whose finances are limited.
EXHIBIT 19–1 Sample Bill for a erapeutic Assessment
Bill For Professional Services
August 9, 20XX
Client: Barbara Jones
100 Main Street
Smalltown, TX 78XXX
D.O.B.: 7–1–56
DSM–IV: 300.40
Date Activity Time CPT Code
a Fee
7–5–06 Diagnostic Interview 1 hour 90801 $180
7–12–06 Psyological Testing 1.5 hours 96101 S270
7–19–06 Psyological Testing 3 hours 96101 $540
7–26–06 Psyotherapy 1.5 hours 90808 $270
8–1–06 Psyological Testing 2 hours 96101 $360
8–2–06 Psyotherapy 1.5 hours 90808 $270
8–4–06 Psyological Testing 4 hours 96101 $720
Total Charges $2610
Stephen E. Finn
Stephen E. Finn, PhD
Licensed Psyologist
(TX license 12345)
Tax ID: XX–XXXXXXX
a ese CPT codes are those that are current at the time of this book’s publication.
You will notice from Exhibit 19–1 that I bill at the same rate for
psyological assessment as I do for psyotherapy. As I have spoken about
(Finn, 2003a), I believe the common practice of arging less for
psyological assessment than psyotherapy fails to recognize the many
professional and personal demands of psyological assessment. If anything
(and this is not to put down the allenges of being a psyotherapist),
psyological assessment oen requires more knowledge, training, and
overhead costs than does psyotherapy, and this is especially true if one is
practicing erapeutic Assessment. Also, as this book explains, I do not see
psyotherapy and psyological assessment as wholly distinct enterprises. I
recognize that not all insurance carriers operate according to this logic, but
we as professionals will not begin to ange su aitudes unless we
ourselves value the work that we do. I also believe that if psyologists are
not appropriately reimbursed for their time doing psyological assessment,
many will simply find it easier to practice psyotherapy and will give up
doing psyological assessments completely. In my mind, this would be a
loss of something distinctive and valuable about being a psyologist.
Negotiating Contracts With ird-Party Payors
is brings up the question of how one negotiates service provider contracts
that honor the value of psyological assessment with third-party payors. As
I have wrien about elsewhere (Finn & Martin, 1997), I found the key to
success in this area involved: (a) developing relationships with gatekeepers
and other “powers that be” in su organizations, (b) educating them about
the validity and potential therapeutic value of psyological assessment, (c)
demonstrating to them that the assessments I conducted were useful in ways
that previous psyological assessments they encountered were not, and (d)
supplying them with resear data and client satisfaction data that
supported the points I was making. With these tactics employed, in several
instances, insurance providers who were previously quite resistant to paying
for psyological assessments started referring difficult and complex clients
for comprehensive evaluations.
Marketing erapeutic Assessment
So how does one successfully develop referral sources for erapeutic
Assessment? First, hone your assessment and psyotherapy skills so that
you do really excellent work, for as the old saying goes, “ality is the best
advertisement.” (I write more to come about how to become trained in
erapeutic Assessment.) Next, you have to get the word out to referring
professionals and the community at large about what you do. When I started
the Center for erapeutic Assessment in 1993,1 asked ea of three highly
successful clinicians in Austin to lun. I told them about erapeutic
Assessment and offered a free assessment of their “hardest client.” All three
of them took me up on my offer, and as I expected, they found the
assessments extremely helpful to them and their clients. Before long, I had
more referrals than I could handle, and had to hire more staff. I am pleased
to say that ea of those three therapists still refers many clients for
assessments today.
ere were other ways I spread the word about my work:
(1) I gave talks about erapeutic Assessment to various professional
organizations, especially those for nonpsyologists. I found many
masters-level psyotherapists and psyiatrists who were eager for
input and support on their difficult clients, and psyological
assessment provided a graceful venue for them to get this.
(2) I took part in supervisor-led or peer-organized psyotherapy
consultation groups. I not only welcomed the support and assistance
with my own cases, when another therapist presented a client whom I
thought might benefit from psyological assessment, I spoke up and
said so. In many instances, the therapist had never even considered this
option.
(3) I accepted invitations to talk in graduate sool courses for
psyologists, social workers, and so forth about erapeutic
Assessment. Many of these students went on to get their degrees and
practice in the Austin area, and some remembered my presentation and
made referrals.
(4) I visited and spoke with ministers and pastors about therapeutic
couples assessments. Many were working with extremely allenging
couples and jumped at the ance to get help from a psyologist.
(Some of these ures even funded the couples assessments they
referred.)
Some of my best referral sources have been satisfied clients. At this point,
approximately 20% to 30% of my requests for erapeutic Assessment do not
come through another mental health professional, but directly from people
who have heard about our assessments from their family, friends, and
neighbors. I have never done any direct advertising to the public, but I know
of a colleague practicing collaborative assessment who once ran an ad in her
local newspaper reading something like: “Facing a major life decision or at a
personal turning point? Get input from a psyologist through the process of
psyological testing…” She got a number of calls from people interested in
brief assessments.
In sum, I have a firm belief that if you do excellent psyological
assessments and let others know about what you are doing, then the word
will spread and soon you too can have a thriving practice in erapeutic
Assessment.
Learning erapeutic Assessment
I am currently thinking a great deal about how to develop training materials
and training opportunities for the increasing number of psyologists who
want to learn to do erapeutic Assessment. is book is one step in that
direction, and I also give training workshops around the world, so contact
me if you would like to receive announcements about those or sedule a
workshop in your area. I also hope to be developing future training materials
that include DVDs of exemplar interactions with clients, su as those
videos I show in my workshops.
In the meantime, if you want to become expert at erapeutic
Assessment, I urge you to:
(1) Read everything you can about erapeutic Assessment and
collaborative assessment. e references at the end of this book contain
many important articles that can tea you a lot.
(2) Begin experimenting with some of the collaborative assessment
teniques wrien about in this book. Feel free to start small, perhaps
by asking clients for assessment questions or by stopping aer a test
administration to inquire what clients noticed or experienced. You’re
unlikely to do any harm with su efforts, and gradually you will find
yourself becoming more confident.
(3) Become as skilled as you can at using and interpreting a number of
psyological tests. Because erapeutic Assessment is about “geing
in clients’ shoes,” you need not only your empathy, but as mu
knowledge as you can about what various test scores might mean. If
you listen to the great “MMPI—ers” and “Rorsaers” of our time,
you’ll notice that they excel at knowing how a particular score or
response translates into clients’ subjective experience and how to put
this experience into words.
(4) Become as knowledgeable about and as skilled as you can with
different types of psyotherapy. is will not only help you envision
what treatment options different clients might need, you can also draw
from different teniques and ways of conceptualizing problems when
conducting erapeutic Assessments.
(5) Finally, expand your self and your compassion and wisdom through
reading novels, traveling, psyotherapy, mindfulness or spiritual
practices, or dedication to a sport, music, art, and so forth. As I covered
in apter 18, one of the allenges of practicing erapeutic
Assessment is that oen we are asked to “feel our way into” clients’
subjective experiences that we may find terrifying, disgusting,
confusing, or initially incomprehensible. e more “inner blos” you
can remove and the more self-awareness you have before you see a
client, the more likely you will be able to understand and ultimately
help that person.
Getting Support
As I have said at various points throughout this book, collaborative and/or
erapeutic Assessment is a allenging line of work, and I believe it is best
practiced in the context of a supportive community of like-minded
professionals. If none exists in your area, what should you do? You might
consider inviting other colleagues to start a reading group on collaborative
and erapeutic Assessment. If there is enough interest, you could
eventually discuss your assessment cases with ea other, or puzzle together
about su questions as, “What might be an appropriate assessment
intervention for this type of client?” Sometimes, it can be invaluable just to
read a difficult set of TAT stories, or a Rorsa protocol, and have others
help you “hold it.”
I also urge you to aend regional and national meetings where we
collaborative assessment people hang out, su as the Society for Personality
Assessment. You can join this organization online at www.personality.org
and get theJournal of Personality Assessment (where many articles on
erapeutic Assessment have been published) with your membership fee.
Finally I welcome you to write or e-mail me about your questions and
experiences with erapeutic Assessment. I know that as this model
develops, many of you will introduce innovations that I have never even
considered. I look eagerly forward to that day.
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Author Index
A
Abidin, R. R., 193, 271
Aenba, T. M., 193, 271
Aerman, S. J., 83, 246, 271
Agazarian, Y. M., xviii, 60, 271
Allen, J. G., 97, 100, 143, 271
Aranow, E., 157, 158, 271
Arbisi, R A., 69, 271
Arer, R. P., 66, 271
Armbruster, G., 45, 46, 47, 49, 53, 273
Armstrong, J. G., 77, 184, 204, 271
Atwood, G., 243, 278
Atwood, G. E., 27, 34, 243, 251, 271, 278
B
Baity, M. R., 83, 246, 271
Barton, A., 40, 271
Bauman, G., 157, 277
Beer, E., 208, 271
Bender, L. A., 88, 199, 272
Ben-Porath, Y. S., 57, 69, 271, 272
Berg, M., 97, 102, 113, 272
Bernstein, E. M., 123, 272
Bihlar, B., 244, 272
Blagys, M. D., 83, 246, 271
Blanard, W., 157, 272
Brabender, V., 132, 278
Branda, B., 34, 243, 278
Bruhn, A. R., 183, 272
Bugental, J. F. T., 38, 272
Buter, J. N., 65, 124, 256, 272
C
Caldwell, A. M., 128, 184, 257, 272
Carlsson, A. M., 244, 272
Claibom, C. D., 10, 276
Cohen, L. J., 97, 98, 272
Cohen, S., 194, 275
Craddi, R. A., 34, 272
D
Dahlstrom, W. G., 124, 256, 272
Dana, R. H., 34, 272, 273
Dies, R. R., 22, 276, 277
Dorr, D., 158, 273
Driggs, J. H., 171, 273
E
Eisman, E. J., 22, 276, 277
Evans, F. B., Ill, 25, 28, 273
Exner, J. E., Jr., 45, 46, 47, 49, 53, 66, 75, 124, 128, 216, 254, 273
Eyde, L. D., 22, 276, 277
F
Finn, S. E., 3, 8, 17, 22, 23, 25, 26, 33, 34, 35, 37, 38, 45, 46, 55, 56, 65, 83, 96, 97, 117, 130, 131, 139, 142,
149, 157, 171, 179, 192, 193, 204, 212, 214, 216, 220, 221, 233, 240, 241, 243, 246, 253, 256, 265, 266, 273,
274, 275, 276, 277, 278
Fiser, C. T., 5, 11, 14, 27, 29, 34, 35, 36, 39, 46, 73, 86, 88, 110, 143, 198, 206, 208, 246, 251, 275
Fomess, S. R., 123, 275
Fromm-Reimann, F., 24, 275
Fulmer, R. H., 194, 275
G
Ganellen, R. J., 66, 69, 275
Giesler, B., 9, 278
Gill, M., 70, 277
Gohara, Y. Y., 208, 271
Graham, E. D., 34, 273
Graham, J. R., 57, 124, 256, 272
Green way, P., 83, 246, 277
Grossman, L. S., 66, 69, 275
H
Hahn, E. D., 8, 35, 277
Handler, L., 5, 13, 27, 157, 158, 211, 275, 276
Hanson, W. E., 10, 276
Harrower, M., 51, 71, 125, 276
Hathaway, S. R., 254, 276
Haywood, T. W., 66, 69, 275
Hilsenroth, M. J., 83, 211, 246, 271, 276
Hirsman, R., 57, 272
J
Jourard, S. M., 38, 276
K
Kaemmer, B., 124, 256, 272
Kamphuis, J. H., 96, 131, 204, 274, 276
Karpman, S. B., 189, 276
Kasari, C., 123, 275
Kavale, K. A., 123, 275
Kay, G. G., 22, 276, 277
Keer, B., 10, 276
King, B. H., 123, 275
Klopfer, W., 158, 276
Kohut, H., 30, 276
Krishnamurthy, R., 11, 66, 271, 276
Krull, D. S., 9, 278
Kubiszyn, T. W., 22, 276, 277
Kugeares, S. L., 131, 204, 276
L
Lance, B. R., 11, 276
Lee, S., 34, 273
Lerner, H. G., 158, 276
Lerner, R M., 5, 243, 256, 276
Lewak, R. W., 65, 276
Loveland, N., 158, 276
Lovi, R., 66, 276
Lowenstein, R. J., 77, 184, 204, 271
M
Marizilda, F. D., 208, 271
Marks, P. A., 65, 276
Martin, H., 96, 265, 266, 274
McKinley, J. C., 254, 276
Meyer, G. J., 22, 66, 69, 70, 276, 277
Middelberg, C. V., 170, 171, 277
Miman, B., 45, 46, 47, 49, 53, 273
Monaco, G., 194, 275
Moreland, K. L., 22, 157, 158, 271, 276, 277
Murphy, K. R., 123, 279
Murray, H. A., 133, 277
N
Nagayama Hall, G. C., 57, 272
Nakamura, N., 158, 160, 277
Nakamura, S., 158, 160, 277
Nelson, G. E., 65, 276
Newman, M. L., 83, 246, 277
Noy-Sharav, D., 158, 160, 277
P
Papp, P., 56, 60, 277
Pelham, B. W., 9, 278
Perry, H. S., 24, 277
Purves, C., 5, 263, 277
Putnam, F. W., 123, 272
R
Rapaport, D., 70, 277
Reed, G. M., 22, 277
Reznikoff, M., 157, 158, 271
Rogers, C. R., 38, 277
Rogers, D., 257, 277
Roman, M., 157, 277
S
Santiago, M. D. E., 208, 271
Sapienza, B. G., 38, 272
Saber, P. M., 96, 278
Sore, A. N., 11, 277
Sroeder, D. G., 8, 35, 139, 221, 275, 277
Shafer, R., 47, 56, 70, 97, 101, 188, 277
Siegel, D. J., 11, 277
Silverstein, M. L., 243, 278
Singer, H. K., 132, 278
Singer, M., 157, 278
Smith, B. L., 243, 278
Smith, T. P., 15, 278
Steere, D., xix, 278
Stein-Seroussi, A., 9, 278
Stolorow, R. D., 27, 34, 243, 251, 271, 278
Sullivan, H. S., 23, 24, 25, 26, 27, 28, 30, 31, 278
Swann, W. B., Jr., 8, 9, 35, 143, 277, 278
T
Tellegen, A., 124, 256, 272
aringer, D. J., 96, 278
Tonsager, M. E., 3, 25, 33, 34, 37, 38, 46, 56, 65, 83, 139, 142, 179, 212, 214, 216, 220, 221, 240, 241, 246,
256, 275
Triolo, S. J., 123, 279
Trop, J. L., 243, 279
W
Wasyliw, O. E., 66, 69, 275
Wesler, D., 12, 86, 133, 279
Weiner, I., 66, 279
Weiss, J., 190, 234, 237, 279
Wenzlaff, R. M., 9, 278
Wilkinson, A. D., 96, 278
Wolf, E., 258, 279
Wynne, L., 158, 278
Z
Zamorsky, J., 15, 279
Ziffer, R. L., 194, 279
Subject Index
A
Acute crisis, erapeutic Assessment and, 262
Adolescents
allowing private assessment questions from, 197
involuntary assessment and, 263
seing goals for assessment of, 37
summary/discussion session and, 205
Adversarial transference, 258
Advertising, direct, 268
Advocates, parents as, 207
Affective management, object relations and, 137
American Psyological Association, 65
Analysis of variance (ANOVA), 245
Antisocial clients, 257–258
Anxiety
awareness of own, 105
graduate personality assessment course and student and instructor, 212–213
AQ-2. See Assessment estionnaire-2
Art projects, 88
Assessment intervention sessions, 13–14, 36, 83–96
discussing how to export successful solutions, 85, 94–95
eliciting, observing, and naming problem behavior, 85, 89–91
exploring context leading to problem behavior, 85, 91–92
goals of, 84
imagining solutions and testing in vivo, 85, 92–94
introducing session to client, 85, 88–89
planning, 85, 86–88
selecting a focus for, 85
steps in conducting, 85–95
Assessment of process, 36
Assessment estionnaire-2 (AQ-2), 139
Assessment questions
client’s unconscious plans and, 236–238
gathering, 214–216
multiple motives behind, 191
Assessment task
conceptualization of, 216
feedba for student performance of, 218
instructor demonstration of, 216–217
modifying, 219
repeating, 219–220
students performing, 218
students role-playing, 218
Assessor
anowledging own influence on assessment when reporting results, 250–251
awareness of own anxiety, 105
behavioral tests of, 238–240
building collegial relationship with referring professionals, 105
clarifying goals with referring professionals, 110
empathy for dilemmas of ange and, 95
establishing rapport with clients, 58–59
influence of assessments on, 252, 253–259
involving referring professional in interpreting test data and client feedba, 111–112
learning compassion and firmness, 253–259
overcoming security operations of, 31
as participant-observer, 27–28
role enactments and, 103–104
sharing reactions with clients, 39–40
vulnerability of referring professionals and, 100–101
Aention deficit disorder (ADD), therapeutic assessment of man with, 117–148
Aention Deficit Scales for Adults, 123
Authenticity, 40
B
Barrier experience, 60
Behavior. See also Problem
behavior context and, 244, 246–247
Behavioral tests of assessor, 238–240
Belief in innate healing potential, 40–41
Bender Visual Motor Gestalt Test, 88, 89, 199, 219
Billing, for erapeutic Assessment, 264, 265–266
Buter, James, 18
C
Caldwell, Alex, 257, 258
Case studies/examples
assessment intervention session, 133–142
collaborative sequence analysis, 149–155
Consensus Rorsa in couples assessment, 164–176, 185–187
consulting with referring professional, 135–136
contacts with collateral sources, 121–122
eliciting problem behavior, 87–90
exploring context of problem behavior, 92
exporting solutions to outside world, 94–95
failure of erapeutic Assessment, 179–192
first session, 118–121
follow-up, 138–142
graduate student in personality assessment, 221–229
integrating MMPI-2 and Rorsa findings in client feedba, 74–80
interpreting test results, 127–132
introducing assessment intervention session to client, 88–89
man with “ADD,” 117–148
observing problem behavior, 91
planning assessment intervention session, 85–86
projective counseling example, 51–52
referral, 117–118
second session, 122–124
standardized testing sessions, 122–126
summary/discussion session, 136–138, 187
taking advantage of regressive pull of Rorsa, 48–50
third session, 124–126
transference crisis following Rorsa, 50–51
using Rorsa to introduce material into psyotherapy, 47–48
wrien feedba and follow-up, 138–140, 145–148
Center for erapeutic Assessment, 6, 97, 267
information sheet, 106–107
Change, dilemmas of, 56, 60, 61, 62, 79
Child Behavior Chelist, 193
Children, seing goals for assessment of, 37. See also Collaborative ild assessment
Classification, erapeutic Assessment for purpose of, 261–262
Client-centered psyotherapy, 38
Clients
antisocial, 257–258
assessment questions and unconscious plans of, 236–238
assessments used to harm, 263–265
behavioral tests of assessor and, 238–240
anging life stories of, 142–143
as collaborators, 25
conflicts of interest and, 61
Control-Mastery theory and, 234
differing views of, 112–113
goals of, 25–26, 35, 37–38
handling distressed, 224–225
integrating MMPI-2 and Rorsa findings in feedba to, 70–74
introducing assessment intervention session to, 88–89
involvement in co-interpreting assessment data, 248–249
labeling as defensive, deceptive, uncooperative, 58–62
preparing for assessment, 110–111
privacy of, 26
sharing reactions with, 39–40
testing mid-therapy with Rorsa, 45–53
triangulations in assessment referrals and, 99–100
understanding subjectivity of, 252
Coarctated Rorsa, 70
Cognitive-behavioral psyotherapy, xviii
Collaborative ild assessment, 193–209
asking parents to be tested as part of ild’s assessment, 202–203
asking parents to corroborate and modify findings, 205–207
asking parents to observe ild’s testing, 198–200
asking parents to prepare ild, 197–198
asking parents to review reports, 207
enlisting parents in collecting historical information or systematic data, 201–202
involving parents in giving feedba to ild, 208
negotiating with parents to allow adolescent to have private questions, 197
seduling family sessions, 203–205
steps in, 195
working with parents to define goals of assessment, 194–196
Collaborative sequence analysis of Rorsa, 149–156
Compassion, learning through psyological assessment, 253–259
Comprehensive System (Rorsa), 18, 46
Conceptions of Modern Psychiatry, 24
Consensual validation hypotheses, 28
Consensus Rorsa, 157–177
alternate procedures, 163–164
case examples, 164–176, 185–187
in couples assessment, 185–187
goal of, 176–177
order of administration, 160–161
procedure, 159–163
seating for, 159
videotaping of, 159
Constricted Rorsa, 70
Consultation, collaborative model of, 4, 5–6, 97–116, 143–144
assessor anxiety and role enactments in, 103–104, 105
building collaborative relationship, 105, 109–114
caveats, 114–115
anging life stories and, 142–143
hidden agendas and, 101–102
information sheet for, 106–107
oracular transference in referring professional, 101
reasons to adopt, 116
spliing among treatment team, 102–103
treatment impasses and, 97–99
triangulation and, 99–100, 108–109
vulnerability of referring professional, 100–101, 104
Context
of behavior, 244, 246–247
of problem behavior, 91–92
test data interpretation and, 53
Contraindications for erapeutic Assessment, 261–265
Control-Mastery theory, xviii, 190, 234–235
erapeutic Assessment and, 235–242
Countertransferences, 192
Couples assessment, 268
assessment questions, 151–152
Consensus Rorsa in, 185–187
contradictory goals in, 237–238
flow art of, 150
procedures, 150–151
standardized testing, 152–153
using Consensus Rorsa in, 157–177
Course contract, 216
Cultural differences, summary/discussion session and, 206–207
Custody assessments, 57, 60–61, 63
D
Davis, Douglas A., 23
Defensive test protocols, giving feedba about, 55–64
Diagnosis, referral for, 110
Diagnostic and Statistical Manual of Mental Disorders, 251
Diagnostic interview, billing, 265
Diagnostic labels, 29
Digit Span subtest, 133–134
Digit Symbol test, 36
Dilemmas of ange, 56, 60, 61, 62, 79
Direct advertising, 268
Dissociative Experiences Scale, 123–124
Drama triangle, avoiding, 189–190
E
Early Memory Procedure (EMP), 183
Ego psyology, 234
Empathy, 243
learning, 255–256
Empathy magnifiers, psyological tests as, 38–39, 142
Employment screening, 70
Evocative description, 29
Existential-phenomenological psyology, 246
Experiaction, 36
F
Failed assessment, 240–241
Control-Mastery theory and, 233–242
couples assessment case study, 179–192
Family dynamics, generating assessment questions and, 196
Family sculpting, 176
Family sessions, 203–205
Consensus Rorsa and, 157
Family systems intervention, collaborative ild assessment as, 193–209
Family systems theory, 241
Feedba
for instructor, 217–218
integrating MMPI-2 and Rorsa findings in, 70–74
postassessment, 187–188
regarding defensive test protocols, 55–64
for student, 220
wrien. See Wrien feedba report
Feedba sessions, 8, 9. See also Summary/discussion sessions
development of, 34–35
Firmness, learning through psyological assessment, 257–259
First person, use of in assessment reports, 27–28, 250
Follow-up
immediately following assessment, 138–140
long-term, 140–142
Follow-up sessions, 14–15
Forensic assessment, 63
MMPI-2 and Rorsa results in, 69–70
Fusion of Psychiatry and Social Science, The, 24
G
Gestalt therapy, 14
Goals
of assessment intervention sessions, 84
of ild assessment, 194–196
clarifying referring professional, 110
client, 25–26, 35, 37–38
Graduate course in personality assessment, 211–229
assessment questions, 214–216
assessment task, 216–217, 218
case example, 221–229
allenges of, 212–213
course contract, 216
feedba for instructor, 217–218, 221
feedba for students, 218, 220
flow art of, 214–221
performing assessment task with client, 218
repeating assessment task with another client, 219–220
role-playing assessment task, 218
erapeutic Assessment principles applied to, 212–213
trying out modifications of tasks, 219
wrien report, 220–221
Group therapy, 245–246
Guarded test protocols, 55–64
H
Hampton, Ken, 254, 255
Hennepin County Medical Center (Minneapolis), 24, 34, 253
Historical information, collecting, 201–202
Humanistic Psychologist, The, 33
Humanistic psyology, 34, 241
I
Identity, 142
Individualized assessment, 73
Individualizing Psychological Assessment, 246
Information-gathering model of psyological assessment, 4, 37
Information sheet, for referring professionals, 106–107
Informed consent, 64
Initial sessions, 10–11
Instructors. See also Graduate course in personality assessment
demonstrating assessment task, 216–217
student feedba for, 217–218, 221
Intellectual testing, 18, 261–262
Interpersonal theory, 241
Interpersonal Theory of Psychiatry, The, 24
Intersubiectivity theory, xviii, 5–6, 34, 241, 243–246
benefits of, 251–252
allenges of, 251–252
lessons for psyological assessment, 246–251
Introspection, 243
Involuntary psyological assessments, 61, 63, 214–215, 263
IQ testing, 261–262
J
Journal of Personality Assessment, 21, 270
K
Karpman’s drama triangle, 189–190
L
Lerner, Paul, 188, 190, 256
Level 1 findings, 8, 9
Level 2 findings, 8, 9
Level 3 findings, 8, 9, 10
Levels of personality, 73
Life-centered assessment, 36
Life stories
anging, 10
collaborative assessment and, 142–143
Listening, in erapeutic Assessment, 28
M
Malingering, 69–70
Marketing erapeutic Assessment, 267–268
Masoism, payoff of, 190
Ministers, therapeutic couples assessment and, 268
Minnesota Multiphasic Personality Inventory (MMPI), 18, 254, 257–258
guarded test protocol and, 56–57
Minnesota Multiphasic Personality Inventory-2 (MMPI-2), 26
case studies, 74–80, 124, 127–128
Content Scales, 127, 128
in couples assessment, 152–153, 159, 164–165, 171–172, 183–184
custody assessments and scores on, 57, 60–61, 63
Harris-Lingoes subscales, 127, 129
high disturbance on, 67–68, 69–70, 72
high L and K and low F, 247–248
importance of feedba regarding results of, 65
integrating Rorsa findings with, 70–74
involving referring professionals in interpreting client’s, 112
low disturbance on, 68–69, 70, 72
order of testing and, 12
response paerns, 67–70, 72
as sole standardized test, 13
testing parents with, 203
understanding results of, 66–67
Myth of the Isolated Mind, 251
N
Narrative therapy, xviii
Noncollaborative therapeutic assessment, 4, 5
O
Object relations theory, 190, 234
Observation, in erapeutic Assessment, 28
Observer, role in interpersonal relationships, 244
One-genus hypothesis, 30–31
Oracular transferences, 188–189
Oracular view of assessment, 101
P
Parent-ild sessions, 203–205
Parenting Stress Inventory, 193
Parents
as advocates, 207
asking to corroborate assessment findings, 205–207
asking to observe ild’s testing sessions, 198–200
enlisting in collecting historical information or systematic data, 201–202
helping define goals of ild assessment, 194–196
involving in oral/wrien feedba, 208
negotiating with to allow adolescents to have private assessment questions, 197
preparing ild for first meeting with assessor, 197–198
reviewing reports for sools, therapists, referral sources, 207
role in ild assessment, 193–194, 208
testing as part of ild’s evaluation, 202–203
Passive-to-active testing, 235, 239–240
Pastors, therapeutic couples assessment and, 268
Personal growth, erapeutic Assessment and, 31
Personality, levels of, 73
Personality assessment. See Graduate course in personality assessment; erapeutic Assessment
Phenomenological psyology, xviii, 5–6
Power, of psyological assessment, 17–22
Preemployment evaluations, 63
Privacy, client, 26
Problem behavior
collecting information on, 201–202
eliciting, 87–90
exploring context of, 91–92
imagining and testing solutions to, 92–94
observing, 90–91
standard assessment interventions for types of, 96
Problems in living, traumatic experience and, 234
Professional organizations, speaking to, 267
Projective counseling, 73, 125
Rorsa and, 51–52, 53
Projective drawings, 176
Projective identification, 165–166, 255
Proximity, altering, 201–202
Pseudo-agreements, 161
Psyiatric disability, test results of clients applying for, 69–70
Psychiatric Interview, The, 24, 26
Psyiatric terminology, skepticism regarding, 28–29
Psyodrama, 88
Psyological assessment
case studies, 21–22
collaborative. See Collaborative ild assessment; Collaborative model of assessment consultation
frame of, 247–248
influence on assessors, 252, 253–259
as interpersonal event, 21
intersubjectivity theory and, 246–251
intervention focus, 10
involuntary, 61, 63, 214–215, 263
life-centered, 36
one-genus hypothesis and, 30–31
oracular view of, 101
power of, 17–22
resear agenda for, 22
role of theory in, 241–242, 250
subjectivity problem in, 249–250
therapeutic, 4–6. See also erapeutic Assessment
traditional, 3–4, 20–21
types of, 4
Psyological Assessment Work Group, 22
Psyological tests/testing
billing, 265–266
as empathy magnifiers, 38–39, 142
Psyology of invitation, 38
Psyotherapy
billing for, 265–266
consultation groups, 267–268
using Rorsa to introduce material into, 47–48
Pursuer-avoider dance, 171
R
Referrals for psyological assessment, 106
of man with “ADD,” 117–118
reasons for, 97–98
sources of, 268
treatment impasses and, 97–99
Referring professional
anxiety in assessor and, 103–104
aending client’s summary/discussion session, 113–114
building collegial relationship with, 105
clarifying goals with, 110
collaborating/consultation with, 109–114, 135–136
collaborative psyological assessment and, 143–144
follow-up with, 114
helping depersonalize helpfulness of assessment, 112
hidden agendas and, 101–103
information sheet for, 106–107
involving in interpreting test data and feedba for client, 111–112
maintain empathy for, 104
maintaining contact during assessment, 111
oracular transference in, 101
preparing client for assessment, 110–111
reasons for referral, 97–98
reviewing wrien summary report, 114
taking on agendas of, 191
treating differing views of clients, 112–113
treatment impasses and, 98–99
triangulation and, 99–100
vulnerability of, 100–101
Reimann, Frieda Fromm, 24
Retraumatization, 176
Role enactments, 176
assessor anxiety and, 103–104
Role plays, 88
of assessment task, 218, 219
parents role-playing ild, 204–205
of ways to handle distressed clients, 224–225
Rorsa
administration of, 67
case studies, 74–80, 124–126, 128–132
coarctated, 70
in collaborative ild assessment, 204
collaborative sequence analysis of, 149–156
Comprehensive System for, 18, 46
Consensus. See Consensus Rorsa
constricted, 70
first experience giving, 18–20
high disturbance on, 67–69, 72
with high Lambda, 247–248
integrating MMPI-2 findings with, 70–74
involving referring professionals in interpreting client’s, 112
learning to administer, 216, 223–224, 254–255
low disturbance on, 69–70, 72
order of testing and, 12
response paerns, 67–70, 72
taking advantage of regressive pull of, 48–50
testing own clients mid-therapy with, 45–53
transference crisis following, 50–51
understanding results of, 66–67
using to introduce material into psyotherapy, 41–48
S
San Francisco Psyotherapy Resear Group, 234
Schizophrenia as a Human Process, 23
Sroeder, Glenna, 18–19
Seating, for Consensus Rorsa, 159
Security operations, overcoming, 31
Selection, erapeutic Assessment for purpose of, 261–262
Self
in intersubjectivity theory, 244
erapeutic Assessment and anges in, 29–30
Self-presentation, MMPI-2 and, 66
Self Psyology, xviii, 30, 34, 234, 241
intersubjectivity theory and, 243
Self-system, 29–30
Self-verification theory, 9
Service provider contracts, 266–267
Society for Personality Assessment, xviii, 257, 270
Solutions
exporting to outside world, 94–95
to problem behavior, 92–94
Standardized testing, 11–13, 88, 122–126
couples assessment, 152–153
interpreting results, 127–132
order of, 12
reviewing, 183–185
Stoholm Comparative Psyotherapy Study, 244
Students
end-of-course feedba session for, 220
feedba for instructor, 217–218, 221
feedba on task, 218
modifying assessment task, 219
performing assessment task, 218
repeating assessment task, 219–220
role-playing assessment task, 218
wrien feedba report for, 220–221, 226–229
Subjectivity
as problem in psyological assessment, 244–245, 249–250
understanding client’s, 252
Sullivan, Harry Sta, 23–31
one-genus hypothesis, 30–31
parallels with erapeutic Assessment, 25–31
writings of, 23–25
Summary/discussion sessions, 8–10
case studies, 136–138, 187
allenges presented in, 83–84
parents’ role in, 205–207
referring professional aending, 113–114
Systems-centered group therapy, xviii
T
TAT. See ematic Apperception Test
Teaching and Learning Personality Assessment, 211
Tellegen, Auke, 18
Terminology, psyiatric, 28–29
Testing. See also Standardized testing
client involvement in co-interpreting data, 248–249
passive-to-active, 235, 239–240
presenting results, 35
Test invalidity, best response to, 62–64
Test validity, 45–46
ematic Apperception Test (TAT), 18, 112, 133, 134–135
eory, role in psyological assessment, 241–242, 250
erapeutic Assessment, 6–7. See also Collaborative ild assessment; Collaborative model of
assessment consultation
assessment intervention sessions, 83–96
assessor as participant-observer in, 27–28
belief in innate healing potential and, 40–1
billing for, 264, 265–266
anges in self and, 29–30
client goals in, 25–26, 37–38
consultation and, 191–192
contraindications for, 261–265
control-mastery theory and, 235–242
cost of, 107
couples assessment, 149–155
demonstrating assessment task, 216–217
development of, 33–36
failed assessments, 179–192, 240–241
flow art of, 7–15, 214–221
history of, 7–15
humanistic elements of, 37–41
integrating MMPI-2 and Rorsa findings, 70–74
learning, 268–269
of man with “ADD,” 117–148
marketing, 267–268
modifying plan, 15
negotiating contracts with third-party payers, 266–267
parallels with Sullivan, 25–31
practicing, 261–270
primacy of listening and observation, 28
principles applied to graduate course in personality assessment, 212–213
referral for, 97–99, 106
respect for client privacy, 26
sharing reactions with clients, 39–40
skepticism regarding psyiatric terminology, 28–29
step 1, initial sessions, 10–11
step 2, standardized testing session(s), 11–13, 122–126
step 3, assessment intervention sessions, 13–14, 83–96
step 4, summary and/or discussion sessions, 8–10, 83–84
step 5, follow-up sessions, 14–15
step 5, wrien feedba, 11, 27–28, 78–80, 250
support for practice of, 270
teaing in required graduate course, 211–229
training sessions, xvii
treating referring professional and client as collaborators in, 144
types of assessment, 106
using psyological tests as empathy magnifiers in, 38–39
erapeutic assessment, 4–5
collaborative, 4, 5–6
noncollaborative, 4, 5
ird-party payers, negotiating contracts with, 266–267
ought disorder, 47
Traditional assessment, 3–4, 20–21
assessor as objective observer in, 27
Transference
adversarial, 258
oracular, 188–189
in erapeutic Assessment, 192
towards assessors, 99–100
Transference projections, testing clients mid-therapy with Rorsa and, 46–7, 48, 50–51
Transference tests, 235, 238–239
Trauma Content Index, 77, 184, 204
Traumatic experiences, problems in living and, 234
Treatment impasses, referral for psyological assessment and, 97–99, 108–109
Treatment team, collaborative assessment and spliing among, 102–103
Triangulation, 99–100
in family system, 198
forestalling, 108–109
U
Unbearable embeddedness of being, 251
Unconscious agendas, 235
assessment questions and, 236–238
Uncooperative, labeling clients as, 58–62
University of Texas at Austin, 24, 33, 211
V
Validity indicators, interpreting, 57–58, 60
Videotape, of Consensus Rorsa session, 159
W
Washington Sool of Psyiatry, 24
Wesler Adult Intelligence Scale-Ill (WAIS-III), 12–13, 85, 133
Digit Symbol test, 36
Wesler Individual Aievement Test-II (WIAT-II), 85–86
Wrien feedba report, 11
case study, 138–140, 145–148
involving parents in, 208
referring professional reviewing, 114
sample leer, 78–80
for student, 220–221, 226–229
use of first person in, 27–28, 250
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