I wrote my first psychological test report while in training, in the early 1970s. In those years, there was a more or less standard battery that had changed little since the 1940s and which was employed irrespective of the patient’s history and clinical presentation.
This battery consisted of the WAIS for adults and the WISC for children/adolescents. Less often, the Stanford-Binet was administered, usually in cases of suspected mental retardation or giftedness. In addition, psychologists administered the Bender-Gestalt Test as a test of “organicity” and “projective” measures, notably, human figure drawings; the Thematic Apperception Test/TAT, the Children’s Apperception Test/CAT and the Rorschach Test. The Bender-Gestalt Test was also employed as a projective technique.
In the case of adults, the original MMPI, developed in the late 1930s, was sometimes substituted for a projective battery by psychologists with a more empirical orientation and who were less influenced by psychodynamic case formulation and theory.
Pre-schoolers and patients over the age of 60 were rarely evaluated. Test batteries were, all too often, administered indiscriminately. Psychiatric inpatients were routinely tested even when an acute and/or rapidly evolving mental status precluded obtaining reliable results.
Test reports usually did not circulate outside the setting in which the assessment was conducted. Patients and their families were almost never informed about findings or given copies of the test report. Back then, “they didn’t ask” and psychologists “didn’t tell.” Reports were generally viewed as an exclusive and arcane communication between the psychologist and the referral source, typically psychiatrists and psychiatrists trained as psychoanalysts.
The psychologist’s opinions, while sometimes overlooked, were rarely scrutinized or challenged despite the fact that many reports were replete with convoluted formulations, speculation and inconsistent statements. Overpathologizing was rampant, particularly diagnoses of childhood and adult schizophrenia.
Test interpretation and recommendations were based far more on “art” than “science,” were highly theory driven (typically a blend of classical Freudian and ego psychological conceptualizations) and significantly influenced by “oral tradition” handed down from one clinical supervisor to another.
There was little appreciation of the impact of neurodevelopmental influences, the tester’s counter-transference and situational, demographic variables and socio-cultural factors on test performance and interpretation.
Testing was subject to considerable criticism due to its weak empirical support. Through the mid-1980s, many in academic and professional psychology predicted its imminent demise.
However, instead of disappearing from professional psychology, testing has undergone a dramatic metamorphosis since the mid-1970s which has significantly bolstered its scientific legitimacy. The validity of psychological tests is now thought to be comparable to medical test validity.
Still, with such remarkable progress have come new and formidable challenges. Today, there are a daunting array of test instruments from which to choose and no widely accepted “standards of care” to guide test selection.
There is a much broader group of referral sources and recipients of psychological test data. The psychologist has to communicate test findings in ways that can be readily understood by a diverse group of consumers, including patients and their families.
Psychologists are subject to careful evaluation of their test assessments particularly in the legal arena. Since the establishment of the Daubert Standard in 1993, testimony based on psychological tests is rigorously scrutinized, including inquiries regarding the “error rates” of the tests and the “base rates” of “abnormal” scores.
Psychologists are also vulnerable to ethics complaints and malpractice suits based on their conduct of test evaluations, the billing for these services and the content/conclusions of the report.
Managed care companies dictate the time allotted and payment for psychological testing. Psychologists often face the draconian choice of turning down the referral due to concern about insufficient time and payment to conduct a proper assessment or run the risk of completing a sub-standard evaluation which could trigger a complaint of misconduct.
The future of assessment psychology will depend of the success at integrating professional psychology into primary care, the use of shorter and briefer screening level batteries aimed at addressing circumscribed questions and the adoption of clearer “standards of care.”
Research which, it is hoped, demonstrates that testing can be “cost effective” by shortening treatment and improving outcomes would as well help to improve the outlook for psychological assessment.
The viability and growth of testing will also be contingent on graduate faculty and internship supervisors encouraging excellence in clinical assessment. Teachers and trainers need to advocate strongly for the increased availability of graduate course work in assessment, pre-doctoral specialty tracks and post-doctoral fellowships in assessment psychology as well as the inclusion of testing in DSM-V as an important aid to diagnosis, case formulation and treatment planning.
Primary care physicians, pediatricians, psychiatrists and neurologists need to support efforts to improve access to and payment for psychological testing for their patients.
Jerrold M. Pollak, Ph.D., ABPP, ABN, is coordinator of the Program in Medical and Forensic Neuropsychology and a staff clinician in emergency services at Seacoast Mental Health Center in Portsmouth, N.H. His e-mail is: firstname.lastname@example.org.