Psychological Assessments of Individuals who are Involved in MVAs: Why Do They Take So Long to Perform?

Clinical psychological evaluation has been demonstrated to be a scientifically sound and effective undertaking for the identification of psychological impairments for treatment planning purposes and for the identification of psychological disability. Meta-analytic research on assessment validity reveals that many psychological tests detect psychopathology as accurately and effectively as do medical tests.

For instance, psychological tests measuring depression, dementia, or psychosis detect these conditions just as accurately as medical tests such as Magnetic Resonance Imaging (MRI), pap smears, and electrocardiograms detect physical pathology.  Neuropsychological testing for instance has been shown to detect dementia as accurately as MRI (Daw, 2001). However, in order for a psychological assessment to produce accurate and clinically useful findings, the assessment needs to be conducted carefully and comprehensively, which takes time.

I am frequently asked why a psychological assessment under the SABS requires a booking of three to four or sometimes even five hours. The purpose of this article is to provide a more indepth explanation of what a psychological assessment entails, why we ask claimants to sit for several hours collectively between the clinical interview and psychological testing, and why a second appointment is often necessary.

Assessing individuals who have been involved in motor vehicle accidents requires not only that we identify if any psychological impairment exists and the magnitude or severity of these impairments but also whether such impairments result from the motor vehicle accident (i.e., causality). To do so requires that we understand the individual’s background history and in particular, his or her mental health history. Unlike our colleagues who assess physical impairment, psychologists do not have x-rays or MRIs that allow for comment on whether an injury is old or new. We must rely on what the examinee tells us as well, our clinical observations, psychological test results, and a detailed review of a medical file, which might be hundreds if not thousands of pages in length. Some might argue that the heavy weight placed on an examinee’s self-report renders the psychologist impotent or ineffective in obtaining an objective and credible account of the participant’s functioning, especially given that base rates for overreporting of difficulties in litigious populations have been shown to be significant (e.g., Mittenberg et al., 2002).

While it is true that the objective data that we rely on from psychological tests by definition comes from the examinee’s reports, it would be incorrect to conclude that we cannot provide objective and empirically validated evidence of psychological impairment. Interpretation of objective psychometric measures does not involve taking a participant’s endorsement of “I often feel sad and blue” (for instance) at face value. Instead, objective psychometric interpretation requires examination of profile distortion, response patterns, the configuration of clinical scale elevations, and empirically determined correlates of such profile configurations.

While an in-depth discussion of how this interpretive process works is beyond the scope of this article, suffice it to say that an examinee’s response patterns are interpreted by comparing his or her profile with thousands of others who have completed the same measure under standardized administration and examining what scientific studies have shown us to be true about individuals with similar testing profiles, and not by taking the participant’s individual responses at face value. Indeed, these are empirically validated objective measures rather than subjective measures.

The formidable three-part task of identifying psychological impairments, determining the cause of such impairments (e.g., accident-related or not) and determining the credibility of the interviewee’s report is a complex and time consuming undertaking. The process requires a multimodal examination of different sources of information – the participant’s behavioural presentation over the course of the assessment, his or her reports during the interview, a review of the medical brief, and the administration, scoring and interpretation of objective psychometric measures. Psychologists then engage in discrepancy/convergence analysis – that is, we systematically examine whether these sources of data corroborate each other, whether there are discrepancies, and if there are discrepancies, we must reconcile such discrepancies in our conceptualization of the examinee’s clinical picture. For instance, if the participant exhibits a full range of affect and is engaging at interview (e.g., if he or she is observed to joke with the examiner, engage in spontaneous small talk, etc.) and yet reports severe depressive symptomology at interview (two data points that do not corroborate), an examination of objective validity indices on psychometric tests can provide insight into why the discrepancy is present. If objective psychometric validity indices and tests reveal a strong tendency to over-report or embellish psychological symptoms, the psychologist might hypothesize that the examinee was over-reporting at interview and that the credibility of his or her reports is questionable. On the other hand, if objective validity indices reveal a reliable and forthright approach to the completion of psychological tests (i.e., no evidence of underreporting or over-reporting of symptoms), the psychologist might speculate that the claimant’s depression is in fact quite significant but that he or she can “hold it together” at interview. In this case, the psychologist might downgrade the claimant’s depression to “moderate” rather than “severe” (as severely depressed individuals usually do not present as engaging at interview) but still conclude that the participant’s reports are generally credible and that the depression is genuine.

Causality

Determining the degree to which psychological impairments are a result of a motor vehicle accident requires a careful examination of the examinee’s mental health history. Given what we know about base rates of psychological conditions in the population at large (which are in actuality quite significant), it is necessary for the psychologist to explore possible pre-existing conditions and to determine whether the clinical picture identified in the examination represents a continuation of a pre-existing condition, or whether the accident resulted in an exacerbation or aggravation of pre-existing psychological features, or whether the clinical picture represents newly developed symptoms resulting from the accident. Such an examination requires careful interviewing around the participant’s family history of psychopathology, the participant’s past diagnoses, past relationship functioning, history of alcohol and drug use, past mental health service usage (e.g., psychotherapy or use of psychotropic medication), and the participant’s perceptions of how he or she was doing psychologically during the time period just prior to the accident. This section of the interview alone can be very brief in cases where the individual denies pre-existing psychological problems altogether but can also be very extensive in cases where the participant presents a complicated pre-accident mental health history (e.g., multiple diagnoses, hospitalizations, multiple treatments, etc.) When available, the participant’s family physician’s clinical notes and records are examined and compared with the examinee’s reports to corroborate their version of their pre-accident history.

Determining that a psychological symptom developed following a motor vehicle accident does not in and of itself mean that the symptom is a result of the motor vehicle accident. While the temporal relationship is an important clue, a psychologist also needs to understand the mechanism by which the MVA resulted in the development of the symptom. Consider for instance the case of an individual with a history of recurring Major Depressive Episodes over a 20 year period. If this individual becomes depressed following the accident, the psychologist must understand how and why the depression developed. Perhaps the development of
accident-related pains and associated activity limitations and role loss resulting from physical injury triggered the new depressive episode – in which case the psychologist would conclude that the depression results from the subject accident. It is plausible (albeit not as likely) that the depression developed independently – perhaps triggered by a relationship break up or a job transfer. The take home message is that psychologists must understand the mechanism of action that results in the development of psychological impairment in order to understand its pathogenesis (i.e., causal factors).

It is important to keep in mind that the identification of pre-existing psychological conditions and how they affect accident-related psychological conditions is a complex undertaking. It is relatively easy for a psychologist to assess an individual who denies psychological difficulties prior to the motor vehicle accident altogether and then describes a traumatic accident and significant post-traumatic stress symptoms thereafter. It is immensely more complicated to assess an individual with a pre-existing history of abuse or trauma with ongoing post-traumatic stress who then becomes more symptomatic after a motor vehicle accident that most people would not react psychologically to. Psychologists who work with motor vehicle accident claimants must conduct careful interviews in order to effectively entertain crumbling skull and
thin skull scenarios. Stated differently, careful interviewing allows a psychologist to differentiate between 1) an examinee whose psychological impairments are attributable specifically to the subject accident, 2) an examinee whose psychological impairments represent a continuous cycle of peaks and valleys of psychological symptom severity whereby the “peak” would have occurred anyway, regardless of the accident, 3) an examinee whose psychological impairments represent an exacerbation of pre-existing psychopathology or an unusually strong psychological reaction owing to pre-existing vulnerabilities such as past trauma.

Clinical Interview

A carefully executed psychological assessment of motor vehicle accident victims must include a comprehensive interview in regard to current clinical symptoms and functioning. The psychologist must ask (typically in semi-structured interview format) about symptoms of depression, posttraumatic stress, vehicle anxiety/phobia, other forms of anxiety, sleep functioning, cognitive functioning, and use of alcohol and substances. In order to assess posttraumatic stress, the interview must include having the participant recount what happened during the accident and how the participant reacted emotionally at the time. Moreover, the psychologist must understand the claimant’s perceptions of physical pains, their attitudes and beliefs about their pain, and the coping strategies that they use in the face of physical pains. In this regard, assessment of psychological disability or the need for pain management psychotherapy requires a good understanding of the relationship between physical pains and emotional functioning, catastrophizing processes, self-perceived disability, and whether there is an active or a passive-dependent approach to pain management and rehabilitation.

The psychologist must also properly interview the examinee in regard to his or her current every day functioning. This part of the interview requires more than just a survey of what the participant believes he or she can or cannot do as compared with prior to the accident, but must also aim to understand the link between psychological impairment and functional changes – is there evidence of kinesiophobia (i.e., fear of movement) related to pain? Is the examinee simply choosing to avoid certain activities because of expected pain increases or is there evidence of psychological impairments that preclude them from engaging in such activities? Again, this section of the interview can be conducted very briefly in some cases but can also take a considerable amount of time depending on what the examinee conveys in regard to what he or she can or cannot due and why.

The participant’s understanding of his or her injuries and perceptions of the effectiveness of treatments to date and what he or she believes has been lacking is also pertinent information for a psychologist. The clinical interview typically includes other components as well – information is collected in regard to childhood history, past abuse or trauma, educational and occupational history, family and relationship history, social history, if relevant – developmental history, and if culture is a factor – immigration history and acculturation history (i.e., to what degree has the claimant acculturated to Canadian society). The cultural factors are important to consider when interpreting interview and psychometric test data as certain methodologies could be invalid (e.g., psychometric tests normed on North Americans cannot be interpreted in the standard manner when utilized with individuals from different cultural backgrounds. Psychologists must operate with different assumptions and modify their analytical methodologies accordingly.

It is also important to consider that the duration of the clinical interview also varies as a function of the participant’s communication style. Some individuals effectively provide concise and “to the point” responses whereas other individuals are tangential, exhibit psychomotor slowing (such that they do not provide information as quickly) or provide unusually high levels of detail. Some individuals downplay aspects of their personality or psychological functioning due to a lack of self-awareness or stigma-related concerns such that considerable probing at interview can sometimes be required.

If there is a take home message here, it is that the clinical interview portion of a psychological assessment can range from as little as 1.5 hour in an unusually uncomplicated case to as long as several hours, depending on the purpose of the assessment, the complexity of the case, or the participant’s style of communicating.  The interview process will take even longer when an interpreter is used or if there is a closed head injury superimposed on psychological impairment.

Psychometric Testing

Psychologists typically administer a battery of several psychometric tests to corroborate the examinee’s reports at interview with empirically (i.e., scientifically) based objective data. It is not enough to administer “check lists” or basic unidimensional measures of a psychological construct (e.g., such as the Beck Depression Inventory – II to measure depression) without also ensuring that the participant provided valid psychometric test data. Many of the administered tests are self-report inventories whereby the participant might endorse “false” or “true” or choose between “strongly disagree”, “disagree”, “agree” or “strongly agree.” Consider that the examinee could randomly choose different answers if he or she so desired, such that the test scores would be meaningless. Or, consider that the participant might not understand the nuances or meaning of the test items and provide responses that do not actually represent his or her experience. Alternatively, the examinee could deliberately choose extreme responses in order to convey high levels of suffering, such that test scores would overrepresent the severity of his or her actual symptoms. Finally, the examinee could approach the test in a guarded manner and minimize or underreport psychological difficulties due to a lack of self awareness or due to stigma concerns.

Fortunately, there are well validated “validity indices” on commonly used multidimensional inventories that allow the psychologist to measure the degree of inconsistent or idiosyncratic responding or the degree to which he or she provided a forthright and accurate reflection of actual psychological difficulties. As a general rule, psychological assessments of individuals who have been involved in motor vehicle accidents – whether they are carried out to tailor a Treatment Plan and proposed psychotherapy or whether they are carried out as an insurance examination to determine the necessity of psychological treatment or the presence or absence of psychological disability – should include at least one well validated multidimensional measure with built-in validity scales. While there are exceptions to this rule (a discussion of which is beyond the scope of this article), inclusion of such measures is the only way one can be confident in the reliability and validity of self-report psychometric test data. Unfortunately however, these measures are typically lengthy and can take over an hour or sometimes even two hours to administer. Indeed, these measures typically include over 340 items and can include as much as almost 600 test items. When one considers that a typical testing battery in a comprehensive psychological assessment includes several psychological tests (typically including one or more of these longer measures), it is not unusual for 500 test items to be administered during such an assessment.

When one considers issues related to using interpreters, possible reading or comprehension difficulties and a participant’s need to seek clarification from the examiner, and the fact that there is considerable variability in how long people take to respond to self-report inventories, one can see that the psychometric testing component itself can take over two hours and sometimes longer. Psychologists also administer non-verbal performance-based measures and tests of effort to ensure adequate engagement, adding further to the assessment time. While there is variability in test selection (both as a function of assessor preference and of specific examinee needs), it is typically insufficient to administer two or three screening measures coupled with a brief interview.

While I often read reports that describe such truncated assessments as comprehensive psychological assessments, I would submit that more times than not, these are screening assessments at best and cannot properly provide a defensible opinion as to the participant’s psychological functioning, causality, and credibility with confidence.

Summary

There is considerable variability in the amount of time it takes to conduct a thorough psychological assessment. Assessment time varies as a function of the complexity of the case, the purpose of the assessment and specific referral questions, the participant’s communication style (i.e., do they provide concise and effective responses or do they provide insufficient information spontaneously such that the psychologist has to probe for a more complete answer), the examinee’s history, test taking ability and style, or whether there is an interpreter or need for frequent clarification. Psychologists cannot predict the length of the assessment in advance as only some of the variables that affect assessment duration can be known before the participant arrives.

On average, and depending on the type and purpose of the assessment, psychologists should typically meet with the examinee for between three to six hours for a basic psychological assessment, in addition to indirect service time (e.g., time taken to review the medical brief, write up the assessment report, consult with others assessors or providers on an as-needed basis, etc.) When a psychologist is conducting an assessment for treatment planning purposes, it is also required that the psychologist meet with the participant after the assessment for a feedback session to review assessment findings and details of the report, to communicate applicable diagnoses, to discuss treatment planning and if treatment is in fact being proposed, to have the participant sign and consent to the submission of an OCF-18. This, however, is not usually the case when an insurance examination is performed. When specialized assessments such as neuropsychological or psychovocational assessments are carried out, additional time of several hours duration might also be required over and above that which is described above.

While a psychological assessment usually takes a substantial amount of time due to the complexity of the assessment process, a thorough assessment can provide a truly defensible opinion regarding diagnosis, causality, prognosis, treatment needs, and most other issues regarding disability. One should be wary of brief screening assessments which may fail to provide a reliable and accurate account of the examinee’s clinical picture. When conducted properly and comprehensively, psychological assessments are robust diagnostic tools with strong reliability, validity, and clinical utility for the determination of disability and treatment requirements.

References

Daw, J. (2001). Psychological assessments shown to be as valid as medical tests. Monitor on Psychology, 32(6).

Mittenberg, W., Patton, C., Canyock, E. M., & Condit, D. C. (2002). Base rates of malingering and symptom exaggeration. Journal of Clinical Experimental Neuropsychology, 24(8).

Dr. Frank is registered with the College of Psychologists of Ontario as a Clinical and Rehabilitation Psychologist. He is listed with the Canadian Register of Health Service Providers in Psychology. He is a full member of the Association for Scientific Advancement in Psychological Injury (ASAPIL). He is an associate member of the Canadian Society of Medical Evaluators (CSME). He obtained his doctorate in Clinical Psychology from the University of Windsor in 2004. His training includes assessment, diagnosis and treatment of severe mental and behavioural disorders in psychiatric inpatient hospital settings. Dr. Frank’s training and experience to date also includes work in psychological trauma, the treatment of chronic pain, the assessment of disability, and rehabilitation following injuries. Dr. Frank has considerable teaching experience, having taught numerous undergraduate courses, and having taught and supervised numerous Masters-level clinicians, doctoral students and PhD-level psychologists in supervised practice in clinical and rehabilitation assessment and treatment. Dr. Frank has conducted research on the use of the Personality Assessment Inventory for the psychological assessment of claimants who have been involved in motor vehicle accidents and has coauthored a book chapter with newly developed norms for this population in 2010. Dr. Frank served on the Board of Directors of the Ontario Psychological Association from 2007 to 2010 and has been on the Board of Directors of CAPDA since 2009. He currently serves as Chair of the CAPDA Membership Committee and is involved in the development of the CAPDA board certification/diplomate program. A significant portion of Dr. Frank’s work involves the assessment and treatment of individuals who have been involved in motor vehicle accidents. He has performed hundreds of psychological disability assessments both at the request of plaintiff and defence, largely for individuals who have been involved in motor vehicle accidents (including Catastrophic, Post-104 disability, and assessment of treatment necessity and other specified benefits), for individuals with WSIB claims, and for individuals in other personal injury contexts (e.g., slip and fall, medical malpractice suits). He also has considerable experience providing psychotherapy (with a rehabilitation focus) to automobile accident victims and victims of work-related injuries. Dr. Frank also maintains an active private psychotherapy practice where he sees individuals with a range of psychological difficulties and couples with marital problems.

To schedule an Independent Psychological Examination or Independent Psychological File
Review with Dr. Frank, please contact A.R.S. at 1 (877) 304-2239 or info@arsi.ca.

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