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Responsibilities in Providing Psychological Test Feedback to Clients

Kenneth S. Pope

ABSTRACT: This article on test feedback highlights 10 fundamental aspects of the feedback process: (a) feedback as process; (b) clarification of tasks and roles; (c) responding effectively to a crisis; (d) informed consent and informed refusal; (e) framing the feedback; (f) acknowledging fallibility; (g) countertransference and the misuse of feedback; (h) records, documentation, and follow-up; (i) looking toward the future; and (j) assessing and understanding important reactions.

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Feedback may be the most neglected aspect of assessment. This article presents some of the fundamental aspects of the feedback process that provide a context for the subsequent articles in this series. The aspects described here are by no means original or new. They represent basic concepts often stressed in graduate courses in psychological assessment and clinical work. They tend to be so elementary, however, that they are easy to forget as one wrestles with the complexities, subtleties, and challenges of day-to-day clinical work. When neglected, they tend to limit, and sometimes destroy entirely, the usefulness of an assessment. Carefully considered, they provide a context of clear communication within which the purpose of an assessment can be achieved.

Assessment and Feedback as Process

One of the most fundamental aspects of feedback is that it is a dynamic, interactive process. The forces that urge one to view it otherwise are numerous. First, increasing numbers of people work for managed health and related organizations that can inflict harsh, sometimes unrealistic demands on their time (Pope, 1990; Pope & Vetter, 1992). The bureaucratic allocation of time may allow too little opportunity to sit down with a client to discuss an assessment and attend carefully to the client's questions and concerns. Similarly, federal, state, and private mental health insurance may disallow coverage for all but the most minimal feedback session. For example, there may be a standard, fixed payment for administrating a specific psychological test; the payment may barely (sometimes inadequately) cover the time necessary to administer the test and prepare a brief write-up of the results. The clinician may have to donate pro bono the time required to provide adequate feedback.

Second, advertisements and marketing literature may promote individual tests, versions of tests, or test batteries by stressing how little time they take. One continually reads of quick, brief, short, and abbreviated tests. Such promotion may unintentionally nurture the notion that a complex assessment can be carried out in just a few minutes with no real demands on the time, skills, judgment, or even attention of the clinician. This "rush to judgment" may encourage clinicians to match their quick, brief, short, and abbreviated testing with quick, brief, short, and abbreviated feedback.

Third, on a personal level, clinicians may be uncomfortable discussing the results of an assessment with a client. Some may be reluctant to be the bearer of what they fear the client will receive as "bad news." Others may be uncomfortable trying to translate for the client the technical jargon that clogs so many test interpretation texts, computer interpretation printouts, volumes on diagnosis, and so forth. Still others may be uneasy facing a client's expectations of clear results with test results that may necessarily leave many important questions unanswered.

These and other factors may encourage clinicians to forget that feedback is a dynamic, interactive process that is an aspect of the larger process of assessment, and that the assessment often continues during what is called the feedback session or phase. Consequently, feedback may come to be viewed as simply a pro forma, static method of closure or an obligatory technicality in which the "results" are dumped in the lap of the client (or referral source, etc.); this view of feedback seems so aversive and unproductive that some clinicians may decide—wrongly—to withhold feedback altogether. No rote, by-the-numbers approach to feedback can legitimately replace a thoughtful discussion with the client of what the results are, what they mean, and what they do not mean.

Clarification of Tasks and Roles

Clarification of the goals, strategies, and forms of feedback is an important part of the initial planning phase of an assessment. When roles or tasks are neglected, are improvised as the testing proceeds, or are viewed differently by those involved, problems result. The following brief, fictional scenarios illustrate common problems that can occur when tasks and roles are confused.

Scenario 1: Dr. Able, a therapist, has heard glowing recommendations about Dr. Baker, a testing specialist. He decides to refer one of his new patients to Dr. Baker for a comprehensive assessment. As Dr. Baker conducts the assessment, she discusses with the patient the trends that are emerging and their implications for understanding the patient's life and for treatment possibilities. Dr. Able, listening to his patient's account, becomes enraged. He'd assumed that Dr. Baker would discuss the results only with him, and that he—Dr. Able—would discuss the results with his patient.

Scenario 2: Dr. Chang, a therapist, has heard glowing recommendations about Dr. Dillard, a testing specialist. She decides to refer one of her new patients to Dr. Dillard for a comprehensive assessment. After several weeks of expensive testing, the sole feedback given to Dr. Chang is in the form of a written report. The report is a verbatim transcription of a number of computer-generated interpretations of standard psychological tests. Dr. Dillard had not evaluated the computer-generated printouts in any way or made any attempt to integrate their statements.

Scenario 3: Dr. English, a heavily booked therapist, has for years been a valued source of referrals for Dr. Freund, a testing specialist. While taking a history from one of Dr. English's patients, Dr. Freund learns that the patient believes that he has not received adequate services from Dr. English and wants to change therapists (and perhaps file a formal complaint with the licensing board). The test results suggest that the patient might be much better served by a therapist with expertise in various areas with which Dr. English is unacquainted. Dr. Freund becomes aware of an uncomfortable conflict of interest in her position and the fact that the tasks and roles had never been adequately addressed. She is financially dependent on Dr. English's referrals and feels that he would be outraged by the implications of her findings. She believes that Dr. English tacitly believes that the testing and feedback that he has requested are for his benefit as a therapist.

Scenario 4: Dr. Frank has worked with a patient for 5 years, during which both therapist and patient agreed the patient had made substantial progress. During the 5th year, however, the treatment had become stalled; the patient was experiencing negative transference; and neither therapist nor patient seemed able to reestablish the productive working relationship. Dr. Frank decided to refer the patient to a colleague for an assessment. Such an independent assessment would likely help both therapist and patient to understand the dynamics of the recent therapeutic impasse and to get the therapy back on track. Dr. Gonzales conducted a comprehensive testing. During the third testing session, the patient told Dr. Gonzales that she was pleased that Dr. Frank had referred her for these sessions, and that she was now certain that she wanted Dr. Gonzales to become her therapist. After reviewing all the test results, Dr. Gonzales could see no reason for not accepting this new patient into therapy. Dr. Frank was outraged and filed a formal complaint.

These scenarios illustrate but a few of the many ways in which testing and feedback can go awry because the tasks and roles of all concerned were not sufficiently considered and explicitly clarified at the beginning of the assessment process.

Responding Effectively to a Crisis

Another aspect of the feedback process that must be adequately addressed before beginning to test is the possibility that the testing process may require an immediate intervention by the assessment specialist or may require immediate feedback to third parties. No matter how routine the request for a general assessment, no matter how firm the assurance from a referral source that the testing will show "nothing out of the ordinary," and no matter how benign the client's presenting problem or reason for seeking an assessment, there is always some possibility that the assessment process will reveal an impending crisis, a risk of life-threatening behavior, or information that a clinician is legally compelled to report to third parties.

Information obtained during the course of an assessment that can lead the clinician to provide immediate feedback can take many forms, but the most common probably involve risk of serious violence to self or others, evidence of child, elder, or similar abuse, and a process of impending, rapid psychological decompensation. Assessment specialists must plan for such possibilities, ensure that they are familiar with their legal and professional responsibilities (e.g., child abuse reporting laws), maintain adequate resources for consultation, and know how to reach the referring therapist or other relevant individuals in case of an emergency. For example, an assessment specialist who discovers during the course of an assessment that the client is at severe risk for suicide needs to ensure that the referring therapist receives immediate feedback so that appropriate steps can be taken to minimize the likelihood that the client will take his or her life.

Feedback in the Context of Informed Consent and Informed Refusal

There are at least two major ways in which test feedback is vitally related to informed consent and informed refusal.

First, clients have a right to understand why the assessment is being conducted, what sorts of procedures are involved, and what sorts of feedback (and from whom) they can expect. The degree to which legislation and case law explicitly address this right varies from state to state, and testing situations can become extremely complex when third parties are significantly involved (e.g., court-mandated testings and assessments requested by a private or governmental employer). The ethical principles of the American Psychological Association (APA) emphasize clearly that

In using assessment techniques, psychologists respect the right of clients to have full explanations of the nature and purpose of the techniques in language the client can understand, unless an explicit exception to this right has been agreed upon in advance. When the explanations are to be provided by others, psychologists establish procedures for ensuring the adequacy of these explanations (APA, 1992).

Second, a formal psychological assessment involving standardized tests often provides a client with information on which to base decisions about whether to undertake psychotherapy and, if so, what kind. Thus, the feedback process can be essential to ensuring the client's right to informed consent to or informed refusal of various psychotherapeutic interventions.

Framing the Feedback

The form in which the test results and their implications are presented can heavily influence how a client will interpret their meaning and will decide what courses of action may be most promising. Psychology's vast body of theory and research in such areas as cognitive processes and decision making makes it clear that the language and context in which information is presented can exert profound, sometimes decisive influences.

An example of how the language and context of feedback about treatment options can influence a patient's choices is provided by the research of McNeil and her colleagues (McNeil, Pauker, Sox, & Tversky, 1982). Individuals were presented actuarial data about two forms of treatment for lung cancer as a basis for choosing between the two. The actuarial data for surgical treatment indicated that 10% died during the surgery, an additional 22% died within a year of the surgery, and an additional 34% died within 5 years of the surgery. The actuarial data for radiation treatment indicated that none died during the treatment itself, 23% died within the 1st year, and an additional 55% died within 5 years. Forty-two percent of the individuals presented with these actuarial data chose radiation.

In a second phase of the study, however, the same data were presented using different language and in a different context. Rather than presenting the mortality statistics (i.e., the percentage who died), the investigators presented the survival statistics (i.e., the percentage who lived). The individuals were informed that 90% of the patients in the surgical group survived the surgery, that 68% were still alive at the end of the 1st year, and that 34% were still alive at the end of 5 years. Similarly, they were informed that 100% of the patients in the radiation group survived the treatment itself, that 77% were still alive at the end of the 1st year, and that 22% were still alive at the end of 5 years. Only 25% of the individuals presented with the actuarial data in this form chose radiation.

Those who provide assessment feedback to clients have a significant responsibility to keep abreast of such research and to be aware of its implications for their work.

Acknowledging Fallibility

Some clients and, alas, some assessment specialists may tend to invest the assessment specialist or the tests themselves with an aura of infallibility. It is crucial that assessment specialists not only be aware of the potential sources of bias or error but also explicitly note and discuss them in the feedback process. The feedback process best focuses on hypotheses for which there are varying degrees of evidence in the test findings rather than on any sort of infallible, unchallengeable pronouncements. The clinician has the responsibility to ensure that the client not only understands this general lack of infallibility but also is aware of any specific reservations the clinician has about the validity, reliability, meaning, and implications of specific tests, findings, and so forth. APA policy documents and formal guidelines (e.g., American Educational Research Association, APA, & National Council on Measurement in Education, 1985; APA, 1992) emphasize the importance of attending explicitly to specific threats to validity or reliability. According to the APA (1992) ethical principles, "in reporting assessment results, psychologists indicate any reservations that exist regarding validity or reliability because of the circumstances of the assessment or the inappropriateness of the norms for the person tested."

Countertransference and Misuse of Feedback

Clinicians conducting assessments, no less than clinicians conducting psychotherapy, are vulnerable to a variety of personal, intense, irrational, sometimes unconscious reactions to the individuals to whom they provide services (see, e.g., Shafer, 1954). Unfortunately, such personal reactions—some of which may represent countertransference, others of which do not—can influence, distort, and subvert the feedback process. The clinician who is irritated or angry at a client can use a feedback session or written report to punish the client in an overt or a passive-aggressive manner. The clinician who has a strong, perhaps unacknowledged bias toward a particular theoretical orientation or treatment strategy (e.g., behavioral or psychoanalytic) can slant test findings so that they seem to support interventions based on the favored orientation or strategy.

No one is free from a vulnerability to such reactions, biases, and impulses. What is crucial is that clinicians remain alert, open, and sensitive to their occurrence, that they act promptly to ensure that they do not pervert the feedback process, and that they avail themselves of both formal and informal consultation from colleagues that can help make them aware of personal factors that can undermine their ability to participate effectively in the feedback process.

Records, Documentation, and Follow-Up

Records and documentation can play a useful, sometimes crucial role in the feedback process. For some clients, having a written summary or even a detailed written report can be a useful supplement to face-to-face feedback discussions. The documentation can serve as a reminder of important points and can help a client to sort through the often complex issues that were addressed in the assessment. In some instances, clinicians and clients have found it useful to make an audiotape recording of the feedback session(s). The client can then take the tape home, along with any written documentation. Fischer (1985) described a process in which clients add their own written comments at the end of the report. This approach provides them with an opportunity to describe their reactions to the initial assessment and subsequent feedback sessions.

Records and documentation can play an important role in the feedback process, but the feedback process can also be a significant aspect of records and documentation. For example, knowledge of how a client responded to the feedback (and what additional understanding may have been gained by client or clinician during the feedback process) may be exceptionally useful to subsequent therapists.

Looking Toward the Future

The feedback session(s) with the client should explicitly anticipate and prepare for low-probability events that may not have been relevant to the referral question(s) or the purpose of the assessment. Many of these possibilities will have been discussed with the client before the testing was conducted, as part of the procedure of obtaining fully informed consent. For example, what if the findings are requested (or subpoenaed) in a civil action (e.g., custody hearing, disability evaluation, or worker compensation claim) 2 or 3 years hence (see Pope, Butcher, & Seelen, 2000)? What if the findings become dated and no longer valid as a result of the passage of time or changes in the client's status? What if information uncovered at a later date makes it clear that the inferences drawn from the test results (and documented in a written test report) were incorrect or misleading?

Both clinician and client should understand that such low-probability events may, in fact, occur and should understand the professional, ethical, legal, and related factors that will determine or influence the clinician's decisions about such matters as providing information about or records of the testing to or withholding them from third parties. In a chapter on assessment, testing, and diagnosis, Pope and Vasquez (1998) provided a vignette and set of questions illustrating the sudden demands that can be placed on the clinician to reveal information and to deliver documents. According to the vignette, a 17-year-old male contacts you for a comprehensive psychological assessment. His presenting symptoms are headaches, anxiety, and depression. He now lives with his parents and is a high-school dropout. He has left his wife and 1-year-old baby. Currently, he works full time repairing cars and has insurance coverage that will pay for the testing.

According to the vignette, you complete the assessment and then, during the subsequent year, receive requests for information about the assessment from (a) the client's medical doctor, an internist; (b) the client's parents, who are troubled about their son's sadness; (c) the client's boss, who is faced with a worker compensation claim filed by the client; (d) an insurance company lawyer contesting the worker compensation claim; (e) the lawyer representing the client's spouse, who is seeking divorce and custody of the baby; and (f) the client's lawyer, who is leaning toward suing you for malpractice because he objects to the way you have administered, scored, and interpreted the tests.

In each case, the formal request specifies that you turn over (a) the written report you prepared at the time of the testing, (b) the raw test data, and (c) copies of all of the tests (e.g., the instructions, items, and scoring code for the MMPI-2). Pope and Vasquez (1998) put the questions sharply:

To which of these people are you ethically or legally obligated to supply all information requested, partial information, a summary of the report, or no information at all? For which requests is having [the client's] written informed consent for release of information relevant?

The answers to such questions are specific to each state and to each state's evolving legislation and case law. What can be said with some confidence, however, is that the time to start considering such questions is not when the demands are made for the records and information. Both clinician and client must clearly understand what may become of the information and records of an assessment, and this understanding should be reviewed—with an opportunity for the client to voice concerns and ask questions—during the feedback session(s).

Assessing Understanding and Important Reactions

A final aspect of the feedback process involves the clinician's responsibility to ensure, in approaching the conclusion of a feedback session, that the client has understood adequately and accurately (to the extent possible for that client at that time) the information that the clinician was attempting to convey. The clinician cannot simply assume that the client understood but must exercise professional judgment. Moreover, the clinician must attempt an adequate assessment of the client's important reactions to the feedback process. For example, is the client so agitated and angry that he or she may cancel all future sessions with the assessing clinician, therapist, referral source, and so on? Is the client exceptionally depressed by the findings? Is the client inferring from findings suggesting a learning disorder that the client—as the client has always suspected—is "stupid"? Using scrupulous care to conduct this assessment of the client's understanding of and reactions to the feedback is no less important than using adequate care in administering standardized psychological tests; test administration and feedback are equally important, fundamental aspects of the assessment process.

Conclusion

As emphasized earlier, these 10 vital aspects of the feedback process are neither new nor original. Most clinicians probably learned them as they prepared for their professional life. But they are easy to neglect in the press of day-to-day work and in the complexity of the assessment process itself. These general aspects, essential to the feedback process, may provide a useful context for the two articles that follow.

References

[NOTE: Some references have been updated since the publication of the original article.]

American Educational Research Association, American Psychological Association, and National Council on Measurement in Education. (1985). Standards for educational and psychological testing. (Washington, DC: American Psychological Association)

American Psychological Association. (1992). Ethical principles of psychologists.

Fischer, C. T. (1985). Individualizing psychological assessment. (Monterey, CA: Brooks/Cole)

McNeil, B., Pauker, S., Sox, H. & Tversky, A. (1982). On the elucidation of preferences for alternative therapies. New England Journal of Medicine, 306, 1259-1262.

Pope, K. S. (1990). Ethical and malpractice issues in hospital practice. American Psychologist, 45, 1066-1070.

Pope, K. S., Butcher, J. N. & Seelen, J. (2000). The MMPI, MMPI-2, and MMPI-A in court: Assessment, testimony, and cross-examination for expert witnesses and attorneys, Second Edition. (Washington, DC: American Psychological Association)

Pope, K. & Vasquez, M. (1998). Ethics in psychotherapy and counseling: A practical guide, Second Edition. (San Francisco: Jossey-Bass)

Pope, K. S. & Vetter, V. A. (1992). Ethical dilemmas encountered by members of the American Psychological Association: A national survey. American Psychologist, 47, 397-411.

Shafer, R. (1954). Psychoanalytic interpretation in Rorschach testing: Theory and application. (New York: Grune & Stratton)

 

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