There are a number of reasons lawyers may engage psychologists to test their clients. In a child custody dispute, both children and parents may be referred for testing. In a criminal case, testing may be requested to determine competence to stand trial, to shed light on whether intent existed, and to prepare for sentencing. In a personal injury case, testing may be used to determine the extent of the cognitive or psychological damage. The purpose of this article is to give lawyers a better idea of how to understand the psychologist’s report. There exist, literally, thousands of psychological tests. While no one needs to be familiar with all of them, it makes sense to know about the tests that psychologists use frequently. A typical psychological report is divided into sections including test behavior, history, intellectual (or cognitive) functioning, and personality (or emotional) functioning.
Described often as “Behavioral Observations,” this section describes the client’s behavior during the assessment. For example, if the client is unmotivated or inattentive, the results may not be valid. Alternatively, if the client understands instructions and works diligently, the results are more likely to be an accurate picture of her abilities. The psychologist may also comment on whether the client stayed on task, needed to have instructions repeated, or easily became angry when a task was difficult.
The section of the report entitled “History” — or “Background Information” — should include enough information to understand and place in context the current problem that led to the current testing. In a truly thorough evaluation, the history section begins with prenatal development (e.g., whether the mother used substances) and includes family history, school experiences (regular or special education classes), involvement with the justice system, foster care or DCF involvement, substance or alcohol use, military service, medical history and, in particular, psychiatric and family psychiatric history. It is also important for the psychologist to ask about trauma. In many instances, clients in the criminal justice system have experienced multiple traumas. There is also a high incidence of head injury in this population, which merits inquiry. (Neuropsychological screenings will be discussed below.) Information gleaned from people who knew the client prior to his current situation, such as teachers, may be very important in developing a psychological portrait or in getting a sense of the client’s level of functioning prior to a particular incident. In an injury case, it makes it possible to connect the injury with the current impairment in functioning.
Psychiatric and substance abuse records from inpatient and outpatient facilities provide useful, and relatively unbiased, information. When reviewing such records, diagnostic statements and medication records are particularly informative. How was this client viewed by mental health professionals who had ample opportunity — possibly over months or years as an outpatient or around-the-clock on an inpatient unit for several days or weeks — to observe him? Was he identified as a person with a psychotic illness — the most extreme range of the mental health continuum in which auditory and/or visual hallucinations are common and reality testing is impaired — or was he viewed as a person whose reality testing was intact and whose symptoms were comparatively mild? Was he viewed as someone struggling with a major mental illness who needed a high level of services, or was he viewed as one who sought treatment solely to escape consequences of his behavior? Which diagnoses appeared on documents such as discharge summaries and treatment plans?
Medication records also provide diagnostic information. Was the client prescribed antipsychotics? This typically indicates the presence of disturbed reality testing with hallmark symptoms such as auditory hallucinations, visual hallucinations, and delusions. Was the client prescribed antidepressants, mood stabilizers, or a combination of medications? While it is possible for there to be “off-label” uses for a medication, most psychiatric medications are typically used for specific mental illnesses such as depression, ADD/ADHD, bipolar disorder, or psychotic disorders. A combination of medications suggests the different symptoms that were being targeted. For example, if mental health professionals ordered Depakote and Zyprexa, this suggests that features of both psychosis and bipolar disorder (i.e., impaired reality testing and mood irritability) were present.
Medical records are enormously helpful to psychologists in conducting assessments; the sooner these are obtained, the better. Likewise, it is useful for the psychologist to have access to collateral sources. Both of the information sources potentially provide additional data about the client’s functioning and demonstrate the thoroughness of the evaluation. They can also be used to counter (or to suggest) a claim that the client is malingering or a claim of expert bias.
The Wechsler Adult Intelligence Scale IV (WAIS-IV), along with its predecessors, is the most frequently used adult intelligence test; it was most recently revised in 2008. In this revision, three new subtests were added, four subtests were dropped, and 12 subtests were retained, with modifications. The WAIS-IV now provides a Full Scale IQ, which is the overall score of cognitive functioning, along with four different index scores. The Verbal Comprehension Index (VCI) is a measure of tasks that depends particularly on using words and understanding verbal concepts. The Perceptual Reasoning Index (PRI) is a measure of nonverbal — or visual — reasoning. The Working Memory Scale (WMS) is a measure of the ability to pay attention, concentrate, and manipulate information mentally. Lastly, the Processing Speed Index (PSI) is a measure of the speed, or efficiency, with which one works.
The WAIS-IV is a standardized test, meaning that the client’s performance is evaluated against the performance of others in a standardized sample within the same age group. There are 10 mandatory subtests. Of those, three are classified under the VCI, three are classified under the PRI, two fall under Working Memory (WMI), and two fall under the PSI. Typically, a psychological report will list each subtest and its score, as well as a Full Scale IQ and scores on the indices. It will also indicate whether there is significant difference (i.e., significant strengths or weaknesses) among the different areas. Scores on the WAIS-IV also indicate in which group a client might be classified based on IQ; there are seven groups, ranging from extremely low (69 and below) to very superior (130 and above).
If there is disagreement about the level of cognitive functioning (e.g., whether the client meets the criteria for mental retardation, how capable the client is despite a low IQ), the psychologist may include a functional (or adaptive) assessment tool, such as the Vineland Adaptive Behavior Scales, in order to look at functioning in day-to-day practical skills. The Vineland, revised in 2005, assesses abilities (i.e., “functioning”) in several areas or domains, including communication, daily living skills, socialization, and motor skills. By asking about specific abilities, such as managing money and engaging in self-care, the Vineland provides scores of adaptive functioning and gives an “age equivalent” for each domain. The Vineland also contains a measure of clinically problematic behavior. If there is disagreement about the level of cognitive functioning, it is worth using the Vineland or other test of adaptive functioning to provide additional information. Like the WAIS, the Vineland is a standardized test, meaning that the client’s performance is measured against others in the same age group. Typically, the examiner will ask a parent or caregiver to provide information about the client’s functioning.
While in certain cases it is necessary to conduct a full neuropsychological evaluation, in other instances a neuropsychological screening may be administered to assess whether there are apparent impairments in areas such as attention, memory (immediate and delayed), concentration, attention and language, and thus whether further testing is indicated. The RBANS and the CLQT provide percentile scores comparing the client with the standardized age-equivalent sample. Some factors that might encourage including a neuropsychological screening in a full psychological battery include age, exposure to chemicals at work, substance or alcohol abuse history, head injury, physical abuse, special education, and birth or prebirth trauma.
Personality, or emotional functioning, is another of the psychological report’s major sections. There are two kinds of personality tests: objective tests and projective tests. Frequently used objective tests include the Minnesota Multiphasic Personality Inventory (MMPI), Millon Clinical Multiaxial Inventory (MCMI), and the Personality Assessment Inventory (PAI). In these pencil and paper tests, the client provides a series of responses to forced-choice statements. Typically, the client responds to forced-choice items by indicating agreement or disagreement with statements.The response patterns suggest different personality profiles. These are called objective tests because scoring, whether by hand or by computer, is carried out objectively. Commonly, the data from the scoring sheet is input into a computer and a report is generated.
At present, the MMPI-2 is the most widely used personality test (and has been translated into several languages). The client answers true or false to 567 statements as these apply to the client. The MMPI-A is the version of the test designed for use with adolescents. Most recently, a streamlined version of the MMPI called the MMPI-RF (restructured from) has been developed. This version contains 338 items and is not considered to be an alternative or a replacement for the MMPI-2. In general, the MMPI requires approximately a fifth grade reading level.
Personality profiles were developed by collecting data on how different groups of people, such as depressed people and antisocial people, respond to the statements. The client’s responses are compared to those of people fitting certain clinical profiles, i.e., a sort of actuarial analysis. For example, a client may produce a profile that is most similar to that produced by patients who have experienced trauma. This does not prove that she has experienced trauma; it does indicate that her profile matches that of trauma patients rather than the profile of patients with other disorders. In contrast, another client’s profile may match those of patients who are involved with drugs or alcohol or who have episodes of mania. Again, it is an actuarial match.
In addition to the clinical scales, the MMPI-2 has validity scales that are used to ascertain whether the client is answering truthfully or whether the client is attempting to minimize or amplify symptoms. The validity scales also indicate whether the responses are inconsistent or random. These issues arise particularly in legal proceedings or other circumstances in which gain is associated with a particular outcome. If malingering is at issue, the psychologist may also pay attention to whether there is, in general, an unusual combination of symptoms or atypical symptoms.
Projective tests, in contrast to objective measures, are open-ended. The theory behind projective tests is that clients will project aspects of emotional lives, involving unconscious material, in an unstructured test. The Rorschach (popularly known as the “inkblot test”) is probably the most widely used projective test of personality functioning. The psychologist codes the responses according to an established scoring system that includes scores for content, but also for the way in which the client used the different aspects of the blot to develop the response. Other aspects of the response, including the use of language, are also scored. Commonly, the scores are entered into a scoring program, and the software generates a report containing a personality description.
The Exner Comprehensive Scoring System, developed for the Rorschach, includes norms that compare the client’s responses to responses of individuals in several diagnostic groups. However, in contrast to the objective tests, the Rorschach does not contain validity scales and there is more involvement of the examiner in terms of coding each response. One of the strengths of the Rorschach is that it is less transparent than a self-report. As a result, it can be more revealing of unconscious pathology. Inclusion of both an objective and a projective measure offers a nice balance, allowing the psychologist to apply to the evaluations both readily quantifiable objective data along with clinical skills and experience.
A psychological report describes the results of several different tests, and synthesizes this data with the client’s history in order to answer questions about her and to offer recommendations. As shown, a report integrates both test and nontest data from multiple sources. Lawyers who are familiar with cognitive and personality tests, the role of history in assessment, and the issues in testing (e.g., validity, malingering) will be able to better make use of psychologists’ reports on behalf of their clients. They will also realize the importance of obtaining records and providing information on collaterals to the psychologists they retain.
© The Connecticut Bar Association, 2010. Reprinted with permission of the Connecticut Lawyer.