Off The Couch #9 Psychological Assessments

Why are psychological assessments so important for a private practice? Dr. Daniel P. Brown discusses outcomes research, psychological evaluation and various assessments such as the body sensations questionnaire, the Pen State Worry Questionnaire and structured patient interviews.

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Caroline Baltzer: So, one of my favorite courses that I took with you was Psychological Assessment. And I’m aware that, as a psychologist in Boston, I don’t have many colleagues that use psychological assessment very often. If you want to have a patient tested, if you don’t do it yourself, you need to go and seek somebody who’s very specialized in that field. And I’ve thought that it would be better for psychologists to have more facility with psychological assessment. I wonder if you could talk about your course that you teach and your thoughts about psychology and private practice and assessment.

Dan Brown: Sure. Well, I got interested in it largely for political reasons. It seemed to me that, with the development of managed care in the 1990s, more and more of the assessment and the planning of treatment of cases was being done by the insurance industry, rather than the trained clinicians. I thought there was something fundamentally wrong in that, in that we had all these good outcomes research assessment tools. I remember being asked by a private insurance carrier to treat somebody with generalized anxiety disorder, and they wanted to give three sessions for it. I said, “All the outcomes data suggests that 8 to 12 sessions are what it takes. You show me one outcome study that says you can treat it in three sessions. If you do that, I’ll treat it.” I said, “you have to produce the data,” because I knew that they were presenting false data and were just trying to cut the costs so much that it doesn’t even make any sense to treat anymore. Of course, they couldn’t produce the data. So, I refused to take on the case. I said, “If you pay for 8 to 12 sessions, that’s fair with the outcome data available.”

So, that made me upset, and I began to think that it was all about cost containment and nobody was running the train anymore, and that we had gotten far away from all the preciousness of the outcomes research that we had done for almost 50 years. Then, I began to think that, if you look at how outcomes research is set up, it’s mostly done not in private practice. It’s done in big universities, medical schools, where they have the budgets to do major outcomes research, but not by private practice. That’s different from countries that have national health policies. I taught a lot, in those days, in the Netherlands and in Belgium, and what was unique about the Netherlands and Belgium in those days was that all clinicians in private practice got a research budget. They were expected to do research.

Caroline Baltzer: So luxurious.

Dan Brown: All their continuing education was paid for by the government. They were expected to continue to learn. They were expected to do outcomes research and collect data. So, from a learning point of view, teaching in Europe was therapeutic heaven. Practicing in Europe was therapeutic heaven. And I had seen how far away we, in the USA, got from that model.

Caroline Baltzer: Scientist practitioner.

Dan Brown: Yes, exactly. So, I began to look into the nature of the outcomes research that was done in large universities. And I found that, for convenience in research, what evolved was the use of paper-and-pencil questionnaires for almost every diagnosis. After 5 to 10 years, there would be a certain instrument that would emerge as the premier instrument for the short-term paper-and-pencil assessment of that diagnosis. So, for example, there was a growing consensus in the field that, if you want to assess panic attacks, the Body Sensations Questionnaire is the best questionnaire for that; and if you want to assess generalized anxiety, the best questionnaire was the Penn Worry Questionnaire. So, if you want to assess social anxiety, then the best questionnaires were the Fear of Negative Evaluation and the Social Anxiety and Distress Scale. So, these are paper-and-pencil questionnaires that take about five minutes to administer, at most, and an equally short amount of time to score up. They are based on norms, so if you get above a certain empirically derived cutting score, then the odds of having that diagnosis are 95%. That’s much better than the legal standard of 51%.

So, I decided that I would research all the diagnostic instruments that were out there and develop a course on the best instruments for every diagnosis. I thought that would empower clinicians in private practice to start using these instruments in their private practice, so they would do two things. They would be able to get an accurate assessment of what they were treating in the first place, and if they gave the instruments repeatedly over time, they could actually document and justify that the patient was improving and getting better. That would do two things. First, it would allow them to justify to insurance carriers why the treatment was important, and that it was actually being effective.

And second, it would allow them to collect outcome data on a massive scale, so that we would do outcome studies, not just in big medical schools, and empower private practitioners to pool all their data. Then, we will have a massive data pool. But it never caught on enough, because clinicians are too damn busy and too disempowered by the insurance industry to do this “User-Friendly Clinical Assessment.” People who take it in one day get a packet of all the paper-and-pencil questionnaires that work for every diagnosis. The second day, we cover the structured interviews, the best ones that are out there, for a comprehensive assessment of the same diagnoses. So, it’s a good course for doing a careful assessment that’s empirically derived.

Caroline Baltzer: Are you still teaching that course?

Dan Brown: I just taught it in Australia last year.

Caroline Baltzer: Yeah, it was an excellent course.

Dan Brown: And it was popular. So, I collect the same instruments on all my patients, and I follow them and track that they actually get better over time, according to the instruments, if I’m working with patients in private practice.

Caroline Baltzer: So, when you have a new patient come in your private practice, how do you set up the initial evaluation?

Dan Brown: I ask them what they’re coming in for, and we refine it down from there. And once we decide on what the diagnoses are, I will follow it up by giving them the series of instruments to empirically demonstrate that.

Caroline Baltzer: So, once you have a diagnostic impression, then you select the instruments.

Dan Brown: Yes. So, it might be that it requires a follow-up interview, or if it’s short, because of the anxiety condition, we can probably do it at the same hour. I just go to my computer and print them out and say, “Here, take these before you leave.” It may be that I have to arrange my time logistically so that, if I see a patient for 50 minutes, and then I want them to fill out some paper and pencil questionnaires, I put them in the conference room next door, privately, and they’ll fill out the questionnaires. And then, the end of my next hour, I will go in there and say, “let’s go over it together,” and in my 10-minute break, I will score it up for them and give them feedback so that you can actually do a good assessment in the same day you see the person and give them something they can walk away with.

Caroline Baltzer: It sounds very efficient.

Dan Brown: That makes sense. So, that’s the way I do it usually. Sometimes, it takes a structured interview; that’s going to take more time, so I will reschedule it. Like the Adult Attachment Interview (AAI), or the Structured Clinical Interview for Diagnosis of Axis 1 conditions SCID-I, or Axis 2 conditions SCID-2, or dissociative disorders like the SCID-D. That’s going to take at least another hour.

Caroline Baltzer: So, how many sessions would you say for the average patient encompasses the initial evaluation?

Dan Brown: No more than two sessions. Mostly, I try and do it in one.

Caroline Baltzer: And you do a debriefing with the patient about your findings and recommendations.

Dan Brown: In the same session, at the end of this session. But sometimes, I know in advance. So, if a person has come in for dissociative disorder, the gold standard is the Structured Clinical Interview for Diagnosis of Dissociative Disorder SCID-D. So, if I know that in advance of schedule, I will schedule an hour and a half, and do the intake, do the SCID-D, and give them feedback in the same session.

Caroline Baltzer: Oh my gosh. That’s very efficient.

Dan Brown: I have given so many times. There is a new clinical version of it coming out, and I hope to be one of the people who revise the instrument.

Caroline Baltzer: What’s the difference going to be?

Dan Brown: Well, there are now questions about parts.

Caroline Baltzer: In the IFS model?

Dan Brown: No. Just the parts. In the original SCID-D, the questionnaires that led to the existence of parts were through asking if they have dialogues with themselves. That was an indirect way to lead into the existence of parts – but you can ask more directly, “Do you have parts?” It’s a much more direct way of interviewing. So, those questions were added to the instrument because they work better and give a good clinical yield.

Caroline Baltzer: What are the assessments that you think psychologists should be using more as a standard of course, a standard of treatment?

Dan Brown: Well, the quickest are the paper-and-pencil questionnaires, and we have them for almost every diagnosis. If you want more thorough comprehensive assessments, then you can use structured interviews. Presumably, you ask the same set of questions, you have the same set of scoring rules, and therefore, if 10 clinicians give the same instrument, we should come up with 10 clinicians having the same diagnosis.

Caroline Baltzer: What are those ones, besides the SCID-D.?

Dan Brown: I like this SCID-I, the SCID-II, and the SCID-D. And then, for the assessment of PTSD, I don’t like to SCID-I. I like the Clinically Administered PTSD Scale, the CAPS. That’s the best instrument and the gold standard in research. That’s the one I use for assessment of complex trauma.

Caroline Baltzer: So, how would somebody decide whether to use assessment materials or just do a diagnostic interview alone?

Dan Brown: I don’t think it’s a decision. I think it’s a duty the clinician has to the patient to make the best scientific diagnosis that we can, and that means using the empirically-derived instruments that work. Most clinicians fail in that duty.

Caroline Baltzer: Unfortunately, insurance companies fail, and they don’t provide coverage for the administration of those tests.

Dan Brown: That’s true, but a lot of the simple diagnoses you can do in 5 or 10 minutes of testing. You can fold it in as part of your interview.

Caroline Baltzer: I think a lot of clinicians don’t realize how efficient they can be with the use of the assessment materials.

Dan Brown: But that’s why they were derived in research: because researchers don’t have time, so they wanted some quick assessment, using paper-and-pencil tests, that they could give in 10 minutes and score up in five minutes, and then it’s done. That’s, ironically, how the field developed, and that’s an advantage to clinicians.

Caroline Baltzer: I think that that’s a good message to get out there. Instead of having to feel like it’s something they need to learn, it’s already been developed for them. All they need to do is learn how to administer it and then get the results.

Dan Brown: So, we try to spoon-feed that in this course by giving them the instruments, so they have one master set of the instruments, and then in the PowerPoint slides, all the scoring rules for each instrument. As we go through how to score each instrument up, by the time they finish the course, they know how to administer and score.

Caroline Baltzer: A wealth of material.

Dan Brown: But it’s everything’s in one place, that’s what we try to provide people with.

Caroline Baltzer: I think more people should take that class.

Watch the full clinical interview series:
1. Meet Dr. Daniel P. Brown
2. Overview of Trauma Treatment
3. Attachment Disturbances 
4. CCRT (Core Conflictual Relationship Themes)
5. Three Pillars Approach (Treatment for Attachment)
6. Teaching Psychology
7. Conversion Disorders
8. Factitious & Dissociative Disorder
9. Psychological Assessments
10. Bipolar Disorder Treatment
11. Trauma Bonding Maps
12. Conclusion

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