Should You Have Your Client Re-Tested, or Have a Previous Evaluation Reviewed?
Exploring the Benefits of
Re-Evaluation and Review
You have previous psychological testing on your client, yet your instincts tell you something isn't quite right. Instincts, or 'gut feelings' as they are called, exist in humans for a reason. They are a combination of experience and intellect as well as our own emotional memory giving us a signal. So while instincts can clearly be incorrect, they also should not necessarily be ignored. Here are some varied cases in which re-testing and/or reviews of previous testing revealed and provided information very important to the outcome of the cases. (All identifying information has been changed to protect client confidentiality.)
1. Bias in evaluations can occur. Evaluators are human, and can be unconsciously swayed by a client's presentation. This can result in them viewing test results more negatively or positively, and unfortunately can even affect what they include in their report and their conclusions and recommendations. Thankfully most forensic evaluators are well trained in and skilled at avoiding bias, and we do not believe it happens often. But it does happen. A few years ago we were asked to review a custody evaluation for a family with three teenage boys, where one party felt vastly misrepresented in the report. The attorney explained in hiring us that since it was common for a party in a custody case who did not like the recommendations to take issue with the report, he did not necessarily really expect us to find anything. His client, however, was insistent about a professional review of the data. We found the father's data had been fairly accurately noted in the report, and his test results, interviews, and collateral contacts mostly matched what was written. His test results that elevated into the clinical range, showing anxiety several standard deviations above the mean, however, were minimized as 'mild,' and some possible anger issues were ignored. In contrast, the mother's test data was exaggerated as problematic even when none of her scores elevated into the clinical range, and a large amount of highly relevant positive information provided by collateral contacts was omitted from the report; these two things taken together resulted in a much more negative picture of the mother than test and collateral data would suggest was accurate. (Bias can generally be avoided all-together when psychologists work as a team versus as a sole evaluator.)
2. We were asked to provide a third opinion/evaluation for a fitness for duty case, as the first evaluation had resulted in a 'not fit' recommendation and the second in a 'fit' recommendation. The client, a firefighter, had experienced post-traumatic anxiety after he had witnessed a very difficult scene. The first evaluator interviewed the client and utilized two psychological tests. In reading the report, we were uncertain if the results of one test were included; tests have certain lingo associated with their interpretation, which is how we noticed. We requested test data be sent, and received the scores for that test but no interpretive report. That is unusual but it is possible the evaluator used a manual versus the computerized method. We had the client's answer sheet so we ran an interpretive report. What we found was the results of that test contradicted the results of the other test. Thus rather than report that and perhaps have to say the evaluation results were inconclusive, the data that contradicted the 'not fit' conclusion was left out of the final report. Or, it is also possible it was a mistake and the test was never interpreted, thus not included. In addition, a one-interview format was used, which is common in evaluations, however, a person describing a traumatic event will often present as much more agitated when recounting that event than they appear typically. Lastly, time is an important factor in return to work evaluations. It may very well be he was still too highly anxious to function safely on the job so soon after the event, when the first evaluation was done. Time can help dissipate anxiety, particularly when the anxiety is situational and not chronic. Thus sometimes simply due to time it can be beneficial to have your client re-tested, even if the previous testing was top-notch.
3. Sometimes even if an evaluation is recent, if done for clinical purposes it does not serve a forensic need well. When a client presents for a clinical psychological evaluation, he/she is seeking to determine an accurate diagnosis for effective treatment planning, and when psychologists perform these evaluations, we generally believe what we are told by the client and by others. In forensic evaluations, however, our role is also to question what we hear, and gather collateral information so that information is supported in many ways.
A client self-referred for a psychological evaluation to use in court. She had received two diagnoses from two other mental health professionals based on testing and interviews with her and her husband. She believed her husband would use these diagnoses against her in their custody negotiations. Though she described having been 'evaluated' because she took tests, review of her records revealed no prior comprehensive psychological evaluation other than a few assessment tools used at various times to help determine medication and/or treatment. One test was used by their marriage therapist, as well as collateral information from the husband (who had been the therapist's individual client previous to marriage therapy). She elevated a scale on which people with bi-polar typically elevate, and that can also be elevated when a client is highly stressed, such as when in a high conflict marriage. This therapist diagnosed bi-polar and referred to a MD for medication. The psychiatrist then also diagnosed her with bipolar based again on potentially biased collateral information from the husband who had a highly conflictual relationship with her at the time. In addition, the psychiatrist gave two tests, a mood disorder test and an AD/HD test. The doctor did not adhere to the actual scoring guidelines on the mood disorder assessment, and she administered an AD/HD rating scale meant for individuals under the age of 18 when the patient was clearly well above that age. Thus in this case, re-evaluation allowed the party to contest the original diagnoses she believed were inaccurate and based on faulty data.
4. In clinically complex cases, time can be an evaluator's friend, allowing a wealth of data to accumulate and providing the new evaluator a better opportunity for clinical clarity. This was the case in a disability re-testing we provided. In addition, there are cases in which the evaluation needs to be extremely in-depth and specialized for accurate results. The client had been evaluated numerous times over the past 25 years, beginning with a psychotic episode at age 22. She was diagnosed with bi-polar disorder and medicated. The medication was considered effective in that psychotic symptoms did not reoccur, nor did she experience deep depressions or mania. She had extreme difficulty holding a job, had been through many over the years, and was still financially supported by her parents at age 46. Her parents explained it seemed likely she could not hold a job due to her inability to interact comfortably with others, and noted she was quite socially odd. She wanted to work and was upset by the many job losses.
Social difficulty is not necessarily a problem associated with bi-polar, nor is inability to hold a job when depression and mania are controlled. Rather than too easily attach these as related to the bi-polar, we considered whether alternate diagnoses were possible, and included cognitive testing, in case neurological problems were impacting her ability to work. (Too often, cognitive issues are not assessed when a person has a mental illness and thus their difficulties are ascribed to that.) A comprehensive assessment was conducted that included: clinical interview; observations; cognitive and intellectual testing; emotional and personality testing; collateral interviews; and document review of the past 25 years. Our diagnosis was schizoaffective disorder, bi-polar type, which much better described her. In addition, cognitive testing found deficits in executive functioning, and in particular in areas of cognitive functioning that would directly impact the type of career she had endeavored on. Thus in addition to her bi-polar medication, she had always also needed social skills therapy for her schizoaffective symptoms, and needed to determine if any skill building could allow her to remain in her current field or whether she should seek career counseling to find a field that better matched her strengths.
In summary, as evaluators we would like to point out that most evaluations performed by well trained clinical and forensic psychologists are very good pieces of work. We are certainly fans of the team approach such as we utilize here at the group practice, in which peer review is built into our evaluation process to protect against human error or unconscious bias. (Generally forensic reports here are reviewed by a minimum of three psychologists before finalized.) However, as you can see, it is not only mistakes or bias that can taint a report, but things like the passage of time, the intent of the original report, and the complexity of the case all play a part as well.