When you start to put together all the elements that people want from a health interaction, it’s not surprising that simply having an assessment can be an incredibly powerful experience. So much so that an assessment can be counted as an intervention in its own right. Does that make you think about the investment you put into the process?
Poston and Hanson in a very recent meta-analytic study of psychological assessment found an effect size of d=0.423 (CI [0.321, 0.525]) in a sample of 1, 496 participants over 17 studies. That’s a whole lot of effect – about 66% of participants who went through a psychological assessment changed significantly compared with the control or comparison group. What that means to me is that what we do during the assessment process is just as important as what we do during treatment.
There are confounds for this effect, so let me quickly review them – people often seek psychological help during periods of high distress, so there is likely to be a ‘regression to the mean’ effect of any pre-treatment elevation of scores. We also know that attention, especially personalised attention, has a positive effect on people – maybe some of the effect was simply because people were having some time with a person who cared. And of course, many outcomes such as mood and distress fluctuate anyway.
Having said this though, a very similar finding has been obtained at the Centre in which I work. The people we see may have been waiting for up to six months, they have usually had their chronic pain for about 3 years or more, and they have about a fortnight to complete their questionnaires. The potential for regression to the mean still exists, but distress should not be a key factor because it is ameliorated by the process of referral and the lag between referral and appointment. They will usually wait for at least a month before starting treatment (when the second set of measures are taken), so any ‘attention’ effect should have faded. And yet we still see quite large reductions in things like distress, fear of movement, and disability – and improvements in things like mood, self efficacy for coping with pain, and sleep. I will add that people may have had new medications prescribed at the time of assessment, but these are not likely to improve self efficacy for pain or fear of movement.
So I think we can conclude that assessment is an ‘active ingredient’ in treatment.
Let’s take a look at the implications of this. One of the findings from Poston and Hanson’s paper is that the process of sharing assessment findings, and particularly where the person seeking treatment generates some of the questions and is given feedback on these specific questions, is a powerful ingredient. It seems to give the person the ability to ‘make sense’ of what is happening to them, and it certainly can enhance the therapeutic relationship and help the person recognise that treatment is a collaborative process.
One problem I can see with uncritical adoption of this sharing is if clinicians choose to start to give feedback during the actual assessment process. By this I mean giving the person new information (eg about a chronic pain model, self management etc) during the data collection phase. This can serve to change the way in which the person responds to assessment, and can alter the case formulation process by not giving accurate information about how the person has got to the point where he or she is seeking treatment. I think it’s a good idea to delay information giving or sharing until after the information collection has been completed. The way this happens in the Centre in which I work is that the team (three people see the person over the course of a morning) meet at the end of the assessment, develop a case formulation, and generate recommendations, then one team member returns to the person to provide feedback. It’s at that point that new information can be given to the person – in part because they are ready to hear it, after having heard the rationale for it on the basis of the assessment findings.
Another problem I can see with giving feedback too soon are all those cognitive biases that I’ve written about before. If, as clinicians, we start to confirm a hunch before we’ve gathered all the relevant information, we can possibly counter this because of our awareness of our biases. But patients often don’t have the awareness that we have these biases, so if we prematurely suggest ‘I know what’s going on here’, we may well have a hard time helping the person to shift off one hypothesis and onto another. And I think we’ve probably all had the situation in which ‘the doctor says this disc bulge will need surgery sometime soon’ has got in the way of the person accepting the place of self management, or even that hurt does not equal harm.
On a more positive note, it seems really clear that if assessment does have a treatment effect, then we’re probably justified in investing sufficient time to do a thorough job. And we can particularly justify it if the person we’re seeing is generating some of those assessment questions and is involved in the process of collecting and making sense of some of the information needed. I see this as probably part of an iterative process of assessment – initially led more by the clinician, as in the model I use where a long biopsychosocial assessment starts the process of hypothesis generation. In later sessions the person will be more involved with the question generation and data collection and feedback. Iin our Centre this will typically occur over the first two or three sessions of an individualised programme, or if the person is part of our group programme, during the screening assessment and first few days of the programme.
Poston and Hanson warn that there is much more study needed into the processes of assessment and how they effect change; the dose needed to effect change; and the need to study individual differences (eg ethnicity, gender and so on). They suggest a mix of research methodologies is also required – qualitative and quantitative – to ‘unpack’ what goes on behind the closed doors of assessment.
They also encourage clinicians to emphasise the place of assessment – but oh how I hope treatment also follows!
Poston, J., & Hanson, W. (2010). Meta-analysis of psychological assessment as a therapeutic intervention. Psychological Assessment, 22 (2), 203-212 DOI: 10.1037/a0018679