Psychological Evaluations and the Elephant in the Room

You'll have to read all the way through to find out about the elephant....

A psychological evaluation is defined as a broad variety of evaluative procedures that yield information about a person. Multiple assessment procedures (a holistic approach) gives the best snapshot of the individual’s functioning. This is especially important when the decisions based on the data are life-altering.

What do I need to know before I go?

• The psychologist will keep all of the information about you private, but there are a few exceptions:

• If you sign a document (called an authorization to release information) asking the psychologist to send a copy of the results to someone (such as a lawyer or your doctor).

• If you disclose an intent to hurt yourself or someone else.

• If you disclose child/elder abuse.

• You will sign a document (called informed consent) that states that you understand the nature and purpose of all aspects of the process.

• If you have insurance, you will still be responsible for a portion of the cost. That amount is usually collected up front.

Some things to consider:

• Will you see a psychologist or an intern? Most interns are quite well trained, but if seeing the psychologist himself/herself is important, you might want to ask.

• How long is the wait to get in, and how long will I wait for results after I come for my appointment?

• If you do not feel comfortable with the environment or the provider, leave! You are paying for a service, and you should be happy with the experience.

• Am I ready to be completely open and honest? Some of the information in a psychological evaluation is based on what you tell the psychologist about yourself. In other words, what you tell the psychologist about yourself needs to be truthful.

• Each psychological evaluation should be “tailor made” to suit the needs of the individual client. A “one size fits all” approach simply doesn’t work.

What is the process of setting up an evaluation?

1. Referral – a client can be referred by an insurance company, a lawyer, a counselor, a doctor, an agency (such as CPS for a child in foster care), or the client himself.

2. Initial visit – some insurance companies require an initial visit. The purpose of this visit is to gather enough information so that the psychologist can send

3. Subsequent testing – if approved, you will come back to complete the remainder of the evaluation. Depending on the type of testing needed, this can take anywhere from one hour to eight hours. Some testing materials can be completed via a secure email link, but other must be completed on paper in the office. In addition, other testing materials must be completed in a face-to-face setting with the psychologist.

4. Follow up visit to obtain results – this appointment is usually one-hour long, and you will go over the assessment report (see below for more information).

5. Completing the recommendations – a psychological evaluation should always include recommendations (counseling, a medication evaluation with your doctor, and so forth). It is up to you to take the next steps!

What is an assessment report? An assessment report is the result of the assessment process. The purpose is to pull together an assortment of assessment techniques (interview, testing, surveys) so that it allows for a deeper understanding of what is going on.

What is in the assessment report? All of the elements that are completed during the interview and testing are presented. These elements are:

• Mental Status Exam

• Attitude and Cooperation

• Appearance, Presentation, Behavior, Speech and Language (Height, weight, hair and eye color, clarity of speech)

• Thought Process (Do you answer what you are asked? How long does it take for you to answer? Abstract thinking?)

• Thought Content (Suicidal thoughts? Homicidal thoughts? Obsessive thinking?)

• Perceptual Abnormalities (Delusions? Hallucinations?)

• Mood & Affect (What is the current mood? Sleeping difficulties? Appetite difficulties?)

• Sensorium and Cognition (Do you know what time it is? Where you are? Why you are here? Your name? Estimated level of intelligence and ability to answer general information questions)

• Memory

• Concentration and Attention (Estimate based on the ability to complete 14 tasks)

• Judgment and Insight (What should you do if…?)

• Cognitive Functioning (IQ Test)

• School Functioning (grades, relationship to teachers and peers, special education services)

• Sensory Processing (for children)

• Adaptive Living Skills/Developmental History (developmental milestones, ability to care for self)

• Medical History (prenatal history, major medical complaints or hospitalizations, medication, psychiatric hospitalizations)

• Eating and Sleeping Habits

• Discipline in the Home (for children)

• Childhood Experiences/Family History (sexual abuse, physical abuse, neglect, birth order, relationships with parents)

• Validity of Responses to Objective Testing (are responses truthful?)

• Effects of Trauma or Abuse (if applicable)

• Emotional Functioning

• Executive Functioning

• Interpersonal Functioning/Attachment

• Behavioral Functioning

• Substance Abuse

• Summary

• Diagnostic Impressions

• Prognosis

• Recommendations

Why is a diagnosis necessary? A skillful diagnosis is an important aspect of the clinical assessment and appraisal process. Current research suggests that up to 20% of all children and adults struggle with a diagnosable mental disorder, and approximately 50% will experience mental illness in their lifetime.

• Interventions and accommodations for children with emotional, behavioral, and learning disorders is now required by federal and state law (Per IDEA, a diagnosis is generally necessary to identify students)

• It allows for one practitioner to communicate to another exactly what is going on so that a treatment plan can be developed.

• It allows the client to understand their own prognosis and develop reasonable expectations about their treatment.

• Due to laws like the ADA, employers are required to make reasonable accommodations.

• It is necessary for medical insurance to reimburse. Accurate diagnosis is important because certain diagnoses allow for a certain number of treatments.

What about the elephant in the room? Mental health is expensive. Here are some facts…

• The average hourly rate for cook is $14. A mail carrier makes $25/hour. Lawn maintenance workers typically make $20 per hour (assuming a 40-hour work week). An animal scientist makes $35/hour, while your mechanic typically charges $90/hour.

• The time to administer certain elements of a psychological evaluation varies. Not including the initial visit, it takes approximately 1 hour for cognitive assessment, 2 hours for emotional/personality assessment, and 2 hours to complete a clinical interview/mental status and miscellaneous forms. In addition, a trauma evaluation adds another 2 hours, and a learning disability assessment adds another 2 hours.

• The surveys completed in a typical child evaluation generates up to 160 pages of data that must be read and interpreted. Non-technical reading is typically done at 2 minutes per page. In the interest of full disclosure, I do not take 5 hours to read the information (since I know what I am looking for), but I often take 2 hours. Put all of that together, and there is a minimum of 7 hours of work for the psychologist (assuming no trauma or learning disability) just to get to the point where the assessment report can be typed.

• A typical report is between 15 and 20 pages. Assuming the average typing speed of 40 wpm (which is a high estimate as the “average” is for a document that is copied and does not require “thinking”), the report would take a minimum of 2.5 hours to type.

• The cash price for an evaluation (which includes the follow up visit for results) starts at 750 for 10.5 hours of work…slightly less than 75 per hour.

• In other words, I am charging less that your auto mechanic, who typically has a high school education rather than a Ph.D. and extensive training in test administration and interpretation. I would encourage you to ask a couple of questions:

• Would you tell your mechanic that his hourly rate doesn’t “work” for you and you will only bring your car if he offers a discount?

• What is the value of your mental health?