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Dr. Sharp: Hello, everyone. Welcome to The Testing Psychologist podcast, the podcast where we talk all about the business and practice of psychological and neuropsychological assessment. I’m your host, Dr. Jeremy Sharp, licensed psychologist, group practice owner, and private practice coach.

Hey everyone. Welcome back. I’ve got another return guest with me today, Dr. Jordan Wright. Jordan is here talking all about context-driven conceptualization in assessment. If you don’t know Jordan, he’s been on the podcast two times before, so go check those episodes out. Jordan was here talking about telehealth assessment and supervision of assessment, both great episodes linked in the show notes.

Today we’re talking about context-driven assessment. This is such an important topic. It really gets at the idea that not every diagnosis or every problem is firmly rooted solely in the individual as a personal fault, if you will, of that individual, but that contextual factors are incredibly important as we consider our conceptualization.

So we talk through the different types of contexts that might influence assessment. We talk about how to get at context a little bit better. We talk about the relationship between conceptualization versus diagnosis and how those play into one another and might be separate. We talk about lots of other things, but those are some of the main topics.

Let me tell you a little bit about Jordan before we get to the conversation. He is on faculty at New York University, where he is a Clinical Associate Professor, Director of Clinical Training for the Counseling Psychology PhD program, and Director of the Center for Counseling and Community Wellbeing.

Jordan is the author of multiple books on assessment, including Conducting Psychological Assessment: A Guide for Practitioners; the Handbook of Psychological Assessment; and Essentials of Psychological Tele-Assessment. He does a lot of research. He’s published in the areas of LGBTQIA+ psychology, social justice in psychology education, and integration of context and culture in psychological assessment.

He’s also a regular presenter speaker and CE workshop provider on a number of topics: data integration, report writing, and infusion of culture and context within assessment. He recently led a team of colleagues in the production of a new paper on the state of evidence-based psychological assessment which has been accepted and will be published in Professional Psychology: Research and Practice.

Jordan has his hands in a lot of things. I’m always so amazed at the quality of work that he’s doing given the number of things that he’s doing. So, we’re lucky to have him again and talking about one of those areas of expertise.

Without further ado, let’s get to my conversation with Dr. Jordan Wright.

Dr. Sharp: Hey Jordan, welcome back.

Dr. Jordan: Thanks for having me again.

Dr. Sharp: Absolutely. I think you’re in the three-timers club at this point, which means your jacket is in the mail. So look for that.

Dr. Jordan: Excellent. I look forward to it.

Dr. Sharp: I’m always glad to have you. It is so interesting to me. We’ve talked about this off-air that you seem to do many things well. We’ve had a different topic every time we have talked and they are very distinct. And today’s going to be distinct. I have a lot of admiration for how you seem to be able to be researching and practicing and all these different ways and doing these things well.

Dr. Jordan: It’s my ADHD. I get tunnel-focused on certain things, I get passionate about them and I go deep, deep, deep diving on them, they [00:04:00] become my focus for a good amount of time, and then I move on.

Dr. Sharp: Okay. Well, it seems to be working well professionally, at least. So I’m glad to be able to take advantage of some of that.

So, you are back today. We’re talking about context-driven assessment. We’re going to dive deep into that: what it is, why it’s important and different aspects of that. But I’m curious, just to lead off, as usual, particularly in the context of our beginning comments, why this? Why now? Why are you spending time on this of all the other things?

Dr. Jordan: I think there are big, good movements in our field more generally to understand people more contextually. Our history as a profession has very much localized psychopathology illness deficit within individuals. We’ve decided that ADHD is your brain working wrong. We have decided, unfortunately, that autism is your brain working wrong. That all of these things, even depression, anxiety are localized entirely within yourself and they are yours to deal with. You go to individual counseling. You deal with it yourself.

And I think that we haven’t given enough attention to all of the contextual factors that play a role in the development of these problems, in the maintenance of these problems, in coping as well. Certainly, contextual factors play a role in keeping us going, but there are so many contextual factors that play a role. Some of these are cultural contextual factors. Some are personal history contextual factors.

All of these things multiply determined when someone doesn’t function optimally. When somebody is in distress, is so multiply determined by an interaction between who they are, how their brains work, how their bodies work, how everything works, and all of the context around them.

And when I started looking at all the measures we use, when I started looking at very traditional psychological assessments, we just don’t give this the respect it deserves. We don’t collect data on context using our traditional methods very well. We get little snippets here and there of contextual issues, but not nearly enough to really understand a person as they interact with the world.

One of the things I’ll say really quickly is, there’s been more discussion recently in the literature. Bob Bernstein has done great work in this area. He just published a comment on this in the journal of personality assessment around how people behave differently in different contexts.

So, it’s not just the context that drives things that are pervasive and things that are problematic in our lives, but also we behave differently in different contexts. I know that seems basic, but when we write up our testing report, they assume that we are monoliths. We behave function exactly the same way throughout our lives, across different contexts across time.

And I think more and more, we need to respect the fact that our context, our culture, our society, our immediate context, our interpersonal relationships, all of these things are playing a role in how we function moment to moment throughout our lives.

Dr. Sharp: There’s a lot to unpack there. I totally agree with you. I think that’s something that I’ve been working on across my career is moving away from that idea that an assessment is the rule and a blanket sort of broad document that is meant to cover someone’s entire life basically. And this is just largely born from getting old enough at this point. I’ve evaluated kids multiple times from when they were like 3 to 10 to 17, and I’m like, these results are very different. What’s going on here? I thought I was right the first time.

Dr. Jordan: Absolutely. I think probably developmentally, we do a little bit better. We say let’s retest in three years. Let’s do a little remediation. Let’s do a little intervention.

I think we’re better at that than we are at adults where we slap on a diagnosis. I know we don’t mean to, but diagnoses carry so much power and so much weight and feel so finite. They feel determinant in some way, like, oh, you have a borderline personality disorder. That is who you are across every context, across time. Good luck with it. Get some treatment and maybe you’ll go into remission a little bit. Maybe you’ll be able to function one day. We don’t maybe mean to propose these things in this way, but I think the way diagnosis works implies that too much no matter how careful we are about it. 

Dr. Sharp: That’s true. I’m curious before we really dive into this, do you have a sense of where this practice came from to pen diagnosis, I don’t know if self-imposed is the right word, but do you get what I’m saying? Located within someone versus within our within context. Where’s that coming from?

Dr. Jordan: Sure. It comes straight from Freud, right? We’re talking interest psychic. Freud was brilliant in a lot of ways, gave us a lot, thought a lot about determinism. There’s a lot to take from that. He was also dead wrong about a bunch of stuff. He talked a lot about how things solidify within us from those early interactions from your parents from your mother, all that kind of stuff. But he located everything within the individual.

And even as we progressed, I think psychology became the study of the individual, not necessarily the study of the individual in context or the study of the individual in interaction with other stuff around them. So even the behaviorists, especially the cognitive psychologists are really locating everything within your brain.

When you look at a lot of social psychology research, it’s really looking at social cognition. It’s really thinking about how people are thinking about the social world around them. I am the protagonist. My world around me is just secondary to the way that my brain functions. So it’s been perpetuated, I think, throughout.

And I think there’s a lot of value to a lot of it. I don’t want to throw out everything we know about how brains work and how the mind works and all of that. But I do think we need to start respecting the interaction between us and our environment a little bit more. 

Dr. Sharp: That’s fair. I do want to ask you some questions around that like how do we have some nuance here and balance neurobiology, for example, and things like that, but I think this is a great place to start.

People may have an idea already, but I’d love to get a good working definition of context-driven assessment. What are we talking about with that phrase? And is there a better phrase? I just picked that. 

Dr. Jordan: Yeah. That’s not an exact phrase that I use when I publish in this. I really think about deliberate context-sensitive conceptualization.

So we’re not necessarily mitigating diagnosis. We’re not necessarily negating individual factors. The way that our brains work. We might be talking about brains that represent natural human diversity, right? Not everybody’s brain works the same.

What we’re talking about is when we think about contextualizing how an individual is functioning in their life, we are taking into account in a very methodical deliberate way, the potential role of contextual factors. We’re not saying that everything is contextually driven. We’re not saying that everything is 100% defined by context or defined by things that are outside of the individual brain or the individual mind, but we are saying, let’s at least consider it. Let’s be deliberate in thinking about what other factors are playing a role if you are not functioning perfectly in life. 

Dr. Sharp: Sure. Do you feel like psychotherapy has done a better job of this than assessment over the years? That’s my inclination, but I don’t know. Your face says maybe that’s not the way you think.

Dr. Jordan: That’s not fair. They can’t see my face. I think probably in general, psychotherapy has done a slightly better job. When we think about family systems therapy, when we think about other systemic therapies, they’ve probably done a better job.

However, we also know that the history of psychotherapy has been an individualized treatment. It has absolutely been, let’s make you fit into your context better. Let’s change you. Let’s not change the world around you. Let’s not adapt to your social environment. Let’s change you to pretend that your brain works the way that everyone else’s brain expects it to.

So, I’m actually not sure we’ve done a better job in psychotherapy on the whole. I think some people do a better job. I think there are people who are advocating for change. When I think of, for example, the subfield of counseling psychology, there’s a lot more advocacy that’s happening to change the world around us as opposed to historically I think clinical psychology, which has located most of the work in for psychically.

Dr. Sharp: That’s reasonable. Do you know much about how this shows up in other countries or other cultures assessment-wise? I think about it very simplistically, just like more collaborative cultures versus the US which is a little more individualistic. Do we know anything about what assessment looks like in 

other places?

Dr. Jordan: I would not dare to say that I know across the world and all that, I do know two other cultures which when it gets to the point of psychological assessment, they are necessarily thinking of it as a disease. They tend to actually be much more medically oriented when it comes to this.

I actually think that other disciplines are probably better at this than we are. I think social work is better at considering all of the factors around people when they are conceptualizing. Of course, they’re not doing comprehensive, formal, psychological assessments in the way that we are, but they’re collecting data about individuals. They are writing up little psycho-social reports that try and understand how people are functioning. I think public health does this better than we do because they are just outwardly focused in a way that we’ve become very inwardly focused.

Dr. Sharp: That makes sense. Even this far into the conversation, which is not very far, it’s just recognizing there is so much that we could look into with this. There’s a lot of work to do.

Dr. Jordan: Yeah. As if psych wasn’t complicated enough and brains weren’t complicated enough, now we’re adding 3 million other interactions that we need to respect and pay attention to. 

Dr. Sharp: Yeah. I asked this question when we were chatting about what we will talk about, but that interplay, and what does this do to the integrity of diagnosis, if that’s even reasonable. It’s sort of like foundation. I have this very concrete black and white, all or nothing brain sometimes, and I’m like, okay, if we’re not thinking diagnostically and we have to take all these contextual factors into account, what are we even assessing? And why is [00:16:00] this important? Do people get assessed every year or every six months? So these are all the questions that come up for me. You can take that wherever.

Dr. Jordan:  You said you have a black and white brain sometimes, you mean every time across every context across all of human history, right? You are black and white in everything.

Dr. Sharp: Yes.

Dr. Jordan: Even that is contextual. This is not meant to undermine diagnosis. Diagnosis is a shorthand that we use to communicate with other professionals. It’s a list of symptoms that are clustered together that most psychiatrists have decided to cluster together phenomenologically, and we use it as shorthand. We use it to research. We use it to talk to other professionals about what we’re treating and how we’re treating it. This is a shorthand, but it’s also meant to be contextual. It’s meant to be decontextualized where we’re writing a little checklist of symptoms that you are exhibiting and that’s diagnosis.

So it’s not meant to necessarily undermine that. It is meant to add nuance to it. So we’re talking about conceptualization not diagnosis, and they are of course, inextricably linked, but they are different things. When we talk about conceptualization, you’re talking about thinking about the person sitting in front of us and tying it to psychological feeling. That’s what we’re talking about when it comes to conceptualization. It’s the why is this happening? Not the, what is happening.

Diagnosis is what’s going on. This is all about why this is happening. What led to it? What caused it? What contributed to it? What is keeping it up? What is strengthening it? When is it better? When is it not? That’s all part of conceptualization and that’s what we’re talking about here. Not necessarily the integrity of diagnosis, which is super debatable and a totally different topic. 

Dr. Sharp: Absolutely. I like that distinction. And again, thinking about it in terms of, at least the reports that we write, there is a section where we’re symptom-driven and it’s like, okay, this is showing up. This is showing up. Here’s the diagnosis. But then there’s a whole other section that’s more or less real-world effects, or like, how does all this matter or something. We’re pulling in all this into like you said, the conceptualization, the why and how this actually shows up, and the nuance, I suppose.

Dr. Jordan: Yeah. Often when I’m doing, for example, ADHD evaluations, which are fairly straightforward and someone comes in and says, I want to know, do I have ADHD or not? I always steer them in a different direction and say that that’s not a great assessment question, because if the answer is, yes, that is helpful. If the answer is no. And I say, you don’t have ADHD, have a nice life, that is not helpful at all.

So the real question is what’s underlying your problems with attention, right? You’re coming in for a reason. You probably have some problems with attention or executive functioning or organization or planning or whatever. What’s underlying that?

And so, yes, diagnosis is going to be part of that, but I also need to tell a story of what’s going on for you. Is something exacerbating this? We can have ADHD and some depression or anxiety that is cyclical, right? We can absolutely worsen our anxiety with ADHD. We can absolutely worsen our attention with anxiety. This is a psychological theory that’s helping us be more comprehensive and narrative about what’s going on for a person sitting in front of us, rather than just giving them a big stamp of ADHD on their forehead. 

Dr. Sharp: Yeah. Right. Well, I know in some of your research, you talk about different examples of context, or things we might want to consider. Could we maybe talk about some of those examples?

Dr. Jordan: Sure, I’m happy to.

Dr. Sharp: Okay. Sweet. I was taking some notes while I was reading some of the research and one thing that came up right off the bat was what you call dominant culture mismatch. Can you speak to that? 

Dr. Jordan: Absolutely. I think that, in general, we tend to evaluate the people that we are testing, the people we’re working with, we tend to evaluate them through a white supremacist lens. We were brought up in that. We just can’t help it. We are biased in certain ways. We know from the research that we tend to over-pathologize communities of color, especially children of color are overrepresented in the discipline.

There’s some great research about the exact same behaviors by Latino girls and white girls are attributed as assertive versus aggressive. Latina girls are labeled as aggressive for the exact same behaviors that white girls are labeled as assertive for. There’s just so much to unpack here.

In my paper, I admit that this is not doing justice to the fact that our culture is racist. Our culture is sexist. Our culture is heteronormative. All sorts of isms. So when I talk about it as a mismatch, this is underplaying the real problems, the underlying problems.

But what I mean by it is, when there is a mismatch between how you, a client, behaves in the real world and what is expected by the dominant culture. Sometimes that is actually just us misinterpreting your cultural values. Sometimes it’s not. Sometimes it is a symptom. Sometimes it is problematic. But sometimes we need to take into account maybe our bias is getting in the way and making us interpret this child’s behavior, this adult’s behavior based on my white supremacist lens.

So this is a mismatch. This is a contextual mismatch, right? The way that you’re behaving, which may be absolutely [00:22:00] culturally sanctioned and culturally aligned with how you are brought up.

We know a lot about code-switching. Kids especially learn really early on to behave differently at home where they are within their own culture. If they then have to go to, for example, a white space, which is their school, or a heteronormative space, which is their school, they have to code-switch. They have to behave in different ways.

Some kids who do not code-switch very well are labeled as problems in the school and sent for evaluations. And it actually just has to do with a mismatch between what is culturally sanctioned, what is okay within their culture in terms of their behavior, and what is expected of them in these white supremacists, largely white, largely straight, largely SIS environments. So that is a mismatch.

Dr. Sharp: Yeah. And for anybody who might be interested in deeper discussion, particularly about [00:23:00] kids with color, the episode from a few months ago Beyond ODD and Conduct Disorder with Dr. Akeem Marsh and Dr. Lara Cox, we talk about that a lot.

Do you have examples of a dominant culture mismatch? Anything that comes to mind right off like behaviors or things that we might misinterpret?

Dr. Jordan: Yeah, absolutely. There’s plenty of research and I think the Latina girls’ research is there. I can give some clinical examples from my own practice. And I think that a lot of it has to do with people of color standing up for themselves. That is where I see it a lot. When adults of color in their workplace stand up for themselves, it is seen as aggressive. We for our white supremacist lens absolutely label people of color as some sort of danger.

For some reason, we have a shorter fuse for allowing them to be assertive. And it turns into, oh, you’re angry. You are being aggressive. In this moment, you need to reign it in. This is your problem. When in fact, actually this is absolutely well sanctioned within their culture, at home, they give back as much as they get.

For clients that I’ve seen, this is a fairly normal way of interacting with their families, with their friends. When they are talking they say, I don’t hear it as aggressive. My friends don’t hear it as aggressive. So we need to think about the fact that that is just a mismatch between what’s expected in that white space versus what is culturally sanctioned when they are in their predominantly a space of color, black space, Latino space, whatever it is.

Dr. Sharp: Right. So you also talk about, I think you call it developmental mismatch as well. What’s that all about?

[00:25:00] Dr. Jordan: Yeah. I write a lot about this in the conducting psychological assessment book and elsewhere. This is when an individual’s level of development is mismatched with what is required of them in their everyday life.

I can give two examples. One is probably the more straightforward example that we’re all used to. An adult who is emotionally dysregulated. An adult who emotionally is acting like an adolescent. I shouldn’t say that, but I have a pre-adolescent girl at home right now, so I know it well. I know that their emotions are all over the place at times. But that’s completely normal and adaptive.

It’s normative for a pre-adolescent adolescent to be overly emotional, maybe a little dysregulated emotionally.

But when we get into adulthood, that emotional dysregulation is no longer sanctioned. It’s no longer adaptive. It’s no longer normative. And it is a mismatch with what is expected of you at work, for example, right?

Our schools, especially middle schools may be more forgiving of this because they expect it. It is developmentally matched. We know, oh, okay. Pre-adolescence, adolescence. We expect it. But when we get into a professional space as an adult, there is now a mismatch between my developmental level of functioning and what is expected of me. Now that is a “psychopathology” example.

Another example is the other direction. When a very normally developing child is expected to function more as an adult is parentified, right? As an example, parents getting divorced and one of the parents needs a lot of emotional support from their child. The child is expected to be another surrogate parent. They’re expected to be the strong one, the rock because the parents are all over the place or really hurt, or emotional or whatever.

There is a developmental mismatch between what that child to completely normally developing child is able to handle emotionally, cognitively, socially in that moment and what is expected of them in their environment. That is a mismatch. These mismatches cause problems.

Dr. Sharp: Right. So in that case, it would be the parent bringing the child in for an eval and saying, I don’t know, my kid isn’t communicating like they should be, or my kid is avoidant or something like that, where they’re reacting to being parentified? 

Dr. Jordan: Or depressed.

Dr. Sharp: Or just depressed. Yeah.

Dr. Jordan: I had a client that this is exactly the dynamic that was going on. They went to school and looked depressed. We’re exhausted. We’re tired. They were kept up late at night caring for their parents and they went to school and they just looked withdrawn. They weren’t interested in school. The kid was depressed.

We could absolutely locate the entirety of the depression within this kid and medicate them, give them cognitive behavioral therapy. That is one way to go. But when you take a step back, there was this huge mismatch. There was a contextual factor that was playing a very driving role in what was going on emotionally for this kid.

Dr. Sharp: Absolutely. Let me ask an adjacent question. How might you handle delivering feedback to that parent, for example, in a case like that where I could see that being hard? I’m curious how you approach something like that.

Dr. Jordan: I usually just tell them they’re bad parents and move on.

Dr. Sharp: Great. Okay. Check.

Dr. Jordan: I shake my finger at them. No, I will tell you, since I’ve been really thinking about this contextual conceptualization model, it becomes so useful in feedback. People are so much more open when instead of saying you’re doing bad parenting stuff, we say, okay, there’s a mismatch between what this kid can handle and what is needed of them right now at home.

You have been through so much recently, and I see it. I see the pain that you’re going through. I see the needs that you have. I hope that you will take my recommendation and go and get some support yourself. I don’t say this, but outside of your child. But there is a mismatch. This child is a 9-year-old and is being asked to behave emotionally, behaviorally, socially, like an adult, and really support you.

And that’s great. I think families are there to support each other, but we also need to respect the fact that this kid needs to be a kid. Your son, your daughter, your child needs to be a child. So, even explaining it as a mismatch between this kid’s level of development and what is expected of them in the world, softens it for families. And they’ve been much more receptive in my experience to this kind of feedback than the alternatives.

Dr. Sharp: Right. Nobody likes to be confronted with perceived or intended shortcomings. I like that language. Mismatch is good. That’s going to stick with me, certainly. You also talk about, what is it, personal contextual mismatch. Am I getting that right?

Dr. Jordan: Yeah.

Dr. Sharp: What’s that?

Dr. Jordan: This is more of a catchall for the rest. And this is with reverence and respect to the neurodiversity movement and the neuro-diverse communities and my neuro-diverse colleagues. I have ADHD, but I don’t fully identify as neuro-diverse. So this is with a lot of respect to those communities. 

Dr. Sharp: Could you just do a little sidebar on the neuro-diversity community? For anybody who may not have a great conceptualization of that, what are you speaking about there?

Dr. Jordan: Sure. And you’re going to have to edit this because I’m going to be clumsy about it. I don’t mean to be clumsy about this.

This is a community of individuals whose brains work differently than what we consider allistic or neuro-typical brains. So autistic individuals, learning differences, ADHD. There is a big movement- the neurodiversity movement is pushing us as a field as I think we should to not necessarily think of these things as psychopathology, as abnormal psychology, as problems or disorders or disease, but actually very real representations of human diversity.

Neuro-diverse communities, especially come with so many strengths for us as a society. When it comes to ADHD, for example, there’s a ton of research about entrepreneurship and creativity in ADHD individuals. And if we stamp that out and medicate it out early on, then it’s bad for everybody, not just them.

There are strengths in autistic individuals. There are strengths in learning differences. There are strengths that we need to start respecting. And this is where the neurodiversity community and movement is starting to push us toward.

The personal contextual mismatch, this third bucket that you’re talking about, frankly, it’s just a mismatch between the way that a client’s brain works and what’s expected of them in their everyday life. I’ll give an example. Probably the most common example we see in clinical practice, well, depending on your practice, is our educational system has arbitrarily decided that the best way to learn is to sit with 30 other kids at a desk, listen to lectures, take notes, learn it, and then take tests to show you know it. We have just decided that that is the best way to learn and show knowledge and all this other stuff.

Now, kids with ADHD do not fare well in this. We, as a society has decided that this is a medical problem. This is a psychopathology that we need to Medicaid so that you can fit in better to these very typical Western classrooms that we’ve decided are the best way. But in actuality, maybe we need to be readjusting how we think about education, right? There is a mismatch between how this kid’s brain works and what is expected of them in terms of learning.

When we think of different learning models, for example, one-on-one education, there’s a growing movement for one-on-one education, not necessarily homeschooling, but even in school where you get a ton of individualized attention and it’s tailored to your strengths. And kids with ADHD fare extremely well. And then even test better. They do better on the SATs, which are problematic. And again, arbitrarily have decided this is a good way to show it.

So this is just a mismatch between the way that an individual’s brain works and what we have a society as a society have arbitrarily decided should be expected of everybody.

Dr. Sharp: Yeah. As someone who sent both of our kids to Montessori school for the first 4 or 5 years, I’m very much in favor of different non-traditional learning environments, at least. I totally get on board with that idea. And I think you probably, I’m just running with this example in particular, but you live in a place where I imagine there are so many choices of where kids can go to school if people have the means and the ability. Is that fair?

Dr. Jordan: That is fair. I live in New York City. I’m going to try not to break down crying because I am working on admissions to middle school for my daughter right now and it is horrible. We’re in the public school system. There are millions of choices. It’s a terrible process, but yes, there are many options if you have the means.

But I will say even there are problems in the public schools in New York City. To their credit, they do also have programs that are absolutely tailored to different types of learners. They at least put in some effort to think about kids with learning differences, different types of brains. There’s the NEST program which is a specific program for autistic kids with extremely high IQ. There’s the Horizon program for autistic kids who don’t have high IQs. They tailor the educational environment to the way that these kids’ brains learn best.

Dr. Sharp: That’s great. My reason for bringing that up, I think is that we live in a much smaller place, but we have an astounding amount of school choice here somehow. So I end up in a lot of conversations with parents around what environment might be best. And that’s a gift. That was my point with all this. It’s a gift to be able to have that conversation with some parents and know that we can do something to ameliorate that mismatch sometimes.

Dr. Jordan: That’s exactly it. We didn’t think of it in this way, but you’re doing exactly that. You’re talking about the contextual mismatch. How can we find a better match for the way that your kid works? That is honoring the context. That is thinking about it from a contextual mismatch model. 

Dr. Sharp: So this is where I ask a clunky question maybe. I’m just curious on your perspective of how to reconcile some of this with again, neuroanatomy or biology or whatever, things we know about autistic brains or ADHD brains being functionally different than other brains. How do these two things go together? That’s where I get hung up on the whole person-environment mismatch, and I’m like, oh, there’s some brain stuff going on here too. How do we deal with that? 

Dr. Jordan: I think the key is in the question. If brains are functionally different, that doesn’t mean one is better than the other.

Dr. Sharp: Yeah, that’s so true.

Dr. Jordan: We have placed value on neuro-typical brains. We as a society have placed a value on those who learn well in a general education environment. We’ve placed value on those kids who sit quietly. We know for example that a lot fewer kids are identified by teachers as potentially having ADHD if they are purely inattentive than if they are hyperactive, right? So if they’re hyperactive and out of their seat and disruptive, then absolutely they’re identified by teachers and sent to usually a pediatrician for medication.

Those kids who are anxious, those kids who are inattentive, those kids who are flying under the radar, we value that. And then the ones who are thriving, we value even more. So I don’t think these things are in competition. I think understanding that brains work differently is not saying that one brain is bad and one brain is good. It is saying just that, they work differently. One brain may be better suited to the environment of a traditional school and one brain may not be.

Dr. Sharp: Well said. Not bad, just different. I’ve used that many times. So let’s see. I had another question. Oh, I did want to ask you, you specifically mentioned this example of situating PTSD as a personal diagnosis versus more of a contextual diagnosis. Out of everything, that was pretty compelling to me. Could you talk about that for a little bit? 

Dr. Jordan: Yeah. And I think we as a field again, have underplayed the importance of trauma in a lot of problems. I’m not talking just about PTSD. PTSD is a cluster of very specific symptoms. And it is one small way that a very small proportion of people respond to trauma.

So, the idea and what I write about and what I think about when it comes to trauma is we, again, treat it as pathology and we think about individual treatment of PTSD symptoms and sending to EMDR or exposure or something like that, and how is it within the individual.

We’re a little bit better when it comes to PTSD at least honoring the fact that you’ve been through something terrible. You have had a trauma. You’ve had a capital T DSM-defined trauma. So we at least acknowledge that.

What I think we don’t acknowledge well enough is that trauma responses, how individuals respond to trauma, whether it’s PTSD or the development of what may later be labeled as personality pathology, or a personality disorder or something like that may be the way they survived, right? It may be the only way that they survived that trauma. And it may be a very natural and positive response to that trauma.

When we look at avoidance as a symptom, maybe avoidance is a good thing. Based on whatever that trauma was, maybe avoidance was the only thing that allowed this person to continue functioning in their life, in the years that followed this trauma. Maybe we don’t pathologize avoidance. Maybe we honor it and champion the fact that you survived this. You, your brain, your body has found a way to warn you.

We might think of it as an over-reactive startle reflex. When we hear a car backfire, someone with PTSD may completely freak out and that may actually be a fantastic adaptation. That may be a really good thing for thinking about how your body is warning you of danger because it knows the danger.

This is not to say we then don’t treat it or we don’t try and alleviate some symptoms that are uncomfortable. The idea is that we honor this a little bit more. When we’re conceptualizing, we really deliberately think about, okay, could this be the best way that their brain, their mind, their body could have adapted to this heinous horrible thing that happened to them, this horrible trauma that they went through, maybe this helped them survive even though it’s maybe not comfortable now and maybe not working so well right now.

Dr. Sharp: Sure. That makes sense. I think we’ve talked about a lot of examples, which is great. I also, of course, love to apply some of this. And so, I’m curious where we take this. How do we actually bring context into our assessment? I could go on. I’m going to stop there though. How do we bring context into our assessment process?

Dr. Jordan: One of the things I did was look at most of the major tools that we use: the PAI is the MMPI, the BASC, these sorts of things. I looked specifically for where context shows up on them. And it does show up here and there.

There are traumatic stress scales. There’s a stress scale. There are some family problems subscales here and there. There are interpersonal problems. There are school issues. There are little things here and there, but typically, we’re not very good at systematically collecting data around culture, around context, around adverse childhood experiences, around any of these things that play a role or potentially play a role in problems.

So I worked with a colleague to develop a measure, the WCSCI, and this is a shameless plug. But as I told you before, I’m okay, shamelessly plugging this because we developed it and it is completely free. If you Google WCSCI, it’s going to come up. I encourage people to look at it, use it, adapt it. We’ve started doing research on it and found some very positive benefits to using it in our evaluations.

What it is it’s, it’s the Wright-Constantine Structured Cultural Interview. So it is a structured interview organized around Pamela Hays’ ADDRESSING framework. If you’re familiar with it, great. If you’re not, I highly recommend you look it up, but it is specifically around culture and understanding culture.

Dr. Sharp: Sorry, can I jump in real quick? For anyone who might not be familiar, can you give a brief overview of the ADDRESSING framework?

Dr. Jordan: Sure. The ADDRESSING framework is an acronym. A-D-D-R-E-S-S-I-N-G. Each one of those is a cultural influence on an individual’s functioning. A is age and generational dynamics. D is experienced with disability either developmental or acquired. It goes through. There’s ethnicity. There’s a sexual orientation, gender identity, these other sorts of things. It’s an acronym that helps us understand cultural influences on an individual’s life and functioning.

What we did with the WCSCI was break it down into this, and there are some shortcomings, there are interactions between these when we think about intersectionality is not as prevalent, though it does come out. But we developed a structured interview that typically takes between 30 minutes and an hour depending on how many minoritized identities somebody has, traditionally marginalized minoritized identities, and asks very specific questions about not just how they identify, but what that means for them in their lived experience both historically, currently.

And we’ve built in quite a few of what we consider these contextual potential mismatches, not just pure culture, but also some of these other things. So, it’s just a systematic way of collecting data that can inform the potential contextual mismatches. And again, we’re just not good at this. We’re not good at collecting contextual data. Some people do it informally in their clinical interview, but typically not in a systematic way. 

Dr. Sharp: I love this. Can you give any kind of example of a, I’m not even sure, is it a question on this measure or however you gather this information?

Dr. Jordan: Yeah, absolutely. It’s a little bit of choosing your own adventure type of measure. You do you. There are questions for each of the addressing variables, each of those. The first question is always how you identify. So, you might start with how do you identify in terms of your sexual orientation? I’ll give that as an example. Then depending on the answer, there are different questions to ask for those who identify as heterosexual, those who identify as sexually minoritized individuals, and whatever words or terms they use queer or gay or whatever they term it in their own words.

We follow up with questions and the questions tend to focus on what has it meant being a, let’s say, a queer individual in your life? How has it affected you? How has it affected the way others interact with you? And it goes down. There are some, I’m going to put air quotes, “required questions”. Obviously, nothing’s required. But there are some strongly suggested questions. And then there are a bunch of follow-up questions that you can add to, or not ask depending on how vague it is or if it seems that to be a meatier topic.

We might think about, for example, sexual orientation needing to dig more deeply into the experience of being a queer individual within their family growing up. So there are questions about their identity within their family growing up only because that tends to be a very salient influence on the development of queer individuals. It goes further and further down each rabbit hole one by one some of which you don’t need to ask. Some of which, if it’s not salient, if it’s not important in the lived experience.

Obviously, we’re limited by insight. As any self-report measure is, any clinical interview is or structured interview, we are limited by who is reporting, but the idea is we are trying to honor their lived experience. We’re trying to get their context and their interaction with the world around them, in their own words, in their own experience. And this is how we collect the data that we can then think of when conceptualizing.

I often say this metaphor. I think of this as the pillow on which we lay the clinical presentation. So that whole context of the whole culture, the cultural context of the individual historical context is an understanding of an individual. And then we lay symptoms on top of it. How they’re functioning right now is understood with this foundation, this pillow of their lived experience within their context, within their culture.

Dr. Sharp: Yes. As you’re describing that, it just occurs to me that a huge variable in this process is the lens that we interpret the information through as clinicians. And that’s what power.

Dr. Jordan: Absolutely. I have a mentor who’s one of the smartest people I’ve ever met. And he, when training me and my colleagues, very often said, I have a blind spot for certain things. I have a blind spot for substance use. I just never really asked about it. Or I’d write it off. And he has a blind spot for money.

He had realized what his biases are, what his blind spots are. Most of us don’t right. Most of us know some of our blind spots, know some of our biases, but we don’t know what we don’t know necessarily. So going through systematically, which is the goal of the WCSCI, going through systematically one by one through the addressing variables to ask deliberately and pull these data at least covers some of those blind spots. At least it gives us a little safety net. 

Dr. Sharp: Yeah. That’s what I like about this is you’ve operationalized something that a lot of us maybe aspire to, or do somewhat haphazardly depending on the client. And now, it’s a little more structured approach, which is valuable. It’s very valuable.

Dr. Jordan: And my brain needs it in a linear fashion.

Dr. Sharp: Yes. I can get on board with that. Definitely. You mentioned other things. Are you, are you a fan of using something like the ACES in our assessment or any other measures that are floating around out there? Is there anything helpful?

Dr. Jordan: Yeah, honestly, I’m a big believer in more data, not necessarily let’s just collect every piece of data and make every type1 error we can. Well, when it comes to understanding lived experience, I’m a fan.

So things like the ACES, it’s a fine measure. It’s a research measure. It’s not really a clinical measure. And so it has limited utility yet until they research it more clinically, whoever is doing that, I don’t know if anyone’s researching it clinically. There are benefits to it. There are drawbacks to it. It is reductive.

But if we, for example, did a WCSCI and some really adverse childhood experiences came out, I might throw something in there to better understand it or to give me a more quantitative view to balance my purely qualitative idiographic view that an interview falls prey to.

Dr. Sharp: How does this translate to report writing?

Dr. Jordan: I tend to be conceptualization heavy in my reports. So when I look at the psychological functioning, when I look at the emotional and behavioral functioning, if it’s a kid or personality and emotional functioning, if it’s an adult or something like that, I tend to really care about psychological theory. I tend to really care about not just a list of symptoms or a list of findings and certainly not testify tests. I am a big believer in multi-method assessment and thinking through the WHY.

So when I go to conceptualize a case, when I write up a report, I’m going to have a paragraph that is more of a narrative paragraph that ties together all of the themes that emerged in an assessment. And one of those themes may be something like…

I had an assessment very recently where it just emerged how many invalidations this young adult, it was a young adult male, had had throughout his life. It was a pattern throughout his development of being invalidated. His parents invalidated him in his sexuality. He had had a sexual assault and a rape at one point and was told that his feelings were inaccurate about those. He had been so invalidated in his history that of course, he developed some symptoms of borderline personality disorder.

When you’re told your emotions are wrong, you learn not to trust your emotions and they get wild and erratic. When you’re told your identity is wrong, you start questioning your identity. When you’re told that your way of interacting with people is wrong, or when the people you love are treating you horribly, of course, you don’t trust them and interact with people all that well.

So the idea is when I conceptualize this within a broader contextual framework of here’s why, here’s here is a theoretical, and psychology is all about theory. We’re different than other disciplines because we work in theory. And so, we take this theory of a history of invalidation and its role in the development of symptoms of borderline personality disorder. And we take that seriously.

And when we write it up, when we present that in feedback, again, if I couch it in this history of invalidation, it is so much easier for this guy to hear than if I just listed, oh, you have problems with your identity. Oh, your emotions are erratic. Oh, your interpersonal relationships are problematic. I could just list these symptoms that emerged.

What happened, in this case, is when I gave feedback, starting with the profound history of invalidation, he started tearing up. He said for the first time he felt seen and heard and understood, and that opened him up to all the other findings. And he was like, yeah, my emotions are a mess. I know my interpersonal relationships are a mess and I just can’t help it. But framing it within this contextual framework and taking the blame, some of the blame, at least off of him as an individual, that’s where this lives in reports and in feedback.

Thinking about this just like that parent and explaining it as a contextual mismatch or a developmental mismatch where we’re not placing the blame entirely within an individual for the symptoms they have. We are tying it to a mismatch with what’s going on. We’re tying it to some contextual factors that absolutely explain why you’ve developed the way you’ve developed.

Dr. Sharp: Yes. Well, to circle back to something we chatted about in the beginning, I’m guessing, tell me if I’m wrong, that you didn’t diagnose borderline personality disorder, but it was the explanation that came along with it that just made us so much richer and more nuanced. 

Dr. Jordan: Absolutely. He met the criteria. That’s not going to change. Whether I write about or know about his history of invalidation, he still has emotional dysregulation and problems with interpersonal relationships, the problem problems with identity, with association, he still had them. He met the criteria for BPD. I gave him the diagnosis of BPD. This is just a way for him to create a narrative that doesn’t blame himself entirely.

Dr. Sharp: It makes a lot of sense. And the way you describe it is very powerful. I felt like I was in the room there with him feeling differently for the first time.

This has been a fantastic conversation as always. I love the mix of theory and practice and making it real as much as we can. Gosh, what else are you up to? You seem to always be doing something interesting. Do you have anything interesting coming up here in the future?

Dr. Jordan: Yeah, I’m doing a few CE workshops at the society for personality assessment and through the APA and maybe convention and stuff like that. There are certainly workshops with some of this now intertwined within it. A lot of culture workshops in assessment and social justice workshops to think about anti-oppressive practices in psychological assessment which historically is built around a white supremacist model of pathology, and problems with tests and all that sort of stuff. I’ve got that.

I’m actively working on the next edition of the handbook of psychological assessment. So look for that in, I don’t know, 15 or 20 years or whatever. It may take me a little while. We’re working on that. And just again, I tend to get on my soapbox and I try not to preach too much, but this paper, the deliberate context conceptualization paper is really a call to action.

The take-home message is, it’s really a plea to us as psychologists, those of us who do psychological assessments, to be deliberate in at least entertaining the possibility of context driving some problems, maintaining some problems. It’s just a call for us to respect and honor context a little bit as we’re doing our work to really try and think about taking some of that onus off of the single person sitting in front of you.

Dr. Sharp: I think that is a fantastic note to end on. A good call to action. I love a good call to action. So let’s stick with that. Well, as always, thanks for the time. This was fabulous. I look forward to the next time that we get to chat.

Dr. Jordan: Thanks for having me.

Dr. Sharp: Okay, y’all, thank you so much for tuning into this episode. I hope that you learned a lot. Got some things to think about. And as always, the resources are in the show notes, lots are listed in the show notes today to check out.

Let’s see. I think all of my mastermind groups are full at this point. We just launched new cohorts on a number of levels, the beginner, the intermediate, and the advanced. So starting back over with rolling admission to each of those levels. So if you are looking for group coaching and accountability as you build your testing practice or build a group practice with testing as a component, I would love to help you out. You can get more information that thetestingpsychologist.com/consulting, schedule a pre-group call, and see if it’s a good fit.

All right. That’s all for next time. I will be back with you soon.

The information contained in this podcast and on The Testing Psychologist website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, or medical advice, diagnosis, or treatment.

Please note that no doctor-patient relationship is formed here. And similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.

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