Today is part 1 of a two-part series on Therapeutic Assessment. We talked about Therapeutic Assessment back in episode 10 with Dr. Megan Warner and this two-part series is going to take that information and just go more in-depth into the theory and practice of Therapeutic Assessment. Part 1 will focus primarily on the research and theory, measures involved, how the sessions are laid out, what the process looks like, and how to bill for Therapeutic Assessment. Part 2 will be a case study where we apply all of the information from Part 1 to a case from actual practice.
My guest for this two-part series is Dr. Raja David. Dr. David is a licensed psychologist in [00:01:00] Minnesota. He got his Doctorate in Psychology(PsyD) from the Minnesota School of Professional Psychology and he went on to serve as a faculty member there at Minnesota School of Professional Psychology until it closed recently.
He’s participated in a pretty intense amount of training around Therapeutic Assessment, and he’s worked very directly with Dr. Stephen Finn, who is the creator of Therapeutic Assessment. Dr. David is highly steeped in this model. In fact, he taught several graduate-level courses on this model so he really knows this stuff. In addition to the training and Therapeutic Assessment, he is a child and adolescent specialist and is board certified in Child and Adolescent Clinical Psychology. I’m excited to have him on the podcast today and you’ll be hearing from him for the next two [00:02:00] episodes like I said.
Before I get to the conversation, for those of you who might be looking for CE credit, check out athealth.com. I have partnered with them to offer current and past episodes, I’m sure this will be one of them eventually for CE credit. So you can go to athealth.com. If you use the code “TTP10” you will get a discount off your entire purchase and you can get some CE credits for a podcast that you are already listening to.
All right, without further ado, here is my conversation with Dr. Raja David.
Hey, y’all. Welcome back to another episode of The Testing Psychologist podcast. I’m Dr. Jeremy Sharp. Today I am fortunate to be speaking with Dr. Raja David. [00:03:00] We had an interesting story. Raja reached out to me from the email list, I think it was, is that right, after getting the introduction email?
Dr. Raja: Exactly.
Dr. Sharp: And just reached out and asked if we wanted to maybe do a podcast on Therapeutic Assessment. I, of course, was very open to that. So I appreciate you reaching out and am glad to have you here on the podcast. So welcome.
Dr. Raja: Thank you. Glad to be here, Jeremy.
Dr. Sharp: I think about how I book guests and how sometimes it can be quite a bit of work to track people down and schedule back and forth and just get consent and that sort of thing. So when it happens this way, I love it. When people actually reach out to me and want to do this, it’s incredible.
Dr. Raja: We’re all about collaborating in the Therapeutic Assessment world, Jeremy.
Dr. Sharp: Nice. Well, I have a feeling we’re going to talk a lot about that.
[00:04:00] Dr. Raja: Indeed.Dr. Sharp: I was really excited. I think many of our listeners probably know that we’ve talked about Therapeutic Assessment a little bit in a past episode. I think it was episode 10 with Megan Warner. This time, we’re going to do a real deep dive into Therapeutic Assessment. The intent at least so far is to maybe have a two-part series here with one focusing on the research and theory and putting it into practice, and then the next being an actual case study with Therapeutic Assessment, so folks can really get a sense of what this looks like. So I’m grateful for your time and I’m excited to dig in.
Dr. Raja: Sounds good.
Dr. Sharp: Yeah. Well, let’s just start. I’d like to hear a little bit more about you, how you got where you are today, and what today actually looks like; day to day in your practice.
Dr. Raja: Sure. [00:05:00] I did my undergraduate in psychology and I got certified to teach at the same time. I was originally on a path to becoming a school guidance counselor but there was always some part of me that was really interested in becoming a clinical psychologist. I wound up teaching for some period of time. I was living in Western New York at that point and really enjoying teaching social studies, enjoying really being with adolescents and oddly the best part of my day was lunch duty which most people don’t like. I really liked just bouncing from table to table and talking to kids and getting to know them.
And so over time, I recognized that that kind of role and maybe being a psychologist of some type or therapist of some type was probably more of my calling.
I made a slight detour from Western New York to Quito, Ecuador to do a year of volunteer work. While there, I met a woman who was now my wife and she happened to attend a college [00:06:00] here in St. Paul, Minnesota where I now live. So I wound up coming back here and did another year of teaching then happened to actually stumble in some ways upon the Minnesota School of Professional Psychology, which had a Doctorate in Psychology program. And so, I wound up applying and getting in and was really excited about that.
Quite frankly, as a graduate student, certainly an entering graduate student, I was really more focused on therapy as a potential path for myself and did not know a lot about psychological testing but after my first Rorschach class in particular, I was just fascinated with testing. In my graduate program, we did two practicums that were required. Many did more than that but the first one had to be an assessment. So I was fortunate to do an assessment practicum at a local county community mental health site with a great supervisor and got a chance to do all sorts of testing and really started to, I think, [00:07:00] develop a passion for testing at that point.
I wound up doing my internship out in Portland, Oregon; and had another great assessment supervisor out there. That really got me on a path towards not only doing a lot of testing but doing a lot of forensic evaluations, particularly with the juvenile population. A big part of my practice actually has been that, and I continue to do forensic evaluations on juveniles.
As my skillset grew, I realized, when you’re doing this testing, there’s really more that’s happening than just figuring something out and handing something back to people. As we’re doing testing with people, things are happening in the room and I’m realizing things about them outside of the numbers and they’re realizing things about themselves, I think at the same time. But coming from a traditional information-gathering model, we don’t always pay attention to those factors or stop and do anything with them.
Dr. Sharp: Good point.
Dr. Raja: So I eventually went to Minnesota and was working at a community mental health site here and was leading a child outpatient team. We had a [00:08:00] pre-doctoral internship here, APA-accredited, and was a supervisor and still continued to do a lot of forensic evaluations on juveniles and do a lot of testing. So I became just quite skilled at knowing my test, which is an important part of being a good therapeutic assessor.
In 2010, I wound up, well, I had always did adjunct teaching after graduate school for Argosy University, which at that point had bought the Minnesota School of Professional Psychology and in some of their programs and eventually in my alma mater. And then in 2010, I was recruited by the two people that were the co-chairs of the program at the time to come on as a core faculty.
So from roughly 2010 to 2016 or so, I was a core faculty member and teaching programs teaching courses in the Doctorate in Psychology program largely related to providing psychological services to kids and [00:09:00] families. I’m board-certified in Child and Adolescent Clinical Psychology. Working with teens and now young adults is really in my passion.
I eventually became the Director of Training at the school and then for the last two and a half years, I was the Program Dean until, as I think probably many of our listeners know, Argosy University closed here on March 8th.
Dr. Sharp: Yes.
Dr. Raja: In the same time period, a few things happened relative to what we’re talking about too, Jeremy. I opened up my own private practice in 2008 and I had consistently been doing that, providing therapy and psychological evaluations in a limited scope. That was a common feature for our Doctorate in Psychology program, that all of us were doing something in the field to bring back into the classroom.
In 2011, I had heard about Steve Finn’s Therapeutic Assessment, and this was the real first time I was exposed to the model. [00:10:00] This is roughly my second year of teaching and I decided to go down to Austin, Texas where the Center for Therapeutic Assessment is and where Steve Finn lives and most of the members of the Therapeutic Assessment Institute live. There are some international and other folks outside of Texas who are part of that group but a number of them are there. I did their week-long immersion training program on Therapeutic Assessment. And that was when I really got first immersed in the model.
I’ll just share this story that I’ve shared with others. There are probably like 90 psychologists from really across the world at this training. Steve is there and he’s a very warm and kind man. I’m there a little early and he’s coming around, he’s introducing himself to me and to others. We’re chatting briefly and the day proceeds.
I’m sitting there through the first half day of this week-long training and I’m thinking, this is amazing. This [00:11:00] is great stuff. I’m getting like super excited about what they’re talking about and then somewhere, somehow and I’m not sure quite when the timing was, Monday afternoon of this training, this anxiety started arising in me and I started to realize this is just never going to work. What are these people doing? Literally to the point where I went back to my hotel room that night and I had a brief thought, like, I wonder if I could get my money back, I left and go home.
I share that story in part because as someone of my age, I’m now 50 and had been trained in the traditional information-gathering model and had been working in community mental health where you don’t have a lot of control over scheduling. You’re always fighting for awes and testing. Dollars were tight. I think I was running into this paradigm shift that created anxiety in me about how is this going to work in the real world of mental health.
Dr. Sharp: That’s fair.
Dr. Raja: [00:12:00] Fortunately, I pushed past that obviously and I stayed. I had an amazing experience. I wound up returning in the fall to do what’s called the Advanced Therapeutic Assessment Training. This was essentially Steve and three members of the Therapeutic Assessment Center who led myself and 8 other psychologists doing TAs in just a condensed week with actual clients.
Dr. Sharp: Wow.
Dr. Raja: So you get a chance to meet with these clients and then go back as a group of psychologists and get consultation from these experts on how to apply the model with actual people. All of that gave me a lot of passion for it. I started implementing the model in my private practice. And then I started teaching an elective course at the Minnesota School of Professional Psychology on Therapeutic Assessment. Roughly between 2012 and actually, even till this semester, I’ve taught this course on how to do Therapeutic Assessment.[00:13:00] That’s also been something I’ve really been passionate about.
Because my private practice was really small while I was in that academic role, I didn’t really need a lot of clients and so I was doing probably just two of these a month or so. I had always had thought about growing my practice and that had been in fruition really this last year, even before the university closed. I wound up naming it the Minnesota Center for Collaborative Therapeutic Assessment and creating a website. Now that I am no longer in academics, I’m really trying to grow that and introduce the model to clinicians and to clients because I think it’s so beneficial.
Dr. Sharp: Yeah. Well, it really sticks out that you’re getting it from both sides. That privilege, I suppose, of being able to practice but also teach it is so valuable I would [00:14:00] imagine.
Dr. Raja: Yeah. Wait, well, you going to learn something, go teach it, right?
Dr. Sharp: Exactly. Yeah. That’s fantastic. I’m curious, what compelled you to go that direction in the first place? Why Therapeutic Assessment? Why not deep dive in the Rorschach or projectives in general? What was it about that caught your attention but also held your attention all these years?
Dr. Raja: I think what continues to hold my attention and the part that what I try to, I’ve seen it as a bit of my mission to spread the word on the model and get clinicians even involved with it. As you’ll hear as we go through this, it’s a little bit difficult to have just a quick elevator speech that captures it well. But from a professional standpoint, I don’t know of any other task I’ve done that taps so much into critical thinking, judgment, and reason, [00:15:00] creativity and relationship skills, and managing my own emotions relative to what’s really deep work.
When TAs go really well, the impact on clients can be so tremendous. It’s really quite an honor to be a witness to some of that. I think having seen that and what I was being exposed to at the Therapeutic Assessment Institute and their training, and then starting to see that with my own clients and with other people’s clients, I think that’s a big part of the satisfaction of the model.
If you like the Rorschach, then you like, and I know this might sound weird to some people, but I like scoring Rorschach. I think it’s fun to try to figure this stuff out and put these pieces together and to try to understand people, right? A lot of us go into the field for that reason. So I’ve got that curiosity in me also but then to be able to help people grow that insight about themselves in a way that’s more meaningful than what we [00:16:00] sometimes do in the traditional information-gathering model, I think is really appealing.
Dr. Sharp: Yeah. I hear that. That makes sense. I think that there are a number of us who maybe operate more in this information-gathering model, but know or sense that there’s more to it. It seems like there’s often more to it than wish could integrate more of that outside the numbers approach, like you said earlier.
Dr. Raja: I’m glad you said that, Jeremy because I think as we go through this, I’ll explain the model in the full depth as much as we have time for but there are definitely aspects of the model that anybody in any system working with any population could take and adapt relatively easily and have a greater impact on their clients.
Dr. Sharp: Got you.
Dr. Raja: So I would really hope people listen for some of those ideas, also to try out. You’ll also definitely hear something, for people who’ve been practicing along time, they’re going to hear aspects and say, oh, well I do that. [00:17:00] That’s not new to me, Raja. I would say, yes, that is true, right? We didn’t start from scratch when this model got built. We were building on some of the things that many people did, but the importance of the model is that it gives us steps, it gives us concepts, it gives us language that’s helpful when we’re trying to teach people about how to approach this and when we’re trying to study it as well.
Dr. Sharp: Sure. That framework’s important.
Dr. Raja: Yeah, exactly.
Dr. Sharp: Sure. Well, without further ado, maybe we jump into it and start to really understand this a little bit more. So you’ve done this, right? You’ve talked and taught and you know this stuff inside and out. Where’s a good place to start?
Dr. Raja: Well, probably the best place to start here, Jeremy, would be maybe just with some language and some clarification about what we’re actually talking about.
Dr. Sharp: Great.
[00:18:00] Dr. Raja: I’ll share with you a little bit here because, and much of what I’m talking about, if people are looking to do some readings on this, the best source we have is Steve Finn’s book In Our Clients’ Shoes which came out in 2007 and many people are familiar with that. I know Finn and others are working on a follow-up to that because the one thing we are missing is we don’t have a formal textbook, if you will, for Therapeutic Assessment at this point and so we’re hopeful that’s coming. There is also a case book that Finn, Fischer, and Handler edited that’s really excellent for understanding the model. So I want to put out those resources and what I’m going to talk about comes out of some of that book, Finn’s book, and some of his articles as well.We’re talking about Therapeutic Assessment, and I’m going to be talking about Finn’s model, [00:19:00] that model, and those two words, Therapeutic Assessment. We use TA to describe Finn’s model.
Historically, we’ve seen other people use ta in doing this kind of Therapeutic Assessment and you’ll see that sometimes the literature and sometimes from older articles. Currently, we’re seeing a bit of people writing Collaborative/ Therapeutic Assessment which seems to be a bit of a hybrid. When people are doing the full TA model, there’s certain steps that people follow and at times, either it doesn’t make sense to follow those or people don’t follow them for other reasons depending on clients or time or other factors. I think when people have stepped out of the full model, then they’ve gone to that Collaborative/Therapeutic Assessment language, C/TA versus the full TA.
Dr. Sharp: Okay, so that’s important. I just want to maybe highlight that [00:20:00] it is a fairly well-defined approach to assessment with, I don’t know if you’d use the word rubric necessarily, but a plan. There are steps.
Dr. Raja: Yes. Well, yes, and of course right, Jeremy. I think what Finn would say is that ultimately you’re practicing Therapeutic Assessment if you’re holding the values inherent in this approach. These are defined in the Therapeutic Assessment website, but just to go through them, it’s collaboration, respect, humility, compassion, openness, and curiosity. So when we’re doing this approach, whether we’re saying, I got TA or ta or C/TA with inherent, much of this is that you’re adopting these values related to how you’re approaching this client, this test data and helping the client understand this test data.
And if [00:21:00] you’re following those values, you’re in this ballpark fairly firmly but what Finn has done is laid out some steps to follow which are really helpful when you’re learning the model. I think he would also say, once you learn the steps, like a great jazz artist, you throw them out also, and you do what makes sense for the person in front of you.
Dr. Sharp: Sure. That’s good. So the language is important.
Dr. Raja: Yes. To that end, let me just read you here a definition of the TA model. So Therapeutic Assessment is a semi-structured form of collaborative psychological assessment designed to help clients gain new insights and make changes in their lives. I really want to highlight those last parts. I think from a value standpoint and from a goal standpoint, this is really a different part than what we think about from the traditional information-gathering model [00:22:00] particularly if we’re following a medical model related to that approach, right?
But if I’m doing a TA and it’s successful, at the end people are going to say to me, Raja, things are different for me. I understand myself better, maybe I even feel better. I have more hope. Maybe I’m working with my therapist better than I had been in the past, or I have a better path with my therapist. That to me is like we hit the nail on the head with regard to this TA.
In the information-gathering model, success is often defined by, we got the right diagnosis and we told what is the next treatment plan here or treatment path for people. So we’re a little less concerned about change.
When I’m trying to explain this to people interested in the model clients, the analogy I’ll often use is, if you go to a doctor because you think you have a broken bone and the doctor says, well go get this X-ray and let’s see what it says, we don’t expect the x-ray to heal the bone. It’s going to tell us it’s broken or not, and then that’s going to guide the doctor’s treatment [00:23:00] path. But when we take our psychological tests and we use them in a highly individualized, collaborative way with clients, as you’ll see the case study, you have this chance for people to grow and gain insights about themselves.
Dr. Sharp: Yes. I like that twist and I like that highlight. I think you nailed it. Yeah, we don’t necessarily focus on change in our process somewhat in like neuropsychogical testing.
Dr. Raja: Right. As a result of that, if I’m going to have someone really do hard things and gain insights about themselves, it looks very different that too, Jeremy. Maybe I’ll just take a quick second to explain that a little bit because it might help people see how the structure of it’s different. More often than not, I’m meeting with people for probably 4 to 7 sessions over the course of maybe 6 to 9 weeks, depending on schedules. [00:24:00] Those sessions at the shortest is probably an hour and some of them are two hours. And part of that is the fact that if we’re going to have people examine themselves, look at themselves, and really get to the harder parts of self to look at, then they’re going to need a safe holding environment to do that. So part of what’s happening is, I’m building just trust with them through this process.
Dr. Sharp: And are you enrolling them in that process from the beginning? I’m just curious about the logistics. Do they know they’re about to participate in a Therapeutic Assessment and that involves five to seven sessions over six to nine weeks. How clearly does that get spelled out?
Dr. Raja: So I’ll add this other logistical part. The vast majority of the people that are being referred to me are clients from Masters Level Clinicians that Minnesota largely don’t do any [00:25:00] testing. These clinicians feel like they’re stuck in some way. They’re not sure how to help a client get past something or there’s some plateau that’s occurred or sometimes the clinician’s just really confused about, I’m not really quite sure what’s happening for this person be it diagnostic or maybe even characterological, actually more often the case. And so many of the people that refer to me, I’ve worked with a number of times already so they know how to explain to people what this is going to look like. So clients are hearing it usually before they even talk to me.
Because the model’s different and in Minnesota it’s not widespread, there’s some parts of the country where it’s happening much more frequently, the language isn’t out there with regards to clients or clinicians. And so what clinicians actually tell me is it usually takes two or three conversations before they say, okay, yeah, I’ll talk to Raja.
Once they agree to that, then I usually send them my website and they can get some information there. Then I have a phone call with them [00:26:00] because I want to establish the collaborative relationship from the very first contact with these people. I want to know, well, what are you looking for? What are you hoping to get out of this? I want to make sure they understand this is not going to be just Raja handing them back something, that we’re going to figure this out together.
I also want to make sure in that phone call, quite frankly, it’s a good match with regards to timing in their lives. It’s a good match with regards to insurance and finances and that it’s clear to them what this process is going to look like. So coming back to your question, then I am explaining to them, well, typically these go five, six sessions and this is how it looks.
If someone says, Raja, I got to get this thing done in two weeks, what can we do? I’ll work with on that. There’s ways to make it shorter and still be beneficial to people but part of that, Jeremy, just so you can get the thinking behind it is, as people are learning about [00:27:00] themselves, I want them to have time to really internalize that and take that thinking out into the world. Maybe take what they’ve learned with time with me from a test and take it into their therapist conversation so that we can keep building on that insight and knowledge.
Dr. Sharp: Got you. This is well or right out of the gate; we’re talking a different process than typical assessment. Right.
Dr. Raja: Yes.
Dr. Sharp: I’m tempted to really dive into the logistics here and all the practical parts of the assessment. Before we do that though, I want to make sure that we’ve covered the… is there any lingering theory out there or what’s driving this, why is it important, research on the effectiveness, all that kind of stuff, does that make sense?
Dr. Raja: Yeah. There’s a relatively recent article by Jan Kamphuis, who’s [00:28:00] out of Amsterdam, and Steve Finn on the theory of why Therapeutic Assessments are so beneficial to client. It’s bigger in scope than we have time to go into here but deeply rooted in Fonagy’s work on what’s called epistemic trust and epistemic hypervigilance. This is related to early attachment disruptions and then maladaptive personality characteristics that develop as a result of that, although we probably should rightfully say those were adaptive personality characteristics for these young people but we know that those ways of surviving those difficulties as a child can become problematic for people.
The focus is on building some awareness of that, creating a more compassionate narrative about that, undoing shame relative to those ways of being and those [00:29:00] experiences all within evaluator-client relationship that’s really about attachment. How do I create a strong attachment with this individual and connect right hemisphere to right hemisphere-related nonverbal behaviors to give them this sense of being held and it’s secure?
This allows them to be opened up, if you will, to this new learning that often is the stuff that people defend against. Because we’re in therapy and we may make an interpretation and we say something and for people that don’t feel secure or it’s too hard to talk about what we see, the shame rises, they get rigidified. They can give us cues very overtly or sometimes covertly about, that’s not safe, I can’t go there.
So we want to be really respectful of that in this process as we would be in psychotherapy. [00:30:00] But the test data and in particular as we’ll talk about the performance-based or projective tests because of their ability to tap into the right hemisphere, implicit schema really gives us an opportunity for people to learn these difficult parts of themselves in a compassionate way that allows for growth.
Dr. Sharp: Yeah. I got you. Well said. At the risk of being reductive, it sounds like there’s big anchoring and attachment theory.
Dr. Raja: There definitely is.
Dr. Sharp: The part that continues to stick out but it’s just getting more and more apparent is really this therapeutic part. The relationship sounds like pretty integral to this process.
Dr. Raja: Yes, very much so.
Dr. Sharp: And that interpersonal connection. `
Dr. Raja: Right. And with regards to efficacy, there’s more than 30 articles now published on these C/TA approaches. I’m just reading, [00:31:00] these are just some examples and actually come right out of the case book. Just give us a little sense of it. So decreased symptomology and increased self-esteem in adult outpatients. Other studies, one from 1992, 2008, increased hope in adult outpatients. One of the most consistent things we see that’s really helpful long-term for people is better compliance with treatment recommendations and better connection with their referring therapist. The connection they developed with the TA evaluator seems to translate back to the therapist relationship and that relationship’s often enhanced. Even when it was good, it often becomes better and they’re better able to use therapy.
Dr. Sharp: That’s wonderful.
Dr. Raja: It’s been used with all ages in all types of settings; inpatient settings, outpatient, college, counseling kids with ODD, and folks with borderline personality disorder. One of the most [00:32:00] interesting as of late came out of Amsterdam at a psychiatric hospital there where they treat severe personality disorders and a little different than what we would have at least in Minnesota. Our psychiatric hospital, unfortunately, has a lot of folks who have correctional matters going on, and they wind up there, right?
Dr. Sharp: Yeah.
Dr. Raja: This is, I think, more of a place where they have more pure narcissistic personality disorders, if you will, are paranoid and that ilk. They conducted Therapeutic Assessments with a group of these individuals before starting and didn’t necessarily find a change necessarily with regards to symptom or functioning, but found increased hope for success from treatment, greater satisfaction with treatment and improved alliance for these adults with severe personality disorder, which we know are some of the most difficult folks to treat.
Dr. Sharp: Absolutely. That’s remarkable.
Dr. Raja: And there is just one last and then we can move off of the efficacy here. And this is now maybe [00:33:00] getting a little old but in 2010, Poston and Hanson did a meta-analysis of 17 studies that are under that collaborative therapeutic umbrella. They found essentially moderate effect sizes with regards to improvements for clients. We’ll take that, right?
Dr. Sharp: We’ll take that. Yeah. Nice. I’ll try to link to some of those articles that you mentioned in show notes too, just to grab that out there for listeners. Very cool.
Let’s talk about the application of this. We started to dive into the scheduling, but maybe we could even start a little further back logistically, what does this look like in practice? What measures are you using? What process is happening?
Dr. Raja: Well let me actually answer a different question first, Jeremy, because it’s the question the audience is going to be sitting on, has been my experience and that is how are you billing for [00:34:00] this and how are you getting paid because people always want to know that question. The answer is shifted, obviously this year with our new testing codes. It’s a mix of 90791 diagnostic interviewing. It’s now a mix of the 9613031 and the 3637. I also bill therapy codes like 90834s throughout.
As we go and as you’ll see really more distinctly in the case study, I am administering test and scoring test, so I’m in that 3637 range but the exploration of test is really about building insight and change and trying more viable ways of being for people, which is therapy. And so some combination of those is what’s occurring. Logistically, this is a part that can get tricky, I think, for some systems. And so as [00:35:00] someone in private practice, I can say to someone, well, you’ll come in for an hour on Monday and I’ll see you Tuesday for an hour and a half, and then come back next Monday and we’ll do two hours, right? So there might be these different appointment links that if you’re doing just routine scheduling could get tricky for like a clinic to do but I still think there’s ways to implement these different ways of billing into all sorts of clinics. And that is happening.
The argument I just make there, I worry sometimes that we let our systems dictate what’s best for our clients rather than letting our science dictate how we should shape our systems to be best for our clients.
Dr. Sharp: Sure. That’s a can of worms we could open.
Dr. Raja: Yes, it is.
Dr. Sharp: For now, I’ll just say, I agree.
Dr. Raja: Okay, fair enough.
Dr. Sharp: Yeah. Well, that does trigger some other questions since we’re talking about the billing. Is it routinized, is that the word, [00:36:00] enough to where you can predict, I will bill X number of hours of 90837 and X 90836/37, or do you just go by how it turns out case by case or what?
Dr. Raja: Well, as we’ll see, the first step in the mile is to identify the questions that dictate the testing. So depending on what the questions are, is going to tell me what test I need and to some degree how many then billing units I have. But for most people that I’m seeing, I can ballpark this pretty well, regards to how many hours, how many units, and if they have a high deductible, their potential out-of-pocket costs. I really try to be transparent on that stuff because I think that that’s important with regards to informed consent also.
Dr. Sharp: Yeah. That makes sense. Well, and it fits for me to hear that there’s more of those therapy codes happening with this type of [00:37:00] assessment. That seems like a natural fit at least based on what you’ve described so far. Well, that’s good to know. So the short story is that there is a way to bill insurance and get paid for these kinds of things.
Dr. Raja: Yes. What we’ll see, and this becomes a little bit of the sticking point, the final document that we produce in a Therapeutic Assessment is actually a letter. It’s a more time-consuming document to write than a standard report. And so that becomes, I think, what sometimes people look at and say, I don’t know how am I going to fit that in, but I think it’s worth it for our clients but I also think within given systems, there’s ways to make that work.
Dr. Sharp: Yeah. Is it a stretch to say that would just go under the thinking and analyzing codes that we have now? The report writing codes.
Dr. Raja: Right. I [00:38:00] think what we’re all waiting to see is how many of these are the insurance companies really going to let us have.
Dr. Sharp: Sure. That story has not been written yet or finalized anyway.
Dr. Raja: No.
Dr. Sharp: Got you. Okay. Well now it sounds like there’s a “to be continued” with the billing, but at least it seems like the majority of it is easily billed under the codes that we have.
Dr. Raja: Yes. I believe that’s the case.
Dr. Sharp: Very cool. Okay. So maybe we can talk about some of the measures that you actually use and how this process ends up shaking out.
Dr. Raja: Sure. So again, whatever questions people identify is going to help me figure out what testing to use. The clientele that I have been seeing as of most recent, I’ve had fewer people where I needed cognitive testing and here locally billing for IQ [00:39:00] testing, if you needed authorization for it, you better have a really good reason or that you’re not going to get it. On the opposite side, if you don’t need an audit and you got audited, you better have a really good reason why you did it or sure you might be paying back. So I’ve done less IQ testing, less achievement testing but that certainly could be part of the picture if that’s what people are trying to figure out.
Dr. Sharp: Oh, okay.
Dr. Raja: And so we definitely can do those. I am not a neuropsychologist and so I let people know also at the front end. If they’ve got questions about memory, language, processing, that I think we really need a neuropsychologist here, I’ll let them know what I can figure out about that or not but who might be able to be helpful to them if that feels like it’s going to be something they need.
Dr. Sharp: Interesting. Okay.
Dr. Raja: So then my battery becomes really more in the personality and symptom picture realm. For adults, most of them are doing the MMPI-2 [00:40:00] or the MMPI-2-RF, often the MCMI-IV depending on the clinical picture. What becomes really helpful, as we’ll talk about in seeing the case study are many of the performance-based measures and some of these are pretty unique. If you’re looking for future podcast episodes, this might be some people to tap into, Jeremy but I’ll just describe two of them for you.
One of the ones I routinely now use is called the Wartegg Drawing Completion Test. The Wartegg is a really interesting test. It’s actually this half sheet of paper that has eight boxes. Each box has a mark in it, and you give the person a pencil and you say, essentially, I’d like you to make a drawing in each box using the mark as a starting point, try to draw the first thing that comes to your mind. Try not to draw abstract drawings and a few other [00:41:00] things, and you let them draw. And then it gets coded and scored in a fashion that’s somewhat similar to the Rorschach and entered into a computer and you actually get a lot of the same data that you get from the Rorschach.
The Wartegg was essentially developed in Europe and wound up in East Berlin post-World War II. And so like many things in East Berlin, there was not a lot of contact with the West, right?
Dr. Sharp: Right.
Dr. Raja: It got stuck there, but it’s been widely used in Europe. An Italian psychologist by the name is Alessandro Crisi is the John Exner of the Wartegg. He pulled together all these various systems to standardize it, norm it. There’s a book out by Routledge just this past year on the system. And so it’s often a really helpful test in understanding people.
I often use the Rorschach also under the R-PAS method; I find that really helpful also. The two have incremental validity. The Wartegg is a little less [00:42:00] emotionally arousing than the Rorschach can be. So for people who sometimes can struggle with the Rorschach, this often feels safer for them.
Dr. Sharp: I see. I’ve never heard of that before. So I’m going to […]
Dr. Raja: It’s pretty unique and we can put their website link also there, Jeremy.
Dr. Sharp: I’ll do that.
Dr. Raja: The other one, well, I should say I have the other projectives. I use the Thematic Apperception Test fairly routinely with kids, the Roberts Apperception Test. But there’s another storytelling test that’s also a little lesser known. It’s called the Thurston Cradock Test of Shame. Essentially, it’s 10 cards. It’s a storytelling test and it’s designed to help identify shame in clients. What’s really helpful about it is people have certain defenses that they use to manage shame and [00:43:00] because shame is so elusive: a) it’s hard to measure it through self-report measures, right? If you say, hey, do you feel shameful about these things? People feel shame and then they don’t respond right? They’re not honest with themselves.
So this test allows us to tap into their shame in a different way. It helps us see the defensives. And in many ways, the defenses become the red flags for people because if you can start to realize, oh, every time I start to feel deflated and I pull in, I might be experiencing shame, then you can start to work with that rather than just trying to identify shame.
Dr. Sharp: That makes sense.
Dr. Raja: And so this test is also a great storytelling test that’s widely used in the therapeutic assessment community. And one more that’s really starting to grow, and I’m not certified in this one yet, but there’s a test called the Adult Attachment Projective. And this was developed by Carol George and Malcolm West. We’re probably most well-known for the Adult Attachment Interview. Many people know about that way of assessing adult attachment [00:44:00] following the Bowlby model. Many people have heard about the adult attachment interview and thought, oh, I’d love to use that clinically but it takes two hours to do the Adult Attachment Interview and I think it takes like six hours to code or something like that. After how many years of training?
Dr. Sharp: A lot. Yeah.
Dr. Raja: So you and me don’t have time for that as practitioners. But the Adult Attachment Projective, it’s eight-line drawings. There’s one warm-up and then there’s seven additional stimuli that depict theoretically derived attachment scenes. And essentially clients tell stories about them. There’s a whole coding system and you can classify adult attachment style with it and you can figure out the client’s defenses about attachment anxiety and how they manage because often that’s what’s getting people in some trouble.
Dr. Sharp: I see.
Dr. Raja: And so it’s a really rich way of getting into what’s the harder stuff often for people to understand about themselves because much of that’s really unconscious for us.
Dr. Sharp: Yeah. [00:45:00] So can I back up just a little bit and ask just about the interview process. So when you meet with someone for the initial interview, are you doing a structured interview or is it a proprietary kind of thing you’ve developed over the years or how’s that?
Dr. Raja: I’ll give the short answer. You’ll see it better when we do the case study here. One of the real big differences in this model is we don’t start out with a traditional kind of interview. We spend time with the clients, figure out what questions they want to get answered. As we progress through these different testing sessions, what we typically get out of an interview, I find it comes forward through the discussion of the test in their lives. There may come a point where I think, with somebody, boy, we’ve done a lot of testing. I think I get them, but I just need to do some interviewing and clarify some parts of their life. So I might do that. [00:46:00] But because the ultimate goal of a Therapeutic Assessment is not necessarily to get the right diagnosis, I’m less interested in doing some structured interview that makes sure I hit X, Y, and Z per se.
Dr. Sharp: I see. So what does that first appointment look like generally?
Dr. Raja: So during the first appointment and because I’ve already had a phone call with somebody, they know this. And if it’s one of these therapists that’s worked with people, they’re going to prepare them for this. But basically, they come in and I welcome them and I introduce them to the model.
And what I’ll say to folks is, well, today what we’re going to do is just spend time figuring out what questions you hope to get answered. I go from there.
And as you can might imagine, there’s some people that come in and say, I know my therapist said I should think about this, but I haven’t really thought much about it. And then we go from there. And on the other side of that spectrum, there’s people that come in and said, no, I took down lots of notes. [00:47:00] I’ve got 12 questions already. Here they are, this long list.
Dr. Sharp: Yeah. I bet there’s variability.
Dr. Raja: There’s great variability there. Honestly, I’m just spending that first session figuring out what questions we’re trying to get answered through the testing. We spend a fair amount of time contextualizing and individualizing these questions so we can really get a sense of what does this mean for people. And the main therapeutic technique we use in the first session is the circular questioning technique coming out of the Strategic Family Therapist model. The idea of trying to break up the narrative a bit.
So let’s just say someone has a more simple question like, why do I get anxious all the time? I might just start well; tell me about your anxiety. How do you know when you’re anxious? Are there times you’re anxious more so than other times? Are there times you’re never anxious? Have there been times when you thought you’d be anxious and you weren’t anxious? [00:48:00] And really is trying to break that up and break up what’s ultimately, I think black and white thinking about problems where people can get, it’s like, oh my God, it’s this all the time. When reality is, we know that these difficulties people have really are probably more contextualized than that and are more difficult in certain circumstances than others.
Dr. Sharp: I see. Got you. This is fascinating. So I’m just exercising my brain a little bit and trying to think about how to do this differently. So do you spend any time on history, family dynamic, medical history, I don’t know. I do a very structured interview, so I’m trying to draw some parallels here if there any to be drawn.
Dr. Raja: Sure. So let me throw out a question here from a client, Jeremy because that’ll help you see a little bit, I think. [00:49:00] This a client, a young male who had done some cutting and some other self-harm behaviors. And so one of the questions that he came up with was why have I self-harmed in the past and how did it get to this point? Is this another form of self-sabotage? And so once I start thinking, oh, we have a question about self-harm, now, part of that discussion about this question is understanding, well, what does that actually look like.
So I’m getting some interview data relative to that about if we consider self-harm kind of a symptom picture, right? Well, what does this actually look like in this person’s look like? But firstly, let me give you another one here. This is an older person, a female who had some eating disorder issues. And her question is, why can’t I find a partner? [00:50:00] How is my body image and shame connected to me feeling worthy and unworthy of finding a romantic relationship? And so now we have this question in the room and essentially she’s opened the door to me exploring relationships.
Dr. Sharp: Got you. Okay.
Dr. Raja: I’m going to get it through these different parts of the questions and then through the exploration of the test that we’ll describe in the case study also. Ultimately, again, if I feel like there’s some part of this person’s life that I haven’t touched on that seems important, I might say, it’d be really helpful if I did an interview about this part of your life and here’s why but in this first session in particular, I’m working to minimize the power difference between us as much as possible. And so I want to follow their lead about what’s important.
When we do these structured interviews, and I do them. I still do them for my traditional evaluations. So I totally get the role of them but sometimes I [00:51:00] wonder, people are going along and saying, well, here’s my story, and here’s what I’m dealing with. And then we stop and say, well, now can we talk about your legal history? Alright. Okay. Now can we talk about educational history? It’s like we go into these areas of their lives and I think they get we need to know the whole picture but I’m going to follow your lead on this about what’s important.
Dr. Sharp: I got you. Yeah. Okay. That’s good to know. Just…
Dr. Raja: Yeah. Now I will say, Jeremy, for people learning the model, this was my experience, that initial part was a bit emotionally challenging for me because that we feel safer when it’s like, here’s my step. I did this step, I have this data. Okay, now I know how to think about this person. I can move to this next step. And without that, there was a little bit of like, oh, I feel like I’m missing something.
Dr. Sharp: Yeah. The structure gives us a safety net.
Dr. Raja: Yes. Right. I find over time though, I get the same data. I just have to be patient in what I see.
Dr. Sharp: I see. Cool. Okay. I’m with you. [00:52:00] So let’s keep walking through this process. So you have your initial session and then what happens? There’s maybe some test selection, I don’t know, I’m guessing.
Dr. Raja: Right, so we have the questions that the person’s identified, and then that helps me figure out what tests they’re going to do. The next series of appointments are essentially those testing sessions. I want to make sure this part’s really clear. People doing TAs and myself, we are administering tests in standardized fashion. So everything we learned about how to do a proper WISC administration or Rorschach administration and so on, that’s what we’re doing.
And so I’m setting people up and I’m having them come in. I’m doing testing and I’m following all that protocol. When I’m selecting tests, I’m trying to work from tests that are most face valid to the client nature [00:53:00] to ones that are going to be least face valid. And so just as an example, let’s say one of the client’s questions is, I think I have attention problems and I wonder if I have ADHD or something in that realm. Maybe when they come back, one of the first things I do with them is say, here’s this Barkley Rating Scale on ADHD. This will help us understand some of what your attention problems are like. I’m going to have you complete it now.
What’s a little bit different is, I might have them do something like that and we’ll immediately stop and talk about it. I might walk through all of that with them. It’s not like, okay, you did that thing, I’m going to go score and eventually I’ll come back and talk to you about it. In the moment, we’re going to explore that data.
Dr. Sharp: Yeah. I see. Subtle difference but important.
Dr. Raja: Subtle. Yes. Conversely, let’s say I don’t have a specific question like that, right? And then what I’m typically starting is with something like the MMPI [00:54:00] for adults. A lot of people have heard the MMPI. Often older clients have said, oh yeah, I took that once when I was in college. And so I’ll just explain to people this is the most widely used personality test in the world. It’s going to help us understand who you are but it also might help us understand if there’s things like anxiety, depression, or other things going on and I’m going to connect this back to their questions as much as I can.
I should say, even before I get to that step, Jeremy, I’m sorry, kind of leaped there for a little. Once I have these questions, I go home, I type them up. And then I come back and then next time I see them, and I say, here’s the questions typed up. Let’s look at them again and make sure they still make sense. If you need to edit or tweak or if you thought of something else, let me know. But the questions, because they’re the client’s questions, they become the window through which we can shoot the information, as Finn would say. And so I want to help the client see this test is going to help us answer this question. [00:55:00] And here’s how.
Dr. Sharp: Got you. So do you spell that out to the client pretty clearly?
Dr. Raja: Yeah. Just to use an example of the MMPI, so let’s say, I did have a question here. Let me see if I can find one that’s, well, let’s say someone just got a question just about anxiety. What’s the source of my anxiety or something like that. I might say to them, so we have this question about your anxiety.
One of the things this test will help us understand is what does your anxiety actually look like? So that’s part of what we’ll get out of this. And we’ll probably look at anxiety through other tests too. This is not the only test that’ll tell us about that but it is connected with that and it’ll help us understand who you are because ultimately I could talk to 10 people that have anxiety and what that means for them is 10 different things. And so I really want to know, well, what are you experiencing or what clinician would call the symptoms and who are you? So what your personality and how do these things intersect?
Dr. Sharp: Mm-hmm. Sure. So is there anything else [00:56:00] that goes into the test selection? It sounds like you don’t do all of those measures all of the time. So I’m just curious and maybe this’ll be illuminated in the case study, but I’m curious how you decide which clients get which measures within this framework.
Dr. Raja: Sure. Well, I think very broadly speaking, I am almost always giving people objective testing of some type; MMPI, Millon, others use the PAI. I’m a little less familiar with it, but that would be another important part. The objective testing is really important because it helps us know what clients know about themselves because ultimately people are reviewing these items and thinking, is that me or is that not me, and then they’re responding. And so I want to know what people know about themselves. I then though want to know maybe the parts of themselves they have less [00:57:00] awareness of and here’s where the projective/performance-based assessments really are beneficial.
So I’m usually choosing something from that second basket, if you will. What it is specifically is probably going to be more connected though to whatever their question is. And so if I have someone as an adult who’s got high levels of shame and that seemed to be a big part of the picture, then I might decide just to use a Thurston Cradock Test of Shame with them. Conversely, if I have someone who I think, well, they’re shame, but I think we’re figuring that out. But this seems to be really about unresolved issues related to some of their experiences with their parents. I find that some of the TAT cards might be more beneficial to pull that out.
The other part, quite frankly, that you got to consider, I think particularly related to those kind of tests is the diversity factor there because when you’re working with people from diverse backgrounds, sometimes the TAT cards in particular or if you don’t have like the Roberts cards [00:58:00] for Hispanic or African American children and some of the other tests I use, I think folks from diverse backgrounds can find that off putting and so I’m careful about that.
Dr. Sharp: Such a good point. I’m glad that you highlighted that.
Dr. Raja: Yeah.
Dr. Sharp: Mm-hmm, just to be aware of. Okay. Are there any clients who would not get a projective where you could say, hey, this isn’t relevant.
Dr. Raja: I would probably say no. Well, I should say, if you go back and you look at Steve Finn’s history a little bit, he really started just using MMPIs. And his first book was really just about use of the MMPI in a collaborative fashion. It’s called Manual for Using the MMPI-2 as a Therapeutic Intervention, 1996. Finn is very skilled with the MMPI in ways that I wish I was but he was literally just doing this [00:59:00] collaborative interview with people. What do you want to know about yourself? And then having them take the test and then coming back and doing an individualized collaborative discussion session with them. I think there’s potential for a lot of power for that for people.
And so for people that are hearing this and thinking, oh, I want to do Therapeutic Assessment, but I don’t do projectives, Raja. I don’t think it has to be part of it but I would also just posit though that the projectives are tapping into parts of the self for our clients. That’s really important and I think we can miss that if we just use objective to this.
Dr. Sharp: Sure. Makes sense. So, let’s see, I’m tracking our progress here. So we’re into the testing sessions. They’re coming so this is kind of the middle part of the model. You’re administering tests, discussing results as you go along.
Dr. Raja: Sometimes definitely exploring. And so let’s just say someone comes in, takes the MMPI and I’ll [01:00:00] it on Q-global. And then I’ll say to them, why don’t you come back next week and what we’ll do is we’ll start exploring this together. So I’ll get the MMPI and I’ll review it. One of the things that’s so important about our tests, is these are quick empathy magnifiers. I have someone who just did a test. I can now go to my books, look up and study and figure out what’s this person like? How are they moving through the world? What are their strengths? What are their weaknesses? Maybe where they’re getting stuck. And because I’m quickly already gaining a sense of who this person is, as I’m interacting with them, I have a better understanding of how to be empathic with him and how to collaborate with him.
Dr. Sharp: That’s really interesting. I like that. You’re working on the fly, you’re gaining all this information as you go along.
Dr. Raja: You’re, right. And so let’s say they come back now to the next session. What I probably would say is something like so one of the things the MMPI does is it identifies some items that the authors think are helpful to [01:01:00] review with people when they take them. So I’m wondering if we can just go through some of these. Here’s where a bit of that interviewing happens, Jeremy that I think you were wondering about.
And so I find that sleep is a really easy thing for people to talk about, and so I’ll always look for sleep questions first. So I’ll say, you got a number of items here where you said true to things that are like my sleep’s not good or I’m very tired, those kind of items. And then I’ll just like, tell me about your sleep. What’s it like for? And I’ll just gather information about their sleep patterns as a foray into their world and I’m connecting that back to the test. And then I might go to other items that are maybe, just seem really interesting or more meaningful. Part of what I’m doing here is I’m gathering data from them that’s helpful to me, but I’m also conveying to them this sense of, we’re figuring this out together. I’m going to collaborate with you on trying to understand you through the test.
And so that conversation usually goes for a while. What I’ll often [01:02:00] do, depending on how the tests look, is I will often show people, if I did the content skills page of the MMPI-2 like anxiety, depression, obsessions, fears, and so on because in many ways those scales, I think are easier for people to get their minds around a little bit than the primary scales. And it gives me a chance to orient them to what does it look like to look at a test like this and how we make sense of it. So I’ll often show that to them and explain a little bit about T-score as much as they need and then how we make sense of these different things and start to do some interpretation.
So let’s say depression’s high, I might say so when this is high, often that means people are often blue and down and maybe they don’t feel so great about themselves. I’ll give a little bit and then I’ll stop and say, does that resonate with you? And see where it goes. But I often find particularly [01:03:00] with the objective test, is that we’re really tapping into what we call in the TA world level 1 information. If you recall back to Megan’s podcast with you, she went through the levels and I’ll keep hitting on those a bit, but this level 1 information is really information that people usually already know about themselves.
And so if you have a client that’s 30 years old and has been in therapy for 15 years and they come in and they say, I know I’m depressed. I’ve been on Prozac for 10 years. And then you do an MMPI-2 and you got a spike too and you say this is depression. And they go, yeah, I knew that. Going to be surprising to them, stretch. So it’s not necessarily new information to them but two things that are really important, I think in this process of even explaining these objective tests is one, again, I’m being really transparent with them. I’m not just holding this data. Let’s look at this together. Help me figure it out. Help me understand it for your life. Conveying that sense of collaboration but I’m also doing what’s an [01:04:00] important part of this model is that I’m verifying their experience.
And so in that moment when and… I’m sorry, let me tend you just one second, the good and bad of our test is that they have power. When people see things in writing or diagrams, they think that means more than if I just say, you’re depressed.
Dr. Sharp: Of course. Yes.
Dr. Raja: And so I want to use that power for good and help people see themselves in the test but also explore what that means for them. And when people are being verified by the test and verified by me, that helps create that connection that’s so important when we get to the harder information. And so I think of it like someone has an experience of me saying, well, this is depression and does that match for you? Then feeling like the test got me and Raja got me.
I want to keep letting them have that experience where, oh, the test gets me, the test understands me, [01:05:00] Raja understands me so that when I get to the information that they probably have shame about, that’s going to be harder for them to accept what we call level 3 information, that it’s going to be more palatable to them and they’re going to be more open to accept.
Dr. Sharp: Okay. I’m on board with you.
Dr. Raja: Okay.
Dr. Sharp: Collaborating.
Dr. Raja: A lot of collaborating.
Dr. Sharp: A lot of collaborating, yeah. Okay.
Dr. Raja: A lot of collaborating, a lot of curiosity, right?
Dr. Sharp: Yeah. Well, I think that’s the part that maybe, it diverges a little bit from, like you said, the information-gathering.
Dr. Raja: Yeah, approach.
Dr. Sharp: I like this.
Dr. Raja: What I say to clients often is, I’m an expert on test but you’re an expert on your life. Let’s put our expertise together and try to figure something out.
Dr. Sharp: Mm-hmm, that’s good. Yeah. I’m already thinking through how I might be able to integrate some of these things.
Dr. Raja: Okay. Cool, Jeremy.
Dr. Sharp: Good, yeah.
Dr. Raja: So then after that test, I’m going to go into other tests and do, essentially in the other test where I don’t have to like step away and score and come [01:06:00] back, I’m essentially going to explore that in the moment with them afterwards. And let’s say for example, the next test I give them is a WAIS. This is going to feel, I think, familiar to, I kind of got sense a lot of your folks do a lot of academic and learning testing than probably listen to this, but that idea is as someone’s going through an IQ test or any of our cognitive neuropsychological testing, as evaluators, we’re paying attention to, what’s it like for them? What’s happening to motivation? What are they doing? How do they manage frustration? What’s it like for them when they get it wrong? What’s it like when they get it right? Right. We’re paying attention to all of that stuff.
Dr. Sharp: Mm-hmm. And would you ask about that in the moment?
Dr. Raja: At the end of a test and if I knew I wasn’t going to give another cognitive test, I would explore that with them.
Dr. Sharp: Okay. That’s fair.
Dr. Raja: If I knew I was going to give another test where I thought, oh, if I explored too much of this, this could somehow [01:07:00] invalidate another test I’m going to do. I wouldn’t do it then. But let’s just say, I know this person’s only going to do a WAIS. I might stop afterwards and just explore with them really broadly, what was it like to do that? Which ones did you like? Which ones didn’t you like? What I’m really looking for relative to this model is, how does that match up with how they move through the world and where they might get stuck.
And so imagine someone who takes the WAIS and every nonverbal test, they just like dive right in and they’re like, quickly. And they’re like, oh yeah. And they’re going and every verbal test, they push back from the table a little bit and they’re just like okay. You could just sense that hesitation, right?
Dr. Sharp: Yeah.
Dr. Raja: So I might at the end of the test after I’ve asked them, what is that like and what did you notice? I might say, I noticed something, it seemed like the test that didn’t have words you really got excited about and the tests that had words you were not enthused about. What do [01:08:00] you think of that? Because I’m banking a little bit that the task of taking the task is tapping into some psychological process that they’re using out in the real world. And I’m capturing that behavior right there. And we can maybe make something out of that.
Dr. Sharp: Yeah. This is good.
Dr. Raja: Does that make sense, Jeremy?
Dr. Sharp: Oh, yeah. No, I’m with you.
Dr. Raja: Okay.
Dr. Sharp: I think of all, for the folks who can’t see, we’re on a video call and so I’m just like very pensive. I’m thinking about a lot of these things that you’re saying and how they might come into play even in a traditional neuropsychology. So I’m with you in this.
Dr. Raja: Okay. So then a similar process will occur, quite frankly, with the projective test. Because the projective tests tend to tap into right hemisphere, more emotionally laden parts of people, we have greater opportunity, I think, to have even more meaningful discussions and build some insight. I had mentioned earlier that [01:09:00] we have these different levels of information. So Level 1 information, again, is that information clients already know about them. Level 2 information is essentially information that is a reframe or a different way for the client to think about themselves that they’re going to be able to accept.
I’ll give you an IQ example here just as an example of Level 2 information. Well, we know a lot of people are coming in for testing. In fact, particularly you wind up doing IQ testing; they think they’re dumb, right? They think something dumb.
Dr. Sharp: Oh, yeah. Always.
Dr. Raja: And so let’s say you do IQ testing with someone and you wind up with really good high average scores, but a lower processing speed.
Dr. Sharp: Common enough.
Dr. Raja: And so imagine now you’re explaining to the client after you’ve done your testing, maybe in the discussion session. Well, let me tell you a little bit what this test says about you, and you explain these different subscales and what the processing speed means. Reality is people who are really smart, process quicker [01:10:00] and people that can’t process as quicker, especially around a lot of smart people are going to think I’m dumb. And so I think you probably could picture a conversation where you could help someone reframe how they’ve been thinking about themselves from being a dumb person to a person that just takes longer to get to the same place that everyone else gets. And so if you can do that and they can accept that, we consider that in that level 2 information.
Dr. Sharp: Okay. Got you. They’re learning something about themselves and maybe trying to integrate that with their…
Dr. Raja: Yes, exactly. Or just as one more quick example on a similar vein, you can have the client who comes in and says, I know I’m just lazy. My dad always told me I’m lazy. Everyone’s told me I’m lazy. I have no work motivation. That’s part of it. We have MMPI, we get a spike too, and we got a lot of depression. And we say to that client, well, this tells us about, that maybe there’s depression for you. And we talk about that, and then we provide some psychoeducation about the role of [01:11:00] depression on energy level, motivation, concentration, the tension, and so on and how that can impact performance. And that client for the first time says, oh my gosh, I’m not lazy, I’m depressed.
Dr. Sharp: Sure. Yeah. Major reframe.
Dr. Raja: Yeah, a major reframe and a more realistic and compassionate view of the self. That’s really what we’re going for it’s not going be so threatening to the client that they’re not going to be able to take it. So that’s that level 2 information. And there’s a little gut check here for us as clinicians relative to all the levels. I’m sorry if I’m bouncing around a little bit on you here, Jeremy. But usually if I see level 1 information in the test data, my emotional response is essentially, meh. They know this about the cells. I’m not excited about this. They’re not going to be excited about this. But I see level 2 information, my initial reaction is usually cool, because I’m recognizing this could be really helpful for them if they understood this about themselves and they’re [01:12:00] going to be able to understand about themselves.
Level 3 information, which is often the most important information, is information that is so discrepant from the client’s sense of self that they’re likely to be defended against it and not they’re going to have a hard time accepting it. Often this is the most important data we get out of our test. But the gut check for us as a clinician is it’s often the data that we are like, oh no, how am I going to talk about this? And so as a maybe really simple example, you give them a lot and it’s really like a spike on just narcissism or you identify psychosis in a Rorschach or a high four on the MMPI. Someone who’s really got an antisocial quality to them.
Ultimately, those parts of people are probably what’s getting them into trouble and exacerbating their problems and are going to be the hardest thing for them [01:13:00] to hear and take it. But again, if I can be working with people across sessions where the test is saying, I get you, and Raja is saying, I get you, and I’m supporting them through that, and this is really important, Jeremy, I’m working from a lens of seeing these so-called maladaptive personality characteristics as having been adaptive in some points. Then I believe I can work with people in developing more compassionate narrative about how this came to be and that it was helpful to them and helped reduce that shame that’s often connected with that.
Dr. Sharp: Yes. The framework seems so important. And the empathy that you’ve been developing across this whole process and the connection that you’ve been developing across this whole process.
Dr. Raja: Right.
Dr. Sharp: I see. Yeah.
Dr. Raja: And so our projector/performance-based test in particular give us a lot of that level 2 to level 3 [01:14:00] information. That’s why they become so important. People who’ve done this, I think they probably have seen this because you can give a TAT to someone and even if you don’t ask them, sometimes you can recognize this, but if you ask them afterwards, do any of these stories seem like you? Who kept some people like, no; I don’t think this has anything to do with me.
And conversely, this just happened this past week, I had this kid. We got seven stories in and we had to stop because he recognized every story was about him. And they were essentially, every story is about an invalidating parent. And it became too much. And he recognized it. I recognized that he recognized it. So we were able to have that conversation. Sometimes it’s the projectives tapping into stuff that people can have some sense of, but do so in such a meaningful way. And because it’s their story or their drawing on the Wartegg, it’s got more power to it than me saying something or the MMPI [01:15:00] saying something about it.
Dr. Sharp: Right. No, that totally makes sense. Something about that, like it’s a test. There is some data here.
Dr. Raja: Yeah, I can’t tell you how many clients have cried after the TAT with me and my head goes to, oh my God, how many people have I assessed with a TAT that I never stopped to check-in with them, like, how was that for you?
Dr. Sharp: Mm-hmm. It pulls up.
Dr. Raja: You just plot along sometimes not recognizing the power of the tests.
Dr. Sharp: Sure. So then at what point in the process do you say, okay, we’re done administering and then how do you transition to, is there a feedback, a structure?
Dr. Raja: Yeah. Essentially, at some point I feel like I’ve done enough tests and Mike, I have a strong enough conceptualization of this client. What I do next is what’s called the assessment intervention session, but I’ll save explaining that for the case study because I [01:16:00] think it’ll make more sense when we talk about that, Jeremy. After that session, I do a discussion session. What I try to do and this usually works out, when people are sending me clients, like I said, these Master’s Level Clinicians, I want to try to go to their office and have them there for that discussion session.
Dr. Sharp: The treating therapist.
Dr. Raja: Yes, because I want them to hear it and I want the client to hear it. And so the discussion session of all the steps of the model is going to probably feel the most familiar to most clinicians. A lot of it is got people that are just humanistic and collaborative naturally are going to see those parts themselves in what’s in the model. The difference is that the typical approach to the discussion session is, we are just answering the questions together.
Finn’s [01:17:00] book is called In Our Client’s Shoes. The testing lets us get in our client’s shoes so we can think about how do we interact with them through this process and the discussion section in particular. If I have a high achieving, smart, corporate, older guy who I think is going to do best if I lay out some graph and numbers and talk really professionally, I’m going to adopt that per se. Conversely, if I’ve got a 14 year old that’s pretty fragile and gets easily overwhelmed and is only going to take on so much, I’m going to narrow the scope of what I’m going to talk about with that person.
I want to get in their shoes relative to what they’re going to be able to hear and what’s the best interpersonal style for me. Your recent, that wasn’t too recent, I think it was Laura Postal did the feedback.
Dr. Sharp: Oh, Karen Postal.
Dr. Raja: Karen. Yeah.
Dr. Sharp: Yeah. I was just thinking about that.
Dr. Raja: Yeah. She did a lovely [01:18:00] job of laying this part out too, I thought, that how do we respond to these different type of clients so it’s most meaningful for them.
Dr. Sharp: Sure. Yeah. It’s funny you say that. I was literally just thinking of that segment of my interview with her. I think she called it code switching or something where good feedback providers really do switch it up to whatever is going on for the client and that’s cool.
Dr. Raja: She also made this point is, if you do five tests with people, you have more data that they really can take in. So I want to really be careful in that discussion session about not having so many trees that we lose the forest and thinking about what’s the most important take homes for this person.
Dr. Sharp: Mm-hmm, such a good point.
Dr. Raja: And so we might wind up focusing really on just even one question or two questions because that seems most salient to what’s important for them versus covering all the question. Ultimately, I want to try [01:19:00] to make sure we cover all the questions because the next step as I’ll mention is the letter that’s to come for them. The letter’s going to outline everything. But sometimes in the letter, you really have suggestions and I feel a little safer just saying suggestions are coming to answer these questions versus if I’m trying to help them really understand some more deep part of themselves, some level 3 information.
And so that discussion session usually it’ll go an hour depending on the client and depending on the therapist, if they can make more time work, sometimes we go longer than that. I usually bow out at the end and let the therapist and the client have a little time together so that they can talk about it too.
Dr. Sharp: Yeah. And are you talking with the therapist at any point in the assessment process?
Dr. Raja: Yes. Thank you, Jeremy for asking me that. So at the front-end, I will say to the client, the therapist, therapist do you have any questions you want us to consider? Often, [01:20:00] sometimes therapists dos, the ones I’ve worked with a while, like, no, Raja, I trust that you’ll get the questions we need but sometimes they do. If a therapist has a question, then we’ll talk about it during that first session but if the client says, I don’t like that question. I’m going to respect the client’s choice. And that not going to be part of it. But they’re part of it.
And the other part, what I tell people, Jeremy, is that as you’re going through this process, I want you to still see your therapist on a fairly routine basis if you can logistically and financially because this might bring up some things for you to think about that you can bring back to the therapist. And it’s not uncommon that I’ll have maybe a really moving session with someone, just to go back to this young man with the TAT stories and the invalidating parents, this was a pretty emotional session for him and I called his therapist, not too soon after and said, hey, just a heads up, we just had this conversation. I think it was really challenging for him but also [01:21:00] really helpful for him. Are you seeing him again this week because it might be helpful just to check in, see how he’s doing and follow that thread if it makes sense.
Dr. Sharp: Of course. Yeah. Okay. That’s good to know. I could see that. Okay. Great. So then you’re at the end.
Dr. Raja: We’re at the end. And then there are two final steps. So we write a letter to clients that are very different looking, Jeremy than a typical evaluation. I’m going to have one on my website soon as example, but it’s honestly a personalized letter to the client. It starts with the introduction. It says, here’s the tests we did and this is what they look like. I then answer every question. And then there’s suggestions section where I say, here’s things to think about therapeutically, other interventions in life. And I say goodbye, essentially.
So there’s not, here’s your history, here’s your diagnosis, here’s all those other sections that are part of a traditional evaluation. [01:22:00] And again, I’m writing it with consideration for the reader and who they are. So again, as you can imagine, if I’m writing this for a 14 year old, it looks very different than if I’m writing it for that 45 year old businessman.
Dr. Sharp: Absolutely. I’m just thinking of the amount of flexibility this seems to require for us as clinicians and how you really need to be attuned to your client. Gosh, if you miss it, you’re in big trouble, if you’re not right with them.
Dr. Raja: Oh, yeah. I’ve been fired on them.
Dr. Sharp: That does happen.
Dr. Raja: It does happen because it’s powerful when you start to explore these deeper parts of people.
Dr. Sharp: Right. Got you. And so that’s it. So you send them the letter?
Dr. Raja: I send the letter, I always offer a follow up session if they want to come back and talk about it. I try to get people to do that. In my experience, it’s often tricky to get people back. The analogy [01:23:00] I’ll use is, you ever go visit family that you haven’t seen for a while and you’re there for some period of time and then you leave and you said your goodbye, and then you realize like, ah, crap, I left my wallet in the table. Go back inside and say goodbye again.
Dr. Sharp: Yeah, not the same.
Dr. Raja: The only thing is to not like saying goodbye. I think sometimes clients are like, I said my goodbye to Raja. The chapter’s closed on that part. I’m going to move on. Just to go back to the letter for a second, Jeremy, the letter in itself is an intervention. It captures what we figured out together throughout this process. It’s written personalized language, first person. I try to avoid psychobabble as much as possible.
I’ve had clients say to me, Raja, I got your letter two weeks ago. I’ve read it seven times since then. I read it and then I showed my partner, or I showed my mom. [01:24:00] It holds more weight and meaning, I think, to people than the thousands of other evaluations I’ve written where I’ve sometimes wondered, did anyone ever read that evaluation? I don’t know. Maybe the discussion.
Dr. Sharp: Yeah. I’m sure that’s probably the only part they read, from what we know.
Dr. Raja: Perhaps, right.
Dr. Sharp: Wow, so it’s a hugely powerful process or it certainly can be.
Dr. Raja: It is, yeah.
Dr. Sharp: And then does the therapist get a copy of that letter as well?
Dr. Raja: Yes. Right. Now from a documentation standpoint because this is probably in people’s heads a little bit. Like how is that going to work exactly relative to certain systems. There are certain systems I know people are going to be writing letters, going to have to write some other more traditional, kind of a report or recently, I completed one on this young man who looked to be on a path towards really severe mental illness. And I knew from a system standpoint, what systems he was going [01:25:00] into and what those professionals were going to require from an evaluation. And the letter I wrote to a 14 year old was not going to cut it. So I wound up writing a brief report to capture in more clinical terms what the test had said about him and what we had figured out for that audience.
Dr. Sharp: I see. You mentioned earlier in the interview that letter can be much more time-consuming than a traditional report. Can you ballpark at all how much time you might spend on these letters?
Dr. Raja: Well, I’ll go to the positive. There’s sometimes where the questions and the test data and the client and my conceptualization of the client lines up so well, I could almost just like spill it all out and it goes really quickly. There’s other times often when people have a lot of different questions and reality is right, we’re again [01:26:00] talking about these social, emotional parts of people. The overlap between questions and answers is so great that it gets a little tricky.
What is the typical thinking is it’s probably 25 to 35% more time than a traditional report because you don’t have that, I have a mental template for oh, I’m doing my symptom review when I’m doing a traditional evaluation, a traditional report. And so mentally I can hold that and get through that pretty quickly because I know what it looks like. But because each one of these is so individualized, it taps into your creativity far more. It’s just harder to pull together because of that.
Dr. Sharp: Makes sense. Gosh, I think that’s the hardest part of report writing for a lot of us is the interpretation and summary, and this is like, hyper-interpretation when you’re pulling together a lot of…
Dr. Raja: Yeah. If there’s a part that’s a little easier though is because I don’t have to go through every test step by step. That part maybe helps a little bit balance out the [01:27:00] time.
Dr. Sharp: Mm-hmm, I hear you. Okay. So I’m on board for Therapeutic Assessment. This sounds great. So I feel like we have a pretty good overview of theory, where it came from, why it’s important, who you might use it with, what the model looks like, what it looks like logistically, billing and so forth. We’ve got these practical pieces out of the way or, that feels wrong. Not out of the way. We’ve thrown them in the ring. And unless you have other things to add on this side of things, I think it could be great to transition to more of a case study if you’re up for that.
Dr. Raja: I think that’s a good idea, Jeremy. I think the one part we want to make sure to just loop back to and it makes more sense after the case study is some takeaways. I think sometimes when I talk about the model and [01:28:00] breadth of it, and when people start hearing projectives in particular, sometimes they’re like, oh, I don’t know. And when you hear that deeper relational connection, I think sometimes people are like, I don’t know if I want to take on all of that or that really makes sense for who I am or my practice, which I totally get. But I think, for all sorts of assessment folks, there’s parts of this that you could take away and build, as I said, in small ways that could be beneficial to clients.
Dr. Sharp: Sure. Okay, yeah, let’s bookmark that and I’ll make sure at the end of the case study portion to circle back around and we can talk about takeaways.
Okay, everybody thus concludes part 1 of my conversation with Dr. Raja David on Therapeutic Assessment. Coming up next time, we’re going to apply everything that you just heard to an actual case from Dr. David’s practice. He’ll talk us through the entire model and how it plays out with a real-life individual. So definitely tune in for that one next time, it’ll [01:29:00] be released in quick succession. So check that album.
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All right y’all. Thanks again for listening and we will catch you next time for part 2 of Therapeutic Assessment.