How to Use Inference and Speculation for Psychological Assessment By Tom Medlar, LMHC on 9/14/23 - 9:10 AM

Is it possible to conduct a psychological assessment and to offer treatment recommendations without ever communicating directly with a client? At the very least, aren’t interviews and history-taking minimum requirements to reach such important conclusions?

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I experienced just such a dilemma when I was asked to provide temporary services at a nursing home in Boston. Thinking it an otherwise easy task, I was soon faced with impossible barriers to communication and was not able to conduct a full assessment — at least not in the traditional way. As it turned out, I could only privately speculate on what might lie beneath the limited information available to me at the time. As therapists, when faced with this type of perplexing clinical situation, it is natural to ask, “What else must be true for this to make sense?”

Psychological Assessment with Limited Information

The facility management were dissatisfied with the work of a prior psychiatric service provider. They wanted continued treatment services for residents already receiving them, an audit of the documentation done by the prior provider, and a review of all residents to identify who might need or be able to benefit from behavioral health services.

This was an old brick building in a residential neighborhood that was now a Catholic nursing and rehab facility, serving the needs of a diverse population. One unit was fully populated by American-Vietnamese citizens, half of whom were Catholic, and half were Buddhist. The TV and newspapers were in the Vietnamese language and there were many staff persons who spoke both English and Vietnamese. On several occasions, a bilingual staffer sat in to translate for my interview with a resident.

One day, I pulled out a new chart from the rack at the nurse’s desk and began reviewing the information. I sat next to the nurse and asked if she thought I could provide meaningful service to this resident. The nurse shrugged her shoulders and said, “They just want to know if each person might need psychiatric medication or anything else you provide.” So, I continued to read through the medical record.

This resident had been a single mother of one son, living in Vietnam during the war. According to the record, she had been “deaf and dumb” from birth. Current records described her as having advanced dementia. How might I communicate with a person whose native language was Vietnamese, yet who had major speech and hearing impairments throughout her life, and who was now incapacitated by dementia?

I walked down the hall to a day room where Mrs. Tran was seated in a wheelchair, wrapped with a colorful crocheted blanket, and her nurse’s aide sat quietly beside her. The aide was keeping an eye on Mrs. Tran and on a few other residents across the room watching TV.

I smiled and introduced myself and my role, and made comments to Mrs. Tran, even though I knew she was deaf. I gently placed my fingertips on her forearm as I spoke to her, yet she continued to sit unmoved, with her eyes closed. I asked the aide if Mrs. Tran was sometimes communicative, but the aide explained that Mrs. Tran did not make eye contact or display any direct type of communication.

“Does she show some communicative responses if you hold or stroke her hand?” I asked.

“No, not really,” the aide said.

“How was it to care for Mrs. Tran?” I asked. The aide smiled and spoke of her affection for Mrs. Tran. She enjoyed taking care of her.

“She’s never a problem,” she explained, and added that Mrs. Tran’s son was a frequent visitor, and that he would bring in things that might be needed for his mother’s care, and that he would often assist with feeding his mother.

Clearly, I could not document an assessment, but what personal speculations might help me peer behind the cloud of the unknown surrounding her history?

As it turns out, Mrs. Tran may have been a remarkably capable, resilient, and praiseworthy individual. She might have even had enormous emotional intelligence and social relationship skills. As a young, single mother raising a son during wartime, and burdened by severe speech and hearing impairments, she might have also been especially effective in connecting and somehow communicating with others in the “village” that it must have taken to successfully raise her son, get him to the United States, and help him obtain his education and develop a full life. The loving attachment and close involvement of her son seemed a clear testament to the success of those conceivable efforts.

But all that I was able to formally and ethically document was that Mrs. Tran was stable and quite well cared for, and that no psychiatric interventions were needed. I was satisfied with that outcome.

Questions for Thought and Discussion

How did the author’s account impact you as a clinician? As a person?

What might you have done in this circumstance?

Do you agree or disagree with the author’s conclusions?  

File under: A Day in the Life of a Therapist