Rekindle Podcast Episode 2: What are Psychological Assessments? (Interview with a Clinical Psychologist)

The following interview is from Episode 2 of the Rekindle Podcast: “What are Psychological Assessments? (Interview with a Clinical Psychologist)", and has been edited for clarity and brevity.

Dr Johnben (JB): Welcome to Rekindle Therapy’s podcast, where we aim to educate Malaysians about mental and relational health. This is our second podcast. Today we’re going to focus on psychological assessment: what it is, what it is not, and when might someone go for it?

To handle this topic, I’d like to introduce the latest member to join our team at Rekindle Centre for Systemic Therapy here in Kuala Lumpur, Mr Arman Imran Ashok. Arman joined Rekindle in October this year, after completing his training as a clinical psychologist. His academic background includes a B.A. in Psychology from the University of Minnesota, and then a Master of Clinical Psychology from the programme offered by USM-UPSI (University Sains Malaysia - University Pendidikan Sultan Idris). 

Welcome Arman!

Arman (AA): Thanks for having me, Doctor!‍

JB: To help us get to know you a bit better, tell us about your background. Why did you decide to study Psychology for your undergraduate degree?‍

AA: So, the main reason why I wanted to study Psychology was to understand what makes a person tick. Most of the time, we usually see the after-effects of a person’s thought. We see the end result; the emotional or behavioural reaction to the thought. From my past experiences, I also noticed that vulnerable groups, such as those that were undergoing psychological distress, often go unnoticed or are often neglected here in Malaysia. 

So, I believe this is due to strong stigmatisation in our communities. Did you know Doctor, that based on a 2015 KKM report, around 4.2 million Malaysians suffer from a form of mental disorder, and most of them weren’t aware of it, or aware about where to go and what to do about it. This ties back to the stigmatisation many face. So I would personally like to change that in this country by doing my part in destigmatising mental health.‍

JB: So I’m hearing 2 main reasons why you went into Psychology: firstly, to understand how the mind works (what’s actually going on in the mind behind the behaviour), and secondly, how can we help people get more access to mental healthcare. And you knew this even before you started your undergraduate?‍

AA: Yes, that is because I already saw this in certain communities through volunteering programmes.

‍JB: Right, so when you were doing your undergraduate degree, you were already thinking: “One day I will become a clinical psychologist”, and you did your Masters?‍

AA: Yes, something along those lines.‍

JB: That’s great.

So, according to Dr. Daniel Seal, who is a British clinical psychologist practising here in Malaysia, there are currently around 200 clinical psychologists in Malaysia who serve a population of 33 million people. This is very low compared to countries such as the UK, where 9,500 clinical psychologists serve a population of 67 million. So, to keep it simple, every 1 clinical psychologist in Malaysia will have to serve more than 160,000 people, compared to 1 clinical psychologist for 7,000 people in the UK. What are your thoughts about this?‍

AA: So, despite the small number of clinical psychologists we currently have in Malaysia, the pressure is still not that imminent. So yes, there is a huge lack of awareness and mental health literacy is low, but as of right now, there are more people in Malaysia who are slowly becoming more aware. And Malaysia will eventually, in the long run, feel the strain if there are not enough clinical psychologists here. ‍

JB: So what you’re saying is, with greater mental health literacy, there will also be a growing demand for these services

‍AA: Yes, correct. And we can see that in the current academic programmes offered in Malaysia: there are more Master in Clinical Psychology programmes now offered-

JB: Do you know how many there are in Malaysia currently?‍

AA: I believe there are more than 7 universities offering the Masters programme. So it is growing, and I know the numbers are still increasing. Yet when we go to government hospitals, private hospitals and private clinics, we can see that it is still underfunded, and we are seen as secondary compared to other professionals.‍

JB: Right, okay. So that’s why we’re doing what we’re doing; it’s to try to increase mental health literacy. And as mentioned earlier, we are going to focus on psychological assessment.

You know, there are all kinds of quizzes on Facebook and social media that help people “know themselves better”. Sometimes it’s about choosing your favourite animal or picking your top 3 colours, and then the quiz will tell you what kind of person you are. Now, these kinds of quizzes were a lot more popular before (they are less so now, at least based on my [social media] feeds, and I think it’s because people don’t take them too seriously), but I still see people doing it on my Facebook feed and sharing it. So how are these online quizzes different from an actual psychological assessment?  ‍

AA: Well, one major takeaway from these quizzes and personality tests that you see online, is they are not valid, nor are they reliable. What that means is that the results of these tests should not be taken seriously. A lot of the psychological tests that professionals (such as clinical psychologists) administer undergo rigorous testing to make sure they actually measure what they’re supposed to measure. ‍

JB: What do you mean that the tests undergo “rigorous testing”?‍

AA: In simple terms, there’s a lot of research that goes into designing a psychological test. Whereas you see this 5 minute Buzzfeed quiz online, there isn’t much thought or research that goes into it-‍

JB: It’s not rigorously developed?

AA: Yes, it’s more of a fun thing that you do. So it doesn’t actually measure what it’s supposed to measure. So whatever results that someone may get on these tests should be taken with a grain of salt, in terms of their reliability and validity.‍

JB: Could you give us an example of a psychological assessment? How much time was taken for it to be developed?‍

AA: I’ll give you a good example from an IQ test: the Wechsler Adult Intelligence Scale (WAIS). That would have taken a couple of years of research to develop with thousands of participants in order to get that baseline data. ‍

JB: Right, so a lot of money and time with experts must have been spent just to develop that tool, which is then used with clients. Why is it important to do so much research to develop a psychological assessment tool?

AA: To put it simply, we want to make sure that we’re actually measuring the thing that we’re trying to test or look out for. For example, let’s say I have an assessment tool to measure ADHD. I want to make sure that the questions that are asked on this tool are related to ADHD, and not related to something else. ‍

JB: So it has to be very precise. I would imagine if you asked the wrong questions, then you’re not measuring what you’re supposed to be measuring. 

So sometimes I hear people use the terms “psychological testing” and “psychological assessments”. Is there a difference between these two terms?

AA: Yeah, I can see how people can get these two terms mixed up at times. So, psychological testing is the administration of the actual test itself; that one product, such as the Wechsler [Adult Intelligence Scale]. And psychological assessment is an array or battery of tests that we administer to someone in order to find out or answer a specific hypothesis. 

JB: In a battery of tests, how many tests might you use?‍

AA: For example, for someone with ADHD, we may run the IQ test, the Adaptive Behavior test, and the actual ADHD test. All in all, that’s three tests, not including direct observation as well. 

‍JB: So you would do direct observation, and then you would also (I guess this also differs case to case) potentially use three separate tools. To be able to say what?‍

AA: To be able to confidently say that this person most likely has ADHD, or not. ‍

JB: Wow! So you could administer a whole battery of tests to confidently determine whether a diagnosis is accurate, because you’re looking into the minds of people, and you need to be careful exactly what it is that you’re looking at. 

So what are the different areas or disorders that can be covered through psychological testing? ‍

AA: I found that we can break down the psychological tests we use into five major domains. The first is cognitive; the most common one would be the IQ test, like the WAIS. This is able to measure the entire brain’s functioning. On top of that, there are tests in the cognitive domain which measures specific areas of the brain’s functioning, such as the CTMT, which measures the attention area of the executive functioning of the brain, or the Wechsler Memory Scale, which measures the temporal regions of the brain which relates to memory. ‍

JB: So these cognitive tests are not really covering if someone, let’s say, has a mental illness, ADHD, but it’s designed to figure out how their brain is functioning, in terms of memory, executive functioning-

AA: And in executive functioning, it breaks down into a lot of other subdomains as well, but we won’t get into all that!

JB: It sounds really complicated! (laughs). That’s why you have to spend so many years studying it, to be able to confidently say that you know what it is that you’re assessing. So what other areas, aside from cognitive?‍

AA: Yeah, so you mentioned ADHD right? So that would fall under the neurodevelopmental category, so that would entail assessments relating to ADHD and the autism spectrum disorders. ‍

JB: You used the word “neurodevelopment”. Can you unpack that a little bit?‍

AA: So neurodevelopment means that it has something to do with neural functioning: the brain’s neurology of an individual as they grow up. So many things can happen to a child as they grow up, right? You can have typically developing kids, and those that differ from that typical pathway. So this is where these forms of assessments come in to measure and assess whether that person exhibits symptoms that may suggest ADHD or autism. ‍

JB: So when you say “grow up”, that has to do with development, right? So this neurological development aspect is another domain, and some of these mental disorders are neurodevelopmental. What are the other domains?‍

AA: So the next one is social. Social refers to the person’s adaptive functioning, and includes tools that are common to most people: personality tests, aptitude tests. So these would fall under the domain of social. 

The next one is biological. So this is something that not many clinical psychologists can measure; it’s a bit more on the medical side of things (for example, testing for genetic history). But these questions can be asked during the intake interview.  ‍

JB: So you can do a sort of “genetic testing” as well?

AA: Not specifically, like if you were working in a lab or something like that. But you can ask questions about their extended family tree to see whether there is any other psychiatric history in their family background-‍

JB: For example, what could be genetic?‍

AA: So, like autism and ADHD, even neurotic disorders such as depression and anxiety, they have an increased risk factor in someone who has a relative who has been diagnosed with the disorder as well. ‍

JB: So some of this can be “running” in the DNA?

AA: Exactly, and whether the gene is expressed is a different story. 

JB: I see, so you could have the gene, but you don’t necessarily have it expressed? So that means you don’t show it, you don’t have it. Any other domains? ‍

AA: The last one would be emotional. So I think most students, or those that work in a medical or school setting would be familiar with what we call the DASS-21 (Depression, Anxiety, Stress Scale).  This is a common screening tool that is used to measure these three forms of psychological well-being. Other common tools in this category include the Beck Anxiety Inventory and Beck Depression Inventory.‍

JB: So this is what, in my view, we call “mood”. So you’re calling it emotions, right? And I think that we deal with these a lot in clinical, therapy-oriented work. So you do more than just therapy-oriented work, you assess for a host of different domains within the human mind and functioning.

So you mentioned biology. Some people ask about seeing a doctor or seeing a psychologist or psychiatrist, and they get very confused. What’s the difference, and which one should someone go see? ‍

AA: So I will first focus on my role as a clinical psychologist. Our specialisation is a bit different, but we work closely alongside psychiatrists and other professionals. Now, let me put you in a hospital setting: so you would first be seen by a psychiatrist, and they would manage your case by prescribing medications if needed. And let’s say if they determine that your symptoms can be further managed with therapy, then they would refer you to a clinical psychologist.

Now it is also possible to see a psychologist, or clinical psychologist first-‍

JB: You’re saying “psychologist” and “clinical psychologist”: is it the same thing or are they two different things?‍

AA: I would argue it’s two different things, because a clinical psychologist specifically focuses on the more severe mental health disorders; it’s more clinical, in that sense. Whereas a psychologist, you can just have a Master’s degree in General Psychology, but then jump around to different areas in the field. 

JB: I see. Could you give an example of what a clinical psychologist would do that a general psychologist may not do?

AA: One of the main areas of expertise of a clinical psychologist is administering assessments: to measure and assess whether a person has a mental disorder using assessment tools. Whereas a general psychologist, they would learn or measure looking at the person’s behaviour, but not necessarily administer any forms of formal psychological assessment.

JB: What is the general psychologist doing with patients in the hospital?

AA: Most of them would generally provide forms of psychoeducation or basic therapy. 

JB: I see. So even at that level, you would need a Masters in, say, Health Psychology, or something like that, to be able to function in a hospital as a generalist in mental health. 

What about the psychiatrist versus the clinical psychologist? Which one should one go see?‍

AA: That question is difficult to answer because it really depends on the person’s state of mind at that point in time. So in the Malaysian system, you will always be seen by a psychiatrist (who is a doctor) first, because Malaysia follows a medical model. From there, they would assess whether you are stable enough to see a clinical psychologist, counsellor, or psychologist.‍

JB: So a psychiatrist would still depend on the assessments done by a clinical psychologist to help them have a more nuanced understanding of what’s happening with a patient, is that right?‍

AA: Yes, to a certain extent, depending on the person’s concern. So, let’s say the person was referred due to stereotypical behaviour (poor eye contact, late speech development); the psychiatrist may suspect something related to neurological developmental disorders. That is when they would pass the case to a clinical psychologist to run the necessary assessments to see whether it supports the psychiatrist’s hypothesis that the person has, say, autism. 

JB: Right, I think most people don’t understand that there’s just this much complexity in the work. So before you joined Rekindle, which hospitals were you working at

‍AA: I was in two hospitals: Hospital USM in Kelantan, and Hospital Pengajar UPM in Serdang. ‍

JB: So I imagine there was quite a lot of busyness doing clinical work and assessments. So, your choice then to come into a more private practice setting, tell me about what your intentions and hopes are.

AA: So my intention [coming] here is to assist clients, especially those with mood-related and anxiety-related disorders. You see, in the hospitals, the cases were a lot more extreme, a lot more tiring-

JB: I almost get the sense that the prognosis was not always so positive-‍

AA: Yeah, exactly! In hospitals, the prognoses were not that great because of the severity of their condition, which is why we worked alongside psychiatrists a lot. Whereas here at Rekindle, I noticed that clients who come here seek help because they are in the early stages of their psychological distress. So it’s not at a stage where pharmacological intervention is required, nor do they require hospitalisation. So I would say the prognosis for people who come to see Rekindle’s clinicians are a lot better, because they are still in a state of mind where they are able to function as well as apply the techniques and skills taught to them during therapy sessions. ‍

JB: Yes, and I can say that I vouch for that! For the last twelve years, many people have gotten very much better coming here, and now what I’m hearing you say is it could also be the early stage of intervention. Or maybe, it’s not so severe; they’re not so clinically entrenched in their problems that it requires a lot of maintenance. Although, we do get more clinical cases as well, and we try to help everybody however we can. And I’m really glad you’re here to bring a more clinical piece and also be able to help people have a better understanding of how to improve their mental health. And also, speaking as a relationship specialist, the relationship [piece also] helps, because they really do interact. 

So I know you can give me a lot of answers to this question, but if you were to give me just one piece of advice to the average Malaysian about psychological assessment, what advice would you give?‍

AA: So I would say, don’t self diagnose. In today’s digital age, a lot of Malaysians (or people in general) tend to self-diagnose, especially with apps and social media platforms such as TikTok and Instagram. People just view certain videos for 10 seconds and automatically assume: “Okay, I have ADHD”. So if you come into a session, your answers are going to be more biased, in that sense, and it defeats the purpose of the assessment that we’re going to run, because you would have that diagnosis at the back of your mind being the motivational force of your answers. ‍

JB: And sometimes, it can affect the answers too!

AA: Yes, exactly! It could result in a false positive. So my advice is: just come in with an open mind so that you can get a more truthful, unbiased answer, and your clinician or therapist would be  able to explore the different possibilities with you as well.

JB: That’s great. 

So there you have it folks. A little short podcast on psychological assessments. If you have any questions, feel free to drop us a comment or email; we’d be happy to take any questions. And also, with your feedback, we can also create more podcasts (and I’d love to have Arman be able to do more interviews!), and increase the mental health literacy in Malaysia. Thank you!‍

AA: Thank you so much for having me!