Setup of the Feedback Session

At the outset of the evaluation, you should have spelled out exactly who gets the results (e.g., the client's therapist, medical doctor, lawyer, employer...), what roles are played by the people involved (e.g., the therapist will discuss more detailed results with the client, the lawyer will discuss the implications for court...), and what expectations are possible (e.g., the evaluator will not be able to see the client for therapy). This should also include the HIPAA practices in place in your office. This sets the stage for the evaluation, and finally for the feedback session.

Set the client at ease by discussing any feelings such as anxiety or depression over the feedback you will be offering. You might want to ask if there was anything they wanted to offer or clarify about the testing before you begin. Remind the client of the assessment questions and solicit any additions to this they have considered since the last appointment. Likewise, any crises situations may need to be addressed first.

One way to explain the data is that the test results are a kind of communication from the client about the client's view of the world. They reflect how they make sense of senseless things, how they express their own ideas, how their opinions compare to those of many different groups. They are not infallible, but offer one view, and the point of feedback is to sharpen that view.

Giving Feedback

  • Ask the client about any questions they have, and be sure to answer these questions at some point in the feedback session. While the referral source may have one set of questions, the client may have another, which was the real reason they were willing to undergo the evaluation.
  • Begin with something positive. People can hear weaknesses better if they also hear strengths.
  • Do not just "tell everything" you found in testing. You might begin with the simpler results and move to the more complex ones, or begin with the referral question and explain why you chose the tests you did to answer these questions. In each case, however, begin with findings the client will accept. Gradually move on to something they may have considered, but have not fully reflected on or recognized.
  • Finally, offer one thing you think they were not expecting to hear to see how they can handle this information. If they do well, they may be able to handle more difficult feedback. If they do not, then there may be no need to upset them or assault their defenses with other information they are not ready to hear. In some cases, such as a court referred case, you will have to explain what your final recommendation to the court will be. However, in most cases you may include additional information in the file for the client to access when they are ready for it.
  • Chose your language carefully. I read a study once where they presented statistics on chemotherapy versus operations for cancer. In the first half, they emphasized that more people died from operations while all lived after chemotherapy, and most everyone chose chemotherapy. In the second half, they emphasized that fewer of the people who had chemotherapy were alive at the end of five years, while more who had the operation were. People chose the operation more frequently then. The language can make quite a bit of difference....
  • Tailor the feedback delivery to the client. An audiotape, written letter, or notes can help them remember your feedback and make use of it. I once did neuropsychological testing with an elderly woman who had serious memory impairments. After doing an excellent job of explaining the test findings, I asked her what she would tell her adult daughter about the test results. She replied, "That I'm doing good and my memory is fine." After a few questions, I realized she didn't remember much of what I'd told her, which I should have known given the extent of her memory problems. I obtained her consent to put the feedback in a letter and send it to her and to her daughter.
  • End with some positive note. This may help offset the last feedback you gave if it was more difficult to hear. It can also allow the person to leave feedback feeling that even though they have problems, things are not all bad.

After each finding:

  • Enlist the client in verifying or modifying test findings.
  • If they disagree, can they see how others might perceive them this way? Can they think of any situations in which the feedback might be true? If they believe these things may be true for other people who take the test, but not for them, ask if they can think of any characteristics they might have in common with the people for whom these statements would be true?
  • Pause and support the client's affective reactions as they occur. The feedback you have given them may be hard to understand. Even if they knew it and understood it, it may be very hard to hear it stated clearly from a stranger, or be very hard to realize they revealed this so clearly.

Never argue with a client about a test finding:

  • On the one hand, the data says what it says, and you are sharing it with them to place it in a context to give it meaning. Some of it may be very true and some less true. Some may be true in most settings and some only in a few. There is no point to arguing, as the point of the feedback session is to gain agreement and clarity.
  • On the other hand, the final meaning in the report is the interpretation you give to the data, as it is your professional opinion that was requested. You may alter some of your interpretations about the data after meeting for feedback, but if there are points of disagreement and you will not be altering your professional opinion or the content of the report, you owe it to the client to be honest about this.

Do not omit a test finding simply because it seems embarrassing to raise and discuss. The client may be waiting for an opportunity to talk to someone about the issue with someone, to have it normalized in some way, or simply to have the issue recognized as very sensitive. It might also indicate the need for a referral.

Ethical Concerns

At the end of the feedback session, you should discuss again the release of the report or client record.

  • Discuss who gets the report, and how and when it will be released. According to HIPAA, this means specifying the name of the person to whom it will be released, and the exact method of release, such as by fax to a specified number or by US Postal Service to a specified address. This release must be clearly documented in the file.
  • Include in your explanation "what happens if..." situations, such as
    • what happens if you receive a subpoena for the report (you may be required to release it, but will inform the client of this before you do so)
    • what happens if someone requests a copy of the report a year and a day after the release is signed (the release is expired in Illinois, and a new release from the client must be obtained)
    • what happens if a valid request is received from a non-psychologist (HIPAA mandates that the client can give this release and you must honor it, but your office or agency policy might be not to release the report until you have communicated with the client, explained your reservations about the release, and confirmed the client's continued consent)
  • Remember that although the client may have signed the consent form at the start of the evaluation allowing release of the report, they still have the right to withdraw that consent at any time in most cases. For example, in a court referred case, the person you tested may not have any choice about the release of the report, since the "court" is considered the client. However, in most all other cases, the person you tested is the client and still has the right to withdraw consent. There may be some legal limitations on this. For example:
    • In the case of a child under the age of 12, the parents have the right to give or withdraw consent for release of the client's information; however, you may still obtain the child's assent, by explaining what will be revealed to the school and how you believe it will help the child.
    • If the client is 12 to 17 years old, both the client and parental consent is required in Illinois to release the client's records.
    Explaining these requirements of law again at the feedback session can often prevent confusion and problems later.
  • Remind the client of any other rights they have at the feedback session. For example, Illinois law prohibits secondary disclosures. This means that the person you send the report to can not, by law, release it to someone else. In another example, HIPAA allows that clients, according to the policy in place in your office or agency, can file an addendum to the report that states their agreement, clarification, or disagreement with the findings. This addendum must be saved with the report and released with it. Your office or agency might stipulate that the addendum may be no more than two pages long, must be typed, and must be dated and signed by the client, for example.
  • Finally, remind the client they can contact you in the future if they have additional questions or concerns about the evaluation, or the release of the report.

After the feedback session is completed, you have two tasks left. First, you should document the legal and ethical issues you discussed, and that the client still gave their consent for the release of the report. Second, you should "check in" with yourself. What are you containing you wish you could have said? What went well and not so well with the feedback session? What did you learn?