Testing a Client Who Cannot Read
You are asked to evaluate a 58-year-old client, "M," who recently immigrated and speaks limited English. M has a history of stroke affecting the right hemisphere and reports difficulty with visual-spatial tasks. The referral asks for a "drawing-based assessment to rule out cognitive decline." Your agency has the House-Tree-Person and the Bender-Gestalt II available. M is cooperative but anxious and apologizes repeatedly for "doing it wrong." An interpreter is available for two hours this week. The referring physician wants results before a medication review in five days.
1. Which instrument, if any, should you use, and what are the limits of what you can conclude?
Read the worked answer
Neither instrument supports a "rule out dementia" conclusion on its own, and both are confounded here. The Bender-Gestalt II is a visuomotor copying task; with a right-hemisphere stroke and reported visual-spatial difficulty, poor performance is expected and cannot be attributed to cognitive decline. The HTP is a projective technique with weak validity for diagnosing cognitive impairment; using it to answer this referral would overstate what it can do.
The honest response is to reframe the question. If the physician needs a cognitive screen, use a validated instrument with appropriate norms and interpreter support, or refer to neuropsychology. If the question is about M's functional experience and emotional response to the stroke, drawing can contribute qualitative information, clearly labeled as such.
State limits in the report: language, culture, education, and neurological status all affect performance; results are descriptive, not diagnostic. Do not let the five-day deadline push you into an unsupported conclusion. A report that says "this instrument cannot answer this question, here is what I can offer" is clinically responsible and protects M from a mislabel.
2. How do you manage M's anxiety and the interpreter during the session?
Read the worked answer
M's apologies signal fear of failure, which will distort any task. Begin by normalizing: explain that there are no right answers, that you are interested in how the task feels, and that you will stop if it becomes uncomfortable. Give M control over pacing and permission to decline.
With the interpreter, set ground rules before M arrives: interpret everything, including your asides, and do not summarize or advise. Speak to M, not to the interpreter. Allow extra time; two hours is tight for assessment plus interpretation, so prioritize. Watch for fatigue and stop before it degrades the data.
Interpret anxiety as information, not interference. If M's distress rises, note it and consider ending early. A shortened, valid session beats a complete, invalid one. Debrief with M about how the session felt, and document the interpreter's presence, the language used, and any adaptations, so the record is transparent about conditions.