Therapeutic Assessment With Child Inpatients

Growing evidence supports Therapeutic Assessment (TA), a collaborative and therapeutic approach to psychological assessment, as an effective method for enhancing motivation for and engagement with psychotherapy across a variety of clinical populations and treatment settings. However, to date there are no known studies assessing the use of TA in child psychiatric inpatient settings. This article briefly reviews the structure of child and family TA, enumerates the challenges and risks associated with short-term inpatient stays, and proposes a path for integrating TA into these units as a way to enhance the quality of care and reduce the risk of rapid rehospitalization. The authors provide three case examples from a child psychiatric inpatient unit, each using a modified version of TA and each integrating assessments into brief family interventions. The authors conclude with suggestions for best practice for child psychiatric inpatient TAs.     

The shaping of personality: genes, environments, and chance encounters

I started my career as a clinical psychologist with an interest in personality assessment. But a loss of faith in psychoanalytic theory, projective tests, and clinical case studies in general led to a shift in my interests to personality research. Subsequent jobs at research institutes and universities allowed me to indulge in science. I developed the trait-state concept and its application in tests for affect measurement. For 10 years I did experimental research in the field of sensory deprivation. The sensation seeking idea and tests evolved from this work but soon expanded to many other areas. Research in the biological basis of sensation seeking started with genetic and psychophysiological research, but research conducted in other laboratories also pointed to a psychopharmacological basis for the trait. Over the last several decades, I have formulated a psychobiological model for personality. I have used factor analysis and the biosocial model to develop an "alternative-five" factorial trait structure for personality.     

Trainee and Client Experiences of Therapeutic Assessment in a Required Graduate Course: A Qualitative Analysis

Surveys indicate that practice and training in psychological assessment, and personality assessment (PA) to a lesser degree, has been stable or increasing over the past quarter-century. However, its future arguably remains threatened due to changes in doctoral training programs and beliefs in the field concerning the utility of PA for treatment success. To increase interest in and use of PA, studies of training methods that include trainees' perspectives are needed. This study evaluated the experiences of 10 graduate trainees and their clients who were trained in and conducted a brief Therapeutic Assessment (TA). Qualitative responses to a self-evaluation administered post-TA were coded using directed content analysis. Results indicated that trainees viewed TA/PA as having clinical utility; they had positive feelings about TA/PA, and they desired or intended to use or continue learning about TA/PA. Clients' responses reflected positive feelings about the TA, having gained new self-awareness or understanding, and having a positive relationship with the assessor. The findings suggest that teaching PA from a TA perspective could produce positive benefits for psychology trainees.     

Clinical Validity of Prototype Personality Disorder Ratings in Adolescents

A growing body of research shows that personality pathology in adolescents is clinically distinctive and frequently stable into adulthood. A reliable and useful method for rating personality pathology in adolescent patients has the potential to enhance conceptualization, dissemination, and treatment effectiveness. The aim of this study is to examine the clinical validity of a prototype matching approach (derived from the Shedler Westen Assessment Procedure–Adolescent Version) for quantifying personality pathology in an adolescent inpatient sample. Sixty-six adolescent inpatients and their parents or legal guardians completed forms of the Child Behavior Checklist (CBCL) assessing emotional and behavioral problems. Clinical criterion variables including suicide history, substance use, and fights with peers were also assessed. Patients’ individual and group therapists on the inpatient unit completed personality prototype ratings. Prototype diagnoses demonstrated substantial reliability (median intraclass correlation coefficient =.75) across independent ratings from individual and group therapists. Personality prototype ratings correlated with the CBCL scales and clinical criterion variables in anticipated and meaningful ways. As seen in prior research with adult samples, prototype personality ratings show clinical validity across independent clinician raters previously unfamiliar with the approach, and they are meaningfully related to clinical symptoms, behavioral problems, and adaptive functioning.     

Discussion of Difficult Assessment Cases: Psychodynamic Perspectives

I discuss the papers of Kleiger (this issue), Husain (this issue), and Bram (this issue), each of whom described their personality assessment of a very challenging case. Each case illustrates the way in which experienced personality assessors integrate psychoanalytic theory with clinical reasoning, multi-method assessment, and an understanding of the patient–examiner relationship when evaluating patients with serious psychiatric needs. The discussion elaborates particular aspects of each case and integrates the different estuaries through which personality assessors use psychoanalytic theory to develop diagnostic and treatment inferences.     

On the usefulness of measures of normal personality for clinical assessment: evidence of the incremental validity of the Revised NEO Personality Inventory

As a means of examining the incremental validity of a normal personality measure in the prediction of selected Axis I and II diagnoses, 1,342 inpatient substance abusers completed the Revised NEO Personality Inventory (NEO-PI-R) and the Minnesota Multiphasic Personality Inventory--2 (MMPI-2) and were assessed with structured clinical interviews to determine diagnostic status. Results demonstrated that scores from the NEO-PI-R (a) were substantially related to the majority of diagnoses, accounting for between 8% and 26% of the variance in the diagnostic criteria; (b) explained an additional 3% to 8% of the variability beyond 28 selected MMPI-2 scale scores; (c) increased diagnostic classification an additional 7% to 23% beyond MMPI-2 scale scores; and (d) were significantly more useful when examined at the facet trait level than at the domain trait level. Implications for incorporating measures of normal personality into clinical assessment batteries are discussed.     

A conceptual model and case study for the psychological assessment of hysterical pseudo-seizures with the Rorschach

Conceptual models are being increasingly utilized to guide psychological assessment of complex clinical problems. In this article, I present a conceptual model to direct the assessment of personality processes involved in producing hysterical pseudo-seizures. Pathological personality processes present in hysterical reactions are outlined. Rorschach parameters that have been validated and that are therefore considered good indicators of the relevant personality processes are presented. A case study of a patient with both documented genuine and hysterical pseudo-seizures demonstrates use of the model. I offer a treatment plan that is related to the psychological structure of the patient. Use of this model may improve psychological consultation in medical settings.     

Effectiveness of dialectical behaviour therapy for borderline personality disorder in an inpatient setting

This study evaluates the effectiveness of dialectical behaviour therapy (DBT) for borderline personality disorder (BPD) in an unselected, comorbid population seeking 3-month inpatient treatment. We studied 50 consecutively admitted individuals (44 women, six men) with BPD as defined by DSM-IV at three time points (at admission, at discharge, and at the 15-month follow-up). For the clinical diagnoses, we used the Structured Clinical Interview for DSM-IV (SCID) and compared the frequencies of comorbid axis I and axis II disorders at admission and at the 15-month follow-up. Overall, participants showed a high degree of comorbidity. Psychopathology was significantly reduced at post-treatment and at follow-up. Effect sizes for outcome measures were within the range of those of previous studies. Our findings support the notion that the results of the DBT efficacy research can be generalized to an inpatient setting and to patients with BPD disorder with high comorbidity.     

Relationship between patient characteristics and treatment allocation for patients with personality disorders

Within a large multi-center study in patients with personality disorders, we investigated the relationship between patient characteristics and treatment allocation. Personality pathology, symptom distress, treatment history, motivational factors, and sociodemographics were measured at intake in 923 patients, who subsequently enrolled in short-term or long-term outpatient, day hospital, or inpatient psychotherapy for personality pathology. Logistic regressions were used to examine the predictors of allocation decisions. We found a moderate relationship (R(2) = 0.36) between patient characteristics and treatment setting, and a weak relationship (R(2) = 0.18) between patient characteristics and treatment duration. The most prominent predictors for setting were: symptom distress, cluster C personality pathology, level of identity integration, treatment history, motivation, and parental responsibility. For duration the most prominent predictor was age. We conclude from this study that, in addition to pathology and motivation factors, sociodemographics and treatment history are related to treatment allocation in clinical practice.     

The Ward and the Womb: An Integrated Therapeutic Approach for Treatment Resistant Adolescents

ABSTRACT

In mental health settings, we often meet traumatized and volatile youth who resist treatment and do not respond to engagement attempts. For such patients, the treatment refusal may be a representation of their level of personality organization; it can represent difficulties to relate to others, to regulate affective experiences, and to integrate different self-states. Using a case study of a treatment resistant adolescent in residential care, I discuss the limitations of engagement techniques with patients at the lower end of personality organization and argue that engaging “difficult to treat” adolescents requires a clinical shift from the therapeutic encounter to the development of a system-based “holding” environment. I present a modified intervention model that integrates psychodynamic formulation of personality development with process-oriented systemic work. The model described emphasizes the role of the therapist as the initiator and facilitator, helping to construct a coherent and attuned environment within the residential care system. Through case vignettes, I provide examples for the clinical shift from the therapeutic encounter to the environment of the ward and demonstrate how developing a holding environment can overcome engagement barriers and support the development of the patient’s ego capacities, sense of self, and object relations.     

Personality characteristics of drug addicts and alcoholics on the Millon Clinical Multiaxial Inventory

The Million Clinical Multiaxial Inventory (MCMI) was administered to 106 alcoholics and 100 addicts in separate VA inpatient rehabilitation treatment programs. The alcoholics scored higher on the personality style scales of Avoidant, Passive-Aggressive, Schizotypal, Borderline and Paranoid, while the opiate addicts scored higher on the Narcissistic personality disorder scale. Separate cluster analyses for both groups further revealed common personality styles among both groups. Several MCMI scales showed significant correlations with age, but in no case were the effects attributed to age larger than 5% of the total variance. The MCMI may alert clinicians to subtle similarities and differences between and among alcoholics and opiate addicts.     

Diagnosis of personality disorders: a case study

In this article, I report a case highlighting diagnostic uncertainty about psychopathology on both Axes I and II. It concerns in part the problem of comorbidity in relation to diagnostic classification of Axis II personality disorders. After commenting on these uncertainties in relation to categorical and dimensional models, I also consider a psychoanalytic explanation to illustrate an example in which a theoretical model informs diagnostic interviewing. I emphasize how the clinical information that unfolds from an interview based on this theoretical model generates inferences about psychopathology that extend clinical understanding beyond the formal diagnostic assessment of Axes I and II disorders and assessment by self-report.     

Diagnosis of Personality Disorders: A Case Study

In this article, I report a case highlighting diagnostic uncertainty about psychopathology on both Axes I and II. It concerns in part the problem of comorbidity in relation to diagnostic classification of Axis II personality disorders. After commenting on these uncertainties in relation to categorical and dimensional models, I also consider a psychoanalytic explanation to illustrate an example in which a theoretical model informs diagnostic interviewing. I emphasize how the clinical information that unfolds from an interview based on this theoretical model generates inferences about psychopathology that extend clinical understanding beyond the formal diagnostic assessment of Axes I and II disorders and assessment by self-report.     

Personality prototypes in eating disorders based on the Big Five model

A three factor model of personality pathology was investigated in a clinical sample of 335 female eating disordered patients. Cluster analysis of the Big Five NEO-FFI scales (Costa & McCrae, 1992) yielded three distinct personality profiles, which were consistent with previous studies: (1) a resilient/high functioning cluster with no clinical elevations on the NEO-FFI scales; (2) an undercontrolled/emotionally dysregulated cluster with elevated scores on the Neuroticism scale and low scores on Conscientiousness and Agreeableness; (3) an overcontrolled/constricted cluster showing high scores on Neuroticism and Conscientiousness and low scores on Openness to Experience. Comparing the three personality prototypes with respect to Axis I and Axis II disorders,resilients reported systematically less clinical and personality problems than both undercontrollers and overcontrollers. Compared to the latter, undercontrollers showed more impulsive personality features and behaviors. Finally, cluster membership was not clearly associated with eating disorder subtypes, suggesting that there is considerable variance in personality features and/or pathology within the various eating disorder categories.     

Religious imagery of a schizotypal patient

Psychotherapists are increasingly challenged to become more effective with religiously oriented patients. In this article I summarize a recent stage model of psycho-religious functioning that was developed to help psychotherapists work with religious material in clinical practice. Following this brief introduction, I describe how the paradigm guided my clinical understanding of a young man suffering from a severe personality disorder. The case study depicts the entanglement of his religious thinking with his core psychological and emotional conflicts and supports the assertion that nonjudgmental exploration of religious imagery may be a vital component of psychotherapy with intensely religious patients.     

Validity of the Superiority and Goal Instability Scales as Measures of Defects in the Self

A series of four canonical correlation analyses was conducted to compare the Superiority and Goal Instability scales both with personality pattern and clinical syndrome scales from the Millon Clinical Multiaxial Inventory (MCMI) and with therapist ratings of personality traits and symptom patterns using 91 clients from a cross-section of outpatient and inpatient mental health agencies. The Superiority scale was related to a pattern of social gregariousness, interpersonal exploitation, and impulsivity and Goal Instability was related to a pattern of social withdrawal, depression, and lack of ambitions and goals. These results clarify the meaning of the two self-scales as well as providing preliminary data on self-pathology and character types.     

Validity of the Superiority and Goal Instability scales as measures of defects in the self

A series of four canonical correlation analyses was conducted to compare the Superiority and Goal Instability scales both with personality pattern and clinical syndrome scales from the Millon Clinical Multiaxial Inventory (MCMI) and with therapist ratings of personality traits and symptom patterns using 91 clients from a cross-section of outpatient and inpatient mental health agencies. The Superiority scale was related to a pattern of social gregariousness, interpersonal exploitation, and impulsivity and Goal Instability was related to a pattern of social withdrawal, depression, and lack of ambitions and goals. These results clarify the meaning of the two self-scales as well as providing preliminary data on self-pathology and character types.     

Thoughts on Interpreting

In this paper I examine the value and contra—indications of interpreting. I point out the specific danger of interpreting when patients suffer from a weak ego as is the case in narcissistic personality disorder and borderline psychosis. I highlight the danger of premature interpretations of the shadow. Reference is made to the analyst's counter—resistance to interpreting and to his interpreting being motivated by his psychopathology. The paper contains clinical material to illustrate these views.     

Therapeutic Assessment with couples

Therapeutic Assessment can be helpful to many types of couples, including (1) those who are considering marriage and wish to know each other more deeply, (2) long-term couples who are in distress and considering separating, and (3) couples who have decided to separate but wish to better understand why they were unable to stay together. This article comprises the first complete case study of Therapeutic Assessment (TA) with couples. I describe how those steps common to all forms of TA (initial sessions, extended inquiries, assessment intervention sessions, and summary/discussion sessions) differ when applied to couples. I also discuss the use of the Consensus Rorschach as an assessment intervention with long-term distressed couples engaged in problematic projective identification. The case example involves a young heterosexual couple married for 12 years who were at an impasse in couples therapy. The assessment helped the partners explore mutual conflicts around the expression of anger and dependency needs, and to resolve a power imbalance within the couple. Long-term follow-up showed that the Therapeutic Assessment helped the couple have more compassion for each other and move beyond the destructive role-lock they had fallen into. Also, the referring therapist reported that the TA helped resolve the impasse in the couples’ therapy.     

The Relationship between Personality Disorder Features and Symptom Improvement at an Inpatient Treatment Program for Posttraumatic Stress Disorder

This study examined the association between personality disorder (PD) features and symptom improvement among adult survivors of childhood trauma in an inpatient program for posttraumatic stress disorder (PTSD). Participants completed questionnaires at admission, discharge, and six months following discharge. Multiple regression analyses were used to assess the combined effects of personality features on symptom improvement. Results indicated that improvement in trauma-related symptoms was not related to PD features. By contrast, the PD features were associated with change in other Axis I symptoms often comorbid with PTSD. Overall, results suggested that PD features do not impede improvement in trauma-related symptoms; however, specific accommodations might be needed to address comorbid disorders among individuals with PTSD.