The Impact of Different Thematic Apperception Test Administration Methods on Narrative Length and Story Richness as Measured by the Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G).

The Thematic Apperception Test (TAT) is the second most commonly used performance-based task in clinical practice. However, traditional TAT administration is time-consuming and raises accessibility issues. This study examines the effect of administration modifications (i.e., examiner handwriting versus typing, examiner recording versus participant recording, and re-prompting versus no re-prompting) on narrative length and richness as measured by the Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G). A four-card TAT protocol was administered to 150 college students under one of five conditions. The resulting narratives were scored by two trained raters using the SCORS-G. MANOVA procedures showed (a) no significant differences between examiner handwriting versus typing; (b) the shortest, blandest narratives were produced when the examiner recorded the narratives without re-prompting; and (c) the longest, richest narratives were produced when the participant typed the narratives with re-prompts on the computer screen. Clinical and research implications and future directions will be discussed.

Exploring the Alternative Model for Personality Disorders Using SCORS-G Ratings on Thematic Apperception Test Narratives.

The Alternative Model for Personality Disorders (AMPD) in Section III of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) conceptualizes personality pathology as a combination of impairment (Criterion A) and traits (Criterion B). One measure used to develop Criterion A was the Social Cognition and Object Relations Scale - Global Rating Method (SCORS-G), which is a multidimensional, object-relational clinician-rated measure of personality functioning. Although there are conceptual links between the AMPD and SCORS-G dimensions, there exists no research examining the relationship. To address this, we examined associations between the SCORS-G dimensions and measures of the AMPD constructs in a large, archival dataset of outpatients and inpatients. More pathological scores on SCORS-G dimensions reflecting self- and interpersonal functioning were associated with greater pathological traits and impairment. Overall, results support further investigation into SCORS-G as a useful measure in AMPD research and assessment.

How narrative source impacts convergence of ratings from the Social Cognition and Object Relations Scale-Global Rating Method with psychotherapy process measures.

This study examines the construct validity of the Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G; Westen, 1995; see also Stein & Mulford, 2018) by exploring the degree of convergence across different narrative sources (i.e., early memories [EM] and psychotherapy narratives [PT]) in relation to patient- and therapist-rated psychotherapy process measures. Using a university-based outpatient sample (n = 81), we found limited convergence for SCORS-G ratings across narrative type. First, paired t tests showed that the means for six of the eight SCORS-G dimensions differed significantly between the EM and PT narratives with the majority having a large magnitude of effect. Moreover, despite 29 significant correlations between a SCORS-G dimension and either an alliance or session quality variable, only two of the eight SCORS-G dimensions significantly correlated with the same process variable across narrative type (e.g., patient-rated session depth with SCORS-G Self Esteem [SE] and Identity and Coherence of Self [ICS]). Importantly, the high degree of theoretical coherence in the associations that emerged between the SCORS-G dimensions and the process variables suggest that the lack of convergence was not due to limited validity of the SCORS-G. Instead, the results underscore the importance of multi-method assessment techniques by highlighting that the manner in which a narrative is elicited will impact the object relational content patients provide. Future research and clinical implications related to the SCORS-G, alliance and psychotherapy process are discussed.

Are all narratives the same: Convergent and discriminant validity of the Social Cognition and Object Relations Scale-Global Rating Method across two narrative types.

This study examines the construct validity of the Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G) by exploring the degree of convergence across different narrative sources (i.e., early memories [EM] and psychotherapy narratives [PT]) using a university-based outpatient sample (n = 101). First, we examined intercorrelations between SCORS-G ratings of EM and PT. Intercorrelations between SCORS-G EM and PT revealed that three of the dimensions significantly correlated with themselves across narrative type (Emotional Investment in Relationships [EIR], Experience and Management of Aggressive Impulses [AGG], and Self-Esteem [SE]), but that only AGG had its strongest correlation with itself (i.e., EM AGG to PT AGG). In addition, EM AGG was significantly related to all but one of the PT SCORS-G dimensions. Likewise, EM SE correlated with all but two of the PT SCORS-G dimensions. Second, we examined how narrative source related to clinical findings. With the use of a multimethod approach, we assessed how SCORS-G ratings from both narrative types correlated with selected variables from the Personality Assessment Inventory (PAI) and Rorschach Inkblot Test. Findings indicated that there were only three instances in which both narrative types had significant relationships to the same variable/scale, and all three instances were with the Rorschach. Together, these findings suggest that even when using the same scale (SCORS-G), different narrative sources differentially activate aspects of object relations. In addition, the results highlight that difficulties with self-esteem and poor management of aggression in childhood interactions relates to patients' object relational functioning later in life. Clinical implications and future research are discussed.

When's a story a story? Determining interpretability of Social Cognition and Object Relations Scale-Global ratings on Thematic Apperception Test narratives.

The Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G) measures the quality of object relations in narrative material. The reliability and validity of this measure have been well established. However, a psychometric oddity of this scale is that default ratings are given to select dimensions when the relevant construct is not present. This can result in narrative 'blandness' and may impact clinical findings. The aim of these two studies is to understand these phenomena both psychometrically and clinically. In the first study, we identified 276 outpatients who had SCORS-G ratings for TAT Cards 1, 2, 3BM, and 14, set criteria for narrative 'blandness' across all eight dimensions, and examined group differences. In Study 2, we used a subset (N = 99) of Study 1 and examined how percentage of formal default ratings for Emotional Investment in Values and Moral Standards (EIM), Experience and Management of Aggressive Impulses (AGG), Self-Esteem(SE), and Identify and Coherence of Self (ICS) impacted robustness of correlations across tests of intelligence, psychopathology, and normal personality functioning. Taken together, we identified clinical characteristics of patients who are more likely to produce 'bland' narratives and increased percentages of formal default ratings. Also, an excess of default ratings per protocol impacts robustness of correlations and weakens significant correlations. As cut-off scores increase (>25% and >28.12%), the likelihood of being able to interpret EIM, AGG, SE, and ICS decreases. Psychometric and clinical implications are discussed.

The relationship between trainee therapist traits with the use of self-disclosure and immediacy in psychotherapy.

The goal of the present study was to explore how self-disclosure (SD) and immediacy relate to trainee therapists' personal characteristics. A prospective multitrait multimethod assessment approach was utilized to assess a wide range of trainee characteristics at the beginning of graduate school. Results showed a significant, positive relationship between trainee interpersonal problems and SD for trainees (n = 33) in their third psychotherapy session with their first patient. Moreover, greater use of SD correlated with less session depth, as rated by the trainee. Greater use of immediacy was positively related to trainee undergraduate grade point average and trainee-reported post-session arousal. Notably, all statistically significant findings had a moderate magnitude of effect. Finally, qualitative analyses of the SDs and immediacy statements were included to aid the discussion of potential reasons for the results. Overall, our findings provide preliminary conclusions about which trainees utilize SD and immediacy, what types of SDs and immediacy interventions they tend to use, and how trainees and patients perceived the session in which SD and immediacy were implemented. Implications for supervision and training are discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Extending the Use of the SCORS-G Composite Ratings in Assessing Level of Personality Organization.

The Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G; Stein, Hilsenroth, Slavin-Mulford, & Pinsker, 2011 ; Westen, 1995b ) reliably measures the quality of object relations in narrative material. It assesses 8 dimensions (on a continuum from maladaptive to adaptive) that mediate interpersonal functioning. The 8 dimensions can be averaged to create a global or composite score to represent a person's overall object relational functioning. This study aimed to create levels of personality organization using the SCORS-G global score ratings of Thematic Apperception Test (TAT) narratives and to explore the construct validity of these levels using a multimethod approach (i.e., psychopathology, normal personality, and life-event data). Meaningful relationships were found between the SCORS-G level of personality organization and aspects of psychopathology (Personality Assessment Inventory; Morey, 1991 ), regulation and control (NEO Five-Factor Inventory; Costa & McCrae, 1989, 1992b ), and number of psychiatric hospitalizations, suicide attempts, and educational level. Overall, this study demonstrates the potential value of creating levels of personality organization (LPO) using the SCORS-G composite or global ratings as a supplement to the psychological assessment process and further highlights the utility of this measure in the field of personality assessment. Clinical and research-related implications as well as limitations are discussed.

You really are too kind: implications regarding friendly submissiveness in trainee therapists.

To facilitate patient growth, therapists must immerse themselves in the patient's world while also being able to see what is needed for change. This process requires finding a delicate balance between supporting and pushing patients. Therapists in training are additionally tasked with incorporating supervisors' suggestions with their own views on what is needed to help their patients. Beginning therapists with tendencies to be overly accommodating may struggle to reconcile these competing demands. Thus, the aim of the present work is to explore how trainee friendly submissiveness (FS) interfaces with psychotherapy. Prior to training, clinical graduate trainee (n = 35) FS was assessed using the Inventory of Interpersonal Problems-32. Process and outcome data were then collected from each therapist's first training case. Specifically, each trainee was assigned an undergraduate student volunteer with whom they had four non-manualized therapy sessions over the academic semester. After the third session, patients and trainees completed questionnaires assessing session impact and the working alliance, and two expert raters coded third session videotapes for techniques. Following termination, patients rated the overall helpfulness of the therapy. Trainee FS was significantly negatively associated with patient-rated depth, alliance, and overall helpfulness with moderate effects. Findings from a mediation analysis further suggested that trainees with higher FS struggled to focus the therapy in a way that felt productive to patients. Implications for clinical training are discussed.

External validity of the Psychiatric Diagnostic Screening Questionnaire (PDSQ) in a clinical sample.

This study contributes to the convergent and discriminant validity of the Psychiatric Diagnostic Screening Questionnaire (PDSQ) by investigating its correlations with the relevant clinical scales of the Personality Assessment Inventory (PAI) and life space variables, such as relationship status, education level, job loss, and history of suicide attempts. Bivariate correlations were calculated for a sample of 254 psychiatric outpatients. The results indicated that the PDSQ scales demonstrated good to excellent convergent and discriminant validity with target scales from the PAI. They were also found to be meaningfully associated with a variety of life space variables. For example, five of the subscales and the Total Score correlated positively with a recent job loss, and eight of the subscales were negatively associated with education and/or employment status. Some incongruence with hypothesized relationships was discovered for life correlates classified as markers of psychiatric severity. Overall, these findings add to the emerging body of evidence corroborating the convergent and discriminant validity of the PDSQ.

Exploring the Factor Structure of the Social Cognition and Object Relations-Global Rating Method: Support for Two- and Three-Factor Models.

The Social Cognition and Object Relations Scales-Global Rating Method (SCORS-G) contains 8 scales for coding narrative content. This study explores the factor structure of this measure using college (n = 171), outpatient (n = 239), and inpatient (n = 78) samples. Participants told stories to the Thematic Apperception Test (TAT; Murray, 1943) cards. Stories were transcribed and coded by blind raters using the SCORS-G. Cases were randomly assigned to an exploratory or validation group. Exploratory factor analysis with the exploratory group suggested 2- and 3-factor models. The Emotional Investment in Relationships (EIR) scale did not obtain a primary loading on any factor and was not included in subsequentmodels. After modifications, confirmatory factor analysis indicated good-to-adequate fit for 2- and 3-factor models. Both models showed good fit in the validation group and met criteria for invariance across models. Findings indicated that some SCORS-G scales tap cognitive-structural elements, whereas others assess affective-relational components of narratives. We found mild support separating the affective-relational scales in terms of internal representations for the self and others and relationships. The results reported here indicate that clinicians and researchers can calculate a separate cognitive-structural composite score and an affective-relational composite score when using the SCORS-G to rate TAT stories.

Estimating the Effects of Thematic Apperception Test Card Content on SCORS-G Ratings: Replication With a Nonclinical Sample.

The content of Thematic Apperception Test (TAT) cards can, in some cases, influence how respondents form narratives. This study examines how imagery from select TAT cards affects the narratives of respondents from a nonclinical setting. The Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G; Stein, Hilsenroth, Slavin-Mulford, & Pinsker, 2011 ; Westen, Lohr, Silk, Kerber, & Goodrich, 1989) was used to rate narratives. Forty-nine college students provided narratives to 6 TAT cards. Narratives were rated by two expert raters using the SCORS-G. Consistent with prior research, Card 2 exhibited the most pull for adaptive ratings on SCORS-G scales, and 3 BM exhibited the most pull for maladaptive ratings. Findings for other cards were mixed. Although raters were highly reliable, internal consistency estimates were lower than desirable for 6 of the 8 SCORS-G scales. Variance component estimates indicated that card by person interactions accounted for the largest amount of variance in person-level scores. Results and limitations are discussed in light of prior research. We also make suggestions for further lines of research in this area.

An examination of generalized anxiety disorder and dysthymia utilizing the Rorschach inkblot method.

This study examined transdiagnostic features of generalized anxiety disorder (GAD) and dysthymia in an outpatient clinical sample. Fifteen patients who met DSM-IV criteria for GAD and twenty-one patients who met DSM-IV criteria for dysthymia but who did not have comorbid anxiety disorder were evaluated utilizing the Rorschach. Salient clinical variables were then compared. Results showed that patients with GAD scored significantly higher on variables related to cognitive agitation and a desire/need for external soothing. In addition, there was a trend for patients with GAD to produce higher scores on a measure of ruminative focus on negative aspects of the self. Thus, not surprisingly, GAD patients' experienced more distress than the dysthymic patients. The implications of these findings are discussed with regards to better understanding the shared and distinct features of GAD and dysthymia.

Structured supervision of graduate clinicians in psychodynamic psychotherapy: alliance and technique.

This is the first study to examine longitudinal differences in alliance and technique across multiple cases, controlling for client distress and therapist effects, during structured supervision in psychodynamic psychotherapy. Patient and therapist ratings of alliance as well as independent clinical ratings of psychodynamic interventions were assessed during the 3rd and 9th sessions in the psychotherapy of 58 outpatients, conducted by 24 graduate clinicians. Findings demonstrated that patient-rated alliance was higher across cases at both the 3rd and 9th sessions. These differences in alliance were paralleled by trainees' using significantly more psychodynamic techniques across cases during the 3rd session. All of these differences were in evidence, controlling for patient level of pathology. It is also important to note that there were no significant differences during the course of training for cognitive-behavioral techniques. This is consistent with the specific supervision provided to the graduate clinicians in this training practicum. Practical implications for the use of structured clinical training and issues pertinent to supervision in graduate education are reviewed. Finally, the relationship that structured training may have to graduate clinicians' ability to form a positive alliance with their patients is also discussed.

External validity of the Symptom Assessment-45 Questionnaire (SA-45) in a clinical sample.

This study seeks to evaluate the construct validity of the Symptom Assessment-45 by investigating the instrument's correlation with selected scales from the Personality Assessment Inventory and life-event data in a sample of 93 psychiatric patients. The life-event data used in the study included: education and employment, as well as history of suicide attempts, psychiatric hospitalizations, medical problems, hallucinations, and paranoid ideation. Bivariate correlations were computed to explore the associations among the SA-45 scales and the validity criteria. The results indicated that the SA-45 scales demonstrated adequate convergent and divergent validity with target scales from the PAI. They were also found to be meaningfully associated with a variety of life event variables. These findings add to the emerging body of evidence corroborating the convergent and discriminant validity of the SA-45.

Psychodynamic techniques related to outcome for anxiety disorder patients at different points in treatment.

Although psychodynamic therapy has a well-articulated model of therapeutic change for anxiety, few empirical studies have examined specific treatment interventions related to symptom improvement. We examined the degree of adherence to a psychodynamic model of therapy (Blagys and Hilsenroth [Clin Psychol 7:167-188, 2000) related to changes in anxiety symptoms across early treatment process. Secondary analyses also examined the use of specific psychodynamic techniques across early treatment process in relation to symptom change. The current study sought to extend the findings of , who found a relationship between the use of psychodynamic techniques in the third session (independent clinical ratings) and reduction in anxiety symptoms at posttreatment (r = 0.46, p = 0.04). Using the same sample of anxiety disorder patients (N = 20), we found a significant relationship between psychodynamic technique and posttreatment change in anxiety symptoms at the ninth session (r = 0.49, p = 0.03) and the mean levels of psychodynamic technique across both third and ninth sessions (r = 0.53, p = 0.02). In addition, specific psychodynamic techniques demonstrated significant relationships or moderate to large effects with posttreatment changes in anxiety symptoms at the third and ninth sessions as well as mean ratings across early treatment (third and ninth sessions). These findings indicate that therapist focus on cyclical intrapersonal patterns in patient actions, feelings, or experience as well as suggestions of alternative ways to understand these experiences or events not previously recognized by the patient (i.e., interpretation) in the early treatment process were particularly helpful in reducing posttreatment anxiety symptoms. Clinical implications and areas for future research will be discussed.

SCORS-G stimulus characteristics of select thematic apperception test cards.

There has been surprisingly little research into the stimulus properties of the Thematic Apperception Test Cards (TAT; Murray, 1943). This study used the Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G; Stein, Hilsenroth, Slavin-Mulford, & Pinsker, 2011 ; Westen, 1995 ) to explore the stimulus properties of select TAT cards in a clinical sample. The SCORS-G is a theoretically based and empirically validated measure of object relations that has widely been used in TAT research. A sample of 80 patients referred for psychological assessment at a large Northeastern hospital were administered the TAT (Cards 1, 2, 3BM, 4, 13MF, 12M, and 14) as part of their assessment battery. Trained raters scored the narratives using the SCORS-G. The SCORS-G ratings were analyzed to determine the nature and degree of object representation "pull" both across and within the TAT cards. The results showed that Cards 3BM and 13MF exhibited the greatest card pull for negative pathological object representations, and Card 2 displayed the highest card pull for adaptive and mature object representations. Both clinical and research related implications are discussed.

The dance of psychotherapy.

Using a dance metaphor, this article presents an approach to teaching therapeutic techniques to beginning graduate students in which interventions are first taught separately for purposes of clarity followed by an emphasis on integration, creativity, and flexibility. To illustrate the format of this approach, I provide theory, research, and prototypic clinical examples for the three therapeutic techniques that I use most frequently in my own practice. These techniques are support/empathy, immediacy, and affect exploration, experiencing, and expression. This is followed by a case presentation in which these three techniques are used together in a unique way to facilitate the work.

Development and preliminary validation of the Level of Care Index (LOCI) from the Personality Assessment Inventory (PAI) in a psychiatric sample.

Research over the last decade has been promising in terms of the incremental utility of psychometric tools in predicting important clinical outcomes, such as mental health service utilization and inpatient psychiatric hospitalization. The purpose of this study was to develop and validate a new Level of Care Index (LOCI) from the Personality Assessment Inventory (PAI). Logistic regression was initially used in a development sample (n = 253) of psychiatric patients to identify unique PAI indicators associated with inpatient (n = 75) as opposed to outpatient (n = 178) status. Five PAI variables were ultimately retained (Suicidal Ideation, Antisocial Personality-Stimulus Seeking, Paranoia-Persecution, Negative Impression Management, and Depression-Affective) and were then aggregated into a single LOCI and independently evaluated in a second validation sample (n = 252). Results indicated the LOCI effectively differentiated inpatients from outpatients after controlling for demographic variables and was significantly associated with both internalizing and externalizing risk factors for psychiatric admission (range of ds = 0.46 for history of arrests to 0.88 for history of suicidal ideation). The LOCI was additionally found to be meaningfully associated with measures of normal personality, performance-based tests of psychological functioning, and measures of neurocognitive (executive) functioning. The clinical implications of these findings and potential utility of the LOCI are discussed.

Treatment as usual (TAU) for depression: a comparison of psychotherapy, pharmacotherapy, and combined treatment at a large academic medical center.

Depression is among the most prevalent and burdensome psychiatric disorders in the United States (Kessler et al., Achieves of General Psychiatry 62:617-627, 2005). There is substantial empirical support regarding efficacy of pharmacotherapy, psychotherapy, and combined treatment (both pharmacotherapy and psychotherapy) for treating depression. However, far less is known about the effectiveness of these treatments for real-world patients treated within routine clinical care settings (Cahill et al., The British Journal of Clinical Psychology 49:421-453, 2010). This study seeks to explore the effectiveness of treatment as usual (TAU) for depression in a large cohort of psychiatric outpatients receiving psychotherapy, pharmacotherapy, or combined treatment within an academic medical center. Initial and follow-up self-report assessments were analyzed for 1,322 patients receiving treatment for depression. Using these data, we determined treatment effect sizes, rates of reliable improvement (and deterioration), and rates of clinically significant improvement for psychotherapy, pharmacotherapy, and combined care. On average, all treatments produced significant improvement with effect sizes surpassing our no-treatment benchmark. No significant between-group (treatment) differences in self-report outcomes were found. The rates of reliable change were similar for all treatment groups consistent with past research. The present findings support the effectiveness of psychotherapy, pharmacotherapy, and combined treatment as routinely provided within a large academic medical center for the treatment of real-world patients suffering with depression.

External correlates of the Personality Assessment Inventory higher order structures.

This brief report explores the external correlates of 2 higher order structures of the Personality Assessment Inventory (PAI; Morey, 1991, 2007); Hoelzle and Meyer's (2009a, 2009b) PAI Components and Hopwood and Moser's (2011) Internalizing and Externalizing Dimensions. Scores from these higher order structures were correlated with life-event data including education, marital status, employment, suicide attempts, psychiatric hospitalizations, trauma, medical problems, hallucinations, paranoid ideation, drug abuse, alcohol abuse, and arrest. Although some differences were noted, the results showed that both Hoelzle and Meyer's Components and Hopwood and Moser's Dimensions were meaningfully correlated with a wide range of life outcomes in a conceptually consistent manner. Overall, these findings provide support for the utility of these higher order variables.