Therapeutic Assessment in Personality Disorders: Toward the Restoration of Epistemic Trust.

Research evidence suggests Therapeutic Assessment positively affects clients with problems in living, including clients with personality disorders, who are typically quite resistant to change. Importantly, this change takes place quickly, in relatively few sessions. This article draws on a relatively new evolutionary-based theory of epistemic trust (ET) and epistemic hypervigilance (EH) as a lens to plausibly explain the efficacy of TA, and especially its influence on PD clients' alliance and motivation for subsequent psychotherapy (Fonagy, Luyten, & Alison, 2015). ET is the willingness to take in relevant interpersonally transmited information and it is essential to the immediate success of psychotherapy and its long-term impact. The collaborative, intersubjective framework of TA and many of its specific techniques might be understood as highly relevant to restoring ET in clients, especially those with PD. We close by discussing implications for psychological assessment, psychotherapy, and research.

Training and Consultation in Psychological Assessment With Professional Psychologists: Suggestions for Enhancing the Profession and Individual Practices.

Once central to the identity and practice of clinical psychology, psychological assessment (PA) is currently more limited in professional practice and generally less emphasized in graduate training programs than in the past. Performance-based personality tests especially are taught and used less, even though scientific evidence of their utility and validity has never been stronger. We review research on training in PA and discuss challenges that contributed to its decreased popularity. We then review continuing education requirements for ethical practice in PA and recommend that PA should be reconceptualized as a specialty best practiced by psychologists who have the resources and time to maintain competency. We offer recommendations about how professional organizations concerned with PA can promote its practice and how individual expert clinicians can assist. We conclude by describing a collaborative model for providing group consultation in PA to practicing psychologists. If implemented widely, this model could help promote PA and raise its standard of practice.

"Why am I so stuck?": A Collaborative/Therapeutic Assessment Case Discussion.

Assessors from 3 continents worked together on a single multimethod case study. Their goal was to hold the client at the center and forefront of their attitudes and thinking as each assessor focused on a specific measure or group of measures. The adult client requested a neuropsychological assessment and completed a full battery of cognitive measures as well as the MMPI-2, the Rorschach, and the Wartegg. A basic tenet of collaborative/therapeutic assessment holds that the client is a full partner in the assessment process; he or she is also seen as the final arbiter of the usefulness of the ideas derived. With that in mind, the client worked with the lead assessor to create 6 questions she wished answered by the assessment. Feedback and discussion occurred in a number of ways: through discussion sessions with the lead assessor that included extended inquiry; individualized letters from the other assessors, each addressing her 6 questions; a summary letter from the lead assessor; and a metaphorical, therapeutic story that stressed key findings from the assessment. Results converged powerfully, with similar findings from each assessor. The client stated that she felt heard and understood in the process, even by individuals who she had never met personally.

Implications of recent research in neurobiology for psychological assessment.

In this article, I highlight 3 major findings from current research in attachment, neurobiology, psychopathology, and psychotherapy: (a) attachment failures and early trauma are related to many forms of psychopathology, (b) one of the major sequelae of developmental trauma is disorganization of the right hemisphere, and (c) psychological interventions that promote emotional experience, awareness, and expression are more effective than those that rely solely on cognitive restructuring. I then suggest implications of these findings for the practice of psychological assessment: (a) the relationship between client and assessor is more important than has been acknowledged generally, (b) performance-based personality tests are very useful in part because they tap right-hemisphere and subcortical brain functioning and provide information that clients cannot directly report, and (c) when psychological assessments provide clients with powerful emotional experiences, therapeutic change is often the result. I illustrate these points with excerpts from the Therapeutic Assessment of a 27-year-old man with compulsive sexual behavior.

Therapeutic assessment with children: intervening with parents "behind the mirror".

All the steps in the model of therapeutic assessment used with children (TA-C) are designed to involve and impact the child's parents. However, a distinctive process that parallels and accompanies the testing sessions with the child might be the most significant in helping parents shift their story of their child and family. In this process, parents are invited to observe their child's testing sessions (in an adjacent room through a live video feed, through a 1-way mirror, or in the corner of the testing room) and process the experience with the assessor (either simultaneously in the case of the 2-assessor model or after the fact in the 1-assessor model). We discuss the development and evolution of what we have come to call the "behind the mirror" method. We describe the therapeutic intent of the method and delineate 13 techniques utilized to enlist parents as active collaborators. We illustrate each technique using the case study of a 10-year-old boy where the 2-assessor model and live video feed method were used. We also provide research findings from the case study that address the parents' experience of the assessment and their changed view of their child.

Use of the Adult Attachment Projective Picture System (AAP) in the middle of a long-term psychotherapy.

This article relates how the Adult Attachment Projective Picture System (AAP) was used as a midtherapy intervention with a middle-aged man being treated for relationship difficulties. The man, who was identified via the AAP as having a dismissing attachment status, had difficulties committing to psychotherapy, presumably because he was terrified of experiencing the underlying depression and grief revealed on his Rorschach and AAP. Reading an AAP-based description of his attachment status helped the man become aware of his characteristic defenses against painful affect, and gave him the motivation to stay in therapy while experiencing and getting support for his unresolved mourning. This work led to the man's experiencing less ambivalence about intimate relationships. There are several important ways that the AAP augments a traditional personality assessment battery and is useful in conducting a long-term psychotherapy.

Journeys through the valley of death: multimethod psychological assessment and personality transformation in long-term psychotherapy.

The Psychodynamic Diagnostic Manual (PDM Task Force, 2006) is based on the assumption that an in-depth understanding of clients' underlying emotional, personality, and interpersonal patterns will facilitate their treatment. In this article I show how such an understanding can be achieved through multimethod psychological assessment, and how useful such information can be in long-term psychotherapy with high-achieving, successful clients who struggle with forming and maintaining intimate relationships. Such treatments are extremely difficult, because when these clients attach to their psychotherapists, many of them temporarily become more symptomatic. I illustrate these points with a detailed account of my long-term therapy with a resilient but highly traumatized young man. Repeated use of the Minnesota Multiphasic Personality Disorder-2 (MMPI-2; Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) and Rorschach with my client helped guide us in our work, and also helped create an important therapeutic "opening" into the underlying traumatic material. This and other experiences have convinced me that it is extremely useful for psychologists to have training in both assessment and psychotherapy.

Therapeutic Assessment "on the Front Lines": comment on articles from WestCoast Children's Clinic.

I comment on the articles by Mercer (2011/this issue); Guerrero, Lipkind, and Rosenberg (2011/this issue); and Haydel, Mercer, and Rosenblatt (2011/this issue), which describe their practice of collaborative and therapeutic psychological assessment in a community mental health setting. These articles demonstrate that collaborative and Therapeutic Assessment can be used successfully with clients from underprivileged, high-risk backgrounds. Such assessments are rigorous for both clients and assessors, and their success depends on the ability of clinicians to form trusting relationships with clients. In fact, empathic disruptions by assessors are almost inevitable during the collaborative assessment process, especially if assessors' backgrounds and contexts are quite different from those of their clients. However, if assessors receive enough support to "take off their white coats" and reach into their clients' worlds, such disruptions can be repaired, leading to positive changes in both clients and assessors. This kind of assessment work is not for the faint of heart, but it is immensely rewarding.

Therapeutic assessment of families in healthcare settings: a case presentation of the model's application.

In this article, we present a case study of a Therapeutic Assessment (TA) with an 11-year-old boy who had two unexplained behavioral episodes suggesting neurological impairment, which led to two emergency department visits at a children's hospital. TA is a semistructured approach that blends the extensive conceptualizing benefits of psychological assessment with the principles and techniques of evidence-based child and family interventions. We use this case to illustrate how TA is an adaptive and flexible approach to child-centered family assessment that can meet the goals of psychologists working in pediatric and general medical hospitals, primary care clinics, family medicine practices, and other health care settings. With the current case, the clinician was able to use the procedures of TA to clarify for the family their son's unexplained behaviors, while also providing them with a therapeutic experience. In addition to addressing the family's concerns, the clinician also addressed a number of specific questions provided by the referring neurologist that informed ongoing care of the child. This case illustrates the potential utility and effectiveness of the TA model with children and families referred to a typical psychology service in a health care setting. This case is one of the first applications of the TA model with this population and its success suggests further research in this area is warranted.

The many faces of empathy in experiential, person-centered, collaborative assessment.

Paul Lerner was an amazing clinician and teacher, and he wrote that empathy was the "heart" of his particular approach to psychological assessment. In this article, I discuss 3 meanings of empathy: (a) as an information-gathering tool, (b) as an interpersonal process, and (c) as a healing element in human interactions. I then demonstrate how each of these meanings of empathy is exemplified in Lerner's written work and in collaborative and therapeutic assessment.

Therapeutic Assessment with children: a pilot study of treatment acceptability and outcome.

Therapeutic Assessment (TA) with children is a hybrid of psychological assessment and short-term intervention. It uses the ongoing process and results of psychological assessment to enhance parents' understanding of their child and to facilitate change. Clinical reports and single case studies suggest that TA with children is an acceptable and effective brief intervention. However, no aggregate data have been published to support this claim. This pilot study investigated the acceptability and preoutcome-postoutcome of TA with 14 clinically referred children with emotional and behavior problems and their parents. Results indicated high treatment acceptability as well as significantly decreased child symptomatology and enhanced family functioning as reported by children and mothers. In addition, mothers demonstrated a significant increase in positive emotion and a significant decrease in negative emotion pertaining to their children's challenges and future. The findings, although limited due to the design and small sample size, support assertions from published single case studies that TA is possibly an efficacious child and family intervention for children with emotional and behavioral problems and should be studied in a larger, comparison design.

"Why won't my parents help me?": Therapeutic assessment of a child and her family.

We present a case study of a child's psychological assessment using the methods of Therapeutic Assessment (TA). The case illustrates how TA can help assessors understand the process and structure of a family by highlighting how maladaptive family processes and interactions impact a child's development. It also illustrates how TA with a child can serve as a family intervention. In this case, it became apparent that the child's social difficulties were significant, not minor as initially reported by the parents, and were rooted in an insecure attachment, underlying depression, an idiosyncratic view of the world, and longing for attention, all of which were hidden or expressed in grandiose, expansive, and off-putting behaviors. In addition, the familial hierarchy was inverted; the parents felt ineffective and the child felt too powerful, leading to enhanced anxiety for the child. Intervention throughout, punctuated by the family session and feedback sessions, allowed the parents to develop a new "story" about their child and for the child to experience a new sense of safety. Following the TA, the parents and child indicated high satisfaction, enhanced family functioning, and decreased child symptomatology. Subsequent family therapy sessions allowed the family to further implement the interventions introduced in the TA.

Family sessions as part of child psychological assessment: goals, techniques, clinical utility, and therapeutic value.

Including a family session in a child assessment can significantly advance the assessor's and parents' understanding of the child's problems and enhance the likelihood that parents will follow through on recommendations after the assessment. A family session allows the assessor to observe the child in the family context, test systemic hypotheses, better understand the meaning of individual test results, and try out possible interventions. A family session may also help parents see systemic aspects of their child's problems, help the child feel less blamed, foster positive experiences among family members, and offer the family a glimpse of family therapy. We describe methods and techniques for structuring family sessions and offer guidance on preparing for and conducting such sessions depending on one's case conceptualization. Detailed case examples illustrate each technique and demonstrate the immediate and subsequent impact of family sessions as well as their therapeutic value. We also address common clinical and pragmatic issues.

Therapeutic assessment promotes treatment readiness but does not affect symptom change in patients with personality disorders: findings from a randomized clinical trial.

The field of clinical personality assessment is lacking in published empirical evidence regarding its treatment and clinical utility. This article reports on a randomized controlled clinical trial (N = 74) allocating patients awaiting treatment in a specialized clinic for personality disorders to either 4 sessions of (a) therapeutic assessment (TA) or (b) a structured goal-focused pretreatment intervention (GFPTI). In terms of short-term outcome, TA demonstrated superior ability to raise outcome expectancies and patient perceptions of progress toward treatment (Cohen's d = 0.65 and 0.56, respectively) and yielded higher satisfaction (d = 0.68). Moreover, patients reported marginally stronger alliance to the TA clinicians than to GFPT clinicians (d = 0.46), even though therapists perceived the alliance as equally positive in both groups. No differences in symptomatic ratings were observed. Results are discussed with reference to treatment utility in this particular patient group.

The MMPI-2 Restructured Clinical (RC) Scales and restraints to innovation, or "what have they done to my song?".

Rogers, Sewell, Harrison, and Jordan (2006/this issue) largely replicate in an independent clinical sample the MMPI-2 Restructured Clinical (RC) Scales developed by Tellegen et al. (2003). Nichols (2006/this issue) raises numerous concerns about the development and utility of the RC Scales, which on close appraisal did not change our view that the scales are well conceived and potentially valuable to researchers and clinicians alike. We present two case studies in which the RC Scales helped clarify complex MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) profiles with multiple elevations on the Clinical, Content, Supplementary, and Personality Psychopathology Five (Harkness, McNulty, Ben-Porath, & Graham, 2001) scales. When interpretations refined by the RC Scales were discussed with the clients, each seemed to feel deeply understood. Reservations about instrument innovation can be appreciated as helping to counterbalance change and thereby ensure the MMPI-2's successful ongoing evolution. We discuss specific ways the MMPI-2 community could avoid polarization about the RC Scales.

How psychological assessment taught me compassion and firmness.

In this article, I reflect on 2 specific assessment experiences and how they helped me grow as a person and as a psychologist. I believe that practicing assessment creates opportunities for personal growth in assessors because (a) to truly understand difficult clients, we must find personal versions of their psychological dilemmas in ourselves, which we might otherwise never be called on to face, and (b) to be effective as assessors, we must say difficult things to clients in plain nonjudgmental language, which forces us to develop courage and wisdom.

Therapeutic assessment of a man with "ADD".

In this article I present the first published complete case study of a psychological assessment done by the methods of Therapeutic Assessment. A client-therapist pair had been working together for several years but felt "stuck" in the treatment. The man had been previously diagnosed with attention deficit disorder (ADD) and sought help for disorganization and difficulties in romantic relationships. The therapist asked for diagnostic clarification but gradually revealed a deeper confusion about how to work with the client. Through the collaborative process of the assessment, the client gradually concluded that he did not have ADD, and he and the therapist reached a joint understanding of their next steps in treatment. This case illustrates how collaborative psychological assessment (a) can help clients revise their "stories about themselves and the world" and (b) provides an effective, non-threatening way for a consultant to intervene in a client-therapist system that has reached an impasse.