The Role of Object Relations in the Physician-Patient Relationship in a Primary Care Setting.

ABSTRACT: A good physician-patient relationship is essential for the delivery of quality health care and is associated with better health outcomes. This study explored the association between patients' object relations and the physician-patient relationship. Primary care patients (n = 72) and physicians (n = 21) participated in the study. Patients' early memories were obtained prior to their medical visit and were coded with the Social Cognition and Object Relations-Global Method (SCORS-G). Patients and physicians independently rated the quality of the physician-patient encounter. Results indicated that object relations (SCORS-G Cognitive-structural and Self factors) incrementally predicted physician-patient relationship ratings, as rated by the patient, above and beyond psychological distress, somatization, and level of physician training. Patient education, psychological distress, and level of physician training predicted physician ratings of the medical encounter. The authors discuss the discrepancy between physician and patient ratings as they relate to patients' object relations.

Dependency, Detachment, and Health-Related Behavior in Adult Primary Care Patients.

This investigation examined links between three related personality styles as assessed with the Relationship Profile Test-destructive overdependence, dysfunctional detachment, and healthy dependency-and indices of health and health-related behavior in a mixed-sex (74% female) sample of 100 primary care patients with a mean age of 38.62 (SD = 12.99). Fourteen primary care physicians also participated. As hypothesized, destructive overdependence and dysfunctional detachment scores were positively correlated with number of contacts with the emergency department; healthy dependency scores were inversely related to emergency department contacts and number of overnight hospitalizations. Healthy dependency scores were associated with an array of positive health behaviors; destructive overdependence scores were negatively associated with positive health behaviors. In addition, healthy dependency scores were inversely related to physician ratings of a difficult doctor-patient relationship. These results demonstrate that destructive overdependence, dysfunctional detachment and healthy dependency scores are associated in expected ways with indices of health and health-related behavior, and help illuminate the underlying factors that contribute to comparatively poor health and variations in health service use among overdependent and detached medical patients.

Changes in Defense Mechanisms in Mothers From Pregnancy to 2 Years Postpregnancy.

ABSTRACT: The objective of this study was to assess changes in maternal defensive functioning from the third trimester of pregnancy to 2 years postpregnancy. A community sample of at-risk mothers ( N = 84; non-White [61%], unmarried [67%], high school or less education [72%], and income less than $20,000 [50%]) were recruited for this longitudinal study. Mothers responded to a semistructured interview during pregnancy and at 2 years postpregnancy about the parent-infant relationship; interview transcripts were coded using the Defense Mechanism Rating Scale (DMRS). Results indicated a significant increase in both total defense mechanisms used and the relative percentage of immature defense mechanisms used over time. A significant decrease in the relative percentage of healthy/adaptive defenses was noted. When all seven levels of defenses of the DMRS were assessed, it was an increase in minor image-distorting defenses, mechanisms that supported vulnerable self-esteem, that accounted for most of the change in immature defenses. Stability coefficients of defense mechanisms were reported, with large effect sizes, for overall defensive functioning, and mature and immature defenses over a 2-year period. These findings lend support to the importance of assessing defense mechanisms to better understand stressful life transitions in mothers.

Malevolent object relations: A multimethod study of female survivors of childhood abuse.

Although childhood victimization is associated with impairments in object relations, it is not clear how different measures comparatively perform in assessing this relationship. This study examined the connection between emotional, physical, and sexual abuse in childhood and three methods of assessing malevolent object representations. Sixty adult women, recruited from an urban primary-care clinic, were administered the Thematic Apperception Test (TAT), the Object Relations Inventory (ORI) interview, and a version of the Early Memories Test (EMT)/interview. Ratings of malevolent object relations were obtained using the affect-tone dimension from the Social Cognition and Object Relations (SCORS-G) scale with both TAT and early memory narratives and through Malevolence ratings from the ORI interview. It was found that, outside of emotional abuse, ORI interview ratings of malevolence consistently differentiated adult childhood abuse groups and nonabuse groups, whereas early memory ratings of malevolence differentiated groups in two of four analyses. Malevolence ratings based upon TAT ratings failed to differentiate any type of abuse from nonabuse. These findings suggest that the use of malevolence ratings from the ORI and early memory narratives are preferred methods for assessing malevolent object relations in urban-dwelling women who have been victimized as children.

Integration Between Cerebral Hemispheres Contributes to Defense Mechanisms.

Defense mechanisms are mental functions which facilitate coping when real or imagined events challenge personal wishes, needs, and feelings. Whether defense mechanisms have a specific neural basis is unknown. The present research tested the hypothesis that interhemispheric integration plays a critical role in defense mechanism development, by studying a unique sample of patients born without the corpus callosum (agenesis of the corpus callosum; AgCC). Adults with AgCC (N = 27) and matched healthy volunteers (N = 30) were compared on defense mechanism use across increasing levels of developmental maturity (denial, least; projection, intermediate; identification, most). Narratives generated in response to Thematic Apperception Test images were scored according to the Defense Mechanism Manual. Greater use of denial and less identification was found in persons with AgCC, compared to healthy comparisons. This difference emerged after age 18 when full maturation of defenses among healthy individuals was expected. The findings provide clinically important characterization of social and emotional processing in persons with AgCC. More broadly, the results support the hypothesis that functional integration across the hemispheres is important for the development of defense mechanisms.

Assessment of Personality and Psychopathology in Healthcare Settings: Introduction to the Special Section.

Healthcare in the United States has increasingly benefited from the adoption of multidisciplinary providers. Many multidisciplinary teams include psychologists who often conduct psychological and personality assessments in their practice. This special section highlights areas of personality and psychological assessment in applied healthcare contexts. Nghiem and colleagues review the psychometric performance of various personality and psychopathology instruments and provide recommendations for the assessment of solid organ transplant evaluations. Gottschling and colleagues present a culturally adapted screener for anxiety-related symptoms in geriatric adults that can easily be administered in various healthcare settings. Perry and colleagues provide a rationale and method for including a brief personality assessment for patients with cancer. McCord presents a broadband screener, the Multidimensional Behavioral Health Screen (MBHS), that assesses 9 components of psychopathology. Mitchell and colleagues provide evidence for using the MBHS in primary care clinics as an alternative to the Patient Health Questionnaire-9. This special section provides evidence-based information regarding personality and psychological assessments that will likely be useful in varied healthcare contexts.

Assessing Level of Personality Organization With the Psychodiagnostic Chart: A Validity Study.

Heterogeneity within diagnostic types and comorbidity across diagnostic groups render a specific personality disorder anything but specific, leading researchers and clinicians to increasingly focus on the general severity of personality pathology. Personality pathology severity is reflected in one's level of personality organization (LPO) and research has demonstrated that LPO is a significant predictor of treatment response. This investigation examined the reliability and validity of the Psychodiagnostic Chart (PDC) in assessing the LPO dimension of the Psychodynamic Diagnostic Manual (PDM; PDM Task Force, 2006). Among a sample of 88 urban-dwelling women seeking primary medical care, the LPO dimension of the PDC received fair to good interrater reliability among 6 psychodynamic psychologists. Convergent validity was demonstrated with contrast analysis and individual correlations that yielded statistically significant associations between LPO scores and conceptually related psychodynamic variables (e.g., defensive functioning, object relations) and self-reported personality pathology scores. Support for discriminant validity was limited by the modest power associated with the sample size. Exploratory analyses examining LPO scores and measures of physical health and intimate partner violence were conducted. Our results supported the reliability, validity, and practical use of the LPO dimension of the PDC.

Behavioral Health Assessments and Interventions of Psychology Trainees and Residents During Dual Interviewing: Replication and Extension.

The integration of psychologists and other behavioral health providers in primary care practice continues to evolve and reshape approaches to patient care. This study is a replication and extension of a 2013 study describing dual interviewing encounters involving psychology trainees and family medicine residents within an integrated primary care clinic as it relates to behavioral health assessments and interventions. Psychology trainees provided descriptions of 400 collaborative patient encounters involving 337 single and 63 repeat encounters. Psychology trainees coded the frequency of behavioral health assessments and interventions by the psychology trainee, family medicine resident, or both. Seventy-eight percent of encounters contained an assessment, and 20% contained interventions. Compared to the 2013 study, there were significantly fewer behavioral health interventions offered and a significantly greater number of psychoeducation/supportive interventions offered collaboratively. It was discovered that discussions between psychology trainees and family medicine residents immediately after patient encounters occurred 50% of the time and involved issues of case conceptualization. These informal discussions may be an important source of behavioral health education for family medicine residents. This study adds to efforts to better understand what occurs during these encounters.

Convergent and Discriminant Validity of Personality Inventory for DSM-5-BF in a Primary Care Sample.

A growing body of research supports the validity of the Personality Inventory for DSM-5 (PID-5) in evaluating community and psychiatric samples. Although maladaptive personality also has significant relevance in primary care settings, research on the PID-5 in primary care samples is limited. In this study, the authors examined the intercorrelations, convergent validity, and discriminant validity of the brief form of the PID-5 (PID-5-BF) in 100 primary care outpatients. Results are consistent with findings in other samples in suggesting that PID-5 domains are moderately intercorrelated and associated with a variety of mental health variables. Smaller associations with physical health variables support the discriminant validity of the instrument. Overall, results suggest that the PID-5-BF can provide a useful psychiatric screening tool in primary care settings.

A life-stress, emotional awareness, and expression interview for primary care patients with medically unexplained symptoms: A randomized controlled trial.

OBJECTIVE: Lifetime trauma, relationship adversities, and emotional conflicts are elevated in primary care patients with medically unexplained symptoms (MUS), and these risk factors likely trigger or exacerbate symptoms. Helping patients disclose stressors, increase awareness and expression of inhibited emotions, and link emotions to physical symptoms may improve health. We developed an emotional awareness and expression interview that targets stressful life experiences and conflicts and then tested its effects on primary care patients with MUS. METHOD: Patients (N = 75) with MUS were recruited at a family medicine clinic and randomized to an interview condition or treatment-as-usual (TAU) control condition. In a single 90-min interview in the clinic, the interviewer elicited disclosure of the patient's stressors, linked them to the patient's symptom history, and encouraged emotional awareness and expression about unresolved relationship trauma or conflict. At baseline and 6-week follow-up, patients completed self-report measures of their physical and psychological health. RESULTS: Analyses of covariance, controlling for baseline symptoms, compared patients in the interview condition with TAU at 6-week follow-up. Compared with TAU, the interview led to significantly lower pain severity, pain interference, sleep problems, and global psychological symptoms. CONCLUSIONS: This study provides preliminary evidence for the value of integrating a disclosure and emotional awareness and expression interview into the primary care setting for patients with MUS. (PsycINFO Database Record

The Use of the Social Cognition and Object Relations Scale in a Primary Care Setting.

Research has indicated that as many as 10% to 15% of primary care patients have symptoms that are not well explained medically. These patients could be labeled as "somatizers." This study assessed the extent to which underlying psychological characteristics contribute to a person's level of somatization and service utilization. The Social Cognition and Object Relations Scale-Global Rating Method (SCORS-G; Stein, Hilsenroth, Slavin-Mulford, & Pinsker, 2011; Westen, 1995) was used to rate early memory narratives of 100 patients in a suburban primary care setting. Using principal axis factoring, the SCORS-G was divided into 2 components and these components (cognitive and affective) were used in subsequent analyses. The affective component was significantly negatively correlated with 2 measures of somatization and positively related to physician ratings of global health. The affective component also showed a trend toward significance on overnight hospital stays and patient-rated health. The cognitive component showed a trend toward significance with both measures of somatization, but it was not correlated with other measures of health. This study demonstrates the value of assessing underlying processes (via SCORS-G ratings of early memory narratives) that contribute to increased rates of somatization and health care utilization. Clinical implications for the relationship between affect and physical health are explored.

Childhood abuse in adults in primary care: Empirical findings and clinical implications.

In the healthcare setting, adult patients with histories of childhood abuse are of significant concern and are frequently encountered in the primary care setting. However, there is a dearth of studies investigating the relationships between psychopathology, overall health, healthcare utilization, physician ratings of patient difficulty, and childhood abuse. The present study examines these relationships in primary care patients with (N = 45) and without (N = 129) histories of childhood abuse (physical, sexual, and both). Findings revealed that adult patients with histories of childhood abuse generally scored significantly higher on measures of psychopathology, emergency room use, and doctor-patient relationship difficulty, and lower on a measure of mental and physician-rated physical health. In a multiple regression analysis, income and a history of childhood sexual abuse significantly predicted overall mental health. In a second multiple regression analysis, income, depression, somatization, borderline personality disorder, and difficult doctor-patient relationship ratings significantly predicted physician-rated physical health. Overall, these findings suggest that a history of childhood abuse is associated with a host of negative health outcomes. Findings also suggest that negative feelings about a patient may help physicians identify patients with histories of childhood abuse. It is especially important for physicians to routinely include an assessment of childhood abuse during the psychosocial portion of the medical interview or through screening instruments.

Defense Mechanisms and Utilization in Cancer Patients Undergoing Radiation Therapy: A Pilot Study.

A group of 49 patients who had been diagnosed with cancer during the preceding year and who were receiving radiation therapy were assessed for their use of defense mechanisms, as well as for their level of psychological distress. In addition, their utilization of medical services was determined. It was predicted that the use of services that were under the patients' control-namely, requesting extra outpatient visits and making trips to the emergency department-would be related to the patients' use of defense mechanisms, whereas a treatment option not under the patients' control-overnight hospitalization based on physicians' assessment of condition-would not be related to defense use. The findings confirmed the hypotheses. Outpatient visits were strongly predicted by defense use, whereas hospitalization was determined by psychological distress. However, emergency department visits were determined by both defense use and psychological distress. In addition, an interaction between defense and distress was found to predict hospitalization.

Sidney Blatt's Object Relations Inventory: Contributions and Future Directions.

In this article, we provide a historical overview of the Object Relations Inventory (ORI) and related methods for the assessment of object relations constructed by Sidney Blatt and colleagues (e.g., Blatt, Bers, & Schaffer, 1992 ; Blatt, Wein, Chevron, & Quinlan, 1979 ; Diamond, Kaslow, Coonerty, & Blatt, 1990 ). We clarify terminology that has been used inconsistently in the literature, especially by way of differentiating the methods used to collect descriptions of significant figures, such as the ORI and its predecessor, the Parental Description (PD) task, and the rating scales that Blatt and colleagues constructed to rate those descriptions. We provide a tabular summary of empirical studies of the measure and offer a critical review of those aspects of the instrument that require further empirical investigation and methodological rigor.

Defense Mechanisms of Pregnant Mothers Predict Attachment Security, Social-Emotional Competence, and Behavior Problems in Their Toddlers.

OBJECTIVE: For at-risk (single parent, low income, low support) mothers, healthy adaptation and the ability to manage stress have clear implications for parenting and the social-emotional well-being of their young offspring. The purpose of this longitudinal study was to examine associations between defense mechanisms in pregnant women and their toddlers' attachment security, social-emotional, and behavioral adjustment. METHOD: Participants were 84 pregnant women during their last trimester of pregnancy, recruited from community agencies primarily serving low-income families. Women were followed prospectively from pregnancy through 2 years after birth and completed several multimethod assessments during that period. Observations of mother-child interactions were also coded after the postnatal visits. RESULTS: Multiple regression analyses revealed that mothers' defense mechanisms were significantly associated with several toddler outcomes. Mature, healthy defenses were significantly associated with greater toddler attachment security and social-emotional competence and fewer behavior problems, and less mature defenses (disavowal in particular) were associated with lower levels of attachment security and social-emotional competence. Associations remained significant, or were only slightly attenuated, after controlling for demographic variables and partner abuse during pregnancy. CONCLUSIONS: The study findings suggest that defensive functioning in parents preparing for and parenting toddlers influences the parent-child attachment relationship and social-emotional adjustment in the earliest years of life. Possible mechanisms for these associations may include parental attunement and mentalization, as well as specific caregiving behavior toward the child. Defensive functioning during times of increased stress (such as the prenatal to postnatal period) may be especially important for understanding parental influences on the child.

Convergent Validity of the Early Memory Index in Two Primary Care Samples.

Karliner, Westrich, Shedler, and Mayman (1996) developed the Early Memory Index (EMI) to assess mental health, narrative coherence, and traumatic experiences in reports of early memories. We assessed the convergent validity of EMI scales with data from 103 women from an urban primary care clinic (Study 1) and data from 48 women and 24 men from a suburban primary care clinic (Study 2). Patients provided early memory narratives and completed self-report measures of psychopathology, trauma, and health care utilization. In both studies, lower scores on the Mental Health scale and higher scores on the Traumatic Experiences scale were related to higher scores on measures of psychopathology and childhood trauma. Less consistent associations were found between the Mental Health and Traumatic Experiences scores and measures of health care utilization. The Narrative Coherence scale showed inconsistent relationships across measures in both samples. In analyses assessing the overall fit between hypothesized and actual correlations between EMI scores and measures of psychopathology, severity of trauma symptoms, and health care utilization, the Mental Health scale of the EMI demonstrated stronger convergent validity than the EMI Traumatic Experiences scale. The results provide support for the convergent validity of the Mental Health scale of the EMI.

Resident Ratings of Communication Skills Using the Kalamazoo Adapted Checklist.

BACKGROUND: The Kalamazoo Essential Elements Communication Checklist-Adapted (KEECC-A) is a well-regarded instrument for evaluating communication and interpersonal skills. To date, little research has been conducted that assesses the accuracy of resident self-ratings of their communication skills. OBJECTIVE: To assess whether residents can accurately self-rate communication skills, using the KEECC-A, during an objective structured clinical examination (OSCE). METHODS: A group of 104 residents from 8 specialties completed a multistation OSCE as part of an institutional communication skills curriculum conducted at a single institution. Standardized patients (SPs) and observers were trained in rating communication skills using the KEECC-A. Standardized patient ratings and resident self-ratings were completed immediately following each OSCE encounter, and trained observers rated archived videotapes of the encounters. RESULTS: Resident self-ratings and SP ratings using the KEECC-A were significantly correlated (r104 = 0.238, P = .02), as were resident self-ratings and observer ratings (r104 = 0.284, P = .004). The correlation between the SP ratings and observer (r104 = 0.378, P = .001) ratings were larger in magnitude, but not significantly different (P > .05) from resident/SP or resident/observer correlations. CONCLUSIONS: The results suggest that residents, with a modicum of training using the KEECC-A, can accurately rate their own communication and interpersonal skills during an OSCE. Using trained observers to rate resident communication skills provides a unique opportunity for evaluating SP and resident self-ratings. Our findings also lend further support for the reliability and validity of the KEECC-A.

Personality Assessment Screener, Childhood Abuse, and Adult Partner Violence in African American Women Using Primary Care.

This study assessed the relationship between psychopathology with the Personality Assessment Screener (PAS) and childhood physical and sexual abuse and adult physical and sexual partner violence in a primary care sample of 98 urban-dwelling African American women. Patients completed the PAS, the Childhood Trauma Questionnaire, and the Conflict Tactics Scale. The PAS total score significantly correlated with all measures of childhood and adult abuse. Stepwise regression analyses revealed that PAS element scores of Suicidal Thinking and Hostile Control significantly predicted a history of childhood physical abuse; Suicidal Thinking, Hostile Control, and Acting Out significantly predicted a history of childhood sexual abuse; Suicidal Thinking, Negative Affect, and Alienation significantly predicted current adult partner physical violence; and Psychotic Features, Alcohol Problems, and Anger Control significantly predicted current adult sexual partner violence. The PAS appears to be a useful measure for fast-paced primary care settings for identifying patients who need a more thorough assessment for abuse.

Factor Structure of the Assessment of Qualitative and Structural Dimensions of Object Representations (AOR) Scale.

The Assessment of Qualitative and Structural Dimensions of Object Representations assessment instrument (AOR; Blatt, Chevron, Quinlan, Schaffer, & Wein, 1992 ) is one measure of parental representations used in the literature that assesses nonconscious processes while minimizing self-presentation biases. However, only 2 studies have considered the latent factor structure, with mixed findings reported that raise questions about the constructs being assessed. This study used archival data from 4 previous studies containing clinical and nonclinical samples, totaling 722 participants. Individuals were divided into 2 groups in which an exploratory factor analysis (EFA) was followed by a confirmatory factor analysis (CFA). Results of both the EFA and CFA suggested that a 3-factor solution was best, with factors that were labeled Agency, Communion, and Punitive based on previous research. The implications of these findings are explored, particularly with regard to the punitive aspect of maternal representations, as well as a possible revision to the scoring rubric.