Jenelle Slavin-Mulford

Psychometric Evaluation and Normative Data for the Depression, Anxiety, and Stress Scales-21 (DASS-21) in a Nonclinical Sample of U.S. Adults

Health care professionals are coming under increased pressure to empirically monitor patient outcomes across settings as a means of improving clinical practice. Within the psychiatric and primary care communities, many have begun utilizing brief psychometric measures of psychological functioning to accomplish these goals. The purpose of this study was to evaluate the psychometric properties and clinical utility of the Depression, Anxiety, and Stress Scales—21-item version (DASS-21), and contribute normative data to facilitate interpretation using a sample of U.S. adults (N = 503). Item-scale convergence was generally supported, although assumptions of item-scale divergence were not met. Only 86%, 50%, and 43% of Depression, Anxiety, and Stress items, respectively, correlated significantly greater with their hypothesized scales than other scales. Internal consistency reliability was acceptable for all scales and comparable to existing research (αs = .91, .80, and .84 for Depression, Anxiety, and Stress, respectively). Scale-level correlations were greater than what has been reported elsewhere (range of rs = .68 to .73), and principal components analysis supported the extraction of only one component accounting for 47% of the item-level variance. However, confirmatory factor analysis (CFA) favored a three-factor structure when compared to a one-factor model. The implications for the health care professions are discussed.

Therapeutic Immediacy across Long-Term Psychodynamic Psychotherapy: An Evidence-Based Case Study.

C. E. Hill (2004) recently developed the concept of therapist immediacy to capture discussion by the therapist about the therapeutic relationship that occurs in the here-and-now of a therapy session. This concept has been expanded to include discussion about the therapeutic relationship by both the client and therapist, captured by the term therapeutic immediacy (K. Kuutmann & M. Hilsenroth, 2011). Although prior research has examined the use of therapeutic immediacy across short-term treatment, the present study is the first to examine the use of immediacy across a long-term (4 years) psychotherapy. Also, this is the first study to assess the interrater reliability of therapeutic immediacy, which was found to achieve good to excellent levels across raters. The most frequently used categories of client and therapist immediacy are presented. Finally, the authors provide an in-depth qualitative examination of 5 therapeutic immediacy segments across the treatment judged by the raters to have high levels of depth/intensity (4.5 or higher out of 5) to examine the role of therapeutic immediacy in exploring meaningful treatment issues. Clinical utility, potential limitations, and future research on therapeutic immediacy are discussed.

External Validity of the Personality Assessment Inventory (PAI) in a Clinical Sample

This study contributes to the ongoing construct validation of the Personality Assessment Inventory (PAI; Morey, 1991, 2007) by identifying nontest life-event correlates of the PAI full scales and subscales in a sample of psychiatric patients. The life-event data used in this study included education, marital status, and employment, as well as a history of suicide attempts, psychiatric hospitalizations, trauma, medical problems, hallucinations, paranoid ideation, drug abuse, alcohol abuse, and arrest. Correlations were calculated to explore the convergent and discriminant validity of the PAI scales relative to the life-event data. The results showed that the majority of the PAI scales (11 of 13) had meaningful correlations with at least 1 life-event variable. The PAI BOR scale had the greatest number of correlations and was associated with 8 life-event variables. In contrast, the PAI ANX and MAN scales had no correlations above a predetermined threshold (r ≥.21). These findings add to the growing body of empirical correlates of the PAI and generally provide support for the construct validity of the PAI scales.

Exploring the Construct Validity of the Social Cognition and Object Relations Scale in a Clinical Sample

The Social Cognition and Object Relations Scale–Global rating method (SCORS–G; Stein, Hilsenroth, Slavin-Mulford, & Pinsker, 2011; Westen, 1995) measures the quality of object relations in narrative material. This study employed a multimethod approach to explore the structure and construct validity of the SCORS–G. The Thematic Apperception Test (TAT; Murray, 1943) was administered to 59 patients referred for psychological assessment at a large Northeastern U.S. hospital. The resulting 301 TAT narratives were rated using the SCORS–G method. The 8 SCORS variables were found to have high interrater reliability and good internal consistency. Principal components analysis revealed a 3-component solution with components tapping emotions/affect regulation in relationships, self-image, and aspects of cognition. Next, the construct validity of the SCORS–G components was explored using measures of intellectual and executive functioning, psychopathology, and normal personality. The 3 SCORS–G components showed unique and theoretically meaningful relationships across these broad and diverse psychological measures. This study demonstrates the value of using a standardized scoring method, like the SCORS–G, to reveal the rich and complex nature of narrative material.

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

Abstract 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 Slavin-Mulford et al. (2011), 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.

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.

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.

Seeing red: Affect modulation and chromatic color responses on the Rorschach

Psychoanalytic theories suggest that color perception on the Rorschach relates to affective modulation. However, this idea has minimal empirical support. Using a clinical sample, the authors explored the cognitive and clinical correlates of Rorschach color determinants and differences among four affective modulation subtypes: Controlled, Balanced, Under-Controlled, and Flooded. Subtypes were differentiated by measures of affective regulation, reality testing/confusion, and personality traits. Initial support for the relationship of chromatic color response styles and affective modulation was found.

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

ABSTRACT 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.