Michelle B. Stein

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.

Borderline Pathology and the Personality Assessment Inventory (PAI): An Evaluation of Criterion and Concurrent Validity

Abstract In this study, we examined how patients diagnosed with borderline pathology (BP) would respond on the Personality Assessment Inventory (Morey, 1991) Borderline (BOR) scales in relation to patients without BP pathology. In addition, we examined whether the PAI BOR scales would be related to variables on the Social Cognition and Object Relations Scale (SCORS; Hilsenroth, Stein, & Pinsker, 2004; Westen, 1995) derived from early memory narratives. Results indicate that outpatients with a Diagnostic and Statistical Manual of Mental Disorders(4th ed. [DSM-IV]; American Psychiatric Association, 1994) diagnosis of BP scored significantly higher on the PAI BOR Total (BOR-Total) score, Identity Problems, and Self-Harm scales in comparison to a Non-BP clinical sample. The overall correct classification rate for the presence or absence of BP using the BOR Total scale (T ≥ 70) was 73%. In addition, there were several significant relationships between dimensional PAI BOR scales and the presence versus absence of DSM-IVBP. Moreover, both the BOR-Total and Affect Instability scales were significantly related to the SCORS variable Complexity of Representations. We provide clinical examples to illustrate these research findings in an applied manner.

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.

Validity of DSM-IV axis V global assessment of relational functioning scale: a multimethod assessment.

We investigate the convergent validity of the DSM-IV Axis V Global Assessment of Relational Functioning Scale (GARF; American Psychiatric Association, 1994). This study included 79 patients at a university-based outpatient treatment clinic. We examined clinician-rated GARF and the relationship to self-reported (Inventory of Interpersonal Problems; IIP-C; Horowitz et al. 2000) and free response themes [Social Cognition and Object Relations Scale: SCORS; Hilsenroth, Stein & Pinsker, 2004; Westen, 1995] of interpersonal functioning. Clinician ratings of the GARF scale and SCORS variables were highly reliable and internally consistent. Convergent Validity among the GARF, SCORS, and IIP scores was calculated using a Principal Components Analysis and Confirmatory Factor Analysis (CFA). Results of the Principal Components Analysis revealed that the GARF, SCORS, and IIP scores converged on a single factor, although findings of the CFA did not fully confirm the 1 factor model originally proposed. Intercorrelations among the GARF, SCORS, and IIP variables were analyzed and a pattern of significant relationships was found between the GARF and SCORS variables. This study helps support the convergent validity GARF as a relational functioning measure and is one of the first investigations to examine this scale multidimensionally.

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.

Clinical utility of early memories as a predictor of early therapeutic alliance.

The present study aims to empirically explore the relationship between clinician-rated early memories (EMs) and patient ratings of alliance that were obtained after a therapeutic model of assessment (TMA; Finn & Tonsager, 1997; Fischer, 1994). This study utilizes the Social Cognition and Object Relations Scale (SCORS; Westen, 1995) to obtain information from early memory narratives about an individuals level of object representations. With data gathered from 57 participants, the authors examined whether an individuals EM narratives can provide insight into his or her object representations and how such material relates to the development of an intimate connection with the therapist. Results supported our hypotheses as meaningful correlations were found between certain SCORS variables and patient-rated therapeutic alliance. The clinical utility and research implications of these findings are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

A training outline for conducting psychotherapy process ratings: An example using therapist technique

Aims: This study addresses the effects of structured training on the development of coding skills used in psychotherapy process research. Method: Participants included graduate trainees enrolled in an APA approved Clinical PhD programme. A course outline for training is reviewed and examined in relation to ratings of therapist techniques used during psychotherapy sessions. Results: The effects of this structured training protocol for raters resulted in good to excellent levels of interrater reliability. Different groups of raters were compared along multiple factors such as level of graduate training, training received on a particular measure, and psychotherapy experience. Discussion: The implications of these findings for rater training in psychotherapy process research are discussed.

Relationship between the Social Cognition and Object Relations Scale (SCORS) and attachment style in a clinical sample

This present study examined the relationship between the Social Cognition and Object Relations Scale (SCORS) and two measures of adult attachment: the Relationship Questionnaire (RQ) and the Experiences in Close Relationships Questionnaire-Revised (ECR-R). Forty-five patients (76% female) at a university-based outpatient treatment clinic participated in this study. We hypothesized that higher levels of attachment security would be associated with higher, more adaptive ratings on the SCORS variables. Results indicated that the SCORS Self-Esteem (SE) variable was significantly positively related to the RQs Secure Attachment ratings and negatively related with the ECR-Rs Anxious Attachment scale. Additionally, negative trends were noted between SE and the RQs Fearful and Preoccupied Attachment scores. The SCORS Emotional Investments in Relationships and Affective Quality of Representations variables were associated with higher Secure scores and lower, more maladaptive Preoccupied scores on the RQ. It was also associated with greater attachment anxiety as measured by the ECR-R. Using both clinician (SCORS) and participant-rated measures (ECR-R and RQ), this study provides further understanding on how object representations and attachment style relate within a clinical sample. Results are discussed in light of prior research examining relationships between object relations and adult attachments, and clinical implications are also reviewed. Copyright

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.