Journal of Personality Assessment
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Some Reflections on the Meaning of Psychodiagnosis Harrison Gough To cite this article: Harrison Gough (1992) Some Reflections on the Meaning of Psychodiagnosis, Journal of Personality Assessment, 59:2, 410-423, DOI: 10.1207/s15327752jpa5902_14 To link to this article: https://doi.org/10.1207/s15327752jpa5902_14
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JOURNAL OF PERSONALITY ASSESSMENT, 1992, 59(2), 410-423 Copyright 1992, Lawrence Erlbaum Associates, Inc.
CLASSICS IN PERSONALITY ASSESSMENT EDITOR'S INTRODUCTION The following article by Harrison Gough, originally published in 1971, is the first in a series of classical contributions to the literature in personality assessment that will be reprinted from time to time in the Journal of Personality Assessment. This new feature is intended to acquaint readers with ideas from the past that have influenced the development of the field and that address issues of continuing importance in personality assessment.
Some Reflections on the Meaning of Psychodiagnosis Harrison Gough University of California at Berkeley
Many psychologists tend to look on psychodiagnosis as mere ritual or wheelspinning. In Meehl's (1960) survey of therapists, the statement "It greatly speeds therapy if the therapist has prior knowledge of the client's dynamics and content from such devices as the Rorschach and TAT [p. 191"was included; only 17% of 168 practitioners queried expressed agreement. Rotter (1964) asserts that the diagnostic approach is sterile and has yielded little in over 100 years of application. Rogerians have long since announced their release from the chains and constraints of diagnostic bondage (cf. Ford & Urban, 1963, p. 427; Rogers, Presented at a conference on personality assessment, Veterans Administration Hospital, Palo Alto, CA, March 19, 1970. Published in American Psychologist, 1971, 26, 160-167. Copyright 1971 by the American Psychological Association. Reprinted by permission.
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1957, pp. 101-102). These sentiments of disbelief, dubiety, and impatience are to be encountered in any center where psychologists work and study today. Why then should anyone take diagnosis seriously?Why should psychologists be trained in the methods of appraisal and the ways of thinking that involved in personality diagnosis?Why should we worry about this matter at all, except as a historical oddity such as phrenology or palm reading? It is doubtful whether an answer can be formulated that will satisfy everyone, and it may well be true that disillusionment with diagnosis is fully justified. However, it is not the purpose of this article to dwell on the demise of diagnosis, nor in fact does the writer see the body as ready for interment. He is one of those peculiar souls who believes in diagnosis, as one might say, and therefore the obligation of this report is to delineate some of the reasons thought to justify this perhaps anachronistic point of view. To do this properly requires ranging over a number of ideas and topics-some well known and some not so well known. For the former, the reader's indulgence is requested, and for the latter, his attention.
PURPOSE OF DIAGNOSIS A first notion concerns what might be called the axiomatics of diagnosis. Courtesy in the evaluation of an idea suggests that we hold it for the claims it in fact makes, not for the claims we would like or misbelieve it to make. The goal of diagnosis, for example, is not to label or stigmatize; these outcomes may be unfortunate products or by-products of diagnosis, or they may be unfortunate effects of diagnosis abused. But diagnosis is not a form of lifesmanship, whose goals are to put someone down or to score a debater's point. The function of diagnosis is to identify the ~roblemthe patient has resented in such a way that an appropriate and restorative treatment may be carried out. It is easiest to think of this formulation in medical terms, and indeed the logic of diagnosis is probably most clearly illustrated in the medical treatment of physical illness. Complaints and symptoms may arise from many different sources, and depending on these sources the same treatment may be helpful, inconsequential, or dangerous. To treat abdominal distress with an aperient would be extremely unwise if the underlying condition was an inflammation of the vermiform appendix. Treatment, to be effective, must be addressed to the underlying condition as this is determined by accurate diagnosis. Mere mention of the medical model, of course, is enough to set psychological teeth on edge, and the all too common reaction is one of phobic avoidance. Phobic response in the intellectual domain is as irrational and unproductive as in the behavioral, and doctrinaire beliefs about the independence and ztutonomy of psychology should not be permitted to interfere with rational analysis
of the merits of diagnosis. In fact, there is a certain contradiction when those who oppose "labels" use the label "medical model" as a ploy for invalidating diagnostic concepts.
LOGIC OF CAUSATION A second comment is that diagnostic thinking necessarily involves attention to the logical question of causation. This is a thorny issue, and could by itself discourage one from going very far into the intricacies of diagnosis. We might try to detoxify the problem by examining logical notions of causation to see if any could serve as a reasonable philosophical basis for the diagnostic approach. A first sense of causation is that of the human agency or mediation. An individual causes a consequence, or is responsible for it, when in his voluntary action he brings it about. Cause in this sense usually signifies a sufficient antecedent condition, not a necessary one. Thus, to bring light into a room an individual can press a switch, light a match, or pull back the curtains from a window. The effect must be broadly conceived, as the quality of light produced by each of the causes will be different. The Latin word causa, as used in law, has to do with voluntary actions of this kind for which an individual can be held responsible. A second sense of causality refers to causation in nature, and is an easy extension of the first. A cause is again a sufficient condition, and to discover the cause of an event is to discover something among its temporal antecedents such that, if it had not been present, the event would not have occurred. This is the sense of causation that is employed in the practical sciences; the procedure utilized by the practical scientist differs from that of the ordinary intelligent man only in that he needs to be more careful in his diagnosis of causes and in that he is assisted in this diagnosis by the availability of a large fund of formal and theoretical knowledge. The ideas of J. S. Mill fall into this second category: the cause of a phenomenon is the antecedent or concurrence of antecedents on which it is invariably and unconditionally consequent. Mill's canons of induction require the analysis of complex events into factors and the discovery, by way of experiment and observation, of those factors that are invariably and unconditionally present when a certain phenomenon appears and absent when it does not occur. An assertion of cause, following this, is an expression of confident anticipation, based on the consistency of prior experience. The postulates of Robert Koch, the great bacteriologist, are addressed to this same purpose. A third sense is to view cause as explanation. Now the distinction between antecedent and consequent becomes trivial, and reflects only the biases of experience. The essential notion is that of logical coherence and deducibility: given this set of conditions, this field of forces, this constellation of traits, etc.,
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then these implications will obtain. The effect, that is, may be deduced from the cause. Both the second and third senses of causality are relevant to the notion of therapy: in the second, the emphasis is on those antecedent conditions that will give rise to undesirable and unwanted consequences, and in the third, on the structure of the total field in which unfortunate components are to be found. Put in language more often used by diagnosticians, the search is for etiological factors in either prior circumstance or present situation. The emphasis on prediction in the writing of some diagnostically minded psychologists can be related to this second notion of causality; that is, the purpose of diagnostic appraisal is to forecast what the subject will say or do at a later time. Leon Levy (1963) in his book Psychological Interpretation puts it this way: Psychodiagnosis is a descriptive venture, having as its ultimate goal the provision of a basis for the anticipation of the behavior of the patient under various contingencies. Unless it can be shown that this goal is accomplished by the use of a particular psychodiagnostic approach, continued use of that approach represents sheer ritual. Therefore, if the clinician is not to be found guilty of engaging in ritualistic behavior in the pursuit of his professional goals, he must be able to demonstrate that the product of his psychodiagnostic procedures permits predictions to be made about a patient's behavior at a higher level of accuracy than could otherwise be obtained [p. 1573. In practice, the steps taken in arriving at a diagnosis can be specified with little difficulty. First comes a recognition of the presenting problem or the presenting complaint. Second, facts relevant to the complaint are gathered-how long has the trouble been apparent, does the pain come and go, are there other symptoms, etc. Third, the clinician ponders this information and by induction hypothesizes possible explanations. Fourth, the implications of his hypotheses are checked back against the observations and if necessary new observations are gathered. And fifth, on the basis of confirmation and disconfirmation, a decision is made as to diagnosis. Technical skill and apparatus are important in gathering information, but the capacity to think inductively is of paramount importance in the total sequence. Not everyone has what it takes to become a good diagnostician, just as not everyone has what it takes to become a good therapist or a virtuoso in ainy endeavor that requires a high order of talent and self-development.
OBSERVATION AND DIAGNOSIS In gathering the relevant facts, there are more olr less time-honored areas of attention. First comes the personal history of the patient. The diagnostician
needs to know something of the family background, as certain conditions such as Huntington's chorea and Wilson's disease have known genetic linkage, and others such as diabetes and manic-depressive reactions tend to recur. The work situation is important, and the personal habits of the patient with respect to alcohol, drug usage, and other factors need to be explored. The illness or presenting complaint must also be traced out. Pain is frequently a concomitant of physical illness, and an accurate description of the pain, if present, is needed: its location, duration, periodicity, quality, and the conditions under which it appears; sometimes just this information alone is sufficient to establish diagnosis, as in intermittent claudication. The physical examination comes next, and it too follows a typical format. Visual inspection-of face, eyes, posture, gait, physique, etc.-is carried out. Palpation is a second method, and percussion, a third. It is interesting to note that Leopold Auenberger, who first reported the method of percussion in his lnventum Novum in 1761, credits the method to his boyhood experiences in Graz, Austria, when he learned how to tell whether wine casks were filled or empty by tapping on them and listening to the reverberations. Auscultation, a fourth method, proposed by Rene Laennec in 1819, also came to mind by way of a happy observation. According to his biographers, Laennec was watching a group of youngsters playing on a beam in the courtyard of the Louvre. One child scratched the beam with a pin, and the others, with ears pressed against the beam, called out every time he scratched. Laennec decided to try this on a patient, and took a sheet of paper, rolled it into a cylinder, applying one end to his patient's chest and his ear to the other. To his delight, he heard the heart sounds clearly, and at that moment the stethoscope was discovered. The gradual development of more penetrating and precise aids to diagnosis can be illustrated in the succession of dates for these innovations: accurate timing of pulse rate, 1707; systematic data on body temperature in fevers, 1852; electrocardiograph, 1887; blood pressure cuff (sphygmomanometer), 1896; electroencephalography, 1929. New devices are being invented constantly, and advances in biochemical analyses, computer reduction of data, and other indirect aids are occurring with equal frequency. Although the steps and illustrations just offered refer more to medicine than psychology, similar stages are applicable to the work of the psychodiagnostician. Mensh (1966) in his book Clinical Psychology: Science and Profession makes this statement: By means of data from interviews and from standard objective and projective test techniques, the clinical psychologist develops his inferences about the probable etiology of the behavior he is investigating, the complicating variables in the patient's life and his assets for handling life situations, and the probable optimal mode of treatment. He may also include data from school, work, family, or other sources, just as he also utilizes these avenues in his treatment approach [p. 121.
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CRITICISMS OF DIAGNOSIS One hopes that the text up to this point has giver1 at least partially satisfactory answers to three of the criticisms often made of diagnostics. One of these criticisms is that diagnosis has as its aim the mere labeling of the ~roblem,a kind of pigeon-holing that helps to meet the therapist's need for order but that is of little value to the patient; the answer to this criticism is that the goal of diagnosis is to permit selection of that form of treatment which is most beneficial to the patient. A second criticism is that diagnosis is a philosophically naive enterprise and cannot hold up under logical scrutiny. The answer to this criticism is tlhat diagnosis is but a special case of one of the most interesting and complex philosophical problems known to man-the problem of causality. A third allegation is that diagnosis is a perfunctory endeavor, an easy and pedestrian task to be performed by individuals of modest endowment, who leave the more complicated challenges of therapy to their betters. The answer to this assertion is that diagnosis, properly conducted, is a complex and demanding task drawing on hard-to-acquire skills and a high degree of aptitude in its practitioners. A fourth objection is that there is no need in treatment to attend to this or rhat specific factor, causative or otherwise. Why not, as some therapists announce, simply give the patient what we know will help him, no matter what his trouble may be. Thus, love is all you need say the Beatles-or unconditional regard say the Rogerians-and that is what you will receive. And after all, as the advertisements promise, Guiness is good for what ails you. Now it may be true that certain universal remedies may moderately enhance the well-being of all people, as for example an admonition to any American male to lose five pounds or the injunction immer ohne schlag to anyone from Vienna; but even if these instructions would enhance general well-being, they would not be of much help to someone suffering from Hodgkin's disease, tumor, or other illness in which the dietary factor is trivial or irrelevant. Furthermore, therapy, if rational, should be cumulative in its wisdom, and a therapist should not in glorious ignorance or indifference recapitulate the errors, false starts, mistakes, and miscalculations of past relationships with each new patient. To build rationally on past experience, a method for relating the new to the old is needed, and this bridge is precisely what diagnosis is intended to supply.
LEVELS OF DIAGNOSIS Up to this point, little has been said about the substantive side of diagnosis, a.nd it is therefore time to turn to this issue. That is, if a diagnosis is not merely a classificatory word or phrase, what is it? To treat the matter properly, we must
distinguish levels of diagnosis. Level 1 is that given by the clustering of symptomatic or phenotypical data. A clinician observes that certain behaviors or signs covary, such that when one is detected the others can usually be found. If the pattern recurs and is confirmed by others, it may be designated as a syndrome, as in the Libman-Sach's syndrome marked by persistent moderate fever, progressive anemia, and purpuric lesions of the skin. The push in diagnosis, however, is on to a second level, that of pathology. Thus, whereas both malaria and polio may first be brought to visibility by way of the symptom of fever, the danger of pathological tissue damage in the first is to the spleen and liver and in the second to gray matter in the anterior horns of the spinal column. Insofar as treatment is concerned, relief of symptoms is about all that can be done for syndromes conceptualized at Level 1, barring a happy accident in the discovery of a frankly empirical specific, as for example chlorpromazine and the phenothiazines for some forms of schizophrenia. For illnesses conceptualized at the second level, the possibility of arresting the reaction by means of surgery or other forms of treatment is possible, and curative efforts may be directed at the underlying factor. The third and most basic level of diagnosis is that in which the etiological factor is identified. Thus, malaria is known to be caused by the malarial parasite, transported by the anopheles mosquito, and polio by one of three kinds of virus, Once an illness is conceptualized on this third level, there is the possibility of prevention by way of vaccines or eradication of the conditions uoder which infection can occur. To put this progression into a shorthand formula, we can therefore say that for reactions classified at the first level, therapy can provide relief; for those at the second, cure; and for those at the third, prevention. Thus, no clinical syndrome can, ever be considered fully understood and fully controlled until the diagnostic formulation has been pushed on to the third level and confirmed. One of the exceedingly interesting thing? that begins to happen, as a syndrome is conceptualized at a more basic level, is that what are called "false positives" and "false negatives" begin to appear. At Levels 1and 2, a false+positive subject would be one showing the symptoms but not the ~athology,and a false negative would be one free of the symptoms but suffering the pathology. Proper therapy for true positives and false positives mighr very well be different, and until the diagnostic differentiation is possible, the correct choice of differential treatment could not be made. It is also interesting to observe the deepening of conceptualizations over time. In the early 1800s, a syndrome was observed involving symptoms such as dysarthria, shaky handwriting, alteration of sleep rhythms, pupillary abnormalities, etc. Some 50 years later, it was discovered that patients with this syndrome revealed a typical frontal lobe atrophy, with adhesions between arachnoid and cortex. At the turn of the century, it was established that the causative agent was the treponema pallidurn, verifiable in the cortex. Treatment could then be
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directed against the invading organism (and was, with Ehrlich's "606"), and, since the discovery of penicillin, complete control of the illness-dementia paralytica-has been at least theoretically possible. Not every illness in medicine has been conceptualized at this third level. Cancer, the second leading cause of death among Americans with a rate of 364.5 per 100,000, is an example. The symptomatologyof cancer can take many forms: a slight cough, pain, swelling, alterations of skin tone and texture, bleeding, apparent indigestion, headache, etc. The pathology, on which diagnosis is based, is a form of malignant neoplasm manifesting invasiveness and a tendency to metastasize. The etiology, however, is not yet known; it may be caused by a virus, it could be nutritional, or even a kind of allergic reaction to foreign matter. As an illness conceptualized at Level 2, treatment by means of surgery or radiation therapy is possible, but prevention is not. Empirical knowledge relevant to incidence is available, as for example the statistics on lung cancer among smokers, but a valid etiological conception of the illness has not yet been developed. Polio, on the other hand, is an example of an illness whose conceptualization at the third level was achieved fairly recently. Following the success of Enders, Weller, and Robbins in culturing polio virus, it was only a few years until the development of the Salk vaccine in 1954 and the Sabin oral vaccine in 195;'.
PSYCHOLOGICAL DIAGNOSIS These levels of diagnosis have a counterpart in the psychological realm, and the same push toward more fundamental understanding is as important in this realm as in the physical. The symptomatic-phenotypic level is much the sarne: clients have problems, difficulties, or other features of thought and behavior that are noted to covary. Symptomatic relief may be provided by way of palliatives such as reassurance, sympathy, etc., but with no assurance that these are directed at etiological factors. At the second level, we encounter psychopathology. Thus, excessive dependence on the defense mechanism of repression may be the psychopathological factor underlying a clinical hysteria. Psychotherapy can then be addressed to the defense system, with a greater likelihood of stable improvement in the patient than if attention had been addressed to purely symptomatic phenomena. Just as histological and biochemical analyses may be of great help in identifying these underlying pathological factors in physical illness, so may psychological tests be of help in identifying the psychopathological underpinnings otf a presenting syndrome. One of the distinctions that is frequently made on the Minnesota Multiphasic Personality Inventory (MMP1)-between so-called symptomatic scales such as 7 and character scales such as 6-reflects tlhis difference between Level 1 and Level 2 diagnoses. To the extent that an Mh@I
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scale contains truly subtle items, the more certain we may be that it has penetrated through into the second level of psychopathology. A truly subtle item, incidentally, is one whose scale membership and scoring cannot be guessed by reading, and whose content is not necessarily associated with the domain of manifest concern ordinarily found among persons revealing the clinical picture. One could go even further and say that empirical item analysis such as employed in MMPI scale construction is a reasonably powerful method for discovering whether a diagnostic syndrome at Level 1 does in fact have a psychopathological infrastructure. It may seem on reading Dahlstrom and Welsh (1960) that anything and everything can be scaled on the magic item pool of the MMPI. In fact, this is not the case, and there have been attempts to scale where the yield of subtle items was zero; a negative finding like this, following the aforementioned line of reasoning, suggests that the symptomatic syndrome is just that-a syndrome lacking a demonstrable psychopathological basis and hence one that should be abandoned or redefined. An example can be taken from studies of alcoholics; item analyses of the MMM against this symptomatic cluster nearly always turn out to be inefficient and indirect ways of finding the items in the inventory that say "I have used alcohol excessively." Thus, the empirical analysis confirms what most clinicians already suspect from other kinds of study: there is no single psychodynamic basis for the clinical syndrome. Another example can be drawn from the study of headaches. A survey was made of patients complaining of headaches and for whom headache was a major symptom, contrasting them with other patients matched on age, sex, etc., but free of the complaint. The item analysis carefully brought to light all of the items in the inventory mentioning headaches, but not much else. Thus, from this probe it would appear that "headache" is not a very promising diagnostic concept, and should be left as a word in the symptomatic lexicon. In interpreting tests like the MMPI, skilled workers draw heavily on these underlying or Level 2 notions. In a profile in which Scale 3 is elevated, an interpreter may say nothing whatsoever about manifest ~~mptomatology, but a great deal about dependency and narcissism. O n Scale 4, he may think more about inadequacies of attention span than of behavioral deviation. Complex interactions among test components, in fact, can often appear quite irreconcilable at the symptomatic level, but fully reasonable and revealing at Level 2. Diagnostic thinking at Level 2 is therefore superior to diagnostic thinking at Level 1, and instruments conceptualized at Level 2 are more valuable than those conceptualized at Level 1. One should interject that these remarks do not apply only to tools intended for use in the clinic. The Strong Vocational Interest Blank (Strong, 1943) in the hands of skilled interpreters is read at Level 2 and not at Level 1, and the same assertion can be made for the California Psychological Inventory (CM; Gough,
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1957, 1968) whose scales are named for behavioral clusters observable in the ongoing currents of everyday social life.
PSYCHODIAGNOSIS AT LEVEL 3 The third level in psychodiagnosis is concerned with etiology, as found in the life history and family background. If, in the psychodiagnosis of schizophrenia, we could discover just which factors of pseudo-mutuality and contradictlory message-sending in the family were at the root of the schizoid reaction we could begin work on prevention. It is unlikely, of course, that single causative agents will be found at Level 3 in psychodiagnostic analysis, but even though the conceptual problem will involve clusters and interactions of factors, the polssibility of identifying the etiological progression remains. MacKinnon (1949), among others, has emphasized the need to go back to these root factors in the life history. Our tools of appraisal should likewise be ~ u s h e dback to this third level of understanding, where possible. Other things being equal, the more powerful the scale, the broader the range of life-history antecedents that can be deduced from variations of score on the measure. Most of the psychodiagnostic concepts employed in psychology and psychiatry have been worked through to the second level, but not the third. Solme have not even attained the second level, and as in the case of alcoholism may be essentially symptomatic descriptions rather than diagnostic notions. Anxiety may be another, and the relative inutility for personality assessment of scales for anxiety may reflect this fundamentally phenotypic status of the concept. The redefinition incorporated in the state-versus-trait distinction (Spielberger, 1966) could be the way out of this box. Depression, on the other hand, althougll it seems very symptomatic, has many features of a Level 2 concept. Asymptomatic depression, in other words, is not just a semantic contradiction, and most clinicians would probably grant that the idea has both validity and some interesting implications. With respect to Level 3, life-history and family-background determinants; of scores on personality measures, information is only slowly accumulating. The studies of more and less authoritarian children by Else Frenkel-Brunswik (1948) brought to light elements of family structure conducive to social and intellectual tolerance, and the work of Dale Harris (Harris, Clark, Rose, & Valasek, 1954) has shown that different childhood milieus are related to higher and lower scores on scales for responsibility in adolescence. Retrospective accounts, although heuristic only, have also been assayed. In analyses at the Institute of Personality Assessment and Research in Berkeley, it was found that adult males scoring high on the MMPI D scale tended to describe
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their mothers as "generous," whereas those scoring low described her as "possessive." O n the Rorschach W%, high-scoring males viewed their fathers as prudent and mild, but their mothers as nervous and worrying. On the CM Socialization scale, high scorers saw their mothers as loving, whereas low scorers saw their mothers as criticizing.
ENHANCING DIAGNOSTIC SOPH'ISTICATION If psychodiagnosis is to be practiced, it seems fair to say, it should therefore be addressed to the broader and more implicative concepts of Levels 2 and 3, and it should be aided by tools capable of generating information of this type (cf. Gough, 1965). Present-day psychometric sophistication and computer methodology are of great help in developing such tools, and current literature reveals a flourishing productivity. Thus, for specific syndromes such as depression, we have the Beck (Beck, Ward, Mendelson, Mock, & Ebaugh, 1961) and Zung (1965) scales for self-description and the Hamilton (1960) scale for use by an observer. For more general characterization, we have the Inpatient Multidirnensional Psychiatric Scale of Lorr, Klett, McNair, and Lasky (19631, the Katz Adjustment Scales of Katz and Lyerly (1963), the Brief Psychiatric Rating Scale of Overall and Gorham (1962), the Hospital Adjustment Scale developed by Ferguson, McReynolds, and Ballachey (1953), and others. Diagnostic interpretation of MMF'I profiles is currently available from three sources-Roche Laboratories (Fowler, 1967), the Mayo Program (Rome et al., 1962) as handled by the Psychological Corporation, and the service provided by Alex Caldwell in Los Angeles-and a fourth, the Finney (1966) interpretational program of Lexington, Kentucky, is just becoming operational. Decision-tree models of diagnostic interpretation are also being developed, using the coded interview materials and (potentially) test information. Best known among these at the present time is DIAGNO-11 as developed in New York by Spitzer and Endicott (1969) and their colleagues, The Boston City Hospital Behavioral Check List developed by Peter Nathan (Nathan, Samaraweera, Ausberg, &Patch, 1968)is a close competitor. DIAGNO-I1 draws on a 96-variable input including age, sex, and 94 scaled judgments from an interview device called the Current and Past Psychopathology Scales (CAPPS). Fifty-seven decision points are programmed, leading to 46 different diagnostic classifications. The flow chart or decision tree is modeled on the sequences of decisions actually made by the clinician when he reviews the evidence on a patient and attempts to arrive at a diagnosis. The correspondence between DIAGNO-11's conclusions and those of skilled clinical diagnosticians is remarkable. DIAGNOLI's output. consists of 44 official diagnoses from the American Psychiatric Association handbook, augmented by nonspecific illness with mild symptomatology
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and not ill. The decision-tree model, however, could be applied to other kinds of diagnoses and to psychological classifications at Levels 2 and 3. Psychologists can obviously play a part in these developments and are playing a part. Our training includes a greater emphasis on statistical technique than that of our fellow mental health professionals, and we are therefore in demand when this kind of analysis is indicated. Principles of learning and behavioral modification can also be invoked just as much for the training of a diagnostician as for the therapy of a patient with a problem. HOWshould an apprenticeship in MMPI profile interpretation be conducted? With contingenciesof reinforcement and lots of behavior being emitted, a learning theorist might say. Thus, not only in the analysis of how to approach diagnostic understanding, but in the building of tools and in the training of practitioners to use these tools, psychology has important contributions to make. Our help is needed, and let us hope there will always be enough of us with a knack for diagnostic. work and an interest in it: so that this vital tradition of psychological endeavor can be maintained and transmitted-intact and full of vigor-to each new generation of psychologists.
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Lon, M., Klett, C. J., McNair, D. M., & Lasky, J. J. Inpatient multidimensional psychiatric scale. Palo Alto, Calif.: Consulting Psychologists Press, 1963. MacKinnon, D. W. Psychodiagnosis in clinical practice and personality theory. Journal of Abnormal and Social Psychology, 1949,44, 7-13. Meehl, P. E. The cognitive activity of the clinician. American Psychologist, 1960, 15, 19-27. Mensh, I. Clinical psychology: Science and profession. New York: Macmillan, 1966. Nathan, P. E., Samaraweera, A., Ausberg, M. M., & Patch, V. D. Syndromes of psychosis and psychoneurosis. Archives of General Psychiatry, 1968, 19, 704-716. Overall, J. E., & Gorham, D. R. The brief psychiatric rating scale. Psychological Reports, 1962, 10, 799-812. Rome, H. P., Swenson, W. M., Mataya, P., McCarthy, C. E., Pearson, J. S., Keating, F. R., Jr., & Hathaway, S. R. Symposium on automation techniques in personality assessment. Proceedings of the Staff Meetings of the Mayo Clinic, 1962,37(3), 61-82. Rogers, C. R. The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 1957,21,95-103. Rotter, J. B. Clinical psychology. Englewood Cliffs, NJ: Prentice-Hall, 1964. Spielberger,C. D. Theory and research on anxiety. In C. D. Spielberger (Ed.), Anxiety and behavior. New York: Academic Press, 1966. Spitzer, R. L., & Endicott, J. Diagno II: Further development in a computer program for psychiatric diagnosis. American Journal of Psychiatry, 1969, 125, 12-21. Strong, E. K., Jr. Vocational interests of men and women. Stanford: Stanford University Press, 1943. Zung, W. W. K. A self-rating depression scale. Archives of General Psychiatry, 1965, 12, 63-70.
EDITOR'S EPILOGUE W h e n Harrison G o u g h gave permission for t h e reprinting of this article, h e provided i n a n accompanying letter some comments o n t h e historical context i n which it was written. Like t h e article, these comments should b e of interest to personality assessors w h o follow their history, a n d t h e y are reprinted with his permission. In our clinical program, from around the mid-60s to 1980 or a little later, students (and some staff) were in the anti-diagnosis period, resistant to any ideas about or techniques for assessing patients. My paper was often seen as a misguided attempt to propagandize for the hated "medical model," and as a n apology for tests like the MMPI that were o n their way out. I had taught a n MMPI seminar from arrival in 1949 t o about 1965 or 1966. But at that time the clinical training committee asked me to come in for a meeting, during which I was told that my MMPI seminar was n o longer needed. It was suggested that I give one lecture or two lectures each year, so that students would know about the quaint history of this moribund method. I said n o to this suggestion, and for about 15 years played n o part in the program. Some of the students took my personality assessment year-long seminar, but except for them I had n o contact. Then in around 1980 some new and younger staff members came by and said "you know, we have no training in the MMPI and our students feel this lack when they go into field placements, and meet students
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from other programs who know how to use the inventory. Would you be willing to give a one-quarter seminar on how to use and interpret the MMPI?"My reply to this suggestion was yes, and for the last five or six years of active duty (I retired in June 1986) I taught this seminar. The graduate students rated their courses from the standpoint of helpfulness to them and general value. My MMPI seminar was given a #l ranking each time.
ISSN: 0022-3891 (Print) 1532-7752 (Online) Journal homepage: http://www.tandfonline.com/loi/hjpa20
Some Reflections on the Meaning of Psychodiagnosis Harrison Gough To cite this article: Harrison Gough (1992) Some Reflections on the Meaning of Psychodiagnosis, Journal of Personality Assessment, 59:2, 410-423, DOI: 10.1207/s15327752jpa5902_14 To link to this article: https://doi.org/10.1207/s15327752jpa5902_14
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JOURNAL OF PERSONALITY ASSESSMENT, 1992, 59(2), 410-423 Copyright 1992, Lawrence Erlbaum Associates, Inc.
CLASSICS IN PERSONALITY ASSESSMENT EDITOR'S INTRODUCTION The following article by Harrison Gough, originally published in 1971, is the first in a series of classical contributions to the literature in personality assessment that will be reprinted from time to time in the Journal of Personality Assessment. This new feature is intended to acquaint readers with ideas from the past that have influenced the development of the field and that address issues of continuing importance in personality assessment.
Some Reflections on the Meaning of Psychodiagnosis Harrison Gough University of California at Berkeley
Many psychologists tend to look on psychodiagnosis as mere ritual or wheelspinning. In Meehl's (1960) survey of therapists, the statement "It greatly speeds therapy if the therapist has prior knowledge of the client's dynamics and content from such devices as the Rorschach and TAT [p. 191"was included; only 17% of 168 practitioners queried expressed agreement. Rotter (1964) asserts that the diagnostic approach is sterile and has yielded little in over 100 years of application. Rogerians have long since announced their release from the chains and constraints of diagnostic bondage (cf. Ford & Urban, 1963, p. 427; Rogers, Presented at a conference on personality assessment, Veterans Administration Hospital, Palo Alto, CA, March 19, 1970. Published in American Psychologist, 1971, 26, 160-167. Copyright 1971 by the American Psychological Association. Reprinted by permission.
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1957, pp. 101-102). These sentiments of disbelief, dubiety, and impatience are to be encountered in any center where psychologists work and study today. Why then should anyone take diagnosis seriously?Why should psychologists be trained in the methods of appraisal and the ways of thinking that involved in personality diagnosis?Why should we worry about this matter at all, except as a historical oddity such as phrenology or palm reading? It is doubtful whether an answer can be formulated that will satisfy everyone, and it may well be true that disillusionment with diagnosis is fully justified. However, it is not the purpose of this article to dwell on the demise of diagnosis, nor in fact does the writer see the body as ready for interment. He is one of those peculiar souls who believes in diagnosis, as one might say, and therefore the obligation of this report is to delineate some of the reasons thought to justify this perhaps anachronistic point of view. To do this properly requires ranging over a number of ideas and topics-some well known and some not so well known. For the former, the reader's indulgence is requested, and for the latter, his attention.
PURPOSE OF DIAGNOSIS A first notion concerns what might be called the axiomatics of diagnosis. Courtesy in the evaluation of an idea suggests that we hold it for the claims it in fact makes, not for the claims we would like or misbelieve it to make. The goal of diagnosis, for example, is not to label or stigmatize; these outcomes may be unfortunate products or by-products of diagnosis, or they may be unfortunate effects of diagnosis abused. But diagnosis is not a form of lifesmanship, whose goals are to put someone down or to score a debater's point. The function of diagnosis is to identify the ~roblemthe patient has resented in such a way that an appropriate and restorative treatment may be carried out. It is easiest to think of this formulation in medical terms, and indeed the logic of diagnosis is probably most clearly illustrated in the medical treatment of physical illness. Complaints and symptoms may arise from many different sources, and depending on these sources the same treatment may be helpful, inconsequential, or dangerous. To treat abdominal distress with an aperient would be extremely unwise if the underlying condition was an inflammation of the vermiform appendix. Treatment, to be effective, must be addressed to the underlying condition as this is determined by accurate diagnosis. Mere mention of the medical model, of course, is enough to set psychological teeth on edge, and the all too common reaction is one of phobic avoidance. Phobic response in the intellectual domain is as irrational and unproductive as in the behavioral, and doctrinaire beliefs about the independence and ztutonomy of psychology should not be permitted to interfere with rational analysis
of the merits of diagnosis. In fact, there is a certain contradiction when those who oppose "labels" use the label "medical model" as a ploy for invalidating diagnostic concepts.
LOGIC OF CAUSATION A second comment is that diagnostic thinking necessarily involves attention to the logical question of causation. This is a thorny issue, and could by itself discourage one from going very far into the intricacies of diagnosis. We might try to detoxify the problem by examining logical notions of causation to see if any could serve as a reasonable philosophical basis for the diagnostic approach. A first sense of causation is that of the human agency or mediation. An individual causes a consequence, or is responsible for it, when in his voluntary action he brings it about. Cause in this sense usually signifies a sufficient antecedent condition, not a necessary one. Thus, to bring light into a room an individual can press a switch, light a match, or pull back the curtains from a window. The effect must be broadly conceived, as the quality of light produced by each of the causes will be different. The Latin word causa, as used in law, has to do with voluntary actions of this kind for which an individual can be held responsible. A second sense of causality refers to causation in nature, and is an easy extension of the first. A cause is again a sufficient condition, and to discover the cause of an event is to discover something among its temporal antecedents such that, if it had not been present, the event would not have occurred. This is the sense of causation that is employed in the practical sciences; the procedure utilized by the practical scientist differs from that of the ordinary intelligent man only in that he needs to be more careful in his diagnosis of causes and in that he is assisted in this diagnosis by the availability of a large fund of formal and theoretical knowledge. The ideas of J. S. Mill fall into this second category: the cause of a phenomenon is the antecedent or concurrence of antecedents on which it is invariably and unconditionally consequent. Mill's canons of induction require the analysis of complex events into factors and the discovery, by way of experiment and observation, of those factors that are invariably and unconditionally present when a certain phenomenon appears and absent when it does not occur. An assertion of cause, following this, is an expression of confident anticipation, based on the consistency of prior experience. The postulates of Robert Koch, the great bacteriologist, are addressed to this same purpose. A third sense is to view cause as explanation. Now the distinction between antecedent and consequent becomes trivial, and reflects only the biases of experience. The essential notion is that of logical coherence and deducibility: given this set of conditions, this field of forces, this constellation of traits, etc.,
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then these implications will obtain. The effect, that is, may be deduced from the cause. Both the second and third senses of causality are relevant to the notion of therapy: in the second, the emphasis is on those antecedent conditions that will give rise to undesirable and unwanted consequences, and in the third, on the structure of the total field in which unfortunate components are to be found. Put in language more often used by diagnosticians, the search is for etiological factors in either prior circumstance or present situation. The emphasis on prediction in the writing of some diagnostically minded psychologists can be related to this second notion of causality; that is, the purpose of diagnostic appraisal is to forecast what the subject will say or do at a later time. Leon Levy (1963) in his book Psychological Interpretation puts it this way: Psychodiagnosis is a descriptive venture, having as its ultimate goal the provision of a basis for the anticipation of the behavior of the patient under various contingencies. Unless it can be shown that this goal is accomplished by the use of a particular psychodiagnostic approach, continued use of that approach represents sheer ritual. Therefore, if the clinician is not to be found guilty of engaging in ritualistic behavior in the pursuit of his professional goals, he must be able to demonstrate that the product of his psychodiagnostic procedures permits predictions to be made about a patient's behavior at a higher level of accuracy than could otherwise be obtained [p. 1573. In practice, the steps taken in arriving at a diagnosis can be specified with little difficulty. First comes a recognition of the presenting problem or the presenting complaint. Second, facts relevant to the complaint are gathered-how long has the trouble been apparent, does the pain come and go, are there other symptoms, etc. Third, the clinician ponders this information and by induction hypothesizes possible explanations. Fourth, the implications of his hypotheses are checked back against the observations and if necessary new observations are gathered. And fifth, on the basis of confirmation and disconfirmation, a decision is made as to diagnosis. Technical skill and apparatus are important in gathering information, but the capacity to think inductively is of paramount importance in the total sequence. Not everyone has what it takes to become a good diagnostician, just as not everyone has what it takes to become a good therapist or a virtuoso in ainy endeavor that requires a high order of talent and self-development.
OBSERVATION AND DIAGNOSIS In gathering the relevant facts, there are more olr less time-honored areas of attention. First comes the personal history of the patient. The diagnostician
needs to know something of the family background, as certain conditions such as Huntington's chorea and Wilson's disease have known genetic linkage, and others such as diabetes and manic-depressive reactions tend to recur. The work situation is important, and the personal habits of the patient with respect to alcohol, drug usage, and other factors need to be explored. The illness or presenting complaint must also be traced out. Pain is frequently a concomitant of physical illness, and an accurate description of the pain, if present, is needed: its location, duration, periodicity, quality, and the conditions under which it appears; sometimes just this information alone is sufficient to establish diagnosis, as in intermittent claudication. The physical examination comes next, and it too follows a typical format. Visual inspection-of face, eyes, posture, gait, physique, etc.-is carried out. Palpation is a second method, and percussion, a third. It is interesting to note that Leopold Auenberger, who first reported the method of percussion in his lnventum Novum in 1761, credits the method to his boyhood experiences in Graz, Austria, when he learned how to tell whether wine casks were filled or empty by tapping on them and listening to the reverberations. Auscultation, a fourth method, proposed by Rene Laennec in 1819, also came to mind by way of a happy observation. According to his biographers, Laennec was watching a group of youngsters playing on a beam in the courtyard of the Louvre. One child scratched the beam with a pin, and the others, with ears pressed against the beam, called out every time he scratched. Laennec decided to try this on a patient, and took a sheet of paper, rolled it into a cylinder, applying one end to his patient's chest and his ear to the other. To his delight, he heard the heart sounds clearly, and at that moment the stethoscope was discovered. The gradual development of more penetrating and precise aids to diagnosis can be illustrated in the succession of dates for these innovations: accurate timing of pulse rate, 1707; systematic data on body temperature in fevers, 1852; electrocardiograph, 1887; blood pressure cuff (sphygmomanometer), 1896; electroencephalography, 1929. New devices are being invented constantly, and advances in biochemical analyses, computer reduction of data, and other indirect aids are occurring with equal frequency. Although the steps and illustrations just offered refer more to medicine than psychology, similar stages are applicable to the work of the psychodiagnostician. Mensh (1966) in his book Clinical Psychology: Science and Profession makes this statement: By means of data from interviews and from standard objective and projective test techniques, the clinical psychologist develops his inferences about the probable etiology of the behavior he is investigating, the complicating variables in the patient's life and his assets for handling life situations, and the probable optimal mode of treatment. He may also include data from school, work, family, or other sources, just as he also utilizes these avenues in his treatment approach [p. 121.
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CRITICISMS OF DIAGNOSIS One hopes that the text up to this point has giver1 at least partially satisfactory answers to three of the criticisms often made of diagnostics. One of these criticisms is that diagnosis has as its aim the mere labeling of the ~roblem,a kind of pigeon-holing that helps to meet the therapist's need for order but that is of little value to the patient; the answer to this criticism is that the goal of diagnosis is to permit selection of that form of treatment which is most beneficial to the patient. A second criticism is that diagnosis is a philosophically naive enterprise and cannot hold up under logical scrutiny. The answer to this criticism is tlhat diagnosis is but a special case of one of the most interesting and complex philosophical problems known to man-the problem of causality. A third allegation is that diagnosis is a perfunctory endeavor, an easy and pedestrian task to be performed by individuals of modest endowment, who leave the more complicated challenges of therapy to their betters. The answer to this assertion is that diagnosis, properly conducted, is a complex and demanding task drawing on hard-to-acquire skills and a high degree of aptitude in its practitioners. A fourth objection is that there is no need in treatment to attend to this or rhat specific factor, causative or otherwise. Why not, as some therapists announce, simply give the patient what we know will help him, no matter what his trouble may be. Thus, love is all you need say the Beatles-or unconditional regard say the Rogerians-and that is what you will receive. And after all, as the advertisements promise, Guiness is good for what ails you. Now it may be true that certain universal remedies may moderately enhance the well-being of all people, as for example an admonition to any American male to lose five pounds or the injunction immer ohne schlag to anyone from Vienna; but even if these instructions would enhance general well-being, they would not be of much help to someone suffering from Hodgkin's disease, tumor, or other illness in which the dietary factor is trivial or irrelevant. Furthermore, therapy, if rational, should be cumulative in its wisdom, and a therapist should not in glorious ignorance or indifference recapitulate the errors, false starts, mistakes, and miscalculations of past relationships with each new patient. To build rationally on past experience, a method for relating the new to the old is needed, and this bridge is precisely what diagnosis is intended to supply.
LEVELS OF DIAGNOSIS Up to this point, little has been said about the substantive side of diagnosis, a.nd it is therefore time to turn to this issue. That is, if a diagnosis is not merely a classificatory word or phrase, what is it? To treat the matter properly, we must
distinguish levels of diagnosis. Level 1 is that given by the clustering of symptomatic or phenotypical data. A clinician observes that certain behaviors or signs covary, such that when one is detected the others can usually be found. If the pattern recurs and is confirmed by others, it may be designated as a syndrome, as in the Libman-Sach's syndrome marked by persistent moderate fever, progressive anemia, and purpuric lesions of the skin. The push in diagnosis, however, is on to a second level, that of pathology. Thus, whereas both malaria and polio may first be brought to visibility by way of the symptom of fever, the danger of pathological tissue damage in the first is to the spleen and liver and in the second to gray matter in the anterior horns of the spinal column. Insofar as treatment is concerned, relief of symptoms is about all that can be done for syndromes conceptualized at Level 1, barring a happy accident in the discovery of a frankly empirical specific, as for example chlorpromazine and the phenothiazines for some forms of schizophrenia. For illnesses conceptualized at the second level, the possibility of arresting the reaction by means of surgery or other forms of treatment is possible, and curative efforts may be directed at the underlying factor. The third and most basic level of diagnosis is that in which the etiological factor is identified. Thus, malaria is known to be caused by the malarial parasite, transported by the anopheles mosquito, and polio by one of three kinds of virus, Once an illness is conceptualized on this third level, there is the possibility of prevention by way of vaccines or eradication of the conditions uoder which infection can occur. To put this progression into a shorthand formula, we can therefore say that for reactions classified at the first level, therapy can provide relief; for those at the second, cure; and for those at the third, prevention. Thus, no clinical syndrome can, ever be considered fully understood and fully controlled until the diagnostic formulation has been pushed on to the third level and confirmed. One of the exceedingly interesting thing? that begins to happen, as a syndrome is conceptualized at a more basic level, is that what are called "false positives" and "false negatives" begin to appear. At Levels 1and 2, a false+positive subject would be one showing the symptoms but not the ~athology,and a false negative would be one free of the symptoms but suffering the pathology. Proper therapy for true positives and false positives mighr very well be different, and until the diagnostic differentiation is possible, the correct choice of differential treatment could not be made. It is also interesting to observe the deepening of conceptualizations over time. In the early 1800s, a syndrome was observed involving symptoms such as dysarthria, shaky handwriting, alteration of sleep rhythms, pupillary abnormalities, etc. Some 50 years later, it was discovered that patients with this syndrome revealed a typical frontal lobe atrophy, with adhesions between arachnoid and cortex. At the turn of the century, it was established that the causative agent was the treponema pallidurn, verifiable in the cortex. Treatment could then be
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directed against the invading organism (and was, with Ehrlich's "606"), and, since the discovery of penicillin, complete control of the illness-dementia paralytica-has been at least theoretically possible. Not every illness in medicine has been conceptualized at this third level. Cancer, the second leading cause of death among Americans with a rate of 364.5 per 100,000, is an example. The symptomatologyof cancer can take many forms: a slight cough, pain, swelling, alterations of skin tone and texture, bleeding, apparent indigestion, headache, etc. The pathology, on which diagnosis is based, is a form of malignant neoplasm manifesting invasiveness and a tendency to metastasize. The etiology, however, is not yet known; it may be caused by a virus, it could be nutritional, or even a kind of allergic reaction to foreign matter. As an illness conceptualized at Level 2, treatment by means of surgery or radiation therapy is possible, but prevention is not. Empirical knowledge relevant to incidence is available, as for example the statistics on lung cancer among smokers, but a valid etiological conception of the illness has not yet been developed. Polio, on the other hand, is an example of an illness whose conceptualization at the third level was achieved fairly recently. Following the success of Enders, Weller, and Robbins in culturing polio virus, it was only a few years until the development of the Salk vaccine in 1954 and the Sabin oral vaccine in 195;'.
PSYCHOLOGICAL DIAGNOSIS These levels of diagnosis have a counterpart in the psychological realm, and the same push toward more fundamental understanding is as important in this realm as in the physical. The symptomatic-phenotypic level is much the sarne: clients have problems, difficulties, or other features of thought and behavior that are noted to covary. Symptomatic relief may be provided by way of palliatives such as reassurance, sympathy, etc., but with no assurance that these are directed at etiological factors. At the second level, we encounter psychopathology. Thus, excessive dependence on the defense mechanism of repression may be the psychopathological factor underlying a clinical hysteria. Psychotherapy can then be addressed to the defense system, with a greater likelihood of stable improvement in the patient than if attention had been addressed to purely symptomatic phenomena. Just as histological and biochemical analyses may be of great help in identifying these underlying pathological factors in physical illness, so may psychological tests be of help in identifying the psychopathological underpinnings otf a presenting syndrome. One of the distinctions that is frequently made on the Minnesota Multiphasic Personality Inventory (MMP1)-between so-called symptomatic scales such as 7 and character scales such as 6-reflects tlhis difference between Level 1 and Level 2 diagnoses. To the extent that an Mh@I
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scale contains truly subtle items, the more certain we may be that it has penetrated through into the second level of psychopathology. A truly subtle item, incidentally, is one whose scale membership and scoring cannot be guessed by reading, and whose content is not necessarily associated with the domain of manifest concern ordinarily found among persons revealing the clinical picture. One could go even further and say that empirical item analysis such as employed in MMPI scale construction is a reasonably powerful method for discovering whether a diagnostic syndrome at Level 1 does in fact have a psychopathological infrastructure. It may seem on reading Dahlstrom and Welsh (1960) that anything and everything can be scaled on the magic item pool of the MMPI. In fact, this is not the case, and there have been attempts to scale where the yield of subtle items was zero; a negative finding like this, following the aforementioned line of reasoning, suggests that the symptomatic syndrome is just that-a syndrome lacking a demonstrable psychopathological basis and hence one that should be abandoned or redefined. An example can be taken from studies of alcoholics; item analyses of the MMM against this symptomatic cluster nearly always turn out to be inefficient and indirect ways of finding the items in the inventory that say "I have used alcohol excessively." Thus, the empirical analysis confirms what most clinicians already suspect from other kinds of study: there is no single psychodynamic basis for the clinical syndrome. Another example can be drawn from the study of headaches. A survey was made of patients complaining of headaches and for whom headache was a major symptom, contrasting them with other patients matched on age, sex, etc., but free of the complaint. The item analysis carefully brought to light all of the items in the inventory mentioning headaches, but not much else. Thus, from this probe it would appear that "headache" is not a very promising diagnostic concept, and should be left as a word in the symptomatic lexicon. In interpreting tests like the MMPI, skilled workers draw heavily on these underlying or Level 2 notions. In a profile in which Scale 3 is elevated, an interpreter may say nothing whatsoever about manifest ~~mptomatology, but a great deal about dependency and narcissism. O n Scale 4, he may think more about inadequacies of attention span than of behavioral deviation. Complex interactions among test components, in fact, can often appear quite irreconcilable at the symptomatic level, but fully reasonable and revealing at Level 2. Diagnostic thinking at Level 2 is therefore superior to diagnostic thinking at Level 1, and instruments conceptualized at Level 2 are more valuable than those conceptualized at Level 1. One should interject that these remarks do not apply only to tools intended for use in the clinic. The Strong Vocational Interest Blank (Strong, 1943) in the hands of skilled interpreters is read at Level 2 and not at Level 1, and the same assertion can be made for the California Psychological Inventory (CM; Gough,
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1957, 1968) whose scales are named for behavioral clusters observable in the ongoing currents of everyday social life.
PSYCHODIAGNOSIS AT LEVEL 3 The third level in psychodiagnosis is concerned with etiology, as found in the life history and family background. If, in the psychodiagnosis of schizophrenia, we could discover just which factors of pseudo-mutuality and contradictlory message-sending in the family were at the root of the schizoid reaction we could begin work on prevention. It is unlikely, of course, that single causative agents will be found at Level 3 in psychodiagnostic analysis, but even though the conceptual problem will involve clusters and interactions of factors, the polssibility of identifying the etiological progression remains. MacKinnon (1949), among others, has emphasized the need to go back to these root factors in the life history. Our tools of appraisal should likewise be ~ u s h e dback to this third level of understanding, where possible. Other things being equal, the more powerful the scale, the broader the range of life-history antecedents that can be deduced from variations of score on the measure. Most of the psychodiagnostic concepts employed in psychology and psychiatry have been worked through to the second level, but not the third. Solme have not even attained the second level, and as in the case of alcoholism may be essentially symptomatic descriptions rather than diagnostic notions. Anxiety may be another, and the relative inutility for personality assessment of scales for anxiety may reflect this fundamentally phenotypic status of the concept. The redefinition incorporated in the state-versus-trait distinction (Spielberger, 1966) could be the way out of this box. Depression, on the other hand, althougll it seems very symptomatic, has many features of a Level 2 concept. Asymptomatic depression, in other words, is not just a semantic contradiction, and most clinicians would probably grant that the idea has both validity and some interesting implications. With respect to Level 3, life-history and family-background determinants; of scores on personality measures, information is only slowly accumulating. The studies of more and less authoritarian children by Else Frenkel-Brunswik (1948) brought to light elements of family structure conducive to social and intellectual tolerance, and the work of Dale Harris (Harris, Clark, Rose, & Valasek, 1954) has shown that different childhood milieus are related to higher and lower scores on scales for responsibility in adolescence. Retrospective accounts, although heuristic only, have also been assayed. In analyses at the Institute of Personality Assessment and Research in Berkeley, it was found that adult males scoring high on the MMPI D scale tended to describe
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their mothers as "generous," whereas those scoring low described her as "possessive." O n the Rorschach W%, high-scoring males viewed their fathers as prudent and mild, but their mothers as nervous and worrying. On the CM Socialization scale, high scorers saw their mothers as loving, whereas low scorers saw their mothers as criticizing.
ENHANCING DIAGNOSTIC SOPH'ISTICATION If psychodiagnosis is to be practiced, it seems fair to say, it should therefore be addressed to the broader and more implicative concepts of Levels 2 and 3, and it should be aided by tools capable of generating information of this type (cf. Gough, 1965). Present-day psychometric sophistication and computer methodology are of great help in developing such tools, and current literature reveals a flourishing productivity. Thus, for specific syndromes such as depression, we have the Beck (Beck, Ward, Mendelson, Mock, & Ebaugh, 1961) and Zung (1965) scales for self-description and the Hamilton (1960) scale for use by an observer. For more general characterization, we have the Inpatient Multidirnensional Psychiatric Scale of Lorr, Klett, McNair, and Lasky (19631, the Katz Adjustment Scales of Katz and Lyerly (1963), the Brief Psychiatric Rating Scale of Overall and Gorham (1962), the Hospital Adjustment Scale developed by Ferguson, McReynolds, and Ballachey (1953), and others. Diagnostic interpretation of MMF'I profiles is currently available from three sources-Roche Laboratories (Fowler, 1967), the Mayo Program (Rome et al., 1962) as handled by the Psychological Corporation, and the service provided by Alex Caldwell in Los Angeles-and a fourth, the Finney (1966) interpretational program of Lexington, Kentucky, is just becoming operational. Decision-tree models of diagnostic interpretation are also being developed, using the coded interview materials and (potentially) test information. Best known among these at the present time is DIAGNO-11 as developed in New York by Spitzer and Endicott (1969) and their colleagues, The Boston City Hospital Behavioral Check List developed by Peter Nathan (Nathan, Samaraweera, Ausberg, &Patch, 1968)is a close competitor. DIAGNO-I1 draws on a 96-variable input including age, sex, and 94 scaled judgments from an interview device called the Current and Past Psychopathology Scales (CAPPS). Fifty-seven decision points are programmed, leading to 46 different diagnostic classifications. The flow chart or decision tree is modeled on the sequences of decisions actually made by the clinician when he reviews the evidence on a patient and attempts to arrive at a diagnosis. The correspondence between DIAGNO-11's conclusions and those of skilled clinical diagnosticians is remarkable. DIAGNOLI's output. consists of 44 official diagnoses from the American Psychiatric Association handbook, augmented by nonspecific illness with mild symptomatology
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and not ill. The decision-tree model, however, could be applied to other kinds of diagnoses and to psychological classifications at Levels 2 and 3. Psychologists can obviously play a part in these developments and are playing a part. Our training includes a greater emphasis on statistical technique than that of our fellow mental health professionals, and we are therefore in demand when this kind of analysis is indicated. Principles of learning and behavioral modification can also be invoked just as much for the training of a diagnostician as for the therapy of a patient with a problem. HOWshould an apprenticeship in MMPI profile interpretation be conducted? With contingenciesof reinforcement and lots of behavior being emitted, a learning theorist might say. Thus, not only in the analysis of how to approach diagnostic understanding, but in the building of tools and in the training of practitioners to use these tools, psychology has important contributions to make. Our help is needed, and let us hope there will always be enough of us with a knack for diagnostic. work and an interest in it: so that this vital tradition of psychological endeavor can be maintained and transmitted-intact and full of vigor-to each new generation of psychologists.
REFERENCES Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Ebaugh, J. An inventory for measuring depression. Archives of General Psychiatry, 1961, 4, 53-63. Dahlstrom, W. G., &Welsh, G. S. An MMPl handbook: A guide for use in clinical practice and research. Minneapolis: University of Minnesota Press, 1960. Ferguson, J. T., McReynolds, P., & Ballachey, E. L. Hospital adjustment scale. Palo Alto, Calif.: Consulting Psychologists Press, 1953. Finney, J. C. Programmed interpretation of MMPI and CPI. Archives of General Psychiatry, 1966, 15, 75-81. Ford, D. H., & Urban, H. B. Systems of psychotherapy: A comparative study. New York: Wiley, 1963. Fowler, R. D., Jr. Computer interpretation of personality tests: The automated psychologist. Comprehensive Psychiatry, 1967, 8,455-467. FrenkeEBrunswik, E. A study of prejudice in children. Human Relations, 1948, 1, 295-306. Gough, H. G. Manual for the California Psychological Inventory. Palo Alto, Calif.: Consulting Psychologists Press, 1957. Gough, H. G. Conceptual analysis of psychological test scores and other diagnostic variables. Journal of Abnormal Psychology, 1965, 70, 294-302. Gough, H. G. An interpreter's syllabus for the California Psychological Inventory. In P. McReynolds (Ed.), Advances in psychological assessment. Vol. 1. Palo Alto, Calif.: Science and Behavior Books, 1968. Hamilton, M. A rating scale for depression. Journal of Neurology, Neurosurgery, and Psychiatry, l1960, 23, 56-62. Harris, D. B., Clark, K. E., Rose, A. M., & Valasek, F. The relationship of children's home duties to an attitude of responsibility. Child Development, 1954, 25,29-33. Katz, M. M., & Lyerly, S. B. Methods for measuring adjustment and social behavior in the community: I. Rationale, description, discriminative validity, and scale development. Psychological Reports, 1963, 13, 503-535. Levy, L. H. Psychological interpretation. New York: Holt, Rinehart & Winston, 1963.
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Lon, M., Klett, C. J., McNair, D. M., & Lasky, J. J. Inpatient multidimensional psychiatric scale. Palo Alto, Calif.: Consulting Psychologists Press, 1963. MacKinnon, D. W. Psychodiagnosis in clinical practice and personality theory. Journal of Abnormal and Social Psychology, 1949,44, 7-13. Meehl, P. E. The cognitive activity of the clinician. American Psychologist, 1960, 15, 19-27. Mensh, I. Clinical psychology: Science and profession. New York: Macmillan, 1966. Nathan, P. E., Samaraweera, A., Ausberg, M. M., & Patch, V. D. Syndromes of psychosis and psychoneurosis. Archives of General Psychiatry, 1968, 19, 704-716. Overall, J. E., & Gorham, D. R. The brief psychiatric rating scale. Psychological Reports, 1962, 10, 799-812. Rome, H. P., Swenson, W. M., Mataya, P., McCarthy, C. E., Pearson, J. S., Keating, F. R., Jr., & Hathaway, S. R. Symposium on automation techniques in personality assessment. Proceedings of the Staff Meetings of the Mayo Clinic, 1962,37(3), 61-82. Rogers, C. R. The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 1957,21,95-103. Rotter, J. B. Clinical psychology. Englewood Cliffs, NJ: Prentice-Hall, 1964. Spielberger,C. D. Theory and research on anxiety. In C. D. Spielberger (Ed.), Anxiety and behavior. New York: Academic Press, 1966. Spitzer, R. L., & Endicott, J. Diagno II: Further development in a computer program for psychiatric diagnosis. American Journal of Psychiatry, 1969, 125, 12-21. Strong, E. K., Jr. Vocational interests of men and women. Stanford: Stanford University Press, 1943. Zung, W. W. K. A self-rating depression scale. Archives of General Psychiatry, 1965, 12, 63-70.
EDITOR'S EPILOGUE W h e n Harrison G o u g h gave permission for t h e reprinting of this article, h e provided i n a n accompanying letter some comments o n t h e historical context i n which it was written. Like t h e article, these comments should b e of interest to personality assessors w h o follow their history, a n d t h e y are reprinted with his permission. In our clinical program, from around the mid-60s to 1980 or a little later, students (and some staff) were in the anti-diagnosis period, resistant to any ideas about or techniques for assessing patients. My paper was often seen as a misguided attempt to propagandize for the hated "medical model," and as a n apology for tests like the MMPI that were o n their way out. I had taught a n MMPI seminar from arrival in 1949 t o about 1965 or 1966. But at that time the clinical training committee asked me to come in for a meeting, during which I was told that my MMPI seminar was n o longer needed. It was suggested that I give one lecture or two lectures each year, so that students would know about the quaint history of this moribund method. I said n o to this suggestion, and for about 15 years played n o part in the program. Some of the students took my personality assessment year-long seminar, but except for them I had n o contact. Then in around 1980 some new and younger staff members came by and said "you know, we have no training in the MMPI and our students feel this lack when they go into field placements, and meet students
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from other programs who know how to use the inventory. Would you be willing to give a one-quarter seminar on how to use and interpret the MMPI?"My reply to this suggestion was yes, and for the last five or six years of active duty (I retired in June 1986) I taught this seminar. The graduate students rated their courses from the standpoint of helpfulness to them and general value. My MMPI seminar was given a #l ranking each time.
