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Journal of Personality Assessment Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hjpa20
The Relationship Between Assessment and Psychotherapy Stephen A. Appelbaum Published online: 22 Jun 2011.
To cite this article: Stephen A. Appelbaum (1990) The Relationship Between Assessment and Psychotherapy, Journal of Personality Assessment, 54:3-4, 791-801, DOI: 10.1080/00223891.1990.9674039 To link to this article: http://dx.doi.org/10.1080/00223891.1990.9674039
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
JOURNAL OF PERSONALITY ASSESSMENT, 1990, 54(3&4), 791-801, Copyright @ 1990, Lawrence Erlbaurn Associates, Inc.
The Relationship Between Assessment and Psvchothera~v Stephen A. Appelbaum
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University of Missouri-Kansas City School of Medicine and The Menninger Foundation
The many arguments, pro and con, about the usefulness and roles of diagnosis in general, and a psychological test battery in particular, can be settled only with reference to particular tests, a particular tester, particular patients, with reference to particular questions, in a particular context. Psychologists need to establish the usefulness of tests in cost-effective ways and demonstrate how tests provide a means of studying the mind. It follows that all psychotherapists should be able to use the tests, as all physiologists should be able to use a microscope. The rule of thumb that therapists should not give tests to their patients is unnecessary, though it is preferable that the tests be given early in the relationship, and that patients have the opportunity to explore their reactions to the procedure. To maximize the usefulness of tests given by someone who is not the patient's therapist, the test report should be designed as a means of persuasion toward therapeutic action more than a passive report of findings. An outline for test report writing is suggested. Finally, the use of tests helps elucidate the many factors that contribute to change through psychotherapy.
Freud likened psychoanalysis to a chess game in which only the opening and closing moves can be specified. The in-between moves are not specifiable because they are virtually limitless in number. They are dependent upon such decisions as when and if t o intervene; with what content; how t o intervene in ways that will make an emotional or cognitive difference (i.e., through tone of voice, choice of words, rhythm, and emphasis): whether to use abreaction, clarification, confrontation, interpretation; or whether to address defenses, to support ego functions, to offer content at one or another level of depth or abstraction. How does one choose from among these and other possibilities? A few romantic souls might argue that such decisions are made intuitively, the decisions come from unprepared inspiration. But most psychotherapists would
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agree that even such instances of apparently pure intuition are prepared, they are influenced by clinical experience and theory, however, inchoate or unsystematized such theory might be. Without such preparation there would be little difference between a trained psychotherapist and a neighbor over the backyard fence. Indeed, even neighbors base their opinions on some sort of theory about why people behave as they do. Most psychotherapists recognize that they make choices from virtually limitless possibilities on the basis of assessment. The questions are mainly how aware one is of such assessment, when such assessments are made, and with what measures. (For our purposes here "assessmentn or "testing" refers to a battery of individually administered tests ordinarily including at least a Wechsler LQ. test, the Rorschach test, and the Thematic Apperception test.) Traditionally, assessment refers to measurements made before or at the beginning of treatments in order to establish a diagnosis. On the basis of that diagnosis, treatment decisions are made-hospitalization or not, which if any drugs to use, whether there is subclinical brain damage, whether to recommend psychotherapy or psychoanalysis, supportive or expressive psychotherapy, number of meetings, sex and personality of therapist, problems to be solved and assets with which to solve them, guides to working with the patient, transference dispositions, leqgth of treatment and prognosis. The diagnostic task was the cornerstone ofthe development of clinical psychology as a profession, its means of entry into psychiatric institutions. Thus, from the beginning, assessment was lacad with political implications. Arguments about the usefulness of tests were frequently influenced by needs to promote or to discredit tests in the service of maneuvers for power. An attack on tests was simultaneously, and often designed as, an attack on the merging profession of clinical psychology. A defense of tests was a means of protecting jobs and influence. Once inside the establishment and its institutions by virtue of their function as testers, psychologists were able to pursue the goal of becoming psychotherapists. Once established as psychotherapists,psychologists themselves, ironically, ofien joined with psychiatrists and administratorsin objecting to the use of tests. Politiad objectibns were then replaced by economic ones that continue to the present. Assessmenm, ~geciallyindividually administered tests, are expensive, for both institutions, 3rd testers. In private practice, psychotherapists either run the risk or think that they run the risk of losing the patient when they recommend wpensiye testing procedures, the usefulness of which often tequire some educational effort on their part. Another prominent objection is that the unrzece$aap, because a good interviewer allegedly can learn all that is tests ~i.e necessapy, without the aid of tasts. Some peqk hold that the tests are not only unnecemary but counterproductive. Supp~sedly,they dehumanize the patient, summm SU& transferences as inquisitor or persecutor, and provide infarmation to the rherapislis too far in advance of the patient's readiness far self-discovery. Alleged consequences would interfere with timing and encourage intellectual-
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ization on the part of both therapist and patient. Finally, relying on tests leads to the lack of development or atrophying of skills of interviewers. One has to add that especially with the recently reduced emphasis on teaching testing, fewer and fewer testers are available to adequately answer clinically important questions. Arguments in favor of assessment are based primarily on the medical rule of diagnosing before treating; proponents of testing ask why one should wander around in the darkness of trial and error if one can proceed in the light of knowledge. The applicability of the aphorism, "diagnose before treating," to assessment and psychotherapy depends on whether and in what way assessment contributes to psychotherapy. Those who believe in assessment have to demonstrate the usefulness of the enterprise in cost-effectively helping to answer practical clinical questions in ways that importantly contribute to the patient's welfare. Once the treatment is launched, such assessments may provide an ongoing map or guide, to be referred to at choice points, and as a reminder of the layers of the personality, difficulties and capacities that are easily lost in the immediacy of daily events, or can be hidden behind defenses or in transference make-believe. One may, for example, need to be reminded from time to time, of the negative lurking behind the loving, of the primitive concerns about survival driving what may otherwise seem like common marital disagreements, or the power obscured by self-abnegating and self-destructive displays of helplessness. Sometimes the tests fail to elucidate anything new. They merely confirm what others have thought about the patient. Superficially, that may make the tests seem like a waste of time. Yet, when one looks closely at the reality of psychotherapeutic work one reaches a different conclusion. Probably all psychotherapists, including seasoned veterans, make comments to their patients with more or less anxiety and consequent indecision. They may ask themselves whether the content is right, whether the comment is pitched at the right psychosexual level, whether the patient's defenses at the moment will allow the patient to be receptive to a particular kind of intervention, what words to use, and in what tone of voice. All such judgments can more easily be attended to when the therapids anxiety is at a minimum. The therapist can be helped to achieve that minimum when inferences made from interviews are independently supported by inferences made from the tests. Another consequence of not giving or of overlooking the implications of assessment is how much the absence of such information influences the choice of theory. The rise of the counterculture therapists, many family therapies, and behavior therapy is partly due to their oversimplification of the personality. That oversimplification could be helpfully counteracted by knowledge and use of tests, which offer such an excellent way of familiarizing one's self with the complexity of personality. By contrast, with oversimplification, note the atomistic delineation of the personality as captured in the studied in the Psychotherapy Research Project of the Menninger Foundation. These
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variables included psychological-mindedness, insight, thought organization and affect organization, patterning of defenses, ego strength, anxiety tolerance, self-concept, and others. One could add to this over-30-year-old list more contemporary emphases such as the vicissitudes of object relations and the nuances of self-experience. To many nontesting-oriented practitioners, sometimes within dynamic psychotherapy, and almost always outside of it, such meticulous analyses and conceptualizations are alien. Oversimplification makes for easy-to-learn therapies and provides an easy pathway for people to become professionals. Many patients, also, appreciate that simplicity, which offers a quick sense of control through knowing and being able to speak glibly of one's knowledge. Too often, overly busy or underinformed therapists and overly defensive patients enter into a collusion to stay on the simplistic surface. In keeping with the popular psychology ethos, they produce happy, self-satisfied endings that are unfortunately subject to continued or greater misery when the suggestive effects of the treatment wear off and the slogans become deadened through repetition. In order to evaluate these pro and con arguments about assessment, one needs to specify what measures one is talking about, the skill of the assessor or tester, and the context in which the assessment information will be used. Much of the research on assessment founders on the assumption that the assessor and tests are hiomogeneous. In fact, neither has any inherent reliability nor validity. Rather, reliability and validity can only be established by evaluating a particular unit of test and tester, with respect to particular questions, and in a particular clinical context. In the Psychotherapy Research Project of the Menninger Foundation, I found that the psychologists had made more accurate predicti~psthan did the psychiatric judges who used their interviews with the patient subjects and all other sources of data (Appelbaum, 1977). Ironically, the psychological test report was included in the data available to them. Evidently, the clinician-judges had chosen to ignore the test information at their fingertips in favor d the infotmation available to their eyes and ears during the interviews. The largest source of error was in underestimating the patient%diffialties, thus getting some of the patients into treatment situation^ of gmater intensity and demandingness than they could optimally use. By coqtraal, qnd wnqary to many patient's expectations and many p~yqhologi$s emphasis on p a t h o l q ~ , tests can also be as useful in spotting latent strengths as they are in ferr~ingout latent weakness, Here are two e~amples,Considm those patients who offer lacklu~treperformance on those attributes that ootdinarily suggest s1;1ccess in dynamic psycho~herapy,such as high incelQgew1the ~bilitytp assert control over ideas and fe~lings,and the ability t ~ e n l ifantaey t fox t ~ ~ a p e upprploses. tk Every now and again I have noted among such padqnts, eym tho= who are lackluster on tm msasures sf thoes:&licit;ouscharacteristics, a high %a@on the similarities subtest of the intelligence scale. I have coae to oawidm that a highly
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encouraging indication of a potential for insightfulness, even as it contrasts with all the other gloomy findings. Such a sign encourages greater attention to evidence of possible other latent or hidden assets. It may tilt decisions in favor of more dynamic treatment recommendations, the choice of the therapist, and the number of meetings. It may instill greater hope and enthusiasm on the part of the therapist and, therefore, the patient also. Another such sign of potential strength is the amount and kind of fabulization accompanying Rorschach responses, suggesting a greater capacity for insight than, for example, low Movement responses, constricted interviews, or the history might suggest. Such fabulization suggests a mind with the potential to enliven the world with new, different Ideas, to see possibilities, once repressions are lifted-capacities that may initially escape notice. That they might escape detection, even by some test indices, affirms the need for giving a full battery of tests, and for hypervigilance in worlking up the data. Until recently, psychological test reports, along with other medical records, were protected from the patient's eyes by a culture that found such secrecy unremarkable. With the greater openness developed in the 1960s, as crystallized in the Freedom of Information Act, psychologists had to prepare themselves to share their information with patients. This is especially so in private practice where the practitioner is unprotected by the sheltlering opportunities provided by bureaucracy and service for fee is more starkly apparent. 1faced this change with trepidation. I was afraid of having to reveal information that would upset patients, would be too complex for them to understand, or would be revealed as, or seem to be revealed as, wrong, thus humiliating me as the tester, and undermining my position as the therapist. To deal with these fears, when I was to report m~ytest findings to the patient during the interview, and to facilitate the transmission of information, I jotted down three or four salient points from the test report on a small scratch pad and clutched it like a security blanket. My fears proved to be groundless; I almost never consulted the scratch pad. I really knew what I wanted to say, and once I began the words came without prompting. The patients, for the most part, knew what the test findings were. Indeed, as OUT conversations developed, I found it necessary to interpolate that we were, in fact, discussing test findings, so that I could head off their asking me in so many words for the test findings. More importantly, X was forced to find palatable, helpful ways of putting things, focussing more on adaptation than on pathology. Thus, did good practice force good theory, for in tmth, the use of "pathology," in word and thought, is barely appropriate for psychological matters no matter how useful it may be in medicine, from which its usage by psychologists was derived. After all, whatever the patient does or feels at any given moment is the best that the patient can do, and the patient should be spared the pejorative overtones, if not outright criticism, of the word and concept pathology. Even more to the point, that usage suggests that an external standard is being applied, rather than the
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therapist's seeing the patient's behavior from the patient's point of view. This is at the least a violation of neutrality. Worse, it bespeaks a lapse in empathy, an ignoring of the fact that one does not know what the alternative to such a behavior might be. If that alternative were known, the behavior in question could be seen as adaptive, as preferable to the alternative. Psychosis, for example, as a plea for help from a person who had never learned to ask or expect to be heard any other way than psychosis, is preferable to hopelessness and suicide. On the basis of many test reports that I have read, I believe that psychologists, along with their psychiatric colleagues, overemphasize what they consider to be pathology at the expense of looking for and noting adaptations and strengths. In talking with patients about their test results, the need to avoid narcissistic injury to patients, and to insure hope, forces psychologists to correct for this pathology bias. In sum, the imposition of sharing test results with patients can be responded to as an opportunity, rather than as an intrusion. It provides a chance to mutually clarify goals and at least adumbrate what is to be worked on with what assets. It has long been a rule of thumb that the giver of tests should not be the testee's psychotherapist. The reason for this is that the psychotherapist as tester will summon, if not engineer, relationships such as vulnerable patient and voyeuristic, oracular, persecutory examiner who writes down everything that one says, and proceeds according to a preordained plan designed for everyone, rather than for one's self, 1 deferred to that reasoning for 21 years at the Menninger Foundation. However, for the last 10 years, while I have been in private practice, I have tested almost all of the patients with whom I worked with in psychotherapy or psychoanalysis. I did so for the practical reasons of unavailalcrdity qf other testers and because I believe that I would understand test reports written by myself to myself better then those written by others. These practical seasons, however, are supported by more substantive ones. Separatingthe diagnostic and treatment functions creates an artifikial schism, to the detriment oftester, treater, and patient. It imposes a custom that came about by way of historical accident and is implemented by political iesues having to do with the plower of professions, rather than the nature of nature. To separate the testqr from the treatment function iq to deprive testers of firsthand knowledge of the sitpation that the tester is predicting, a violation of any predictiva and prescribing enterprise. To separate the treater from the formal diagslastic hnction subjects the enterprise to the dangers of miscommunication, whether through test report or verbal report. Warst of ell, it deprives psychotherapist$of a rnicrsciope with which to study their patients and with which they c m eBcient1y learn the psychobgy that under'lies their patient's behavior. David Rap;cport (Rapaplort, Gill, &$chafer, 196% in pursuit of his goal of establishir-gia psychoa~a1ytictheory af ehjnking, trwrnd t~ testing as his micrmscyhpe. In sn dobig, he @#ventit;iouslycre&tda mditio* of psyohd~gical testing rooted in psychoanalytic eg;rr,p~chologythat has tuxnd out to be of
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immense value for clinical purposes. But its main value, as far as Rapaport was initially concerned, was to enable one to study, under relatively controlled and standardized conditions, such factors as defenses, adaptive capacities, derivatives of drives, regressive and progressive shifts in functioning, tolerance for and controls over anxiety and other affects, and the relative emphasis placed on ideation as compared with other means of discharge. But because such factors of the mind have clinical implications as well as research and conceptualizingones, they should be available to all people who work with the mind, including all psychotherapists, who, after all, are the ones who can make the benefits of such knowledge immediately available to patients. Frustrated psychologists tend to complain that their psychiatric and other colleagues understand too little and care too little about an atomistic appreciation of personality. At the same time, those psychologists keep for themselves the best means of learning about such things. How paradoxical it is that the tester should know so much about the patient with whom he will not work, while the one who will work intensively with the patient may be oblivious to much about his or her patient that may or may not be learned from a third party. From this point of view, I conclude and recommend that all therapists, whatever their academic background, be trained in testing. If this quixotic, idealistic, and historically out-of-date recommendation were nevertheless followed, we might be able to avoid such all too familiar clinical missteps as the following:
A patient was referred to me by a training analyst after the patient had angrily quit the analysis with a sense that he was getting nowhere, and that things were asked of him, such as free associations and remembering his early life, that he could not, and did not want, to produce. I tested the patient and found that he failed to meet the usual criteria for analysis, particularly the criteria of sufficient ego strength. While the analyst was interpreting meanings and searching in the patient's past, the patient was struggling for some sense of order in a present, chaotic inner world. So preoccupied, and feeling misunderstood, he could not establish a reliable therapeutic alliance. This situation could have been avoided by having the patient tested before deciding on analysis had the analyst seen and understood how the patient performed on the tests. I further believe that if the analyst had been trained in testing, he might have listened to his patient in such a way as to have recognized the patient's primitive experience and functioning. The difference in orientation, listening, and background is responsible for the growing popularity of the term medical analyst, referring not to academic degree, but to the way that the analyst thinks about
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patients. The term, therefore, is equally applicable to those psychologists and social workers who similarly focus on content to the detriment of structure, who fail adequately to follow rules of evidence, who may rely too much on intuition to the detriment of discipline or on intellectualized discipline to the detriment of emotion, and who may be less sensitized to the language and point of view inherent in psychosexual levels, among other skills that are enabled by knowledge of tests. Casting the therapist in the tester role, in my experience, has not been a major problem. It is best to do the testing at the beginning of the therapy, before enough transferencehas developed to be unduly influenced. The patient should be given the opportunity to discuss his or her experience of the therapist-tester and the testing in order to work through any potentially harmful transference phenomena. Let us assume the ideal circumstance of a well-trained, talented tester, an intellectually and motivationally apt consumer, and a context that has available sufficient options as to make fine distinctions based on tests practically useful. Enter now the problem ofhow to communicate the test findings, usually done by way of a written test report. One measure of the difficulty in communicating by way of test reports is the fact that the reports so ofken seem to require supplementation by way of hallway or telephone conversation. That understandable because test reports are among the most difficult documents one is ordinarily asked to write. To begin with, they are not reports at all, in the laboratory sense of reporting data that are then interpreted by the consumer who takes actions based upon those interpretations. Instead, the writer of test reports interprets the data and makes implicit, sometimes explicit, recommendations for what actions should be taken on the basis of the test findings. The great challenge of test repart writing is to supply the consumer with i n h a t i o n in such a way as will result in the consumer taking actions that the tester thinks should be taken, on the basis of the test findings. Thus, the report is an action document that requires persuasiveness as weU as correctness. Why i a the test report writing task so daubti$ One begins with first-order observations of test behavior and test responses, n$ave$ up the ladder of abstractions to the psychology underlying the test tasks, then integrates these with a theory of personality that in turn has levels of abstraction, and then returns to the concrete task of tracing out the consequences of assessment information for the clinical context. This exercise has to be performed in a way that speaks to a likely variety of consumers who may We4 in their thearetical orientation, their level of training and skill, and for canrats that vary in their wi1Iinp;sless and interest in using material derived from tests. As inciters to action and exercisers in persuasion, the test report writer nnight judiciously borraw techniques from literature rnnd advertising, Too often, it seems to me, writers of test rpposzs give in to a need to sound scientific or
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learned, when their task is to be evocative in the service of winning over minds and hearts. At the same time, that evocativeness and persuasiveness is dependent on instilling a sense of evidence and discipline derived from the scientific use of evidence and inference. All this has to be done briefly, so as not to tax the patience and time of the consumer. Ordinarily, one to two single-spaced pages should suffice. In recent years, individual projective testing has been taught and supervised less frequently in training programs than it was a couple of decades ago. This demise is in many instances deserved. Testing is difficult and has to ~ i e l da product that justifies its expense in time, effort, and money, To test mainly because there is a line in a budget for testing, or because it is a traditional function of psychologists is deplorable. More deplorable, still, is the corrosion of mind and spirit of hypocritically ordering, doing, and accepting the results of testing without truly understanding them or being able to make use of them for optimal patient benefit. The technological challenges of testing have to be addressed rather than ignored or covered up. Some years back, as a member of the faculty of the Menninger Foundation Training Program in Clinical Psychology, and troubled by the problems students were having in managing data and communicating it effectively, I put together an outline for organizing test data. At the time, I thought of it mainly as a device for training, with the objective that each tester be able to write a coherent, useful paragraph for each heading in the outline. Since then, the outline has been used routinely by many at the Menninger Foundation for final clinical reports. In helping to bring order to the mags of data arising from the tests, it spares the tester much of the task of organization. The headings of the outline include: Diagnostic Category; How the Patient Experiences Others; How the Patient Responds to Various Interpersonal Approaches; Intelligence, Action and Thought; Affects and Their Organization; Psychological Treatment; Psychosexual Fixations; Vicissitudes of Aggression and Sexuality; Central Conflicts; and optional categories dictated by particular clinical circumstances. Descriptions of these headings are available in the Bulletin of the Menningm Clinic (Appelbaum, 1972). By mastering the descriptions of the headings one learns a lot about psychoanalytic ego psychology. Thus, the outline serves as a minitext, in addition to being clinically useful. It has, however, an important disadvantage in that the headings are general rather than specific. The one-of-a-kind person as interlocked with similarly individualized calls to action can be lost to the preordained outline. Remember, we are trying to write an action document rather than just giving a passive recitation of characteristics. As a lesson in humility, if nothing else, one might subject each statement in one's test reports to such questions as what practical difference does this statement make, what would a treater do, and what decisions flow from such and such statement! That exercise would result, for many of us, in
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encouraging more useful and a lot shorter test reports, whether written in narrative or outline form. Every now and again one hears that testing might be justifiable for extended treatments, but that it is unnecessary when patients are to be seen only briefly. One can argue just the opposite. When time is at a premium, it is especially important that the enterprise be efficient. There may not be time to wait for missed opportunities to come around again, to recast one's ideas, to change the levels of one's interventions, to backtrack on an interpersonal strategy. One needs all the information one can get, and get it as quickly as possible. It only seems to be a paradox that one may put as much time into a diagnostic procedure as on the treatment itself. Does this mean that testing is less necessary for long-term treatment, especially pq&oanalysis? Hardly. No treatment procedure should risk being less efficient than it could be. The reluctance to use tests prior to psychoanalysis has its roots in two historical and largely superseded ideas. One is that analysis is good for everyone; the second is that change comes about solely through the development of insight. If there is anything that analysts have learned the hard way, it is that analysis is not for everyone. People with fragile egos who decompensate into psychosis when on the couch are eloquent teachers of the hard truth that uncovering and releasing heretofore unconscious ideas and feelings has to be matched by the capacity to maintain ego functions during the uncovering process. Other patients have taught a generation af analysts that analysis is not for everyone. Among these teachers, for example, are certain borderline patients who require more active confrontation and less free association m d certain obsessive patients who remain untouched, by a f k t and therapeutic movement, through years of analysis. The: belief that change comes about solely through insight was in part a function of not seeing anything but insight opera-tingin the therapeutic context. Now one sees a viariety of nonspecific and other specific factors that contribute to change blecause one looks for them, Nonspecific ones include the patients expectations and faith, the ameliorative efhects of having explagati~ns(cight or wrong) of suggestion and placebo in general. Specific ones include putting thgughts and feelings into words, hwing comwxive emotional experimces aqd other interpersonal experiences rhat are heding, and shiftiing patients' clrientettion &om pmsivity to activity. Tests provide a net in which all such qharacteristics can lx caught and examined. Sober, disciplined tqsqing c;an be a force against our trendy, quick-fix, supdcial culture as applied to psychology, an aid to confronting dqpth and devoting oneself to knowledga fsn: its own sake, as well as for patient himefit. I hope that we will canfront the enemies-nihilism and routinization of testing, camplacency, lack of imagination-and so drive to the utmost the quest for those rewmds inherent in exploring the relationship between assessment and psychotherapy.
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ACKNOWLEDGMENTS This article was given as the keynote address at the Conference on Psychological Testing and the Psychotherapeutic Process, held at the Austin Riggs Center, Stockbridge, MA, October 1988. It was also presented to the Mexican Society for Psychology, Mexico City, October 1988.
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REFERENCES Appelbaum, S. (1972). A method of reporting psychological test findings. Bulletin of tk Menninger Clinic, 36, 535-545. Appelbaurn, S. (1977). The anatomy of change. New York: Plenum. Rapaport, D., Gill, M., G. Schafer, R. (1968). Revised edition. In R. Holt (Ed.), Diagnostic psychological testing. New York: International Universities Press.
Stephen A. Appelbaum 4121 West 83rd Street, Suite 119 Prairie Village, KS 66208 Received November 1, 1988
Journal of Personality Assessment Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hjpa20
The Relationship Between Assessment and Psychotherapy Stephen A. Appelbaum Published online: 22 Jun 2011.
To cite this article: Stephen A. Appelbaum (1990) The Relationship Between Assessment and Psychotherapy, Journal of Personality Assessment, 54:3-4, 791-801, DOI: 10.1080/00223891.1990.9674039 To link to this article: http://dx.doi.org/10.1080/00223891.1990.9674039
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-and-conditions
JOURNAL OF PERSONALITY ASSESSMENT, 1990, 54(3&4), 791-801, Copyright @ 1990, Lawrence Erlbaurn Associates, Inc.
The Relationship Between Assessment and Psvchothera~v Stephen A. Appelbaum
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University of Missouri-Kansas City School of Medicine and The Menninger Foundation
The many arguments, pro and con, about the usefulness and roles of diagnosis in general, and a psychological test battery in particular, can be settled only with reference to particular tests, a particular tester, particular patients, with reference to particular questions, in a particular context. Psychologists need to establish the usefulness of tests in cost-effective ways and demonstrate how tests provide a means of studying the mind. It follows that all psychotherapists should be able to use the tests, as all physiologists should be able to use a microscope. The rule of thumb that therapists should not give tests to their patients is unnecessary, though it is preferable that the tests be given early in the relationship, and that patients have the opportunity to explore their reactions to the procedure. To maximize the usefulness of tests given by someone who is not the patient's therapist, the test report should be designed as a means of persuasion toward therapeutic action more than a passive report of findings. An outline for test report writing is suggested. Finally, the use of tests helps elucidate the many factors that contribute to change through psychotherapy.
Freud likened psychoanalysis to a chess game in which only the opening and closing moves can be specified. The in-between moves are not specifiable because they are virtually limitless in number. They are dependent upon such decisions as when and if t o intervene; with what content; how t o intervene in ways that will make an emotional or cognitive difference (i.e., through tone of voice, choice of words, rhythm, and emphasis): whether to use abreaction, clarification, confrontation, interpretation; or whether to address defenses, to support ego functions, to offer content at one or another level of depth or abstraction. How does one choose from among these and other possibilities? A few romantic souls might argue that such decisions are made intuitively, the decisions come from unprepared inspiration. But most psychotherapists would
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agree that even such instances of apparently pure intuition are prepared, they are influenced by clinical experience and theory, however, inchoate or unsystematized such theory might be. Without such preparation there would be little difference between a trained psychotherapist and a neighbor over the backyard fence. Indeed, even neighbors base their opinions on some sort of theory about why people behave as they do. Most psychotherapists recognize that they make choices from virtually limitless possibilities on the basis of assessment. The questions are mainly how aware one is of such assessment, when such assessments are made, and with what measures. (For our purposes here "assessmentn or "testing" refers to a battery of individually administered tests ordinarily including at least a Wechsler LQ. test, the Rorschach test, and the Thematic Apperception test.) Traditionally, assessment refers to measurements made before or at the beginning of treatments in order to establish a diagnosis. On the basis of that diagnosis, treatment decisions are made-hospitalization or not, which if any drugs to use, whether there is subclinical brain damage, whether to recommend psychotherapy or psychoanalysis, supportive or expressive psychotherapy, number of meetings, sex and personality of therapist, problems to be solved and assets with which to solve them, guides to working with the patient, transference dispositions, leqgth of treatment and prognosis. The diagnostic task was the cornerstone ofthe development of clinical psychology as a profession, its means of entry into psychiatric institutions. Thus, from the beginning, assessment was lacad with political implications. Arguments about the usefulness of tests were frequently influenced by needs to promote or to discredit tests in the service of maneuvers for power. An attack on tests was simultaneously, and often designed as, an attack on the merging profession of clinical psychology. A defense of tests was a means of protecting jobs and influence. Once inside the establishment and its institutions by virtue of their function as testers, psychologists were able to pursue the goal of becoming psychotherapists. Once established as psychotherapists,psychologists themselves, ironically, ofien joined with psychiatrists and administratorsin objecting to the use of tests. Politiad objectibns were then replaced by economic ones that continue to the present. Assessmenm, ~geciallyindividually administered tests, are expensive, for both institutions, 3rd testers. In private practice, psychotherapists either run the risk or think that they run the risk of losing the patient when they recommend wpensiye testing procedures, the usefulness of which often tequire some educational effort on their part. Another prominent objection is that the unrzece$aap, because a good interviewer allegedly can learn all that is tests ~i.e necessapy, without the aid of tasts. Some peqk hold that the tests are not only unnecemary but counterproductive. Supp~sedly,they dehumanize the patient, summm SU& transferences as inquisitor or persecutor, and provide infarmation to the rherapislis too far in advance of the patient's readiness far self-discovery. Alleged consequences would interfere with timing and encourage intellectual-
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ization on the part of both therapist and patient. Finally, relying on tests leads to the lack of development or atrophying of skills of interviewers. One has to add that especially with the recently reduced emphasis on teaching testing, fewer and fewer testers are available to adequately answer clinically important questions. Arguments in favor of assessment are based primarily on the medical rule of diagnosing before treating; proponents of testing ask why one should wander around in the darkness of trial and error if one can proceed in the light of knowledge. The applicability of the aphorism, "diagnose before treating," to assessment and psychotherapy depends on whether and in what way assessment contributes to psychotherapy. Those who believe in assessment have to demonstrate the usefulness of the enterprise in cost-effectively helping to answer practical clinical questions in ways that importantly contribute to the patient's welfare. Once the treatment is launched, such assessments may provide an ongoing map or guide, to be referred to at choice points, and as a reminder of the layers of the personality, difficulties and capacities that are easily lost in the immediacy of daily events, or can be hidden behind defenses or in transference make-believe. One may, for example, need to be reminded from time to time, of the negative lurking behind the loving, of the primitive concerns about survival driving what may otherwise seem like common marital disagreements, or the power obscured by self-abnegating and self-destructive displays of helplessness. Sometimes the tests fail to elucidate anything new. They merely confirm what others have thought about the patient. Superficially, that may make the tests seem like a waste of time. Yet, when one looks closely at the reality of psychotherapeutic work one reaches a different conclusion. Probably all psychotherapists, including seasoned veterans, make comments to their patients with more or less anxiety and consequent indecision. They may ask themselves whether the content is right, whether the comment is pitched at the right psychosexual level, whether the patient's defenses at the moment will allow the patient to be receptive to a particular kind of intervention, what words to use, and in what tone of voice. All such judgments can more easily be attended to when the therapids anxiety is at a minimum. The therapist can be helped to achieve that minimum when inferences made from interviews are independently supported by inferences made from the tests. Another consequence of not giving or of overlooking the implications of assessment is how much the absence of such information influences the choice of theory. The rise of the counterculture therapists, many family therapies, and behavior therapy is partly due to their oversimplification of the personality. That oversimplification could be helpfully counteracted by knowledge and use of tests, which offer such an excellent way of familiarizing one's self with the complexity of personality. By contrast, with oversimplification, note the atomistic delineation of the personality as captured in the studied in the Psychotherapy Research Project of the Menninger Foundation. These
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variables included psychological-mindedness, insight, thought organization and affect organization, patterning of defenses, ego strength, anxiety tolerance, self-concept, and others. One could add to this over-30-year-old list more contemporary emphases such as the vicissitudes of object relations and the nuances of self-experience. To many nontesting-oriented practitioners, sometimes within dynamic psychotherapy, and almost always outside of it, such meticulous analyses and conceptualizations are alien. Oversimplification makes for easy-to-learn therapies and provides an easy pathway for people to become professionals. Many patients, also, appreciate that simplicity, which offers a quick sense of control through knowing and being able to speak glibly of one's knowledge. Too often, overly busy or underinformed therapists and overly defensive patients enter into a collusion to stay on the simplistic surface. In keeping with the popular psychology ethos, they produce happy, self-satisfied endings that are unfortunately subject to continued or greater misery when the suggestive effects of the treatment wear off and the slogans become deadened through repetition. In order to evaluate these pro and con arguments about assessment, one needs to specify what measures one is talking about, the skill of the assessor or tester, and the context in which the assessment information will be used. Much of the research on assessment founders on the assumption that the assessor and tests are hiomogeneous. In fact, neither has any inherent reliability nor validity. Rather, reliability and validity can only be established by evaluating a particular unit of test and tester, with respect to particular questions, and in a particular clinical context. In the Psychotherapy Research Project of the Menninger Foundation, I found that the psychologists had made more accurate predicti~psthan did the psychiatric judges who used their interviews with the patient subjects and all other sources of data (Appelbaum, 1977). Ironically, the psychological test report was included in the data available to them. Evidently, the clinician-judges had chosen to ignore the test information at their fingertips in favor d the infotmation available to their eyes and ears during the interviews. The largest source of error was in underestimating the patient%diffialties, thus getting some of the patients into treatment situation^ of gmater intensity and demandingness than they could optimally use. By coqtraal, qnd wnqary to many patient's expectations and many p~yqhologi$s emphasis on p a t h o l q ~ , tests can also be as useful in spotting latent strengths as they are in ferr~ingout latent weakness, Here are two e~amples,Considm those patients who offer lacklu~treperformance on those attributes that ootdinarily suggest s1;1ccess in dynamic psycho~herapy,such as high incelQgew1the ~bilitytp assert control over ideas and fe~lings,and the ability t ~ e n l ifantaey t fox t ~ ~ a p e upprploses. tk Every now and again I have noted among such padqnts, eym tho= who are lackluster on tm msasures sf thoes:&licit;ouscharacteristics, a high %a@on the similarities subtest of the intelligence scale. I have coae to oawidm that a highly
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encouraging indication of a potential for insightfulness, even as it contrasts with all the other gloomy findings. Such a sign encourages greater attention to evidence of possible other latent or hidden assets. It may tilt decisions in favor of more dynamic treatment recommendations, the choice of the therapist, and the number of meetings. It may instill greater hope and enthusiasm on the part of the therapist and, therefore, the patient also. Another such sign of potential strength is the amount and kind of fabulization accompanying Rorschach responses, suggesting a greater capacity for insight than, for example, low Movement responses, constricted interviews, or the history might suggest. Such fabulization suggests a mind with the potential to enliven the world with new, different Ideas, to see possibilities, once repressions are lifted-capacities that may initially escape notice. That they might escape detection, even by some test indices, affirms the need for giving a full battery of tests, and for hypervigilance in worlking up the data. Until recently, psychological test reports, along with other medical records, were protected from the patient's eyes by a culture that found such secrecy unremarkable. With the greater openness developed in the 1960s, as crystallized in the Freedom of Information Act, psychologists had to prepare themselves to share their information with patients. This is especially so in private practice where the practitioner is unprotected by the sheltlering opportunities provided by bureaucracy and service for fee is more starkly apparent. 1faced this change with trepidation. I was afraid of having to reveal information that would upset patients, would be too complex for them to understand, or would be revealed as, or seem to be revealed as, wrong, thus humiliating me as the tester, and undermining my position as the therapist. To deal with these fears, when I was to report m~ytest findings to the patient during the interview, and to facilitate the transmission of information, I jotted down three or four salient points from the test report on a small scratch pad and clutched it like a security blanket. My fears proved to be groundless; I almost never consulted the scratch pad. I really knew what I wanted to say, and once I began the words came without prompting. The patients, for the most part, knew what the test findings were. Indeed, as OUT conversations developed, I found it necessary to interpolate that we were, in fact, discussing test findings, so that I could head off their asking me in so many words for the test findings. More importantly, X was forced to find palatable, helpful ways of putting things, focussing more on adaptation than on pathology. Thus, did good practice force good theory, for in tmth, the use of "pathology," in word and thought, is barely appropriate for psychological matters no matter how useful it may be in medicine, from which its usage by psychologists was derived. After all, whatever the patient does or feels at any given moment is the best that the patient can do, and the patient should be spared the pejorative overtones, if not outright criticism, of the word and concept pathology. Even more to the point, that usage suggests that an external standard is being applied, rather than the
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APPELBAUM
therapist's seeing the patient's behavior from the patient's point of view. This is at the least a violation of neutrality. Worse, it bespeaks a lapse in empathy, an ignoring of the fact that one does not know what the alternative to such a behavior might be. If that alternative were known, the behavior in question could be seen as adaptive, as preferable to the alternative. Psychosis, for example, as a plea for help from a person who had never learned to ask or expect to be heard any other way than psychosis, is preferable to hopelessness and suicide. On the basis of many test reports that I have read, I believe that psychologists, along with their psychiatric colleagues, overemphasize what they consider to be pathology at the expense of looking for and noting adaptations and strengths. In talking with patients about their test results, the need to avoid narcissistic injury to patients, and to insure hope, forces psychologists to correct for this pathology bias. In sum, the imposition of sharing test results with patients can be responded to as an opportunity, rather than as an intrusion. It provides a chance to mutually clarify goals and at least adumbrate what is to be worked on with what assets. It has long been a rule of thumb that the giver of tests should not be the testee's psychotherapist. The reason for this is that the psychotherapist as tester will summon, if not engineer, relationships such as vulnerable patient and voyeuristic, oracular, persecutory examiner who writes down everything that one says, and proceeds according to a preordained plan designed for everyone, rather than for one's self, 1 deferred to that reasoning for 21 years at the Menninger Foundation. However, for the last 10 years, while I have been in private practice, I have tested almost all of the patients with whom I worked with in psychotherapy or psychoanalysis. I did so for the practical reasons of unavailalcrdity qf other testers and because I believe that I would understand test reports written by myself to myself better then those written by others. These practical seasons, however, are supported by more substantive ones. Separatingthe diagnostic and treatment functions creates an artifikial schism, to the detriment oftester, treater, and patient. It imposes a custom that came about by way of historical accident and is implemented by political iesues having to do with the plower of professions, rather than the nature of nature. To separate the testqr from the treatment function iq to deprive testers of firsthand knowledge of the sitpation that the tester is predicting, a violation of any predictiva and prescribing enterprise. To separate the treater from the formal diagslastic hnction subjects the enterprise to the dangers of miscommunication, whether through test report or verbal report. Warst of ell, it deprives psychotherapist$of a rnicrsciope with which to study their patients and with which they c m eBcient1y learn the psychobgy that under'lies their patient's behavior. David Rap;cport (Rapaplort, Gill, &$chafer, 196% in pursuit of his goal of establishir-gia psychoa~a1ytictheory af ehjnking, trwrnd t~ testing as his micrmscyhpe. In sn dobig, he @#ventit;iouslycre&tda mditio* of psyohd~gical testing rooted in psychoanalytic eg;rr,p~chologythat has tuxnd out to be of
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immense value for clinical purposes. But its main value, as far as Rapaport was initially concerned, was to enable one to study, under relatively controlled and standardized conditions, such factors as defenses, adaptive capacities, derivatives of drives, regressive and progressive shifts in functioning, tolerance for and controls over anxiety and other affects, and the relative emphasis placed on ideation as compared with other means of discharge. But because such factors of the mind have clinical implications as well as research and conceptualizingones, they should be available to all people who work with the mind, including all psychotherapists, who, after all, are the ones who can make the benefits of such knowledge immediately available to patients. Frustrated psychologists tend to complain that their psychiatric and other colleagues understand too little and care too little about an atomistic appreciation of personality. At the same time, those psychologists keep for themselves the best means of learning about such things. How paradoxical it is that the tester should know so much about the patient with whom he will not work, while the one who will work intensively with the patient may be oblivious to much about his or her patient that may or may not be learned from a third party. From this point of view, I conclude and recommend that all therapists, whatever their academic background, be trained in testing. If this quixotic, idealistic, and historically out-of-date recommendation were nevertheless followed, we might be able to avoid such all too familiar clinical missteps as the following:
A patient was referred to me by a training analyst after the patient had angrily quit the analysis with a sense that he was getting nowhere, and that things were asked of him, such as free associations and remembering his early life, that he could not, and did not want, to produce. I tested the patient and found that he failed to meet the usual criteria for analysis, particularly the criteria of sufficient ego strength. While the analyst was interpreting meanings and searching in the patient's past, the patient was struggling for some sense of order in a present, chaotic inner world. So preoccupied, and feeling misunderstood, he could not establish a reliable therapeutic alliance. This situation could have been avoided by having the patient tested before deciding on analysis had the analyst seen and understood how the patient performed on the tests. I further believe that if the analyst had been trained in testing, he might have listened to his patient in such a way as to have recognized the patient's primitive experience and functioning. The difference in orientation, listening, and background is responsible for the growing popularity of the term medical analyst, referring not to academic degree, but to the way that the analyst thinks about
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patients. The term, therefore, is equally applicable to those psychologists and social workers who similarly focus on content to the detriment of structure, who fail adequately to follow rules of evidence, who may rely too much on intuition to the detriment of discipline or on intellectualized discipline to the detriment of emotion, and who may be less sensitized to the language and point of view inherent in psychosexual levels, among other skills that are enabled by knowledge of tests. Casting the therapist in the tester role, in my experience, has not been a major problem. It is best to do the testing at the beginning of the therapy, before enough transferencehas developed to be unduly influenced. The patient should be given the opportunity to discuss his or her experience of the therapist-tester and the testing in order to work through any potentially harmful transference phenomena. Let us assume the ideal circumstance of a well-trained, talented tester, an intellectually and motivationally apt consumer, and a context that has available sufficient options as to make fine distinctions based on tests practically useful. Enter now the problem ofhow to communicate the test findings, usually done by way of a written test report. One measure of the difficulty in communicating by way of test reports is the fact that the reports so ofken seem to require supplementation by way of hallway or telephone conversation. That understandable because test reports are among the most difficult documents one is ordinarily asked to write. To begin with, they are not reports at all, in the laboratory sense of reporting data that are then interpreted by the consumer who takes actions based upon those interpretations. Instead, the writer of test reports interprets the data and makes implicit, sometimes explicit, recommendations for what actions should be taken on the basis of the test findings. The great challenge of test repart writing is to supply the consumer with i n h a t i o n in such a way as will result in the consumer taking actions that the tester thinks should be taken, on the basis of the test findings. Thus, the report is an action document that requires persuasiveness as weU as correctness. Why i a the test report writing task so daubti$ One begins with first-order observations of test behavior and test responses, n$ave$ up the ladder of abstractions to the psychology underlying the test tasks, then integrates these with a theory of personality that in turn has levels of abstraction, and then returns to the concrete task of tracing out the consequences of assessment information for the clinical context. This exercise has to be performed in a way that speaks to a likely variety of consumers who may We4 in their thearetical orientation, their level of training and skill, and for canrats that vary in their wi1Iinp;sless and interest in using material derived from tests. As inciters to action and exercisers in persuasion, the test report writer nnight judiciously borraw techniques from literature rnnd advertising, Too often, it seems to me, writers of test rpposzs give in to a need to sound scientific or
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learned, when their task is to be evocative in the service of winning over minds and hearts. At the same time, that evocativeness and persuasiveness is dependent on instilling a sense of evidence and discipline derived from the scientific use of evidence and inference. All this has to be done briefly, so as not to tax the patience and time of the consumer. Ordinarily, one to two single-spaced pages should suffice. In recent years, individual projective testing has been taught and supervised less frequently in training programs than it was a couple of decades ago. This demise is in many instances deserved. Testing is difficult and has to ~ i e l da product that justifies its expense in time, effort, and money, To test mainly because there is a line in a budget for testing, or because it is a traditional function of psychologists is deplorable. More deplorable, still, is the corrosion of mind and spirit of hypocritically ordering, doing, and accepting the results of testing without truly understanding them or being able to make use of them for optimal patient benefit. The technological challenges of testing have to be addressed rather than ignored or covered up. Some years back, as a member of the faculty of the Menninger Foundation Training Program in Clinical Psychology, and troubled by the problems students were having in managing data and communicating it effectively, I put together an outline for organizing test data. At the time, I thought of it mainly as a device for training, with the objective that each tester be able to write a coherent, useful paragraph for each heading in the outline. Since then, the outline has been used routinely by many at the Menninger Foundation for final clinical reports. In helping to bring order to the mags of data arising from the tests, it spares the tester much of the task of organization. The headings of the outline include: Diagnostic Category; How the Patient Experiences Others; How the Patient Responds to Various Interpersonal Approaches; Intelligence, Action and Thought; Affects and Their Organization; Psychological Treatment; Psychosexual Fixations; Vicissitudes of Aggression and Sexuality; Central Conflicts; and optional categories dictated by particular clinical circumstances. Descriptions of these headings are available in the Bulletin of the Menningm Clinic (Appelbaum, 1972). By mastering the descriptions of the headings one learns a lot about psychoanalytic ego psychology. Thus, the outline serves as a minitext, in addition to being clinically useful. It has, however, an important disadvantage in that the headings are general rather than specific. The one-of-a-kind person as interlocked with similarly individualized calls to action can be lost to the preordained outline. Remember, we are trying to write an action document rather than just giving a passive recitation of characteristics. As a lesson in humility, if nothing else, one might subject each statement in one's test reports to such questions as what practical difference does this statement make, what would a treater do, and what decisions flow from such and such statement! That exercise would result, for many of us, in
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encouraging more useful and a lot shorter test reports, whether written in narrative or outline form. Every now and again one hears that testing might be justifiable for extended treatments, but that it is unnecessary when patients are to be seen only briefly. One can argue just the opposite. When time is at a premium, it is especially important that the enterprise be efficient. There may not be time to wait for missed opportunities to come around again, to recast one's ideas, to change the levels of one's interventions, to backtrack on an interpersonal strategy. One needs all the information one can get, and get it as quickly as possible. It only seems to be a paradox that one may put as much time into a diagnostic procedure as on the treatment itself. Does this mean that testing is less necessary for long-term treatment, especially pq&oanalysis? Hardly. No treatment procedure should risk being less efficient than it could be. The reluctance to use tests prior to psychoanalysis has its roots in two historical and largely superseded ideas. One is that analysis is good for everyone; the second is that change comes about solely through the development of insight. If there is anything that analysts have learned the hard way, it is that analysis is not for everyone. People with fragile egos who decompensate into psychosis when on the couch are eloquent teachers of the hard truth that uncovering and releasing heretofore unconscious ideas and feelings has to be matched by the capacity to maintain ego functions during the uncovering process. Other patients have taught a generation af analysts that analysis is not for everyone. Among these teachers, for example, are certain borderline patients who require more active confrontation and less free association m d certain obsessive patients who remain untouched, by a f k t and therapeutic movement, through years of analysis. The: belief that change comes about solely through insight was in part a function of not seeing anything but insight opera-tingin the therapeutic context. Now one sees a viariety of nonspecific and other specific factors that contribute to change blecause one looks for them, Nonspecific ones include the patients expectations and faith, the ameliorative efhects of having explagati~ns(cight or wrong) of suggestion and placebo in general. Specific ones include putting thgughts and feelings into words, hwing comwxive emotional experimces aqd other interpersonal experiences rhat are heding, and shiftiing patients' clrientettion &om pmsivity to activity. Tests provide a net in which all such qharacteristics can lx caught and examined. Sober, disciplined tqsqing c;an be a force against our trendy, quick-fix, supdcial culture as applied to psychology, an aid to confronting dqpth and devoting oneself to knowledga fsn: its own sake, as well as for patient himefit. I hope that we will canfront the enemies-nihilism and routinization of testing, camplacency, lack of imagination-and so drive to the utmost the quest for those rewmds inherent in exploring the relationship between assessment and psychotherapy.
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ACKNOWLEDGMENTS This article was given as the keynote address at the Conference on Psychological Testing and the Psychotherapeutic Process, held at the Austin Riggs Center, Stockbridge, MA, October 1988. It was also presented to the Mexican Society for Psychology, Mexico City, October 1988.
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REFERENCES Appelbaum, S. (1972). A method of reporting psychological test findings. Bulletin of tk Menninger Clinic, 36, 535-545. Appelbaurn, S. (1977). The anatomy of change. New York: Plenum. Rapaport, D., Gill, M., G. Schafer, R. (1968). Revised edition. In R. Holt (Ed.), Diagnostic psychological testing. New York: International Universities Press.
Stephen A. Appelbaum 4121 West 83rd Street, Suite 119 Prairie Village, KS 66208 Received November 1, 1988
