Robert M. Gordon,Ph.D. ABPP

Most psychologists agree that the combination of objective psychological tests (such as the MMPI-2) and qualitative data (i.e. structured interview, observations, collateral interviews and documents) produces the most accurate assessments. Nevertheless, psychologists are often confused about the research showing that objective tests are more valid than clinical judgment. These studies show the superior reliability of objective tests and actuarial formulas over different types of qualitative data and different levels of expertise in clinical judgment (Dawes, Faust, & Meehl, 1989). This is true, but there is a bit of card stacking in such research.

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The MMPI-2 is our most used and best objective test of psychopathology. The MMPI-2 is very stable and is useful in screening, diagnoses and in measuring treatment outcome (Gordon, 2001).  It was originally based on clinical cases (qualitative data) that were translated into quantitative data (clinical scales). The MMPI-2 clinical scales reflect the internal inconsistencies, conflicts and defenses of the normative patient groups. Pure statistically derived quantitative scales based on the behavioral assumption of internally consistent items have not led to better tests of diagnoses (Gordon, 2006c).  

However, the MMPI-2 can have low predictive validity. A large study with 1035 men and 1447 women outpatients showed the correlations of their MMPI-2 scores with history and ratings (Graham, Ben-Porath, and McNutly, 1999).  For example, the intake rating of "Prevailing Mood- Angry" was most correlated with the MMPI-2 clinical scale Paranoia, but only for men. The correlation was .16. This finding is highly reliable, but it is too low to have practical utility. It is more practical to ask individuals how angry they get and interview family members about their anger.  The gap between research and clinical utility is clear in this example.

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The MMPI-2 scales are more reliable than the various skills of interviewers. However, the information obtained from interviewing (and perhaps records) maybe much more powerful than the reliable but weak test data. Therefore, it is the combination of reliable but often-weak quantitative data and the less reliable but often-powerful qualitative data that gives the clinician the most useful information. 

Let me offer you examples of how qualitative and quantitative data are used together and how to resolve conflicting information.  In case #1, the MMPI-2 F scale was T 100 and most the clinical scales were also very elevated. Actuarial research considers this a faking to look bad invalid profile. However, the patient records showed several psychiatric hospitalizations, and the patient seemed confused and disoriented in the interview. The qualitative data set the stage for interpreting the MMPI-2. Due to the qualitative information, MMPI-2 was valid and consistent with psychosis. The high F in this case was reflecting the unusual psychopathology that is found in schizophrenia.

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In case #2: the MMPI-2 Lie and K scale were both high and the F scale was low. The actuarial research considers this a faking to look good profile. This is often found with those who are required to take psychological testing for employment considerations or in child custody evaluations. The qualitative information will determine just how we interpret these scores.

One of the best ways to make a qualitative assessment is with the new Psychodynamic Diagnostic Manual (PDM, 2006). The PDM is more theoretically and empirically grounded than the DSM-IV. The PDM represents the most useful overall conceptualization of personality for all psychotherapeutic orientations. The PDM can enhance the understanding and interpretations of psychological tests such as the MMPI-2.

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The PDM is divided into three dimensions: 1. Personality Patterns and Disorders, 2. Mental Functioning, and 3. Manifest Symptoms and Concerns.  Although all the dimensions are important for making a diagnosis, for now I will only focus on the level of severity of Personality Patterns and Disorders.  

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The first thing to do is to determine the level of personality severity or Levels of Personality Organization (Healthy, Neurotic and Borderline). The types of specific personality disorders follow a determination of Level of Personality Organization. For example, a Dependent Personality Disorder may be at the Neurotic or Borderline Level.

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It is a simple matter of first determining if a person is at the Healthy Level. A person at the Healthy Level has a stable identity, good interpersonal relations, affect tolerance, good affect regulation, moral integration, good reality testing and good ego strength and resiliency. A person at the Neurotic Level has most of these abilities but to a lesser degree, but has problems with rigidity and inhibitions. They tend to favor repression as a defense. A person at the Borderline Level of Personality Organization has serious problems with identity, relationships, affect tolerance, affect regulation, reality testing, ego strength, resilience, and moral consistency. They tend to favor primitive defenses such as spitting, denial, and projective identification.

Now we will use these three main PDM classifications of personality organization to look at our MMPI-2 case #2 with the high Lie and K scales and the low F scale. This "faking to look good profile" for someone at the Healthy Level would suggest a test set of wanting to look good, but with high stress tolerance, good reality testing and good ego-strength. This same profile for someone at the Neurotic Level would suggest repression, inhibitions, perfectionism and good reality testing. This same profile for someone at the Borderline Level suggests the use of denial and splitting as favored defenses, poor capacity to deal with reality, and poor ego resiliency. Only by first determining the level of personality organization, is it possible to have an accurate MMPI-2 interpretation.

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In case #3, a police applicant produced an elevated MMPI-2 Schizophrenia scale. However, the interview and history were negative for any serious psychopathology. According to the PDM, the person was between the Healthy and Neurotic level of Personality Organization. It turned out that the young man had a mother who was a psychologist. He was raised to introspect and self-disclose. As a result, he over-admitted to common dynamics that are usually repressed. This inflated his Schizophrenia scale and produced a false positive profile. The PDM qualitative classification helped to interpret his MMPI-2 scores.

The combined use of the PDM classification of Healthy, Neurotic and Borderline Personality Organizations and the MMPI-2 produces a powerful assessment tool. It will lead to more accurate and useful determinations. 

 

References

 

Dawes, R. M., Faust, D., & Meehl, P. E. (1989). Clinical versus actuarial judgment. Science, 243(4899), 1674.

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Gordon, R. M. (2001). MMPI/MMPI-2 Changes in Long-Term Psychoanalytic Psychotherapy. Issues in Psychoanalytic Psychology, 23(1), 59-79.

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Gordon, R. M. (2006c). False Assumptions About Psychopathology, Hysteria and the MMPI-2 Restructured Clinical Scales. Psychological Reports, 98, 870-872.

 

Graham, J. R., Ben-Porath,Y.S., and McNutly,J.L. (1999). MMPI-2 Correlates for Outpatient Community Mental Health Settings: University of Minnesota Press.

 

PDM, Task Force (2006). Psychodynamic Diagnostic Manual. Silver Spring, MD: Alliance of Psychoanalytic Organizations.