Psychologists

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Psychologists and social workers perceptions of
personality disorders in substance abusing
clients.

• Morten Hesse and Birgitte Thylstrup

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Background

• The role of psychologists in the substance abuse
  treatment field has been a topic of debate
• Psychologists differ from other professionals in
  the field by having an education in clinical
  psychology, personality psychology and
  developmental psychology
• Psychologists could be expected to be more able
  to assess personality traits than social workers
• General training has not been identified as a
  robust predictor of clinician effectiveness
  (Najavits, Crits-Christoph and Dierberger, 2000)

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Clinical diagnosis vs. self-report

• Questionnaires and semi-structured interviews
  rely primarily on direct query about behaviours,
  cognitions and emotions
• Clinicians tend to rely on clients narratives
  and behaviours in the clinical settings (Westen,
  1997)
• Thus, diagnosis based on clinical observation and
  self-report are likely to differ

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Clinical diagnosis and self-report (2)

• In general, clinical diagnosis and self-report
  show rather modest agreement
• Diagnosis based on clinical observation tend to
  over-diagnose common and well-known diagnoses,
  and under-report less common diagnoses compared
  with structured interviews and questionnaires
  (Rogers, 2003)

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But how about psychologists and social
workers?Do they differ?
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Method and material

• Clients were rated using 10 rating scales
  representing the 10 personality disorders of the
  DSM-IV
• A total of 101 drug and alcohol abusers from 15
  different settings participated all were
  administered the DIP-Q (Ottoson, 1999)
• A total of 20 psychologists and 28 social workers
  participated
• Psychologists made a total of 29 client
  estimations, and social workers made a total of 79

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Comparisons of severity ratings

• All study clinicians rated patients on scales
  from 0 to 100 representing each of the 10
  personality disorders
• A Danish translation of the DSM-IV criteria for
  all personality disorders were made available,
  and 3 keywords were printed on the scoring sheet
  for each disorder
• Ratings were compared using ANCOVA controlling
  for self-reported symptoms

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Self-reported severity (DIP-Q)
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Ratings of severity
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Significant differences in severity ratings
(plt.01)

• Paranoid
• Antisocial
• Histrionic
• Dependent
• Compulsive
• All showing lower ratings from psychologists.
• All after controlling for self-reported severity.

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Differences in concordance
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A speculative model
Interpersonal sensitivity Overt behaviour Psychologists Better judge
Paranoid Yes No Under-rate Equal
Schizoid Yes No Rate as others Psychologist
Schizotypal Yes Yes Rate as others Social workers
Antisocial No Yes Under-rate Social workers
Borderline Yes Yes Rate as others Equal
Histrionic No Yes Under-rate Social workers
Narcissistic No Yes Rate as others Social workers
Avoidant Yes No Rate as others Psychologist
Dependent Yes No Rate as others Psychologist
Obsessive-Compulsive No Yes Under-rate Social workers
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Discussion (1)

• Psychologists were generally more conservative
  with regard to assigning personality disorder
  related traits to patients
• This difference was more marked for socially
  undesirable traits

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Discussion (2)

• No evidence was found that psychologists were in
  general better judges of character than social
  workers
• Scales that converged better for psychologists
  than social workers shared manifest interpersonal
  vulnerability
• Scales that psychologists under-rated shared the
  absence of manifest vulnerability.

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Discussion (3)

• General educations or training programs in
  psychotherapy may have little impact on the
  ability to diagnose personality disorders
• If diagnosis or other forms of goal-directed
  clinical observation is to be enhanced, training
  such probably be specific, rather than general.

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Discussion (4)

• The behaviour of a client towards a psychologist
  is likely to differ from the clients behaviour
  towards a social worker
• The behaviour of the psychologist is determined
  by a different role within the treatment context
  than that of the social worker

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Example
Client is in session and works on his
trauma history and interpersonal fears
Client leaves therapy room and starts conflict
with other client
Social worker intervenes, has a loud argument
with client
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Diagnostic judgments

• Psychologist sees
• Client as relatively cooperative, and motivated
  for change
• Anxiety, insecurity, trauma, and relationship
  issues
• Social worker sees
• Client as unhealthy, aggressive, unmotivated, and
  a trouble-maker
• Acting-out, sense of entitlement, manipulative
  behaviour

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Discussion (5)

• Failure to cope adequately with differences in
  role and responsibilities is a source of
  disagreements between staff members
• Clients who cope through splitting are likely to
  create splitting among staff members in such
  clinical contexts (e.g., the prototypical
  borderline client)
• Clients who manipulate are likely to take
  advantage of these disagreements (e.g., the
  prototypical antisocial client)

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Limitations

• The statistical power to calculate differences
  between correlation coefficients is very limited
  in small groups
• The samples used in the present study were
  non-random, and may not be representative

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Conclusion

• Psychologists are not immaculate judges of
  character
• Different ways of working with a substance
  abusing patient gives unique and useful
  information.
• The challenge is not to win the power struggle
  between professions, but to integrate different
  perceptions for the benefit of treatment