Perceptions of Personality Disorders in Substance-Abusing Clients

1. Psychologists’ and social workers’ perceptions of personality disorders in substance abusing clients. Morten Hesse and Birgitte Thylstrup

2. 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)

3. 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

4. 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)

5. But how about psychologists and social workers?Do they differ?

6. 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

7. 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

8. Self-reported severity (DIP-Q)

9. Ratings of severity

10. Significant differences in severity ratings (p<.01) • Paranoid • Antisocial • Histrionic • Dependent • Compulsive All showing lower ratings from psychologists. All after controlling for self-reported severity.

11. Differences in concordance

12. A speculative model

13. 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

14. 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.

15. 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.

16. Discussion (4) • The behaviour of a client towards a psychologist is likely to differ from the client’s 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

17. 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

18. 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

19. 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)

20. 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

21. 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