A self-report inventory is simply a list of questions completed by the subject. Most are in paper-and-pencil form, though some are also computer administered. Self-report tests are available for almost every conceivable theoretical concept and clinical condition. Each usually consists of a minimum of about eight items to a maximum in the several hundreds. Answer formats vary from simply true versus false, to never, seldom, often, and always. The variations are endless. Short tests usually assess only a single construct;
longer tests, called self-report inventories, might assess 20 or more. On longer tests, scale scores may be plotted as a profile configuration.
Because self-reports represent the subject's own responses, they can be especially valuable in quickly identifying clinical problems. Unless the individual is violent or psychotic, a self-report inventory can be given at any point during the clinical process, often with minimal supervision. A profile obtained at the beginning of therapy, for example, can be used as a baseline to evaluate future progress. Some questions, such as, "I am too outgoing for my own good," assess personality traits. An item like this might be answered true by a histrionic personality, for example. Other questions, called critical items, are written to assess desperate situations that should receive immediate clinical attention, such as, "I intend to commit suicide." In the era of managed care, where progress must be carefully documented, brief serial assessments with self-report measures chart the clinical course with speed and convenience.
A rating scale can be completed by anyone who knows the subject well, perhaps a spouse, teacher, parent, coworker, priest, or even parole officer. Such persons are in a position to offer a unique perspective on the problem, its severity, and its causes. Rating scales and checklists may also be completed by the clinician, who makes a series of judgments on the basis of all available information, including the clinical interview. Here, rating scales and checklists often serve as a memory aid, ensuring that everything relevant to the disorder is included in developing a treatment plan. Rating scales usually have more items than the DSM-IV diagnostic criteria for the same syndrome and are usually held to a higher standard of scientific rigor. Because they have more items, they provide more fine-grained measurements, but they also take more time to complete. For example, the revised Psychopathy Checklist (PCL-R; Hare, 1991) consists of 20 items, whereas the DSM-IV offers only seven criteria for the diagnosis of antisocial personality disorder. Although the PCL-R is widely used in the study of psychopathy, few rating scales exist for use with other personality disorders.
The clinical interview is usually thought of as the criterion standard in psychopathology, against which the validity of all other assessment instruments is judged. The development of a variety of formalized, systematic clinical interviews, beginning around 1960, remains an important milestone in the history of clinical assessment. Because interviews standardize the questions asked of patients, they greatly increase interdiagnostician reliability, defined as the extent to which different clinicians agree about the diagnosis of the same subject. This is especially true for the personality disorders, which are broad and overlapping constructs.
Two kinds of clinical interviews exist, structured and semistructured. Structured interviews are intended to be administered by trained nonprofessionals and are usually used in large research projects, not in normal clinical work. A fixed series of questions is asked, and the interviewer is not allowed to deviate from these questions in any way. This standardizes the assessment process across interviewers, thus compensating somewhat for their lack of professional experience. Otherwise, the interviewer might get lost in some irrelevant tangent and waste time or record unnecessary information. Many structured interviews are exclusively research instruments to be used in conjunction with governmental research funding. Subjects are often paid to participate and may answer questions for several hours.
In contrast, semistructured interviews draw on the experience and knowledge of the professional by allowing additional probes to be inserted as desired. Thus, if the subject makes a statement that might be relevant to any part of the assessment, the clinician is free to pursue the issue immediately, if desired. Some semistructured interviews are geared to a comprehensive assessment of Axis II. These can take up to two hours to administer and score, even with training. Other semistructured interviews focus on a single construct and take only about an hour. Given the necessary time commitment, semistructured interviews are not widely used in actual clinical practice. Nevertheless, they can be extraordinarily useful in clinical training. Because they already contain interview questions of demonstrated utility, they allow the student to quickly acquire a degree of knowledge in unfamiliar diagnostic terrain.
Some situations offer a chance for flexibility, novelty, and the expression of individual differences in behavior, and others do not. When situations are highly scripted, environmental constraints dominate and the behavior of different individuals tends to converge, regardless of their personality traits. Almost everyone stops at a red light, and almost everyone cries at a funeral or at least tries to look sad. In contrast, when the social pull for any particular behavior is weak, behavior is no longer determined by the environment but by factors inside the person. An observer is, therefore, entitled to ask, "Of all the possible ways of behaving, why these particular responses, rather than others?"
Projective techniques seek to draw out internal, and frequently unconscious, influences on behavior by presenting the subject with inherently unstructured, vague, ambiguous situations. The Rorschach Inkblot Test is the classic example. The subject is presented with a series of 10 blots in turn and asked to report what he or she sees. Although the blots are not intended to look like anything in particular, subjects almost always report seeing something, ranging from the trivial to the obviously psychotic. In the Incomplete Sentence Blank, the subject writes in a response following an item stem, such as "My mother_." The Thematic Apperception Test uses pictures of various interpersonal situations. The subject constructs a story to explain what is happening in the picture, what led up to these events, and how matters will end. Because projective instruments are time-consuming and not widely regarded as being as scientific as self-report inventories or interviews, their use has waned in recent years, especially with the ascendancy of managed care.
Measurement in all sciences is limited by biasing and distorting factors. In the physical sciences, these influences can often be quantified directly to limit the loss of measurement precision. Stars twinkle because of heat and atmosphere impurities. Instruments on large earth-based telescopes, however, now sample the properties of the atmosphere and mathematically factor out the twinkle to produce sharper images. In personality and psychopathology, however, such precise control is usually not possible. Instead, information is limited in both its quantity and quality. Some subjects are poor historians, show little insight, or have limited verbal ability. Even when intellectual level and memory are good, subjects can report only what they know about themselves or what they believe they know. God may have a monopoly on truth, but human beings must work with fallible indicators. Psychodynamic critics might even argue that the most important truths are the most threatening and, therefore, the most likely to remain repressed in the unconscious, beyond the reach of either self-report instruments or clinical interviews.
Certain distortions arise because of the personality style of the respondent or interviewer. Different personalities construe the world in different ways. Persons with an extraordinarily passive approach to life, such as the immature dependent personality, are unlikely to develop nuanced representations of self and other. With their instrumental surrogates to take charge of life and confront the world, immature dependents fail to develop functional competencies. As such, they may acquire only a thin fund of information about the world around them. Similarly, schizoids withdraw from social life, possessing little interest in anything, even their own emotional affairs. Likewise, histrionics are notoriously scattered and impressionistic. When asked detailed questions during a clinical interview, all three are vulnerable to interpretations cast in coarse cognitive categories; they fail to make distinctions where real distinctions exist. In effect, the test or interview items are often more nuanced, subtle, or complex than the subject's own understanding, leading to significant limits on validity.
Other limitations on clinical information arise from subjects' motives and their level of personality pathology. Compulsives, for example, fear condemnation from authority figures and from a punishing, sadistic superego that insists perfectionist standards be maintained. As a result, such individuals are highly motivated to appear normal; Leary (1957), in fact, referred to the compulsive as the "hypernormal personality."
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