Dear Sonja,

I’ll try to answer your somewhat mystical question. Do you mean that you don’t want to come up with a ‘negative’ diagnoses in a way that your patients feel less worthy?

In this case suggest you can better avoid to use MMPI, which compares traits and states from a ‘better/worse’ perspective. At least in my opinion.

If you’re using the test for official reports, you can consider to use a test (like neo-pi(-r)) which differentiate between the 5 types of personality as used in the BIG Five model of personality (Extraversion, Agreeableness, Conscientiousness, Neuroticism, and Openness to Experience).

If it’s more informal you can try a type indicator like the Myers Briggs type indicator. This indicates 4 dichotomies of personality (extraversion/introversion, sensing/intuition, thinking/feeling and judging/perception). Many people like this indication because it’s not judgemental but may help to overcome social dilemma’s in for example working environments.

thank you Hessel

4-dkl as alternative? Sonja, what is the patients age?

thank you Evelien

sorry, she's 28 y.o.

sorry, she's 28 y.o.

Interesting question! It depends a lot on what are your profession and professional context, and whether you want to arrive at a profile or a diagnosis.

From a therapeutic point of view, I would say - if your context will allow it - to simply do your evaluation and use descriptive terms and your choice of a behavioural, cognitive, psychodynamic or relational framework to make your summary and recommendations. 

From a philosophical framework, I would say that none of the current approaches are truly satisfying or valid. The starting points of how even to define a person are not consensually validated in the fields of psychology, psychiatry and psychotherapy. 

That said, if you are talking about diagnosing personality traits or disorders, choose your preferred guidelines - ICD, DSM or other - but just be clear as to which approach you are using and be scrupulous about applying the criteria of that approach and understanding and communicating the assumptions and warranted conclusions based on that approach and its results. 

As to the notion of "personality disorders," I have philosophical (what's a person? what's a disorder? what's a personality disorder?), methodological (the notion of "personality disorder" has some consensus or "robustness" as a construct, as do two of the currently recognized so-called personality disorders - "borderline" and "antisocial," while the other types have rather low discriminatory power), and practical questions and doubts (e.g., stigma). 

Finally, every approach has or should have an implicit or explicit psychology (understanding of persons). What is yours? Again, some professions, systems or jurisdictions impose certain ways of working based on an implicit or explicit model. If you are not limited by such constraints, you can make more choices and render them more meaningful for your work and for your patients. 

I hope that helps. 

Vincenzo Di Nicola

Psychologist, Psychiatrist and Philosopher

Professor of Psychiatry, University of Montreal

Thank you Vincenzo, very interesting point(s) of view.

I greatly appreciate the previous suggestions and responses. I will add from a different direction.  When you say "very vulnerable patient" and want to avoid anything that might be construed as "negative," you make me think from a very clinical perspective.  You raise the image that your 28 year old patient may overreact to or misinterpret a diagnosis no matter how accurate it may be.  Therefore, you want to avoid categorizations (diagnostic labels) and talk about strengths, patterns of behavior, developing or improving coping skills, helping her identify her distorted thinking and utilize what the "patient" identifies as goals to find areas she will commit to explore with you.  You become the best instrument to elicit those dimensions in a meaningful way from the patient.  One of the goals for this patient, seems to me, to be helping her face herself and tolerate hearing uncomfortable assessments or information of that nature.  I would speculate that it would transfer to a difficulty in facing conflict.          

I appreciate the question, which we frequently face in the clinical work we encounter.

Stanley Selinger, Ph.D.

Clinical Psychologist

The Family Institute

Thank you very much Stanley

If you were to use the MMPI-2, I would recommend looking at "Therapeutic Feedback with the MMPI-2: A Positive Psychology Approach" by Levak, Siegle, Nichols, and Stolberg (2011). It contains feedback statements as well as treatment and self-help suggestions for a number of code types.

I'd give the SWAP (Shedler-Westen Assessment Procedure) a whirl. It's a 200-item personality Q-sort including items indicative of problems (e.g., DSM-5 symptoms) as well as items indicative of strengths described in narrative form. The measure is clinician-administered, and the items arranged according to a fixed distribution. You could probably do one for free (it's quite easy to use) and get an interpretative report at their website (www.swapassessment.org). It would probably take about 45 minutes for someone just learning about the measure.

I like it a lot because it's both norm-referenced (individual profiles are compared to a clinical normative sample and not norm-referenced (individual profiles describe that individual, and items can be arranged in narrative format with a little editing to create a pretty useful case formulation). One of my favourite things about it is its jargon-free-ness and the fact that scales of personality strength are clear. So although it describes psychopathology, it also describes psychological strengths and resources, which are sort of missing in a lot of assessment measures.

I think the main point to bear in mind is that personality is not the same thing as psychopathology. Although some aspects of personality can be problematic, others are quite adaptive or at least neutral.

If you want to understand someone without your main focus being on the ways in which they are disturbed, then you should avoid tests that mainly assess pathology - such as the MMPI and MCMI. There are lots of self-report instruments that measure more-or-less "normal" personality characteristics. Two that have been used by counselors for a long time would be the factor-analytic 16PF and the empirically keyed California Psychological Inventory (sometimes referred to as "the sane man's MMPI). Somebody else mentioned the NEO-PI, which is a well-constructed factor-analytic measure, though it has less of a history or literature in counseling. You also could move away from reliance on self-reports, but you might not want to take the trouble to master the proper use of instruments like the TAT or Rorschach.

I also agree that you should do some reading on therapeutic assessment, a tyope of treatment introduced by Finn in the 1990s.

All that being said, if your client really is that vulnerable, there may well be some psychopathology present. And you won't be doing her a service if you just ignore it.