Impact of Addictions: Foundations of Addiction & Addictive Behaviors

Impact of Addictions 

Robbyn R. Wallace 

Foundations of Addiction & Addictive Behaviors 

October 30, 20016 

Impact of Alcohol  

 Identifying a drinker may appear simple when signs—such as slurred speech, uncoordinated movements, lowered inhibitions, even alcohol breath—are recognizable, but identifying a deeper addiction may not be as simple. It is not uncommon for alcoholics to hide obvious symptoms of the addiction for long periods of time, and equally common for the addict and surrounding people to ignore the addiction—state of denial. Of course, alcoholism is the most severe form of problematic drinking, involving not only all symptoms of alcohol use disorder (AUD) but also involving physical dependence. Reliance on alcohol to function or experiencing physical compulsion to drink strongly suggest alcoholism/alcohol addiction.   

Addiction involves more than simply stereotyping disease conceptions of alcoholism or the inherent addictive quality of narcotics cast upon anyone who might use alcohol/substance. This is highly contingent upon prevailing societal views—i.e. The evolution of marijuana from a spiritual tool to a recreational substance to a substance with tremendous medicinal potential; as studies continue to confirm the medicinal value and low risk to well being, society will continuously become more accepting of its use—even as a recreational activity.  The removal of the legal problems in The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; APA, 2013) appears to indicate a cultural shift away from criminalizing substance users, revealing a progressive susceptibility to social and political influences (Robinson & Adinoff, 2016). Substance/alcohol use has become less of a taboo subject. Biological, cognitive, behavioral, psychological and sociocultural factors are all thought to play a role in the development of alcohol dependence (Lewis, 2014). Similar styles of alcohol usage and/or dependence is commonly found to exist within the same nuclear family—many times generational—however, it should be noted that other behaviors or traits run in families that may have little or no biological basis. The contribution of genetic and other biological factors to susceptibility in the development of AUD appears significant.  

According to Garland and Pettus-Davis (2012), adolescents with extensive trauma histories tend to engage in more extreme patterns of substance misuse than do adolescents with minimal or no exposure to trauma, which may also account for more severe psychiatric symptoms (Garland & Pettus-Davis, 2012). Many times individuals with trauma history's attempt to self-medicate their consequential psychological distress. Out of a reportedly 176.6 million alcohol users in 2014, only an estimated 17 million have AUD (SAMHSA, 2016). It is not uncommon for drinking to begin at an early age as evidenced in self-report data. There are differing levels of drinking such as; (a) moderate drinking—up to one drink each day for women and two for men, (b) binge drinking—five or more drinks per occasion, blood alcohol concentrations (BAC) greater than 0.08 g/dL, at least one day per last 30 days, (c) heavy drinking—five or more drinks on same occasion five or more days within last 30 days (SAMHSA, 2016). Heavy or excessive drinking leads to greater risk of development of AUD as well as other health and safety concerns.  

Impact of History upon Addiction Theory and Treatment 

All throughout history ways to alter consciousness, to include perceptions of one’s sensate body, has been sought by humans through taking herbs, drugs or psychoactive substances—including alcohol. These practices have led to many impressive, important contributions to culture and in the field of science. Not only do these practices have historical relevance but some continue to have present value, some herbs/substances are used as a spiritual tool. Addiction theories integrate to provide complimentary theoretical synthesis for a more holistic perspective and cover the following domains; (a) genetic theories—inherited mechanisms causing or predisposing individuals to addiction, (b) metabolic theories—biological, neuroscience and cellular adaptation to chronic exposure of substance/alcohol, (c) conditioning theories—cumulative reinforcement of drug/alcohol or other associated activities, (d) adaptation theories—exploration of psychological and social functions enacted by drug effects. Theories create a frame in which to understand addiction, construct proper assessment and conduct appropriate treatment.  

The ever-changing historical and cultural milieu influence the prevailing legal, moral, and medical and mental health conceptualizations of substance use. The history of a disorder, if understood, provides critical information needed to assess and treat—including preventive strategies—alcohol use disorder (AUD). AUD ranges, on broad continuum, from occasional problematic overuse to chronic, progressive alcohol dependence. Clinically, AUD is qualified based on standardized criteria—abuse vs. dependence—and range in frequency, severity, and symptoms. Having an awareness of the history of AUD is helpful in risk assessment and building an evidence-based treatment plan with effective strategies personalized to individual and social contextual considerations.   

When comorbidity between alcohol use disorder and other mental disorders occurs, it does not equate a causal relationship irregardless of one appearing first. Alcohol abuse may lead to experiences of one or more symptoms from another mental disorder—for example, there is an increased risk for psychosis in marijuana abusers. There is a reciprocal vulnerability that having a mental disorder could lead to substance/drug abuse, such as the use of tobacco as means to lessen mental distress and improve cognition in a client with schizophrenia. When factors—such as genetic vulnerabilities, underlying neurological deficits, and/or early exposure to stress or trauma—overlap, it can cause substance use disorders and other mental disorders (NIH, 2016). The underlying role of psychopathology in the onset and maintenance of addiction is the therapeutic focus, from a psychological theoretical perspective.  

There is a high prevalence of substance abuse/dependency among individuals with mood and anxiety disorders, also there is an even higher prevalence of mental disorders among patients with drug use disorders (NIH, 2016). Environment influences complex gene interaction involving multiple genes, such as protein influence response to substance—experience is pleasing or not—as well as determining duration substance remains in the body. Genes indirectly alter the stress response system, also responsible for increasing the presence of risk-taking/novelty-seeking behaviors, and can influence development of AUD and other mental disorders. The way stress increases vulnerability to addiction is explained by dopamine pathways, which indicates use of medications that directly target dopamine regulation. Stress is thought to increase susceptibility to addiction as well as other mental disorders, likely sharing a common neurobiological link between addiction and other mental disorders.  

Changes in the brain are involved in both substance use disorders and other mental disorders and because of the overlap of brain areas involved one (substance or mental) disorder is thought to affect other disorder(s) (mental or substance). In other words, substance abuse that precedes initial symptoms of mental illness are thought to produce changes in brain structure and subsequently function that modify gene expression. However, vice-versa associated brain activity changes are thought to increase the vulnerability to substance abuse—due to enhancement of positive effects, reduction in awareness of negative effects, or the alleviation of unpleasant effects (NIH, 2016).  

DSM-5 Criteria and Severity 

Although humans have a lengthy and complex relationship with substances throughout history, the mental health involvement, with addiction to help regulate the extremes associated with excessive use of substances, is a more recent part of human history. The DSM, considered the official nosology of the American mental health system, evolved from psychoanalytic roots in effort to develop a unified nosology. The DSM-III achieved significant advancements, guided by atheoretical, consensus-based diagnostic entities, in diagnostic reliability and validity—supportive to the scientific development of the mental health field (Robinson & Adinoff, 2016, p. 18). However, currently it is assumed that clinicians are able to conceptualize in much more diverse ways such as an integration of of theories in effort of a more three dimensional vantage, in ways that provide opportunity to conceptualize data from theoretical frameworks—such as biopsychosocial, providing opportunities to incorporate more personalized evidence-based strategies into treatment plans. Clinicians retain perspectives from accumulated personal experience and education, creating unique conceptualizations of causal etiology of AUD.   

The severity of an AUD—mild, moderate, or severe—is based on the number of criteria met within a 12-month period (APA, 2013). AUD diagnostic criteria include loss of control over consumption, continued alcohol use despite harmful consequences, tolerance buildup, drinking leading to risky situations, or withdrawal symptoms developing. When excessive recurrent alcohol use begins to cause clinically and functionally significant impairment—e.g., medical issues, disability, and failure to accomplish important responsibilities at home, work or school—substance use disorder is indicated and is evidenced by risky use, social impairment, impaired control, and pharmacological criteria (APA, 2013). AUD is one of the most common of the substance use disorders; excessive use increases the risk of the development of serious health issues including the issues associated with intoxication behaviors and withdrawal.     

Addiction should not be automatically assumed without appropriate assessment; instead, it should cue therapist to conduct an alcohol risk assessment—such as the Alcohol Use Disorders Identification Test (AUDIT; AUDIT, 2010)—aimed at recognizing or confirming diagnosis. The AUDIT (2010) is a 10-item screening tool, developed by the World Health Organization (WHO), and is used to assess alcohol consumption, drinking behaviors, and alcohol-related problems. Scores of 8 or more indicates hazardous or harmful alcohol use. The AUDIT demonstrates standards across genders and wide spectrum of racial/ethnical groups, making it clinically relevant for diverse populations.  

Social and Cultural Issues 

The struggle to restrict usage within acceptable social limits leads to the aberration of addiction. This usually takes place overtime, leading to desensitization—tolerance is built. Initially, use may be enjoyed in a recreational type way, like when an individual gets into the habit of having a drink daily to relieve work-day stress or when an individual uses cocaine as a way of staying up late to study for exams. Although some may be able to continue occasional usage, other do not possess such capacity for casual use. Addiction can be gradual for some and abruptly for others, as the use increases, more time, energy and attention is devoted to thinking about getting intoxicated/high, purchasing substance/drug, preparation and active use increases until it is primary focus in the individuals life. At this point other responsibilities, such as employment, familial and peer relationships, and community obligations, began to deteriorate.  

Legal and Social Consequences 

The misuse of alcohol can be not only harmful to the user, it affects others and can have a negative impact on relationships as well as society—such as decreased productivity at work, increase in accidental injuries, aggressive behavior toward others, or child and/or spousal abuse. Alcohol cost the United States of America approximately 224 billion dollars annually, including health care costs, crime, and lost work productivity (NIH, 2016).  The legal consequences, such as with a driving under the influence (DUI) conviction, can become costly and time consuming as well as interfere with normal routines. It become even more complicated for someone struggling with AUD when they get their second, third, perhaps even fourth DUI and face a felony conviction. Or perhaps, any number of crimes that can be easily committed when some people are intoxicated depending on the level of intoxication.  

A biopsychosocial perspective (Buckner, Heimberg, Ecker & Vinci, 2013) on alcohol use disorders with consideration to a lifespan, person-in-environment perspective, the reciprocal nature of the individual and the social context influence the creation and maintenance of the alcohol use disorders. With marijuana, the medicinal value is worthy of reconsideration as social perception changes given evidence of medicinal value. Steve Jobs—e.g., Apple—once stated, in an interview (Fink & Segall, 2015), that doing LSD/acid/hallucinogen—when he was younger and before his success—was one of the best decisions he had ever made, and furthermore, he contributes much of his success to such experiences. In order to understand and effectively treat someone with AUD, the impact of the family should be considered (AAMFT, 2016; Lander, Howsare & Byrne, 2013). There is a reciprocal relationship between the addiction process and environment, just as people influencing their social environment and in turn are influenced by the social environment.  

References 

Alcohol Use Disorder Identification Tool (AUDIT). (2010). Retrieved from: https://www.drugabuse.gov/sites/default/files/files/AUDIT.pdf  

American Association of Marriage and Family Therapy (AAMFT): Substance Abuse and Intimate Relationships. (2016). Retrieved from: https://www.aamft.org/imis15/AAMFT/Content/Consumer_Updates/Substance_Abuse_and_Intimate_Relationships.aspx  

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. 

Buckner, J. D., Heimberg, R. G., Ecker, A. H., & Vinci, C. (2013). A biopsychosocial model of social anxiety and substance use. Depression & Anxiety (1091-4269), 30(3), 276-284. doi:10.1002/da.22032  

Fink, E. & Segall, L. (2015). CNN Money: I did LSD with Steve Jobs. Retrieved from: http://money.cnn.com/2015/01/25/technology/kottke-lsd-steve-jobs/   

Garland, E. L. & Pettus-Davis, C. (2012). Self-medication among traumatized youth: Structural equation modeling of pathways between trauma history, substance misuse, and psychological distress. Journal of Behavioral Medicine, 36, 175–185. DOI 10.1007/s10865-012-9413-5.  

Lander, L., Howsare, J. & Byrne, M. (2013). The Impact of Substance Use Disorders on Families and Children: From Theory to Practice. Social Work Public Health, 28(0), 194–205. doi:10.1080/19371918.2013.759005  

Lewis, T. F. (2014). Substance abuse and addiction treatment: Practical application of counseling theory. Upper Saddle River, NJ: Pearson  

National Institute on Drug Abuse: Advancing Addiction Science (NIH). (2016). Retrieved from: https://www.drugabuse.gov/ebook/azw/1155  

Robinson, S. M., & Adinoff, B. (2016). The Classification of Substance Use Disorders: Historical, Contextual, and Conceptual Considerations. Behavioral Sciences (2076-328X), 6(3), 1-23. doi:10.3390/bs6030018 

Substance Abuse and Mental Health Services Administration (SAMHSA): Substance Use Disorders. (2016). Retrieved from:  http://www.samhsa.gov/disorders/substance-use 

Psychopathology: Selecting a Diagnosis

Selecting a Diagnosis

By

Robbyn Wallace

Principles of Psychopathology

May 3, 2015

Selecting a Diagnosis

The purpose of this paper is to review trauma- and stressor-related disorders—“in which exposure to a traumatic or stressful event is listed explicitly as a diagnostic criterion” to include “reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disorder (PTSD), acute stress disorder, and adjustment disorders” (APA, 2013, p. 265), more specifically PTSD—which is “presumed to have a specific etiology, and exposure to a Criterion A stressor is considered to be a major etiological factor for the disorder although there are numerous other risk and protective factors (Kilpatrick, Resnick, & Acierno, 2009, p. 374)” (Courtois, 2014, p. 24). In addition to reviewing PTSD, this paper will explore how PTSD symptoms, if not appropriately identified, can mislead diagnosis, as well as how frequent co-occurring disorders (Meltzer, Averbuch, Samet, Saitz, Jabbar, Lloyd-Travaglini, & Liebschutz, 2011) such as depression, anxiety, and panic impact PTSD diagnosis.

DSM-5 Diagnosis

PTSD is strongly associated with traumatic stress and encapsulates “the dominant clinical understanding of trauma impact” (Eagle & Kaminer, 2011, p. 25), defined as “the consequences of experiencing extreme stressors, referred to as traumas” (Nolen-Hoeksema, 2014, p. 110). The DSM 5 considers traumas to be events of exposure to “actual or threatened death, serious injury, or sexual violation” (Nolen-Hoeksema, 2014, p. 110). In the wake of a traumatic event, a PTSD risk assessment may identify risk factors such as pre-trauma—prior trauma history with childhood conduct problems, peritrauma—perceived threat, heighted arousal, as well as dissociation, and post-trauma factors— such as hardiness and social support (Wisco, Marx, & Keane, 2012).  The DSM 5 Criteria require the duration of symptoms—Criteria B, C, D, and E—be beyond 1 month; causing “clinically significant distress or impairment in social, occupational, or other important areas of functioning” (Nolen-Hoeksema, 2014, p. 112); and, “not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition” (p. 112).  PTSD symptoms include four primary categories; (1) re-experiencing the trauma, (2) numbing of response, (3) hyperarousal, and (4) avoidance and cognitive and emotional changes (Courtois, 2014, p. 146-151). An individual’s response to trauma is dependent upon “individualized experience, perspective, and temperament” (p. 180). Exposure to a traumatic or stressful event is usually captured through such clinical characteristics as “anhedonic and dysphoric symptoms, externalizing angry and aggressive symptoms, or dissociative symptoms” (APA, 2013, p. 265), which may or may not include anxiety- or fear-based symptoms (Eagle & Kaminer, 2015). Even though complex trauma was not added to the DSM V—while some disagree with that choice (Eagle & Kaminer, 2015), it is essential to explore and understand the impact when trauma is repeated and/or layered—why it is “usually more damaging, sometimes causing the victim to lose his or her sense of self altogether” (Courtois, 2014, p. 676)—and how it increases vulnerability to future trauma and microtraumas.

Symptoms characteristic of PTSD can be grouped into three categories (Courtois, 2014): (1) Re-experiencing symptoms—such as flashbacks to include physical symptoms like a racing heart or sweating, nightmares or bad dreams, and/or frightening cognitions—arises from the individual’s cognitions and emotions, and triggered by verbal, objects, or situations perceived as reminders of the traumatic event which causes problems in the individual’s daily routine; (2) Avoidance symptoms—avoiding places, events, or objects that are reminders of the experience; feeling emotionally numb, strong guilt, depression, or worry; loss of interest in activities once enjoyable; and, difficulty with remembering the dangerous event—triggered by reminders of the traumatic event and can cause personal routine change; (3) Hyperarousal symptoms—such as easily startled, feeling tense, having difficulty sleeping, irritable and/or having anger outbursts—are usually constant, causing distress and anger, and may make daily tasks, including concentration, more difficult. An individual must have all the following for at least 1 month; minimum of one re-experiencing symptom, minimum of three avoidance symptoms, minimum of two hyperarousal symptoms, and symptoms that make daily life, school, work, relationships, and/or important task more difficult. Although trauma does not always lead to a disorder, it may find expression in complex patterns. Risk factors influence the likelihood of an individual developing PTSD, whereas resilience factors can help in the reduction of the individual to develop PTSD. Some of these factors are present in the individual before the trauma, where others become essential during and post-event. Trauma exposure shatters basic assumptions and negative attributions are central to the impact of trauma, which leads to the importance of “enduring alterations to meaning systems” (Eagle & Kaminer, 2015, p. 25) in the presentation of PTSD symptoms.

Theoretical Models and Etiological Approaches

Mental health is modernly thought to be best captured by an integrated approach, the biopsychosocial approach, which recognizes that often it is “a combination of biological, psychological, and sociocultural factors” (Nolen-Hoeksema, 2014, p. 24) that is responsible for the development of psychological symptoms. Those factors are considered risk factors, which increase likelihood of psychological problems. This is considered a more holistic perspective.

Childhood trauma exposure and maltreatment are considered significant in the development of neurological pathways that determine vulnerability to external stress, especially with no caregiver mediation of the experience(s) (Eagle & Kaminer, 2015). Therefore, those exposed to trauma during childhood, especially chronic or complex trauma, are much more vulnerable to developing PTSD (Nolen-Hoeksema, 2014, p. 115). Abnormally low levels of cortisol, as is suggested (Nolen-Hoeksema, 2014), “may be one heritable risk factor for PTSD” (p. 117). Epigenetics—gene expression is affected by environmental conditions—may provide an understanding of how PTSD might invoke genetic and environmental factors. A social cognitive and affective neuroscience approach (Lanius, Bluhm, & Frewen, 2011) can be used to understand and explain the psychology as well as neurobiology of complex history of post-traumatic stress, the difference it has on the presentation of PTSD, and effective treatment.

Cognitions—thoughts or beliefs—shape our experience by means of behavior and emotive expression. Traumatic experience can cause dysfunction in the individual’s ability to make meaning due to hyperarousal of the stress-response. This can sometimes lead to a negative thinking style, which can exacerbate symptoms such as anti-social behaviors.  A cognitive approach allows an opportunity to “identify and challenge…negative thoughts and dysfunctional belief system” (Nolen-Hoeksema, 2014, p. 40).

The availability of social support is also a predictor of vulnerability to the development of PTSD and can have an effect on the length of the recovery process. Prior to a traumatic event, individuals who experience psychological distress and poor interpersonal relationships (Nolen-Hoeksema, 2014) may be more vulnerable or susceptible to developing PTSD. The effects of PTSD may play out in an intergenerational cycle, where, usually, trauma is either passed down indirectly or directly. Many beliefs are socially constructed and are subjective, these beliefs can either serve as a protective factor or as a risk factor for PTSD development.

Forces Shaping the Development of Post-Traumatic Stress Disorder

During World War II, PTSD was first called war neurosis (Millon, 2004) and was treated for the most part with drug therapy, which was mainly unsuccessful “in helping these anxiety-ridden patients overcome their painful memories” (p. 360). From a historical perspective, traumatized people seeking treatment “were likely to be viewed with suspicion and even stigmatized for both their trauma history and their symptoms” (Courtois, 2014, p. 115). Instead of treatment focusing on trauma, or even consider it, therapists concentrated on symptoms, problematic behavior—to include addictions, genetics, and possibly personality structure (Courtois, 2014).

Risk factors for PTSD include: living through dangerous events and traumas; having a history of mental illness; getting hurt, seeing people hurt or killed; feeling horror, helplessness or extreme fear; having little or no social support after the event; and, dealing with extra stress after the event, such as losing a loved one, pain and injury, or loss of a job or home (Eagle & Kaminer, 2011). Resilience factors that may reduce the risk of PTSD include: seeking out support from other people, such as friends and family; finding a support group after a traumatic event; feeling good about one’s own actions in the face of danger; having a coping strategy, or a way of getting through the bad event and learning from it; and, being able to act and respond effectively despite feeling fear (Eagle & Kaminer, 2011).

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Courtois, C. A. (2014). It’s not you, it’s what happened to you: Complex trauma and treatment. Washington, DC: Telemachus Press, LLC.

Eagle, G. T., & Kaminer, D. (2011). Traumatic stress: Established knowledge, current debates and new horizons. South African Journal of Psychology, 45(1), 22-35. DOI: 10.1177/0081246314547124.

Lanius, R. A., Bluhm, R. L., & Frewen, P. A. (2011). How understanding the neurobiology of complex post-traumatic stress disorder can inform clinical practice: A social cognitive and affective neuroscience approach. Acta Psychiatrica Scandinavica, 124(5), 331-348. doi:10.1111/j.1600-0447.2011.01755.x

Meltzer, E. C., Averbuch, T., Samet, J. H., Saitz, R., Jabbar, K., Lloyd-Travaglini, C., & Liebschutz, J. M. (2011). Discrepancy in diagnosis and treatment of PTSD treatment for the wrong reason. Journal of Behavioral Health Services & Research, 39(2), 190-201.

Millon, T. (2004). Masters of the mind: Exploring the story of mental illness from ancient times to the new millennium. Hoboken, NJ: John Wiley & Sons, Inc.

Nolen-Hoeksema, S. (2014). Abnormal psychology (6th ed.). New York, NY: McGraw-Hill.

Resick, P. A., Bovin, M. J., Calloway, A. L., Dick, A. M., King, M. W., Mitchell, K. S., & ... Wolf, E. J. (2012). A critical evaluation of the complex PTSD literature: Implications for DSM-5. Journal of Traumatic Stress, 25(3), 241-251. doi:10.1002/jts.21699

Wisco, B. E., Marx, B. P., & Keane, T. M. (2012). Screening, Diagnosis, and Treatment of Post-Traumatic Stress Disorder. Military Medicine, 7-13.

Personality Assessment Techniques

Personality Assessment Techniques

By Robbyn Raquel Wallace / RRW


Before personality is assessed, it should be understood. Personality could be viewed as patterns of implicit cognitions and explicit behaviors that are unique to each individual at any given time, yet can be manipulated and/or changed by internal processes and/or external variables—i.e. realization or having a baby. Personality is impacted by the dynamics of—and between such factors as—life-experiences, biological make-up and cultural identity; thus, the formation of coping strategies or lack there of. From many perspectives, personality is viewed as being manipulated by concepts such as self-esteem, self-concept, or self-image. From a Rogarian perspective, individuals are governed by an organismic valuing process throughout the lifespan defining the evaluation process of the individual by their subjective perception. Therefore, essentially if an individual has a low self-esteem it may cause that individual's perception of any given experience to have a more negative tone, which—when chronic—can lead to such problems as anti-social behavior or oppositional defiance disorder among others. On the other hand, the higher one's level of positive self-regard, it is more likely that individual received more positive regard from their parents or caregivers. Conceptually, these concepts can be intense manipulating forces throughout a lifespan, which would cause fluctuations with the individual's personality. The notion of coping is, generally speaking, the personality handling stress. In other words, coping is a strain on personality subsequently increasing potential of negative expression or dysfunction. An important aspect of personality dysfunction is the impairment of perception and subjective reasoning. (Panayiotou, Kokkinos, & Kapsou, 2014)

Techniques used to assess personality utilize either objective—structured instruments or assessments such as Personality Assessment Inventory (PAI)—or projective—such as when clients are asked “to describe, tell a story, or respond in some way to relatively unstructured stimuli” (Whiston, 2013, p. 207). Projective techniques are considered more ambiguous, whereas objective techniques are usually more obvious. Projective techniques are thought to provide an avenue to detect malingering or faking, to confirm or not a suspicion or doubt  of whether a client is being truthful. It is thought this allows client’s to project their personalities as they respond (Whiston, 2013). However, some instruments, such as the PAI, are gaining notoriety in specific scales ability to detect malingering or faking (Rios & Morey, 2013) making it clear that it is more about clinician preference and substitution—for various reasons the clinician uses formal assessment to either confirm or disapprove diagnosis and to inform treatment rather than rely solely on analysis of available client data and observation impressions. Formal assessments quickly elicit specific client information aimed at achieving quicker diagnosis and access to appropriate treatment plan. This rings especially true in the age of managed care, when everything has to be approved and to be approved the assessment must be essential to care. The most enduring and important way to understand a client’s personality is observation, as stated above. Yet, there are many clients who could benefit from formal assessment, which can inform clinical decisions—especially with children. Assessments can provide a shortcut to identification of client issues or problems (Whiston, 2013). Assessment also has value in many other fields such as academic, career or employment based, etc., and when reliable and valid can provide individual data that is valuable in making informed decisions in the respective fields—specifically value to clinical judgment. As new client information emerges through interaction and observation, but sometimes formal assessment is considered—such as needing to assess a client for post-traumatic stress disorder so that specific treatment interventions can be discussed and considered. It can provide an understanding of how the client differs across dimensions—such as how clients react, whether consciously or subconsciously, in different situations or does client have a set pattern of coping strategies—when responding to psychological distress. (Panayiotou, Kokkinos, & Kapsou, 2014)

In a rural area, community mental health clinicians generally use observation but only have access to resources according to budget and managed care approval. Projective techniques along with good observation and analytical skills, when used properly, can provide a wealth of information if the clinician has sufficient knowledge and specific direction. Also, simple verbal checklist may be useful as well. Information-gathering is an integral part of good treatment planning. Clinicians should take great care in not assuming based off limited information though, as people are multi-dimensional and complicated beings and some may be overly-sensitive with destructive insecurities in their subjective perception leading to anticipation of not being heard or understood—potentially triggered easily. Our calm presence can sometimes be the very thing that catapults positive growth in a client.


References:

Panayiotou, G., Kokkinos, C. M., & Kapsou, M. (2014). Indirect and direct associations between personality and psychological distress mediated by dispositional coping. Journal of Psychology, 148(5), 549-567. doi:10.1080/00223980.2013.817375

Rios, J., & Morey, L. C. (2013). Detecting feigned ADHD in later adolescence: An examination of three PAI–A negative distortion indicators. Journal of Personality Assessment, 95(6), 594-599. doi:10.1080/00223891.2013.821071

Whiston, S.C. (2013). Principals & applications of assessment in counseling. Belmont, CA: Cengage Learning.

The ABCDEF Model - Addressing Dysfunctional Beliefs

The ABCDEF Model - Addressing Dysfunctional Beliefs

By Robbyn Wallace (2006, edited 2023)

The ABCDEF Model, developed by Albert Ellis, is a six-step plan structured to identify, assess, dispute and modify beliefs. 

Identification and description of the activating event is the first step, A, in the model. 

This is the experience that first initiates negative thoughts, emotions, and behaviors. An example experience is someone stating “my professor took off a point on my paper.” 

The second step, B, is someone’s perception or belief, be it negative, positive, or neutral, to the experience or activating event. 

A further example, including the second step, is “my professor should acknowledge my talent and is a mean person for not giving me more credit. It’s a shame I worked so hard on it, just for him to grade me so harshly.” 

Even though a person may not have control over an event or experience, they do have a choice in how they perceive the event or experience, be it rational or irrational.

The next step is C, which stands for consequences of the belief. The belief can determine the consequence. 

Irrational beliefs can lead to self-destructive or inappropriate emotions such as rage, anxiety, or depression. They can also lead to self-destructive or inappropriate behaviors such as excessive use of alcohol or drugs, blaming of self and others, or withdrawal. 

On the other hand, rational beliefs can lead to more appropriate emotions, such as disappointment or annoyance, and appropriate behaviors, such as attempting to change the situation or distracting their self in productive ways.

D, dispute, is the next step in the model, which can also be referred to as debate. To determine whether the belief is rational or irrational it is necessary to explore both the belief and the consequence. 

There are four questions that can be used to determine if the belief is irrational. 

By using logic: “Where is the logic that this should not have happened to me?” 

Next is empirical evidence: “Where is the evidence that this should not have happened to me?” 

The third is pragmatic or functional: “How will holding this belief help me achieve my goals?” 

Finally, there is constructing an alternative rational belief: “What is an alternative belief that would better help me achieve my goals?” 

The belief in the example discussed earlier is disputed in this step by the above questions.

Describing the desired outcome of the debate is the fifth step, E, which stands for effective. 

By disputing the beliefs in the example a more rational belief was formed such as: “Although I am disappointed that I received a “B” on my paper, it won’t kill me. I will try harder on my next paper and hopefully get an “A.” 

The final step, F, represents the new feelings and behaviors resulting from the effective rational beliefs. 

Expanding on the previous examples the following emotions and behaviors were reported: “I am still feeling disappointed with my grade, but it no longer makes me angry and resentful. I am confident that my next paper will receive an “A.” I will meet with my professor and verify the standards and format for an “A” paper.” 

This process is much more complicated than it may appear. It is a complex process and a challenge to change an irrational belief to a rational one. It is requires effort and practice.

Seek & Expand with RRW

An Exercise in Empathy by ~Sage Croft~

Introducing my peer in graduate school, Sage Croft. Her story is inspiring as well as courageous!! Thank you, Sage, for allowing me to share this wonderful story on my blog. ~Robbyn Wallace~

Imagine yourself going to kindergarten. You've been looking forward to going to school like a big girl, filled with excitement and dread in equal measure, and by the time that special day arrives you've built it up into something so huge you're hardly able to contain all the emotions inside. You get to the school and all the kids look so much bigger than you had expected. You feel pretty small, but you're determined to go forward. Without realizing it, your fingers clench a little tighter to your mother's hand. Belying your inner turmoil, you hold your head up so as not to miss a thing, and you walk into your very first classroom.
Everything is coming at you at once, leaving you a bit dizzy from the overload. Then the ringing in your ears is replaced with your teacher's first sentence welcoming you to her class. Only, something's not quite right; the words "little boy" are echoing in your ears. Surely she wasn't talking about you, right? After all, you are a little girl. There have been some others that have called you a boy before, but you really expected your teacher to get it right. How could this be happening?
You are directed to a group of a few other children playing. These children are playing with blocks and trucks, and the teacher is gently steering you toward them. On your way there, you see another small group of kids playing with dolls and kitchenware. You change the course of your steps to go in that direction to play with the little girls, where you belong. But no, the teacher says you are to play with the boys.
This goes on all day and again the next. In fact, it goes on every day for as long as you can possibly stand it. The heartbreak is too great, and the pressure has built to the point where you really believe your very being is sure to break in two. You aren't in any way able to express these feelings or make things right because, whenever you try, you get into trouble. Your teacher is frustrated with you. Your mom is always mad at you. Your dad doesn't know what to do with you. Nobody wants to be your friend or play with you. You are all alone with all of these bad feelings and WRONG is just growing bigger every day.
The doctor has given you medicine that is supposed to help you calm down. Other medicine is supposed to help you sleep. Another doctor gives you more medicine to stop the twitching. In fact, there are so many medicines that you don’t even know what they are all for anymore. All of the medicine doesn’t stop the WRONG from growing.
Now imagine, at this point, someone finally sees the real you. What if this someone, your mother perhaps, could see that you really are a little girl? What if she helped you tell your teacher, your dad, and the other kids in your class, that you are really supposed to go play with the dolls and kitchenware? Instead of taking you to the barbershop at the end of this month, she takes you to buy a pretty, pink brush. When she finds that horrible G.I. Joe t-shirt you hid under your bed again, this time your mother throws it away. Finally, when you pull her toward the pretty clothes in the store, she actually follows you!
The noise is dying down in your head. You don’t have to let a tiny bit of the bad out by throwing yourself on the floor and crying yourself to exhaustion. Your teacher smiles at you. Other kids let you play with them at recess. Daddy looks at you with wonder when you start giggling during dinner.
Soon, like the distress you had been feeling for so long, the medications begin to fall away. Each of the 14 drugs you had been forced to take in an effort to make you “normal” simply disappears. You were a walking pharmacy. But nothing was wrong with you. Society was forcing you into a mold that simply didn’t fit. They saw your penis and assumed you were a boy. It was more than you could handle and, over time, you started to come undone. Once everyone learned how to really listen to you and understand what was going on, they stopped forcing a role on you that wasn’t yours to play. With the freedom of being allowed to live authentically, the WRONG went away.
Many people have commented on how you’re a different child now. But really, you were always there. Everyone was pushing you down into this really small part of who you were. You were being buried under all the stuff they were trying to turn you into. After discontinuing your posturing and removing your disguise, you are shining, resulting in a visible change. You really do look like a different child in every way, but you always knew who you were.
Thank you for reading this far. Being exposed to stories such as this one, or through films such as Boys Don’t Cry, “can help build empathy for and understanding of the issues and prejudices faced by transgender individuals” (Gladding & Newsome, 2010, p. 87).
The particular client population that I envision advocating for is transgender children. This demographic needs advocacy for the freedom to live authentically, to bring their gender expression into congruence with their gender identity, and to no longer be pathologized, discriminated against, and dehumanized for being trans.
Promoted by Dr. Kenneth Zucker, a punitive approach was adopted in the 1970’s for treating transgender children. Zucker’s reparative therapy techniques prescribed corporal punishment for gender nonconforming behavior in children, most especially in natal males who displayed female tendencies (WPATH, 2011). The 7th edition of the Standards of Care put forth through the World Professional Association of Transgender Health (2011) no longer sanctions Zucker’s technique. There is not an established protocol for treating transgender children, but WPATH advises that clinicians adopt an individualized approach of support when treating this population group.
For those “born in the wrong bodies,” the relationship between gender identity and gender expression often results in efforts at bringing the two into congruence. Released just two years ago was the first of its kind, in-depth research on the findings of transgender specific outcomes in American society; however, even this comprehensive report failed to include research on pre-adolescent members of this population. Findings of the study reflect adolescent and adult transgender people suffer long-term consequences that are a direct result of discrimination against their transgender status in the community (Grant, et al., 2011). While scientists are starting to discover the outcomes of successful transitions in adults, as well as the problems inherent in not transitioning, there has been exceedingly little research done on any of the factors relating to transgender children.
Of the limited information that has been collected on transgender youth, being denied social acceptance for their gender identity and expression was identified as the primary contributing factor for suicidal behavior. Some of the variables that influenced the degree to which acceptance was achieved center around who the transgender person was with. Acceptance among family, friends, at school or the workplace, in a place of worship, at the doctor’s office, with a landlord, contact with police, or interacting with strangers are likely to elicit profoundly differing degrees of understanding and acceptance for the transgender person (Grant, et al., 2011).
These findings illustrate the tremendous pressure transgender children are faced with, and the potential damage such expectations for conformity can have on them as individuals and to society as a whole. Social perceptions of transgender children place a stigma on the parents during the child’s early years, and the shame shifts to the individual as he or she grows older. With the advances in the professional community that have begun promoting compassion, there is hope for increased tolerance in the general population resulting from greater understanding through continued education.
What draws me to this client population and issue? I am the lucky mother of an incredible transgender child who has taught me the true meaning of courage as she simply goes about living.
-Sage Croft 
References:
Gladding, S. T., & Newsome, D. W. (2010). Clinical mental health counseling in community and agency settings (3rd ed.). Upper Saddle River, NJ: Merrill.
Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at every turn: A report of the National Transgender Discrimination Survey, executive summary. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force. Retrieved from http://endtransdiscrimination.org/PDFs/NTDS_Report.pdf
WPATH (2011). Standards of care, 7th edition. World Professional Association of Transgender Health. Retrieved from http://www.wpath.org/documents/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf