Strengths in Psychological Assessment

It has long been noted that psychological tests of personality and functioning tend to over-emphasize the weaknesses of our clients, and underestimate the strengths. Some argue our assessments have thus been unbalanced for the last 50 years as a result. The solution often presented to try to devote a full 50% of our conceptualization to weaknesses, with the other full 50% to strengths. While this might help to offset the "averaged bias" in psychological reports over the last 50 years, it might also not be very helpful. In client who come to see us, often the weaknesses out number the strengths; otherwise, they wouldn't be in our offices. Further, I think that many psychologists like me are wary of "smiley face" reports that seem to focus on strengths but offer vaguely positive statements that aren't very helpful in conceptualizing the case, and may even mislead the therapist into under-estimating the difficulties the person will face in changing and benefiting from services, which ultimately hurts the client.

So, we're stuck. We know we need to focus on strengths far more than we do, but our tests don't support this easily, and some clients don't support it easily. If we overcome that, some colleagues won't support it either. We could change our tests, but some of the measures out there that might seem to be the answers to our problems are short, under-researched, and lack needed norms.

I have struggled with this myself, and have only worked out a short-term solution... but here it is...

Step One - Conceptualize Strengths

There are three ways to deal with the issue of incorporating client strengths into conceptualizations:

• Don't - Just assume your clients are bundles of pathology with few redeeming qualities. This is of course "more of the same" and why we're in a fix now
• Add a Smiley Face - I've seen reports where people add comments about strengths which are useless. Consider "Ms. Smith suffers from periods of severe depression which are associated with very low motivation, withdrawal from supportive others, and feelings of worthlessness. She does, however, retain a good sense of fashion, and seems to be able to choose the right amount of jewelry to wear for the occasion." OK, so it's not been that bad, but you get the picture.
• Put Strengths in Context

Saying someone has depression says more. It says they likely have cognitive symptoms of pessimistic thinking, emotional symptoms of feeling worthless and helpless, and social symptoms including withdrawal and impaired effectiveness in meeting the responsibilities of daily life. Saying someone has a good sense of humor doesn't seem to say much more than they can laugh a good joke.

Step Two - Rely More on the Interview

I think we can compensate for the problems with our tests, both the well-established tests of pathology and the newer tests of isolated strengths, with greater attention in the interview to strengths. Consider asking about previous substance abuse treatment, the following sobriety, and the reasons for relapse. This gets to weaknesses for sure, but what about strengths? So how were you able to maintain sobriety that long? What was most helpful? When you look back on why you relapsed, what do you now wish you had done differently that might have made a difference? When you think about relapse prevention in the future, what do you think will help you the most?

Step Three - Use New Instruments Cautiously

Some of the newer instruments out there can offer some basic and isolated areas of strength, for example, a sense of optimism. However, others, which aren't really normed, could offer some help in designing your interview and asking about the client's outlook and coping, even if they aren't as rigorous as an MMPI2. Further, other tests like the NEO PI R and PAI allow for a better assessment of strengths since they were designed differently. Some tests, like the TAT and ISB, might allow you to focus on strengths if you read the stories and sentences for them. Consider stories in which characters consider problems carefully before acting, show good understanding of others' motivations and needed, and are presented in an organized and clear fashion...

Step Four - Presentation of Results

I've been toying with the idea of scrapping the way I write personality conceptualizations, and re-organizing the results into a coping framework.

With all this in mind... I'll offer the following conceptualization of strengths.

Humor

Already noted above is Freud's view of humor as a kind of ego defense. He also noted it was a triumph of the pleasure principle as well, showing the id was "strong enough to assert itself here in the face of adverse real circumstances."

Some of the research about humor as a trait of strength has been confounded by conceptualizing and measuring humor. Is it the ability to write and say funny things? A quality peers could judge? The ability to appreciate funny cartoons or stories? The stated preference to see things in a humorous light to avoid being distressed by them? A positive and optimistic quality, or a sometimes self-depreciating and biting quality? See what I mean?

Martin and colleagues have devised the Coping Humor Scale. A number of things have emerged:

• low scores have been associated with mood disturbances, as if lacking a sense of humor places one at greater risk for depression after a stressor
• this seems to hold true even after controlling for the number of negative life events the person faces
• people with lower scores seem to have a lower threshold for discomfort when ill, and people with higher scores can show increases in immune system responses when they laugh or smile (although these are short-term)
• people with higher scores were more likely to label upcoming events as "challenges" rather than "stressors" and to more accurately appraise their chances for future success. This may tap into optimism in some ways, or be a facet of depression
• higher scores have been positively correlated with extroversion, freedom from dysfunctional attitudes, and stable and positive self-esteem, and negatively correlated with neuroticism

Of note, however, many of these correlations are weak - in the .30s and .40s. That is to say, they seem to explain about 10-15% of the variance in functioning in these areas, which isn't much. However, when you consider that we will never account for much more than 80% of the variance, and that situational factors beyond their control, as well as a other personality and coping factors could also come into play... five factors each accounting for a unique 10-15% of the overall picture could account for a total of 50-75% of the overall picture, which isn't so bad.

Also of note, some of these studies have not been strongly replicated or have only been partially supported in more limited ways (see Anderson and Arnoult, 1989 and Portersfield, 1987). Further, much of the research has been based on college students.

Others like Bell and colleagues have argued humor per se does not produce positive effects in life. Rather, it attracts others, increases social support, and the benefits of humor are based on increased social support. As a result, measures like the Humor Style Questionnaire include four subscales - affiliative (increasing social contact), aggressive (decreasing social contact), self-enhancing, and self-defeating.

Gratitude

OK, I know this sounds kind of Oprah-ish, but there is some research on this. Gratitude comes from a Latin root meaning grace, gratefulness, and appreciation. Some see it as being maintained from an evolutionary standpoint as it prompts social connections and social cohesiveness, supports fulfilling social obligations, and reinforced "moral" behavior to the benefit of the group. It can be understood as having four components:

• intensity (how strong it is)
• frequency (how often one feels it)
• span (how many situations it covers)
• density (how many people are the object of it)

The possible individual benefit is that people scoring high on measures of gratitude tend to appreciate daily events by interpreting them as positive more often, creating more positive affect and less negative affect. It has been associated with higher optimism, exercise, alertness, energy, and enthusiasm.

Forgiveness

Forgiveness has been difficult to define in the literature. I like Thompson and Thompson's view - they see it as changing negative thoughts, emotions, behaviors, memories... into neutral or positive ones. Confronting a wrong-doer or feeling compassion for them is not required, but a sense of vengefulness runs completely counter to this idea. They thus see it as an intrapersonal process. McCullough and colleagues see it as decreased avoidance of the offender, benevolence for the offender, and decreased desire for vengeance. They thus see it as an interpersonal process. Tangney walks the line, seeing it as the ability to recognize the wrong-doing, but "cancel the debt" and stop investing energy in thoughts of vengeance or retaliation, and moving on to invest that energy in other, more productive pursuits. Some have used the Heartland Forgiveness Scale and found that low scores (less forgiveness) was a better predictor of marital dissolution than hostility.

Two other scales are the Forgiveness of Others and Forgiveness of Self scales. Low Forgiveness of Others scores have been found to be correlated with feelings of alienation, cynicism, and passive-aggressive behavior. Low Forgiveness of Self scores have been found to be correlated with neurotic immaturity, negative self-image, and self-control and motivation deficits. Both correlate with a higher denial of needs for affection, a sense of persecution by others, and being overly sensitive in interpersonal relationships.

This is still pathology focused, but turned the other way, greater forgiveness of others could support greater connection to others, a more optimistic outlook, and more assertive behavior. Greater forgiveness of self could support more mature decision-making, better self-image, and better self-control and motivation after setbacks. Both could support better awareness of emotions, taking personal responsibility, and more stable relationships.

Empathy

Empathy is thought to be maintained from an evolutionary standpoint because it motivates altruism, desires for fairness and justice, and inhibition of aggression. It comes from identifying with another's emotional state (positive or negative) and being aware that the emotions one feels are based on another's emotions. Sympathy stems from this, with the pairing of a desire to end the other's distress. Distress stems from this, with the pairing of a desire to end one's own empathy to end one's own subsequent distress.

It's been a hard concept to test out, because social desirability for the different gender roles has let to it being harder to find in men and easier to find in women. Ideally, it could spell out strengths in that it might allow one:

• to see beyond one's own problems (think of going to a support group and realizing some people have it worse than you)
• to engage in more action-focused coping (consider doing something to alleviate someone else's suffering and both feeling better self-esteem yourself, as well as learning something more about possible resolutions to your problems)
• to engage in less aggression and more forgiveness (see above)

Self-Esteem

Self-esteem can be seen as the emotional response one has when considering one's self-concept, or the total picture of who you are - values, strengths, name, weight, appearance, thoughts... It is another characteristic that may result in a smiley face sticker.

On the one hand, those with higher self-esteem have been shown to feel better about themselves and their efficacy, to handle negative feedback more objectively, and to feel more respect and valuing in their relationships. Those with lower self-esteem are at greater risk for depression, loneliness, and alienation, and likely to be more shy and withdrawn. Put another way, higher self-esteem might lead to more problem-focused coping efforts (since one optimistically sees them as more likely to be successful), greater social support, and a greater potential to recognize and learn from mistakes.

On the other hand, narcissistic personalities have very good self-esteem at times. They tend, however, to overestimate their abilities, underestimate the challenges they face, learn little from mistakes, and alienate others by demanding attention, breaking rules, and blaming others for their own failures. See what I mean? Just saying someone has good or poor self-esteem means little.

Self-esteem is also embedded in a social milieu. How others reflect back to you your worth is part of your building and internalizing a sense of worth. Thus, it might not be very stable of an attribute either, depending on the situation.

Self-esteem can be broken down into several parts:

• performance esteem (think of ability to succeed, general sense of competence, school and job performance, and sense of self as capable and smart)
• social esteem (think of the perception of being liked and admired, and the lack of social anxiety)
• physical esteem (think appearance, weight, attractiveness, body judgments, athletic skill, identification with ethnic group...)

Optimism

Optimism is having more hopeful and positive expectations and goals. Considering goals though requires reflecting on the detail - very specific and explicit to very general and broad - and confidence. Optimists attribute problems to unstable, specific, and external causes, and attribute successes to stable, global, and internal causes (thus getting to the duration, generalization, and self-esteem associated with the issue). This is associated with high motivation, achievement, and physical well-being, as well as low depression and physical symptoms of illness. They are also tend to be confident and persistent; when faced with a problem they can resolve, they act, and when faced with an unresolvable problem, they may switch to a resolvable one and act on it. This is not the same thing as "control," as an optimist can think in terms of the opportunities they actively create, or in terms of the opportunities life presents them which they recognize and act on.

Pessimistic people do the opposite and have the opposite reaction, experiencing more depression and illness. Some research, however, supports that it is the "stable" and "global" expectations for problems that have the most powerful and negative effects. Pessimists tend to be less confident, more likely to give up, and to stay "stuck" with an unsolvable problem, possibly turning to more negative emotion focused coping efforts.

Optimism and pessimism may be two ends of a continuum, but there is plenty of research to support they are related but different constructs which may be based additively on the experiences you have, or may extend beyond the sum of the experiences and be an emergent quality. Relevance may also come into play, with some domains having little impact upon one's sense of optimism or pessimism, and other domains having significant impact. Pessimism may also be related to hopelessness (see the Beck Helplessness Scale), although it is not the same, and Neuroticism, although this is a much larger construct. One good measure for optimism is the Life Orientation Test - Revised.

Presenting A Strength Conceptualization

To better understand functioning, I think we need to better understand coping. Generally, there are four common coping responses in the literature:

• problem-focused (how do I change the situation - efforts to solve the problem, gather info, plan, resolve conflicts...)
• emotion-focused (how do I handle my feelings about the situation - efforts to vent, soothe, control feelings)
• social-focused (how can I gain aid in handling this - efforts to gain others' support for emotion or problem-focused efforts)
• avoidant-focused (how can I avoid facing this - efforts to escape the stressor).

There are four ways to organize coping:

• reactive coping (dealing with past traumas that impinge on the present)
• anticipatory coping (dealing with current stressors due to situational anxiety, with an eye to resolving them now)
• preventative coping (dealing with current stressors due to trait anxiety, with an eye to resolving them for the long-run)
• proactive coping (turning "stressors" into "challenges" and gaining adaptive skills to cope in the future)

Coping hopefully produces Positive Affect and stimulates meaning:

• situational meaning (meaning just for this issue)
  • coping regulates distress (positive emotions can provide a break from stress, or help turn apprehension to eagerness, anxiety to excitement)
  • coping helps manage situations that lead to stress (positive emotions can lead to gaining specific task-oriented skills)
  • coping leads to appraisals about controllability and success (positive emotions can lead to confidence, pride, and relief)
  • coping is influenced by personality dispositions (positive emotions can broaden one's focus of attention, and result in more varied resources
  • coping is influenced by social resources (positive emotions can attract others)
• global meaning (meaning for life, existential)
  • finding meaning, mastery, and self-enhancement in life
  • causal explanations for why things happen, why to us, and how important they are, increasing sense of control, self-worth, and self-esteem
  • benefit reminding, or noticing the good (this can lead to rating stressors as challenges instead of problems)
  • benefit finding, or a style of "looking for the silver lining" (this can lead to optimism)

However, coping is the positive outcome of an effort to manage stressors. Traditionally, people have seen it as successful and conscious, and seen failed and unconscious efforts as defenses. However, this distinction is largely artificial. The DSM IV described defense mechanisms as efforts "to mediate the individual's reaction to emotional conflicts and to internal and external stressors." Thus, some argue that it is not stress that leads to pathology, because it could just as easily not lead to pathology, but rather that maladaptive coping responses to stress lead to pathology. Three key things are seen in such responses:

• functional inflexibility - rigid application of efforts regardless of whether they fit the situation
• vicious circles - problematic responses create problems
• structural instability - decompensation under stress

Take the O/C Personality. They tend to see "the world in terms of rules, regulations, time schedules, and social hierarchies" leaving them ill-prepared to cope with problems that need an immediate response. They may take action, and look problem-focused, but they can not flexibly re-prioritize as they need to. They are inflexible. They go on to interpret things in limited ways according to preset conceptualizations. Thus, they have a hard time expanding and growing to meet new challenges. They create new problems by failing to adapt and to grow. Even mild levels of stress become very overwhelming and they deteriorate.

Consider a Paranoid Personality. By having a hypervigilant and confrontational style, they can not trust others and instead expect others will be hostile and deceptive. Their behavior provokes this in others. Because of their rigid style, they create vicious circles.

Consider an Avoidant Personality. They fear exposure and shame, and so they avoid and actively withdraw from situations in which they might achieve as a general rule and learn good problem-focused strategies. They have a hard time changing this approach. They avoid asking for help and seeking support, and things get worse. Others don't understand why they cope so poorly, and the Avoidant feels confirmed in that other judge, reject, and shame them. Thus, they never learn to overcome anxiety, soothe it, or simply tolerate it. They fail to develop emotional regulation strategies and decompensate when stressed.

Also consider an Axis I disorder like depression. Depressed people engage in more ruminating and brooding, focused on the causes of their depression instead of coping with it, which prolongs and amplifies their depression. They engage in fewer positive and distracting activities, and continue to selectively recall and process information, reinforcing their sense of helplessness and worthlessness. While they may take some actions to feel better (e.g., substance abuse or extravagant spending to gain approval from others), these make matters worse. Their rumination ultimately increases their future risk for depression.

Seeking support must also be part of the picture. Schneider (1950) described a personality disordered patient as those people who "either suffer personally because of their abnormality or make a community suffer because of it." They lack insight into others' motivations, needs, desires, and feelings and miss the subtle cues others give. "The ambivalent resistance of the Passive Aggressive personality, the demanding self-aggrandizement of the Narcissistic pattern, and the manipulative dependence of the Histrionic pattern commonly serve ultimately to sabotage available social support networks."