A Standard vocabulary for Case Description

The Shedler-Westen Assessment Procedure (SWAP) is an assessment instrument designed to provide clinicians of all theoretical orientations with a standard vocabulary with which to express their observations and inferences about personality functioning (Shedler & Westen, 1998, 2004a, 2004b; Westen & Shedler, 1999a, 1999b). The vocabulary consists of 200 statements, each printed on a separate index card. Each statement may describe a given patient very well, somewhat, or not at all. A clinician who knows a patient well can describe the patient by ranking or ordering the statements into eight categories, from those that are most descriptive of the patient (assigned a value of 7) to those that are not descriptive (assigned a value of 0). Thus, the SWAP yields a score from 0 to 7 for each of 200 personality-descriptive variables. (Web-based software will soon allow clinicians to input SWAP scores and receive computer-generated diagnostic reports. The program can be previewed at http://www.SWAPassessment.org).

The standard vocabulary of the SWAP allows clinicians to provide in-depth psychological descriptions of patients in a systematic and quantifiable form. It also ensures that all clinicians attend to the same spectrum of clinical phenomena. SWAP statements are written in a manner close to the data (e.g., "Tends to be passive and unassertive," or "Emotions tend to spiral out of control, leading to extremes of anxiety, sadness, rage, etc."), and statements that require inference about internal processes are written in clear and unambiguous language (e.g., "Tends to blame own failures or shortcomings on other people or circumstances; attributes his/her difficulties to external factors rather than accepting responsibility for own conduct or choices."). Writing items in this jargon-free manner minimizes idiosyncratic and unreliable interpretive leaps. It also makes the item set useful for all clinicians regardless of their theoretical commitments.

The SWAP is based on the Q-Sort method, which requires clinicians to place a predetermined number of statements in each category (i.e., it uses a "fixed distribution"). The SWAP distribution resembles the right half of a normal distribution or "bell-shaped curve." One-hundred items are placed in the "0" or not descriptive category and progressively fewer items are placed in the higher categories. Only eight items are placed in the "7" or most descriptive category. The use of a fixed distribution has important psychometric advantages and eliminates much of the measurement error or "noise" inherent in standard rating procedures2 (see Block, 1978, for the psychometric rationale underlying the Q-sort method).

The SWAP item set was drawn from a wide range of sources including the clinical literature on PDs written over the past 50 years (e.g., Kernberg, 1975, 1984; Kohut, 1971; Linehan, 1993); Axis II diagnostic criteria included in DSM-III through DSM-IV; selected DSM Axis I items that could reflect aspects of personality (e.g., depression and anxiety); research on coping and defense mechanisms (Perry & Cooper, 1987; Shedler, Mayman, & Manis, 1993; Vaillant, 1992; Westen, Muderrisoglu, Fowler, Shedler, & Koren, 1997); research on interpersonal pathology in patients with PDs (Westen, 1991, Westen, Lohr, Silk, Gold, & Kerber, 1990); research on personality traits in nonclinical populations (e.g., Block, 1971; John, 1990; McCrae & Costa, 1990); research on PDs conducted since the development of Axis II (see Livesley, 1995); extensive pilot interviews in which observers watched videotaped interviews of patients with PDs and described them using earlier versions of the item set; and the clinical experience of the authors.

Most importantly, the SWAP-200 (the first major edition of the SWAP) is the product of a seven-year iterative revision process that incorporated the feedback of hundreds of clinician-consultants who used earlier versions of the instrument (Shedler & Westen, 1998) to describe their patients. We asked each clinician-consultant one crucial question: "Were you able to describe the things you consider psychologically important about your patient?" We added, rewrote, and revised items based on this feedback, then asked new clinician-consultants to describe new patients. We repeated this process over many iterations until most clinicians could answer "yes" most of the time. A newer, revised version of the SWAP item set, the SWAP-II incorporates the additional feedback of over 2,000 clinicians of all theoretical orientations. The iterative item revision process was designed to ensure both the comprehensiveness and the clinical relevance of the SWAP item sets.

Because the SWAP is jargon-free and clinically comprehensive, it has the potential to serve as a universal language for describing personality pathology. Our studies demonstrate that experienced clinicians of diverse theoretical orientations understand the items and can apply them reliably to their patients. In one study, a nationwide sample of 797 experienced psychologists and psychiatrists of diverse theoretical orientations, who had an average of 18 years practice experience post training, used the SWAP-200 to describe patients with personality pathology (Westen and Shedler, 1999a). These experienced therapists provided similar SWAP-200 descriptions of PDs regardless of their theoretical commitments, and fully 72.7% agreed with the statement, "I was able to express most of the things I consider important about this patient" (the highest rating category). In a subsequent sample of 1,201 psychologists and psychiatrists who used the SWAP-II, over 80% "agreed" or "strongly agreed" with the statement, "The SWAP-II allowed me to express the things I consider important about my patient's personality" (less than 5% disagreed). The ratings were unrelated to clinicians' theoretical orientation. Virtually identical agreement rates were obtained in a national sample of clinicians who used the adolescent version of the instrument, the SWAP-II-A.

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