Conclusion integrating science and practice

A clinically useful diagnostic system should encompass the spectrum of personality pathology seen in clinical practice and have meaningful implications for treatment. An empirically sound diagnostic system should facilitate reliable and valid diagnoses: Independent clinicians should be able to arrive at the same diagnosis, the diagnoses should be relatively distinct from one another, and each diagnosis should be associated with unique and theoretically meaningful correlates, antecedents, and sequelae (Livesley & Jackson, 1992; Millon, 1991; Robins & Guze, 1970).

One obstacle to achieving this ideal has been an unfortunate schism in the mental health professions between science and practice. Too often, research has been conducted in isolation from the crucial data of clinical observation. The results often strike clinicians as naive and of dubious clinical relevance. Ultimately, the most empirically elegant diagnostic system will have little impact if clinicians do not find it helpful for understanding their patients (Shedler & Westen, 2005). On the other hand, clinical theory has too often developed with little regard for questions of falsifiability or empirical credibility. The results have often struck researchers as scientifically naive.

The SWAP represents an effort to bridge the schism between science and practice by quantifying clinical wisdom and expertise and making clinical constructs accessible to empirical study. It relies on clinicians to do what they do best, namely, making observations and inferences about individual patients they know and treat. It relies on quantitative methods to do what they do best, namely, aggregating observations to discern relationships and commonalities, and combining data to yield optimal predictions (cf. Sawyer, 1966). The findings raise possibilities for developing a classification of personality disorders that is both empirically sound and clinically (and psychodynamically) meaningful; for integrating descriptive psychiatric diagnosis with clinical case formulation; for assessing personality change (not just symptom remission) in psychotherapy; and for assessing individual patients in ways that integrate the best features of clinical judgment and psychometric rigor. The SWAP attempts to provide a "language" for case description that is at once clinically rich enough to describe the complexities of the patients we treat, and empirically rigorous enough to meet the requirements of science. There remains a sizeable schism between clinical practitioners and empirical researchers. Perhaps this new language will be a step toward one that all parties can speak.

Note: This chapter is adapted from a chapter of the same title previously published in the Psychodynamic Diagnostic Manual (Shedler & Westen, 2006).

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