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Personality Diagnosis with the Shedler-Westen Assessment Procedure (SWAP)

Bridging the Gulf Between Science and Practice

Jonathan shedler

During a routine medical exam, a friend had an abnormal finding on a lab test. His physician ordered more tests, then referred him to an oncologist. The oncologist ordered more tests, then referred him to a team of oncology specialists, researchers at the cutting edge of their discipline. My friend underwent a liver biopsy. The oncologists diagnosed advanced liver cancer and told him he had only months to live.

In the ensuing panic there were few voices of reason. One happened to be that of a psychiatrist, my friend's senior colleague. She asked a simple question: Had he been feeling sick? He had not. The psychiatrist raised an eyebrow. Her wordless gesture spoke volumes: Something did not add up. The pieces did not fit. If my friend had advanced liver cancer, he would likely be deathly ill.

Indeed, he did not have cancer. After additional biopsies (and ineffable emotional turmoil), the oncologists eventually concluded that his liver had an area of dense blood vessel growth (hemangioma) that had probably been present from birth and was of no medical consequence. One might reasonably ask how these research-oriented oncologists had gotten it so wrong and why an elderly psychiatrist who had not practiced medicine in decades had shown greater diagnostic acumen. No doubt many factors were at work, but I believe one factor is that the oncologists focused on laboratory findings to the exclusion of other meaningful data, including the data afforded by their own eyes and ears. Additionally, they failed to consider how the data fit together. Had the laboratory findings been contextualized by what else the doctors knew or could have know about their patient, they may have regarded them differently—as pieces of a diagnostic puzzle, not the diagnostic picture in its entirety. To the extent that they relied on laboratory technology to the exclusion of clinical observation, judgment, and inference, the oncologists functioned more as technicians than as clinicians.

In recent decades, the mental health professions have also emphasized data from the research laboratory over data from the clinical consulting room. Personality diagnosis once depended on expert clinical judgment and inference about subtle, textured, and nuanced personality processes. Clinicians considered a range of data, relying not just on what patients said but also on how they said it, drawing complexly determined inferences from patients' accounts of their lives and important relationships, from their manner of interacting with the clinician, and from their own emotional reactions to the patient. For example, expert clinicians tend not to assess lack of empathy, a diagnostic criterion for narcissistic personality disorder, by administering self-report questionnaires or asking direct questions. Often, an initial sign of lack of empathy on the part of the patient is a subtle sense on the part of the clinician of being interchangeable or replaceable, of being treated as a sounding board rather than as a fellow human being. The clinician might go on to consider whether she consistently feels this way with this particular patient and whether such feelings are characteristic for her in her role as therapist. She might then become aware that the patient's descriptions of important others come across as somewhat two-dimensional, or that he tends to describe others more in terms of the functions they serve or the needs they meet than in terms of who they are as people. The clinician might further consider whether and how these issues dovetail with the facts the patient has provided about his life, with the problems that brought him to treatment, with information gleaned from family members or other collateral contacts, and so on. When clinicians function as clinicians and not as technicians, it is this kind of thinking, reasoning, and inference that they engage in.

It is just such clinical judgment and inference that psychiatry and psychology have turned away from. As successive editions of the Diagnostic and Statistical Manual (DSM) have minimized the role of clinical judgment and inference, personality diagnosis has evolved into a largely technical task of tabulating behavioral signs and symptoms with relatively little consideration for how they fit together, the psychological functions they serve, their meanings, the developmental trajectory that gave rise to them, or the present-day factors that maintain them. Indeed, the diagnostic "gold standard" in personality disorder research is the structured research interview. Such assessment methods are personality diagnosis with swap

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