“I try to frame [a psychological assessment] as an opportunity to grow, as opposed to a process of labeling or judging. We aren’t saying ‘you are bad, because you have this.’ It’s more like: ‘you are human.’”
“[Your] Problems Could Be Linked to a Source of Strength”
This is the seventh in a series of posts introducing the people who make up Driftwood Recovery’s community of caregivers.
Through these conversations, you’ll get a chance to meet the people on Driftwood’s team—from its executives to its care coordinators. You’ll learn about the programs they facilitate, and about how their work serves Driftwood’s overall treatment philosophy. You’ll learn about the various paths that brought them here. And you might pick up a book or Austin restaurant recommendation.
In this post, Kuraĝo editor Matt Williamson talks with Driftwood’s Director of Psychology, Vanessa Kennedy, PhD.
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Matt Williamson: During the admissions process, you’re the person who administers psychological assessments, right?
Vanessa Kennedy: We’ve actually just had a licensed psychological associate come onboard named Michelle. She’ll be helping me out part-time and adding more expertise to our staff: assessing cognitive issues—neuropsychological testing, in particular. But yes, I do the psychological assessments.
MW: “Neuropsychological” meaning that she’ll focus on brain injuries and things like that?
VK: Brain injuries, early signs of dementia, and learning issues like ADHD. Sometimes people struggle in one area of functioning—like their visual skills. We look at a new resident’s different areas of intelligence and try to discover what their strengths and weaknesses are. That can be helpful in designing interventions, strategies, or therapies that are more helpful for them.
MW: But not everyone gets a psychological evaluation when they come to Driftwood? How do you decide who gets a psychological assessment?
VK: Usually, the reason we might recommend an evaluation is if we don’t quite know what a person’s diagnosis is, or we don’t have full clarity about the origins of somebody’s difficulties.
For example, if someone comes in and has had recently had a manic or psychotic episode—if they’ve experienced dramatic changes in mood or energy, or they weren’t sleeping, or have been acting impulsively—we’ll try to find out whether that was induced by drugs or alcohol, or was just natural to their brain chemistry. While that person detoxes off of whatever substances they were on, we get a clearer picture of how they’re functioning, and can start to tell whether the person has a mood disorder or a psychotic disorder that’s developing, or whether those episodes were strictly related to their drug and alcohol use.
MW: One unusual thing about Driftwood, I gather, is that it specializes not only in addiction—in getting people sober—but also in treating underlying disorders and problems.
VK: Yeah, absolutely. We are what would be considered a “dual diagnosis” program, but I think “dual” is a bit of a misnomer. It’s rare that someone comes in with only two issues. The traditional meaning of “dual diagnosis” would be a substance-use disorder plus a mental-health issue. So there are two categories, sure. But oftentimes, the mental health issues are quite complex. They might involve various things like anxiety and depression, or, for instance, an eating disorder.
MW: And people use drugs and alcohol to mask—or to survive—those other problems.
VK: A lot of people are self-medicating, yes.
MW: I have a friend in recovery who has a pretty severe anxiety disorder. It’s prevented her, at times, from leaving the house. I’m just thinking about how unhelpful it would have been for a program to help her stop drinking and then say: “Okay, so just keep doing this. Stay sober, and keep going to meetings.” That would have left her where she’d started years earlier, with this anxiety that was so intense that it was often incapacitating.
VK: Exactly, exactly. I often meet people here who have been trying for a long time to manage underlying mental health issues. Those issues could have started as far back as childhood or adolescence. They’ve been managing those issues for years without really knowing that that’s what they were doing.
MW: When you’re conducting an initial assessment, what are some of the specific tests that you use? How do they work?
VK: The tests I like to give, involve objective assessments and projective assessments. Objective assessments use normative samples of individuals to come up with specific cutoff scores for certain disorders. One objective assessment I use is the Minnesota Multiphasic Personality Inventory, or MMPI. Since the 1960s, it’s been given to countless people. The way people answer the questions reflects things about their behavior or the psychological symptoms they’re experiencing. That particular test is easy to explain because it gives me a line graph that shows a personality profile. It may show an elevation on a scale that measures depression and one that that measures anxiety, and I can show the person: okay, this is the severity level of this symptom for you.
MW: What kinds of questions are included on the MMPI?
VK: They’re all true/false questions. People are asked to agree or disagree with statements like: “most mornings, I wake up feeling fresh and rested.” “I cry easily.” “People have told me that at times, I’ve gotten too excited and too interested in too many things.” So they’re all questions that fit specific symptom categories. The first two I just mentioned, for instance, are for depression. The third was for more manic bipolar presentation. They also ask about patterns in your life. So they are geared toward looking at long term chronic issues that that person is dealing with.
MW: What are some of the other diagnoses that can come out of the MMPI?
VK: They include generalized anxiety disorder, major depressive disorder, psychotic disorder. People may describe paranoid symptoms—seeing visions, hearing hallucinations. The MMPI can also help me diagnose a personality disorder, which is kind of a chronic way of thinking, of processing your feelings and operating in relationships, that tends to create problems in your life. Someone with narcissistic personality disorder, for example, values their own thoughts and opinions much more highly than those of others, and is resistant to feedback or criticism. And that can create problems in their relationships and a lot of tension.
Borderline personality disorder is another one. The name captures the idea that the person is on the border between neurosis and psychosis. Sometimes they are not quite grounded in reality. They may dissociate—mentally escaping to remove themselves from things that are uncomfortable or painful. They may become slightly paranoid in their relationships. They may struggle to get a hold on these really intense fluctuations in their emotions. They may have really strong anxiety and fear of people leaving them and feeling abandoned. And then they might act on those feelings with behaviors like cutting or burning themselves, or doing things that are impulsive and self-destructive: using drugs, engaging in an eating disorder, spending a whole lot of money without regard for the consequences, things like that. But the core issue is that they’re trying to get a handle on the ups and downs in their mood.
MW: This is a “freshman psych” question, probably, but: all these things that you’re describing—I think anyone will recognize themselves in those descriptions, to some extent. How do you determine when someone requires treatment?
VK: The cool thing about an objective assessment like the MMPI is that it has 567 questions. Taking the test, you get a lot of opportunity to say true or false to these items. An average person may endorse two or three items of narcissism or two or three items of borderline personality, but they’re not going to endorse ten or fifteen. In the Diagnostic and Statistical Manual of Mental Disorders, the differentiating factor for making a diagnosis is not just whether you meet the criteria for the disorder—but also whether it creates some kind of problem in your functioning, in your life? Are you able to meet obligations with work? Are you causing a lot of problems in your relationships? Are you able to meet your goals at school? Things like that.
MW: I feel like we all know people who are probably, like, a 10 out of 10, on some of those—but they’re high-functioning, and perceive themselves as happy, healthy, and successful.
VK: Exactly. Those people are not going to seek treatment.
MW: You also used the term “projective tests.”
VK: In a projective assessment, the person is projecting their own worldview, their own emotions, onto neutral pictures or inkblots. One of the projective tests I give is the TAT, the thematic apperception test. I show them images of ambiguous situations and the person tells me a story about what the people in the pictures are thinking and feeling. People tend to invoke their own ways of coping in these stories. I ask them at the end of the test: “How do you relate to these characters? Are there any that you that stand out to you?” And they’ll tell me: “This one reminds me of my childhood, because my parents were always forcing me to practice the violin when I didn’t want to.” And that might shed light on an ongoing dynamic that’s playing out in adult life.
MW: I’m looking at the picture of the child staring hard at the violin. You described the image as “neutral.” It really looks to me like the kid is bored, or unhappily putting off violin practice. I’m trying to imagine more positive interpretations. Maybe the boy is concentrating—trying to mentally walk through a musical performance. Do people ever look at this picture and say things like “the boy is gleeful?”
VK: Well, sometimes a picture is designed to evoke some kind of emotion. I mean, this one is ambiguous, but it’s certainly not neutral, right. Sometimes, when people see something negative in the picture—“he’s bored, he’s frustrated, he’s struggling”—they next offer a positive coping response to counteract that. So they might say, “he’s persevering, he’s going to get really good, and blow everyone away at the concert.” A strong desire to put a positive spin on every conflict might signal that a person is avoiding uncomfortable emotions. And then that avoidance becomes one of the issues that they can continue to look at in therapy.
Sometimes people also focus on features of the drawing, rather than on telling me a story about the people in the drawing. “I think the artist was trying to capture something here.” Or: “This shading suggests that the artist doesn’t have much skill.”
MW: Oh, interesting. What does that sort of response reveal?
VK: It might suggest that they tend to avoid talking about emotions or exploring their internal thought process. Or it could just be that they don’t have any exposure to psychological thinking. Sometimes it can be a nice springboard to talking about thoughts and feelings. “Oh, yeah, I guess I do avoid that.” “That’s the way I was raised. We never talked about anything in my family.”
MW: Do people ever mention the kid’s Bieber-esque haircut?
VK: I don’t think I’ve gotten that one. “This is a picture of Justin Bieber when he was a young man, busking on the streets of Toronto and posting videos on YouTube.”
MW: What are some other projective tests that you use?
VK: Another cool one that you’ve heard of is the Rorschach Inkblot Test. It’s kind of controversial. Some researchers have questioned its value. But there are things in the test that reveal useful information about how people function. I’ll show the person I’m interviewing these images—some are kind of abstract, some are black and white, some have color. I look at how a person reacts to color, how the person incorporates features of inkblots. Do they look at the whole inkblot and make it all one thing? Or do they look at little pieces? Do they identify the elements that people usually see? There are some popular answers for each card. I’m interested in seeing how far someone departs from the typical interpretation.
MW: And so, if someone is fixating on some unusual aspect of the color, for instance, what does that indicate?
VK: Let’s say a person is working with a card that’s mostly black with some red splotches. If they see those red splotches as formless, if they get really involved in describing the color—“wow, this red is really vivid; I can’t even see the black anymore.”—that might suggest that the person is getting flooded by intense emotions, and struggling to feel grounded. If they said something more like, “Oh, I see some splotches of red here, they kind of look like little butterflies”—if they give it more form or shape, that might mean they have coping resources when they’re facing intense emotions. If they don’t even mention color through the whole test, that might mean that they avoid emotions, that feelings are a kind of blind spot for them.
MW: I read and article recently saying that if you give people a series of images and ask them to summarize the story that the images tell, people typically assume that the pictures do tell a coherent narrative. They don’t respond by saying, “this is absurd, this is nonsense.” They’re more like “yeah, this makes sense. This happened, and this happened. And this happened, I get the story. The events are all causally linked.”
VK: Sometimes on the TAT, people will pull a character from one card into another picture. “This is the same person from that first card. They’ll start to draw some connections there.” I definitely notice that, because, of course, the cards aren’t related at all.
MW: On these projective assessments—what are some answers that a person could give that would indicate a robust state of mental health?
VK: Throughout the testing, if they’re able to show a nice balance between appreciating negative emotions, as well as positive emotions—if, when there are any conflicts, they can present solutions or coping responses to the conflicts—those are definitely signs of psychological health. If they’re able to use the color on something like the Rorschach, and you know, pay attention to it, bring it into their answers in a way that has some form to it, that can be a good sign.
MW: And while you’re administering these tests, you’re customizing a program of treatment for them?
VK: Definitely. The testing clarifies the work clients have ahead of them. It’s a first step toward gaining useful insights into psychological problems. In 30 days of individual and group therapy, people can really dive deep into these things, and make a lot of progress, if they’re ready.
MW: I can imagine feeling shame or anxiety on hearing for the first time that I had a personality disorder. How do you walk them through that process?
VK: I try to focus not only on negatives. If somebody feels vulnerable—that they’re under a microscope—it can be challenging for them to be receptive to intervention. So I really try to look in the testing for any signs of positive coping resilience. A person with narcissistic personality disorder might also be very social, gregarious, influential with other people. The person’s problems could be linked to a source of strength. Helping people see the potential to get back to those strengths and reconnect with their values is something that I try to instill when I’m giving testing feedback. Like: “Hey, this does not define you as a person. It’s giving you one piece of a puzzle. But that doesn’t mean that there aren’t a hundred other things that the testing is showing that are positives, resources that you have to work with.”
I try to separate out the moral judgment and stay very objective. Sometimes I’ll say to the person: “I have traits of three or four of these disorders—I’ve got obsessive compulsive personality traits, some borderline personality traits. These are things that we all have a mixture of.”
The assessment also presents an opportunity to get it all out on paper and come up with a plan of attack. How often in your life do you take a timeout to do that? To say: “these are some issues I’m dealing with. Here are some ways that I can look at those and improve my life. I try to frame it as an opportunity to grow, as opposed to a process of labeling or judging. We aren’t saying “you are bad, because you have this.” It’s more like: “you are human.”
There are people who find some relief in the initial assessment, because they’ve been suffering for a long time. Not really being able to put words to what they’re going through. And so sometimes getting an accurate diagnosis can help them feel more normal, and more connected to other people. And there are resources, and I can start directing them to things that will help them find more hope.
By tuning into your own thoughts and feelings, having compassion for yourself and self-awareness, you get more adept at catching those behaviors and asking: “is this serving me or not?”