CLIENTS WITH MMPI HIGH D-PD: THERAPY IMPLICATIONS

WAYNE ANDERSON AND BARBARA BAUER

University of Missouri-Columbia

The personal characteristics of 80 clients with elevated 2-4 (D-PD) scales on their MMPIs were compared with those of 109 clients without these elevations. Clients with the 2-4 elevated were significantly more depressed, had lower self-esteem, and were more likely to come from disturbed families. They also had poor relationships with the opposite sex, became more dependent on the therapist, and often made little improvement in therapy. In comparison to previous descriptions of hospitalized patients with similar profiles, the counseling center clients continue to function in the community and show less pathological behavior. Implications for therapy are discussed.

The MMPI, a useful tool for helping therapists and counselors understand clients and plan treatment strategies, continues to be used widely in nonpsychiatric settings (e.g., Fee, Elkins, & Boyd, 1982; Moreland & Dahlstrom, 1983). The therapist can use a number of methods to arrive at a meaningful interpretation of an MMPI profile. It generally is recognized that there is an interaction between scales such that an elevation on one scale can change the interpretation of another scale (e.g., Duckworth, 1979; Graham, 1977). As a result, frequent use has been made of the two-point code as an aid in interpretation (e.g., Dahlstrom, Welsh, & Dahlstrom, 1972; Gynther, Altman, & Sletten, 1973; Lewandowski & Graham, 1972). However, this method misses inter- pretative material because other scales that are elevated along with the two-point code also may make a significant contribution to the overall understanding of the client’s problems. An alternative is to use a “cookbook” approach in which a profile to be inter- preted is matched to a standardized profile configuration (e.g., Gilberstad & Duker, 1965; Marks, Seeman, & Haller, 1974). This approach allows a more complete response to all of the elevations on the profile. The weakness of this system is, however, that a set of profiles developed in one type of setting may be useful for only a small proportion of patients or clients in another setting (Gynther et al., 1973). A second weakness lies in the possibility that elevations that in one setting reflect pathology may not do so in another setting (e.g., Kunce & Anderson, 1976; Levinson, 1962).

It is important to recognize that the way in which an elevated scale (e.g., Scale 4, PD) is interpreted is related to the elevation of other scales. A client with an elevated 4 and 9 (PD and MA) presents a different treatment problem from a client with an elevated 2 and 4 scale (D and PD) (e.g., Duckworth, 1979; Graham, 1977). Lykken (1957) in- dicates that underlying characteristics or dynamics of a person with an isolated 4 (PD) or a 4-9 (PD-MA) may be different from a person whose elevated 4 (PD) is accompanied by the anxiety of an elevated 2 (D).

In addition to the use of a codebook and the two-point code, another possible ap- proach to interpretation must be kept in mind. It may be possible that, within a popula- tion, there are subgroups of scales that will provide valuable information with consisten- cy even when they are not the high point codes. In Marks et al. (1974) the commonalities of individuals with profiles with elevated 2-4 (D-PD) in code patterns in which either 7

The authors extend their gratitude to Mark Rogers for his assistance in the statistical analysis of these

Requests for reprints should be sent to Wayne Anderson, Counseling Services, 302 Parker Hall, Univer- data.

sity of Missouri-Columbia, Columbia, Missouri 6521 I . 181

182 Journal of Clinical Psychology, March 1985, Vol. 41, No. 2

(PT) or 8 (Sc) also are elevated are: The individual is insecure and has a high need for affection and attention, which conflicts with a fear of emotional dependency. These in- dividuals are seen as argumentative and irritable. They seem to have conflicts about sex- uality. There are conflicts with the opposite sex indicated by a lack of dating experience and by marital discord if they are married.

The Gilberstad and Duker (1965) sample appears to be more disturbed, but their patients with a 2-4-7 (D-PD-PT) pattern have many of the same characteristics as their patients with a 2-4-8 (D-PD-SC) profile: Alcoholic, anxious, with much tension and feelings of inferiority. They have feelings of guilt and are described as hostile and im- mature. They have poor marriages if married and have unstable job histories. They are described as having unusually close relationships with their mothers. Other studies (e.g., Gilbert & Lombardi, 1967; Gynther, Altman, & Warbin, 1972; Sutker, 1971) emphasize abuse of alcohol and/or drugs, depression, and feelings of inadequacy in persons with elevated 2-4s (D-PD). The overall picture that one gets from these studies is that patients or clients who have elevated 2-4s in their profiles feel miserable, have considerable hostility, low self-esteem, are dependent, and are generally difficult to work with in counseling or therapy.

It is also true that profile interpretations may not be consistent across populations. Although Marks et al.’s (1974) 2-4-7s (D-PD-PT) were much like Gilberstad and Duker’s (1965), some significant differences exist because of the nature of the populations that they studied. Gilberstad and Duker’s VA population frequently were chronic alcoholics and made a poor response to treatment. Marks et al.’s hospitalized population were argumentative; however, their pre- and post-MMPI profiles suggest a considerable lessening of symptoms after treatment.

The research questions for this study were: 1.

their MMPI profiles? 2.

hospitalized populations discussed above? 3.

therapists?

What are the characteristics of nonhospitalized clients who have elevated 2-4s in

Are these charzcteristics similar to those reported on more severely disturbed

What special problems do clients with these elevations present to their

METHOD Subjects

Examinations of several hundred files indicated that an elevated 2-4 (D-PD) was a frequently occurring pattern among clients who were seeking treatment at the University of Missouri Counseling Center. This population included not only students, but staff, faculty, and members of the community. These individuals typically were given the MMPI because they presented a treatment problem to the therapist.

The sample chosen for this study consisted of 189 clients who had been seen in the years 1975 to 1982. The 80 experimental cases were clients who had MMPI profiles with both the 2 (D) and the 4 (PD) above a 70 T score and Scales 1 (Hs) and 3 (HY) at least 5 points less than the lowest of the 2 and 4 scales. For subjects to be chosen for the ex- perimental group, these two scales had to be either the two highest or among the four highest with the other high scales being 7 (PT) and/or 8 (Sc). The 109 cases in the control group were selected randomly from all clients who had taken the MMPI.

Both authors, blind to the MMPI profiles, read all files and made independent judgments as to the therapy outcome and client characteristics or symptoms mentioned by the therapists in the case notes. Categories that reflected common client characteristics were established. Clients were scored as exhibiting a dimension only when it was felt by both judges to be clearly represented in the case notes. The reader should

D-PD: Therapy Implications 183

keep in mind that this report probably presents only minimum percentages. That is, one needs to take into consideration that we are dealing with (a) what the client decides to report to his/her therapist; and (b) what the therapist chooses to put into the notes. Logically, it can be assumed that in almost all cases the percentage of these characteristics would be expected to be higher than those presently reported.

Chi squares were performed on the computer using the Statistical Analysis System (1979).

RESULTS The mean MMPI profiles of the control and experimental groups are given in Table

1. While the 2 (D) and 4 (PD) spikes were the basis on which the profiles were chosen, Table 1 shows that when the 2 and 4 scales are elevated, other scales are likely to be elevated as well. The main additional elevations are on the 7 (PT) and 8 (Sc) scales. The results that follow must take into consideration that behavior that differentiates these clients from others also is reflected in the elevations of these two scales. What is reported here appears to be true of persons with profiles in which the 2-4-7-8 scales are all T score over 70. In addition, the 2 and 4 scales have definite elevations above the 1 (Hs) and 3 (W. Table 1 Comparison of Mean MMPI Scale T Scores

Control High 2-4

M SD M SD t P

L 48 7.2 46 5.5 2.08 .05 F 60 12.7 71 11.0 6.14 .oo I K 52 9.0 50 7.5 1.61 ns Hs 58 13.2 57 9.9 .57 ns

D 66 14.0 79 11.9 6.67 .oo1

HY 63 10.5 64 9.2 .61 ns

PO 66 12.2 82 9.5 9.11 .oo I P A 65 10.0 69 9.9 2.65 .01

PT 68 14.0 19 11.6 5.44 ,001

sc 69 16.9 81 13.1 5.31 .oo 1

M A 62 13.0 62 11.8 .oo ns

Sr 58 11.8 61 10.5 6.55 .oo I A 58 11.4 61 8.3 6.04 .oo 1

R 49 10.0 51 9.9 1.32 ns

Es 41 12.2 44 8.1 I .95 ns LB 54 10.3 53 9.5 .67 ns CA 59 10.6 67 10.4 5.06 .ool DY 51 10.1 65 8.7 5.63 .oo 1

Do 53 9.3 48 9.4 2.83 .o I RE 50 8.7 45 8.4 3.87 .oo 1

P R 48 10.2 54 9.6 4.01 .MI 1

ST 57 8.9 54 8.4 2.30 .05 CN 58 11.1 65 10.6 4.27 .oo1

184 Journal of Clinical Psychology, March 1985, Vol. 41, No. 2

It will be noted that other nonclinical scale scores of the experimental group also were significantly different from those of the control group. These scales are SI (Social- introversion), A (General Maladjustment), DY (Dependency), PR (Prejudice), and CN (Control). As will be seen from the results and discussion that follow, these scores reflect behavior that was reported by the therapists.

The subjects in two samples did not differ significantly on age (group mean 23.6), number of sessions (15.3), sex ratio (62% female), marital status (25.6% married), or the number who had been seen by more than one therapist (32.2%).

The answer to our first question, “What are the characteristics of nonhospitalized clients who have elevated 2-4s?” is given in Table 2, which shows the differences between clients with elevated 2-4s (and 7 and/or 8) and the control group on a number of present- ing problems and personality characteristics. The individuals with an elevated 2-4-7-8 profile in this setting are likely to differ from a random sample of clients by being more depressed, having lower self-esteem, and coming from families that the clients report as being disturbed, frequently with fathers who are violent or alcoholic. In addition, they have poor relationships with the opposite sex, have rigid rules by which they guide their behavior, have problems with intimacy and making friends, tend to be disorganized and confused, and often make little improvement as a result of therapy.

In answer to question 2, “Are there characteristics similar to those reported on more severely disturbed populations?”, we can say that these counseling center clients

Table 2 Client Symptoms

Control Elevated D-PD X 2 P Symptoms (N = 109) ( N = 80)

Depression” 38 75 25.9 .oOOl Low self-esteem 38 61 10.3 .01

Disturbed home life 27 69 33.2 .0001

Father 18 55 27.7 .om I Mother 14 41 18.4 .ooOl

Lacks intimacy, few friends 33 56 10.2 .01

Poor relationships opposite sex Sex problems Disorganized-confused Role problems Previously hospitalized Rigid rules Over-intellectualization Dependency Failure to carry out assignments Bizarre ideation Angry or hostile Alcohol &drugs Manipulative Client terminates

44

I I 22

27 4 4

22

1 1

28

12

28 14

9

28

72

32

41

41

15

42

40

34

36

10

36 22

6 44

15.0

13.3

8.2

4.5 8. I

43.5

7.2

14.4

1.21

.70

1.6

2.3 .5

5.4

.oo 1

.oo I

.o 1

.05

.o 1

.om I

.o 1

.w I ns ns ns ns ns

.02

No improvement in therapy 29 55 12.6 .oo I

“Numbers given are percent for comparison purposes.

D-PD: Therapy Implications 185

with elevated 2-4-7-8 profiles share many of the same characteristics of the hospitalized patients studied previously with these profiles. These similarities are such things as difficulty with relationships, depression, and low self-esteem. It should be noted, however, that there are definite differences in this nonhospitalized population. We can conclude that similar elevations on these scales in different settings do call for different inferences on the part of the therapist concerning client behavior. Those clients who have come for therapy to a nonpsychiatric setting are more likely to have an attenuated set of symptoms. They continue to function in the community and in many cases are successful at jobs or in school. Their behavior is less pathological. For example, they exhibit less problems with drugs and alcohol and less hostility than is reported in hospital studies.

In view of the elevations on the 2,4,7, and 8 scales, a number of differences were ex- pected that did not appear. Given the elevated PD scale, we would have expected more anger and hostility, greater problems with alcohol and drugs, and more therapist reports of manipulative behavior on the part of the client. Based on the elevated 2-4, we would have predicted more failure to carry out assignments. The elevated 7 and 8 would have led to a prediction of more bizarre ideation. The fact that these differences did not occur may be due to the elevated control scale of individuals with these profiles.

DISCUSSION In the university population used in this study, the clients with the elevated 2-4-7-8

profiles are significantly more depressed than the control sample. Examples from the files are, “frequent crying,” “a paralysis of will which leads to not being able to manage things,” “feeling miserable.”

Over half of the clients with a high 2-4-7-8 report low self-esteem: “He doesn’t feel he is a worthwhile person,” “She does a lot of negative self-talk, especially in social situations.” The most significant difference between clients with high 2-4-7-8s and the control group is in the number who have had problems with their families. These are some sample comments: “The client had an extremely poor family situation with the father very ill for a long time before he died a year ago. Her mother seems very demand- ing and rigid, providing little support for the client.’’ “She describes her mother as im- possibly religious, critical and nervous.” “He stated his life would have been fine if his mother had not died and left him with a physically and mentally abusive father.’’

The picture that develops in these cases is of an individual raised in a family environ- ment in which there was not much love or the love was seen as inconsistent, which resulted in the client having low self-esteem. This probably laid the groundwork for future feelings of unworthiness and depression. When a person with an elevated PD gives responses that indicate difficulty with parents and family, the usual interpretation is that the client, in fact, was difficult and that the family often put up with considerable disrup- tive behavior (e.g., Dahlstrom et al., 1972). In these cases, when the 2 (D) is elevated along with the 4 (PD), it would seem that the parents are truly difficult people. The client’s report seems to reflect a real situation rather than a psychopathic interpretation of reality.

A significant percentage of these clients have rigid rules or “shoulds” by which they guide their own behavior. “She has a set idea of what a therapist should be and an idea of how she (the client) should act.” “She seems to be caught between the wants and shoulds in her life.” “We discussed the rigid requirements and rules by which she controls herself.” “He is self-critical, and has high expectations for himself developed partly through fantasies.”

This emphasis on control may well be consistent with the family situation. The parents often were seen as demanding and rigid, but at the same time unpredictable in terms of their behavior. Many of the parents were reported as violence prone or emotionally explosive. The rigid rules by which the client is now attempting to live could

186 Journal of Clinical Psychology, March 1985, Vol. 41 , No. 2

be the result of this early parental modeling and demands. Another possible interpreta- tion is that by setting up rigid rules the individual controls his/her own fears of being like his/her parents. The equation seems to be, “emotions are dangerous-they need to be controlled-therefore, I need to follow definite rules of behavior to control them.”

The need for control was shown by these clients in other ways. The use of intellec- tualizations to control emotions was a frequent theme in their therapy. “She seems to control her emotions very tightly and offered only facts during our sessions.” “1 think you have to be careful not to get into word games and philosophical trips with him. I think he’s using them to get away from talking about his feelings.”

In spite of the presence of rigid rules of behavior and attempts to control emotions, a frequent complaint is disorganization and/or confusion in thinking. “Generally he feels confused and without answers.” “He would jump so quickly from one topic to another that the chain of his thinking was obscure.” “Complains that she is not able to concen- trate on her classes or homework. She also has a hard time maintaining her train of thought during a conversation.”

Given the above reports of confusion and disorganization, it is not surprising that many report role problems. “She expressed an inability to really decide what she likes and even in defining who she really is.” “She is not clear what she wants from her female role. She knows a standard wife role is not for her.”

The high 2-4-7-8 group complains frequently of a lack of intimacy with others and a feeling of having no “real” friends. Individuals with this profile are also likely to be hav- ing problems, specifically, in their relationships with the opposite sex. “Much of the time he has thoughts of women as sexual objects, something to be conquered.” “She has a boyfriend in but does not care for him anymore. She continues seeing him because she has no one else to go out with.” “He has had a series of unhappy and un- successful relationships with women.”

Our third question was, “What special problems as clients do these individuals pre- sent to their counselors?” Given their problems of relating to others and their history of difficulty with parents, it is not surprising that they are seen as problem clients by their counselors. While many stay in therapy for some time (16.2 sessions as opposed to 6.2 center average), they do not seem fully involved in their treatment. The client seems to expect the therapy to be mainly a result of the therapist’s activities. This dependency also is reflected in the high mean score on the MMPI scale for dependency (DY = 65).

A large number of these clients appear to make no progress in therapy. The counselor either stated that no progress had been made or did not give any indication of changes in client feelings or behavior. While a number of these clients made minimal therapeutic progress, very few could be said to have made significant changes as a result of therapy.

Because these clients are time consuming and difficult, can we predict which ones are ready to profit from counseling and which are not? On the MMPI, the mean profiles of those who make some progress and those who do not are quite similar. There were no significant differences between the two groups in their presenting or developed problems. Depressions, family problems, low self-esteem, and difficulty with relationships are very similar between the two groups. Some differences occur where one would expect them. Successful clients do not terminate abruptly at a point at which progress is likely to oc- cur. As a group, improved clients tend to carry out instructions and do assigned homework. In the experimental group, none of the cases that made progress in therapy had any notes that indicated that the client would not or could not carry out homework assignments. Half of those who failed to make progress did have such indications in their case notes.

All of this suggests that some of the clients are not really ready for the kinds of changes that a therapist expects. At best, they are seeking change in the context of a set of rules that they, the clients, have established. According to these rules, feelings are not

D-PD: Therapy Implications 187

to be explored, and the therapist is to be the responsible change agent. While the therapist is given responsibility, he/she is not given power to do what needs to be done. “He would show his desire to be close to the counselor and then withdraw and deny his needs. His basic trust issues remained conflicted.”

I t also may be that therapists have expectations that are beyond those of the client. That is, the clients’ backgrounds limit their expectations to being understood and accepted. No further depth or change is anticipated or desired. Perhaps our goals in these cases should be very minimal.

In those cases in which improvement occurred, frequent mention is made of an im- proved self-image of the client. “She gained an important sense of her strengths.” “Counseling focused on the responsibility to make decisions and a more positive self- image.” “He learned to accept positive feedback from others.”

From these reports, it can be surmised that therapists helped the clients increase their self-esteem and strengthen their egos primarily by providing a safe environment and much personal support. They did not spend much time on client dynamics or insight and allowed the client to examine feelings at the individual’s own pace. They also found some way to involve the client in taking an active part in treatment, such as engaging in ac- tivities outside of the sessions to elicit more positive feedback from other people.

Different therapists appear to do this in different ways, but it seems that more of the clients would have shown improvement if the above approach had been followed more universally. For these clients, therapy is scary. To express emotions is difficult. Guardedness in interpersonal relations is the norm. They evidently don’t expect much, and they are not good at spontaneously eliciting from others the support that they want and need. Therapists need to be aware that they may have trouble giving this group of clients the support and positive feedback that they appear to need. They also should keep in mind that these clients respond slowly and do not react positively to the exploration of feelings.

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CHARACTERISTICS OF FEMALE CLIENTS THAT INFLUENCE PREFERENCE FOR THE SOCIALLY INTIMATE

AND NONINTIMATE FEMALE PSYCHOTHERAPISTS MARILYN P. MINDINGALL

Auburn University at Montgomery

This study documented the relationship among various client characteristics and client preference for therapists who exhibit intimate and nonintimate therapy styles. Seventy-five female college students were administered in random order measures to assess their levels of social intimacy, sex role type, locus of control, therapy expectancy, and authoritarianism. The par- ticipants then watched in random order of presentation the audiovisual recordings of first therapy sessions that reflected intimate and nonintimate therapy styles. After each tape was presented, the participants completed a measure to assess their perceptions of the therapeutic relationship and a preference form. Results show that the socially intimate women have a preference for the intimate therapist. Results also show that women expect the therapist to exhibit intimate behaviors and that those who prefer this type of therapist perceive her as possessing significantly higher levels of in- timacy, regard, empathy, and unconditional acceptance.

There exists a persistent clinical belief that psychotherapeutic outcome depends in part upon characteristics of the client and the therapist operating in interaction. Such an effect has been demonstrated empirically in several studies concerned with a variety of characteristics (Carson & Heine, 1962; Cartwright & Lerner, 1963). The sex of the therapist has been discussed in terms of therapy outcome and therapist preference.

Preference does appear to influence therapy process and outcome (Gardner, 1964). Preferences for different therapists can be related to personality and other variables in clients and may be a major contributor to an enhanced initial relationship (Rosen, 1967).

This article is based on the author’s doctoral dissertation in clinical psychology completed at the Penn- sylvania State University under the direction of Juris G. Draguns.

Special thanks are due to committee members Judith L. Fischer, Leon Gorlow, and Richard M. Lundy. The author also wishes to thank Carolyn Mazure and Leta Myers for their assistance with this project and Kenneth R. Mindingall for his comments on earlier drafts.

Requests for reprints should be sent to Marilyn Paul Mindingall, Auburn University at Montgomery, Department of Psychology, 210 Goodwyn Hall, Montgomery, Alabama 36193.

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