Generated Outcome Measure of Suffering for Use with Clients with Illusory Mental Health

11 (1), 32 https://doi.org/10.29044/v11i1p32 Development and Case Study Application of a Proxy- Generated Outcome Measure of Suffering for use with Clients with Illusory Mental Health © 2020 Giulia Guglielmetti and Enrico Benelli Abstract (genuinely healthy). This phenomenon has an impact The concept of illusory mental health is described as on a considerable part of the population, the rationale for needing an approach for working with approximately 10% - 20% (Ward & McLeod, 2018), individuals who are unaware of their suffering and are and is characterized by low scores on symptom therefore unable to describe their problems through measures, by indications of high levels of mental self-report instruments. The use of a nomothetic health problems in projective and narrative approach using self-report or clinician-generated techniques, and clinical judgement, with an observable standardised instruments is compared with an discrepancy between different sources of data about idiographic approach for working with such individuals. existence of mental health difficulties (Shedler et al., A case study is used to illustrate the development and 1993). Shedler, Kaninger & Katz, (2003) provide a list first application of a Proxy-Generated Outcome of characteristics that are often observable in persons Measure (PGOM) that allows clinicians, observers who exhibit IMH, that includes: a predominantly and researchers to trace an individualised negative affect tone, with manifestations of insecurity; understanding of a client’s core sufferings and the experience of the Other as malevolent (e.g. as changes occurring during the process of sources of pain, punishment, frustration) and as acting psychotherapy. A comparison with a nomothetic in cruel and destructive ways; the presence of negative outcome measure is also presented. early memories concerning abandoning, unprotective, Keywords or abusive caregivers .Shedler (Shedler et al., 1993; Cousineau & Shedler, 2006) notes that this Illusory Mental Health (IMH), Proxy-Generated phenomenon shows an important implication for Outcome Measure, idiographic, Psychodiagnostic practice, as it seems to coincide with a higher risk of Chart-2, nomothetic, client’s implicit suffering, developing physical health problems. Those clinician’s subjective experience, guided clinical individuals identified as having IMH are physiologically judgment, systematic observation, psychotherapy over-reactive and tend to express distress somatically outcome assessment, Psychodynamic Diagnostic with real physiological costs. Accordingly, a study Manual-2, psychodynamic psychotherapy. conducted in Massachusetts by Bram, Gottschalk & Introduction Leeds (2018) adds the possibility that IMH could reflect Illusory mental health (IMH) is the phenomenon in a deficit or defensive structural weakness in the ability which individuals do not recognize their own suffering to access and process painful feelings. If so, as a defensive denial against awareness of unrecognized and unprocessed emotional distress threatening memories and emotions. It tends to be would, therefore, be experienced and expressed characterized by a need to see themselves as well primarily on a somatic level. This perspective would adjusted despite underlying vulnerability (Shedler, also explain the chronic fatigue syndrome, which is Mayman & Manis, 1993). In this sense, Shedler and characterized by medically unexplained fatigue: colleagues suggest a distinction between clients who somatic symptoms are somatized manifestations of a present mental health on self-reports but are judged defensive disavowal or deficit in emotional processing. distressed by clinicians (apparently healthy) and Shedler and colleagues emphasize another important clients who present themselves as mentally healthy in implication of IMH phenomenon for the psychotherapy correspondence with the clinicians' judgements outcome research, since it suggests that some International Journal of Transactional Analysis Research & Practice Vol 11 No 1, June 2020 www.ijtarp.org Page 32 feedback and monitoring tools may not provide developmental history of individuals as well as their accurate information about the client's situation. In subjective interpretation and responsiveness to reality particular, Cousineau & Shedler (2006) highlight the (Grice, 2004). Over the years, both approaches have limitations of self-report questionnaires and suggest claimed to be theoretically founded and scientifically that implicit measures have an important role to play in valuable. mental health research. Consistently, a Dutch study Nomothetic Approach (Wineke, Eurelings-Bontekoe, Dijke, Moene & Gool, In recent decades, psychological problems have been 2015) conducted on clients with somatoform disorders defined primarily on the basis of observable symptoms - who report somatic complaints attributed to an and behaviors. According to a nomothetic approach, unexplained medical condition – underlines how these which establishes laws and generalizations based on clients tend to deny the influence of psychological the study of large groups of people, these observable factors on self-report measures, showing a favourable aspects of psychotherapy process and outcome are self-presentation which may be related to defensive assessed through appropriate instruments (e.g. denial that characterizes the phenomenon of IMH. The questionnaire and structured interviews), by clients results of this study are in line with the increasing themselves (self-rated) or by an external observer awareness that many psychological processes are (proxy-rated). This approach generates a hypothetical- implicit rather than explicit, and not accessible via self- deductive thinking that identifies explanatory and reports (Shedler et al., 1993; Cousineau & Shedler, generalizable aspects regarding how much an aspect 2006; Westen & Shedler, 2007; Wineke et al., 2015). is common and recurrent within an extended sample, Bringing further support to the usefulness of implicit to the detriment of subjective connotations. Indeed, the procedures, the German study of Subic-Wrana and traditional use of nomothetic, standardized and self- colleagues (as cited in Wineke et al., 2015) shows that rated measures, such as the Patient Health among clients with somatoform disorders, low levels of Questionnaire 9-item (PHQ-9; Spitzer, Kroenke & emotional awareness - assessed with an implicit Williams, 1999) that scores each of the nine DSM-5 projective measure (LEAS) - are associated with a low criteria for symptoms of depression, locates level of impairments in self-reports. In this regard, individuals within a larger population on general Wineke and colleagues suggest that the utility of self- factors and norms. Having said that, self-report report measures may be limited in clients who tend to measures have emerged that would seem not to be describe themselves as overly positive among these sensitive to factors or situations that could influence instruments, such as those clients with somatoform the quantitative change in scores, such as social disorders, and that future research should include desirability (Paulhaus, 1986; McLeod, 2001, Caputo, observer ratings, complementary to self-reports. 2017). The term nomothetic derives from the Greek word In addition, a poor correspondence between nomos meaning law, and is used in psychology to quantitative and qualitative data has been observed in establish generalization, such as diagnosis, referring clients who tend to deny their own observable suffering to objective classification under similar condition. The (Shedler, et al., 1993). Such evidences call into term idiographic comes from the Greek word idios question the reliability of the nomothetic self-report meaning own, private, and refers to aspects of tools, as they seem to be affected by socially-desirable subjective experience that make each person unique responding or self-deception (Shedler et al., 1993; (Pagnini, Gibbons & Castelnuovo, 2012; McLeod, Cousineau & Shedler, 2006). Moreover, self-report 2007). In 1937, Gordon Allport first introduced to measures of mental health, perceived stress, life American psychology the distinction between the events stress and mood states, do not predict health idiographic and nomothetic approach, starting the outcomes and do not detect those psychological ongoing philosophical debate in the field of processes that are implicit rather than explicit, and that psychological sciences regarding the theoretical and are therefore not accessible via self-report tools methodological assumptions that should guide (Cousineau & Shedler, 2006). Indeed, these measures personality research (Grice, 2004). Precisely, in do not capture the implicit dimensions (unconscious) clinical psychology, the debate addresses the of the client’s suffering. Since these implicit classification of personality and other taxonomies, as dimensions, for example the intensity of the sufferings, well as the use of diagnosis (Pagnini, et al., 2012). On are excluded from the client's awareness, they cannot the one hand, nomotheists have argued that be evaluated with nomothetic self-report instruments personality psychologists should focus on generalities from the client's explicit point of view. For these and discover and quantify phenomena observed in reasons, some practitioners resort to the use of groups of individuals. On the other hand, idiographists nomothetic, proxy-rated measures, such as the have argued that the field of personality should be Hamilton Depression

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