Psychoanalytic Psychology 2016 American Psychological Association

2016, Vol. 33, No. 3, 530 534 0736-9735/16/$12.00 http://dx.doi.org/10.1037/a0039649

BOOK REVIEW

Psychological Testing That Matters: Creating A Road Map for Effective Treatment, by
Anthony D. Bram and Mary Jo Peebles. Washington, DC: American Psychological
Association, 2014, 468 pp. (ISBN 9781-4338-1674-1, US $79.95)
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Reviewed by

Sandra W. Russ, PhD

Case Western Reserve University

A Model for Psychological Assessment

Psychological Testing That Matters is an outstanding text for many reasons. The approach
to psychological testing that Bram and Peebles take provides an excellent model for
integrating test findings with a focus on treatment planning. The authors are experts in
psychological assessment and are seasoned clinicians. They tackle the hard question of
how to weigh the evidence and decide which conclusions can be said with confidence and
which are speculative. Principles of inference-making are presented. This is a clinically
sophisticated presentation that uses language that is understandable for beginning stu-
dents. The focus of the book is to explicate methods of inference-making and synthesis
that answer referral questions, create an experience of the person of the patient, and affect
treatment meaningfully (p. 8).
The organization of the book is unique and makes sense conceptually. The framework
is that of a psychodynamic perspective that is focused on internal processes and person-
ality characteristics that underlie symptoms. Using a psychodynamic approach in psycho-
logical testing teaches about personality development and processes such as affect
regulation, self-other differentiation, and conflicts that influence thinking and perceiving.
The benefit of this approach to clinical psychology graduate students is that they learn
about the subtleties of psychological processes as well as personality assessment. As the
authors point out, an understanding of the person from a psychodynamic framework does
not imply psychodynamic treatment. There are many examples in this book of psycho-
logical testing leading to a cognitive-behavioral approach to treatment.
One of the strengths of the book is the identification of four key psychological capacities
that should be focused on in assessment. These are reality testing and reasoning, emotional
regulation, experience of self and other-implications for the therapeutic alliance, and experi-
ence of self- and other-narcissistic vulnerabilities. These areas were chosen because of their
importance in determining what type of treatment is appropriate and what issues may arise in

Correspondence concerning this article should be addressed to Sandra W. Russ, PhD, Department
of Psychological Sciences, Case Western Reserve University, Cleveland, OH 44106-7123. E-mail:
swr@case.edu

530
 BOOK REVIEW 531

treatment. They also transtheoretically, empirically, and clinically have been shown to be
associated with positive outcome in therapy: alliance, focus, patient engagement, and structural
vulnerabilities and strengths (p. 79). Problems in these four key capacities are viewed as
resulting from developmental disruptions. This developmental approach throughout the book
makes it appropriate for teaching child psychological assessment as well as adults. The book
focuses on adults and the many case vignettes and fuller case presentations are all of adults.
But the basic principles of the book are applicable to assessment of children as well as adults.
The psychodynamic framework as applied to children points to a major treatment goal of
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

getting the developmental process back on course. (Freud, 1965; Russ, 1998). If there is a
This document is copyrighted by the American Psychological Association or one of its allied publishers.

developmental disruption in a particular area, intervention should focus on that area. As with
adults, optimal treatment may be from a psychodynamic, family, educational, or cognitive-
behavioral treatment approach.
As each of the core psychological areas are discussed, four basic sources of testing
information are reviewed: Wechsler intelligence tests, Rorschach, Thematic Apperception
Test (TAT), and patient-examiner data that occur during the testing session. The focus is on
where to look in each test/area to assess each core capacity. This presentation is a very
comprehensive and detailed model of how to proceed in test interpretation. The framework for
interpretation had already been set in Chapter 2, Principles of Inference-Making. How do we
make valid statements from the test scores and content about the individual and treatment
implications? Bram and Peebles suggest a number of principles, stressing that, as Weiner
(2000) stated, for each interpretative statement in a report, the path of reasoning should be
articulated and confidence in each statement should be stated in the report.
The key question is, How do we weigh the data from the assessment? They suggest
heavier weighting when there is: repetition of a finding within the test data; convergence
of similar findings across different tests or different types of data; representational versus
symbolic inference (closer to the data the better); and singularityvery unique responses.
The validity of the test and the test score is also a key variable in deciding how much
confidence to have in the interpretation. What does the research say about, for example,
how valid the form quality of perceptions on the Rorschach is in capturing reality testing
that affects daily behavior? Is low form quality alone enough to make a statement in a
report with confidence? What other scores should be considered? The authors provide an
excellent overview of current empirical support for the Rorschach, using Exners Com-
prehensive System. In 2013, Mihura, Meyer, Dumitrascu, and Bombel carried out a
meta-analysis of Rorschach variables (Mihura, Meyer, Dumitrascu, & Bombel, 2013).
Based on empirical evidence, they categorized Rorschach scores as having different levels
of empirical support including excellent, good, modest, little, and absence (no studies). In
my opinion, this review and meta-analysis provides the guiding principles for Rorschach
interpretation. Bram and Peebles consistently refer to the Mihura et.al classification
throughout their interpretation discussion. They also refer to the new Rorschach Perfor-
mance Assessment System (R-PAS; Meyer, Viglione, Mihura, Erard, & Erdberg, 2011).
In general, their literature review in the area of performance-based assessment techniques
(historically termed projective techniques) is comprehensive and up-to-date.
The TAT interpretation is necessarily more subjective with less empirical support, because
there is no commonly used validated scoring system. However, the Social Cognition and
Object Relations Scale (Westen, 1993) is a well-validated measure of object relations. I
thought that this scale and the conceptual framework of the scale could have been referred to
in the TAT interpretation sections. Nevertheless, the use of the TAT to understand internal
representations and the interpersonal world of the individual is very well-done.
 532 BOOK REVIEW

Model of Synthesis and Integration

Throughout the text, the authors model where they get their information, how they weigh
it, how they integrate the test data, and how their understanding of the four core
psychological processes lead to treatment recommendations. This modeling process is an
excellent one for teaching test interpretation. It also provides an excellent refresher course
for the experienced clinician. They model interpretation of the Wechsler Adult Intelli-
gence Scale (WAIS), Rorschach, TAT, and patient-examiner data for each of the four core
psychological capacities. For example, when evaluating reality testing and reasoning, we
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

are led through the Rorschach scores most indicative of a persons strengths and weak-
nesses in this area. A case example is presented with treatment -centered answers to the
referral question. Next, the TAT is discussed with a where to look guide to assessing
reality testing and reasoning. A case example that utilizes the TAT follows. A similar
section follows for the Wechsler test (WAIS or Wechsler Intelligence Scale for Chil-
drenFourth Edition) and for patient-examiner information. The case examples are very
useful in understanding the synthesis process. The chapters on emotion regulation,
experience of self and other-implications for the therapeutic alliance, and experience of
self and other-narcissistic vulnerabilities follow the same outline. The TAT presentations
focused on self-other issues are very helpful. For example, a list of possible questions that
the TAT might answer are posed such as to what extent are helping relationships
represented? or what gets in the way of help-seeking and help-receiving, and what
facilitates both? Are others trustworthy? Assessing the capacity for developing a thera-
peutic alliance is important for all types of psychotherapy. Assessing capacity for
self-reflection and psychological mindedness is also important for determining the type of
treatment. This book gives suggestions for collaborative reflections about the tests. For
example, after the TAT administration, commenting about how sad the characters are
about loss and asking whether that is something the patient thinks about, could offer
information about the patients ability to engage in introspection.
Throughout these chapters is a discussion of the path of inferences and how much
confidence one can have in the interpretations. The discussions are very detailed. The levels
of interpretation move from test scores to content of responses to symbolic interpretation.
Empirical support is usually available for the test scores and are referred to. When a particular
Rorschach score was used in an interpretation (form dimension) that had little to no support
in the Mihura et al. (2013) meta-analysis, the authors carefully explained, convincingly, why
they used it. When using symbolic interpretations of content, they follow Weiners (1998)
recommendations that one must be careful in interpretation. Symbolic responses that are
interpreted with confidence should be responses that show clarity with meaning that is
immediately transparent. They also use advanced interpretation and symbolic interpretations
that are supported by theoretical frameworks and clinical experience. For example, Peebles
uses configural and minisequence analysis on the Rorschach. What kinds of shifts in psycho-
logical functioning occur within a response or in two or three responses in a row? They model
the integration process and confidence level of including these interpretations. From my
experience teaching graduate students, for the beginning student, especially if they are not
attuned to psychodynamic theory, it will be unclear where the interpretations are coming
fromthe leaps of inference from the data will seem very large. It takes time for the clinical
experience to build into a useful repertoire. However, this model of the process of inference
and deciding what to include and what not to include will be very useful to the beginning
student. They can include the empirically supported interpretations in their report with some
obvious repetitive themes and patient-examiner interactions. As they develop as clinicians and
 BOOK REVIEW 533

become more sophisticated in their understanding of personality, they will learn how to
integrate increasing clinical experience and theory into their test interpretations.
There is a section on diagnostic considerations based on types of developmental
disruptions. This section focuses on the source of the patients symptoms, which is
essential for treatment planning. Peebles four paradigms of structural weakness, trauma,
conflicts and splits, and maladaptive character patterns are presented with identifying
features in the test data. Case examples of each type and test data are presented.
The final section of the book focuses on report writing and giving feedback about the
assessment. There is a good discussion of inference mapping in putting the report together.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

Inference mapping involves scoring the test, listing referral questions as a focus, creating
clusters of findings, and connecting the clusters. This inference mapping is a very helpful
approach in identifying converging evidence. Guidelines for organizing the report stress
the transparency of reasoning, defined as unpacking clinical reasoning in simple, under-
standable phrases (p. 359). The treatment implications section discusses therapeutic
alliance, relational patterns, type of treatment, and areas of vulnerability.
The book concludes with a detailed case example, test data, and final report. Again, this
is a very valuable presentation and good model for how to organize a report and give verbal
feedback.
One of the values of this book is that it provides a clear framework for understanding
the inner world of the individual. Core psychological processes are identified and opera-
tionalized in psychological tests and interpretation of tests. This approach captures the
complexity of individuals and an approach to psychotherapy that focuses on the devel-
opment of the whole individual, not only on symptom reduction. Again, this approach is
especially appropriate for children. A developmental approach to childhood problems and
disorders does focus on optimal growth along developmental pathways.
One of the joys in reading this book is that it is also a model of integrating ones
clinical experience and the theoretical literature with the teachings of ones supervisors
and mentors. The framework of test interpretation followed by the psychologists at the
Menninger-Topeka Clinic pervades the book as do teachings and writings of classic
figures in psychology such as Mayman, Appelbaum, Lerner, and Weiner. It shows how
one grows as a clinician over time and continually integrates and synthesizes new
information into ones solid foundation in assessment. This book also ensures that the
legacy of teachings from the clinicians at Menningers will be carried forward.
As you may have deduced, I think this is truly an outstanding text that is a major
contribution to the field. I have ordered it and will be using it as a text in my upcoming
Methods of Assessment seminar for clinical psychology graduate students. It will greatly
benefit my students learning and my teaching. Bram and Peebles provide an outstanding
synthesis of the process of test interpretation and treatment planning.

References

Freud, A. (1965). The writings of Anna Freud: Normality and pathology in childhood: Assessments
of development (Vol. 6). New York, NY: International Universities Press.
Meyer, G. J., Vigilione, D. J., Mihura, J. L., Erard, R. E., & Erdberg, P. (2011). Rorschach
Performance Assessment System: Administration, coding, interpretation, and technical manual.
Toledo, OH: Rorschach Performance Assessment System.
Mihura, J. L., Meyer, G. J., Dumitrascu, N., & Bombel, G. (2013). The validity of individual
Rorschach variables: Systematic reviews and meta-analyses of the comprehensive system.
Psychological Bulletin, 139, 548 605. http://dx.doi.org/10.1037/a0029406
 534 BOOK REVIEW

Russ, S. W. (1998). Psychodynamically based therapies. In T. Ollendick & M. Hersen (Eds.),

Handbook of child psychopathology (pp. 537556). New York, NY: Plenum Press. http://
dx.doi.org/10.1007/978-1-4615-5905-4_22
Weiner, I. B. (1998). Principles of Rorschach interpretation. Mahwah, NJ: Erlbaum.
Weiner, I. B. (2000). Making Rorschach interpretation as good as it can be. Journal of Personality
Assessment, 74, 164 174. http://dx.doi.org/10.1207/S15327752JPA7402_2
Westen, D. (1993). Social cognition and object relations scale: Q-sort for projective stories
(SCORS-Q). Cambridge, MA: Department of Psychiatry, Cambridge Hospital and Harvard
Medical School.
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
This document is copyrighted by the American Psychological Association or one of its allied publishers.

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