This podcast is brought to you by PAR. PAR offers the SPECTRA Indices of Psychopathology, a hierarchical-dimensional look at adult psychopathology. The SPECTRA is available for Paper-and-Pencil Assessment or administration and scoring via PARiConnect. Learn more at parinc.com\spectra.
For a limited time, you can get one free administration and score report for the SPECTRA on PARiConnect by calling PAR at (855) 856-4266. Just mention a promo code S-P-E-C.
All right y’all, welcome back. I have another fantastic episode for you today.
I am honored to be talking with my guests, Dr. Mark Blais and Dr. Justin Sinclair. They are the co-developers of the SPECTRA, which is a new-ish measure of psychopathology. So we talk all about the SPECTRA, what it is, what it looks like for clients, what clinicians can expect.
We also get into a discussion around different methods of assessing psychopathology. So we talk a lot about the hierarchical versus dimensional model. We also talk about how to integrate the SPECTRA in your reports including with a neuro-psych battery and go over two cases to try and bring the measure to life.
There’s a lot to enjoy here. And I walked away from this clearly interested in the SPECTRA and wishing that I tested more adults so I could use it more. But as you heard in the ad before the podcast started, there’s a code that will be listed in the show notes as well where you can get free use of the SPECTRA if you call PAR and give them that code.
Before I transition to our conversation, I want to invite any advanced practice owners or aspiring advanced practice owners to consider the Advanced Practice Mastermind for the testing psychologist. The next cohort starts in June.
This is really a group coaching experience for assessment psychologists who have testing as part of their practice and want to take their practices to the next level. So if you’re thinking about hiring or hiring more, trying to get your schedule under control because you got so busy as a solo practitioner, additional streams of income, anything like that, this could be a good group for you. So you can check that out at thetestingpsychologist.com/advanced and get more information.
All right, let’s get to my discussion with Dr. Mark Blais and Dr. Justin Sinclair.
Dr. Sharp: Justin, Mark, welcome to the podcast.
Dr. Justin: Thank you. Thanks for having us.
Dr. Mark: Yes, absolutely, Jeremy.
Dr. Sharp: I am thrilled to be talking with you guys. I’m always a little star-struck when test authors reach out because y’all are doing this work that feels so worldly and amazing to me that I’m like, “Oh, you want to talk to me? What!” So yeah, I’m so grateful that y’all agreed to come on and talk through the SPECTRA. I really appreciate it.
Dr. Mark: I appreciate you having us.
Dr. Sharp: It’s going to be fun. I have so many questions for you. I think a lot of people in the audience are really curious about the SPECTRA as well. I’m ready to dive into it.
I was hoping that we might be able to start with the why and the where and the how I suppose. So like I said, test development is like nothing I would even know where to start with. So I’m so curious. Where did you start with this whole process? Where did it come from?
Dr. Justin: So the SPECTRA is actually kind of an old story, I think. It’s something Mark and I have been working on for quite a while. So it goes back to… I actually was lucky enough to do my training with Mark back in 2006. I went on my internship with him. I was lucky enough to stay with him and train with him. I got my first job with him. And one of the first things that I was working on with him was the department that we were working at Massachusetts general hospital, it was essentially incorporating this measurement-based system to inform care that was going on.
And we were using different sources of information. So this is back during the DSM-IV. So we were collecting GAF scores and wellbeing scores using a scale that the market developed and basically looking to see how patients were doing in our clinics at the hospital. And that was the beginning of discussions that led to the development of the SPECTRA which was really kind of anchored in, I think, desire to be more useful and specific with respect to how we were measuring different symptoms and how patients were doing in these different care clinics. And so, the Genesis for it started about 2009.
Mark, does that sound about right to you when we started working on this?
Dr. Mark: 2009, yes.
Dr. Justin: And then we basically were looking at the literature looking for a measurement framework that made sense to us and it would have utility. And it was back in the early days of the hierarchical-dimensional model of psychopathology, which has really gained popularity over the last 10 years or so. But that really became the framework for developing this SPECTRA as a new but distinct assessment tool that potentially could have utility.
Dr. Mark: As we were doing that, Justin and I were leading the project that implemented all the procedures for collecting the data and then distributing the information back to the clinicians. And once that infrastructure was created, the department said, “Well, we should have a better test” and we asked us to look around with proprietary tests and the costs. We made a proposal that we would create a broad base, flexible, easily manipulated test that would be able to track outcomes across a wide range of disorders, but also incorporating the three core dimensions, Internalizing, Externalizing, and Reality-Impairing so that you could have a much broader outcome.
And we were working on that. Then we got funding from the hospital and from the medical school, and then they bought EPIC. The electronic medical record came into being, and it had all of the scales attached to it. So the PHQ 9 has hundreds and hundreds of scales included. And so they allowed us to finish up creating the test and then to see if we could find a company to publish it like PAR.
Dr. Sharp: Right. That’s fantastic. So I think a lot of projects like this, you were just trying to solve a problem that you were seeing in your work and you just took it to the next level?
Dr. Mark: To solve a problem. And Justin and I have done numerous psychometric studies and projects and different testing programs that we’ve implemented. And so it’s just fun. We just like to do things. that have to do with measurement and that can be applied clinically.
Dr. Sharp: God bless you. I’m glad that there are people who like measurement. That’s fantastic.
So tell me, I always do this, I’ll just jump right in and start asking all these questions, but let’s back up real quick. What’s the elevator pitch for the SPECTRA? So what is it if people, for whatever reason don’t know what the SPECTRA is?
Dr. Mark: It’s a measure of psychopathology that matches the emerging empirically derived, hierarchical-dimensional structures of psychopathology. It allows you to step outside of the DSM. It allows you to supplement or complement the DSM, but then it gives you a whole different way, an excitingly new way of thinking about and measuring psychopathology.
Dr. Sharp: Love it. You have used the term hierarchical a couple of times already here in the interview. I know that that is a big conceptual component of the SPECTRA. Could we dive into that for a bit and why that’s important, why he chose to go that route and how it ended up around that framework?
Dr. Mark: I’ll get it started. So we were really influenced by the core three dimensions following the developments in multi-variate quantitative psychopathology research. So Internalizing, Externalizing, and Reality-Impairing. And while we were working on creating those as scales, the discovery of the P factor- the higher-order factor started to show up in the literature. Leahy was the first to describe it in 2012. And looking at our data, it was clear that the three dimensions- Internalizing, Externalizing, and Reality-Impairing are intercorrelated. And that suggests that there’s a higher factor above it. And that’s what they had found. And so we began exploring the hierarchical factor structure of the test, and we also found a P factor. And then we’re able to incorporate that into the design of the test.
Dr. Sharp: And so, for folks who may not be super familiar with this area, say more about the hierarchical model and how that might be different than what we’re used to, contracting with the categorical model, and why this is unique for a measure like this SPECTRA?
Dr. Mike: Justin.
Dr. Justin: Mark, you’re probably better equipped.
Dr. Mark: Okay. So relatively soon after the DSM-IV, the literature start to research or to point out the difficulties with high comorbidity, in particular, the fact that if you have depression you are likely to have anxiety. The fact that if you had one qualified for one personality diagnosis, you’d likely had two and a half, so the high comorbidity began.
And now the DSM-IV had to be made more reliable. You could see this coming through in the research.
Then the other component of it that was frustrating is if you use the 5/9 approach to identifying disorders, you end up with a lot of people having the same diagnosis, but very few shared symptoms. So you have heterogeneity within a class and then you have comorbidity across classes. And people began to see that. At first, it was a problem. Researchers tried to find ways around it to get rid of it. But what people eventually did was embrace it and say that it is pointing to something about the structure of psychopathology.
And so factor analytic studies looking at multiple disorders, 10, 15, 20 disorders at a time began to show the dimensions, Internalizing, Externalizing, and Reality-Impairing. And when you start to look at the dimensional level, you don’t have to worry about comorbidity because anxiety, social anxiety, PTSD, depression, dysphoria, somatization are all one dimension, the Internalizing dimension.
Same with Externalizing- substance use, antisocial behavior, oppositional personality, explosive, aggressive behavior, you don’t have to worry about where the boundaries are because they all are represented by the higher level dementia. And then once you’re at the dimensional level, you no longer have to be concerned about if you have 5 or 8 or however many of these you have to qualify to hit the threshold.
You can use it as a real dimensional scale and you can have from 45 to 57 to be normal, and you can have 56 and 57 up to 63 to be mildly impaired/moderately impaired and you can really use the whole range of the trade.
Dr. Sharp: Yeah.
Dr. Justin: It’s very similar to how cognition or cognitive function is assessed hierarchically. A good analog to think about it as full-scale IQ at the top dropping down into these SPECTRA structures, verbal comprehension, perceptual reasoning, and then those breaking down into the specific subtests that make up those indices. It’s really about thinking about how they’re organized and how they do a good job in aggregate describing these higher-order abilities. It’s interesting too that psychopathology research has only just now come to this given how long IQ and assessing IQ has been around. But it’s a very similar concept.
Dr. Sharp: Yeah, it is fascinating. It is totally fascinating. I talked to Dr. Katherine Jonah’s from HiTOP maybe 18 months ago about the hierarchical model and it is just shocking to me that we have not been going that route forever. It just makes sense. And it matches my clinical experience with how difficult it is to separate diagnoses`.
Dr. Mark: To build a little bit on Justin’s analog to intelligence testing. So if you think about disorders as being individual subtests, if you only had the subtests and you were trying to describe somebody’s cognition, you would be hard-pressed. But if you are able to roll the subtests up into working memory, processing speed, verbal and non-verbal intellectual or cognitive functioning, and then roll that up into a higher total overall G factor or a full-scale IQ, then you can see the importance of being able to measure at different levels of specificity, or as we say in psychopathology, at different bandwidths across the trait.
Dr. Sharp: Yeah. You said the P factor. This was fascinating to me when we had our pre-podcast discussion only because I don’t really live in this world or this research so much, but can you talk about that P factor. Is it the wrong thing to call it a general personality factor? I’m trying to…
Dr. Mark: Psychopathology.
Dr. Sharp: Psychopathology. Yeah. So what is that and how does that relate to the measure and this dementia or hierarchical model?
Dr. Mark: In my mind, it’s the most fascinating and still the least understood of all the insights that have come out of the quantitative or empirical approaches to psychopathology. So Leahy first identified it in 2012 and gave it that name and said it conceptually would be the G factor. Spearman’s G. And now it’s been studied in adults. It’s been studied in kids. It’s been said in adolescents. It’s been studied cross-sectionally and largely tutoring. It’s been studied with a host of different measures, either disorder themselves or psychological scales or symptom clusters.
And what it is, it’s the final dimension after you take your observation. So in the SPECTRA, we have 12 clinical scales that give us our observations. Those 12 scales make the first level of dimensions- Internalizing, Externalizing, Reality-Impairing, and then above that is the overarching P factor or our global pathology index which takes all the interrelationships at the level of the dimensions and creates a single factor out of that.
So it’s taking variants. So you have variants coming up from the disorders to the dimensions and then into the P factor. And it correlates with or predicts impairment, chronicity, whether or not you’re going to respond traditionally or typically to most treatments, the risk for relapse. It has a modest correlation with intelligence. Is it an actual thing? Possibly not, but it shows that well will they ever find a neuro… people are now trying to find the neuroanatomical or neurocognitive systems that undergird this. But if they can’t find that, the ability to summarize all of this information, just like we’ve never found G, the ability to summarize that in one number gives you an incredible power for prognosis and for helping clinicians understand the intensity and duration of treatment that they need and help set reasonable expectations for patients.
Dr. Sharp: Right.
Dr. Justin: It’s also different information in measuring and aggregate that way. It really is a marker of complexity and of overall burden which is different than the information that you get at the level of the SPECTRA or the clinical scales. So using it clinically, can be used to answer different kinds of clinical questions particularly when people are coming in for assessments and they’re not doing well, they’re not responding well to treatments. Part of the problem may be reflected in that complexity. And so this gives you a nice empirical marker of what that might look like.
Dr. Mark: And it takes all the information in that you don’t say, well, that’s subclinical, so we’re not going to count that. Or well, you only got 3/9 there. You didn’t get enough for that to be a disorder. It takes every symptom that you have and finds the commonality across all those symptoms and expresses it as a single number of severity that at a minimum reflects severity and impairment.
Dr. Sharp: I see. Yeah, I really want to get into some clinical applications and really bring this to life. And I think we are going to be able to do that. Before we move in that direction, I wonder if y’all could speak just a little bit to the difference or differences between the SPECTRA and some of the other measures that we may know about more. Like, are we in the same ballpark as the MCMI the MMPI, the PAI. People always hate these compare and contrast questions when you’re a test developer, but I’m curious just to bring it to something that is more familiar for folks. How is it different? How is it similar?
Dr. Mark: Well, it has a lot, I’ll give my impression. It has a lot of similarities to those three tests. Our lab, Justin, and I have done a lot of PAI research and published a lot of our PAI research. So it’s similar. It has scales of scales. You can use them like you use the PAI scales. We like to think it’s in the ballpark. We certainly would like to move into that neighborhood at the very least.
How it’s different is that it has multiple levels. I mean, if you think about the PAI, you look across and you see elevations or dips, and that’s what you get. That’s your information. You can go to the end and get the mean clinical elevation but there are no summary statistics with it. And if you think about it, that the foundation of the DSM. Everything siloed. And then you have to come up to a certain level. And if you cross that magic T of 70, all of a sudden, you’ve got something important. If you’re one of the T of 68, is that not valuable information? It has those similarities, but conceptually, it’s just different in that we’re looking… It’s important to know the symptom expression because that’s what the patient is telling you about themselves.
But in our mind and from the test perspective, it’s much more important to know the dimensions, the Internalizing, Externalizing, and Reality-Impairing, and the P factor rather than the actual symptoms. Because in this model, and in this research, you expect those symptoms to fluctuate. You could have high anxiety for a period of time to treat that, then all of a sudden some depression will emerge and your overall standing on internalizing might not change but the symptom expression has changed.
Dr. Sharp: Right.
Dr. Justin: I think the framework is what makes it different. There’s been research on the PAI and the MMPI that has also captured these hierarchical dimensions to varying degrees. But when we were developing this 10 years ago, I think it was at the, at least as far as we knew, it was the only test that was developed our priority with this hierarchical dimensional model in mind. So we were actually… whereas it tests like the PAI and the MMPI, there may be more breadth covered in terms of the constructs that are assessed. We were actually trying to go after these purist markers of these higher-order dimensions because we wanted it to work vertically as well as it did horizontally as a framework.
Dr. Sharp: The way that you talk about it, it sounds a little revolutionary and really cool for lack of a better word. I’m excited to be able to use it.
Dr. Mark: It just gives you a chance to think differently about psychopathology. I’ve been doing this for 33-35 years, and a chance to actually come at something from a different perspective is as has been really energizing. Even in the pandemic, it has upped my enthusiasm.
Dr. Sharp: Well, that says a lot.
Dr. Mark: Just a bit.
Dr. Sharp: Well, I think that’s a nice segue to start to bring it to life a little bit. So let’s start with some basics. What does it actually look like in terms of simple stuff: number of questions, reading level, like what’s the client experience when they take the SPECTRA?
Dr. Justin: So it’s much shorter than a lot of the other broadband measures that are out there. It’s only 96 questions as opposed to multiple hundreds of questions. So it’s shorter. I think it’s a little bit more streamlined in terms of the constructs that they assess with the main goal of trying to capture these higher-order spectra. So we were more concerned with trying to figure out what the purest markers of those higher-order dimensions were as well as trying to have a nice representation of constructs assessed.
But it’s 96 questions. Like Mark mentioned, it maps into 12 clinical scales, 4 scales each that wrap up into these higher-order dimensions. So depression, generalized anxiety, social anxiety, post-traumatic stress, wrapping up into this Internalizing dimension. Drug and alcohol use, antisocial personality qualities, and severe aggression wrapping up into the Externalizing dimension. And then more severe psychiatric symptoms, psychosis or psychotic perception, paranoid ideation, and the more severe end of mania- manic activation, high levels of grandiosity, wrapping up into the Reality-Impairing dimension.
Those constructs, again, sort of being selected. We spent quite a bit of time actually trying to figure out based on the research that was coming out, what were the best markers across these research studies that were assessing these higher-order dimensions. And so…
Dr. Mark: Trying to balance both clinical utilities. We want disorders that had a reasonable frequency so that they would show up in the clinic, but then also what had been shown through multiple studies to be associated with the three core dimensions.
Dr. Sharp: I see.
Dr. Justin: And then it gives it a balance. So 4/4. And even at the T item level, there’s only about a 5-item day difference across the higher level scales.
Dr. Sharp: I got you. So then it’s a shorter test. Do you know the reading level?
Dr. Justin: 4th grade.
Dr. Sharp: Okay. And what’s the age range?
Dr. Justin. 18years and up.
Dr. Mark: Yeah, 18years to 91 years in the normative sample.
Dr. Sharp: Okay, fantastic. So let’s talk about it. I would love to talk about clinical uses. So I will start with a very broad question that we can drill down into as we discuss. If someone was considering bringing this into their repertoire, what is an ideal situation to administer the SPECTRA from a clinician standpoint?
Dr. Mark: So it grew out of our work at the Pearl, the psychological evaluation and research laboratory. And that’s just an assessment referral center where if you’re treating somebody and they’re not getting better, or you’re not sure of what the diagnosis is, or they’ve had a change in condition, you can send them in and we’ll do so psychiatric patients who are in care for one we believe it would have.
Justin recently published a study where it was used in an inpatient setting. So almost any place where psychopathology is a prime component of whatever is going on. So, inpatient outpatient, college-there are college norms in the manual. So college counseling centers, outpatient practices, and we believe that it has utility for medical patients. We have a sub-set of the normative sample that rated their physical health as being either fair or poor on the 5-point scale. And we broke them out to see how they did on the test and they report more psychopathology and the internalizing around than other than the rest of the sample. So we believe it has utility there.
Dr. Sharp: Right. That’s great. And are there, I don’t know if this is the right term, but comparison groups or anything like that? I mean, is it to that point yet, or are you trying to get to that point where there specific populations that we can use this?
Dr. Mark: Well, like I said, we have the college sample. There are 428 college kids and that’s a complete normative. It gives you all the statistics for that. Then there’s sufficient information in the manual to be able to make comparisons to a mild clinical group, to a real patient in our clinic. And then in the mild clinical group are people in the normative sample who said that they had been in psychiatric treatment in the past. They weren’t currently, but in the past, they had psychiatric care. And then also the physically less healthy sample. And we are working to get a more robust demographically setting and larger and a true clinical sample like the skyline for the PAI.
Dr. Sharp: Okay, fantastic. I would love to hear from y’all too, how do we use this data that we get? Well, first of all, what data do we get? What does that look like? These are such naive questions. But what does the score report look like and what do we get from the administry again? And then maybe we can talk about what do we do with it.
Dr. Mark: Justin.
Dr. Justin: So the score reports that get generated are… it’s funny, Mark and I were just talking about this the other day. There’s a couple of different worksheets that PAR has published for us which we liked in different ways. There’s this hierarchical worksheet that people can use, which you can actually plug in your scores from the General Psychopathology Index all the way down to the indices, then down to the subtests or the specific clinical scales so you can get a sense of how psychopathology organizes that way and how you might want to organize your thinking around what’s going on.
The way that the output prints it, however, is in a similar way to PAI graphs are printed. The clinical scales appear first on the graph moving left to right. They’re organized by domain. So you’ll get the T scores for depression and anxiety and trauma, et cetera. And then on the right-hand side, they print the SPECTRA scores and the General Psychopathology Index as a cluster.
So you almost have to, or at least when I look at them, I usually will start on the right and then work my way left because I like to see initially looking first at general psychopathology, just to get a sense of complexity and of burden and then seeing where there’s the greatest expression in the specific SPECTRA scores and then working my way down to the clinical scales to try to figure out where that’s getting expressed the most.
PAR also prints a table for you. So for people who are more inclined to look at tables, they’ll have it all in tabular form and you can look at the T scores and the percentiles. And you can look at it that way if you like. Visually, I think it looks pretty good. Again, I think I prefer the top-down method just because that’s how I think about it conceptually. But it’s fairly easy. It’s very similar to the PAI tables or MMPI tables that are printed just in terms of the vertical axis being T scores. So that’s what’s printed. Mark, did you want to talk about organizing it?
Dr. Mark: Well, I also wanted to say that in addition to the 12 clinical scales, there are 3 supplemental scales that include cognitive complaints, psychosocial functioning, and suicidal ideation- suicide risk. So in addition to the clinical scales and the hierarchical dimensional scores, you also get this information, the client will tell you or the patient will tell you if they believe they’re having common cognitive difficulty, can’t find, lose stuff, can’t plan, has trouble expressing themselves the way they want to.
And then also psychosocial functioning and the psychosocial functioning scale, we’re proud of it. It taps four components of psychosocial functioning: well-being, agency, social support, and if you have secure housing and resources to meet your basic needs. And that’s the only scale that as it rises, it’s saying that you’re doing better. So it also gives you a way to see if there was a risk response style in terms of all good or all bad.
Dr. Sharp: Okay. I was going to ask about anything along those lines of validity scales or effort that sort of thing or malingering that sort of stuff?
Dr. Mark: And so it has one embedded scale to measure whether you paid attention. So like the inconsistency or infrequency scales of the PAI. It has three low endorsement items scattered or place evenly throughout the test. And that’s the main validity scale for you paid attention. It has a profile classification index which we created a little post-talk, but it looks at how many elevations there are at the higher level. And it’s unusual for you to have three or more elevations at the dimensional level. And when that happens, 0 to 2, it’s acceptable, 3 and above it’s called elevated. It doesn’t say it’s invalid, just says it’s elevated.
Some people might have a reason for having that much psychopathology. And it’s one of those things where you can finish a test and you think to yourself, well, maybe we could have put more effort in that part having validity scales, but it’s just a part of it. We’re not special forensic psychologists. People come in, they’re in treatment, they’re treatment-seeking people and we suspect… and we also just never give it as a standalone test. We test these use a battery of tests.
Dr. Sharp: I’m glad you said that. I would love to dig into that a little bit. Can you walk me through, if you have an example, a case or two, or even a conglomeration of cases. How does this fit into a battery? Is it appropriate for “neuro-psych testing” or just more of a social-emotional assessment? How do you see this fitting in with other measures?
Let’s take a quick break to hear from our featured partner.
The SPECTRA Indices of Psychopathology provides a hierarchical-dimensional look at adult psychopathology. Decades of research into psychiatric disorders have shown that most diagnoses can be integrated into a few broad dimensions. The SPECTRA measures 12 clinically important constructs of depression, anxiety, social anxiety, post-traumatic stress, alcohol problems, severe aggression, antisocial behavior, drug problems, psychosis, paranoid ideation, Manic activation, and grandiose ideation, and organizes them into the three higher-order psychopathological spectra of Internalizing, Externalizing, and Reality-Impairing. These scores provide a quick assessment of the overall burden of an individual psychiatric illness also known as the P factor.
The SPECTRA is available for Paper-and-Pencil Assessment or administration and scoring via PARiConnect- PAR’s online assessment platform. Learn more at parinc.com\spectra.
And for a limited time, get one free administration and score report for the SPECTRA on PARiConnect by calling PAR at (855) 856-4266 and mention promo code S-P-E-C.
All right, let’s get back to the podcast.
Dr. Mark: Our clinic is pretty standardized anyway. We do an IQ. We do a WASI. We do Trails A & B. We do List Learning Story Memory, Visual-Spatial tasks. We do the Hooper Outline Orientation tests. Language Fluency category and semantic fluency, the Stroop, and Wisconsin Card Sorting Test, then PAI, the SPECTRA, NEO, the short five-factor model, and […] cards and sometimes the test of occurs for attention- self-report attention, and other times, maybe a PID-5. So the personality disorder inventory for the DSM-V 100 item version, the PID-5.
Dr. Sharp: Got you. Oh my gosh. The blessing of a university or hospital clinic where you can do such a comprehensive evaluation. Amazing.
Dr. Mark: And we’ve been doing that for years and we have a de-identified database with over 1300 independent cases in it with all that data and demographics.
Dr. Sharp: That’s incredible, I’m so jealous. I was talking to my APEC intern yesterday about doing research in private practice and just how to get that ball rolling. It’s hard when you’re separated from some of those institutions. I miss it. So y’all have tons of data and it sounds like you’re doing a really comprehensive battery. I would love to hear how you just think about integrating the SPECTRA data in a report where there’s a lot of neuro-psych testing going on. How, again, just trying to bring it to life a little bit how you might integrate that information with the cognitive data that you’re getting?
Dr. Mark: So we still suffer from that dual mind-body thing. So we still present the neuro-psych data first. And when that concludes, then we go into the psychological profile. And what I do is I present the SPECTRA data as the first paragraph. I work big to small. I work from the P factor from the Global Psychopathology Index.
I have my first… after saying everything was valid and revealing or not revealing, then I will say something like endorsed moderate levels of overall psychopathology at a T score of 67 on the SPECTRA Global Psychopathology Index. A score in this range suggests a substantial burden of psychiatric illness, vulnerability to a relapse, a likelihood of impairment in their life based on psychiatric factors, increased likelihood of not responding typically to treatment- so either suboptimal or on a typical response to treatment.
And then down to the dimensional level. So if symptom expression was confined to one domain, the statement is that majority of symptoms that were reported were indicative of Internalizing psychopathology, Internalizing scale T 78 could suggest that type of psychopathology is confined into one dimension will likely respond to standard internalizing types of treatments- SSRI and Cognitive-Behavioral Therapy.
If it’s broader, psychopathology was expressed in 2 or 3 separate domains of psychopathology suggesting get increased complexity at the level of symptom expression suggesting that multifocal treatments going to be required and the intensity of treatment may need to be increased. And then down to the clinical scales to say, and specifically, this is the type of symptoms that have been expressed: depression, anxiety, alcohol, anger, and paranoid ideation.
Dr. Sharp: I got you. So you will get down that granular and talk about that.
Dr. Mark: Right down the pyramid.
Dr. Sharp: That’s great. That was fantastic and eloquent. You’re the test author, so where does all this information come from? Are there any materials to help us interpret the data or know how to phrase things? So I guess I’m asking like, is there an interpretive reporter or is this in the manual or how do we know what to do with this stuff?
Dr. Justin: So there are materials in the manual that help with applying these to different cases, different clinical presentations you might see, and how to think about organizing the test scores. So there are materials there. I actually teach right now and I’ve been teaching students how to organize it into these bigger integrated assessment reports that I still do and train under Mark and doing at Mass General. So that the same evaluations that he does.
So I’ll talk with people about how to integrate them that way. It’s still a fairly young test and I think Mark and I are still very much in the process of actually trying to disseminate this out into the world right now. But I think those are probably the best sources of information, I think right now, currently. Mark and I have actually been talking about building a website dedicated to the SPECTRA where we can actually begin to post some of these specific resources, some training videos, some worksheets clinicians can use, those kinds of things,
Dr. Mark: samples, things like that. I’ve been teaching report writing. Again, I keep dating myself, but again for 25 years to interns and post-docs and junior faculty, and I’ve had to rethink again how I have written reports even though I published on writing reports. And so now that first paragraph is a little different than it was in the past. And it may change in the workshop that I gave for Crespi. The slide leading it to write up the report said” A work in progress.” It’s like, we’re still … that’s what I like about being on this exploration with the SPECTRA is that we’re still discovering, learning things, how to apply it, what it’s telling us, how to communicate it back to the psychiatrist and neurologists and primary care doctors.
Dr. Sharp: Right. Well, kudos to you for being flexible and revising your approach. That’s not a given in our field necessarily. So we talked a little bit before we started recording just about the benefits to clients. And I think that we’ve certainly touched on that just through our discussion. But is there anything more explicit to say about how a measure like this could be more helpful for clients or ways that you translate the info to clients that may be different than what we have?
Dr. Mark: Well, one of the things that I’ve been pleasantly surprised is that in feedback sessions, they’ve been by zoom primarily, that the being able to say to somebody, yes people have you have anxiety, you have depression, you have social phobia, you have all this, it internalizing. It’s one thing. You don’t have seven different disorders. You don’t need seven different treatments. It’s not that daunting. It’s internalizing psychopathology and if we’re lucky enough, it’s confined to that. So that’s how we’ll approach it. It’s all in the transdiagnostic treatment of emotional disorders. We’ll try to hook you up with that care.
So that has been easier. It’s been better received than the laundry list of I think this is your primary thing, but then you’ve got this and that.
Dr. Sharp: Right. So this is the part where I go off script and start to make people nervous I think with my questions. But here’s what running through my mind. And this could be a completely naive question. Again, just not living in this research world. How do you reconcile that with, I don’t know if diluting is the right word, but I think a lot of people maybe hang on our diagnoses as a proxy for clarity and what we recommend, you know, like treatment for depression looks like this and treatment for anxiety looks like this. But you just mentioned a transdiagnostic treatment model, and that’s a relatively new term for me. So I’m really curious how y’all think through that?
Dr. Mark: But outside of a clinical trial that has incredible rule-outs and other kinds of ways to exclude patients, nobody comes in with just depression. Nobody comes in with just anxiety. If you’re saying that to somebody you’re kind of fibbing with them. You can say you have mostly depression or mostly anxiety or mostly PTSD, and we’re going to ignore the other stuff you have, and we’re going to focus on this until we get it pretty much under control, then we maybe refer you to… And it sort of matches the way so far that nature says psychopathology gets organized
Dr. Sharp: I love what you’re saying.
Dr. Mark: because it’s the DSM which is just a bunch of expert committees that have opinions.
Dr. Sharp: Right.
Dr. Mark: And storms other things that they need to maintain.
Dr. Sharp: Yeah. That’s a can of worms to open which one day I need to do that episode “Why is the DSM even a thing?”
Dr. Mark: Don’t advertise it because they’ll probably shut you down.
Dr. Sharp: Right.
Dr. Mike: Big DSM will come and get you.
Dr. Sharp: Yes. Okay, let’s edit that out. But it almost seems too easy the way that you’re presenting it like we’re cheating or something to just say, “Hey, this is just internalizing this is a suite of internalizing concerns. And here’s what we do about that.” That feels like my job will get so much easier if I can do that.
Dr. Mark: And what is wrong with that?
Dr. Sharp: Sure.
Dr. Mark: Again, if you go back to the analogy to intelligence testing, you do that all the time. You have very strong verbal strengths, very strong verbal abilities. What can we do to help you find something that maximizes that and minimize your need to do this visual-spatial stuff that you’re not that good at?
So, we don’t sit there and say, well, block design was this, and picture comprehension was that. And it’s like, you move it up to the next level of organization. But you can certainly go down. I mean, do you have the 12 clinical scales, the scales they map back? They were designed to map back to DSM construct. So if you want to do that, you could treat it like the SCL 90, and just say here are these 12 things and you have a bunch of them or just these two.
So it’s up to you. You don’t have to… It’s like having a car that has a lot of horsepowers. You don’t have to drive it fast.
Dr. Sharp: That’s a good analogy. Justin.
Dr. Justin: I was just going to say, I’m going back to your question from a second ago in terms of what makes it different or what makes it unique? I think one of the things that have been written about and looked at in psychological assessment specifically is this idea, people do a different assessment, but this concept of multi-method assessment and the idea of method variants basically varying the different ways you look at how somebody is doing, how they’re feeling, how they’re functioning, but using different techniques.
So the battery that Mark just went through, he talked about different tests that capture in different ways. I think one of the ways that when I use the SPECTRA in my own practice and I think it also relates to your feedback question, when I’m using the SPECTRA, I’m usually using it in concert with other methods. And the reason that I’m doing that, and I don’t mean to like over-intellectualize this, but I think it’s a conceptual question. The thing that I think makes the SPECTRA unique is that it captures different information than other standard psychological assessment tools that are out there- particularly broad other broadband measures, like the PAI in particular or MMPI. Although the MMPI has created these indices of the SPECTRA, post-hoc, but the idea is that when you’re able to capture this information, I think it gives you a different insight into how somebody is doing, where their primary areas of difficulty are, and or, how much complexity is present in somebody’s presentation when they’re coming to see you.
So sometimes I think about when I do this work, it’s almost like layers of an onion. Basically, like Mark said, it’s not one thing you’re really grappling with. Part of how I understand the work is, I’m trying to organize hierarchically the multiple things that are going on with somebody in a way that helps me understand them, helps them know that they’re being understood, and then based on that information, create a more specialized and refined treatment plan or set of steps that somebody could take whether it’s medicines that might or classes of medicines that might be useful or different psychotherapies or other treatment approaches that would be helpful.
I think it’s that different information and the way it gets organized differently, that is what makes it useful. And you can use it as part of a standalone battery. I also think one of the nice things about it is kind of like the PAI or other broadband measures are out there, you can use them in different contexts. You can use them in screening contexts. Here in Boston, I know of a number of different neuro-psychology practices that are now using it for the adults that they’re seeing.
So I think there’s just a lot of versatility, a lot of flexibility with the tool. And I think it’s again, that method variance idea that the way in which you’re capturing this information, it’s really different than all of the other instruments that you’re including in a battery. And because of that, I think it adds value and helps you organize feedback information back to the people that you’re working with in a way that might be more helpful.
Dr. Sharp: I wonder if I can put you on the spot a bit and ask about particular cases. I don’t know if either of you has one in mind because I would love to hear how this shows up in real life. When you say, I get different information or it gives me these different layers, is there anyone that you can think of off the top of your head that might illustrate some of this? I’m taking a long time to ask the question to give you time to think. And if the answer is no, that’s okay. But I thought I’d ask.
Dr. Justin: It’s funny and Mark may have cases too. So I teach Advanced Assessment for doctoral students in Clinical Psychology right now. And basically, I teach cases like cases that have been really interesting to me and where I’ve used this.
And there was a particular case that I actually got done teaching not too long ago. It was of a woman who came to see me who was being treated for OCD. She had been at an OCD for about five or six months. Her treatment wasn’t going well. She was having a hard time focusing in sessions. She basically wasn’t completing her homework exercises outside of the session. It was a very ERP approach to OCD. And so in the context of the conversation with the therapist, it had come up that the woman had been diagnosed with ADHD earlier in childhood, I think in the 8th grade. And so when the referral came to me, it was, is this ADHD, is there data to support ADHD or is it more anxiety-driven or more OCD-driven?
So that was the basis for the referral.
So I have this woman come in, I interview her, I begin to go down this path of doing this assessment. And one of the things that Mark taught quite a bit is this flexible battery approach and being able to shift and be flexible where you need to in terms of what you administer. So I’m interviewing this woman. She’s peculiar. I mean, there’s a question as to what’s happening as I’m working with her. I sort of mentioned all these funny stories and why I teach it in my class, but one of the things that happened is, I was finishing the cognitive testing, I was about to start the performance by Rorschach I was going to give her and her phone rings. She reaches into her bag and pulls out her phone and realizes that’s not the phone. And then reaches back into her bag, pulls out this other phone, takes the call, and then hangs up.
And I said to her, why do you have two phones? And she started telling me about how she was a little concerned that her parents were listening to her conversations. And I was like, “Okay.” And so I hadn’t planned to give a Rorschach at that point, decided I was going to give a Rorschach because I was beginning to wonder about just peculiar, odd thinking. Anyway, fast forward, I go through my standard. There was a PAI, I gave a SPECTRA, I gave a NEO, a Rorschach, a few other self-reports to get ADHD symptoms. And one of the things that really helped me… So ultimately my clinical formulation was that this was not OCD. It was not even within the Internalizing spectrum. I was actually worried about Prodromal Schizophrenia that was starting to bud.
So she elevated some of the psychotic scales on the PAI. But it was really the SPECTRA that helped me organize it because General Psychopathology Index was fairly elevated, but it was the Reality-Impairing spectra that she elevated the highest. She also had some depression and some anxiety.
And it was interesting because when I was interviewing her, I was asking her lots of questions about overt, hallucinations, delusions, ideas of reference, those kinds of things. And she wasn’t reporting anything to me. She mentioned a couple of unusual ideas to me. But it wasn’t really until I started to look at her profile in conjunction with other things I was seeing in the Rorschach and the PAI, but it was really this Reality-Impairing spike where I really started to shift my thinking more towards something in a thought disorder domain.
So clinically, that was useful. I can tell you when I gave the feedback to her and to the treatment team that had referred her, they thought I was nuts. They thought I was completely off base and they were actually upset. And it wasn’t until about a month later after she had fired her first psychiatrist a month later, she actually was scheduled to see her follow-up psychiatrist, her psychiatrist who I was friends with actually gave me a call.
And she was like, Justin, I just wanted to let you know that I read your report. She came into the office today and she was floridly psychotic. They had to call security actually and take her to the emergency room. But it’s not to say that I was right. It was really the SPECTRA that brought me away from/move me away from these initial referral questions, these initial hypotheses which sometimes I talk to my students about, it’s when people, at least in the adult world where we’re working with people who have a lot of psychiatric complexity, these initial referral questions, you almost have to take them with a grain of salt because usually, it’s code form. We just don’t know what’s happening and we need some help. So that’s a recent clinical case that comes to mind where I think the SPECTRA did a nice job organizing it and doing something different.
Dr. Sharp: Right. That’s a great example. Mark.
Dr. Mark: So I had a very similar experience early in the use of the SPECTRA. And I used it in the workshop. As a case, a gentleman who was referred had a longstanding.. he’s mid-30s, college-educated, professional job, not advancing much in his career. Actually, he was being demoted at work and then had this convoluted relationship that ended, fiance left. He wound up with 2 Boston apartments. It’s hard enough to support 1 Boston apartment but to have 2 apartments in Boston that you’re on the hook for.
And then there were a few other things in history and made me wonder. The life didn’t seem as coherent as it should have been based on how it was presented in the referral. And so I did the evaluation and again, the very comprehensive battery that we use. But the SPECTRA was very… He was referred. It was on anxieties. They thought he had just like Justin’s case thought it was ADHD because he couldn’t get organized going into his work. And he had anxiety on the PAI and on the SPECTRA at the clinical scale level spiked above 80. He had a lot of anxiety. No other internalizing psychopathology. So the Internalizing spectra level scale wasn’t that elevated whereas he had a bunch of paranoia and psychotic responses on both the PAI and the SPECTRA and the psychotic SPECTRA level scale was the highest. And he had a high Global Pathology Index.
So it’s not a common case. They’re missing what is causing all this disruption in the rest of his life. And then he had hard for him to work and collaborate with his caregivers. And so now that I use it to say confirmation bias. Okay, he’s got anxiety. He is being treated for anxiety. He spikes anxiety like crazy. It’s all he wants to talk about in a clinical interview, his anxiety. He must have anxiety.
Well, he had more things. And even looking at the data printed out, you could have been so impressed by the hike because it was really a spike in anxiety. It was a T score in the low 80s, which is pretty darn high. But when you aggregated it, Internalizing and Reality- Impairing, the Reality-Impairing was slightly higher in terms of the SPECTRA level.
And I had one that was the other way round. The person was paranoid and was having trouble again at work. Actually, he was referred by a PCP and it was having trouble dealing with a medical issue that needed him to trust the doctor and take his medicine and follow up with things. And he wasn’t doing it. And his global level of psychopathology was low.
It was actually in the average range. He spiked paranoia. It wasn’t quite clinically elevated, but then a lot of it was cleaned, a little bit of depression. And I said this doesn’t fit. And they did an MRI, it had a stroke. They found a PFO. So he had the little hole in his heart. He threw a clot, he had a very small stroke and it was in an area which can disrupt your ability to process interpersonal interactions.
Dr. Sharp: These are great examples. Goodness. These are the perfect clinical examples for clinician edification too, right?
Dr. Mark: And also just to take the leap of faith and say no, that the data is not saying that they thought he was a paranoid personality disorder, that it hadn’t come out. He was in his early 50s. It hadn’t come out previously. And he had had a good work history in property management and doing other things that made him have to interact with people. And it just didn’t fit. It was there a little bit, but it wasn’t there pervasively enough to make me think that it was just psychiatric.
Dr. Sharp: Right. I appreciate y’all talking through those two. I know there are probably many more that we could talk about, but those are good. It’s helpful for me just to map it onto a real person and see how it might work. I’m excited to use it. And I’m going to have to start seeing some young adults, here again, so I can check it out.
So as we start to wrap up, what have we not talked about that feels important? Anything that y’all want to make sure and highlight before we sign off here. Is there anything that sticks out? Any parting words?
Dr. Mark: Just remember, if you want to use it, you have the code from PAR that can get you that one free administration. But for me, it’s finally an exciting time in assessment and psychopathology that after 30 years of lock grip of the DSM where papers had to have DSM diagnoses to get published, grants had to have DSM diagnoses, treatments at DSM diagnosis, the licensing exam required you to use the DSM and you had to do it, you still have to do it to get paid, that this is finally loosening up and you can at least publish research. You can think about things in a different way. And you can go back to your training as a psychologist and an empirical scientist and try to understand.
And for me, I have written about it. It’s in two book chapters that I’ve written about how to get out of being locked into just assessment. That we’re such a small professional click. We have SPA, we have division 12 section 9, we have division 5 that we can belong to, but it’s not a lot of us. And what our research journals publish is test data and test validation and test stuff.
So, these dimensions: Internalizing, Externalizing, and Reality-Impairing are being used in epidemiological research. They’re being used in child development and adolescent longitudinal research. They’re being used in neuroscience research. And this allows you to step out and link what you do to new findings in related fields in a way no one’s going to give the MMPI or the PAI or even the SPECTRA to 1000 people and then follow them. You’re not going to do that. But you give some measures and then you can use the same statistical techniques factor analysis to find the dimensions. And then you can find the correlates of those dimensions. And it’s reasonable to expect that there’ll be the same for the assessment instrument.
So for me, it’s a way that just is more integrated into a broader field of psychology and mental health.
Dr. Sharp: Yeah. Well said. I’m just thankful that y’all are part of this movement a pretty big piece to develop a measure like the way that you’ve done it. When I first stumbled on to the hierarchical taxonomy of psychopathology, I was like, “This is amazing. This is the way that we really should be thinking about things.” And so, to see us moving slowly but surely in that direction, like I said, not only makes our job easier in some ways, but it’s also more accurate, I think for clients, and helps us do better work in the long run. So thank you all for the work that you’re doing.
And this measure, you briefly mentioned the code, I know it’s probably in the pre-roll and post-roll too, but I just want to emphasize that’s in the show notes. For anybody who wants to try the SPECTRA, there’s that code through PAR.
I really appreciate your time, guys. This is fun.
Dr. Justin: Thank you for having us.
Dr. Mark: Really appreciate coming on and sharing our work with you.
Dr. Sharp: Okay, y’all, thanks for listening. Thanks as always. These guys were super nice, super knowledgeable. And like I said, certainly instilled some excitement about checking out the SPECTRA. So I am going to be digging into that. And you can too with the code that you heard during the episode, it is also in the show notes. So check that out if you want to give the SPECTRA a world.
And like I said, in the beginning, if you are an advanced practice owner and you’d like to get some support and accountability in building your practice and living a more sane, profitable life, this group could be for you. So check out The Testing Psychologist Advanced Practice Mastermind. A new cohort is starting June 10th. You can get more information at thetestingpsychologist.com/advanced.
All right, take care. I will be back with you next time.
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