Psychologist Rebecca Shiner on Narrative Identity & Personality Disorders

An Interview with Clinical Psychologist Rebecca Shiner

Rebecca Shiner, Ph.D. is Professor of Psychological and Brain Sciences at Colgate University. She specializes in the intersection of personality, clinical, and developmental psychology.

Sara Wilson:  Hi, everybody. Thank you for joining us today for this installment of The Seattle Psychiatrist Interview Series. I'm Sara Wilson, a research intern at Seattle Anxiety Specialists. We're a Seattle-based psychiatry, psychology, and psychotherapy practice specializing in anxiety disorders.

And today I'd like to welcome with us clinical psychologist, Rebecca Shiner. Dr. Shiner is Charles A. Dana Professor of Psychological and Brain Sciences at Colgate University. Dr. Shiner is recognized for her pioneering research at the intersection of personality, clinical, and developmental psychology. In addition to the books Handbook of Temperament and Handbook of Personality Development, she has written extensively on the assessment causes and consequences of personality disorders in youth. So before we get started today, could you please let us know a little bit more about yourself and what made you interested in studying personality development and its implications?

Rebecca Shiner:  Okay. Yeah, thank you so much for inviting me to do this, Sara. I'm really looking forward to it. I got interested in studying personality development when I was in seventh grade. I'm not sure if you want me to go back this far, but anyhow, I will tell you briefly the story. So when I was in seventh grade, I had to write my first term paper, and it felt like a very big deal and very serious. And so I went to the library looking for sources of inspiration, and I came across a book that was a children's book about Freud. And so it covered all of Freud's theories in age-appropriate levels of description. It went and talked about the anal stage, the oral stage, the Oedipus complex, all of that. And when I read it, I thought, "Oh my gosh, this is amazing. I can't believe that no one ever told me about this."

And I was just completely captivated. There was something about taking seriously the idea that there's continuity across the course of people's lives, but also that people change over time that just grabbed me. And so I wrote my term paper on Freud, and that really has been my passion ever since. And so when I got to grad school and I realized that I could actually study people's development over time, that I could look at longitudinal studies where they follow the same group of people and I could look for traces of continuity and change, I decided that that's what I wanted to do.

Sara Wilson:  That's beautiful. I love that.

So in a recent talk you gave about narrative identity in the context of personality disorders in adolescence, you've discussed three levels of personality over the course of our development. Could you introduce each of these to our audience?

Rebecca Shiner:  Okay, sure. So personality is more than just people's personality traits. So I think often when people hear the term personality, the first thing they think of is personality traits. And that really is an essential part of our personality. So our traits are the ways that we tend to be at least somewhat consistent across situations and across time, and they summarize general ways that we have of interacting with the world. A good example of a personality trait that everyone knows, I think, is extroversion versus introversion. But another trait that's really relevant to clinical psychology is neuroticism, which ties into Freud. And also really what it reflects is our individual differences in how much we're prone to experiencing negative emotions like anxiety and irritability, vulnerability, and so on. So those are traits, and those emerge early in terms of our temperament. Some of the traits even emerge within infancy, although they change considerably over time.

Okay, so that's the first level, level one. Then the next level is level two. And level two, it has different names. Sometimes it's called characteristic adaptations, but level two has to do with tendencies that we have in terms of what we're trying to accomplish and the goals we're pursuing, the ways that we're motivated in our daily lives. So for example, people vary in terms of the goals that they have for themselves. So for one person, it might be deeply important for them to connect with other people, and then another person might have really strong motives for achievement, or you may have different goals depending on the context you're thinking about. So that's level two, and then that emerges elementary school age when kids start to be more able to control what they're doing and are able to really act as motivated young people.

And then finally, the last part is level three, it's narrative identity. And so that's what we're going to be focusing on today. This does not emerge until adolescence. And narrative identity has to do with individual differences in the way that we make sense of our lives, in terms of the stories that are important to us that we use to tell who we are and what we are about, how our past is connected with who we are in the present and the future. So we vary, very much in terms of the way that we narrate or tell the stories of our lives.

So a good example would actually be the story that I told you about why I decided to study personality development. That was a narrative describing how I came to be excited about this area of research, and we could analyze it in terms of different themes that pop up or how the emotional language in it is positive versus negative and so on. So we all grow in terms of the stories that we tell. As I said, it starts in late or middle to late adolescence, and then it's something that we're really working on over the whole course of our lives.

Sara Wilson:  Yeah, so interesting. Yeah, that example's so good too.

Now, where does a personality disorder come into all of this, and why is narrative identity relevant? What is a personality disorder?

Rebecca Shiner:  Okay, okay. So yeah, we'll start by talking a little bit about what a personality disorder is. Personality disorders are distinguished from other psychological disorders that people might have in a couple of different ways. The key features of them are that people are experiencing persistent difficulties in terms of their sense of self or sense of identity and/or, in most cases, and, they're struggling with different aspects of how they're relating to other people. So it's a fundamental disturbance in both the sense of self and in the sense of relatedness to other people. And so clearly identity is part of that because some of the disturbances in the self have to do with disturbances in the person's sense of identity, in terms of how they understand themselves, say across time, or how they see themselves in terms of their self-esteem and so on. There is a very big burst of interest right now in trying to understand how narrative identity relates to personality disorders because people haven't really been studying that directly until I would say the last five years or so.

Sara Wilson:  Yeah, I think that this topic is so interesting, especially narrative identity, just because you have, in some sense, so much agency over the active construction of this self, and then at the same time, it's like a working schema that affects the self directly. So it's like this feedback loop.

Rebecca Shiner:  Yeah, I agree. I think it's an exciting area to research because I think there's... And it's exciting from a clinical perspective too, because I think there's more of a sense of potential for making significant changes in narrative identity, in part because it's likely to be less heritable and is really evolving over time. So yeah, there's the potential for change there.

Sara Wilson:  Yeah. One thing that I was very curious about was how does narrative identity differ from our actual real identity? And I don't even know what that means, I guess.

Rebecca Shiner:  No, no, it's a great question because I think that there are different ways of conceptualizing identity. So very often when people think about identity, they think about it in terms of just how we see ourselves in terms of our role, in terms of our sense of vocation. So for example, a person's identity may involve their race or their sex or their sexual orientation. It may involve the kind of occupation that they have or their status as being a married person or a parent and so on. And those aspects of identity are fundamentally important to who we are as individuals, but they're distinct from narrative identity because narrative identity really has more to do with how we tell the stories of our lives. So you could be someone who has exactly the same sense of identity across all of these dimensions as another person, and yet your narrative identity is still going to be distinct to you because it's going to have to do with your own history and how you make sense of how your earlier experiences have impacted who you are now.

Sara Wilson:  Now, as you have conveyed in a lot of your work, feeling a lack of agency over your life can really be the root of enduring mental health and personality problems. But then on the flip side, it might also come with this immense pressure to define who we are and take action because our narrative isn't going to write itself. And I was curious how, from your point of view, we should go about reconciling this kind of tension that comes with narrative identity.

Rebecca Shiner:  Yeah. So let me say a little bit about what agency is and how that links up because I think that these ideas can be very abstract and hard to understand. When people share a story from their past, those stories that they tell, you can actually look at them across a bunch of different dimensions. And when people are doing research on narratives, what they do is they ask people to tell the story about something significant, for example, a turning point that helped establish their sense of who they are. So you can take those stories and you can code them along dimensions that typically characterize stories that people tell.

And so one of the really fundamental dimensions that you can look at, or you can at least look for in any narrative is a sense of agency. That is considered a motivational theme that gets at how people understand themselves in terms of how they're moving through the world, how they're motivated. Agency has to do with having a sense that you are the director of your own life. So you tell your story in a way where you're in control of the things that are happening to you, and you are active rather than just being a passive victim at the whim of your circumstances. So you're making things happen, you may be growing and changing and so on.

And agency has turned out to be one of the most important aspects of the way that people tell their stories, because across a huge number of studies, looking at a lot of different outcomes, having a stronger sense of agency, being the author and the director in your stories, it's linked up with all kinds of well-being. So a greater sense of satisfaction with life, lower levels of different psychological symptoms like depression and so on. So it seems to be really good and really positive in general.

Yeah, one other important finding that's been found by John Adler, he did a study where he was looking at the narratives that people wrote after they had therapy sessions, so while they were in the course of therapy. And people who produced stories after each therapy session that were characterized by stronger agency tended to be the ones who are getting better over the course of therapy too. So it actually seems to be not just a correlate of doing well, but seems to be an active ingredient that helps people to do better. But your question is about a sense of agency, how we go about creating that. Is that what you're asking? I want to make sure I'm answering the right question.

Sara Wilson:  Yeah, and also maybe are there any caveats or trade-offs when it comes to just this pressure to define who we are. As we're shedding more light on it in a clinical context, I was wondering if there's any trade-offs to agency?

Rebecca Shiner:  Yeah, that's a great question. I think that if it's agency that's being forced by someone else, it's not really agency at all, because that would be... If a person is feeling a kind of pressure to be agentic, in a way that is undermining the very essence of what it means to have a sense of agency because it's action that's initiated on your own and where you see yourself as freely choosing to act and to do things in your life. I don't know of any studies that have found a negative relationship between agency and well-being. There are definitely studies where it's not related to the outcomes that they're looking at.

Sara Wilson:  This is very interesting. It's a very promising finding with the therapy sessions and the really tangible effective role of narrative identity and meaning-making and agency being very interconnected with our belief systems.

Rebecca Shiner:  Right. And I think it's important to note too that it's not like people are consciously... Normally, people aren't consciously necessarily deciding that this is how they're going to tell their story. I think they could. They could. But in most of these studies, it just seems to be a process people aren't even necessarily aware of. And so the people who tell those stories with a sense of agency do turn out to be doing better.

Sara Wilson:  On that note, what is the role or importance of meaning-making and why is there this focus on the client's relationship to their beliefs, narrative therapy, and in other therapeutic techniques more broadly?

Rebecca Shiner:  Yeah, that's a great question. There's a whole separate line of research that's about meaning-making in life and purpose in life that in general finds that it's really an essential component of wellbeing. It's not the same as being happy, for example, but it's another really important sense of thriving in the world. So meaning, being able to make meaning out of your experiences, I think especially negative or traumatic experiences I think is fundamentally important. People can make meaning in different ways. They can make meaning by pursuing something that they feel called to do. They can create meaning by doing something in service of other people, for example. But narratives also give us a way of making meaning, because it's our way of trying to understand how the things that have happened to us have affected us, and how our own choices and ways of navigating the world also are impacting the way that we're doing right now.

I think narrative is another important contributor to a person's sense of meaning. So for example, if someone has had something very painful, very traumatic happen to them, one way of trying to make sense of that is to try to understand the impact of it and to really find a way to weave that into the story of your life rather than having it be just this standalone, horrible thing that has happened. So there's something very powerful about the process of trying to understand the impact and how perhaps you can carry that with you moving forward. That is really helpful, and I think that that is part of what can happen in the process of therapy.

Sara Wilson:  I think that this is so fascinating, especially because it's not really the content necessarily of the narrative or your belief and/or your story that's changing, it's the meaning around it and the organization of it, and I guess the degree of how attentive you are to certain things, how integral they are to you, which relies a lot on your relationship to this content.

Rebecca Shiner:  That's right. I think that's right, because it doesn't necessarily mean that you have to change the content of what you believe, but through the stories that you tell yourself about what you've experienced, it may affect the way that you can imagine yourself moving forward into the future.

Sara Wilson:  Yeah. One study of yours that I was very curious about your paper, “The Relations between Narrative Identity and Personality Pathology among Clinical Adolescents: Findings from a Multi-Ethnic Asian Sample”, this was the first study to assess the links between themes of narrative identity and personality disorder domains in a clinical adolescent sample. Could you explain the study a little more to our audience, why you chose the participants you did, and just your findings more broadly?

Rebecca Shiner:  So this is a paper... The first author of this paper is Amy See, who at the time that she did this study was a PhD student at Utrecht University in the Netherlands working with Theo Klimstra, who is a colleague of mine whose studies actually identity development in adolescence. Amy See herself was from Singapore, and so she was very interested in trying to look at whether the narratives of adolescents are linked with their emerging personalities and particularly personality difficulties that they might be having. As I mentioned, adolescents, teenagers are really in the very earliest stages of starting to develop their narrative style and are really starting to have a richer sense of what are the most important episodes from their lives.

What Amy did was she recruited a clinical sample. These were teenagers who were being seen at the largest mental health clinic for adolescents in the country. And so she asked them to write about a turning point that they had experienced. And a turning point is a specific kind of narrative where you ask the person to share something, to share an experience that they've had that really informed the way that they understand themselves, that really changed the way that they perceive themselves. So she asked them to write about that, and then she also asked them to fill out a questionnaire about difficulties they were having in terms of their personalities. So these were not young people who were diagnosed with personality disorders, they were having clinical struggles, and they were just reporting on personality difficulties they were having.

So the most striking finding from it was that there was a particular dimension of those narratives that was related to personality difficulties that the young people were having. And that dimension is one I haven't mentioned yet, which is communion. Communion is a motivational theme similar to agency that describes how much the person tends to talk about positive, loving, close relationships with other people, with friends or romantic partners. If you're looking at a sample of adults, it may also be caregiving relationships or any sort of feeling of connection with other people.

And so what we found in this paper is that the teenagers who were having more personality difficulties tended to express lower levels of this kind of positive communion with other people in the turning point stories that they told. We're not sure which came first. We don't know if it may be that they were having problems in their relationships, and so then that's reflected in their narratives. It could be that the way they tell stories was affecting their mental health, for example, by making them more depressed. I thought, if it's okay, I could share a couple really short narratives from that study because I think it will make the findings a little more concrete. Is that okay?

Sara Wilson:  Yes, we would love that!

Rebecca Shiner:  Okay, so here's a first turning point narrative from one of the teenagers. "I was diagnosed with depression one year ago. I was not myself and caused a lot of problems for my family. After a number of sessions with the psychologist, I started understanding myself better and why I behaved the way I did. This made me change my mindset, and I told myself to enjoy life more. I am now feeling happier and approach life in a more positive manner." So this person is talking about learning and growing through the process of therapy, but they're also suggesting that they had been having a lot of problems with their family. But they're talking about this positive connection with the psychologist and this more positive mindset that came out of it. So they're expressing a sense of communion.

In contrast, here's one from a participant who expressed a low level of communion. "So I was sexually abused by a family member a few months ago. It made me feel hurt, horrible, and disgusting. I now flinch when someone touches me, and I hate this feeling. This has made me less trusting of others, including my family." So you can see this is a turning point for this young person when asked to think about an experience they had that really changed their sense of self. They describe something that's really painful, and they talk about that painful experience of abuse leading to them not trusting people anymore. So you can see this clear distinction in terms of that theme of communion there.

Sara Wilson:  Yeah. And whether the turning point itself is articulated in positive or negative terms.

Rebecca Shiner:  Right. Yeah, in this case, there's a clear difference in the overall tone of those two narratives that you can see there. But I think it's interesting too, this is an Asian sample, and so in general, Asian cultures tend to be more collectivistic and to have a stronger focus on interdependence across people and stronger need to think about the group rather than just the individual. Whereas a US sample, for example, is more individualistic. So it would be really interesting to know whether the pattern would replicate in a Western sample where maybe communion is not so clearly linked with problematic personality traits.

Sara Wilson:  Yeah, Because I noticed in your results that communion was perceived as more a significant dimension in that sample in particular, as opposed to agency.

Rebecca Shiner:  Right, which is an unusual finding actually. Agency is more consistently associated with wellbeing in general than communion is. There are a lot of studies where communion is just not related to whatever positive outcome measures you have. And so it raises questions about whether maybe this is a cross-cultural difference that I think would be worth studying more.

Sara Wilson:  Right, yeah. It also definitely raises the question of how narrative identity is highly convoluted by nurture and just your social situation and upbringing. So it's subject to change I guess.

Rebecca Shiner:  Yeah, absolutely. I think narratives are a place where culture plays a big role because different cultures have different preferred ways of telling stories. US samples have a very strong preference for redemption narratives where things start out bad, but then by the end of the story, they turn out to be positive. We love a good redemption story in the United States. And that's not always necessarily a positive thing, but it's a clear cultural preference that we have.

Sara Wilson:  Yeah, it's so interesting because it's not real in some sense, it's very socially and culturally dependent and context relevant, but then at the same time, it manifests itself in very real situations. It very much changes your belief systems.

Rebecca Shiner:  Right. That's right, but the outcomes may vary again, depending on the culture. So I think it's important in thinking about narratives to not assume that narratives that are positive in one culture are necessarily going to have positive outcomes in another.

Sara Wilson:  One more study I wanted to talk about. Can you discuss a little about your study exploring narrative identity and PTSD symptoms in veterans? I was especially curious about the finding that even if patients experienced a loss of control during traumatic military experiences, it may be possible to help them find ways of narrating their life in more agentic terms in the present through the process of therapy.

Rebecca Shiner:  Yeah, let me describe that study. This was a study that was actually inspired by one of my honors students at Colgate, and this is before I really had done much narrative research. So I had a student who wanted to study veterans for his honors project, and he wanted to look at PTSD. And so we hit it on the idea of asking veterans to tell us about their most stressful experiences that they had had in the military. And we wanted to look at whether their way of narrating those really stressful experiences was predictive of whether they had PTSD symptoms or not. It's really interesting because in a lot of the literature on PTSD, there's the assumption that the memories themselves are highly relevant to developing PTSD or not, but they're not looked at in terms of narrative identity, they're more looked at in terms of whether the memories are fractured or fragmented or not.

But we thought that it seemed likely that the narrative style, the way that people tell the stories of those really stressful experiences would be highly relevant to whether people have PTSD symptoms or not. So we collected stories about the most highly stressful military experience in a sample of veterans. We found that, in fact, there was a link between narrative identity and PTSD, so specifically the veterans who told these stories in a more agentic way and also with a stronger sense of growth tended to have lower levels of PTSD symptoms. So I think this is really, really important because it suggests that, again, those memories are important because they become part of a person's narrative identity. There may be ways of working with those memories to help people to begin to narrate them in a way that is going to bring some relief to them.

It's really interesting to me that the treatment method that has the most evidence for its effectiveness for treating PTSD is something that's called prolonged exposure, which is where the person with PTSD is asked to tell, in as much detail as they can, the traumatic experience that they have had that has left them with PTSD. So they have to recount in great detail everything that they can remember about that experience. Which is obviously extremely difficult and painful to do, particularly the first time. And then they're asked to retell this story and actually to listen to recordings of them having told the story themselves. The contention is that the reason this is working is because it's exposing them to the story or the memory of something that they have been trying very hard to avoid having direct contact with.

And I believe that that's true. I believe that it's exposure that helps them put aside the avoidance that is playing a really important role in why that model works for helping people get over traumatic memories. But I also expect that there's something about the retelling of that story that helps people to actually gain a sense of mastery over it. And I think it would be really interesting to actually do a study where you looked at whether those stories change in terms of whether the person feels a greater sense of agency in the retelling of the story over time.

Sara Wilson:  This is such amazing research, really, and such important implications, and it's just starting to be tapped into its full potential. Yeah, I totally definitely agree with you. I think it's very good work that you're doing.

Rebecca Shiner:  Thank you. I feel very lucky to have had people who are willing to let me collaborate on this kind of work with them.

Sara Wilson:  When you discuss this epistemic gap in clinical theory regarding personality disorders, I think it's interesting that you cite one of the reasons for this deficit in knowledge to be the desire to protect youth from stigmatizing diagnoses. How might a diagnosis in any domain, I guess, actually contribute further to poor narrative identity? How can we go about this maybe more carefully or be more sensitive to this in therapeutic practice?

Rebecca Shiner:  Yeah, it's a great question. Historically, there's been a lot of hesitancy to use labels of personality disorders for teenagers. And in fact, the diagnostic manual, the DSM has encouraged clinicians to be cautious about using personality disorder diagnoses for people below the age of 18, even though it's recognized that these personality patterns start earlier in life, so they don't just emerge out of nothing when a person gets 18. And this has been because in the past, people saw personality disorders as being chronic and very hard to treat, like once you have a personality disorder, you are destined to have that personality disorder forever. And that seems too stigmatizing to apply that to a young person.

However, it turns out that there are a bunch of mistakes that have been made in those assumptions. It turns out personality disorders are amenable to treatment. It turns out that they do naturally change over time even without treatment. And it turns out that personality disorder problems actually may be at their worst during adolescence. And so that suggests that there may be value in at least thinking about personality disordered patterns in young people like paying attention as a clinician to whether the young person you're working with has problems with their sense of self and identity, or chronic problems and how they're relating to other people.

That being said, I have a lot of sympathy for this concern about using personality disorder diagnoses on young people. And that is because as we've talked about, teenagers are in the process of developing their sense of narrative identity. They're only just beginning to figure out what are the important stories from their lives, how do their past experiences affect who they are now? And so there is a great risk, I think, actually in giving them a label that would lead them to formulate a sense of identity that is going to be really pathological, that is going to discourage them from feeling hopeful about change.

And I'm especially concerned about this now because on social media, there has been this profusion of teenagers and/or young adults self-professing that they have personality disorders, particularly borderline personality disorder. And there's a strong tendency for people almost sometimes to almost relish having this diagnosis that makes them feel special or celebrates their sense of being a victim in a way. This has become rampant on TikTok with mental health in general, young people posting TikToks about their diagnoses and so on.

And so this is something that I have actually been gradually rethinking for myself, because in the past, I have encouraged clinicians to think about personality disorder diagnoses for young people and to very carefully present that information to young people. But I think that as those diagnoses have been promulgated in social media, I am beginning to see more and more the potential risks that are associated with that, especially because of young people's emerging sense of identity and the way that that diagnosis may play a part in how they're crafting the narratives of their lives.

Here's where I'm at on this at this moment. I may change my mind again, I still think it's vitally important to be paying attention to those core personality disorder features for people who are working with teenagers to really pay attention. Is this a person who's struggling with intimacy, is struggling with how they see other people? Do they tend to view other people in a black and white way, for example, that might characterize borderline tendencies? Is this a young person whose sense of identity is so profoundly unstable that they're having trouble beginning to navigate decisions about what they want to do after high school and so on?

So I think those are things that clinicians should be paying attention to and should develop some competence in learning how to treat, because those problems are significant for a large number of teenagers with clinical problems. On the other hand, I think that there's a really important role for being cautious about giving a personality disorder diagnosis. And I think it's important to be careful in how that is articulated to the young person. And I think explaining it in the kind of language that I've been using, it's likely to be more helpful, that these are ways of seeing the self and seeing other people interacting with them that are profoundly important, but also open to change so that the young person can start to develop narratives about who they are that are both realistic and more healthy.

Sara Wilson:  Yes. Yeah, I think that expressing a critical sensitivity to narrative identity and the reality of it in therapy especially, will inevitably strengthen the therapist-patient relationship just because a lot of traditional therapeutic practices stigmatize the client's point of view as something that's disordered or subjectively inaccurate. But instead of discrediting the content of the narrative itself, the narrative therapist helps to consciously separate the story from the client and sees narrative identity as a construction over which we have agency that's separate from our core.

Rebecca Shiner:  I agree. Although I think that there's a place too for reality testing in the sense that I think that the best narratives are in contact with reality, but are also healthy. A narrative identity that is entirely positive, but disconnected from a person's actual reality is going to be a problem perhaps in a different way than a narrative that's unduly negative, if that makes sense, yeah. So I think that it's important for the person's sense of identity to be both flexible and reality based, and ideally positive because there's the potential for change there.

Sara Wilson:  Yeah. Thank you so much for joining us today. I really think that this is such an important concept right now, especially as so much research on the self is emerging and in our relationship to selfhood, what is the self? And there's obviously so many levels to it with so many pressing implications and very real importance for who we are and for wellbeing. So I think that this is very, very important research and a very cool concept. Is there anything else you would like to share with our audience today, Dr. Shiner?

Rebecca Shiner:  I had one last thought that I wanted to mention. There's a brand new study, it actually hasn't been published yet, but it's been accepted for publication, that was looking at this construct of the hero's journey. This is a popular motif that a number of people have recognized that the most loved stories across many different cultures seem to take this form of the hero's journey, where the person begins in the dark, but then they feel this calling to leave their safer childhood home, and they venture out and they find a mentor and they have to battle the foes that may thwart them and so on. So there's a particular form that this hero's journey story takes.

Anyhow, this study has found that there's actually value in telling your own story as a hero's journey and being able to see your life in terms of that pathway from a maybe sheltered existence, but moving forward into facing your foes and your challenges and being defeated, but then continuing to move forward. This was a series of studies that showed that actually adopting that kind of sense of your own story as a hero's journey, it's good for us, and maybe it gives us courage to face the things that are inevitably going to be painful and difficult.

Sara Wilson:  I wonder, do you think that we inherently value that as an intrinsically good narrative organization, or do you think it's maybe very convoluted by cultural norms, what we've been accustomed to?

Rebecca Shiner:  Yeah. Right, that's a great question. I think that part of the impetus for studying this is that this is a very common narrative format across historic time and across place. There's something about this kind of story that deeply appeals to all of us and suggests that there may be something universally, humanly relevant about it.

Sara Wilson:  How would you suggest that someone goes about trying to develop their narrative identity?

Rebecca Shiner:  Yeah. I have a few ideas. One is I think reading good books is a good way of doing it. Actually, over Thanksgiving break, I have gone back to... I pulled out one of my childhood books that I love very much called A Little Princess. It's like a classic, classic girl's book. Anyhow, and just reading it actually makes me really... It actually follows the hero's journey pathway. And I realized how much I internalized that narrative form as a kid when I was reading it.

So anyhow, I do think there's a place for watching good movies and reading good books and so on to have a sense of the narratives of other people's lives. I also think that there's really good value in well done therapy. I definitely think some therapies are better than others for developing a sense of narrative. I think all therapies do it, but I think for people who are trying to gain more of a sense of understanding of themselves, I think some of the more traditional therapies like psychodynamic can be especially useful. I think journaling. I really think anything that has to do with self-reflection and deep thinking about yourself.

Sara Wilson:  So interesting.

Rebecca Shiner:  Very useful, yeah.

Sara Wilson:  How many layers there are, and how many different ways there are to get in touch with yourself and make real change. Yeah, I've been very interested in the concept of self throughout my psychology and philosophy major at Colgate. And the more I study it, the more I'm just blown, mind blown. It really is such an incredible concept. It's just unbelievable how much there is to it. And the more I study it, the more I'm just dubious of what it even is, what it even means. The research is just so interesting. And I think it's so relevant nowadays, especially right now with so much more research going on with regards to what mind is and major developments in neuroscience. And I think that this very much deserves to be paid attention to, especially in neuroscience and the mechanisms behind this. It really is just unbelievable.

Rebecca Shiner:  It's fantastic that you've been able to study it. Yeah, my hope is that people will be inspired to learn more about it. I highly recommend anything that has been written by the person who developed this concept, who I should have acknowledged at the very beginning of this interview, who is Dan McAdams, a psychologist at Northwestern, who really I think pioneered the... Who was drawing from a lot of existing traditions within psychology, but really helped to pioneer the empirical study of narrative identity. So I commend anyone looking up Dan McAdam's work.

Sara Wilson:  Thank you so much for joining us today. It was such a pleasure to talk with you. This was Dr. Shiner.

Rebecca Shiner:  Great questions, yeah.

Sara Wilson:  Of course. It was so amazing.

Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.

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Editor: Jennifer (Ghahari) Smith, Ph.D.

Psychiatrist Christine Adams on Tantrums & Meltdowns

An Interview with Psychiatrist Christine Adams

Christine Adams, M.D. is a child and adolescent psychiatrist who is double board-certified. She is an award-winning, best-selling author regarding how emotional conditioning effects relationships.

Nikayla Jeffrey:  Thank you for joining us today. I'm Nikayla Jeffrey, research intern at Seattle Anxiety Specialists. I'd like to welcome with us child and adult psychiatrist, Christine B. L. Adams, MD. She is co-author of the bestselling, award-winning, Living on Automatic: How Emotional Conditioning Shapes Our Lives and Relationships. A double board certified psychiatrist, some of her work deals with topics such as tantrums and meltdowns in adults, and that's what we'll be discussing today. Before we get started, Dr. Adams, can you please let us know a little bit about yourself and some about the work and writing you've done?

Christine Adams:  Sure. Thank you for inviting me. I've been a child and adolescent psychiatrist and also worked with adults for 42 years, and I've worked primarily in private practice doing psychotherapy rather than medications with people to help them understand the roots of their problems. I also was a professor at a medical school and worked in community mental health centers. I also, for 25 years, was a forensic child psychiatrist who gave expert testimony in child abuse cases, mainly sexual abuse, and also divorce and custody and parental alienation cases. I worked for a while with the Social Security Administration doing disability appeals on children, and I worked with the Department of Defense for a while. So that's kind of my work background.

My writing background is pretty varied. I have a blog at PsychologyToday.com where we look at all sorts of issues having to do with relationships, how people manage emotions, custody disputes, whether sole custody or shared custody is best for children and under what circumstances, and also parental alienation. My book, Living on Automatic, is a study done by two psychiatrists, me and my mentor, Homer Martin, and it covers 40 years of work for him and 40 years of work for me, and we looked at the development of people's personalities and how parents shape them early in their lives. By age three, we found the personality is rather set. So that has been the bulk of my writing interest over the last 10 years.

Nikayla Jeffrey:  Wonderful. What do you think made you first become interested in this field? What sparked your interest in these topics?

Christine Adams:  Well, when I was in training, I began to observe things, and I didn't understand, and so I began asking my supervisors. And Dr. Martin was one of my mentors. And the things that I began to observe were things like why are siblings so different when they're raised in the same family? And why are people that I would see in psychotherapy from different families so similar to one another? And that perplexed me, and I started asking questions, and he encouraged me to keep observing and to research more on this. But that's kind of what got me started, questions that I couldn't really answer, and that most of my supervisors couldn't answer.

Now, what got me into psychiatry was that I was kind of overloaded with psychiatry as a child. My father was a child psychiatrist. My mother's grandfather was a psychiatrist at the turn of the century, the early 20th century, and my mother worked for a psychoanalyst in New York City. So I had all these books available. I heard all this talk all the time about psychiatry. I thought people were fascinating, because I didn't understand them as a child, and that's what got me into the field. And then as I got older, I realized children need a voice. They often get lost in their families and they need a voice. They need somebody to help them articulate what they're thinking and feeling, and to learn how to tell their families, because it will cut down on their emotional suffering.

Nikayla Jeffrey:  In one of your pieces, you write about tantrums and meltdowns specifically in adults, rather than in children. Can you touch on what the differences are between these two things and perhaps how one can maybe turn into the other?

Christine Adams:  Sure. I think this is from a blog that I have on Psychology Today that you read. A tantrum is an emotional blowup when somebody is thwarted from getting something that they want. When they don't get it, they pitch a fit. That's what a tantrum is. A meltdown is an emotional blowup or an emotional shutdown when a person is unable to cope with a situation, so it's a coping problem. They're totally overwhelmed. Now, it may be something extraordinary that is overwhelming, like a divorce or a custody battle or the death of somebody that you're close to. Or it may be, depending on your personality, something rather trivial that you can't cope with. And the example I often use is a person who can't get to work on time gets reprimanded by their boss for being late, and they have a meltdown because they just can't cope with the idea that they need to get to work on time every day. So we can discuss later, some personalities suffer tantrums and some personalities are more prone to meltdowns.

Nikayla Jeffrey:  So it has to do a lot with your specific personality type, whether or not you'll be prone to tantrums or meltdowns as an adult?

Christine Adams:  Yes. And the circumstances will be very different for the two personalities is what we discovered.

Nikayla Jeffrey:  So with talking about types of personalities, you mention in that same piece something about divergent personalities. I was wondering if you could define that?

Christine Adams:  Well, this gets into our research that's in our book, Living on Automatic. What we discovered is that there's two main roles or personalities that people form. These are formed by the way parents shape you emotionally, unbeknownst to you and unbeknownst to parents, early in your life, so that by age three, your personality is pretty much set, which is kind of scary, because that happens before you're largely verbal. But you learn all these emotional cues from your family about how you're to see yourself and how you're to see other people.

And it turns out that they're pretty much opposites. We call them one type, the omnipotent personality, and the other type is the impotent personality. And the omnipotent personality is very, very strong. They're very high in self-control. They give unlimited care to other people. They give very poor care to themselves. As a child, parents expect a great deal of them. So when they grow up later on, they expect a great deal out of themselves. And you can see how as I describe these two types of personalities that emotional problems set in with each type of a different variety and in a different way. But the way parents condition people makes them prone to emotional illnesses or suffering and relationship conflict down the road.

Now, the impotent personality is just that, impotent. Feels very helpless about themselves. Feels they can't conquer things. They expect others to care for them. They expect others to meet their needs. They expect others to take responsibility for them and troubleshoot for them, and they have very poor self-control. Parents overindulge them and expect very little from them in the way of accomplishments and in the way of giving care to other people that they care about. So you can see how these are divergent. These are very opposite and different. And, of course, we go into tremendous detail from infancy through people in their 90s in the book, Living on Automatic. So you can read more about it in the book if you're curious.

Nikayla Jeffrey:  And this stronger omnipotent personality, they expect more from themselves, that you mentioned is connected to experiencing meltdowns, correct?

Christine Adams:  Yes. What happens with an omnipotent, is omnipotents rarely have tantrums, because they're not good at promoting things they want. So they will easily acquiesce to other people, so they will rarely have tantrums where they pitch a fit for something they desire. But if they're totally overwhelmed by somebody asking or wanting something from them that they want to deliver but they can't because it's impossible, then they will have a meltdown. Tears, lots of guilt over failing the other person's request. They can have rage at themselves. Their suicide risk can go up at these points. So that's what their meltdowns look like.

Now, an impotent can have a meltdown, the example I gave before, being reprimanded for being late at work, they can say, "This is awful. This is unfair." And be full of tears and rage and anger. But the anger is not at themselves. The anger is at the person who's reprimanding them. So they project the anger that should be their responsibility onto the person who's complaining about them. So the meltdowns are for different reasons in the two personalities, and only the impotents have tantrums. Omnipotents don't have tantrums when they need to have a tantrum or should have a tantrum.

Nikayla Jeffrey:  In discussing tantrums, you said that it's important to decide whether a tantrum is a reasonable response for that situation for these people. They've said whether a tantrum is called for, almost. And I would ask, is a tantrum ever a reasonable response?

Christine Adams:  Yes. What I often advise omnipotent patients is you need to have a... I call it designated tantrum with the person who's asking too much of you. You need to pitch a fit or do something to get their attention so that they know they're being unreasonable with you. Because an omnipotent personality tends to acquiesce and say, "Okay, you're being unreasonable, but I'll try and do what you want." So it's reasonable for an omnipotent to occasionally throw tantrums with people when they're overstepping their boundaries with them. But for impotent personalities, they so often easily resort to tantrums that there's really no need to promote that behavior. There's the opposite need to promote not having a tantrum and to letting them assume responsibility for what they have done.

Nikayla Jeffrey:  And when it comes to these emotional blowups that happen, you also mentioned that a reality check is needed. Can you give an example of what a reality check might be? And then talk about whether one personality type may be more resistant to a reality check than another.

Christine Adams:  Yeah. When I talk about a reality check, it's evaluating how reasonable your thinking and your behavior is for the situation you find yourself in. So it's sort of saying to yourself, well, let me take a time out with myself and let me look at the situation not with my emotions, but with my brain, and think about what am I doing here, what am I feeling, what am I saying, how am I behaving, and is this reasonable for the situation?

So an omnipotent might say, "My boss has asked me to work all weekend on a project. I was going to go on a short trip and now I have to cancel the trip and turn in this project first thing Monday morning. And I'm going to cancel my plans and work on this all weekend." So they might say to themselves, "Is this reasonable behavior on my part in thinking that I believe I can do this and should do this?" Now, an impotent will be late to school repeatedly and need to say to themselves, the reality check, "Am I being reasonable here being late to school every day? Everybody else gets there on time. I'm missing classwork. I'm disturbing the classroom when I come in."

So it's a way of evaluating for the situation whether you're being reasonable or not. And it's difficult for both personality types to do reality checks. And we talk in the book, Living on Automatic, how you do this with yourself, regardless of your personality, because both personality roles or types need to do this. So we talk about how you do this, because each role must work diligently through their lifetime to undo some of this emotional conditioning and bring themselves sort of from afar back to the middle where they can be more reasonable with themselves and other people.

Nikayla Jeffrey:  So both personality types need reality checks, but it looks different for each type of personality?

Christine Adams:  Yes, absolutely. You got it.

Nikayla Jeffrey:  Okay. Perfect. Those are all my specific questions, but I know you wanted to talk a little bit about the research that you're doing, correct? The new research about your book.

Christine Adams:  Well, I also wanted to say, if you encounter a situation with yourself or with a family member or coworker who's having emotional blowups, you might be able to help yourself or them by looking at two different issues. The first is what kind of person am I dealing with? Am I dealing with an omnipotent who rarely blows up at anybody or am I dealing with an impotent person who blows up a lot and has tantrums a lot? And then you can help them do a reality check. Ask yourself or them, okay, what circumstances provoke the episode you're having? What does the person talk about or focus on? Are they upset with themselves or are they upset with another person? Who do they lash out at, themself or another person? If it's a tantrum, is anything really reasonable wanted? Or is it in the realm of it's just something you want and it's not very reasonable? If it's a meltdown, is it an overwhelming event or is it a trifle situation? And I would ask them or ask yourself what can you say or do differently next time to see if there's any learning involved in how to better manage the situation? And this sometimes makes people pause and think about what they're doing, and it's a way to help others and it's a way to help yourself.

I am doing a lot of book marketing for Living on Automatic. I have podcasts, media interviews, articles, Psychology Today blogs, all on my website, DoctorChristineAdams.com. I'm going to be teaching a webinar that will be posted on my website about emotional conditioning and these two personality types. And I'm also on LinkedIn, Facebook, and Twitter. And if you want to write me, ask questions, you can do that through the website. I have a newsletter that you can join. And I'll just hold up the book one more time, so you can see it. It's got a picture of two people with cogs in their head, one's a man and one's a woman, and the cogs are turning around.

Nikayla Jeffrey:  Perfect, thank you.

Christine Adams:  Yeah. Thank you very much. Do you have any other questions?

Nikayla Jeffrey:  I don't think so unless you have any last parting words of advice on how to work with the different personalities in your life. Or any parting words. But besides that, no more questions.

Christine Adams:  Well, I just think it's most of the time we go through life and we think other people are like us, and they're not. People are very different. But we found that they do kind of fit into two opposite, divergent roles or personalities. So if you can learn to identify the different types of people then you know better how to deal with them.

Nikayla Jeffrey:  Thank you very much.

Christine Adams:  Thank you.

Please note: The views expressed by the interviewee are for educational and informational purposes only, are not meant to diagnose or treat any condition, and do not necessarily reflect the views of Seattle Anxiety Specialists, PLLC.

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Editor: Jennifer (Ghahari) Smith, Ph.D.

Psychologist Priyanka Shokeen on Psych assessments

To learn more about Psychological Assessments, click here.

To request an appointment for a psychological evaluation with our practice, click here.

An Interview with Psychologist Priyanka Shokeen

Dr. Priyanka Shokeen is the Clinical Director of the Psychology and Psychotherapy Department at Seattle Anxiety Specialists. She manages the diagnostic evaluations and assessments sector of our practice and has extensive experience in working with trauma and personality disorders.

Jennifer Ghahari:  Hey, thanks for joining us today for this installment of “The Seattle Psychiatrist” Interview Series. I'm Dr. Jennifer Ghahari, Research Director at Seattle Anxiety Specialists. I'd like to welcome with us, psychologist, Priyanka Shokeen. Priyanka is the Clinical Director of the Psychology and Psychotherapy Department at Seattle Anxiety Specialists.

Her clinical work is focused on providing comprehensive psychological evaluations, primarily for diagnostic clarification. Before joining our practice, Priyanka was the clinical fellow at Columbia University. Can you tell our listeners a bit about yourself?

Priyanka Shokeen:  Oh, yeah. It's always difficult to think about where to start on a question like that, especially after the introduction you gave me. So, thank you for that.

Jennifer Ghahari:  Sure.

Priyanka Shokeen:  Well, let's see, I've been studying Psychology since the age of 16, and it never fails to amaze me each year as to how little I know, for the fact that I'm still interested in learning more. I'm originally from India, and for the better part of the last decade I was working in New York City.

I'm somebody who's always been interested in advocacy, and throughout my life that's looked different depending on where I am personally and geographically. Then, I'm an avid reader. I don't get as much time to read anymore, but that's a lifelong habit I plan on keep trying to be better at. So, that's a bit about me.

Jennifer Ghahari:  What types of books do you read?

Priyanka Shokeen:  Oh, mostly fiction. I used to read a lot more theoretical texts, old texts, based in Psychology, back in grad school, even starting as early as undergrad, but right now I think fiction is a good way to detach from work.

Jennifer Ghahari:  Yeah. Nice. So, what is it that got you interested in becoming a therapist?

Priyanka Shokeen:  Funny enough, fiction.

Jennifer Ghahari:  Really?

Priyanka Shokeen:  Yeah. This is why I like fiction, the ability to engage with it is so transformative in that it allows you to really flex your imagination. It teaches you to how to imagine the mind of a character, how to experience strong emotions in a safe enough manner.

So, I initially thought this interest would translate into a career in literature and writing. And that was a quick lesson in the fact that hobbies are not necessarily things you're good at, and they probably shouldn't be. It's a good thing that hobbies are not things you're good at.

So, I kept following my interest, not just in the experience of emotions, but also with regards to my curiosity in terms of the confidence that make people behave in the way they do. And those include race and gender and class and culture, apart from, say, biology and family environments. So, I followed a story.

Jennifer Ghahari:  Great. I'm going to put you on the spot. Who is your favorite fictional character?

Priyanka Shokeen:  Ooh. You know what, I'm not sure if this is a popular book, but it is definitely my most quoted book. It's this book called Shantaram. It's about this convict who escapes from Australia and reaches Mumbai, I think back in the '80s. And it's him getting involved with the underworld there. So, the main character for that is my favorite fictional character.

Jennifer Ghahari:  Awesome. Great.

Priyanka Shokeen:  Yeah.

Jennifer Ghahari:  Thanks for sharing. So, in clinical practice, are there any areas or disorders that you specialize in treating?

Priyanka Shokeen:  Well, let's put it this way, my professional areas of interests are the areas I continue to build specialization in. So, with that in mind, I have a lot of experience with personality disorders and trauma, and that's where my primary interest and work lies. I, in the past, enjoyed doing group work a lot. I've run inpatient groups, I've run outpatient groups, I've run groups in counseling centers. I think they have a lot more power than we give group therapy credit for.

Then, like you mentioned in my introduction, I do specialize in differential diagnosis, which again, the personality disorders or the trauma work, for me, remains an area of knowledge that I keep growing in.

Jennifer Ghahari:  Great. For our listeners, can you explain a bit about personality disorders, maybe which are the most common, just a bit about them?

Priyanka Shokeen:  Yeah, I think if we were to look at personalities as somebody's unique signature in that it is their way of relating to themselves, to other people and to the world around them, that's what we call personality, ideally. Personality disorder is when your characteristic ways of being either with yourself or with people or with the world, they become problematic, they start causing you harm or they start causing people around you harm.

Jennifer Ghahari:  Okay.

Priyanka Shokeen:  So, in the past, personality disorders have been, according to diagnosis, certain axes. So, the kinds that we see a lot, or that gets talked about a lot, even though it's not that common, is "borderline personality disorder", because that is one of the hardest to deal with. It comes with a lot of emotional dysregulation, a lot of identity instability, risk factors.

But just as common is, more common than BPD, is "avoidant personality disorder" (AVPD) or OCPD, which is different from OCD. So, OCPD is "obsessive compulsive personality disorder", different from "obsessive compulsive disorder".

Jennifer Ghahari:  Great. So, if anybody thinks that they may have one of these, reaching out to someone you would be good, to talk about and possibly get an evaluation-

Priyanka Shokeen:  Absolutely.

Jennifer Ghahari:  ... as an example. Great.

Priyanka Shokeen:  I think one of the first points of entry into getting help is if you have started noticing that your characteristic ways of acting are not bringing you what you want or that people around you have started noticing something before you have. So, they're giving you consistent feedback about certain ways in which you act, say, for people who have really explosive anger.

Jennifer Ghahari:  Okay.

Priyanka Shokeen:  People around them are the first to notice that, "Hey, I think you need to get help." So, yeah, absolutely, I would be very happy to help. And if I feel that I'm not the most competent person to help, I would absolutely provide a good referral.

Jennifer Ghahari:  Great. So, aside from something like explosive anger that people are telling you may have a problem with, what are some other signs or symptoms that people should be on the lookout for?

Priyanka Shokeen:  Well, it depends on different things. It depends on your priorities. So, let's say if you have avoidant personality disorder, the characteristics of life where we measure functionality, where you're functioning well, is what is generally agreed upon as health. Different degrees is, self-care, it is your relationships, it is occupation, student, whatever job you're doing.

So, if you start noticing something going wrong in either of these areas, that's important for you to know. So, if you, as I was mentioning with avoiding personality disorder, you do want to form relationships, but just the task of it, the fear of it is so much you avoid them to the extent that it starts affecting you, that you end up being self-isolated. And again, the last three years have taught us, self-isolation is especially punishing.

So, that can be one of the signs to look out for. For "narcissistic personality disorder", it's very hard. Self-reflection is not the first criteria for it. So, people around can start saying, "Hey, you take a front to seemingly small things." They feel very personal to you. And as somebody who's going through it, you may think, initially, that they're saying it to hurt you or they don't value you, but depending on the number of contexts you're getting that feedback in, it becomes harder and harder to deny.

So, people may come in for complaints of depression or anxiety, which, once resolved, you might realize, once those symptoms are done, there are still lingering symptoms in these areas of occupational functioning, your relationships, your self-care. And that's generally when personality disorders initially start getting addressed, unless there's something as dramatic or as explosive as, say, BPD.

Jennifer Ghahari:  Wow. Great. Thank you. That's really helpful. So, let's say someone contacts you and makes an appointment and goes to see you for X, Y, or Z, how can you explain your treatment approach? What can someone expect to experience if they're going to therapy with you?

Priyanka Shokeen:  Okay. So, I'm going to try and break it down into my overall clinical approach, and then say what an initial couple of sessions with me can look like and what the purpose of asking certain questions is. My approach to clinical work is largely integrative. Most therapists out there, you'll ask, that's what they end up following, because we've been taught so many things and we know how to draw on different things, depending on what the client is presenting with.

With regards to case conceptualization, which is an overarching view of what I think the nature of someone's presenting problem is, I have a psychodynamic approach. So, I use my training in, say, diagnostic tools in psychological tests, and I put a focus on developmental history. I keep an eye out for differential diagnosis. I try and understand, what is the larger family context or the cultural context in which someone's presenting complaints operate?

So, the psychodynamic framework, it allows me to start building a coherent narrative of someone's life with the data that I've gathered from different perspectives. That said, I also use a lot of CBT and DBT techniques in session, depending upon, again, what the presenting problem is and what the client needs. So, that's more my approach, overall, throughout the course of treatment.

With initial sessions, intake with me can take anywhere from two to three sessions. Those three sessions are a good place for me to decide if I have the clinical competence to provide you the best care with what you're coming to me with, and that's a good way for you to assess if you would want to, keep coming to me, if you like my style, if you feel comfortable talking to me, even if not about everything, just initially.

So, the goal of that initial exploration is to get an understanding of what the client is coming to therapy for, they're presenting complaints, the history of that complaint, and then the circumstances in which the client is, as well as their own personal characteristic that keep those situations that they have a problem with or those symptoms operational.

I say this often enough to most all my clients that you're not reacting in a vacuum. There's two parts to this. There's the internal and there's the external. So, as part of this initial exploration, there's a lot of attention that I pay to developmental history, so trying to gather data about someone's attachment patterns.

I try to attend to the mention of key figures or key moments in somebody's life, specifically in early development, but also crucial details or crucial figures clients either forget to talk about or avoid talking about, because for me, that's the beginning of trying to understand somebody's presentation.

So, in this manner, guided by this dynamic framework, the goal is to start bringing what feels nonintegrated parts of the client self in order to provide them with greater access to their own internal world.

Jennifer Ghahari:  Great. So, talking about all these different diagnoses that people may have, and you run our practice’s psychological evaluation program. Can you explain what that is that you're running and what people can expect to experience if they reach out for an evaluation?

Priyanka Shokeen:  So, generally speaking, psychological evaluation or assessment, it's an evidence-based approach which makes use of information from a number of different sources to arrive at a holistic picture of how a person's mind functions and the ways in which they experience the world.

So, psychological evaluation or assessment, it makes use of clinical interviews, it makes use of behavioral observations, and then standardized psychological tests to understand a more comprehensive profile of what your strengths and weaknesses are, and what are the next steps for your mental health journey. I think you asked me another question as part of this, but I seem to have forgotten.

Jennifer Ghahari:  No, that's okay. So, if I'm going for a test, what can I expect to do? Am I going to fill out one of those old-time Scantron sheets where you pick A, B, C or D? Is it going to be, do people actually take the Rorschach tests, things like that? What do you do?

Priyanka Shokeen:  So, yes to the Rorschach, absolutely yes to the Rorschach. It's one of my favorite instruments to use. When used well and in a standardized setting, it can be one of the biggest sources of information about somebody's personality. But let's, again, start from the beginning.

So, an assessment would involve either question coming from the client, their loved one, their psychiatrist, their therapist. They don't need to be in therapy with me for us to go through evaluation. So, the process begins with, what is the referral question? What are you looking to get assessed? Once we've had a referral question, we'll set you up.

The first point of contact is a clinical interview. And the purpose of this interview is to gather detailed information about what is your current functioning and how you were functioning at a previous time. After the clinical interview is done, comes the process of the assessment. So, yes, there are forms to fill out, there are Rorschachs to do, but these are all different standardized tests.

And they can be part of a whole battery of tests. So, it might just be you end up doing one big test, like the Rorschach or the MMPI, which is also a personality measure, or you end up doing a bunch of different tests, like we do with our ADHD assessment, to understand different aspects of the functioning and how best to answer the referring question.

Once testing is done, we score it, we explain the results to you, we compile everything into a detailed report. And the final part of the assessment is a debriefing session where we go over with the client about what we found, what test was meant to do what… And it carries actionable recommendations on what to do with this information that we've learned, where to go next.

So, a lot of the times, this assessment in and off itself is enough to answer the referral questions. Sometimes we might feel we haven't gathered enough information or you need some other kind of assessment that we're not yet providing. And in that case, we make those referrals in addition to the recommendations that we're providing.

Jennifer Ghahari:  Great. So, I think we're in a society where people want instant gratification, so I'm presuming that this whole process is not an instant thing. Like you said, there's a debriefing and a full report. In general, let's say I came to you for some tests and we did the test today, when could I expect to get my results and the debriefing and all that? How long does it usually take?

Priyanka Shokeen:  Yeah, again, I wish I had more of a straightforward answer to that, but it really does depend on the referral question. On average, you can think of budgeting anywhere between five to 10 hours for the entire assessment process. That includes the clinical interview and the debriefing session. So, the hours-

Jennifer Ghahari:  Is that at one time?

Priyanka Shokeen:  I'm sorry?

Jennifer Ghahari:  It all happens...

Priyanka Shokeen:  Oh, my God, I would never. I think it would defeat the purpose because exhaustion and fatigue are a thing that affect performance. No, it definitely happens over, again, depending on the test battery. So, let's say a particular test is supposed to take anywhere between two to three hours. For a particular client it ends up taking to four hours. So, that would be one. But that's all we're doing that day.

Then, the rest of the things that we need to get done, we'll do it over 2-3 hour sessions over the next couple of days. So, definitely not putting anyone through that in one go.

Jennifer Ghahari:  They don't have to bring pajamas or a pillow or anything?

Priyanka Shokeen:  If it comes to that, we will provide the sleeping bags. (laughing) But you also mentioned when you can get the results? So, oftentimes it takes a lot of hours to score the tests in a particular way, to consult norms, to make sure you're doing the right thing, and then compiling them into a report. So, if you think assessment is time-taking on the administration, and believe me, it's double that on the report end.

So, I generally give anywhere between three to four weeks from the last testing session for me to compile reports because I don't want to do it in a way that misses out on any detail or skims on any part of the report. So, 3-4 weeks for you to get the report, and that's when we'll have the debriefing session and we'll go over the report together.

Jennifer Ghahari:  Perfect. And I think what sounds really nice about this process is, there are surveys online that people could take for this or that, and you hit a button and that's instant gratification, especially put in your email address, for so many websites.

But with this, like you said, it's really customized. You're a trained psychologist who, again, knows what you're doing to be able to look at the nuances of what a specific answer means, especially in conjunction with other tests and other answers.

So, I think the fact that we can provide these detailed reports for people, even though it is slightly more time consuming, the quality of what you walk away with is so much better than more of the quicker, instant gratification type of things that people can do on their own. So, I think this is great what you're doing.

Priyanka Shokeen:  I'm glad. I don't begrudge people on what makes them reach out for the instant gratification of doing an online quiz. It is the most accessible thing. Going through an assessment requires a lot of time and resource, commitment as well, but it isn't just about our report being most tailored to your question, it's that it's accurate. The reason why I say that is oftentimes people can get versions of tests online, but they don't know how to read the report.

You can assign a numerical value, but people might not know how to read that numerical value. Does that numerical value mean a different thing for a clinical population versus research subjects? And psychologists are the only profession that are trained to do this kind of testing. Not to give that example, but do you remember when this part of the previous president's cognitive test, some part of it got leaked online and people thought it was very easy.

It was one question in a neuropsych battery, and people were making assumptions about easy or difficult, but that had nothing to do with what that test represents. So, misinformation is vast and very easily accessible also.

Jennifer Ghahari:  That's a great point. And I think too, if people walk away with not really having the right diagnoses, they're potentially going to take a wrong path then, which would hinder their mental health recovery even longer. If I am actually presenting with diagnosis B, but I think I have diagnosis A, I might follow the wrong path and, actually, potentially get worse.

So, by going through something this, you're able to get the treatment that you need or at least the guidance that you need in order to have a better recovery and get the outcome that you're looking for, right?

Priyanka Shokeen:  Yeah, absolutely. And the thing with diagnosis is also, there's a lot of emotion attached to it. It can be hard to get a particular diagnosis because of how it's perceived. For some people it can be very relieving to get a diagnosis. For most people, the diagnostic categories don't represent a 100% of what they're experiencing. So, even the nuance of why we're saying this is a diagnosis versus that, even that is an important part of treatment.

Jennifer Ghahari:  Great. Before our last question, I'm going to change directions a bit here. What's your favorite part of Seattle? It could be anything.

Priyanka Shokeen:  Oh, my God. It's the proximity to my niece. She just turned two, and, oh, my God. I used to think it was the summers here, which also, beautiful, but tiny, cute baby learning words…

Jennifer Ghahari:  Nice answer. Do you have any final words of advice or is there anything else you'd to share with our listeners?

Priyanka Shokeen:  Oh, I hope somebody, whoever's listening, to whatever extent, that they can derive meaning out of it. The idea of comparison is so extremely prevalent, be it you comparing yourselves to coworkers, to family members, to people on social media. It's very easy to think that somehow everybody else can do things that somehow are very difficult for you or they're getting to places that you're not getting to.

They look a certain way, they do a certain thing. And I think the weight of those comparisons can really run you ragged. Or the thing that I find a lot of clients doing and have over the past several years of working has been when people in extremely hard conditions finally seek help, and it is very hard for them to give themselves the space to be tired, to be exhausted, because somehow everybody else is going through it too, how come they get rest?

Or somehow other people have it more difficult than them. And I always tell them, we're not playing the “Misery Olympics”. So, we don't know what goes into making somebody function. We don't know if what we're looking at is the real picture. We don't know the kinds of support they have or the resources they have, the protective factors, or on the flip side, we don't know what they're hiding or how close they are to a break.

So, it's okay to look at those things and think of them as either places you'd want to be or things you'd want to do, but that does not need to be a determinant in how you should feel about yourself when you should seek help, when you should seek rest. So, I hope some somebody listening can find some meaning in it.

Jennifer Ghahari:  Well, I've found meaning in it, so thank you.

Priyanka Shokeen:  I'm glad.

Jennifer Ghahari:  Now, this has been great. Thank you so much, Priyanka, Dr. Shokeen, for joining us today for this installment of “The Seattle Psychiatrist” Interview Series. And if anybody would to reach out to Dr. Shokeen or perhaps schedule an appointment at some time or some type of evaluation, you're welcome to do so by contacting info@seattleanxiety.com, and we'll get back to you shortly. Again, Priyanka, thank you so much, and we wish you all the best.

Priyanka Shokeen:  Thank you so much. Have a good one.

Jennifer Ghahari:  You too.

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Editor: Jennifer (Ghahari) Smith, Ph.D.