Clinical Assessment of Psychological Adaptive Mechanisms

in Medical Settings
Thomas P. Beresford
University of Colorado
The psychological adaptive mechanism (PAM) model for systematic clinical assessment can be applied
in any human setting in which individuals adapt to the conditions of their lives. This report focuses on
applying the PAM assessment technique to the stress and anxiety of physical illness. To do so, we
must consider maturity of PAMs simultaneously in relation to the cognitive functioning of the brain as
assessed either in the office or at bedside. After considering case examples to illustrate this application,
the discussion proceeds to include larger patient groups to which clinical PAM assessment might be
applied, with special reference to cognitive function. The report concludes with suggestions for further
improvement of the PAM clinical recognition method as well as its current practical applicability as
an acquired clinical skill designed for use in everyday practice. C 2014 Wiley Periodicals, Inc. J. Clin.

Psychol.: In Session 70:466–477, 2014.

Keywords: defense mechanisms; clinical assessment; cognitive functioning

Introduction: The Practical Use of Psychological Adaptive Mechanism Recognition

in Diagnosis and Treatment
The working model of psychological adaptive mechanisms (PAMs) offers clinicians a unique
method of assessing human individuals’ adaptation in relation to the specific stressors they
encounter. PAM assessment can be used in any setting in which one’s conscious sense of self,
referred to in psychoanalytic theory as the ego, encounters a circumstance that threatens to
upset its equilibrium. Analogous to classic physiological descriptions of the cell, in this model
the ego, when perturbed, responds in such a way as to reestablish its own equilibrium. In this
way, recalling the term coined by Anna Freud (1977), the ego defends itself with psychological
mechanisms designed to restore its subjective harmony. “Ego defense mechanism” as a concept
grows out of this intrapsychic theory of psychological functioning. At the same time however,
Miss Freud rightly pointed out that such “defenses” result in specific behaviors that can be
described by an outside observer.
The elegant longitudinal studies of George Vaillant (1971, 1973, 1998) went on to establish the
empirical reliability of ego defense mechanisms both by inter-rater agreement and in repeated
observations over time. Viewed from an external vantage point, Vaillant described these as
adaptive behaviors, introducing the idea of the mind finding a repertoire of ways in which to
come to terms with, or adapt to, the threat of the anxiety created in an awake and conscious
sense of self. In his work, humans are capable of responses to the discomfort of anxiety in very
primitive, restricted, ways—such as ignoring a stressor as though it did not exist—through a
hierarchy ending in highly flexible mature adaptive responses that describe human health.
Vaillant’s longitudinal studies of three very different subject groups found the commonality
of the hierarchy among them irrespective of gender or socioeconomic variables. Rather, critical
factors in reaching the psychological health of the mature adaptive styles included (a) normal
neural maturation in the brain, (b) a sufficiently stable and caring environmental upbringing—
akin to D. W. Winnicott’s concept (1992) of “good enough mothering”—while brain maturation
takes place, and (c) an absence of ongoing threats to the progression of maturity as seen in
disorders such as alcoholism, malnutrition, or medical injury to the brain, among many others.

Please address correspondence to: Thomas Beresford, 1055 Clermont Street (116), Denver, Colorado,
80220-0116. E-mail: thomas.beresford@ucdenver.edu

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 70(5), 466–477 (2014) 

C 2014 Wiley Periodicals, Inc.

Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.22090

 Clinical Assessment 467

Table 1
Clinical Characteristics of Psychological Adaptive Mechanisms (PAMs)

PAMs:
• Occur spontaneously
• Cap (moderate or limit) anxiety
• Respond to perceived stress that threatens conscious psychological homeostasis
• Allow time to deal with stress maximally
• Exist on a hierarchy of domains from primitive to immature to neurotic to mature
• Develop along this domain hierarchy from infancy through adulthood.
• Are normal by domain at different life stages
• May develop toward higher domains at slower rates in socially vulnerable settings
• Actively resolve stress at the level of the mature domain
• Vary over a spectrum of responses from rigid (primitive) to flexible (mature)
• Engage at the most mature level available in individual cases
• Depend on optimal brain development and functioning for the greatest maturity of response
• Regress to lower, less mature domains with impaired brain functioning
• May regress to lower, less mature domains with overwhelming or prolonged stress
• Result in observable behaviors that can be measured
• Empirically predict mental and physical health in relation to age appropriate maturity

Note. Table 2.1 from Psychological Adaptive Mechanisms (p. 18), by T. Beresford, 2012, New York: Oxford
University Press. Reprinted with permission.

In a recent book (Beresford, 2012) aimed at offering a specific clinical approach to assessing
observable adaptation styles in the specific patient seen in the office or at the bedside, I have
referred to these adaptive styles as PAMs. This term is both one of conceptual simplicity and
of reference to those observable behaviors that provide the most successful adaptation available
to the person at a point in time. It is also one of convenience in teaching psychiatric residents
over the past 20 years (Beresford, 2005). The relative de-emphasis of psychodynamic models in
the present era training programs has rendered the term “ego defense mechanism” much less
intuitively understandable than PAM, stated in standard English.
From work on developing adaptive theory and empirical data into a useful clinical tool, in
Table 1, below, I offer the characteristics of PAMs that can be taken into account when seeing
persons who seek the assistance of any mental or behavioral health practitioner.
I have also created a decision algorithm (see Figure 1 below) for PAMs.
As explained in Beresford (2012):

This diagram . . . begins with clinical identification of the current stress and of the
anxiety that the stress generates in waking consciousness. It then proceeds in a step-
wise fashion. First, it assesses whether or not the patient recognizes the stress itself
or ignores it in the style of the Primitive Domain adaptive mechanisms. If the patient
recognizes the stress, it next asks whether he or she regards the stress as something
within his or her range of responsibility or control, or locates it outside the Self. Ex-
ternal location defines the adaptive strategy of the Immature Domain mechanisms.
If the patient perceives the stress in waking consciousness and as within the purview
of the self, the algorithm next asks whether the cognitive and emotional contents
of the stress work together or whether they remain unintegrated. The lack of inte-
grated thought and feeling characterize the Neurotic Domain strategies. Finally, if
the person (1) recognizes the stress, (2) regards it as part of his or her life with its res-
olution belonging to him or her, and (3) integrates the thought and feeling contents
of the stress, he or she functions in the Mature Domain of psychological adaptive
mechanisms. Mature Domain mechanisms move to resolve the stress. (p. 28)

For those wishing to learn in a more detailed fashion about these different aspects of PAM
assessment, ranging from theoretical modeling through attributes and then to clinical hypotheses
468 Journal of Clinical Psychology: In Session, May 2014

Figure 1. Recognition algorithm for psychological adaptive mechanisms.

Note. Table 3.1 from Psychological Adaptive Mechanisms (p. 28), by T. Beresford, 2012, New York: Oxford
University Press. Reprinted with permission.

in particular patients, I suggest the extended discussion in Psychological Adaptive Mechanisms,

Ego Defense Mechanisms in Practice and Research (Beresford, 2012).
In the present discussion, I have opted to take the reader on rounds, as it were, in specific
instances of PAM deployment that can be seen in the transplant clinic and in general hospi-
tal wards as human beings come to terms with often difficult, and sometimes overwhelming,
stressors. As discussed previously, and in the following examples, PAMs frequently advance and
regress in the service of both cognitive and emotional stressors as well as the adequacy of brain
functioning that can be addressed effectively by bedside mental status testing, including specific
cognitive tests that offer assessments of different parts of the brain. The first examples derive
from a unique clinical group: otherwise physically healthy persons who desire to undergo surgery
removing one of the two lobes of the liver in order to donate it to a person whose native liver
has failed.

“Willing” Donors
The availability of organs limits the capacity of liver transplantation to save lives. Lobe donation
from live donors increases availability. To recipients and transplant teams, preserving lives
constitutes a final good.
Most live donors will agree. To those who must evaluate their suitability for liver graft
donation, however, a potential donor’s willingness to undergo the procedure carries a greater
complexity with clinical, ethical, and potentially legal implications (Trotter et al., 2007). Both
publicized cases of untoward outcomes and systematic observation of higher than expected
rates of suicide among living donors raise concerns not only about mental health among donors
but also considerations of free will in choosing a course of action. Although a technically safe
procedure in the hands of an experienced transplant team, live donation nonetheless carries
the potential to take lives. The wide psychological variation among individuals who request
this elective, highly invasive major surgery continues to speak for the necessity of a systematic
method for their clinical assessment that surgeons, hepatologists, psychiatrists, psychologists,
social workers, nurses, and other mental health professional discipline members can all agree to.
 Clinical Assessment 469

A few case examples, in heavily disguised form, will illustrate the clinical challenges as well as
outline an approach to evaluation.

Case 1
Twelve months after a closed-head injury in an auto accident, this 37-year-old male sought
Good Samaritan donor status. His family agreed. At interview, his cognitive examination re-
vealed deficits in both short-term memory and frontal lobe executive functions. An assessment
of his operating PAMs identified primitive avoidance/distortion in his belief that the public
notoriety from his liver donation would restore his business that had failed after his accident.
The psychiatrist and the transplant team agreed on pursuing his candidacy no further.

Case 2
A 33-year-old three times divorced female presented for live donation to a married but childless
woman in her late twenties, an alumna of her college sorority, who she met at a social gathering.
At interview the potential donor described an incident at age 10 when neighbors found her
mother’s body, dressed in her sorority sweater, on their living room floor, a victim of suicide by
poisoning as established at autopsy. In the psychiatric interview, the donor candidate presented
a clear cognitive state but became vehemently upset and argumentative at the suggestion that the
donation might be related to her mother’s death. She said her donation was only so the recipient
would be healthy enough to have children and it made her sad to think that the recipient could
not without a “new” liver.
The donor’s highest observable PAM was a very brittle reaction formation that suggested that
she would not do well when she found that live donation did not resolve her early own trauma.
The psychiatrist advised the team against transplant. The team disagreed and successfully grafted
the donor’s lobe into the recipient. Three months after the procedure, the team began receiving
phone messages from the donor saying that her life was worthless. She refused further psychiatric
contact, saying, “They don’t know what I’m going through.”

Case 3
This 26-year-old married father of a 6-month old son presented with his wife for lobe donation.
A jet pilot himself, he wished to donate to his uncle, a former astronaut whose heavy drinking
had resulted in terminal cirrhosis. At interview, he described growing up in a chaotic household
with two drug-abusing parents and looking to his uncle as the guiding star of his life. He readily
acknowledged that he hoped to extend his uncle’s life because his example had meant so much
to him. His wife, aged 23 years, said she doubted the uncle’s continued sobriety and that she did
not like her husband taking unnecessary health risks with their infant son at home and their
plans to have more children.
The psychiatrist reviewed the likely consequences of the procedure—including the potential
loss of his flying career due to health status—and described the alternative of cadaveric donation
for his uncle. In the setting of a clear cognitive examination, a reaction formation–in which he
put his own well-being at risk to save his uncle–made up his adaptive mechanism. Two weeks
later, after further discussion between husband and wife, however, he withdrew his request and
asked for a referral to “talk to someone about feeling sad.”

Case 4
A 32-year-old married teacher and mother of two junior high schoolers learned that her best
and longest childhood friend, her first cousin and “other sister,” needed transplant for Primary
Sclerosing Cholangitis–a poorly understood disorder involving inflammation and scarring of
the bile ducts leading from the liver that results in liver failure. At interview she and her husband
described their concern on hearing the news 7 months before and then, together, learning about
liver disease, transplantation, and donation, all through online searches and reading. They began
discussing it with her physician 2 months before interview and then with their extended family.
470 Journal of Clinical Psychology: In Session, May 2014

Several family members mentioned concern for her health and also applauded her willingness
to consider donations; none had tried to influence her toward a decision to donate.
At interview, her cognitive state was normal. Asked how tissue mismatch or other medical
concerns precluding donation might affect her, she said she would rest comfortably knowing she
had “done all I could for my sister.” She and her husband described their plans for childcare and
economic adjustment during her operative recovery. True altruism, a mature level defense, con-
stituted her primary adaptive mechanism, along with that of anticipation. Both the psychiatrist
and the transplant team agreed with her proceeding to graft donation.

As illustrated, potential donors follow many paths to the transplant team’s door. Careful
clinical evaluation can assess their mental capacities as well as motivation and states of mind.
In the first case, assessment of the donor’s cognitive state led to the differential that revealed
the brain trauma history. Both his history and cognitive state fit with his primitive adaptive
mechanism, in his case a primitive distortion of the purpose of a liver lobe donation: to save
the family business. As noted throughout the current discussion, PAM maturity requires a fully
functioning brain. For wide application, a combination of the Mini-Mental State Examination
(MMSE; Folstein, Robins, & Helzer, 1983) and the Frontal Assessment Battery (FAB; Dubois,
Slachevsky, Litvan, & Pillon, 2000) provide effective cognitive screens for basic and complex
cognitive assessment, respectively.
The remaining three cases, all with clear sensoriums and no loss of cognitive capacity, present
much greater clinical challenges and controversy. In the second case, the donor projected her
own anger onto the psychiatrist, placing her in the immature PAM domain of adaptation. At her
best, she presented a very brittle neurotic domain pseudo-altruism, a form of reaction formation
in which her idealized donation was really aimed to assuage her own love and ego needs. The test
lay when his apparent altruism crumbled after the donation when her otherwise heroic act left
her with even more desperation. In contrast to the third case, the second donor had no ability
to consider alternatives, including reviewing her own sources of motivation, projecting her need
outward instead.
By contrast, the jet pilot in the next case, who also used a reaction formation in risking his
own health and that of his family to save an idealized uncle, evidenced the flexibility to weigh
alternatives and experience the sadness needed to give up the reaction formation. This specific
contrast between cases 2 and 3 suggests that assessing the ability to consider alternative actions
is empirically useful in the clinic.
The fourth case, that of a careful decision process, involved (a) unimpaired cognition, (b) an
independent examination of the pros and cons of the procedure itself, (c) a review of concerns
with others not part of the transplant team, (d) no evidence of family coercion, and (e) empirical
assessment of adaptive mechanisms. In this case the patient employed mature adaptive mecha-
nisms: Asked about not donating, she stated a sense of comfort in having exhausted all of the
alternatives. Contrast this to projecting negative emotions for subjective sadness as in case 2, or
in choosing the present over the past as in case 3.
While most will see the advantages of the above-mentioned assessments (i.e., as sources
of data in addition to the standard history and physical examination), the inclusion of PAM
evaluation may seem foreign to some. To those untrained in their clinical use, the language of
PAM nosology alone, one that uses very specific definitions of commonly used words, may sound
like meaningless psychologizing. In fact, a large empirical literature supports their observable
occurrence “in nature,” so to speak. Developing the nascent literature on their use in clinical
populations constitutes one of my research and teaching interests.
The practical need for PAM assessment appears in the disagreement between psychiatrist and
transplant team in case 2. Practically speaking, the recipient remained alive and was better off.
One can argue that the donor was worse off, however, and that this eventuality was evidenced
beforehand. Did the team’s decision honor the medical dictum primum non nocere—first, to do
no harm—in the second donor’s case? Did extending the life of the recipient because of the liver
graft outweigh the clinical importance of the donor’s psychological state postdonation? No clear
or simple answers appear. The greater clinical precision afforded by PAM recognition, however,
does offer a new and useful method of weighing psychological harm against physical benefit.
 Clinical Assessment 471

This may lead to better clinical definitions of psychological harm. In the meantime, the care and
assessment of those who come to us to put their own health at risk deserve our best efforts in
understanding their heroism, their vulnerability, and our own practice.

PAMs, Stress, and Cognition

Case 1: Death Before Dishonor
A 47-year-old female came to a transplant clinic in a tertiary care hospital on the West Coast.
She had been referred by her cardiologist for consideration of a heart transplant due to severe
deterioration of the heart muscle itself because of her extensive drinking history until age 43.
Presenting to the cardiologist’s office, she described 4 years of continuing abstinence from alcohol
and this allowed him to put her name forward. On her first encounter with the transplant team,
she was informed that a psychiatric consultation was a routine part of the assessment needed for
transplant candidacy. She at first refused to make an appointment for a consultation and was
informed that without it she would not be considered for the operation. At the same time she
agreed to all of the other assessments that needed to be done, including those by social work,
nursing, and a series of medical specialists.
She arrived by herself at the psychiatrist’s office and did not bring a significant other person
with her despite instructions to do so. She repeated her history of 4 years abstinence from alcohol
and stated that although she had used marijuana as well as tranquilizing drugs in her twenties,
she had been free of them for a number of years. On cognitive exam, both her basic and complex
cognition responses were well within statistical performance norms. There was also a history
of three marriages, all ending in divorce. Two of the marriages had resulted in the birth of two
daughters, both now grown women who lived out of state. The patient herself had suffered from
intermittent depression as well as an eating disorder also when in her twenties, had been free of
both for over 10 years, and was no longer on an antidepressant medicine.
At the transplant team conference discussing her case, it became evident that her alcohol
and drug use history was uncorroborated by anyone in her social network. This led to follow-
up phone calls from the psychiatrist to her daughters. Each of them independently described
her mother as having been actively drinking in intermittent binge-style episodes during the
previous 2 years. Neither had knowledge of marijuana or other drug use. In discussing this
information with the psychiatrist in the company of one of the clinic nurses, the patient abruptly
left the interview commenting, “I don’t really need a heart transplant.” She followed this with a
complaint letter to the hospital administration alleging that the psychiatrist talked with her in
a condescending tone of voice and that she would no longer see any psychiatric specialists. She
was not placed on the transplant waiting list.
Following the decision path in Figure 1, this patient’s need for the heart surgery constituted the
stress felt as anxiety—a sense of impending disaster that she first projects onto the psychiatrist
in pointing out his inadequacies and refusing to talk further, rather than considering her own
ongoing alcohol use that, unless treated, would disqualify her from a lifesaving graft. Seeing
her anxiety as being caused by others, rather than by her own behavior, characterizes her in the
immature PAM range and identifies her behavior as a nonpsychotic projection in which all but
she are to blame for the situation. More remarkably, rather than address her alcoholism, she
retreats further into the primitive domain, stating that she did not need a cardiac transplant.
This is the characteristic of the primitive domain PAMs: the problem—stressor and its anxiety—
simply do not exist. Rather than come to terms with the alcoholism, she chooses a path that will
result in her own death. One can see in this her perception that the emotional stress of giving up
the alcohol is greater than that of untreated cardiac failure.
At the same time, however, continuing heavy use of a brain depressant drug—the alcohol—
advances the case that, in some subtle way, her brain has been affected by the alcohol and is itself
not functioning properly, such that she is no longer capable of reaching the two highest levels
of adaptive functioning. This case illustrates the power of stress to drive down PAM maturity
of functioning as well as a similar effect in the loss of power in a subtly dysfunctional brain. At
this point, the two are difficult to tease apart clinically with respect to which may be the greater
472 Journal of Clinical Psychology: In Session, May 2014

cause. We have much more to learn about the interaction of stress, brain functioning, and PAM
maturity in this regard.

Case 2: Too Much Too Soon

A 72-year-old White male by his account lived happily in a continuously good state of health until
developing a blood clot in his left leg that resulted in respiratory failure when a series of small
clots reached his lungs. He was treated acutely in an intensive care unit for 2 weeks and another
week in a step-down unit, both in a private hospital. He was then transferred to his local city
hospital for further recuperation. He had no evidence of stroke or any other symptoms or signs
of localized brain disorders. On his second day in the city hospital, a consultant psychiatrist was
called in to evaluate his complaints of pain that appeared to have no basis in known anatomical
patterns of sensation. At that time, this patient appeared lucid and generally cooperative but
complained of not receiving sufficient pain medicines and blamed his doctors and nurses for
this. Neither, however, could he point to any specific focus of pain in his body.
On cognitive exam, he accurately stated his location and appeared to converse well. His mood,
however, was somewhat irritable throughout and he had difficulty with occasional brief outbursts
in which he sounded angry and repeated the phrase, “Misery is pain and I’m miserable, don’t
you understand?” He endorsed neither hallucinations nor delusions. In further testing of his
cognitive abilities, however, he registered four objects but could recall only one of the four after
5 minutes. Despite a college education, he could not add 20 +15 accurately. Asked a standard
judgment question about what he would do were he the first to discover a fire in a crowded
theater, he gave an overly detailed answer of ushering people out the door one by one, row by
row, but did not come up with the standard response which was to call for help in some way.
Most profoundly, when asked to perform the Verbal Trails B (Trotter et al., 2007) test that
requires repeating the alphabet and sequential numbers in an alternating pattern beginning with
“3-C,” he could not apprehend the directions and responded with “4-C, 5-C, 6-C” until stopped
by the interviewer. Two further attempts at repeating the directions had the same result. His
response was far short of the normal cut point in which persons are able to progress to 13-M or
further without error in the space of one minute.
With the working diagnosis of delirium, in which a person becomes acutely confused with a
marked loss of their usual cognitive abilities, the psychiatrist and the medical team treated him
with a very low dose of the dopamine blocking agent, haloperidol. Two days later, his irritability
had gone and he discussed his case with the psychiatrist in a very calm and welcoming manner.
He stated that he had no memory of the first two weeks in the other hospital. He noticed that
his pain was now localized in the lumbar section of his back and that his medications were
appropriate and controlling the pain. In his view, his doctors and nurses were assisting him
as best they could. Most strikingly, he did far better on memory, calculation, judgment, and
especially the executive functions located in the dorsolateral prefrontal portion of the frontal
lobe, carrying the verbal trails B test through “20-T” in the space of a minute without error.
PAM analysis in this case focuses on his use of the concept of pain and the anxiety it generates.
His description of others not understanding his pain during his confusion episode places the
blame for it on them. This fits the immature domain criterion of the anxiety belonging outside of
this man’s brain when, in fact, the failure of his brain to apprehend his circumstance excludes his
ability to recognize his role in it. There is not otherwise an operative stress involved, other than
that of his perceiving his own “misery” that he cannot articulate more specifically. After a low
dose of the haloperidol, however, his brain recovers its integrity of functioning and he returns
to a much higher level of PAM maturity, in which he no longer blames others but perceives his
ailments more specifically and as his own. A return of measurable cognitive function in this case
means a return of optimal psychological adaptation.

Case 3: Never Walk Alone

A few days after a cold snap involving subzero temperatures, the city police brought this
63-year-old White male to his local veterans’ hospital when they noticed his inability to walk. On
 Clinical Assessment 473

examination he was discovered to have gangrene–progressive tissue death–in both feet, thought
due to a combination of poor circulation because of his diabetes and acute tissue injury he suf-
fered from frostbite. He was sent from the emergency department to the operating room where
he underwent a bilateral amputation, one reaching midway up his lower right leg and the other
at the distal end of his lower left leg.
Two days later, the surgical team called in the consultant psychiatrist to assess him with
respect to depression. At interview, this overweight man gave no evidence of any of the triad of
hopelessness, helplessness, or worthlessness that characterize depressive mood disorders. Rather,
he seemed remarkably affable and attempted, somewhat awkwardly, to make a joke when asked
whether he had encountered any unusual perceptions in the hospital.
At the same time, however, asked why he was in hospital, he replied, “I was having trouble
getting around.” Asked what he meant by that, he avoided any detailed answer and repeated his
first response. Asked how his doctors had described his condition, he stated he did not know,
and whether he had had a surgical procedure, he stated that he understood he had but did not
know the nature of it. When the psychiatrist offered that the surgical team noted his having had
an amputation of his feet, he acknowledged that this was the case but did not elaborate.
Further in the assessment this patient described having lived “outdoors” in a homeless state
for the previous 30 years. He stated that this was by his choice and he was looked on as one to
whom the other homeless persons in his acquaintance would ask for help and advice. When the
psychiatrist offered that the loss of his feet would very likely change his ability to return once again
to living on the streets, he agreed but then added, “I’ve got lots of hope.” Cognitive testing, toward
the end of the interview, revealed marked difficulties with his short-term–working–memory at
being able to recall none of four registered objects after 5 minutes. He also did very poorly on
bedside frontal executive testing, losing the Verbal Trails B sequence after “6-F,” far short of
the normed cut point at 13-M. A magnetic resonance image scan revealed large patches of end
vessel disease in the periventricular white matter part of his brain, which appeared due to a
combination of his poorly controlled diabetes and high blood pressure associated with it.
As is often the case, this man’s minimizing his circumstance in describing his illness state is
best characterized as his avoiding the issue, consistent with the primitive domain in which the
person does not acknowledge the presence of painful thoughts or painful feelings. While this
patient’s cognitive performance signaled clinically significant limitations, he was nonetheless
able to work back to an accurate recognition of his clinical state, namely, his amputations,
when the psychiatrist gradually led the way in their dialogue. With assistance, he was able to
move from avoiding consideration of his physical state with euphemisms like “having trouble
getting around” to a state of acknowledging with the psychiatrist that the amputations were life
changing with regard to his living a homeless lifestyle.
Reluctantly and without an expression of his painful emotions, he nonetheless had sufficient
capacity to speak of it in an intellectualized way—conversant in the cognitive realization of the
amputations’ effect on his life putting him in the neurotic domain of intellectualized, isolated af-
fect behavior. With the assistance of the psychiatrist, he was able to reconstitute a higher domain
maturity at the end of the interview than at its beginning. This relatively rapid reconstitution
implies sufficient brain function for it to occur despite the overwhelming nature of the stress of
the change the amputations brought to his life. The possibility of PAM regression is ubiquitous
and can occur when stress becomes overwhelming. The important clinical consideration here lies
in the resilience of PAM maturity. This in turn serves as a function of (a) prior PAM maturity, (b)
the lack of an intervening block to resilience such a illnesses, toxic states, or other occurrences
affecting the brain, and (c) sufficient brain function reserve to allow for a neural platform to
maximize reconstituted PAM maturity.

Further Uses of PAM Assessment in Clinical Practice and Research

PAM Maturity as an Outcome Measure in Clinical Research and Treatment Trials
Cancer and depression. Our university oncology colleagues posed the question as to
whether antidepressant use was helpful in cancer patients. They felt beleaguered by cancer patient
474 Journal of Clinical Psychology: In Session, May 2014

advocacy groups, on the one hand, claiming the field’s underuse of antidepressant medicines in
cancer patients and, at the same time, an uneasy sense of prescribing antidepressants frequently
but with little evidence of efficacy in their own clinical observations. Reviewing the published
data on controlled treatment trials of antidepressant medicines in cancer subjects, the reported
literature contained only a few studies and those delivered contradictory results. Their methods,
however, were similar in that all of them used depression symptom scales as primary outcome
variables.
Much-publicized studies of group psychotherapy among cancer victims (Fawzy, Canada, &
Fawzy, 2003; Spiegel et al., 1999) raised the possibility of alternative models of treating de-
pression, but, unfortunately, large, randomized, multicenter trials could not verify the early
conclusions (Goodwin et al., 2001). One difference was that the early studies charted outcome
only in those subjects who arrived for the psychotherapy sessions. Earlier studies of psychother-
apy had attributed attendance to psychological health: Psychologically healthier individuals
come to therapy, whereas those with more significant disorders often do not (Buckley, 1984;
Conte, Plutchik, Buck, Picard, & Karasu, 1991).
This led our group to consider application of the PAM model to survival outcome in late stage
cancer patients (Beresford, Alfers, Mangum, Clapp, & Martin, 2006). As outcome measures,
we employed both depression symptom ratings (Beck & Steer, 1984) and the Defense Style
Questionnaire (DSQ; Bond et al., 1989), a 40-item survey of specific adaptive styles. We then
looked at the sample extremes of (a) the most versus least depressed, and (b) the immaturely
versus maturely adapted, each in respect to survival among a series of stage 3 and 4 cancer
patients. Depression symptoms did not separate the two groups until 3 years after the initial
study contact and did not reach significance at any time. By contrast, PAM maturity as assessed
on the DSQ separated the two groups almost immediately and with striking clinical results that
were well beyond chance expectations.
Comparing survival rates, 50% of the maturely adapted remained alive at 5 years, whereas
50% of the immaturely adapted had died by 18 months. This finding strongly suggested that
the PAM model had useful applications in understanding the behavioral factors involved in
cancer survival, as compared to a standard depression model, and brought forth hypotheses for
further research. It also suggested that antidepressant drug trials in populations such as this one
couldn’t depend on standard depression scale ratings to generate clinically useful outcome data.
Rather, measures of the spectrum of PAM maturity appear to be far more useful.

Posttraumatic Stress Disorder (PTSD). The Department of Veterans Affairs (VA) hos-
pital system is probably the largest treatment organization for combat-related PTSD anywhere
in the world. At the same time, it provides compensation and pension for veterans who have
undergone war injuries, including PTSD and related conditions. As a result, the VA struggles
with a built-in confounding factor when it attempts to assess outcome in its treatment programs:
Subjects may underreport improvement in their symptoms for fear of losing their symptom-
related benefits. In theory, PAM assessment should offer data that is transparent to this concern
among veteran subjects since it does not directly assess PTSD symptoms, but rather mechanisms
by which humans respond to stress.
One potential use therefore is comparing PAM maturity in a pretreatment to posttreatment
study design to assess whether changes in the ability to manage traumatic emotional stress
improves over a course of treatment. We have begun studies in this regard with target goals of (a)
assessing whether PAM assessment reflects individual improvement and (b) better understanding
which patient subgroups make best use of which PTSD treatment modalities.

Traumatic Brain Injury (TBI). Following a thesis of this discussion—that PAM ma-
turity varies directly with brain health and function–persons with TBI might be expected to
evidence regressions to more immature PAMs immediately after injury, with return to premor-
bid mechanisms with healing. Anecdotal evidence supports this, especially in the acute phase
of the injury. More subtle phenomena can occur, however, after the first year postinjury when
the brain’s own healing mechanisms have had their maximum effect. This can be true espe-
cially in the most common “mild” forms of TBI in which affective lability–a loss of the brain’s
 Clinical Assessment 475

capacity to manage the expression of emotional states—has not returned to a healthy premorbid
state of affective regulation, resulting in presentations that resemble mood or anxiety disorders.
Our group’s own pilot treatment trial of post-TBI affective lability has raised the possibility
of PAM regression in mild TBI subjects whose affective lability remains after 1 year. Further
treatment outcome research will benefit from focus on measures of PAM regression in charting
improvement in response to specific medicinal treatments.

Alcoholism. Anyone familiar with alcoholism treatment will note the behavioral progres-
sion of the Twelve Steps along the path leading from uncontrolled alcohol use to stable abstinence
in the setting of high-risk drinking. From the First Step in recognizing a problem with alcohol
use–that is, beginning to question the primitive avoidance or denial of alcohol use disorder—the
abstinence path leads through the Twelfth Step in using hard-won sobriety in the mature altru-
ism of helping others. This progression exemplifies the PAM hierarchy of adaptive maturity as
found in nature, so to speak. Yet our understanding of the brain factors that assist healing along
this PAM model remains largely unknown. For example, work from our group suggests that the
brain’s neuroendocrine mechanisms that engage with alcohol abstinence may play a significant
role in the recovery of brain function that we refer to as healing. How the PAM hierarchy and
its underlying theoretical model might relate to specific mechanisms in brain healing remains
largely unexplored.

The Need for a Decision-Directed Practical Structured Interview

One practical concern in considering further research and clinical improvements in PAM recog-
nition lies in the need for a valid and reliable structured interview that can be used clinically
for PAM assessment in multisite studies. To date, consideration of appropriate assessment tech-
niques has been influenced by the statistical requirements of large-scale research designs. Our
work, however, asks the field to take one step further: to consider the usefulness of the clinical
PAM algorithm, illustrated above, in the setting of a single practitioner working with a single
patient. In that context, tool-building research might include a practical structured interview
that might be devised as simply and yet as accurately as possible for everyday clinical use.
At present, the PAM recognition algorithm depends for its accuracy on the method of clinical
art: perceiving the patterns in behaviors. Practical, reliable, standardized interview techniques
that use the stepwise approach of the PAM recognition algorithm may offer a useful advance in
this specialized area of diagnosis and treatment measures.

Applying Neuroscience to PAM Maturity Assessment

Underlying the belief that PAM assessment and recognition can be employed clinically is the
assumption–employed throughout this article–that PAM behaviors reflect brain functions. Links
to brain development, such as the ongoing myelination of the brain through growth and de-
velopment of childhood and adolescence that call forth increasingly mature PAMs, strongly
suggest this. However, the possibility of a specific neural circuitry of PAM expression requires
the necessary caveat that behaviors of this kind are complex and involve many different brain
structures and their webs of communication. In this respect, PAMs may simply be the total
expression of a fully functioning brain viewed as a single entity.
Still, validating this hypothesis may require a much more sophisticated understanding of how
the brain’s many complex facets function both in space, relative to each other, and over time
in the setting of development. Our understanding of the various facets of the brain’s healthy
functioning remains a considerable distance from its own maturity of knowledge. At the same
time, these investigations constitute one of the most exciting and interesting areas of science in
our era.
476 Journal of Clinical Psychology: In Session, May 2014

Conclusion
Even as research looks for more answers, people naturally seek out the help of mental health
professionals in coming to grips with the pain of their lives, one expression of which is the stress
and anxiety engendered by painful thoughts and painful emotions. Mental health professionals
have used a number of models to understand, and be of use to, those who come to us in their
distress. One of the most widely used models at present is simply the descriptive one that has
been reified in the Diagnostic and Statistical Manual of Mental Disorders series. In the hands
of many, however, this serves an overly simple “cookbook medicine” approach to diagnosis
because it has limited ability to look beyond surface description and into a more dynamic view
of the functioning of human beings.
The era is at hand, however, in which other more sophisticated models, such as that of the
PAM model, can be used expertly, and reliably. In its present form as a recognition algorithm,
it can accurately (a) assess current and adaptive styles, (b) point the way to change whether
through psychotherapy or medicinal interventions, and (c) follow up with assessments that can
chart growth and higher levels of adaptive functioning. Providing a systematic clinical tool for
this approach was the rationale for publishing Psychological Adaptive Mechanisms, a guidebook
that teaches practitioners how to adapt this empirically derived knowledge to specific cases.
The discussion in this article broadens the range of use to include medical assessments but
also notes that the decision algorithm can be used clinically in any setting in which persons
present difficulty in adapting to their environments. It is a new and exciting approach and one
that will be further refined as mental health and other practitioners find it useful.

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