Although Albert Ellis was originally trained as a psychoanalyst, he is an important figure in the history of the cognitive therapy movement. His transformation is striking, as it represents a philosophical shift from that which is deep and mysterious in human nature, namely the unconscious, to that which is more or less obvious, the rational process and errors of reasoning.
The movement Ellis founded is called rational-emotive therapy. According to Ellis, logical reasoning is the foundation of mental health. Psychopathology is the product of illogical inferences and other irrational beliefs. From this, it follows that mental unhap-piness, ineffectuality, and other disturbances can be eliminated when people learn how to maximize rational thinking. Correct your reasoning, and your emotions will follow. The task of the therapist, then, is to identify errors in the reasoning process, showing patients that their difficulties result largely from distorted perceptions and erroneous beliefs. Not surprisingly, then, rational-emotive therapy tends to be more confrontive than supportive: The patient is doing something wrong, and this must be identified and exterminated. Patients' mistakes are their disease. Like other cognitive theorists, Ellis's thinking does not generate a series of personality constructs, but instead addresses cognitive processes as they cut across most mental disorders.
Carl Rogers, perhaps the single most influential theorist on therapy from the 1960s through the 1970s, is opposite Ellis, both philosophically and in bedside manner. Whereas Ellis is confrontive and highly directive (you must show patients their errors), Rogers impressed patients as a kind grandfather, always listening and reflecting their own emotions as a gentle commentary, intended to make them feel understood rather than thrusting their mistakes into awareness. According to Rogers, each person is innately right; that is, individuals possess their own innate sense of what is required for their own growth as a unique person. Healing emerges from the quality and character of the therapeutic relationship. Rogers' movement, therefore, became known as client-centered therapy. Growth could be facilitated through certain therapist attitudes, notably genuineness and authenticity.
Rather than learn complicated techniques founded in some abstract theoretical model, therapists should "be themselves," expressing their thoughts and feelings in a constructive way that honors the person, but without pretension or the cloak of professional authority. For Rogers, "unconditional positive regard" was the key. Clients should be respected as beings of intrinsic worth and dignity, no matter how unappealing and destructive their behaviors might be. However, Rogers also emphasized that clients must assume full responsibility for their own growth. Through accurate empathy and positive regard, the therapist lays the foundation. Only the client can follow through.
is that all therapies are more alike than different, and a better psychotherapy can be created by returning to the core principles and techniques from which particular therapies diversify. Third, therapeutic eclecticism holds that the techniques of various schools should be incorporated into treatment as necessary, without regard for the theoretical model in which the technique was first developed. By divorcing theory from techniques, therapists are free to draw on any technique to optimize the therapy of any particular case.
These movements, however, are only the latest in a long series of adaptations, not the final word. More appropriate to the symptom disorders of Axis I, they represent only an intermediate step toward a psychotherapy logically coordinated to the personality disorders. Personality pathologies are notoriously resistant to treatment. They not only make for fragile gains that are often suddenly and dramatically reversed, but also complicate transference and countertransference reactions with unanticipated issues and just naturally tend to generate Axis I symptoms. The borderline personality, infamous among therapists, provides an outstanding example. Borderlines often improve, only to suddenly become depressed and suicidal again as termination approaches. Moreover, contemporary therapies fail to recognize an intrinsic contradiction between the formal properties of therapy as it is currently practiced and the formal properties of psychotherapy that personality disorders logically require. The premise is simple: Because personality is more than the sum of its parts, therapy must be also (Millon, 1999).
To provide a background against which synergistic psychotherapy can be understood, we first provide an overview and critique of the contemporary trends identified previously. Next, synergistic psychotherapy is discussed as a logical outgrowth of the personality construct itself. Finally, barriers to the synergistic psychotherapy are presented, namely, the content shortcomings of the DSM and its lack of coordination to personality theory.
Brief therapy, the common factors approach, and therapeutic eclecticism are the dominant reactions to the dogmatic past. Their greatest virtue lies in putting the emphasis on efficacy and the importance of treating the individual case.
Modern times have seen the development of an entire species called brief therapies. With names such as the Focused Approach (Malan, 1976), the Anxiety-Provoking Approach (Sifneous, 1972), the Confrontational Approach (Davanloo, 1980), Experiential Group Therapy (Budman, 1981; Budman & Gurman, 1988), Planned Single Session Therapy (Bloom, 1992), and the Brief Personality Approach (Horowitz et al., 1984), these therapies seek to accomplish as much or more than the long-term approaches of the past. All share certain common features: They are defined not so much by any therapeutic school as by the time interval in which therapy is practiced. Therapy must be structured so that something gets done. The therapist becomes more directive, and the patient is expected to take an active role in treatment. The themes to be discussed are often agreed on in advance and formalized in a therapeutic contract. If therapy stalls, anxiety-provoking techniques may be engaged to get things going again. Where brief therapy draws on some substantive guiding theory, it mainly seeks to adapt the techniques of a particular perspective to the time frame preferred by contemporary economic constraints.
The common factors approach seeks to identify what is common to all therapies and then associate these factors with positive outcomes. Common factors enthusiasts are often fond of noting that most psychotherapies appear to be about equally effective. One of the original common factors proponents, Garfield (1957), for example, notes that treatment begins when an individual experiences a degree of discomfort sufficient to lead to consultation with a therapist as a socially sanctioned healer. Patients are universally afforded the opportunity to express their difficulties, to confide personal matters, and to unburden themselves of confusing or troubling thoughts and feelings. In turn, the therapist exhibits attentive interest and asks questions that elaborate what is presented. Further, every patient develops a relationship with the therapist. Most are good alliances with a reasonable level of mutual respect and trust. The patient gains the opportunity to rethink both self and situation and gains perspective on reality as well as a sense of increased competence and good fortune. Last, most therapists believe in the effectiveness of whatever therapy they practice. By conveying this positive outlook to the patient, they strengthen the conviction that their particular approach will be successful. J. D. Frank (1961) suggested that trustworthiness, competence, and the level of caring of the therapist are fundamental for effective psychotherapy. Also significant are arousing hope, encouraging behavioral change, stimulating emotional arousal and the corrective emotional experience, and developing new ways of understanding yourself. Further, all therapies, according to Frank, must confront demoralization, particularly loss of self-esteem and feelings of incompetence, alienation, and hopelessness. In the contemporary era, the number of common factors has multiplied greatly.
More and more, clinicians identify themselves as eclectic, borrowing tools and techniques from wherever necessary to make treatment most effective. Accordingly, eclecticism is regarded as being open-minded and centered on what actually helps people, humanitarian virtues that are difficult to criticize. In contrast, school-oriented forms of psychotherapy dictate the perspective from which cases are conceptualized and often dictate the specific techniques to be employed in therapy as well. Nevertheless, almost everyone would agree that the therapy should be tailored to the patient, not the patient to the therapy. Eclecticism thus constitutes a giant step forward. Lazarus (1973, 1976, 1981), for example, argues that therapy techniques can be drawn from any number of schools and matched to the presenting problems, without necessarily accepting the theoretical orientation with which these techniques were originally associated. Evaluation, according to Lazarus, should proceed according to the BASIC IB—behavior, affect, sensation, imagery, cognition, interpersonal relationships, and biology—but also be selected on the basis of actual empirical evidence for their effectiveness. Developing their own brand of technical eclecticism, Beutler and Clarkin (1990) stress that outcome depends on numerous factors other than any specific treatment technique, including the outlook of the therapist and patient personality and history, as well as other specific and interactive aspects among treatment methods. In contrast to other eclectics, Beutler (1986) acknowledges that the number and diversity of variables and interactions among patient, therapist, situation, history, and current problems are so potentially vast that theory should be used as a guide to therapeutic selectivity.
Although the preceding contemporary trends represent an innovative improvement over the past, they nevertheless share an important shortcoming: They fail to develop forms of psychotherapy specific to Axis II and, therefore, implicitly treat the personality disorders as if they were identical with the symptom disorders of Axis I.
A corollary to Murphy's Law, "Anything that can go wrong, will go wrong," states that "Work expands to fill the time allotted it." With the rise of managed care, however, psychotherapists are now required to accomplish more in less time. The emphasis on efficiency has produced a variety of short-term and brief therapies, listed previously. Unfortunately, such therapies are unified only by their emphasis on the duration of therapy, not its substance. The duration of therapy should be dictated by the nature of the problem, not by economic necessity. Modes of therapy constructed to fit a given time frame naturally home in on the presenting problems. The goal is to resolve immediate difficulties and terminate therapy.
Personality, however, is enduring across time and situation. Moreover, personality disorders create a vulnerability to the development of other psychopathologies that endures across time and situation. Once additional Axis II disorders develop, their course and treatment are further complicated by the presence of personality problems. Clinicians know that a depressed patient with a personality disorder is much more difficult to treat than one without a personality disorder. The tendency of brief therapies to focus exclusively on the most severe immediate problem reflects a bias toward what is overt and easily operationalized. To optimize outcome, therapy should combine multiple interventions in a way that they become more than the sum of their parts, as is personality itself.
Enthusiasts of this approach seek elements common to all successful psychotherapies. In itself, this is a laudable beginning. However, it is doubtful that a single necessary and sufficient set of characteristics will prove uniformly effective for all mental disorders. Instead, these characteristics provide a foundation for effective therapy, against which the efficacy of specific treatments can be evaluated. We should certainly require that cognitive therapy for depression be more effective than simple warmth and empathy from a likable therapist, for example. In the same way, it would be very surprising if all subjects could be treated effectively with cognitive therapy alone, regardless of their personality disorder. The finding that all forms of school-oriented therapy are about equally good shows not that all therapies have common factors, but that no partial view of personality can be expected to succeed more often than any other. Because personality is the patterning of variables across the entire matrix of the person, efforts to treat the total phenomenon through a single perspective are doomed in advance. When applied to the personality disorders, the truth is not that all forms of therapy are about equally good, but that they are all about equally bad.
There is no doubt that eclecticism is an advance over the school-oriented psychotherapy of the past. Unfortunately, therapists are heard to say, "I consider myself an eclectic," as if eclecticism were like a political party to which you might belong rather than an attitude toward the practice of therapy. Technical eclecticism is a laudable effort to move forward in the face of stubborn difficulties, not the least of which is the contentious climate of hundreds of psychotherapies and perhaps an equal number of theories of psychopathology and personality. By appealing to whatever works, change as the ultimate goal of therapy moves to the forefront. Psychological theories are prevented from laying claim to certain disorders and thereby preempting other forms of treatment.
Eclecticism, however, is only an intermediate stage in the development of psychotherapy. In the absence of a complete theory of human nature, one that encloses each individual nature inside a matrix of psychological laws, we must all remain eclectics. In this case, eclecticism simply co-opts whatever techniques seem to go farthest given the nature of the difficulties to be resolved, essentially functioning as a means of coping with the complexity of persons and their pathologies until some better theory or better means is developed. Eclecticism thus reflects the relative immaturity of the field, not its essential nature.
Even if eclecticism were successful in almost every case, it would not be scientific until research could determine why it was effective. Knowing that it works is not enough. A technique or instrument may work well and even be used to great social benefit, but while its inner mechanisms remain a mystery, it begs for scrutiny. As an applied science, then, psychotherapy cannot advance by simply documenting the effectiveness of a particular technique with a particular disorder. Discovering a highly effective therapy may make you famous and may endear you forever to various managed care concerns, but it does not make you a scientist.
The process of therapy must be coordinated to the substance of that which is treated. To be both successful and scientific, therapeutic logic and technique should derive from a taxonomy that sorts essential kinds of personality pathology into a coherent framework. From the perspective of the physical sciences, this statement must seem obvious. Physics has the Standard Model, and chemistry has its Periodic Table. The first groups together the various subatomic particles; the second sorts the various elements. A chemical engineer who wants to perfect the chemical process used to make a particular compound, for example, may indeed examine what is common to other approaches, but only in connection with the logic of chemistry itself, to develop a superior solution that makes sense. Features from other approaches cannot be adopted simply according to their frequency. Instead, the laws of chemistry, in conjunction with the characteristics of the particular compound, dictate what will be successful.
Likewise, therapists must understand the characteristics and dynamics of the patients they treat, for these determine the outcome of therapy. Far from showing that psychotherapy has evolved, then, the contemporary approaches described previously reflect a broken and disjoint psychopathology, one in which the pure and applied branches of the science have developed independently. In the final analysis, we can only conclude that it is the formal synthetic properties of personality that dictate new forms of psychotherapy, provide a pathway to the integration of the historical dogmatic schools, and account for the rather startling finding that most psychotherapies are about equally effective.
In retrospect, the revolution against the dogmatism of the historical schools was inevitable. Whether psychoanalytic, cognitive, behavioral, or biological, each constitutes only a partial view of human nature. In the hard sciences, advancement occurs through attempts to falsify established models. The results support one theory while rejecting others. In contrast, the social sciences are intrinsically less bounded; advancement more often occurs when some new content area surges to the center of scientific awareness, creating a new way of looking at the field, a new paradigm. Thus, the psychodynamic school stresses the importance of the unconscious, defense mechanisms, and early object relations; therapy should make the unconscious conscious or unravel the noxious residuals of early caretaker relationships. The interpersonal school stresses the principles of correspondence and complementarity; therapy should not become ensnared in the same old vicious cycles, but instead promote the development of novel modes of conduct through noncomplementary responses. The cognitive school stresses the importance of automatic thoughts and cognitive distortions and beliefs; therapy educates clients to identify such thoughts and replace them with functional alternatives. Each perspective illuminates important domains of personality, but provides no necessary integrating principles. Instead, an intelligent eclecticism, a selectivity based mostly on past experiences with similar clients, is the current norm in psychotherapy.
The definition of personality, however, the patterning of variables across the entire matrix of the person, cannot support this norm. Personality is an inextricably interwoven structure of behaviors, cognitions, and intrapsychic processes. The interpenetration of psychic structures and functions is what distinguishes the disorders of personality from other clinical syndromes. The resulting synergism lends the whole personality an emergent tenacity that makes personality disorders exceedingly difficult to resolve, at least for traditional forms of therapy. Accordingly, a therapy of personality must have much the same formal structure as personality itself. Therapy must be more than the sum of its parts, just as personality is more than the sum of its parts. Therapy should be as integrated and, therefore, as potentially efficacious, as personality is integrated and, therefore, tenacious. In what the senior author of this text has termed synergistic psychotherapy, each intervention technique should be selected not only for its efficacy in resolving a singular pathological feature, but also for its contribution to the overall constellation of treatment procedures, of which it is but one. Personality pathologies thus represent that class of disorders for which the logic of the integrative mind-set is explicitly required. Any other choice is suboptimal. Otherwise, the personality disorders are simply misnomered and would be better regarded as the "cognitive disorders," the "interpersonal disorders," or the "psychodynamic disorders" (Millon, 1999).
The idea that personality is a functional-structural system makes certain predictions about personality and its most appropriate modes of therapy. First, it explains why personality disorders seem so clinically difficult. Every system naturally seeks the internal stability of homeostasis. For example, the stresses of everyday life make demands on the disordered personality, just as they do on the normal personality. These range from the mundane, such as getting up in the morning, to the profound, such as the death of a parent or the possibility of failing at a lifelong dream. Subjectively, such stressors make the person feel anxious, which can be dealt with in any number of ways. Rational coping mechanisms can be engaged in pursuit of a realistic solution;
alternatively, defense mechanisms can be used to repress, rechannel, or transform anxiety. Either way, however, the goal is always stability, not change. For personality, each domain uses the others as ballast, reinforcing the entire structure. As enduring and pervasive ways of thinking, feeling, and perceiving, personality disorders have as their goal a homeostasis that is intrinsically at odds with the psychosocial world, leading to vicious circles that perpetuate their same dilemmas repeatedly. By definition, theirs is a stable, pervasive, enduring pathology that has the whole matrix of the person as its ballast. Accordingly, the very nature of personality predicts that strongly school-oriented interventions, those that issue from a single perspective, should be notoriously infectious with the personality disorders. And that is the real-world experience of clinicians everywhere.
To return to the theme presented at the beginning of this section, strictly linear interventions cannot succeed with disorders that are maintained by reciprocal causality. By fighting fire with fire, by applying multiple techniques in coordination with the substantive characteristics of the individual case as identified in the assessment, therapy can be applied so that the equilibrium of the personality is "punctured," setting into motion change processes that build on and reinforce each other, leading to change across the entire system. Synergistic psychotherapy is thus concerned with the application of multiple techniques, potentially drawn from every domain of personality, but selected specifically to exhibit an emergent efficacy beyond what would be expected from the application of any technique alone. In contrast, school-oriented therapy can be regarded only as linear and Newtonian, and the efficacy of therapeutic eclecticism, which lacks any theoretically derived taxonomy and its coordination with the personality domains, through which individuals are understood, can be regarded only as random. Synergistic psychotherapy, school-oriented psychotherapy, and eclectic therapy are contrasted in Figure 4.2.
Potentiated pairings (Millon, 1990, 1999) draw on two or more techniques applied simultaneously to overcome problematic characteristics that might be refractory were each technique administered separately. Such therapeutic composites pull and push for change on a variety of fronts, leading to a therapy of integrated techniques sufficient to address the tenacity of personality pathology itself.
Potentiated pairings are designed to be applied simultaneously. In contrast, catalytic sequences plan the order of interventions as a means of optimizing their impact. The catalytic sequence is the psychotherapeutic equivalent of the one-two punch in boxing. In effect, it is the opposite of a vicious circle, in that it constitutes a constructive arrangement of techniques designed to produce a spiral back toward psychological health.
The ability to borrow and interweave techniques from multiple perspectives gives syner-gistic psychotherapy tremendous scope: Because personality is cognitive, interpersonal, psychodynamic, and biological, the nature of the personality construct itself dictates that techniques can, should, and must be pulled from any of these perspectives as needed. Eclecticism is simply opportunistic concerning techniques, but the nature of personality
Personality is a system of interacting domains. Each reinforces the others, contributing to the stability of the whole and making change difficult.
School-oriented therapy leaves remaining perspectives unaddressed.
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FIGURE 4.2 Contrast of School-Oriented, Eclectic, and Synergistic Psychotherapy.
as a construct specifically predicts the inutility of therapy administered from any single perspective alone. Accordingly, synergistic psychotherapy specifically requires that multiple techniques be pulled from the various perspectives and coordinated to the substance of the pathology. As such, the design of synergistic arrangements assumes extensive knowledge of the individual case. Assessment must be carried beyond the level of simple diagnosis. The important questions are the same for any assessment: What defense mechanisms are typically employed by the person? What are the sensitive issues that evoke these mechanisms? How do they impact relationships with others? How do they exacerbate long-standing problems? What cognitive style and interpersonal conduct descriptors best capture the flavor of the case? How do others react to the individual's interpersonal attitude? How does this attitude prevent or promote the solution of problems
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