The theme of this chapter is that assessment and therapy should be continuous with personality as an integrative construct. Assessment is the basis of therapy. The clinician should gain a complete scientific understanding of the interaction of current symptoms, personality traits, and psychosocial factors. The axes of the multiaxial model should be separately assessed and then integrated into a single composite, the case conceptualization.
In the relationship between pure and applied science, the nomothetic approach seeks to find universal principles applicable to all individuals in a population. The idiographic approach emphasizes the complexity of the individual seeking to understand the totality of a single person. In diagnosing a person, the DSM attempts to retain the best of a construct-centered approach, while allowing for a measure of individuality. First, the DSM allows multiple personality disorder diagnoses to be assigned. Combinations of two, three, or even four personality disorders are not uncommon. Second, each personality disorder is operationalized as a prototype that consists of many characteristics. There are probably hundreds of ways of satisfying the diagnostic criteria for any two personality disorders. Such vast possibilities are intended to accommodate individuality within the diagnostic system, while the shorthand of diagnostic labels nevertheless recognizes that all subjects who receive the same diagnosis bear a family resemblance. In any categorical classification system, the question is which labels the subject will receive. The idiographic perspective, however, reminds us that taxonomies take us only so far—that diagnostic constructs are only reference points that facilitate understanding, against which the individual should be compared and contrasted. Because the goal is an idiographic understanding of the person, assessment is really an endeavor to show the limitations of the diagnostic system with respect to the person at hand.
In contrast to the physical sciences, measurement instruments in personality and psychopathology are inherently imprecise. Five broad sources of information are available to help describe the clinical problem. Each has its own advantages and limitations. In the first source, the self-report inventory, subjects literally report on themselves by completing a standard list of items. In the second source of information, rating scales and checklists, a person familiar with the subject completes this form in order to provide an alternative perspective. Third, in the clinical interview, the clinician asks the questions and the subject responds verbally, often in a free form style. The clinician is free to following any particular line of questioning desired and usually mixes standard questions with those specific to the current problem. Finally, the fourth source, projective techniques, is an attempt to access unconscious structures and processes that would not ordinarily be available to the subject at the level of verbal report. The use of intimates of the subject who can act as informants, perhaps a spouse, teacher, parent, or good friend, someone who can provide perspective on the problem, might also be considered a source of information. Physiological measurements, neurotransmitter or hormone levels, for example, provide a final source, though these are not available to most therapists.
Measurement in all sciences is limited by biasing and distorting factors. Certain distortions arise because of the personality style of the respondent or interviewer. Different personalities construe the world in different ways. Other limitations on clinical information arise from subjects' motives and their level of personality pathology. In other cases, some personalities consciously distort information to somehow take advantage of the system or avoid some unpleasant consequence of their own behavior. Most self-report instruments have indexes that can detect attempts to fake good or fake bad, though they must be interpreted cautiously in the context of other test information. Whatever the situation, clinicians are always advised to keep the principle of self-interest firmly in mind.
Most patients who require psychological testing present with one or more Axis I disorders. Traits refer to long-standing personality characteristics that endure over time and situations. In contrast, states refer to potentially short-lived conditions, usually emotional in nature. Anxiety, depression, and loss of reality contact can all affect the results of personality testing. Crossover effects from state to trait are an expectable part of assessment and must be considered by whomever interprets the test results.
Psychological tests can be interpreted at different levels: items, scales, and profiles. The item is the standard stimulus in psychological assessment. Since every subject who completes an instrument answers the same items, their responses can be directly compared to those of others. A scale is composed of many items that tap the same psychological construct, so that a scale score reflects a summary of the particular behaviors expressed in those same item responses. A set of scale scores is referred to as a profile or profile configuration. The profile stands in place of the person as a collection of scales, just as a collection of items stands in place of the construct they assess.
A variety of self-report instruments are available to assess the personality disorders. With more than 550 items, the Minnesota Multiphasic Personality Inventory-2 (MMPI) is not so much a standardized test as a standardized item pool that belongs to psychology itself. Literally hundreds of personality scales have been derived from the MMPI throughout its long career. In fact, there are now more auxiliary scales than there are items on the MMPI. The Millon Clinical Multiaxial Inventory (MCMI), now in its third edition, is far the most widely used personality disorder test. A principal goal in constructing the MCMI-III was to keep the total number of items constituting the inventory small enough to encourage use in all types of diagnostic and treatment settings, yet large enough to permit the assessment of a wide range of clinically relevant behaviors. At 175 items, the final form is much shorter than are comparable instruments, with terminology geared to an eighth-grade reading level. As a result, most subjects complete the MCMI-III in 20 to 30 minutes. The inventory is intended for subjects believed to possess a personality disorder and is generally not used with normals. The MCMI is frequently used in research. More than 650 publications to date have included or focused primarily on the MCMI, with approximately 60 to 70 new references currently published annually. Both the MMPI and MCMI have variants designed for use with adolescents.
A number of clinical interviews are available for the personality disorders. The Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) is a semistructured diagnostic interview assessing the 12 personality disorders included in DSM-IV. The Structured Interview for DSM-IV Personality (SIDP-IV; Pfohl et al., 1997) is a semistructured clinical interview that assesses all the personality disorders of the DSM-IV, plus the self-defeating personality from the revised third edition of the DSM (the sadistic personality is not included).
The history of psychotherapy is fraught with dogmatism. In the past few decades, however, dissatisfaction with school-oriented therapy (e.g., behavioral, psychody-namic), together with a new emphasis on efficacy motivated by managed care, has led to the development of compromise approaches. Three trends currently dominate: First, brief therapy claims to achieve as much or greater progress in less time by carefully selecting patients and providing highly structured forms of intervention specific to the presenting problem. Second, the common factors approach seeks to unify much of psychotherapy by identifying factors common to all effective therapies. The argument here 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. While these contemporary trends all 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.
Synergistic psychotherapy, on the other hand, is 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. Potentiated pairings draw on two or more techniques applied simultaneously to overcome problematic characteristics that might be refractory were each technique administered separately. 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 ability to borrow and interweave techniques from multiple perspectives gives synergistic psychotherapy tremendous scope: Since 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.
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