Moderating Severe Personality Disorders

Abstract

“Would it not be a great step forward in our field if diagnosis or psychological assessment, following a series of interviews, tests, or laboratory procedures, actually pointed clearly to what a clinician should do in therapy?” (p. ix). This quote is from the preface of the reviewed book, and it nicely captures the authors' overarching goal in this series of books. Dr. Millon is regarded as one of the major personality theorists; his theory incorporates components of evolutionary progression as well as stages of biosocial development. Dr. Millon maintains that his theory contains the elements of all mature clinical sciences in that the theory provides the basis for coherent taxonomies (i.e., classification into clinical personality prototypes). These personality prototypes are then coupled with empirically based assessment instruments that identify and measure the problematic components of each prototype, the results of which are used to develop highly individualized and change-oriented interventions. This process, with its focus on the identification of the unique aspects of a patient's psychological composition that guide the formulation of empirically based and personalized therapeutic interventions, is termed personalized psychotherapy. The authors' notions are provocative; they challenge practitioners who use a single modality of therapy for all patients as using an outdated and simplistic approach to psychotherapy. Likewise, they argue that eclectic approaches are intellectual blends of different theories that fail to consider the patient's unique personality composition. The authors cogently argue that the patient's personality (rather than theory or theories) should guide the formulation of a treatment plan. The authors also note the inadequacy of the traditional medical model in describing the causes and complexity of symptoms. In this vein, they caution against treating Axis I disorders without consideration of whether these are simple reactions that reflect chiefly external precipitants versus complex clinical syndromes in which the same disorder may be fueled by pervasive personality vulnerabilities. In essence, the authors' contention is that truly personalized psychotherapy proceeds not by using a single theory or even a combination of therapies haphazardly woven together. Instead, no theory or technique is given preferential status, and the process of therapy is guided by the unique configuration of the patient's personality and symptoms. It is only after the problematic aspects of a patient's personality have been quantified by customized assessment instruments that the tailored sequence and combination of therapies or interventions are formulated and then utilized in a synergistic fashion. The clinician may select either of 2 instruments for this process: the Millon Clinical Multiaxial Inventory-III (MCMI-III) or the newly-developed Millon-Grossman Personality Domain Checklist (MG-PDC). The MCMI-III is a true-false self-report personality inventory long used to assess Axis II disorders. The MG-PDC measures the following domains: behavioral, interpersonal, self, cognitive, and biological, plus 3 domains from psychoanalysis. The clinician first rates the patient (by making first, second, and third best-fit choices) on these 8 domains by use of 15 trait choices that correspond to personality prototypes. These ratings are then used to determine the 3 personality prototypes that best fit the patient. Last, the overall level of social and occupational functioning is ranked. This quantitative measurement thus identifies the most likely personality prototype and problematic domains and subsequently guides the development of a highly individualized treatment plan. The reader should be aware that the volume reviewed is the third in a series on the topic of personalized psychotherapy. The 3 volumes (all of which were published in 2007) are an extensive revision of Dr. Millon's book, Personality-Guided Therapy, which was published in 1999. The first volume is devoted to Axis I disorders and, consistent with Dr. Millon's theory, maintains that “all the clinical syndromes that constitute Axis I can be understood more clearly and treated more effectively when conceived as an outgrowth of a patient's overall personality style” (p. xi). The second volume addresses resistant personality disorders, while the volume reviewed is devoted to severe personality disorders. All 3 books are similarly organized, with part 1 providing the theoretical rationale for personalized psychotherapy, a very brief synopsis of Dr. Millon's model, and a description of the MG-PDC and its use. Part 2 consists of descriptions of the personality prototypes and interventional goals and therapeutic modalities for each of the prototypes. The reviewer is unsure exactly how the authors divided the personality disorders into resistant and severe categories. Certainly, those personality disorders known to be associated with schizophrenia are considered severe, but the volume reviewed includes some disorders without such an association. The book is clinically rich with numerous illustrative cases seen by the senior author over the past 40+ years. The prose is, in Dr. Millon's fashion, a bit formal and rich in substance. Dr. Millon's theory of personality, which provides the theoretical underpinning for personalized psychotherapy, is referred to frequently. However, the synopsis of Dr. Millon's theory is so brief that the reader who is unfamiliar with Dr. Millon's work may acquire a greater appreciation for personalized psychotherapy after becoming more familiar with his theory of personality. This can be accomplished by visiting Dr. Millon's Web site, http://millon.net, and by reviewing the book, Disorders of Personality: DSM-IV and Beyond,1 by Drs. Millon and Davis and published in 1996. In addition to the rather skimpy synopsis, there are some logistic problems with the MG-PDC. As personalized psychotherapy hinges upon assessment, which then guides the therapy process, it comes as no surprise that much of the book is devoted to the MG-PDC. However, it appears that the instrument is not yet published but is available at http://millon.net/instruments/MG_PDC.htm. Also, no psychometric data are presented, but such will hopefully become available as the instrument gains acceptance. In sum, Moderating Severe Personality Disorders: A Personalized Psychotherapy Approach is both provocative and eminently relevant. While careful study of this volume will help clinicians avoid the traps of single-modality psychotherapy or sloppy eclecticism, the prudent clinician can also acquire state-of-the-art knowledge about character pathology and its treatment. C. Don Morgan, Ph.D. University of Kansas School of Medicine, Wichita, Kansas