 Personalized Psychotherapeutic Intervention
The great philosophers and clinicians of the past viewed their task
as creating a rationale that took into account all of the complexities
of human nature—the biological, the phenomenological, the
developmental, and so on. By contrast, modern conceptual thinkers have
actively avoided this complex and broad vision. These theorists appear
to favor one-dimensional schemas, conceptual frameworks that
intentionally leave out much that may bear significantly on the
reality of human life. Personalized psychotherapy joins with thinkers
of the past and argue that no part of human nature should lie outside
the scope of a clinician’s regard, e.g., the family and culture,
neurobiological processes, unconscious memories, and so on.
We hope to lead the profession back to “reality” by exploring both
the natural intricacy and diversity of the patients we treat. Despite
their frequent brilliance, most schools of therapy have become inbred;
more importantly, they persist in narrowing the clinician’s attention
to just one or another facet of their patient’s psychological makeup,
thereby wandering ever farther from human reality. They cease to
represent the fullness of their patient’s lives, considering as
significant only one of several psychic spheres—the unconscious,
biochemical processes, or cognitive schemas, and so on. In effect,
what has been taught to most fledgling therapists is an artificial
reality, one which may have been formulated in its early stages as an
original perspective and insightful methodology, but one which has
drifted increasingly from its moorings over time, no longer anchored
to the clinical reality from which it was abstracted.
If our wish takes root, a forthcoming series of books by Millon and
Grossman, to be published in 2007 by John Wiley and Company, will
serve as a revolutionary call, a renaissance that brings therapy back
to the natural reality of patients’ lives. In line with the preceding,
We hold to the proposition that the diagnostic categories that
comprise our nosology (e.g., DSM-IV) are not composed of distinct
disease entities or separable statistical factors; rather, they
represent splendid fictions, arbitrary distinctions that can often
mislead young therapists into making compartmentalized or, worse yet,
manualized interventions. Fledgling therapists must learn that the
symptoms and disorders we “diagnose” represent one or another segment
of a complex of organically interwoven elements. The significance of
each clinical component can best be grasped by reviewing a patient’s
unique psychological experiences and his/her pattern of
configurational dynamics, of which any specific component is but one
part.
[top] Looking at a patient’s totality can present a bewildering if not
chaotic array of possibilities, one which may drive even the most
motivated young clinician to back off into a more manageable and
simpler worldview, be it cognitive or pharmacologic, and so on. But,
as we will contend, complexity need not be experienced as
overwhelming; nor does it mean chaos, if we can create a logic and
order to the treatment plan. This we have sought to do by
illustrating, for example, that the systematic integration of Axis I
syndromes and Axis II disorders, is not only feasible, but is one that
is conducive to both briefer and more effective therapy. Of course,
therapeutic concepts and methods can never achieve the precision and
idealized model of the physical sciences. In our field we must deal
with subtle variations and sequences, as well as constantly changing
forces that comprise the natural state of human life.
As we trust will be evident, the scope of these books will not
limit the therapeutic focus only to the treatment of personality
disorders. We will attempt to show that all the clinical syndromes
that comprise Axis I can be understood more clearly and treated more
effectively when conceived as an outgrowth of a patient’s overall
personality style. To say that depression is experienced and expressed
differently from one patient to the next is a truism; so general a
statement, however, will not suffice for a book such as this. Our task
requires much more. These books provide extensive information and
illustrations on how patients with different personality
vulnerabilities perceive and cope with life’s stressors; and, with
this body of knowledge in hand, therapists should be guided to
undertake more precise and effective treatment plans. For example, a
dependent person will often respond to a divorce situation with
feelings of helplessness and hopelessness, whereas a narcissist, faced
with similar circumstances, may respond in a disdainful and cavalier
way. Even when both a dependent and a narcissist exhibit depressive
symptoms in common, the precipitant of these symptoms will likely have
been quite different; furthermore, treatment—its goals and
methods—should likewise differ. In effect, similar symptoms do not
call for the same treatment if the pattern of patient vulnerabilities
and coping styles differ. In one case—dependents—the emotional turmoil
may arise from their feelings of low self-esteem and their inability
to function autonomously; in narcissists, depression may be the
outcropping of failed cognitive denials, as well as a consequent
collapse of their habitual interpersonal arrogance.
In our view, current debates regarding whether "technical
eclecticism” or “integrative therapy" is the more suitable designation
for our approach are both mistaken. These discussants have things
backward, so to speak, because they start the task of intervention by
focusing first on technique or methodology. Integration does not
inhere in treatment methods or their theories, be they eclectic or
otherwise. Integration inheres in the person, not in our theories or
the modalities we prefer. It stems from the dynamics and interwoven
character of the patient's traits and symptoms. Our task as therapists
is not to see how we can blend intrinsically discordant models of
therapeutic technique, but to match the integrated pattern of features
that characterize each patient, and then to select treatment goals and
tactics that mirror this pattern optimally. It is for this reason,
among others, that we have chosen to employ the label "personalized
therapy" to represent our brand of integrative treatment.
[top] Integration is an important concept in considering not only the
psychotherapy of the individual case but also the role of
psychotherapy in the broad sphere of clinical science. For the
treatment of a particular patient to be integrated, the several
elements of a clinical science should be integrated as well. One of
the arguments advanced against technical eclecticism is that it
explicitly insulates therapy from the broad context of clinical
science. In contrast to eclecticism, where techniques are justified
methodologically or empirically, integrative treatment reflects the
logic of a comprehensive and relevant theory of human nature. Theories
of this nature are inviting because they seek to encompass the full
multidimensionality of human behavior; personalized therapy grows out
of such a theory. Let us elaborate its rationale briefly.
Whether we work with "part functions" that focus on behaviors, or
cognitions, or unconscious processes, or biological defects, and the
like, or whether we address contextual systems that focus on the
larger environment, the family, or the group, or the socioeconomic and
political conditions of life, the crossover point, the place that
links parts to contexts, is the person. The individual is the
intersecting medium that brings them together. Persons, however, are
more than just crossover mediums. As will be elaborated in this book,
they are the only organically integrated system in the psychological
domain, inherently created from birth as natural entities, rather than
experience-derived gestalts constructed through cognitive attribution.
Moreover, it is the person who lies at the heart of the therapeutic
experience, the substantive being who gives meaning and coherence to
symptoms and traits—be they behaviors, affects, or mechanisms—as well
as that being, that singular entity, who gives life and expression to
family interactions and social processes.
It is our contention that therapists should take cognizance of the
person from the start, for the parts and the contexts take on
different meanings, and call for different interventions in terms of
the person to whom they are anchored. To focus on one social structure
or one psychic form of expression, without understanding its
undergirding or reference base is to engage in potentially misguided,
if not random, therapeutic techniques.
[top] Personalized therapy insists on the primacy of the overarching
gestalt of the whole person, one that gives coherence, provides an
interactive framework, and creates an organic order among otherwise
discrete clinical techniques. Each personality is a synthesized and
substantive system: The whole is greater than the sum of its parts.
The problems that our patients bring to us are an inextricably
interwoven structure of behaviors, cognitions, and intrapsychic
processes, bound together by feedback loops and serially unfolding
concatenations that emerge at different times and in dynamic and
changing configurations. The interpretation of one of Millon's
psychological inventories, the MCMI, for example, does not proceed
through a linear interpretation of its single scales. Instead, each
scale contextualizes and transforms the meaning of the others in the
profile. In parallel form, so should personalized therapy be conceived
as a configuration of strategies and tactics in which each
intervention technique is selected not only for its efficacy in
resolving singular pathological features but also for its contribution
to the overall constellation of treatment procedures, of which it is
but one.
All psychic pathologies represent disorders for which the logic of
the integrative mindset is the optimal therapeutic choice. The
cohesion (or lack thereof) of complexly interwoven psychic structures
and functions is what distinguishes our model of therapy from other
clinical forms of treatment; it is the careful orchestration of
diverse, yet synthesized techniques that mirror the characteristics of
each patient’s psychological make-up that differentiates personalized
psychotherapy from its integrative counterparts. The interwoven nature
of the components comprising personalized treatment makes a
multifaceted and synergistic approach a necessity. Therapies that
conceptualize clinical disorders from a single perspective, be it
psychodynamic, cognitive, behavior, or physiological, may be useful,
and even necessary, but are not sufficient in themselves to undertake
a therapy of the patient, disordered or not. As stated, the
“revolution” we propose asserts that clinical disorders are not
exclusively behavioral or cognitive or unconscious, that is, confined
to particular expressive form. The overall pattern of a person’s
traits and psychic expressions are systemic and multi-operational . No
part of the system exists in complete isolation from the others. Every
part is directly or indirectly tied to every other, such that there is
an emergent synergism that accounts for a disorder’s clinical
tenacity. Personality is “real”; it is a composite of intertwined
elements whose totality must be reckoned with in all therapeutic
enterprises. The key to treating our patients, therefore, lies in
therapy that is designed to be as organismically complex as the person
himself; this form of therapy should generate more than the sum of its
parts. Difficult sounding as this may appear, we hope to otherwise
demonstrate its ease and utility.
[top] Personalized therapy employs two basic strategies, the first I have
termed "potentiated pairings." Here, treatment methods are combined
simultaneously to overcome problematic characteristics that may be
refractory to each technique if administered separately. These
composites pull and push for change on several fronts, so that
treatment is oriented to more than one expressive domain of clinical
dysfunction. A currently popular form of treatment pairing is found in
what is called “cognitive-behavioral” therapy. The second personalized
procedure is labeled "catalytic sequences". Here, the order in which
coordinated treatments are executed, is considered. Therapeutic
combinations and progressions are designed to optimize the impact of
changes in a manner that would be more effective than if the order
were otherwise arranged. In a catalytic sequence, for example, one
might seek first to alter a patient's stuttering by direct behavioral
modification procedures which, if achieved, would facilitate the use
of cognitive methods in producing self-image changes in confidence
which, in its turn, would foster the utility of interpersonal
techniques to effect social skill improvement. Personalized therapy is
conceived, therefore, as a configuration of strategies and tactics in
which each intervention technique is selected not only for its
efficacy in resolving particular pathological difficulties, but also
for its role in contributing to the overall constellation of treatment
procedures, of which it is but one.
The logic for combining therapies has now become a central theme
for a wide variety of health problems. A recent study of depression
among the elderly has shown that those given both medication and
psychotherapy recovered more than twice as frequently as did those who
received either medication or psychotherapy alone. In treating AIDS,
it has been found that a cocktail of three drugs in combination works
appreciably better than any of the drugs alone; moreover, these data
have held up with patients at different stages of the HIV disease. In
difficulties such as smoking cessation, recent studies show that a
combination of an antidepressant, nicotine replacement, and
psychological counseling sharply increases (40-60%) the success of
those who are trying to give up smoking, as compared to those who
attempt cessation utilizing only one of these methods (5%). Diabetes
is a disease in which any of several anatomic structures and
physiochemical processes can go awry; it has now become a standard
practice with these patients to administer two or more medications,
each of which addresses one or another of the possible inherent
defects. The goal is to cover all potentially contributing biophysical
difficulties; the consequent drop in blood sugar levels among
multi-treated patients is nothing less than miraculous. Recent studies
demonstrate that the combination of smaller than usual dosages of two
or more drugs for hypertension has proven much more effective than
administering just one of the antihypertensives. The logic here, one
no less applicable to mental disorders, is that the action of certain
modality combinations broadens the range of efficacy to include a
variety of potential clinical dysfunctions; together they complement
each other and, most importantly, they produce a synergistic result in
which the reduced dosage combination results in fewer side effects and
a greater level of efficacy than each modality can do on its own.
[top] Eclectic combinations of several treatment modalities, such as
those proposed by Lazarus, are a good start toward the goal of
synergizing therapy, that is, to combine methods that are mutually
reinforcing, hence strengthening what each modality can achieve
separately. The logic for selecting modalities, however, should not be
based on “school-oriented” habits, random choice, or superficial
analyses, but rather on a knowledge of the inherent traits and psychic
processes that characterize different personality styles or disorders.
Whether we employ a cognitive modality first, followed by a
behavioral, or a family-oriented, or an intrapsychic approach, should
be determined by knowing the structure and the character of the
patient’s personality makeup, knowledge that may be achieved by
employing the MCMI-III with its new facet scales or the new MGFPDC
instrument, both discussed in this website.
The combinational revolution in general health treatment has been
proposed as a first-line approach to the treatment, not only of
medical conditions, but of psychological disorders, as well. These
books strongly favor this new model, proposing to guide not just any
therapeutic combination, but one built on, and informed by, a
thoughtful examination of all of the expressive features (domains)
that characterize the person being treated—his/her cognitive
distortions, interpersonal conduct, self-image, and the like. Just as
medications for diabetes or hypertension are not randomly or
habitually chosen, so, too, we in our field must recognize the several
spheres of psychic function that characterize our patient’s
difficulties. A focused assessment should enable us to identify which
specific vulnerabilities and styles prove troublesome, and to
understand how they synergistically relate in a pathological manner.
With this knowledge as a guide, we can begin to approach our
therapeutic task with a justifiably high measure of confidence. As
health professionals in other fields have argued, informed
combinational therapy is the “wave of the future.”
A contemporary revision and extension of an earlier book, Millon's
Personality-Guided Therapy book, a 975 page volume published in 1999
by John Wiley & Sons, Inc., is currently underway and co-authored by
Drs. Millon and Grossman. To be published as a three-volume set of 300
or so pages each, it will be entitled Personalized Psychotherapy. The
first volume is oriented to the personalized treatment approach as it
is applied to the Axis I Clinical Syndromes. The second volume will
focus on those personality disorders of Axis II that are notably
treatment resistant. The third volume will illustrate the application
of the therapeutic model to the most severe of the personality
disorders. All three books will be published in early 2007 by the
Wiley company.
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