This chapter is written for readers not fully acquainted with Chapter 1 of the first book, Resolving Difficult Clinical Syndromes, of this Personalized Psychotherapy series (Millon & Grossman, 2007). It provides a brief synopsis of the essential themes and rationale of this new approach to psychotherapy.
Are not all psychotherapies personalized? Do not all therapists concern themselves with the person who is the patient they are treating? What justifies our appropriating the name "personalized" to the treatment approach we espouse? Are we not usurping a universal, laying claim to a title that is commonplace, routinely shared and employed by most (all?) therapists?
We think not. In fact, we believe most therapists only incidentally or secondarily attend to the specific personal qualities of their patients. The majority come to their treatment task with a distinct if implicit bias, a preferred theory or technique they favor, one usually encouraged, sanctioned, and promoted in their early training, be it cognitive, group, family, eclectic, pharmacologic, or what have you.
How does our therapeutic approach differ? In essence, we come to the treatment task not with a favored theory or technique, but giving center stage to the patient's unique constellation of personality attributes. Only after a thorough evaluation of the nature and prominence of these personal attributes do we think through which combination and sequence of treatment orientations and methodologies we should employ.
"Personalized" is therefore not a vague concept or a platitudinous buzzword in our approach, but an explicit commitment to focus first and foremost on the unique composite of a patient's psychological makeup, followed by a precise formulation and specification of therapeutic rationales and techniques suitable to remedying those personal attributes that are assessed as problematic.
We have drawn on two concepts from our earlier writings, namely, personality-guided therapy (Millon, 1999) and synergistic therapy (Millon, 2002), integrating them into what we have now labeled "personalized psychotherapy." Both prior concepts remain core facets of our current treatment formulations in that, first, they are guided by the patient's overall personality makeup and, second, they are methodologically synergistic in that they utilize a combinational approach that employs reciprocally interacting and mutually reinforcing treatment modalities that produce a greater total result than the sum of their individual effects.
The preface recorded a parallel "personalized" approach to physical treatment recognition in what is called genomic medicine. Here medical scientists have begun to investigate a particular patient's DNA so as to decipher and remedy existing, missing or broken genes, thereby enabling the physician to tailor treatment in a highly personalized manner, that is, specific to the underlying or core genetic defects of that particular patient. Anomalies that are etched into a patient's unique DNA are screened and assessed to determine their source, the vulnerabilities they portend, and the probability of the patient's succumbing to specific manifest diseases.
Personalized psychological assessment is therapy-guiding; it undergirds and orients personalized psychotherapy. Together, they should be conceived as corresponding to genomic medicine in that they seek to identify the unique constellation of underlying vulnerabilities that characterize a particular mental patient and the consequent likelihood of his or her succumbing to specific mental clinical syndromes. In personalized assessment, we seek to employ customized instruments, such as the Grossman Facet Scales of the Millon Clinical Multiaxial Inventory (MCMI-III), to identify the patient's vulnerable psychic domains (e.g., cognitive style, interpersonal conduct). These assessment data furnish a foundation and a guide for implementing the distinctive individualized goals we seek to achieve in personalized psychotherapy.
As will be detailed in later sections, we have formulated eight personality components or domains constituting what we term a psychic DNA, a framework that conceptually parallels the four chemical elements composing biologic DNA. Deficiencies, excesses, defects, or dysfunctions in these psychic domains (e.g., mood/temperament, intrapsychic mechanisms) effectively result in a spectrum of 15 manifestly different variants of personality pathology (e.g., Avoidant Disorder, Borderline Disorder). It is the unique constellation of vulnerabilities as expressed in and traceable to one or several of these eight potentially problematic psychic domains that becomes the object and focus of personalized psychotherapy (in the same manner as the vulnerabilities in biologic DNA result in a variety of different genomically based diseases).
Psychotherapy has been dominated until recently by what might be termed domain-or modality-oriented therapy. That is, therapists identified themselves with a single-realm focus or a theoretical school (behavioral, intrapsychic) and attempted to practice within whatever prescriptions for therapy it made. Rapid changes in the therapeutic milieu, all interrelated through economic pressures, conceptual shifts, and diagnostic innovations, have taken place in the past few decades. For better or worse, these changes show no sign of decelerating and have become a context to which therapists, far from reversing, must now themselves adapt.
The simplest way to practice psychotherapy is to approach all patients as possessing essentially the same disorder, and then utilize one standard modality of therapy for their treatment. Many therapists still employ these simplistic models. Yet everything we have learned in the past 2 or 3 decades tells us that this approach is only minimally effective and deprives patients of other, more sensitive and effective approaches to treatment. In the past 2 decades, we have come to recognize that patients differ substantially in the clinical syndromes and personality disorders they present. It is clear that not all treatment modalities are equally effective for all patients, be it pharmacologic, cognitive, intrapsychic, or another mode. The task set before us is to maximize our effectiveness, beginning with efforts to abbreviate treatment, to recognize significant cultural considerations, to combine treatment, and to outline an integrative model for selective therapeutics. When the selection is based on each patient's personal trait configuration, integration becomes what we have termed personalized psychotherapy, to be discussed in the next section.
Present knowledge about combinational and integrative therapeutics has only begun to be developed. In this section we hope to help overcome the resistance that many psychotherapists possess to the idea of utilizing treatment combinations of modalities that they have not been trained to exercise. Most therapists have worked long and hard to become experts in a particular technique or two. Though they are committed to what they know and do best, they are likely to approach their patients' problems with techniques consonant with their prior training. Unfortunately, most modern therapists have become expert in only a few of the increasingly diverse approaches to treatment and are not open to exploring interactive combinations that may be suitable for the complex configuration of symptoms most patients bring to treatment.
In line with this theme, Frances, Clarkin, and Perry (1984, p. 195) have written:
The proponents of the various developing schools of psychotherapy tended to maintain the pristine and competitive purity of their technical innovations, rather than attempt to determine how these could best be combined with one another. There have always been a few synthesizers and bridgebuilders (often derided from all sides as "eclectic") but, for the most part, clinicians who were trained in one form of therapy tended to regard other types with disdain and suspicion.
The inclination of proponents of one or another modality of therapy to remain separate was only in part an expression of treatment rivalries. During the early phases of a treatment's development, innovators, quite appropriately, sought to establish a measure of effectiveness without having their investigations confounded by the intrusion of other modalities. No less important was that each treatment domain was but a single dimension in the complex of elements that patients bring to us. As we move away from a simple medical model to one that recognizes the psychological complexity of patients' symptoms and causes, it appears wise to mirror the patients' complexities by developing therapies that are comparably complex.
As will be elaborated throughout the text, certain combinational approaches have an additive effect; others may prove to possess a synergistic effect (Klerman, 1984). The term additive describes a situation in which the combined benefits of two or more treatments are at least equal to the sum of their individual benefits. The term synergistic describes a situation in which the combined benefits of several treatment modalities exceed the sum of their individual components; that is, their effects are potentiated. This entire book series is intended to show that several modalities-pharmacotherapy, cognitive therapy, family therapy, intrapsychic therapy-may be combined and integrated to achieve additive, if not synergistic, effects.
It is our view that psychopathology itself contains structural implications that legislate the form of any therapy one would propose to remedy its constituents. Thus, the philosophy we present derives from several implications and proposes a new integrative model for the rapeutic action, an approach that we have called personalized psychotherapy. This model, which is guided by the psychic makeup of a patient's personality-and not a preferred theory or modality or technique-gives promise, we believe, of a new level of efficacy and may, in fact, contribute to making therapy briefer. Far from being merely a theoretical rationale or a justification for adhering to one or another treatment modality, it should optimize psychotherapy by tailoring treatment interventions to fit the patient's specific form of pathology. It is not a ploy to be adopted or dismissed as congruent or incongruent with established therapeutic preferences or modality styles. Despite its name, we believe that what we have termed a personalized approach will be effective not only with Axis II personality disorders, but also with Axis I clinical syndromes.
Integration should be more than the coexistence of two or three previously discordant orientations or techniques. We cannot simply piece together the odds and ends of several theoretical schemas, each internally consistent and oriented to different data domains. Such a hodgepodge will lead only to illusory syntheses that cannot long hold together (Messer, 1986, 1992). Efforts such as these, meritorious as they may be in some regards, represent the work of peacemakers, not innovators and not integrationists. Integration is eclectic, of course, but more.
As we will argue further, it is our belief that integration should be a synthesized system to mirror the problematic configuration of traits (personality) and symptoms (clinical syndromes) of a specific patient-at-hand. In the next section, we discuss integration from this view. Many in the past have sought to coalesce differing theoretical orientations and treatment modalities with interconnecting bridges. By contrast, those of us in the personalized therapeutic persuasion bypass the synthesis of theory. Rather, primary attention should be given to the natural synthesis or inherent integration that may be found within patients themselves.
As Arkowitz (1997) has noted, efforts to create a theoretical synthesis are usually not fully integrative in that most theorists do not draw on component approaches equally. Most are oriented to one particular theory or modality, and then seek to assimilate other strategies and notions to that core approach. Moreover, assimilated theories and techniques are invariably changed by the core model into which they have been imported. In other words, the assimilated orientation or methodology is frequently transformed from its original intent. As Messer (1992, p. 151) wrote, "When incorporating elements of other therapies into one's own, a procedure takes its meaning not only from its point of origin, but even more so from the structure of the therapy into which it is imported." Messer illustrates this point by describing a two-chair gestalt procedure that is brought into a primary social-learning model; in this assimilation, the two-chair procedure will likely be utilized differently and achieve different goals than would occur in the hands of a gestalt therapist using the same technique.
Furthermore, by seeking to impose a theoretical synthesis, therapists may lose the context and thematic logic that each of the standard theoretical approaches has built up over its history. In essence, intrinsically coherent theories are usually disassembled in the effort to interweave their diverse bits and pieces. Such an integrative model composed of alternative models (behavioral, psychoanalytic) may be pluralistic, but it reflects separate modalities with varying conceptual networks and their unconnected studies and findings. As such, integrative models do not reflect that which is inherent in nature, but invent a schema for interweaving that which is, in fact, essentially discrete.
As will be discussed in the following section, intrinsic unity cannot be invented, but can be discovered in nature by focusing on the intrinsic unity of the person, that is, the full scope of a patient's psychic being. Integration based on the natural order and unity of the person avoids the rather arbitrary efforts at synthesizing disparate and sometimes disjunctive theoretical schemas.
Efforts at synthesizing therapeutic models have been most successful in desegregating the field rather than truly integrating it. As Arkowitz (1997, pp. 256-257) explains:
Integrative perspectives have been catalytic in the search for new ways of thinking about and doing psychotherapy that go beyond the confines of single-school approaches. Practitioners and researchers are examining what other theories and therapies have to offer....
Several promising starts have been made in clinical proposals for integrative therapies, but it is clear that much more work needs to be done.
As noted, it is the belief of the authors that integration cannot stem from an intellectual synthesis of different theories, but from the inherent integration that is discovered in each patient's personal style of functioning, a topic to which we now turn.
Unlike eclecticism, integration insists on the primacy of an overarching gestalt that gives coherence, provides an interactive framework, and creates an organic order among otherwise discrete units or elements. Whereas the theoretical syntheses previously discussed attempt to provide an intellectual bridge across several theories or modalities, personalized integrationists assert that a natural synthesis already exists within the patient. As we better understand the configuration of traits that characterize each patient's psyche, we can better devise a treatment plan that will mirror these traits and, we believe, will provide an optimal therapeutic course and outcome.
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Excerpted from Moderating Severe Personality Disorders by Theodore Millon Seth Grossman Copyright © 2007 by John Wiley & Sons, Ltd. Excerpted by permission.
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