From Philosophy To Theory

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A good theory should allow techniques across many modalities to be dynamically adapted, or integrated as ongoing changes in the patient occur, or as new information comes to light. What has been termed multimodal therapy in the sense of "technical eclecticism" (e.g., see Lazarus, 1976) is a quantum leap in terms of opening formerly rigid eyes to the many possibilities of blending data levels from different psychotherapy "camps." However, eclecticism is an insufficient guide to effective synergistic therapy. It cannot prescribe the particular form of those modalities that will remedy the pathologies of persons and their syndromes; it is also too open with regard to content and too imprecise to achieve focused goals. The intrinsically configurational nature of psychopathol-ogy, its multioperationism, and the interwoven character of clinical domains, simply are not as integrated in eclecticism as they need be in treating psychopathology. An open-minded therapist is left, then, with several different modality combinations, each with some currency toward understanding the patient's pathology, but no real means of bringing these diverse conceptions together in a coherent model of what, exactly, to do. Modality techniques considered fundamental in one perspective may not be so regarded within another; further, their fundamental constructs are different. Rather than inherit the modality tactics of a particular perspective, then, a theory of psychotherapy as a total system should seek some set of principles that can be addressed to the patient's whole psyche, thereby capitalizing on the naturally organic system of the person.

Before proceeding to a reasonably detailed outline of assessment and treatment techniques that will foster an informed psychotherapy based on thoughtful, meaningful diagnosis, we would like to make some comments in favor of the utility of a theory of the person. Kurt Lewin's words of more than 60 years ago, that "there is nothing so practical as a good theory" (1936), still resonate soundly in this argument. In spite of those who would shun theory for its subjective qualities, it is simply impossible, despite the efforts of empiricists and others who would hold to only "pure" observable phenomena, to remove any theoretical bias. Furthermore, theory is unavoidable if you want a system that can be investigated both for its reliability and validity (Carson, 1991; Loevinger, 1957; Millon, 1991). Theory, when properly fashioned, ultimately provides more simplicity and clarity than unintegrated and scattered information. Unrelated knowledge and techniques, especially those based on surface similarities, are a sign of a primitive science, as has been effectively argued by modern philosophers of science (Hempel, 1961; Quine, 1961). The key lies in finding theoretical principles for psychotherapy that fall "beyond" the field of psychology proper. It is necessary, therefore, to go beyond current conceptual boundaries to more established, "adjacent" sciences. Not only may such steps bear new conceptual fruits, but they may provide a foundation that can guide our own discipline's explorations.

Evolution as a Natural Framework

Such a search for fundamental principles, we maintain, should begin with human evolution. Just as each person is composed of a total patterning of variables across all domains of human expression, it is the total organism that survives and reproduces, carrying forth both its adaptive and maladaptive potentials into subsequent generations. As the evolutionary success of organisms is dependent on the entire configuration of the organism's characteristics and potentials, so, too, does psychological fitness derive from the relation of the entire configuration of personal characteristics to the environments in which the person functions.

The evolutionary theory comprises three imperatives, each of which is a necessary aspect of the progression of evolution:

1. Each organism must survive.

2. It must adapt to its environment.

3. It must reproduce.

Each of these imperatives relates to a polarity allowing for its expression in the individual's life. To survive, an organism seeks to maximize pleasure (enhance life circumstances), and minimize pain (avoid dangerous or threatening stimuli). To adapt, an organism must, at appropriate times, either passively conform to, or actively reform, the surrounding environment's constraints and opportunities. And finally, to regenerate, an organism must adopt either a self-oriented or other-oriented strategy, judiciously "choosing" to self-invest or nurture other significant organisms (Millon, 1990). Anywhere in the universe, these are the fundamental evolutionary concerns, and there are none more fundamental.

Polarities, that is, contrasting functional directions, representing these three phases (pleasure-pain, passive-active, other-self) are the basis of the theoretically anchored prototypal classification system of personality styles and clinical disorders (Millon & Davis, 1996) that we will demonstrate for its interventional utility. Such bipolar or dimensional schemes are almost universally present throughout the literatures of mankind, as well as in psychology-at-large (Millon, 1990). The earliest may be traced to ancient Eastern religions, most notably the Chinese I Ching texts and the Hebrew's Kabala. In the life of the individual organism, each individual organism moves through developmental stages that have functional goals related to their respective phases of evolution. Within each stage, every individual acquires character dispositions representing a balance or predilection toward one of the two polarity inclinations; which inclination emerges as dominant over time results from the inextricable and reciprocal interplay of intraor-ganismic and extraorganismic factors. For example, during early infancy, the primary organismic function is to "continue to exist." Here, evolution has supplied mechanisms that orient the infant toward life-enhancing environments (pleasure) and away from life-threatening ones (pain). So-called "normal" individuals exhibit a reasonable balance between each of the polarity pairs. Not all individuals fall at the center, of course. Individual differences in both personality features and overall style will reflect the relative positions and strengths of each polarity component. A particularly "healthy" person, for example, would be one who is high on both self and other, indicating a solid sense of self-worth, combined with a genuine sensitivity to the needs of others.

The expression of traits or dispositions acquired in early stages of development may have their expression transformed as later faculties or dispositions develop (Millon, 1969). Temperament is perhaps a classic example. An individual with an active temperament may develop, contingent on contextual factors, into several theoretically derived "prototypal" personality styles, for example, an avoidant or an antisocial style, the consequences being partly determined by whether the child has a fearful or a fearless temperament when dealing with a harsh environment. The transformation of earlier temperamental characteristics takes the form of what has been called "personological bifurcations" (Millon, 1990). Thus, if the individual is inclined toward a passive orientation and later learns to be self-focused, a prototypical narcissistic style ensues. But if the individual possesses an active orientation and later learns to be self-focused, a prototypical antisocial style may ensue. Thus, early developing dispositions may undergo "vicissitudes," whereby their meaning in the context of the whole organism is subsequently reformed into complex personality configurations.

At a slightly more finite level of specification are what we have termed the personality subtypes. This idea of subtypes recognizes two fundamental facts. The first derives from the chance side of the evolutionary equation, and draws on the long descriptive tradition in psychology and psychiatry, as perhaps best expressed in the works of the turn of the century nosologist Emil Kraepelin: In the ordinary course of clinical work, we find that every disorder seems to sort itself into ever finer subcategories, which rest on an a priori basis, but instead flow from cultural and social factors and their interaction with biological influences such as constitution, temperament, or perhaps even systematic neurological defects. Accordingly, if society were different, or if the neurotransmitters chosen by evolution to bathe the human brain were different, the subtypes would be different also. Such entities are the pristine product of clinical observation, and however sharp the classification boundaries may be drawn between them, they are, in fact, unusually soft.

While the concept of prototype and subtype allows the natural heterogeneity of persons to be accommodated within a classification system, there are as many ways to fulfill a given diagnosis as there are subsets of the number of diagnostic criteria required at the diagnostic threshold. For example, there are many ways to score five of a total of nine diagnostic criteria, whatever the actual syndrome. In the context of an idealized medical disease model, which Axis I approximates, the fact that two different individuals, both of whom are depressed, might possess substantially different sets of depressive symptoms is not really problematic. The symptoms may be expressed somewhat differently, but the underlying pathology process is the same and can be treated in the same way. For example, while one person gains weight and wakes early in the morning, and the other loses weight and sleeps long into the day, both may be treated with an antidepressant and cognitive therapy. Personality, however, as represented in Axis II of the DSM, should be seen to follow a fundamentally different conceptual model. Whereas variance from the prototypal ideal is usually considered irrelevant in the Axis I medical model of clinical syndromes, it is the very essence of Axis II. Personality styles or disorders are reified for clinical utility, but are most accurately thought of as variants of personality prototypes, a phrase that communicates their relatively unique clinical "complexion," without conveying the erroneous connotation of a distinct disease entity.

The evolutionary thesis may also be seen to provide a basis for deriving the so-called "clinical syndromes" of Axis-II, as well. To illustrate briefly, consider the anxiety disorders. Without explicating its several variants, a low pain threshold on the pleasure-pain polarity would dispose such individuals to be sensitive to punishments that, depending on covariant polarity positions, might result in the acquisition of complex syndromal characteristics, such as ease of discouragement, low self-esteem, cautiousness, and social phobias. Similarly, a low pleasure threshold on the same polarity might make such individuals prone to experience joy and satisfaction with great ease: again, depending on covariant polarity positions, such persons might be inclined toward impulsiveness and hedonic pursuits, be intolerant of frustration and delay, and, at the clinical level, give evidence of a susceptibility to manic episodes.

To use musical metaphors again, DSM-IV's Axis I clinical syndromes are composed essentially of a single theme or subject (e.g., anxiety, depression), a salient melodic line that may vary in its rhythm and harmony, changing little except in its timing, cadence, and progression. In contrast, the diversely expressed domains that comprise Axis II seem constructed more in accord with the compositional structure known as the fugue where there is a dovetailing of two or more melodic lines. Framed in the sonata style, the opening exposition in the fugue begins when an introductory theme is announced (or analogously in psychopathology, a series of clinical symptoms become evident), following which a second and perhaps third, and essentially independent set of themes emerge in the form of "answers" to the first (akin to the unfolding expression of underlying personality traits). As the complexity of the fugue is revealed (we now have identified a fullblown personality disorder), variants of the introductory theme (that is, the initial symptom picture) develop counter-subjects (less observable, inferred traits) that are interwoven with the preceding in accord with well-known harmonic rules (comparably, mechanisms that regulate intrapsychic dynamics). This matrix of entwined melodic lines progresses over time in an episodic fashion, occasionally augmented, at other times diminished. It is sequenced to follow its evolving contrapuntal structure, unfolding an interlaced tapestry (the development and linkages of several psychological traits). To build this metaphorical elaboration further, not only may personality be viewed much like a fugue, but the melodic lines of its psychological counterpoints are comprised of the three evolutionary themes presented earlier (the polarities, that is). Thus, some fugues are rhythmically vigorous and rousing (high "active"), others kindle a sweet sentimentality (high "other"), still others evoke a somber and anguished mood (high "pain"), and so on. When the counterpoint of the first three polarities is harmonically balanced, we observe a well-functioning or so-called normal person; when deficiencies, imbalances, or conflicts exist among them, we observe one or another variant of the personality disorders.

Creation of a Meaningful Personologic Diagnosis

The validity of a pragmatic assessment and diagnosis depends on the validity of the system of categorized types and trait dimensions that might be brought to bear on the individual case. The prototype construct, which is one of the favorable attributes of the DSM, represents a synthesis of both categorical and dimensional models. Prototypal models assume that no necessary or sufficient criteria exist by which syndromes and disorders can be unequivocally diagnosed. The synthetic character of the prototypal model can be seen by comparing what is saved and discarded in the three approaches. The categorical model sacrifices quantitative variation in favor of the discrete, binary judgments. The dimensional model sacrifices qualitative distinctions in favor of quantitative scores. Of the three models, the prototypal is the only one that conserves both qualitative and quantitative clinical information.

However, the DSM's personality prototypes represent an approach that is necessary, but not sufficient. It simply lists characteristics that have been found to accompany a particular disorder with some regularity and specificity. Although the DSM puts forth several domains in which personality is expressed (notably cognition, affectivity, interpersonal functioning, and impulse control), these psychological domains are neither comprehensive nor comparable, and this limits the utility of this approach. Because of this, the DSM-IV lacks a basis to organize these structures of personality meaningfully, in a manner amenable to intervention. Further, these problems exist both within and between disorders, so that different disorders evince different content distortions. Finally, theoretically derived "prototypes" are a good basis for understanding how "real world" blends of personality style appear, but the DSM does not provide the undergirding for understanding such blends. For example, it is relatively easy to identify a schizoid by checking off enough DSM-IV criteria for the construct, but it is impossible, by these criteria, to make finer and more useful distinctions as they are more likely to appear outside of textbook-style, theoretically derived prototypes (e.g., what subtype of schizoid a particular patient might be), since the criteria to discriminate between subgroups simply do not as yet exist. As will be seen, learning to conceptualize these blends of personality styles is a vital skill in formulating syn-ergistic treatment plans.

Both the nature of the person and the laws of evolution require that the stylistic domains of personality be drawn together in a logical fashion. No domain is an autonomous entity. Instead, the evolution of the structure and content of personality is constrained by the evolutionary imperatives of survival, adaptation, and reproductive success, for it is always the whole organism that is selected and evolves. To synthesize the domains of the person as a coherent unity, we draw on the boundary between organism and environment. What we call functional domains relate the organism to the external world, while other domains serve as structural substrates for functioning, existing "inside" the organism. Table 2.1 lists and describes the domain matrix of the structures and functions of personality, as derived from the expression of evolutionary polarities.

The preceding issue points to the inadequacy of any approach that links classification to intervention without theoretical guidance. The argument is merely that diagnosis should constrain and guide therapy in a manner consonant with assumptions of the theoretically derived prototypal model; without a philosophical framework, there is no sound basis from which to derive principles that contextualize the person and his or her integrated structures and functions with a thorough intervention reflective of the complexity of this personality. The scope of the interventions that might be considered appropriate and the form of their application are left unattended. Any set of interventions or techniques might be applied singly or in combination, without regard to the diagnostic complexity of the treated disorder. In the actual practice of therapy, techniques within a particular pathological data level, that is, psychodynamic techniques, behavioral techniques, and so on, are, in fact, often applied conjointly. Thus, systematic desensitization might be followed by in vivo exposure, or a patient might keep a diary of his or her thoughts, while at the same time reframing those thoughts in accordance with the therapist's directions when they occur. In these formulations, however, there is no strong a priori reason why any two therapies or techniques should be combined at all. When techniques from different modalities are applied together successfully, it is because the combination mirrors the composition of the individual case, not because it derives its logic on the basis of a theory or the syndrome.

The whole clinical enterprise is thereby changed. The purpose is not to classify individuals into categories, but instead to augment the classification system in a more comprehensive attempt to capture the particular reality that is the person. The purpose is not to put persons in the classification system, but instead to reorient the system with respect to the person by determining how their unique, ontological constellation of attributes overflows and exceeds it. The classification thus becomes a point of departure for comparison and contrast, a way-station in achieving a total understanding of the complexity of the whole, not a destination in itself. When in the course of an assessment the clinician begins to feel that the subject is understood at a level where ordinary diagnostic labels no longer adequately apply, the classification system is well on its

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