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Psychological Assessment 1992, Vol. 4, No.

1,5-13

In the public domain

Normal Personality Assessment in Clinical Practice: The NEO Personality Inventory


Paul T. Costa, Jr., and Robert R. McCrae
Gerontology Research Center National Institute on Aging, National Institutes of Health Baltimore, Maryland Personality psychologists from a variety of theoretical perspectives have recently concluded that personality traits can be summarized in terms of a 5-factor model. This article describes the NEO Personality Inventory (NEO-PI), a measure of these 5 factors and some of the traits that define them, and its use in clinical practice. Recent studies suggest that NEO-PI scales are reliable and valid in clinical samples as in normal samples. The use of self-report personality measures in clinical samples is discussed, and data from 117 "normal" adult men and women are presented to show links between the NEO-PI scales and psychopathology as measured by Jackson's (1989) Basic Personality Inventory and Morey's (1991) Personality Assessment Inventory. We argue that the NEO-PI may be useful to clinicians in understanding the patient, formulating a diagnosis, establishing rapport, developing insight, anticipating the course of therapy, and selecting the optimal form of treatment for the patient.

In the past two decades there has been remarkable progress in one of the oldest branches of personality psychology: the study of traits or individual differences. The conceptual status of traits has been clarified (Costa & McCrae, 1980; Funder, 1991; Tellegen, in press), and trait measures have shown evidence of convergent and discriminant validity across instruments (McCrae, 1989) and observers (Kenrick & Funder, 1988). Longitudinal studies of both self-reports and ratings have shown impressive stability of a wide range of traits across the adult lifespan (Block, 1981; McCrae & Costa, 1990). Perhaps most exciting is the growing agreement among personality psychologists that most individual differences in personality can be understood in terms of five basic dimensions: Neuroticism (N) vs. Emotional Stability; Extraversion (E) or Surgency; Openness to Experience (O) or Intellect; Agreeableness (A) vs. Antagonism; and Conscientiousness (C) or Will to Achieve (Digman, 1990; John, 1990; Norman, 1963; Wiggins & Trapnell, in press). These factors have been recovered in studies of self-reports and ratings, lay adjectives and standardized questionnaires, adults and children, and several different cultures. This five-factor model is a theoretical advance that has important implications for many applied areas, including clinical practice. By assessing traits from each of the five factors, the clinician can obtain a comprehensive portrait of the client's personality, and the clinical researcher can systematically examine relations between personality and treatment variables. Recent articles and symposia have examined the utility of the five-factor model in counseling (McCrae & Costa, 1991), abnormal psychology (Widiger & Trull, in press), and clinical psychology (Spielberger, 1989). This article is intended to de-

Correspondence concerning this article should be addressed to Paul T. Costa, Jr., Laboratory of Personality and Cognition, Gerontology Research Center, 4940 Eastern Avenue, Baltimore, Maryland 21224.

scribe a measure of the five factors, the NEO Personality Inventory (NEO-PI; Costa & McCrae, 1985, 1989), and its use in clinical settings. Of course, "normal" personality assessment, using such instruments as the Sixteen Personality Factor Questionnaire (16PF; Cattell, Eber, & Tatsuoka, 1970) and the California Psychological Inventory (CPI; Gough, 1957), has long been part of clinical practice. The NEO-PI is, however, the first inventory based on the five-factor model, and a discussion of its use may provide some fresh perspectives on the relevance of normal personality traits to clinical psychology. Clinicians often think of psychological assessment as part of the diagnostic process. Although not designed as a measure of psychopathology, we believe the NEO-PI can contribute information that is relevant to diagnosis. But perhaps more important are the ways in which the instrument may help the clinician understand the patient, select appropriate treatments, and anticipate the course and outcome of therapy. For these purposes, much more is needed than measures of psychopathology; the full range of personality characteristics must be considered, and it is here that the five-factor model provides a guide. The first factor, Neuroticism, is most familiar to clinicians. It represents the individual's tendency to experience psychological distress, and high standing on N is a feature of most psychiatric conditions. Indeed, differential diagnosis often amounts to a determination of which aspect of N (e.g., anxiety or depression) is most prominent. We will discuss later the relations between this dimension of personality and psychopathology. Extraversion is the dimension underlying a broad group of traits, including sociability, activity, and the tendency to experience positive emotions such as joy and pleasure. Patients with histrionic and schizoid personality disorders differ primarily along this dimension (Wiggins & Pincus, 1989), and Miller (1991) has pointed out that talkative extraverts respond very

PAUL T. COSTA, JR., AND ROBERT R. McCRAE differently to talk-oriented psychotherapies than do reserved and reticent introverts. Clinical psychologists may recognize Openness to Experience as one of the goals of Rogerian therapy. We use the term to refer to a broader constellation of traits. High-O individuals are imaginative and sensitive to art and beauty and have a rich and complex emotional life; they are intellectually curious, behaviorally flexible, and nondogmatic in their attitudes and values (McCrae & Costa, 1985, in press). Although these traits are probably considered desirable by most clinicians, they are not necessarily associated with good mental health: Conventionality and conformity are also viable paths to adjustment. Differences in O are related, however, to the manifestations of psychopathology (e.g., high-O individuals tend to use intellectualization as a defense, whereas low-O individuals use suppression or denial, McCrae & Costa, in press) and to the types of treatment that the patient is likely to find acceptable. Agreeableness, like E, is primarily a dimension of interpersonal behavior. High-A individuals are trusting, sympathetic, and cooperative; low-A individuals are cynical, callous, and antagonistic. As Homey (1945) pointed out in her distinction between moving toward and moving against others, both ends of this factor may be associated with psychopathology. In addition, A is clinically important because it directly affects the rapport between patient and therapist (Muten, 1991). Finally, Conscientiousness is a dimension that contrasts scrupulous, well-organized, and diligent people with lax, disorganized, and lackadaisical individuals. The former are more prone to compulsive personality disorder, the latter to antisocial personality disorder (Lyons, Merla, Ozer, & Hyler, 1990). Conscientiousness is associated with academic and vocational success (Digman & Takemoto-Chock, 1981); to the extent that psychotherapy can be considered work, C should also affect the outcome of therapy, and there is some evidence that it does (Miller, 1991). In a brief introduction such as this, it is natural to focus on the five broad domains rather than on the individual traits that constitute them, and those who are unfamiliar with the fivefactor model are well advised to attend first to the distinctions among the domains. In the long run, however, the detailed information that clinicians need can only be provided by an instrument that makes distinctions within the domains. For example, anxiety and depression are both aspects of N, but the distinction between them is often critical in selecting appropriate treatment. The NEO-PI is intended to offer both a global portrait of the individual's personality and more detailed information on specific facets of the broad domains. suaded us to include two newer, 18-item scales to measure A and C when the NEO-PI was published in 1985. Facet scales for A and C are being developed and should be available soon (Costa & McCrae, in press-c; Costa, McCrae, & Dye, 1991). The current 181-item version of the inventory has two forms: S for self-reports, and R for observer ratings, with parallel items phrased in first- and third-person. Items are answered along a 5-point Likert scale from strongly disagree to strongly agree, and scales are balanced to control for the effects of acquiescence. Table 1 lists the domain and facet scales of the NEO-PI and some of their psychometric properties. Despite the brevity of the facet scales, most have good internal consistency, and all show substantial stability (which is a lower-bound estimate of reliability) over a 6-year interval. Perhaps the most important data in Table 1 are given in the last column: These are validity coefficients that demonstrate significant and substantial agreement across sources for all 18 facets and five domain scales. Additional validity studies have examined correlations with peer ratings, a wide variety of other questionnaires and adjective checklists, sentence completions, and expert ratings based on spontaneous self-concept descriptions (Costa & McCrae, 1985, 1989). Recent reviews of the instrument are provided by Hogan (1989) and Leong and Dollinger (1990). Although lay observer rating scales have been widely used in personality research, they have rarely been published. Form R of the NEO-PI is available in two versions (one for rating men and the other for rating women) and has profile sheets based on normative studies of adults. As Table 1 shows, the scales of Form R show a pattern of reliability and stability very similar to that seen for Form S, and the self-spouse correlations in the fifth column are also evidence of the validity of Form R scales. Similar results (with rs ranging from .32 to .54, p < .001) are found for individual peer ratings, and larger correlations are seen when ratings are aggregated across peers (McCrae & Costa, 1989). We believe that ratings by knowledgeable others can and should be more widely used as an adjunct to the self-reports usually found in clinical assessment (cf. Muten, 1991). Other features designed to make the NEO-PI more useful to clinicians include computer administration, scoring, and interpretation; a mail-in scoring system; separate norms for college students; a short, 60-item version (the NEO Five Factor Inventory, or NEO-FFI) that gives scores for the five domains only and may be useful when time for assessment is limited; and a test feedback sheet (Your NEO Summary) that can be used to involve the patient therapeuticalry in what McReynolds (1989) called "client-centered assessment." Until recently, almost all research on the NEO-PI was conducted on normal volunteer samples, and clinicians may rightfully wonder how well its psychometric properties hold up in clinical populations when used as part of clinical assessment. The nature of the sample or the conditions of administration could affect the validity of the instrument. Three recent studies have examined the instrument in three different clinical settings: a behavioral medicine clinic (Muten, 1991), a sexual behaviors consultation unit (Pagan et al, 1991), and a private clinical practice (Miller, 1991). In all three samples, patients scored about one standard deviation higher in N and about one-half

Assessing Personality: The NEO-PI


The NEO-PI was developed over the past 15 years as a measure of the five-factor model. Our original interest was in only three of the factors that we conceptualized as broad domains N, E, and Oeach containing many more specific traits or facets (Costa & McCrae, 1980, in press-c). The NEO Inventory (as it was then called) included six 8-item facet scales for each of the three domains. Research on the five-factor model per-

SPECIAL SECTION: NEO-PI IN CLINICAL PSYCHOLOGY

Table 1 Some Psychometric Properties of NEO-PI Scales for Self-Reports (Form S) and Spouse Ratings (Form R)
Coefficient alpha NEO-PI scale Neuroticism Anxiety Hostility Depression Self-consciousness Impulsiveness Vulnerability Extraversion Warmth Gregariousness Assertiveness Activity Excitement Seeking Positive Emotions Openness Fantasy Aesthetics Feelings Actions Ideas Values Agreeableness Conscientiousness FormS (n = 983) Form R (n = 167) 6-year stability FormS (n = 398) Form R (n = 167) Self-spouse agreement (=135)

.93 .85 .77 .84 .74 .73 .77 .87 .75 .66 .76 .74 .67 .79 .89 .81 .81 .75 .64 .79 .74 .76 .86

.94 .89 .87 .87 .74 .79 .82 .88 .84 .79 .72 .82 .66 .81 .91 .84 .86 .79 .73 .84 .76 .88 .91

.83 .75 .74 .70 .79 .70 .73 .82 .72 .73 .79 .75 .73 .73 .83 .73 .79 .68 .70 .79 .71

.83 .75 .78 .72 .76 .75 .68 .77 .75 .73 .72 .68 .69 .77 .80 .73 .79 .70 .75 .75 .76

.54 .51 .60 .47 .38 .53 .32 .53 .51 .54 .53 .48 .45 .53 .60 .40 .62 .43 .47 .53 .63 .50 .43

Note. Adapted from Costa & McCrae, 1988. In the public domain. All correlations significant at p < .001. Agreeableness and Conscientiousness were not measured at baseline.

standard deviation lower in A and C than did normal volunteers; they did not differ in E or O. Further, standard deviations themselves were comparable to normative values, suggesting that the metric provided by the norms is appropriate for clinical samples. Pagan et al. reported reliabilities for the domains of .94, .87, .90,'.76, and .85 for N, E, O, A, and C, respectively (values that are virtually identical to those found in the first column of Table 1) and replicated the factor structure of the facet scales. Muten showed that Form S NEO-PI scales were meaningfully related to other self-report scales in his behavioral medicine sample, and significantly correlated with spouse ratings on Form R, with cross-observer correlations ranging from .29 to .71. Piven et al. (1990) reported significant correlations between NEO-PI domain scales and expert ratings of four of the factors based on psychiatric interviews. Such findings suggest that clinician ratings of personality are likely to concur with patient self-reports. These studies are certainly encouraging, but they represent only the first stages of research on the use of the NEO-PI in clinical samples. Many questions need to be addressed in future studies: For what other clinical populations (inpatients, psychotics, adolescents) is the NEO-PI appropriate? How does treatment affect NEO-PI scores? What are the personality profiles of different diagnostic groups? How do personality traits of the clinician interact with those of the patient? How well do self-reports or lay ratings agree with clinician's views of the patient's personality? Does the NEO-PI offer incremental validity over traditional measures of psychopathology in predict-

ing diagnosis or prognosis? Research on all these topics would be welcome.

Special Concerns in Clinical Assessment


The traditional distinction between normal and abnormal psychology has led some clinicians to the belief that instruments designed for the measurement of normal personality dimensions are irrelevant to or inappropriate for clinical assessment. We believe this conclusion is unjustified, for two reasons. First, the populations overlap considerably: An appreciable number of individuals in normal volunteer samples would be found to have diagnosable psychiatric disorders if they were systematically assessed, and many of the patients whom clinical psychologists treat are relatively well-adjusted individuals facing situational stressors. Second, many aspects of personality are relatively unaffected by psychopathology. The presence of an anxiety disorder, for example, need not affect one's intellectual curiosity or need for achievement. Although there are certainly circumstances (such as advanced dementia or catatonia) in which the assessment of normal personality is impossible and perhaps meaningless, we believe that most patients can be profitably described in terms of the dimensions of the fivefactor model, and that the NEO-PI will be a useful way to measure standing on these dimensions. However, there are two issues that require special consideration here: (a) problems of test invalidity due to defensiveness, socially desirable respond-

PAUL T. COSTA, JR., AND ROBERT R. McCRAE There is also evidence that attempts to improve the validity of self-reports through the use of special items or scales is often counterproductive. Wrobel and Lachar (1982) showed that scales using subtle items were less valid than those composed of obvious items. A series of studies using normal volunteer samples has shown that correcting self-reports using lie, social desirability, and defensiveness scales does not increase their validity with respect to external criteriaindeed, in many cases it substantially reduces their validity (McCrae, 1986; McCrae & Costa, 1983; McCrae et al., 1989). These paradoxical findings result from the inability of most social desirability scales to distinguish between individuals who falsely present themselves as having desirable characteristics and those who accurately report desirable traits. Certainly for normal samples the dangers of mistakenly distrusting valid self-reports outweigh the benefits of identifying invalid responses, and we suspect that the same will hold true in clinical samples. The success of psychological assessment depends in considerable measure on the clinician's ability to elicit the patient's trust, interest, and cooperation. The use of instruments designed to outwit or entrap the respondent hardly contributes to the development of rapport. We recommend that clinicians who use the NEO-PI explain to their patients that it measures some of the important ways in which people differ in their thoughts, feelings, and actions, and that honest responses will contribute to the success of clinical evaluation or therapy. We think these instructions will lead to valid scores in most cases. There are doubtless occasions when self-reports are not trustworthy. A patient may be uncooperative or cognitively impaired, or may have powerful incentives to distort self-presentation. We think it is unlikely that useful information will be obtained from self-reports in such cases, with or without the use of corrections, and this was one of the major reasons we developed and validated the observer rating form of the NEO-PI. We would encourage clinicians to use ratings from knowledgeable informants such as spouses or parents as an adjunct to or substitute for self-reports whenever there is reason to suspect that self-reports may be seriously distorted.

ing, or malingering, and (b) effects of psychopathology itself on personality scale scores.

Defensiveness, Social Desirability, and Malingering


NEO-PI items are obvious; that is, they ask directly about the characteristics they are intended to measure. There are three major ways in which the resulting personality scale scores can be interpreted. The most straightforward is to view them as measuresfallible measures, and thus actually estimatesof what the individual is really like. A more subtle, second interpretation is that they represent the individual's self-concept: how he or she sees him- or herself. Third, questionnaire responses, and thus scale scores, can be seen as self-presentation. In this view, scores represent the ways in which the individual wishes to be viewed by others, either in general or on the specific occasion when the test is administered. It is probably the case that all three interpretations are correct to some extent; the interpreter's task is to determine how much weight to assign to each. It is in regard to this issue that the NEO-PI breaks most clearly with the traditions of testing in clinical psychology. Perhaps because of the early influence of psychoanalysis (with its emphasis on unconscious processes and mechanisms of defense), concerns about defensiveness, social desirability, faking, and malingering have created in the minds of many clinicians a profound mistrust of patient self-reports. In response, psychometricians have expended prodigious efforts seeking ways to avoid, detect, or correct for these sources of invalidity. The MMPI used empirically keyed scales with subtle items, and most clinical instruments (such as Jackson's, 1989, Basic Personality Inventory and Morey's, 1991, Personality Assessment Inventory) include validity scales to measure lying, defensiveness, or socially desirable responding. Although NEO-PI interpreters are of course advised to check protocols for missing data and evidence of gross acquiescence or random responding (Costa & McCrae, 1989), special validity scales are not included. A single item that baldly asks respondents whether they have answered the questions honestly and accurately is the only validity check. The omission of validity scales was not an oversight, but a decision based on several lines of evidence and reasoning that need to be understood by users of the NEO-PI. We would not deny that personality scores are sometimes distorted by response sets and styles, and that individuals, particularly those with emotional and interpersonal problems, frequently lack insight into their own personalities. But we believe that these problems are not as crippling as they are often portrayed, and that there are better ways to deal with them than through the use of validity scales. There is substantial evidence that self-reports from patients are, in general, trustworthy. For example, Jackson (1989) showed convergent correlations between Basic Personality Inventory (BPI) scales and professional ratings of hospitalized psychiatric patients, ranging from .31 to .51 (all p < .05); corrected for unreliability of the ratings, these correlations rose as high as .66. Muten's (1991) data show similar levels of agreement between patients' self-reports and their spouses' ratings on the NEO-PI.

Effects of Psychopathology on Scale Scores


Responses to personality questionnaire items are based on the self-image, the view the individual has of him- or herself. Studies comparing self-reports with observer ratings support the conclusion that self-images are generally accurate (McCrae & Costa, 1989), but clinical psychology provides many counterexamples, from delusions of grandeur to distortions of bodyimage among anorectics. In some cases, such irrational beliefs about the self may affect personality trait measures, and the clinician must keep this possibility in mind when interpreting scores. One example is provided by narcissism. Narcissists have an inflated self-image, and may portray themselves as well-adjusted, extraverted, and perhaps conscientious. But studies using both normal (Costa & McCrae, 1990) and psychiatric (Lyons et al., 1990) samples have found negative correlations between narcissism and self-reported Agreeableness, so apparently narcissists are not prone to describe themselves as humble, sympathetic, or self-effacing. Nevertheless, personality rat-

SPECIAL SECTION: NEO-PI IN CLINICAL PSYCHOLOGY ings might be particularly useful in cases in which a diagnosis of narcissism is suspected. A more pervasive problem, and one on which there is already some research, is the effect of mood disorders on self-presentation. There is considerable evidence that temporary moods do not influence scores on personality inventories in normal samples (Costa & McCrae, in press-b; Underwood, Framing, & Moore, 1980). But clinical depression does affect self-image: Depressed patients have lowered self-esteem that is manifested in their responses. It appears that the primary effect of this bias is seen on measures related to Neuroticism. Liebowitz, Stallone, Dunner, and Fieve (1979) have reported that Neuroticism scores, but not Extraversion scores, increased as patients entered a depressive phase. Hirschfeld et al. (1983) administered the Maudsley Personality Inventory (MPI; Eysenck, 1962) and the Guilford Zimmerman Temperament Survey (GZTS; Guilford, Zimmerman, & Guilford, 1976) twice to depressed men and women and reported that measures of N (MPI Neuroticism and GZTS Objectivity, reversed) decreased over a 1-year period for depressed patients who had recovered, but not for those who had not. Recovery from depression did not lead to changes in GZTS General Activity and Ascendance (measures of E) or GZTS Thoughtfulness (a measure of O). Additional studies, especially including measures of A and C, are needed here, but it appears that the major effect of depression is to exaggerate scores on measures of N. Because individuals who are prone to depression are also likely to have elevated premorbid N scores (Hirschfeld et al., 1989), this bias is unlikely to change the overall shape of the personality profile. Most important, depression is unlikely to affect scores on E and O, dimensions that may be useful in selecting the optimal form of therapy (Miller, 1991). intended to provide psychometrically sophisticated measures of major dimensions of psychopathology in both normal and clinical populations. Both instruments were administered to a subsample of men and women in the Baltimore Longitudinal Study of Aging (BLSA; Shock et al., 1984) who had completed the NEO-PI 2 years earlier. The 60 men and 57 women who provided data on one or both instruments ranged in age from 21 to 94, with mean ages of 67.5 and 64.5, respectively. Because both these instruments are relatively new, it is of interest to consider first their convergent and discriminant validity as alternative measures of psychopathology. In general, good agreement was found. For example, PAI Somatic Complaint had its highest correlation (r = .72) with BPI Hypochondriasis; PAI Anxiety and Anxiety-Related Disorder scales had their highest correlations with BPI Anxiety (rs = .66, .48, respectively). Intercorrelations among all the scales in Tables 2 and 3 are available from us. Table 2 gives correlations between the NEO-PI domain scales and BPI scales. The correlations of Anxiety with N, Social Introversion with E, Denial with O, Interpersonal Problems with A, and Impulse Expression with C require little comment; they show the parallelism between psychopathological and normal personality dimensions that we hypothesized. The negative correlation between BPI Denial and N illustrates the problematic nature of validity scales. Should we conclude that some individuals score low on N because they deny undesirable traits they possess, or should we conclude that people low on N really have fewer undesirable traits? Both are logically possible, and we suspect the latter is more plausible. Data from observer ratings would be needed to resolve this issue. It is notable that only one of the BPI scales, Thinking Disorder, is unrelated to any of the five factors. This finding is consistent with earlier speculations that "a sixth dimension of aberrant cognitions might be needed to fully describe personality disorders" (Costa & McCrae, 1990, p. 370) and illustrates the complementary nature of measures of personality and psychopathology. The PAI is a new instrument designed "to provide information on critical clinical variables" (Morey, 1991, p. 1). In addition to 11 clinical scales (most with subscales), it also contains four validity scales, two interpersonal scales, and five scales related to treatment and case management. Table 3 provides means, standard deviations, and coefficients alpha for the PAI clinical and treatment scales, as well as correlations with NEOPI domain scales. Comparison of means shows that the present sample is similar to the normative group of normals in most respects. Internal consistencies are high except for the Drug Problems and Stress scales, which show relatively little variance in this predominantly older sample. Correlations of the clinical scales with the NEO-PI domains show a pattern previously seen in analyses of the MMPI and MCMI. Borderline Features, Anxiety, and Schizophrenia are strongly related to N; Mania is related to E; Paranoia and Antisocial Features are negatively related to A, and none of the scales is strongly related to O or C. The inclusion of treatment scales is an interesting feature of the PAI. Aggression and Suicidal Ideation refer to characteristics of the individual that clinicians should attend to, although

Linking Clinical and Normal Personality Instruments


We have argued that most clinical populations are not dramatically different from normal volunteer samples with regard to the structure of personality. Similarly, we would argue that most dimensions of psychopathology have parallels in dimensions of individual differences in the normal range. One of the intriguing questions for future research concerns the nature of the relation between traits and psychiatric disorders: Do traits predispose individuals to certain disorders or result from the disorders, or are mental disorders merely extreme forms of otherwise normal personality characteristics (cf. Widiger & Trull, in press)? Whatever the form of the relationship, we know from many studies that there is substantial overlap between measures of personality and psychopathology, and pointing out these correspondences may be a useful way to acquaint the clinician with the constructs measured by the NEO-PI. Previous studies (Costa & McCrae, 1990; McCrae, 1991) have examined correlations between the NEO-PI factors and scales from two of the most widely used clinical instruments, the Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1983) and the Millon Clinical Multiaxial Inventory (MCMI; Millon, 1983); most of the scales were related to N or E. We have recently collected data on two newer measures of psychopathology: Jackson's BPI and Morey's Personality Assessment Inventory (PAI). Both of these instruments were

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PAUL T. COSTA, JR., AND ROBERT R. McCRAE Table 2 Correlations ofNEO Personality Inventory Domain Scales With Jackson's Basic Personality Inventory (BPI) Scales (N = 109) NEO Personality Inventory domain BPI scale Hypochondriasis Depression Denial Interpersonal Problems Alienation Persecutory Ideas Anxiety Thinking Disorder Impulse Expression Social Introversion Self Depreciation Deviation Neuroticism .29** .32*** -.48*** .33*** .12 .29** .60*** .07 .33*** .16 .38*** .26** Extroversion
-.19* -.27** -.19* .05 .12 .00 -.08 .01 .29*** -.44*** -.43*** .02

Openness
-.02 -.05 -.45*** .14 .15 -.03 .06 -.13 .30*** -.15 -.35*** .01

Agreeableness
-.08 -.18 .18 -.56*** -.40*** -.21* -.01 .00 -.16 -.28** -.17 -.17

Conscientiousness
-.17 -.21* .21* -.07 -.09 -.07 -.28** -.11 -.36*** -.04 -.35*** -.02

*/><.05. **p<.01. ***p<.001.

they are not necessarily the basis of particular psychiatric diagnoses; note the negative correlation between Aggression scores and A. The clinician may also want an indication of how much stress the individual is exposed to and how much social support he or she receives. These variables are usually conceptualized as situational factors, but as Table 3 shows, self-report measures of stress and social support are affected by neuroticism (cf. McCrae, 1990). Disagreeable people also report less social support, perhaps because they have antagonized the people who would otherwise provide it. Finally, there is a strong negative

correlation between N and treatment rejectiona perfectly reasonable result: In this normal, volunteer sample, well-adjusted people see little need for psychotherapy. The correlations in Tables 2 and 3 illustrate meaningful links between clinical constructs and normal personality dimensions. There are, of course, important differences between clinical depression and normal dejection, between mania and high-spirited extraversion, between obsessive-compulsive behaviors and conscientious organization. But in many cases the difference is one of degree. Dimensions of psychopathology are

Table 3 Correlations of NEO Personality Inventory Domain Scales With Personality Assessment Inventory (PAI) Scales (N = 114) NEO Personality Inventory domain PAI scale Clinical scales Somatic Complaints Anxiety Anxiety-Related Disorders Depression Mania Paranoia Schizophrenia Borderline Features Antisocial Features Alcohol Problems Drug Problems Treatment scales Aggression Suicidal Ideation Stress Nonsupport Treatment Rejection
M
12.1 13.1 17.0 14.3 21.1 14.0 13.9 13.9 10.8 3.5 2.9 11.8 2.2 3.2 4.7 15.4
SD 8.9 8.2 6.9 6.7 8.6 6.4 5.7 7.7 6.7 3.9 3.6 5.9 3.3 2.6 3.0 3.7 .86 .86 .77 .77 .83 .81 .70 .84 .76 .74 .59 .75 .74 .57 .68 .71 N E O A

.24** .63*** .55*** .40*** .18 .43*** .51*** .67*** .13 .17 .07
.32*" .20* .38*** .25** -.60***

-.19* -.13 -.23* -.38*** .37*** -.07 -.27** .07 .38*** .19* .08 .21*

-.03 .09 -.07 -.18 .33*** .03 .02 .26** .26** .14 -.04 .23* .08 .08 .10 -.26**

-.11 -.04 -.20* -.16 -.27** -.52*** -.35*** -.36*** -.37*** -.20* -.15

-.14 -.16 .00 -.27** .27** -.04 -.18 -.16 -.03 -.10 -.08 -.07 -.06 -.10 .03 .26**

-.08 .00 -.07 -.01

-.43*** -.19* -.14 -.39*** .19*

Note: One item (of 24) is missing from the Depression scale, and one item (of 12) is missing from the Alcohol Problems scale. N = Neuroticism; E = Extraversion; O - Openness; A = Agreeableness; C = Conscientiousness. */><.05. **/?<.01. ***/>< .001.

SPECIAL SECTION: NEO-PI IN CLINICAL PSYCHOLOGY

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not a world apart from dimensions of personality; both are spanned by the same five dimensions. Clinical Uses of Personality Data In 1986 we argued that clinicians could benefit from routine assessment of the five basic factors of personality (McCrae & Costa, 1986). It seemed obvious to us that they would want to understand the enduring emotional, interpersonal, experiential, attitudinal, and motivational styles of their patients, just as they need to consider age, sex, education, and cultural background. It soon became clear to us, however, that more is needed than a guide to the elements of personality: Clinicians also need to learn how to use this information. Not surprisingly, many of the most important insights in this regard have come from practicing psychotherapists who have used the NEO-PI themselves (Pagan et al, 1991; Miller, 1991; Muten, 1991). We summarize some of their experience here. Understanding The most basic function of psychological assessment is to give the clinician a sense of what the patient is like. Although self-reports are not infallible, there is considerable evidence that the NEO-PI provides relatively accurate information on patients from a variety of clinical populations. Because the fivefactor model is comprehensive, the profile the NEO-PI provides covers the full range of personality traits and can give the clinician a sense of both the patient's strengths and weaknesses. Knowledge of personality traits can also set in context the specific problems that led the patient to therapy: Are they reactions to recent events or difficult situations, or are they symptoms of enduring and pervasive maladjustments? Diagnosis NEO-PI scores may suggest possible diagnoses or be used to rule out various disorders. Elevated N scores are common among patients in psychotherapy, but the particular facets of N that are most elevated may focus attention on specific diagnoses. Very high Self-Consciousness scores, for example, should lead the clinician to consider the diagnosis of Social Phobia, which is distinguished by a persistent fear of acting in a way that will be humiliating or embarrassing. Extreme scores on normal personality traits are not necessarily an indication of psychopathology (e.g., a patient may be very extraverted without being histrionic), but extreme scores are often contraindicative of certain diagnoses (e.g., very high E scores are inconsistent with the diagnosis of schizoid personality disorder). Empathy and Rapport Patients want to be understood, and they expect therapists to be experts at understanding human nature. When therapists are informed by NEO-PI results early in the therapeutic process, they appear more knowledgeable and empathic to the patient, allowing a more rapid development of rapport. This is particularly important in short-term therapy, in which sessions spent learning about the patient may be time lost from treatment. Clinicians themselves may also find it easier to empa-

thize with patients when they consider nonpathological aspects of personality, such as the individual's intellectual interests or capacity for joy. Feedback and Insight Traditionally, the results of clinical assessments have been for the eyes of the therapist only; it was assumed that they would be confusing and upsetting to patients. Certainly, this is true for some instruments and some patients. But more recently, the value of sharing test results has been emphasized; McReynolds (1989) has called this approach client-centered assessment. Clearly, it is easier to discuss with patients the results from a measure of normal personality than from measures of psychopathology, and a brief, nontechnical sheet, Your NEO Summary, has been developed to provide feedback to individuals who take the NEO-PI or NEO-FFI. At least one clinician (Muten, 1991) routinely reviews the full profile sheet with patients, taking the time to explain the labels for the scales and the interpretation of normed scores; further, he refers back to this profile as relevant issues arise in therapy. In this way, the scale scores are tied to concrete examples of problematic behavior to help the patient achieve insight into his or her behavior. Research is needed to establish the utility of this process and the patient populations for which it is appropriate, but clinical experience to date is encouraging. Anticipating the Course of Therapy The success of psychotherapy depends not only on the therapist's skill, but also on the patient's cooperation, motivation to work, and capacity for therapeutic benefit. Patients with deficiencies in these areas need special attention from the therapist, and the NEO-PI can signal potential problems in these areas. Scores on A are particularly relevant to issues of trust and cooperation. The patient with very low A scores may be skeptical about the entire therapeutic enterprise and expect the clinician to prove him- or herself. Conversely, excessively high A scores can point to an overly compliant patient who easily becomes dependent on the therapist. Many kinds of therapy require that the patient do some form of homework between sessions (e.g., record dreams, chart eating behaviors, keep a diary of emotional reactions). As in academic settings, some people are more prone to take such assignments seriously than others are, and this is gauged chiefly by C. Patients who are very low in C may not even remember to keep therapy appointments. Law C scores can alert the clinician to the need to provide structure and motivation for the patient. Finally, scores on N are prognostic of ultimate outcome. Patients who are relatively well-adjusted to begin with are those who benefit most from therapy. In the case of extremely high N scores, the clinician needs to foster realistic expectations about the benefits of therapy. No form of therapy is likely to affect a complete cure of lifelong dysthymia or a borderline personality disorder; instead, the goal of therapy may be to limit distress or teach the patient how to manage it. Personality dispositions and the disorders to which they predispose individuals tend to be very stable in adulthood; clinicians should measure progress

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PAUL T. COSTA, JR., AND ROBERT R. McCRAE Costa, P. X, Jr., & McCrae, R. R. (1985). The NEO Personality Inventory manual. Odessa, FL: Psychological Assessment Resources. Costa, P. T., Jr., & McCrae, R. R. (1986). Personality stability and its implications for clinical psychology. Clinical Psychology Review, 6, 407-423. Costa, P. T., Jr., & McCrae, R. R. (1988). Personality in adulthood: A six-year longitudinal study of self-reports and spouse ratings on the NEO Personality Inventory. Journal of Personality and Social Psychology, 54, 853-863. Costa, P. X, Jr., & McCrae, R. R. (1989). The NEO-Pl/NEO-FFI manual supplement. Odessa, FL: Psychological Assessment Resources. Costa, P. X, Jr., & McCrae, R. R. (1990). Personality disorders and the five-factor model of personality. Journal of Personality Disorders, 4, 362-371. Costa, P. X, Jr., & McCrae, R. R. (in press-a). Manual for the Revised NEO Personality Inventory (NEO-PIR) and NEO Five-Factor Inventory (NEO-FFI). Odessa, FL: Psychological Assessment Resources. Costa, R X, Jr., & McCrae, R. R. (in press-b). Multiple uses for longitudinal personality data. European Journal of Personality. Costa, P. X, Jr., & McCrae, R. R. (in press-c). The NEO Personality Inventory. In S. R. Briggs & J. Cheek (Eds.), Personality measures (Vol. 1). Greenwich, CT: JAI Press. Costa, P. X, Jr., McCrae, R. R., & Dye, D. A. (1991). Facet scales for Agreeableness and Conscientiousness: A revision of the NEO Personality Inventory. Personality and Individual Differences, 12, 887898. Digman, J. M. (1990). Personality structure: Emergence of the five-factor model. Annual Review of Psychology, 41, 417-440. Digman, J. M., & Xakemoto-Chock, N. K. (1981). Factors in the natural language of personality: Re-analysis, comparison, and interpretation of six major studies. Multivariate Behavioral Research, 16, 149-170. Eysenck, H. J. (1962). The Maudsley Personality Inventory. San Diego, CA: EdITS. Pagan, P. J., Wise, T. N, Schmidt, C. W, Ponticas, Y, Marshall, R. D., & Costa, P X, Jr. (1991). A comparison of five-factor personality dimensions in males with sexual dysfunction and males with paraphilia. Journal of Personality Assessment, 57, 434-448. Funder, D. C. (1991). Global traits: A Neo-Allportian approach to personality. Psychological Science, 2, 31-39. Garfield, S. L. (1978). Research on client variables in psychotherapy. In S. L. Garfield & A. E. Bergin (Eds.), Handbook of psychotherapy and behavior change: An empirical analysis (2nd ed.; pp. 191 -232). New York: Wiley. Gough, H. G. (1957). California Psychological Inventory manual. Palo Alto, CA: Consulting Psychologists Press. Guilford, J. S., Zimmerman, W S., & Guilford, J. P. (1976). The Guilford-Zimmerman Temperament Survey Handbook: Twenty-five years of research and application. San Diego, CA: EdITS. Hathaway, S. R., & McKinley, J. C. (1983). The Minnesota Multiphasic Personality Inventory manual. New \brk: Psychological Corporation. Hirschfeld, R. M. A., Klerman, G. L., Clayton, P., Keller, M. B., McDonald-Scott, P., & Larkin, B. (1983). Assessing personality: Effects of depressive state of trait measurement. American Journal of Psychiatry, 140, 695-699. Hirschfeld, R. M. A., Klerman, G. L., Lavori, P, Keller, M. B., Griffith, P., & Coryell, W (1989). Premorbid personality assessments of first onset of major depression. Archives of General Psychiatry, 46, 345-350. Hogan, R. (1989). [Review of The NEO Personality tinattory]. In J. C. Conoley & J. J. Kramer (Eds), The tenth mental measurements yearbook. Lincoln, NE: Buros Institute of Mental Measurements. Horney, K.. (1945). Our inner conflict's. New York: Norton.

against this standard, rather than against the often unrealistic standard of perfect mental health (Costa & McCrae, 1986).

Matching Treatments to Patients


Therapists have known for decades that some treatments work better with some patients than with others. The medical model suggests that the diagnosis should dictate the treatment, but this model is often inapplicable to psychotherapy. Research on the differential effectiveness of different kinds of therapy has emphasized patient characteristics such as gender and social class (Garfield, 1978) and has offered only limited insights. We believe that a consideration of personality traits may be more fruitful. The two dimensions of clearest relevance to the choice of therapies are E and Q Extraverts are sociable, talkative, and demonstrative, and will find therapies that require interpersonal interaction congenial. Miller (1991) has noted that both client-centered therapy and psychoanalysis require considerable spontaneous speech from the patient and are difficult for introverts. By contrast, low-E patients may prefer and benefit more from behavior therapy or Gestalt, in which the therapist has a more active role. Shea (1988) has shown that interpersonally involved depressed patients benefit more from interpersonal therapy; detached patients benefit more from antidepressant medications. It is also reasonable to hypothesize that differences in O will affect the patient's response to therapy. Individuals who are closed to experience are conventional in their tastes and beliefs, and they will probably prefer directive psychotherapies that offer sensible advice, behavioral techniques that teach concrete skills, or client-centered therapies that provide emotional support. Patients who are high in O are much more willing to consider novel ideas and to try out unusual approaches to problem solving. Gestalt, psychoanalysis, or Jungian analysis may appeal to them. It is certainly true that what the patient prefers is not necessarily what the patient needs: Group therapy may be exactly what an avoidant introvert requires. But the clinician who understands the enduring dispositions of the patient will be in a much better position to select a treatment and to explain to the patient why it is needed and how it should work. This is an area in which much more research is needed, and the five-factor model provides a comprehensive framework within which to conduct research on the relation of individual differences to treatment outcomes. References
Block, J. (1981). Some enduring and consequential structures of personality. In A. I. Rabin, J. Aronoff, A. M. Barclay, & R. A. Tucker (Eds.), Further explorations in personality (pp. 27-43). New York: Wiley-Interscience. Cattell, R. B., Eber, H. W, & Tatsuoka, M. M. (1970). The handbook for the Sixteen Personality Factor Questionnaire. Champaign, IL: Institute for Personality and Ability Testing. Costa, P. T, Jr., & McCrae, R. R. (1980). Still stable after all these years: Personality as a key to some issues in adulthood and old age. In P. B. Baltes & O. G. Brim, Jr. (Eds), Life span development and behavior (Vol. 3, pp. 65-102). New York: Academic Press.

SPECIAL SECTION: NEO-PI IN CLINICAL PSYCHOLOGY Jackson, D. N. (1989). Basic Personality Inventory manual. Port Huron, MI: Sigma Assessment Systems. John, O. P. (1990). The "big five" factor taxonomy: Dimensions of personality in the natural language and in questionnaires. In L. Pervin (Ed.), Handbook of personality theory and research. New York: Guilford. Kenrick, D. X, & Funder, D. C. (1988). Profiting from controversy: Lessons from the person-situation debate. American Psychologist, 43, 23-34. Leong, F. T. L, & Dollinger, S. J. (1990). NEO Personality Inventory. In D. J. Keyser & R. C. Sweetland (Eds.), Test critiques (Vol. 8; pp. 527539). Austin, TX: PRO-ED Liebowitz, M. R., Stallone, F., Dunner, D. L, & Fieve, R. F. (1979). Personality features of patients with primary affective disorder. Ada Psychiatrica Scandinavica, 60, 214-224. Lyons, M. I, Merla, M. E, Ozer, D. J, & Hyler, S. E. (1990, August). Relationship of the "big-five" factors to DSM-IH personality disorders. Paper presented at the 98th Annual Convention of the American Psychological Association, Boston. McCrae, R. R. (1986). Well-being scales do not measure social desirability. Journal of Gerontology, 41, 390-392. McCrae, R. R. (1989). Why I advocate the five-factor model: Joint analyses of the NEO-PI and other instruments. In D. M. Buss & N. Cantor (Eds.), Personality psychology: Recent trends and emerging directions (pp. 237-245). New York: Springer-Verlag. McCrae, R. R. (1990). Controlling neuroticism in the measurement of stress. Stress Medicine, 6, 237-241. McCrae, R. R. (1991). The five-factor model and its assessment in clinical settings. Journal of Personality Assessment, 57, 399-414. McCrae, R. R., & Costa, P. X, Jr. (1983). Social desirability scales: More substance than style. Journal of Consulting and Clinical Psychology, 51, 882-888. McCrae, R. R, & Costa, P. T, Jr. (1985). Openness to experience. In R. Hogan & W H. Jones (Eds.), Perspectives in personality (Vol. 1; pp. 145-172). Greenwich, CT: JAI Press. McCrae, R. R., & Costa, P. X, Jr. (1986). Clinical assessment can benefit from recent advances in personality psychology. American Psychologist, 41,1001-1003. McCrae, R. R., & Costa, P. X, Jr. (1989). Different points of view: Self-reports and ratings in the assessment of personality. In J. P. Forgas & J. M. Innes (Eds.), Recent advances in social psychology: An international perspective (pp. 429-439). Amsterdam: Elsevier. McCrae, R. R., &Costa, P. X, Jr. (1990). Personality in adulthood. New York: Guilford. McCrae, R. R., & Costa, P. X, Jr. (1991). The NEO Personality Inventory: Using the five-factor model in counseling. Journal of Counseling and Development, 69, 367-372,375-376. McCrae, R. R, & Costa, P. X, Jr. (in press). Conceptions and correlates of Openness to Experience. In S. R. Briggs, R. Hogan, & W H. Jones (Eds.), Handbook of personality psychology. New \brk: Academic Press. McCrae, R. R., Costa, P. X, Jr., Dahlstrom, W G, Barefoot, J. C, Siegler, I. C, & Williams, R. B, Jr. (1989). A caution on the use of the

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MMPI /^-correction in research on psychosomatic medicine. Psychosomatic Medicine, 51, 58-65. McReynolds, P. (1989). Diagnosis and clinical assessment: Current status and major issues. Annual Review of Psychology, 40, 83-108. Miller, X (1991). The psychotherapeutic utility of the five-factor model of personality: A clinician's experience. Journal of Personality Assessment, 57, 415-433. Millon, T. (1983). Millon Clinical Multiaxial Inventory manual (3rd. ed.). Minneapolis, MN: Interpretive Scoring Systems. Morey, L. (1991). Personality Assessment Inventory: Professional manual. Odessa, FL: Psychological Assessment Resources. Muten, E. (1991). Self-reports, spouse ratings, and psychophysiological assessment in a behavioral medicine program: An application of the five-factor model. Journal of Personality Assessment, 57, 449-464. Norman, W X (1963). Toward an adequate taxonomy of personality attributes: Replicated factor structure in peer nomination personality ratings. Journal of Abnormal and Social Psychology, 66,574-583. Piven, J, Landa, R., Wzorek, M., Gayle, J, Costa, P. X, Jr., Boulton, P., Cloud, D., Chase, G, & Folstein, S. (1990). Personality characteristics of the first degree relatives of autistic individuals. Manuscript submitted for publication. Shea, M. X (1988, August). Interpersonal styles and short-term psychotherapy for depression. Paper presented at the 96th Annual Convention of the American Psychological Association, Atlanta, GA. Shock, N. W, Greulich, R. C, Andres, R, Arenberg, D, Costa, P. X, Jr., Lakatta, E. G, & Xobin, J. D. (1984). Normal human aging: The Baltimore Longitudinal Study of Aging (NIH Publication No. 842450). Bethesda, MD: National Institutes of Health. Spielberger, C. D. (Chair). (1989, April). Use of the five-factor model in clinical assessment. Symposium presented at the 1989 Midwinter Meeting of the Society for Personality Assessment, New York. Xellegen, A. (in press). Personality traits: Issues of definition, evidence and assessment. In D. Cicchetti & W Grove (Eds.), Thinking clearly about psychology: Essays in honor of Paul Everett Meehl. Minneapolis: University of Minnesota Press. Underwood, B., Froming, W J., & Moore, B. S. (1980). Mood and personality: A search for the causal relationship. Journal of Personality, 48,15-23. Widiger, X A., & Trull, T. J. (in press). Personality and psychopathology: An application of the five-factor model. Journal of Personality. Wiggins, J. S, & Pincus, A. L. (1989). Conceptions of personality disorders and dimensions of personality. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 1, 305-316. Wiggins, J. S., & Xrapnell, P. D. (in press). Personality structure: The return of the big five. In S. R. Briggs, R. Hogan, & W H. Jones (Eds.), Handbook of personality psychology. New \brk: Academic Press. Wrobel, X A., & Lachar, D. (1982). Validity of the Wiener subtle and obvious scales for the MMPI: Another example of the importance of inventory-item content. Journal of Consulting and Clinical Psychology, 50, 469-470.

Received March 4,1991 Revision received March 20,1991 Accepted March 20,1991