JOURNAL OF PERSONALITY ASSESSMENT, 72(3), 407425

Copyright 1999, Lawrence Erlbaum Associates, Inc.

Approaching Psychotherapy of the

Personality Disorders From the
Millon Perspective

Darwin Dorr
Department of Psychology
Wichita State University

Millons integrative model for a clinical science begins with a theory that is consistent
with current knowledge, establishes a taxonomy for classification, develops a coordi-
nated assessment system, and develops and implements interventions with the guid-
ance of the preceding elements of the model. In recent years, work on the last step of
the model, clinical interventions, has accelerated rapidly, and the model now permits
the therapist to directly extrapolate specific treatment goals, objectives, and tech-
niques to the practice of therapy with the individual patient. This article summarizes
how treatment planning and implementation flows logically from the Millon model.

As part of his efforts to find ways to encourage integration in psychology, Millon

and his colleagues (Millon, 1990; Millon & Davis, 1996) developed a model for a
mature clinical science. The model articulates explicit theories that serve as explan-
atory and heuristic conceptual schemas that are consistent with established knowl-
edge. Further, Millon established a taxonomy for purposes of classification,
designed instrumentation based on theoretical groundings and taxonomies, and
used these theoretical and psychometric tools to plan and implement psycho-
therapeutic interventions. His work over the past 30 years resulted in significant de-
velopments in the first three steps of this model. In recent years, work on the fourth
step, clinical interventions, has accelerated rapidly, and the model now permits the
therapist to directly extrapolate specific treatment goals, objectives, and techniques
to the practice of psychotherapy with the individual patient. This article summa-
rizes how treatment planning and implementation flows logically from the Millon
model. This extension of the theory promises to be one of the most exciting devel-
opments in the melding of the clinical science of assessment and intervention.

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Millon (Millon & Davis, 1996) strongly emphasized that in a clinical science,
theory should relate directly to intervention. Millon (1995) was sharply critical of
the practice of applying therapeutic interventions based on what one has learned in
ones training rather than by careful assessment of the personality and
psychopathology of the patient. He observed that most therapists fail to link
thoughtful diagnosis to thorough treatment planning. To Millon, the person is at
the center of the psychotherapeutic experience, and it is there that therapeutic plan-
ning should begin. Otherwise, we would all be like small boys plying our respec-
tive therapeutic hammersbe they cognitive therapy, psychodynamic, gestalt,
behavioral, or family therapyoblivious to the therapeutic needs of the patient.
Millons theory is inclusive and anticipates the current integrative approach to
psychotherapy (Norcross & Goldfried, 1992). In the second edition of his personal-
ity disorders volume, Millon (Millon & Davis, 1996) cited the work of Werner
(1940), who maintained that development proceeded in three stages: (a) from the rel-
atively global, to (b) the relatively differentiated, to (c) an integrated totality. Millon
wrote that if the emerging field of psychotherapy had developed according to
Werners model, we might today have an integrated theory of psychotherapy. In-
stead, we have a therapeutic Tower of Babel with literally hundreds of specific types
of therapies described in the literature (Garfield, 1994). Millon (1990) described
how schools of psychotherapy sometimes evolve into imperious dogmas that close
off other points of view. Disciples submit to infallible authorities who vehemently
dispute the validity of competing theories. Indeed, as early as 1969, Millon asserted
that the disciples of such schools, often less creative than their creators, tend to un-
critically and devotedly defend the tenets of the theory as sacred dogma. In fact,
Millon speculated that dogmatism serves to protect the adherent from experiencing
underlying self-doubt and insecurity concerning validity of ones convictions.
Turning his attention from dogma to eclecticism, Millon (Millon & Davis,
1996) asserted that at least eclecticism had the virtue of humility. To Millon, eclec-
ticism is a response to practical necessity. Patients present with a multitude of
problems, and compassionate therapists reach for every available tool to respond
to clinical exigencies. Eclecticism is more empirical than theoretical. It represents
a pragmatism in which the clinician chooses whatever psychotherapeutic tech-
nique works best with the patient. Literally meaning to select from what appears to
be the best, eclecticism is the precursor of the contemporary integration movement
in psychotherapy. Eclecticism, of necessity, is atheoretical. Millon referred to it as
more of a movement than a theoretical orientation. Technical eclecticism accepts
the position that therapeutic techniques could be separated from their generative
theories and applied to clinical problems without endorsing or validating the the-
ory. To Millon, eclecticism is a more reasonable alternative to dogma. However,
he pointed out that eclecticism is more like a coping mechanism than a consciously
developed theoretical orientation. Further, he remarked that there are actually no
theory-neutral facts. Theory can be ignored, but it will not go away. Thus, Millon

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 PSYCHOTHERAPY WITH PERSONALITY DISORDERS 409

argued that a clinical science must begin with conceptual theories from which tax-
onomies, assessment instruments, and, ultimately, interventions are derived. Sci-
ence can never be truly atheoretical. Hence, he argued that there is a need to move
beyond eclecticism toward a more integrative approach to therapeutic theorizing.
Millons model calls for an integrative approach in which specific therapeutic
strategies and tactics derive logically from the theoretical conceptualization of the
person at the center of the therapy.
Millons current approach to psychotherapy is a logical extension of his
biosocial-learning theory. Depending on the purposes of the writing, the approach
has been alternatively described as synergistic psychotherapy, personologic psy-
chotherapy, personality therapy, or simply the Millon perspective. The admixture
of spheres incorporated in the name biosocial-learning theory emphasizes the view
that personality and psychopathology develop as a result of the interaction be-
tween organismic and environmental forces, an interaction not well recognized at
the time that Millon (1969) introduced the idea. In his view, this interaction is
ceaseless, beginning at conception and continuing throughout the life cycle. As a
result, persons who share similar biological and constitutional predispositions may
present with differing personality characteristics and clinical syndromes as a func-
tion of their experiences. Biological and constitutional factors can shape, facilitate,
or limit the nature of the individuals learning and experiences in multiple ways.
Consider, for example, the role of perception. As a result of differing constitu-
tional characteristics, persons may perceive the same objective environment in dif-
ferent ways that, in turn, may contribute to marked individual differences in their
reaction to the environment. Through this mechanism, the same objective envi-
ronment becomes, in psychological actuality, multiple environments.
Millon does not imply a simple, unidimensional biological determinism in this
model, contending that biological maturation is dependent on a favorable environ-
mental experience. The biosocial-learning model posits a circularity of interaction
in which dispositions in early childhood evoke counterreactions from others that
subsequently enhance these dispositions. Children actively interact with their envi-
ronment, thus contributing to the conditions of their environment, which, in a recip-
rocal manner, provide a template for reinforcement of their biological tendencies. In
Millons words, Each person possesses a biologically based pattern of sensitivities
and behavioral dispositions that shapes the nature of his or her experiences and may
contribute directly to the creation of environmental difficulties (Millon & Davis,
1996, p. 67).

POLARITIES

Millon (1969) presented an initial version of his biosocial-learning theory in which

he posited three broad polarities that govern all mental life. These polaritiesac-

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tivepassive, pleasurepain, and selfotherare used as a means of describing

various types of pathological personalties. For example, the narcissistic personality
is described at that time as a passive-independent character.
Millon continued to reassess, revise, and extend his conceptualization of per-
sonality and personality disorders. He was influenced by Godels (1931) incom-
pleteness theorem that no self-contained system can prove its own propositions.
As a result, he voyaged beyond the parameters of psychology to examine universal
principles that can be found in older, more established sciences such as physics,
chemistry, and biology. Using observations gleaned from this broad, scientifically
historical view, Millon concluded that the principles of evolution are essentially
universal and that the lessons to be learned from evolutionary principles have a
close correspondence to his earlier (1969) biosocial-learning theory. In his book
on personology (Millon, 1990), the polarity model was reconceptualized as conso-
nant with evolutionary theory. For example, the pleasurepain polarity reflected
the matter of actually being versus nonbeing, existence versus nonexis-
tence. Organisms exist (i.e., resist entropy) by seeking pleasure (life enhance-
ment) or by avoiding pain (life preservation). The basic polarities were plaited into
a complex matrix that faithfully described the broad styles of the various personal-
ity styles.
In the personality disorders, these polarities are imbalanced in various ways.
The configuration and direction of the imbalance globally describes the pathology
characteristic of the specific personality disorder. They provide the therapist with a
general template that can be used in developing overall long-range treatment strat-
egies that guide the entire course of the therapy. The overarching objective is to
rebalance the imbalanced polarities. To give a few examples: schizoids, avoidants,
and depressives are pleasure deficient. Thus, a long-range therapeutic strategy for
these patients may be to enhance their capacity to experience pleasure and to en-
gage in life-enhancing tendencies. The avoidant and the depressive personalities
are imbalanced in the direction of the pain polarity. Thus, a long-range strategy
would be to lessen their cathexis to pain. In the case of the self-defeating and the
sadistic personalities, there is a reversal in the pleasurepain polarities. Hence, the
long-range strategy is to transpose the painpleasure discordance. In the case of
borderline personality disorder, the motives and aims inherent in each of the polar-
ities are of average strength, but all three of the polarities are in conflict. There is
intense conflict between enhancement and preservation, accommodation and
modification, as well as individuation and nurturance. The conflicting polarity
vectors reflect an unstable pattern of intense ambivalence and inconsistency that
characterizes the borderline syndrome. Millons model describes the emotional
vacillation and the behavioral unpredictability. Thus, the overall therapeutic strat-
egy is to reduce conflict among the painpleasure, activepassive, and selfother
polarities.

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 PSYCHOTHERAPY WITH PERSONALITY DISORDERS 411

Millon also identified what he called perpetuating tendencies, or characteristics

of the personality disorder that actually contribute to the perpetuation of the disor-
der itself. For example, the overall style of the histrionic is to orient his or her at-
tention to the external world. Passing details become preoccupations, preventing
experiences from being digested and embedded within the persons inner world.
This preoccupation with the external world interferes with the process of reflective
self-examination, resulting in a failure to link affect and behavior. Behaviors are
emitted before they are linked and organized by the mental processes of memory
and thought. Unless life events are metabolized and integrated, the individual
gains little from them. Hence, the histrionics maturation is unchanged by experi-
ence. The maturity learning curve remains flat. The opportunity to develop a foun-
dation of life learning experiences from which to draw in future interactions is lost.
The histrionic is bereft of an inner storehouse of memories, ideas, and thoughts
that add up to ego strength. The histrionics excessive preoccupation with the ex-
ternal, to the neglect of the self, perpetuates the shallowness or emptiness, which in
turn propels the person to further seek gratification and a sense of substance from
others.
A therapist sympathetic with the Millon approach might attempt to help the his-
trionic person turn more toward the self, to look inward, pause, and reflect on what
is happening intrapsychically. Perpetuating tendencies, by definition, contribute to
the long-standing patterns of maladaption seen in the personality disorders. For
this reason, interventions aimed at altering perpetuating tendencies are classed,
along with balancing polarities, as strategies aimed at broad, long-term objectives.

DOMAINS

Millon (1990; Millon & Davis, 1996) maintained that an integrative theory must
consider multiple spheres or domains of personality (described in detail in other ar-
ticles in this series). Based on a review of the research literature, Millon delineated
eight major domains of personality. Specifically, a Millonian therapist would re-
view the clinical data, including available assessment instruments, for indications
of deficiencies in one or more of the eight functional or structural domains. Se-
lected domains are targeted for specific tactical interventions at the individual ses-
sion level. To illustrate, borderline patients tend to be highly deficient in the
interpersonal domain. Described as interpersonally paradoxical, they need atten-
tion and affection, yet they tend to be unpredictable, contrary, manipulative, and
volatile. Thus, they may elicit rejection rather than support. Given this dynamic, in-
terpersonal therapeutic approaches such as those of Benjamin (1993) might be em-
ployed. Specifically, there would be an emphasis on the development of a strong
alliance. Next, the patient would be encouraged to examine and recognize these

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maladaptive interpersonal patterns. Role play, discussion, teaching, and modeling

are techniques that might be used to help the patient understand these maladaptive
interpersonal patterns. The therapist may step into the role of coach, supporting
healthy life choices and severing maladaptive relationships.
The morphologic organization of the borderline person is split. Inner structures
are sharply segmented and conflictual. There is a marked lack of consistency or
congruity leading to limited psychic order and cohesion. Nonintegrated emotional
functioning and eitheror thinking are present. Cognitive therapy may be em-
ployed to address the pervasive splits. The patient may be asked to critically reas-
sess assumptions and cherished beliefs that underlie the persisting splitting
defense. The tendency to lump ideas and people into categories may be chal-
lenged. For example, the patient who sorts others into dichotomous classes such as
trustworthy versus untrustworthy may be helped to understand that there are de-
grees of trustworthiness within multiple social conditions. Matters of gradation
and degree would be emphasized over sharp dichotomies.
The borderline is also deficient in the self-image domain. The self-image is de-
scribed as uncertain. Identity is nebulous and wavering. There may be an inner
sense of emptiness. The individual may present with an as-if quality or with sev-
eral selves, often misperceived as dissociative identity disorder. The interven-
tions summarized earlier may contribute to a more stable sense of identity by
fostering a greater sense of emotional and behavioral control. The self-image may
be further stabilized by the therapists control of countertransference. Specifically,
the histories of borderline patients are often littered with the bones of shattered re-
lationships. Self-image naturally suffers as a result. When the therapist under-
stands the personal dynamics of the borderline patient, it is easier to control the
potential negative countertransference reactions, allowing the therapist to control
the session and to be compassionately available. In this safe holding environment
in which the borderline patients interpersonal antics cannot disrupt the relation-
ship, the patient can develop a healthier self-image, or at least a self-image that is
not damaged or loathsome.
To summarize thus far, Millons approach to treatment is both strategic (broad/
long-term) and tactical (immediate/within session) in nature. The personologic
therapist engages in broad, strategic interventions that seek to realign imbalances
in polarities and to counter perpetuating tendencies as well as session-based tacti-
cal interventions that target deficiencies in specific domains.

SELECTING TACTICAL MODALITIES

It must be emphasized that Millons personologic psychotherapy is not yet another

school of psychotherapy. Rather, it is a psychological and philosophical model
that allows the thoughtful integrationist to conceptualize the assessment and treat-
ment of individuals and utilize this conceptualization as a guide in drawing on a

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 PSYCHOTHERAPY WITH PERSONALITY DISORDERS 413

wide array of therapeutic modalities from which to mount the treatment plan. The
model is inclusive rather than exclusive. However, unlike eclecticism, which can
be disorganized and haphazard, Millons personologic therapy provides a theory of
psychopathology and a method for directing deliberate interventions that are logi-
cally derived from the model. It affords the clinician a matrix for planfully building
a treatment plan based on logic and thoughtful assessment of the patients needs,
deficiencies, and tendencies. Tactical modalities may be chosen from the array of
therapeutic techniques available to all therapists. The point is that therapeutic inter-
ventions are selected based on careful conceptualization of the case. Tactical mo-
dalities are chosen according to their potential relevance to treating deficiencies
within each of the domains.
Consider, for example, the behavioral realm. The behavioral construct includes
both concrete and observable actions. One of the behavioral domains is expressive
acts. Expressive acts may be generally thought of as the operant and respondent
repertoire of the person. The expressive domain encompasses the observable as-
pects of physical and verbal behavior including what a person actually does and
says. When working with problems within this domain, it is obvious that tech-
niques drawn from behavior therapy would be employed. We may be reminded
that Millon considered his initial conceptualization to be a variant of social learn-
ing theory (biosocial-learning theory), and it is not surprising that he would be
sympathetic to the behavioral approaches to therapy in the behavioral realm. Even
in its contemporary form, the Millon conceptualization asks where the patient
seeks reinforcement (self or other) and in what manner reinforcement is sought
(active or passive). Working within the Millon point of view, Donat (1995) de-
scribed the varieties of behavioral interventions that may be employed when work-
ing within the Millon system. Respondent (classical) conditioning techniques may
be chosen to deal with emotion-based conditioning problems such as social phobia
and generalized anxiety disorders. Operant forms of behavioral therapy may be
employed, particularly when it is essential that the expressive acts of the patient
are harmful to self or others. Of special relevance are the self-management proce-
dures. The therapist may employ self-monitoring procedures, examine self-state-
ments associated with the problem behavior, or identify subjective units of distress
for interventions.
The other behavioral domain is interpersonal conduct. Interpersonal behavior
has expressive significance in social interaction. Deficiencies in the interpersonal
realm are typically remediated with interpersonal therapies. Millon favors the
work of Kiesler (1986) and Benjamin (1993). To the interpersonal therapist, the
problems of individuals reside in their current transactions with significant others.
When interpersonal interactions are fraught with misperceptions, poor communi-
cation, failing to attend, and other unsuccessful interchanges, self-defeating mal-
adaptation takes place. Interpersonal therapy focuses on the patients habitual
interactive and hierarchical roles in the social system that perpetuate the pathol-

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ogy. Millon noted that interpersonal therapy broadens the scope of the therapy
from the individual to the system in which the individual is functioning.
Millon also emphasized the role that group therapy can play in treating difficul-
ties in the interpersonal domain. By its very nature, group psychotherapy provides
a forum for dealing with interpersonal issues in an emotionally charged atmo-
sphere. Maladaptive interpersonal strategies become quickly apparent and may be
handled within the context of the group. Craig (1995) presented a concise review
of the use of interpersonal therapy within the Millon approach. Craig advocated a
time-limited approach. The patient usually knows in advance how much time will
be devoted to the therapy. Interpersonal therapy is focused and stream of con-
sciousness process therapy is not done. Interpersonal therapy concentrates on the
present, not on the past, and centers on interpersonal relationships in the here and
now. Various techniques include advice giving, suggestion, setting limits, educa-
tion, and direct help.
Domains falling within the phenomenological realm consist of cognitive style,
self-image, and object relations. Cognitive therapy techniques are favored when
addressing deficiencies in cognitive style. According to Will (1995), Stoic philos-
ophy was the earliest precursor of contemporary cognitive therapy. The basic as-
sumption is that one can change ones emotions by changing ones cognitions.
Millon noted the cognitive therapy tactics of Beck and Freeman (1990). Cognitive
therapy examines the patients schemas, specific rules that govern information
processing and behavior. Schemas may be classified into a number of categories
such as personal, cultural, and family. Patients are helped to focus on automatic
thoughts and their contribution to emotions. Patients are also encouraged to assess
their cognitions and are given ways to challenge them when appropriate. Assump-
tions are examined, sequences of thoughts are reviewed, and strategies to correct
maladaptive cognitive styles are mounted. Will (1995) outlined the theoretical as-
sumptions cognitive therapy makes about human behavior and how it can be con-
ducted within the context of the Millon point of view. He described how
maladaptive functioning in the cognitive domain is approached by demonstrating
the link between thoughts and emotions.
Deficient object relations result from inaccurate, vacillating, or sterile inter-
nalized representations of others. A contemporary psychoanalytic model, object
relations theory represents the nexus of selected tenets of classical psychoanaly-
sisHartmanns (1939/1958) concept of the conflict-free portion of ego, social
concepts from Sullivanian (1953) theory, elements of developmental theory, and
existential and humanistic thought (Dorr & Woodhall, 1986). Millon cited Green-
berg and Mitchell (1983) as proponents of object relation therapy. I would add
that the works of Mahler, Pine, and Bergman (1975), Kernberg (1985), and Mas-
terson (1976) are especially helpful to the therapist working with object relations
difficulties. Van Denberg (1995) described an approach to treating deficient ob-
ject relations within the context of Millons theory. He emphasized the use of

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 PSYCHOTHERAPY WITH PERSONALITY DISORDERS 415

transference interpretations, describing how the patient relives old conflicts,

placing the therapist into roles from the past. The clinician must be sensitive to
these subtle projections and resist the patients attempts to replay past conflicts
while remaining libidinally available. A major focus of the therapy is to counter
the patients tendency to reestablish and, thus, reexperience pathological object
relations. If therapist and patient are successful, the patient will come to develop
new and healthier relationships with significant others.
With regard to approaches to difficulties with self-image, Millon employed the
work of self-image therapists ranging from the early European existentialists to the
reality therapy of Glasser (1965). As understood by Millon, the aim of self-image
therapists is to free patients to develop a more realistic and favorable self-image.
Millon also cited the work of Rogers (1967) in which unconditional positive re-
gard helps the patient to develop a nonjudgmental self-view. Drawing on the work
of Kohut (1971, 1977), McCann (1995) outlined a means of treating self-image
within a Millonian perspective. Kohut viewed the self as a stable structure that lies
at the center of all psychological experiences, providing the individual with a sense
of selfhood. A Kohutian approach emphasizes empathic attunement to the pa-
tients experiences of self. The major role of the therapist working with self-image
deficiencies is to understand and to explain. The therapists compassionate empa-
thy for the patients wound helps the patient to feel understood, respected, and ac-
cepted. This permits healthy growth of the sense of self. Explanation can be in the
form of interpretation in which the meaning of certain themes or conflicts is
brought to light for the patient. A second method of explanation is enactment, in
which a patients unconscious conflicts are expressed in a particular interpersonal
context.
The intrapsychic realm consists of two domains, regulatory mechanisms and
morphologic organization. Regulatory mechanisms are strategies of self-defense,
self-protection, need gratification, and conflict resolution. They represent impor-
tant internal processes that may serve to organize all other functional domains in
some form of unobservable, self-protective strategy. Kubacki and Smith (1995)
reviewed approaches to treating defective ego defenses in a manner that is consis-
tent with Millons perspective. They employed contemporary psychoanalytic con-
cepts and methods. After attuning contemporary psychoanalytic taxonomies with
the Millon categorization, they ordered defensive strategies by psychostructural
level. (The reader may wish to consult Stone, 1980, for a discussion of psycho-
structural levels.) At the psychotic level of personality organization, defenses are
archaic, without boundaries, and primitive. Defenses are mounted primarily to
avert total disintegration and loss of self. Treatment at this level focuses almost en-
tirely on the lack of a validated self. At the prepsychotic to borderline levels, de-
fensive strategies are also primitive and include splitting, primitive denial,
primitive idealization, and omnipotence. These patients are very difficult to work
with because of the pervasiveness of the splitting and the potential for projective

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identification to pull the therapist into a destructive countertransference. The pri-

mary means of dealing with these matters is to control the countertransference as
carefully as possible. In so doing, the therapist resists being caught up in the more
destructive defensive strategies, such as projective identification, while remaining
compassionately available to the patient. Confrontation and clarification may some-
times help the patient work toward some degree of internalization. Of course, one
always works to promote higher level defenses through avenues such as activity
therapy when it is available. At the neurotic level, the therapist is freer to use
higher levels of confrontation and interpretation. The neurotic is better able to tol-
erate interpretation of resistances and to access unconscious material to work it
through.
Morphologic organization (structure) is the architecture that serves as a scaf-
folding or framework of an individuals psychic interior. Millon suggested the use
of intrapsychic therapy for intervention at the morphologic level. Intrapsychic
therapy focuses on internal mediating processes and structures that presumably
underlie and give rise to overt behavior. Intrapsychic therapists seek to help recon-
struct the patients personality. Dorr (1995) described how psychoanalytic psy-
chotherapy addresses morphologic deficits in various personality disorders. This
work draws heavily on contemporary analytic thinking and techniques drawn from
object relations theory. Specific techniques such as clarification and confrontation
are suggested. However, Dorr placed special emphasis on relatedness and the role
of transference and countertransference in the therapy. Because of the fragile
structure of personalities of patients with personality disorder, they do not have a
healthy internalized sense of self or rich, enduring internalized representations of
significant others. As a result, their interpersonal relations are usually tumultuous,
destructive caricatures of mature relatedness. This view holds that healthy struc-
ture is built through healthy relatedness. A major factor that perpetuates the defi-
cient or fragile structure is continued pathological interactions with significant
others. Further, in treatment, pathological transference reactions may develop with
the patients own therapist, which may foment destructive countertransference re-
actions in the therapist, thus perpetuating the structural pathology in the patient. If,
on the other hand, the therapist carefully controls the countertransference reaction
while maintaining a compassionate holding environment, the patient no longer has
the opportunity to play out unhealthy relatedness. Because of the emotional avail-
ability of the therapist, healthy relatedness is experienced, perhaps for the first
time, and morphological structure strengthens.
Finally we come to the biophysical realm with its single domain, moodtem-
perament. Characterological mood suffuses virtually every aspect of an individ-
uals existence. It colors all experiences and relationships. Two domain-specific
interventions are discussed. First is the practice of using medication. A Millonian
therapist would not likely be opposed to referring a patient for a medical consulta-
tion if it is believed that medication might be useful to the patient. However, medi-

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 PSYCHOTHERAPY WITH PERSONALITY DISORDERS 417

cations are usually not terribly helpful in treating the personality disorders
themselves, but are primarily useful with Axis I disorders. If a medication were
used, a Millonian therapist would be especially interested in the patients psycho-
logical response to the changes brought about by the medication. Of cardinal inter-
est would be the meaning the patient makes of the changes brought about by the
medication. Although a given medication may produce the same biological effect
in all patients, the psychological impact of the medication is more important to the
psychotherapy. For example, one depressed patient may respond well to an antide-
pressant and utilize the renewed psychic energy to tackle and overcome the endur-
ing problems that led to the depression in the first place. Another might respond
physiologically to the medication in a similar way, yet believe that the therapeutic
effect is artificial and feel guilty that the therapeutic effect was not based on psy-
chological work. To Millon, the determinant of the effectiveness of a medication is
not its chemical effect, but rather, the psychological significance of the effect.
Another approach to intervention in the moodtemperament domain was articu-
lated by Hyer, Brandsma, and Shealy (1995), who described the use of experiential
therapies in treating pervasive moodtemperament difficulties. They described ex-
periential therapies as a broad array of techniques ranging from Gestalt to client cen-
tered to types of psychoanalytic approaches and so on. Affect is considered to be
primary, and experiential therapy helps the patient to focus attention on the target
feeling, to symbolize the experience, and to consolidate new meanings that grow out
of the experience. Affect contributes to the unfolding of the process. In the authors
view, the change process consists of many small steps in which events are
reexperienced emotionally in the here and now, resulting in meaning shifts. Experi-
ential therapy seeks to help the patient go through a corrective emotional experience
that allows the psychological structure to change in a healthy direction.

POTENTIATED PAIRINGS AND

CATALYTIC SEQUENCES

Millons therapeutic system also employs potentiated pairings and catalytic se-
quences to mount a therapeutic program. Potentiated pairings occur when the ther-
apist combines two or more therapeutic procedures simultaneously to overcome
problematic characteristics or resistances that might compromise a single ap-
proach. Potentiated pairings are selected in a manner that is logically consistent
with the theoretical conceptualization of the patients problems.
Catalytic sequences utilize multiple treatment modalities in succession. These
are procedures in which serial treatments are applied in an order designed to have
the most impact. There are no discrete boundaries between potentiated pairings
and catalytic sequences. The expectation is that interventions in tandem or se-
quence will contribute to therapeutic synergy, thus increasing the effect size. The

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action of combining interventions is especially important with the personality dis-

orders because of their notorious resistance to treatment. To illustrate the use of
potentiated pairings and catalytic sequences, let us return to the example of the his-
trionic patient in whom we have polarity imbalance and perpetuating tendencies
that interfere with growth. A first step might be to help the patient control
hyperemotionality because it leads to a sense of being overwrought or out of con-
trol. The therapist may teach the relaxation response, encourage the patient to
stay in the present, instruct the patient in self-soothing exercises, or engage in
any other intervention that will help the person feel in control of strong emotion.
This intervention may be accompanied or followed by cognitive cause-and-effect
reasoning, interchanges that may further encourage the calm, thoughtful process-
ing of information. The development of clear thinking skills may set the stage for
longer term exploratory therapy. If depression is present, a referral to a physician
for a medication consultation may be made. As the initial crisis settles, the thera-
peutic relationship becomes especially important in keeping the patient in treat-
ment to get on with the work and in using the therapeutic process to help the patient
develop a deeper, healthy relationship with the therapist. This, in turn, may pro-
vide a foundation for healthier, more sustained relationships with significant oth-
ers. Family or couples therapy may help to repair and strengthen relationships.
Group therapy with persons having similar problems may provide opportunities to
see histrionic behavior in others that patients may not readily see in themselves.
Finally, their own growing maturity may be recognized by the group, which may
be an especially powerful reinforcer for the patients.

COMMON FACTORS, TECHNIQUES, AND

THERAPIST VARIABLES

Millons conceptualization is mindful of the common factors in psychotherapy

(Garfield, 1995). Millon viewed the common factors approach as a useful gauge by
which to estimate the incremental efficacy achieved by theoretically integrative ef-
forts. Because they represent distillations of the active ingredients of therapy, the
common factors may represent the lowest common denominator of therapy. To
Millon, they, at best, constitute the minimum of what good therapy should be. The
common factors approach does not represent the maximum of what good therapy
might achieve.
Millon is cognizant that technique accounts for only about 15% of the outcome
variance in psychotherapy research. On the other hand, he is less than enthusiastic
about the common factors because, like eclecticism, the common factors approach
is insufficiently theoretical. Millon described the common factors as a necessary
but not sufficient basis for a scientific psychotherapy. He pointed out that even if
the common factors were more clearly delineated, it would be difficult to articulate
the underlying mechanisms mediating their efficacy.

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 PSYCHOTHERAPY WITH PERSONALITY DISORDERS 419

As to technique, as Millon conceptualized his approach to therapy, it is unlikely

that any legitimate therapeutic technique would be summarily excluded from a
personologic therapy plan. However, the clinician would be closely questioned as
to why a particular intervention was chosen for a particular client, why the inter-
vention was selected at a particular time in the therapy, and what the strategic or
tactical goals and objectives might be for the intervention. Millons conceptualiza-
tion does not present a tight description of a rigid orthodox approach to each per-
sonality disorder. Rather, there is an attempt to address the therapeutic issues
raised in a manner that is logically consistent with the conceptualizations of the
personality disorders as articulated within the model of personologic therapy.
Millon has little to say about the personality of the psychotherapist. However,
considering the research (Lambert & Bergin, 1994) that identifies considerable in-
dividual differences in effectiveness across therapistseven when training was
manualizedsome discussion of therapist variables may be useful. It is reason-
able to conclude that the personologic psychotherapist must possess a broad view
of personality, and for that matter, psychology itself. There is little room for
dogma in Millons system. Because people are so complex, theoretical conceptu-
alizations (and therapists) must respect this complexity. Interventions must flow
logically from broad and rich formulations of the person. Rigid adherence to a par-
ticular conceptualization of psychopathology or to a particular technique would
not allow the therapist to access the entire scope of the change process that might
be utilized with a specific patient. In short, a personologic therapist would likely be
high on the characteristic of openness and low on authoritarianism.

TREATMENT PLANNING: AN EXAMPLE

The Millon system insists that the choice of therapeutic interventions flows directly
out of the overall theoretical conceptualization of the patient. Consider the case of
the antisocial personality. The therapeutic strategies and tactics employed by the
Millon system are summarized in Table 1. The matter of goals is clear. In designing
a treatment plan for the antisocial, as for all patients, the clinician should maintain a
balance between the overall conceptualization of the person (strategies) and more
specific session-based aims (tactics). Viewing the antisocial person as one in whom
there is a serious imbalance among the great polarities of life, the personologic ther-
apist would seek to establish some reasonable equivalence between the unbalanced
polarities.
Personologic theory conceptualizes the antisocial as weak on the preservation,
accommodation, and nurturance polarities; average on the enhancement polarity;
and strong on the individuating and modifying polarities. Accordingly, the thera-
pist would use a strategy that attempts to reduce the patients almost exclusive em-
phasis on the self by encouraging him or her to develop a stronger awareness of

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TABLE 1
Therapeutic Strategies and Tactics for the Prototypical Antisocial Patient

Strategic goals
Balance polarities
Shift focus more to needs of others
Reduce impulsive acting out
Counter perpetuating tendencies
Reduce tendency to be provocative
View cooperation and affection positively
Reduce expectancy of degradation
Tactical modalities
Offset heedless, shortsighted behavior
Motivate interpersonally responsible conduct
Alter deviant cognitions

others who are separate human beings, who have value, and who are in possession
of rights. In time, the patient may gain an increased sensitivity to the needs and
feelings of others as well. The overly active style of extracting rewards by exploit-
ing others would be confronted. The value of flexible accommodation of others
would be taught. The therapist may appeal, if necessary, to the patients prideful
self-interest by pointing out that his or her needs could be fulfilled faster and easier
if these new attitudes were adopted.
The antisocial is weak on the life-preserving polarity of the survival aims. This
weakness may have resulted in physical injury as well as financial and social
losses. With this characteristic in mind, the therapist would teach the patient the
survival value of moderating this behavior to avoid unnecessary loss.
Another strategic goal that emerges from the conceptualization of the patient
would be to counter perpetuating tendencies. In the antisocial, the potential for
perpetuating tendencies to cause difficulty is enormous. The pathological ele-
ments of the antisocial disorder itself perpetuate its continuance. The antisocial
person perceives others as dangerous and untrustworthy and treats them as such.
This behavior provokes like-mindedness in others and evokes their aggressive be-
havior. The result is that the patients perception of others as dangerous is continu-
ally reinforced, perpetuating the maladaptive behavior.
A related perpetuating tendency is often the antisocials protective attitude of
anger and resentment. It should be pointed out that this very attitude is the agent
provoking the response from others that the patient is so quick to defend against.
Equally, it should be pointed out, like the flip side of a coin, that nondefensive,
prosocial behavior will likely elicit from others a nondefensive prosocial behavior.
At the more immediate tactical level, specific deficiencies in selected domains of
personality functioning would be targeted for work during the session. In the antiso-
cials profile, the primary domain dysfunctions are expressive acts, interpersonal
conduct, and regulatory mechanisms. For example, in the expressive acts domain,

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 PSYCHOTHERAPY WITH PERSONALITY DISORDERS 421

the antisocial is described as impetuous, irresponsible, and acting hastily and spon-
taneously in a restless, spur-of-the-moment manner. He or she can be counted on to
be short-sighted, incautious, and imprudent. The antisocial person often fails to plan
ahead, consider alternatives, or heed consequences. It would not be unacceptable to
the personologic therapist to utilize external forces to help control the antisocials
impetuosity, irresponsibility, and restlessness. Legal or domestic restraints may ex-
ert external controls that would help consequate and confine these expressive ten-
dencies. Various limit-setting tactics might be employed as well as cognitive
approaches that would help the patient reframe the short-sighted, imprudent tenden-
cies that cause such difficulty. It might benefit the antisocial patient to appraise the
thought processes underlying behavior and the manner in which these lead to nega-
tive consequences.
The interpersonal domain is another area of deficiency. Interpersonally, the an-
tisocial is untrustworthy; unreliable; and unable to meet personal obligations of a
marital, parental, occupational, or financial nature. Antisocial persons actively in-
trude on and violate the rights of others. They transgress established social codes
through deceitful or illicit behavior. Personologic therapy enlists the help of inter-
personal therapy to remediate deficiencies in the interpersonal realm. Benjamin
(1993) assumed that antisocials have not had a social learning history character-
ized by warm, nurturing caregivers that might have led to reciprocal warmth and
attachment. The interpersonal therapist counters these tendencies with modulated
warmth in an attempt to overcome socialization deficits. Great care, however,
should be taken not to allow the patient to believe that warmth equates with weak-
ness, as the antisocial will be quick to attempt to exploit the perceived weakness,
thus sabotaging the therapy.
The regulatory mechanisms domain is also deficient in the antisocial. The pri-
mary regulatory mechanism of the antisocial is acting out. The antisocial is rarely
constrained. Socially odious impulses are not refashioned in sublimated forms. In-
stead, they are discharged directly and hastily, usually without guilt or remorse. In
psychodynamic terms, the regulatory mechanisms of the antisocial are like primi-
tive defenses such as acting out, projection, splitting, and primitive denial. The
personologic therapist might employ cognitive interventions as described by Beck
and Freeman (1990) in addressing these deficiencies. The therapist may attempt to
help the patient understand that getting even is not synonymous with getting
ahead. The therapist may confront the antisocial person with the futility of the
talon principle. That is, the patient may be asked if he or she wants to get even or
get better. The antisocial person may be taught that long-term gain may be ac-
quired by binding frustration and using it as a source of energy to attain success. A
tactical goal would be to help the patient understand that acting out may provide
short-lived advantage (e.g., To get the offending guy off your back!), yet this
style has caused untold travail in the long run. I add that the goals could be de-
scribed as fostering prosocial thinking and behavior, reducing criminal thinking

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422 DORR

while increasing prosocial thinking, enhancing empathy, generating control over

drives and affect, and promoting postponement of gratification.

CONCLUSIONS

This article briefly summarized some of the ways in which Millons model based
on theory, taxonomy, and instrumentation directly impacts the process of planning
and implementing psychotherapy with the personality disorders. Therapeutic inter-
ventions flow logically and easily from the assessment process that is guided by the
theory. The clinician may choose from the broad array of approaches available to
any therapist, but the selection process is guided by the overall conceptualization
and assessment of the personality and psychopathology of the patient.
In a clinical science, the primary purpose of taxonomy or assessment is to help
clarify the nature of the patients difficulties so that the therapist can be more effi-
cient and effective in formulating and implementing interventions. Most good cli-
nicians probably perform this task more or less naturally. However, Millon would
argue that the process of clinically integrating assessment information and treat-
ment planning still tends to be haphazard. At the least, the process is not formal-
ized and orderly; thus, it is not as amenable to empirical examination as it might be.
Millon called for a more formal and purposive examination of the manner in which
the clinician integrates assessment data with treatment planning.
Millon proposed a broad design for more efficiently linking treatment planning
to assessment results. His model is extremely ambitious. We may ask if our clini-
cal science is ready to move on to a more accurate articulation of exactly how our
assessment findings logically guide treatment planning and implementation.
Millon offered an approach that is at once straightforward and complex. It is ame-
nable to empirical assessment. At issue is not whether the model fits standard sta-
tistical models perfectly. Rather, the question is whether this model instructs and
guides the clinician in the process of assessment and treatment. The endpoint of a
clinical science is successful treatment. If it is found through research and practice
that Millons taxonomy guides the choice of appropriate treatment modalities, the
effort will have been a success. The hope is that his conceptualizations will stimu-
late clinical research toward exactly these questions.
The work of Millon and his coworkers is so extensive and thorough that is
tempting to view it as complete. This would violate Millons purpose. His intent is
to stimulate new theoretical and empirical approaches to the problems and issues
facing our clinical science. Although a large number of projects might be pursued
in the future, only four are summarized herein.
First, although Millon-inspired instruments are widely accepted, Millon (Millon
& Davis, 1996) himself called for further work on instrumentation. For example, he
pointed out that no dimensional assessment that examines merely scale elevation is

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 PSYCHOTHERAPY WITH PERSONALITY DISORDERS 423

adequate to answer questions about the shaky stability, inflexible adaptations, and
vicious circles of personality pathology. Instrumentation in the future may be in-
creasingly sensitive to the contexts in which individuals function. We may work to-
ward developing entire systems of instrumentation.
A second form of future investigation may focus on advancing the philosophy
of science. A small number of investigators have called for a new subdiscipline of
theoretical psychology (Slife & Williams, 1997). They argue that theoretical activ-
ity in psychology is fragmented, that we cannot separate method from theory, and
that science is a theory among theories about how one evaluates theories. A formal
theoretical psychology could inform and guide researchers as to the types of explo-
ration and methods that are being employed and to determine whether these ap-
proaches are appropriate to the assumptions being made.
A third area of future investigation is the interaction among the individuals
personal systems and the social and contextual systems in which that person at-
tempts to function. Homeostasis does its work within persons and within the per-
sons social systems. When, during treatment with personologic therapy, a patient
begins to improve, the larger system in which the person is attempting to function
is likely to react, usually negatively, with attempts to reestablish homeostasis.
Thus, there is much more work to be done in assessing the ecological context in
which individual change is to take place.
I add a final note of special interest to me. Freud (1905/1993) said diseases are
not cured by the drug but by the personality of the physician (p. 259). As noted
earlier, the Millon system has little to say about the personality of the therapist. Yet
in my years of clinical experience in working with severe personality disorders, the
personality of the therapist is of utmost importance in effecting a positive response
to treatment. It would seem that a treatment system that places so much emphasis
on careful assessment of the recipient of treatment would also thoroughly examine
the personal attributes of the person performing the treatment. I hope that future re-
search will examine the role of the psychotherapists own personal characteristics
as these relate to common factors, the establishment of the therapeutic alliance,
and the role of instilling hope and expectancy in the patient.

ACKNOWLEDGMENT

I would like to thank Stephanie Tilden Dorr for her editorial assistance in preparing
this article.

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Darwin Dorr
Department of Psychology
Wichita State University
Wichita, KS 672600034

Received January 18, 1999

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