personality disorder attributes as supplemental goals for change in interpersonal psychotherapy

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Journal of Contemporary Psychotherapy [jcp] ph187-jocp-462382 February 27, 2003 14:35 Style file version Nov 28th, 2002

Journal of Contemporary Psychotherapy, Vol. 33, No. 2, Summer 2003 (C© 2003)

Personality Disorder Attributes as SupplementalGoals for Change in Interpersonal Psychotherapy

Jason A. McCray and Alan R. King

Interpersonal Psychotherapy (IPT) is a manualized, short-term (usually12–16 sessions) based on the assumption that psychological disorders often emergesecondary to social and interpersonal problems that require active intervention toachieve symptom remission. The time-limited nature of IPT compels therapists toestablish the goal of diminishing, on a weekly basis, a small number of focusedinterpersonal problems with a decided emphasis on proximal rather than historicconflicts and associated patterns of behavior. This strategy discourages the adop-tion of diffuse therapy goals and directions that have more opportunity to emergein long-term, unstructured treatment modalities. The role of traditional personalitytesting in short-term therapy, when it occurs, is to identify and quantify symptomclusters that warrant attention as dependent measures in the treatment process.The role of personality factors in the genesis or maintenance of psychologicaldisturbance is rarely addressed. The present article explores theoretical and prag-matic objections to the use of personality testing in IPT. A method is proposedfor the limited but systematic incorporation of personality testing in the IPT treat-ment process using the Millon Clinical Multiaxial Inventory (MCMI-III). Whileunreasonable to expect personality transformation through short-term therapy,the partial attenuation of maladaptive behavioral, attitudinal, and emotional re-actions to stressors could prove exceedingly helpful to short-term treatments suchas IPT.

KEY WORDS: Interpersonal Psychotherapy; IPT; Millon Clinical Multiaxial Inventory; MCMI-III;Axis II comorbidity; short-term psychotherapy.

Interpersonal Psychotherapy (IPT) is a manualized, time-limited treatmentapproach that focuses primarily on the interpersonal contexts that contribute tothe development and maintenance of psychological disturbance. IPT (Klerman &

1Address correspondence to Alan R. King, Psychology Department, University of North Dakota, P.O.Box 8380, Grand Forks, ND 58202-8380; e-mail: [email protected].

79

0022-0116/03/0600-0079/0C© 2003 Human Sciences Press, Inc.

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80 McCray and King

Weissman, 1979, 1984) practitioners assume that psychological disorders oftenemerge as maladaptive responses to interpersonal stressors that require identifi-cation and active intervention to achieve symptom remission. The social contextis thought to play a vital role in the genesis and maintenance of the presentingpsychological symptoms.

IPT is structured to partially resolve problems associated with interpersonaldisputes, role transitions, complicated bereavement, and broader social skillsdeficits. The time-limited nature of IPT (usually 12–16 sessions) compels ther-apists to focus on salient social stressors that maintain the identified symptoms.The objective of therapy is to diminish, on a weekly basis, this small numberof focused interpersonal problems as a method of attenuating distress and im-pairment. Similr to other short-term therapies, IPT attempts to provide practicalalternative coping strategies with a decided emphasis on proximal rather than his-toric conflicts and associated patterns of behavior. This strategy discourages theadoption of diffuse therapy goals and directions that have more opportunity toemerge in long-term unstructured treatment modalities. Nonetheless, personalityvariables can be conceptualized as underlying mechanisms within this frameworkthat serve to trigger, maintain, or magnify the interpersonal problems that mediateAxis I symptom expression. While personality disorders may be inappropriate forprimary intervention through IPT, relevant individual traits within these constel-lations may sometimes serve as important supplemental target(s) for short termintervention that attempts to alter interpersonal problems that produce Axis I symp-toms. Some readers may prefer to use the term “moderator” rather than target formore generalized features where the expectancy of change will be less complete.We will use the terms target and moderator interchangeably for purposes of ourdescription of this new procedure.

IPT has accrued considerable empirical support over the past twenty years.Randomized, controlled trials have supported the utility of IPT for the treat-ment of depression (Elkin et al., 1995), postpartum depression (Klier, Muzik,Rosenblum, & Lenz, 2001; Stuart & O’Hara, 1995), dysthymia (deMello,Myczowisk, & Menezes, 2001; Weissman & Markowitz, 1994), marital disputes(Foley et al., 1989) obesity (Rouch, Sztulman, Sanguifnol, & Ruffie, 2001), andbulimia nervosa (Fairburn, Jones, Peveler, Hope, & O’Connor, 1993). Empiricalsupport for this popular therapy modality also extends to group intervention (Klier,Muzik, Rosenblum, & Lenz, 2001) and the treatment of adolescents (Mellin &Beamish 2002), older adults (Reynolds et al., 1999), and Puerto Rican Americans(Rossello & Bernal 1999).

The role of traditional personality assessment in contemporary manualized,short-term therapies has not been established. IPT and CBT treatment protocolsidentify a range of assessment instruments that are recommended for use in thediagnostic phase of treatment. The purpose of psychological testing, when it oc-curs, is to identify and quantify symptom clusters that warrant attention as de-pendent measures in the intervention process. The role of personality factors in

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IPT Supplemental Personality Targets 81

the genesis of psychological disturbance has rarely been addressed in empirically-supported, short-term, manualized treatment protocols. In fact, theorists have evencautioned against the incorporation of personality dynamics into the IPT process.Markowitz (1998) warned interpersonal psychotherapists not to confuse trait andstate mood symptoms while emphasizing that IPT “eschews claims to characterchange” because of the acknowledged “limitations of any brief therapy to alterlong-established” personality qualities. Indeed, Weissman and Markowtiz (1994)partially defined IPT by its focus on the immediate social context rather than theorigins of social problems or enduring aspects of personality. This contemporaryfocus appears to preempt consideration of the generalized cognitive, behavioraland emotional response tendencies that often contribute to the development andmaintenance of current interpersonal difficulties.

The appeal of IPT appears to have been broadened considerably by earlyefforts to distinguish this intervention from traditional, unstructured, insight-oriented, long-term treatments. The exclusion of “personality” targets in the ap-plication of IPT further affirmed its status as a progressive approach dissociatedfrom analytic assumptions about the importance of distal motives in initiating andmaintaining contemporary psychological functioning. Conversely, the concept ofthe “schema” goes largely unquestioned in the CBT literature. Schemes have beendescribed as cognitive structures of beliefs and rules that organize experience anddirect behavior, affect, and cognition, including automatic thoughts (Beck et al.,1990). Personality disorder concepts may gain wider acceptance with definitionsthat focus on their maladaptive consequences rather than developmental originsand purposes.

Has IPT been artificially limited by its defining features? How does thetreatment presently differ for clients who present with Axis II features that arepronounced and consequential? While unreasonable to expect personality trans-formation through short-term therapy, has the futility of trait modifications assupplemental treatment goals been empirically established? The effectiveness andbenefits of efforts to achieve modest personality change have not been systemat-ically investigated. This disillusionment with the value of personality concepts incontemporary psychotherapies is a curious development given the historic valueattached to psychometric testing in clinical assessment (Einhorn & Hogarth, 1978;Leli & Filskov, 1984; Wedding & Faust, 1989; Wilson, 1996, 1997; Derkson &Stoore, 1999).

Personality disorders are primarily manifested in persistent interpersonaldisputes, social skills deficits, and difficulties adapting smoothly to role transi-tions or personal losses. The nexus between these response tendencies and so-cial problems which produce and maintain psychological disorders would seemself-evident for at least a subset of clients. A method to efficiently assess andincorporate personality features into the course of IPT has been regrettably ab-sent from the literature. The differential success of IPT among clients with andwithout Axis II comorbidity has also been left largely unexplored. The testing of

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82 McCray and King

supplemental components to the IPT protocol should occur as a natural evolutionof this empirically-supported treatment. The external validity of efficacy researchthat relies on restrictive “purified” treatment samples has raised concerns (Garfield,1996), and community practitioners have not always found outcome research tobe of practical value (Morrow-Bradley & Elliot, 1986; Mussell et al., 1999).Applied research which describes and evaluates methods to systematically tar-get and integrate complicated comorbid Axis II features into practical short-termtreatments may be well-received.

PERSONALITY ATTRIBUTE SELECTION PROCESS

Traditional IPT can be easily modified to assess and, where appropriate, tar-get one or more prominent personality disorder features for modest change. Theusual course of IPT would be followed using initial sessions for diagnostics andthe identification of major psychosocial stressors. As in other short-term thera-pies, IPT relies on didactic presentations and homework readings to assure thatthe client understands the principles of therapy, accepts personal responsibility forchange, and develops realistic expectations for the treatment outcome. The sched-uled administration of a major personality inventory such as the Millon ClinicalMultiaxial Inventory (MCMI-III: Millon, Millon, & Davis, 1994) prior to the thirdsession would represent the primary deviation from the traditional course. Theclient should be provided justification for the selection of the particular test inven-tory used in the assessment such as its value in the identification of personalityfeatures that may complicate or disrupt adaptive interpersonal functioning. Theclient should understand that it is usually, but not always, possible to incorporatetest results directly into the IPT treatment plan. A promise should be made to pro-vide formal test feedback at the beginning of the fourth session when an agreementwill be reached regarding the case formulation (causes of the problem) and therapyplan (treatment of the problem).

Rationale for the MCMI-III

The MCMI-III can make unique contributions to the IPT assessment andcase formulation process. This inventory appears ideal for the selection of specificpersonality moderators because of its extensive prior scale by scale concurrentempirical validation with meaningful clinical attributes (Millon et al., 1994). TheMCMI-III validation process required practitioners to describe clients in termsof a large number of observed behavioral, attitudinal, and emotional responsetendencies. These descriptions were provided without knowledge of the MCMI-III profile generated by the client. The profile panels of Table I detail the clin-ical attributes that were frequently associated with each scale elevation. TheseMCMI-III correlates represent response tendencies that will often mitigate against

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P1: IZO


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adaptive interpersonal functioning. MCMI-III results can thus be used to facil-itate the early identification of personality attributes that may contribute to themaintenance or exacerbation of presenting interpersonal difficulties. The role oftherapist inference, interpretation and confrontation in identifying maladaptiveclient attributes can be minimized through the use of these impersonal, or at leastless personal, test indicators. Clinical judgment can then be used to merely rein-force client efforts to identify the most relevant attribute(s) identified in the profilepanel. Client and therapist will not always find personality test results as to beuseful in treatment planning, but the administration and interpretation of an instru-ment such as the MCMI-III will assure the completion of a more comprehensiveevaluation process. The value of incorporating objective and interview data in clin-ical decision-making has been widely extolled (Derkson & Stoore, 1999; Wilson,1996; 1997; Wedding & Faust, 1989; Leli & Filskov, 1984; Einhorn & Hogarth,1978). Other major personality disorder inventories such as the NEO-PI (Costa& McCrae, 1992), MMPI-2 (Colligan, Morey, & Offord, 1994), Coolidge Axis IIInventory (CATI: Coolidge & Merwin, 1992), or Personality Assessment Inven-tory (PAI: Morey, 1991) may also warrant trials to determine their value in theidentification of supplemental IPT intervention targets.

Case Formulation

The fourth session represents an important juncture when the client is askedto commit to the full course of IPT. A working case formulation requires client andtherapist to mutually establish a small number of testable hypotheses regarding therelationship between the Axis I symptoms and specific interpersonal stressors in theform of disputes, deficits, role transitions, or bereavement. The process by whichinterpersonal treatment target(s) selection occurs has been described elsewhere(Klerman & Weissman, 1979, 1984), and the present article instead describes aprocess that potentially culminated in the inclusion of one or two supplementalpersonality moderators into the case formulation. The inclusion of supplementalpersonality moderators into IPT should be justified by evidence that the identifiedpenchant exacerbates the interpersonal problems that are thought to maintain thepresenting symptoms. Attenuation of the core Axis I symptoms would remain thecentral criterion of treatment success, but the inclusion of personality testing inIPT assessment would expand the potential personal and environmental variablesthat could be manipulated through treatment to achieve favorable change.

The results MCMI-III testing can be seamlessly incorporated into the IPTassessment and treatment planning. The therapist begins by again discussing thisparticular test inventory and its special value in the assessment of personality fea-tures or attributes that may serve to complicate and sometimes disrupt adaptiveinterpersonal functioning. The concept of personality should be defined as ten-dencies to respond to interpersonal stressors in particular ways. These behavioral,

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attitudinal, and emotional response tendencies or attributes have been correlatedwith scores on the 13 personality dimensions of the MCMI-III. It should be em-phasized that single test items have little independent meaning, and that the resultsidentify a list of personality attributes that are derived from the overall pattern of re-sponse. The limitations and fallibility of personality measures should be concededat the outset, with the client made comfortable to reject putative attributes thatare found unacceptable. Personality testing is utilized to facilitate and not disruptthe smooth progression of manualized IPT. Counterproductive debates over testfindings are to be avoided, and personality attribute moderators for interventionmust be found to be mutually and readily acceptable to warrant inclusion in thecase formulation.

Table I presents profile panels which detail the personality disorder attributesassociated with elevations on each of the MCMI-III personality disorder scales(Millon et al., 1994). It is recommended that the template be used for the personalitydisorder dimension that represents the highest base rate score exceeding 74. Theclient is presented with the profile panel of “personality attributes” associated withthe either the highest MCMI-III elevation generated from the testing or the profilemost likely to frustrate meaningful interpersonal relationships. The client is askedto read over and circle each attribute in the profile panel that accurately represents apersonal proclivity that warrants consideration for change. The therapist and clientthen revisit the circled items together to determine which attributes seem mostclosely linked to the presenting interpersonal problem(s). This discussion shouldculminate, when applicable, in the selection of one or two personality attributes thatare hypothetically linked to the interpersonal stressors and symptoms identified inthe first three assessment sessions.

The Nexus of Personality Traits & Social Problems

Personality testing will probably be most useful in IPT for cases where inter-personal disputes primarily mediate the presenting symptoms Axis I symptoms.Klerman et al. (1984) described one such case study of an interpersonal role disputealtered favorably through IPT. Alice E. found work in her husband’s business to bedissatisfying. The martial relationship had deteriorated markedly for many months,and she felt increasingly ignored and taken for granted in her role as spouse. Adevelopmental analysis suggested that she harbored “lifelong feelings of loneli-ness associated with her inability to establish and maintain intimate” (p. 108) andsocial relationships. Depression symptoms were attributed to her social isolation,lack of assertiveness, and inability to gain the respect and attention of her husband.The treatment selected and tested strategies on a weekly basis to reduce the maritalrole disputes as identified in the assessment.

A distinction can and should be drawn between maladaptive behavior thatis specific to one relationship and that which generalizes across many social

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situations. Specific social problems that are not a direct consequence of maladap-tive coping seem ideally suited to traditional IPT. Social problems can also emerge,however, as a consequence of maladaptive patterns of behavior that manifest ineither specific or pervasive forms. The identification of elevations on personalitydisorder scales may suggest recurrent patterns of maladaptive coping that underliethe specific social problems identified during IPT assessment and case formulation.The case of Alice E. seems to represent the more typical case where both specificand generalized coping inadequacies can be identified. The case description hintedat dependent, avoidant, or self-defeating personality features which might com-plicate treatment. Consider the potential benefits of selecting one of the followingpersonality traits to supplement the IPT treatment plan: a) belittles own aptitudesand competencies (profile 2, avoidant personality); b) engages in self-sacrifice andmartyrdom (profile 3, dependent personality); c) provokes rejection then feels hurtor humiliated (profile 8B, self-defeating personality). Most MCMI-III attributeslend themselves to the kind of weekly IPT self-monitoring that is employed to eval-uate changes in social problem severity and symptom change. There is nothingto prevent an IPT treatment plan from including strategies to diminish belittle-ment, self-sacrificial behavior, and/or provocation of rejection from others as asupplemental approach to improving a client’s relationship with his or her spouse.

The potential value of supplemental personality moderators in the IPT treat-ment of role transitions or interpersonal deficits also seems evident. Interpersonaldeficits may often be associated with detached, anxious, or ambivalent personalityqualities that are readily identified by personality measures. Extreme and inflexibleattitudes and behavioral tendencies may detract from smooth role transitions, andpersonality disorder attributes are often thought to mitigate against the initiationand maintenance of interpersonal closeness and bonding. The role of personalitytesting in the treatment of grief reactions would seem less direct and apparent.

Case Illustration

The case material presented here was modified to ensure confidentiality.Michael N. is a 72 year-old man who presented for treatment after experiencingdysphoria and other depressive symptoms. Michael was not sleeping or eating well,had lost pleasure in most of his numerous hobbies, and had become very concernedand preoccupied with his perceived inadequacies. He had recently allowed a friendto stay at his home while recovering from a major surgical procedure. Michael’sfriend was released from the hospital with the understanding that he not be leftalone for the first several days of his convalescence. He subsequently came to findthe responsibilities and this role transition to be distressing than initially expected.MCMI-III testing revealed an obsessive-compulsive disorder elevation (Scale 7)which was presented to Michael in the form of Panel 7 during the test feedbackcomponent of the case formulation meeting (4th session). Michael identified sev-eral attributes as contributing to the stress he was experiencing over his friend’s

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cohabitation and illness. He agreed the phrases “meticulous and perfectionistic,”“insists others do things his way,” “values restraint and emotional control,” and“especially fearful of making errors” aptly described him. The attributes “insistsothers do things his way” and “values restraint and emotional control” were chosenas supplemental treatment targets due to the mutual assessment of Michael and histherapist that they probably interfered with the identified role transition.

The standard IPT approach was followed to identify that Michael was expe-riencing a challenging role transition from a casual friendship to a primary andintimate caretaker. Early intervention focused on examining his feelings and re-sponses to this change including the distorted expectations he had held regardingthe extent of this new ommitment. This exploration revealed important ways thatthe identified personality traits interfered with this role transition. His insistence ondoing things his way and emotional inaccessibility appeared to prompt avoidableconflict and sabotage his efforts to deepen his friendship. Michael longed to estab-lish an intimate friendship, but only on his terms and without interpersonal risks.A negative change in his friend’s health eventually left him unable to return homealone, and Michael took this chance to offer the friend lodging and deepen theirburgeoning relationship. After many years of living alone Michael found havinga housemate both rewarding and frustrating. He relished the company, but wantedeverything around the house to be done his way. Complicating matters, Michaelrestrained himself from discussing relatively small matters with the roommateuntil he was quite upset.

Treatment focused on a weekly review of the extent to which Michael was in-sistent that his friend comply with his wishes and acted unnecessarily constrainedin his expression of both positive and negative emotion. Special emphasis wasplaced on encouraging appropriate expression of emotion and extending reason-able control to his friend over house rules and decisions. IPT sessions were usedto brainstorm ways to better balance and defer control and authority to Michael’sfriend. These “control” challenges were sometimes difficult for Michael to acceptsince he perceived his friend to by physically impaired by aspects of his surgicaltreatment. Michael accepted the need to be less controlling during the case formu-lation session, and so the IPT therapist role revolved around offering suggestionsfor how to effectively balance the relationship by relinquishing reasonable levelsof control over time. The IPT therapist also monitored the degree to which Michael“insisted that others do things his way” on a weekly basis. Self-monitoring andbrainstorming of options also occurred in regard to making Michael more adaptivein his emotional expressiveness. IPT sessions were enhanced by role-playing andproblem-solving exercises focused on problems which arose during the prior week.Emphasis on these two personality traits nicely complimented the more generaland traditional IPT focus on practical strategies to diminish the stress Michael wasexperiencing as a caretaker and friend.

Over the 16 weeks of therapy Michael was observed to diminish the tar-geted personality attributes while improving the relationship with his friend. His

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symptoms of depression (diagnosed formally as Dysthymic Disorder) diminishedgradually over time as he assumed a more satisfying and meaningful social role.His friend was an avid tennis player who eventually taught Michael how to play.Michael was initially inclined to resist the invitation, but his IPT therapist en-couraged him to agree as an example of success in altering his rigidity. Michaelwas initially out of his depth on the court with the roommate, but he agreed toplay weekly with the friend. Michael’s work ethic eventually improved his game,and surprisingly the two came to play as a doubles team on a regular basis. Inthis case obsessive- compulsive tendencies were modestly attenuated to enhancea role transition and deepen an important interpersonal relationship. As Michaelbuilt a more rewarding social life his dysthmic symptoms remitted with hardlya notice. As he put it, this trial of IPT and his improved social life caused himto stop focusing on the “imperfect elements” of his relationships and expresshimself more freely. This time-limited treatment was unlikely to change fun-damentally alter his obsessive-compulsive personality disorder but it did teachhim to monitor the ways that the selected traits interfered with his interpersonalrelationship(s).

Implications

This article describes a systematic and efficient method to incorporate person-ality testing into short-term, manualized therapies. IPT seems particularly well-suited for the proposed integration. The use of supplemental personality moderatorsin IPT may enhance the effectiveness of treatment in that subset of clients expe-riencing comorbid Axis I and II conditions. It has been suggested that the incor-poration of personality attributes as therapy targets may diminish the efficacy ofthe treatment by compromising the focus on specific interpersonal behaviors andconsequences. This risk can be diminished by restricting this subset of attributetargets to one or two prominent MCMI-derived personality features that seemclearly linked to the presenting social problems and symptoms. Only personalityattributes that have intuitive and mutual appeal to client and therapist should beselected for inclusion in the case formulation.

The role of personality testing in manualized and short-term psychotherapyhas become progressively limited. This article proposes one approach to reintegratepersonality concepts and measures into short-term treatment. The comparison oftraditional IPT with variations supplemented by personality testing would providea new and interesting line of research that holds promise for advancing the ef-fectiveness of available short-term interventions. Further, incorporation of morecomplex case presentations may serve to attenuate some clinician concerns re-garding the applicability of treatments typically investigated in outcome research.The effectiveness of traditional and personality-supplemented approaches couldalso be examined as a function of the presence or absence of Axis II pathology in

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a natural extension of this research. It must first be established that the inclusionof supplemental personality moderators does not mitigate against the level of ef-fectiveness now expected from these treatments. The specific suggestions offeredin this model provide a method for testing these related hypotheses.

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personality disorder attributes as supplemental goals for change in interpersonal psychotherapy

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