Journal of Personality Assessment

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Millon's Evolutionary Model of Personality Assessment: A Case for Categorical/Dimensional Prototypes Seth D. Grossman To cite this article: Seth D. Grossman (2015) Millon's Evolutionary Model of Personality Assessment: A Case for Categorical/Dimensional Prototypes, Journal of Personality Assessment, 97:5, 436-445, DOI: 10.1080/00223891.2015.1055751 To link to this article: http://dx.doi.org/10.1080/00223891.2015.1055751

Published online: 07 Jul 2015.

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Date: 15 October 2015, At: 00:06

Journal of Personality Assessment, 97(5), 436–445, 2015 Copyright Ó Taylor & Francis Group, LLC ISSN: 0022-3891 print / 1532-7752 online DOI: 10.1080/00223891.2015.1055751

SPECIAL SECTION: Personality Assessment and the DSM: A Match Made in Heaven?

Millon’s Evolutionary Model of Personality Assessment: A Case for Categorical/Dimensional Prototypes SETH D. GROSSMAN1,2

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1

Herbert M. Wertheim College of Medicine, Florida International University 2 Private Practice, Fort Lauderdale, Florida

Theodore Millon (1928–2014) was arguably one of the most influential figures in conceptualizing and detailing personality styles and disorders in the latter 20th and early 21st centuries. A prominent member of the Axis II Work Group of DSM–III, III–R, and IV, Millon continued refining his evolutionary model long after his active involvement with these committees, and remained focused on the future of personality assessment until his death in 2014. This article is an exploration of his latter works, critiques of recent DSM–5 developments, and commentary on the usefulness of his deductive methodology as it continues to apply to the study, classification, and clinical application of personality assessment.

Nature does not meet our need for a tidy and well-ordered universe. The complexity and intricacy of the natural world make it difficult not only to establish clear-cut relationships among phenomena but to find simple ways in which these phenomena can be classified or grouped. In our desire to discover the essential order of nature we are forced to select only a few of the infinite number of elements which could be chosen; in this selection we narrow our choice only to those aspects of nature which we believe best enable us to answer the questions we pose. The elements we have chosen may be labeled, transformed and reassembled in a variety of ways. But we must keep in mind that these labels and transformations are not “realities.” The definitions, concepts and theories scientists create are only optional tools to guide their observation and interpretation of the natural world; it is necessary to recognize, therefore, that different concepts and theories may coexist as alternative approaches to the same basic problem. —Theodore Millon, Modern Psychopathology (1969, p. 36)

It is an honor to be invited to participate in this special series on the future of personality diagnosis and assessment, and to be challenged with the not-insignificant task of articulating directions desired by my late mentor, Theodore Millon, for the future of personality assessment. Although I am, first and foremost, a clinician, and one who has used Millonian conceptualization for much of my work, I assume the more objective, academic position in summarizing his work and its critiques, examining core areas of convergence and divergence with currently popular factor-driven models, and providing commentary on directions he favored moving into the future. Of no small significance in this is the Millon Clinical Multiaxial Inventory (4th ed. [MCMI–IV]; Millon, Grossman,

Received September 28, 2014; Revised April 27, 2015. Address correspondence to Seth D. Grossman, 10400 Griffin Road, Suite 109, Cooper City, FL 33328; Email: [email protected]

& Millon, in press); its main architecture was largely completed by Millon before his death in January 2014, and it is now moving toward completion. It probably will come as a surprise to no one that Millon had mixed feelings about the direction of the Diagnostic and Statistical Manual of Mental Disorders (5th ed. [DSM–5]; American Psychiatric Association, 2013) and the proposals of the Personality and Personality Disorders Work Group. However, it might be surprising that Millon also had misgivings regarding the Board of Trustees’ decision to drop the proposed model and retain the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM–IV]; American Psychiatric Association, 1994) personality disorders in their entirety, as he would have preferred to see greater movement toward a clinically useful dimensional consensus. Central to his perspective was the idea that radical departure from the established DSM–IV constructs was ill-advised. Instead, constructive progress should further dimensionalize the existing clinical diagnostic prototypes to better understand the whole person (Millon, 2013). Millon was committed to perpetually developing a scientific system to explain normal and abnormal personality functioning and to identify different types of personality styles and disorders based on deductive reasoning. This contrasts with the emerging inductive methodology that defined dimensions of personality functioning and adjustment based on factor analysis of a lexicon of personality characteristics as exemplified by the Five-factor model (Costa & McCrae, 1992), as well as the now considerable number of alternatives following a similar approach. Although there are multiple points of convergence among these approaches (e.g., Choca, Retzlaff, Strack, Mouton, & Van Denburg, 1996; Rossi, Elklit, & Simonsen, 2010; Simonsen, 2010), several underlying assumptions (or fundamental differences), such as disagreement on linearity of constructs, impose difficulties in establishing concordance (Millon, 1994, 1999b; Millon, Weiss, & Millon, 2004; Mullins-Sweatt & Widiger, 2007; Widiger & Simonsen, 2005).

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Indeed, Strack and Millon (2007) asserted that the complexities and underlying systems of personality, as reflected in Millon’s theory, were never explicitly designed to fit a predictable factor structure based on atheoretical traits. Rather, these traits, conceptualized theoretically, are viewed within the theory as subcomponents of major prototypes (Millon, 2011; Millon & Davis, 1996). Although Millon’s taxonomy is organized around the concept of prototypes for purposes of convergence with traditional categories of personality disorder found in DSM–III through DSM–5, there is nothing inherent in the evolutionary model framework that prevents their expression as dimensionally based constructs. In fact, dimensionality has been inherent in the theory from its roots in his original biosocial-learning articulation (Millon, 1969). The prototypes might be better understood as higher order dimensions drawn from evolutionary principles, which then contain a series of functional and structural domains as lower order traits. This delineation is detailed in a subsequent section.

MILLON’S APPROACH TO DEDUCTIVE METHODOLOGY Millon posited that much could be learned from assessing what observable characteristics were present in a system of personality, but this was only the beginning of the picture. Beyond data-driven models attempting to make inductive discoveries of latent phenomena, Millon thought a truly mature classification and assessment system needed a kind of “glue” that would allow for explanatory frameworks, generativity of hypotheses, and prediction of observable data. This would be found in a theoretically guided, deductive methodology tied into the web of natural sciences (Hempel, 1965). To Millon, that which was simply observable to the naked eye, and face valid enough to be explained by a simple common language description, could not possibly capture the operational complexities and systemic workings comprising something so rich as a personality, no matter how statistically pure the metric. It was this that led to much of his thinking about personality constructs as they would appear in DSM–III and DSM–IV, and the apparent regression to surface-level trait-based thinking that he would lament in reflecting on much of the DSM–5, including, but not limited to, the personality disorders (Millon, 2013). A theoretically deduced system of organizing phenomena in personality and psychopathology, then, could answer many of these shortcomings. Millon’s earlier writings (e.g., Millon, 1969, 1981) feature his theoretical system incorporating a biosocial-learning thesis as an integrative schema for generating prototypal patterns commonly seen and understood in society via admixtures of underlying motivations and characteristics. Although these were generative and explanatory, Millon sought to further explicate personalities with a system that allowed for full expression of all the various facets of personality, which at the time he saw as occupied disparately and singularly by the various schools of psychological inquiry, such as cognitive, humanistic, psychodynamic, biophysical, and so on (Millon, 1990). He believed that bridging all aspects of personality would require an organizing principle hierarchically superior to that of psychology proper. Any given attempt at integration from “within” psychology would, by nature, find bias toward the theorist’s point of view, leading to

437 explications of personality wherein one school of thought is subservient to another (Choca & Grossman, in press; Grossman, 2004). In essence, this occurs in the current categorical model, despite declarations of atheoretical construction. Any personality disorder, for example, chosen at random, will undoubtedly have an unevenly distributed data set, perhaps skewed toward the cognitive, the behavioral, the affective, and so on. Millon’s goal was to create a theoretical system that could simultaneously account for all of these different personality dimensions while noting prominence of certain traits, so that each personality prototype could be described by a matching set of domains and could more accurately reflect individuals in their deviation from a prototypal dimension (rather than be given two or more personality disorder diagnoses), as they appear in reality. Within this system, it is conceivable that a person might present with prominent cognitive features reflective of one prototype, for example, and perhaps subtle but still important dynamic aspects of another, among other identified features. According to Millon, the other major advantage to a deductive theory of personality would be the interconnectedness linking the most functional, clinical applications (e.g., assessment and intervention) directly to an overarching system of explanatory principles that is generative of the aforementioned operational nosology of personality prototypes. Here, Millon explicated the necessary relationship as follows (Millon, 1990, 2011; Millon & Davis, 1996): Universal principles: A philosophical system of explanatory principles giving rise to a clinical science’s theory. Millon identified evolutionary science for this purpose. Theory: The subject domain for the clinical science. Millon used a historic term, personology, to define the naturally occurring clinical science of personality, and used explanatory principles from evolutionary science to describe its phenomena. Nosology: The language and system for describing and delineating the various parts, expressions, and structures of the theory. Within personology, Millon used evolutionary dimensions and, from there, deduced a growing set of prototypes of persons, now numbering 15, along with their structures and functions. Instrumentation: This is the primary domain for assessment. Once a nosology is described, there should be a reliable and valid means of qualifying and quantifying its elements (herein, prototypes), and demonstrating the relationship between those elements. Millon noted that an assessment instrument should accurately reflect the theory’s taxonomy by constructing it in accordance with that theory. However, this measure must also be validated by means of comparison to other established measures purporting to measure the same phenomena from a different perspective. Intervention: Millon believed that this is what makes a science clinical. The aforementioned elements could be applied to any observational science; adding intervention, or the ability to modify, moves a science from one of observation to a dynamic, operationalized study and endeavor. Like instrumentation, the best means of intervention grow naturally from the theory and use the theory’s measures as markers for effective inroads and therapeutic direction.

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Most important, intervention in this structure becomes based on the nature of the personality construct that has been described, identified, and assessed by the preceding element in the system. Mirroring the system of personality assessment proposed by Millon’s theory, a central consideration of these five key elements is the interactive interrelationship between the elements in enhancing and reinforcing one another. In this way, the overall science becomes one in which its whole is more useful and informative than each element in isolation (Millon, 2005). By connecting these elements, one may be usefully informed by another. A given intervention, for example, is not simply driven by a generic syndrome (e.g., anxiety or depression) in a manualized, one-size-fits-all manner. Rather, the intervention would be meaningfully informed by its preceding scientific elements, inclusive of a measurement system derived from a true taxonomy, representative of a theory of the person in context with an experienced distress such as depression and, ultimately, guided by principles that explain underlying basic motivations of the person. Each step informs another, beginning with the most basic motivating strategies of an individual within the environment.

AN EVOLUTIONARY FRAMEWORK FOR UNDERSTANDING PERSONALITY PATHOLOGY In selecting an appropriate superordinate science for understanding, assessing, and treating persons, Millon found evolutionary science to be the best fit for its observed overlap of basic motivating aims shared among living organisms (Millon, 1990). Large ecosystems (e.g., rainforests, food chains), microscopic molecular formations (e.g., behavior of ions within single atoms), and, from Millon’s perspective, personality, share a few central explanatory laws that could generate all basic expressions of living phenomena. These common patterns were found throughout classical evolutionary theory literature (e.g., Darwin, 1859; Huxley, 1870; Spencer, 1870) as well as within modern conceptions of evolutionary biology; the latter had already posited connections between human social functioning and the larger expanses of biology (e.g., Wilson, 1978). The precedent to apply similar principles to the study of the human psyche had also been partially articulated by Freud (1895). Millon used these explanatory laws, as they appeared across the world of living organisms, to organize and explicate his revised theory of personality processes as the following bipolarity-oriented motivating aims (see Figure 1): 1. The Existence aim: The most fundamental aspect of the theory is based on the simplest observation: Any living organism must simply exist or, in more dynamic and operational terms, survive. Simpler organisms adopt a very simple strategy to achieve this. They might orient toward the avoidance of environmental threats (predators, weather, etc.) in a manner that would decrease the likelihood of sustaining injuries or life-threatening vulnerabilities (a painavoiding tactic). On the other hand, they might take on actions geared toward increasing life fulfillment, such as

FIGURE 1.—Motivating aims and functional/structural domains.

overtaking nourishment and resources (a pleasure-enhancing course). In setting this bipolarity in the context of human personality functioning, however, a successful strategy would require a level of flexibility depending on the particular circumstances and challenges. A less adaptive strategy would begin to approximate simpler organisms in remaining immovable in a preferred strategy despite needs to the contrary (this basic flexibility rule applies to all three bipolarities). 2. The Adaptation aim: Once the organism is viable per the survival aim, it then requires interactivity in its environment. Again, this aim is set as a bipolarity, with simpler organisms evidencing preference toward one or the other strategy. The organism might attempt to fit into an existing system, making changes to itself to thrive harmoniously within its environment (a passive-accommodating strategy). The opposite strategy, then, is for the organism to act on its external ecosystem, modifying it to suit its needs (an active-modifying tack). Translated to human personality, once again, an individual will have a preferred mode but must adjust to demands as needed. 3. The Replication aim: No living organism exists eternally. The success of a species requires a means of regeneration. Evolutionary biology recognizes a bipolarity of r-strategy versus K-strategy (Cole, 1954). In the r-strategy, individual organisms (e.g., mollusks) will produce enough offspring to assure regeneration and, ultimately survival, with limited to no involvement of the progenitor, as enough offspring will survive by chance (in personality: a self-propagating tack). In the K-strategy, typified by mammals, individual organisms are limited in their generative capacity, and must nurse offspring until they are viable on their own (an other-nurturing approach). Viability, again, in the context of human personality, requires adaptation to conditions as indicated by the two preceding aims (Millon, 1990). Millon also included a fourth aim, Abstraction, not structured as a bipolarity, as it has many areas of focus. He posited this area as one belonging primarily to human personality, although some more advanced mammals evidence aspects of

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MILLON’S EVOLUTIONARY MODEL OF ASSESSMENT this branch of evolution. The abstraction aim delineates emergence of competencies in terms of higher order mental processes. Some of these competencies include rational decision making, executive functioning, and the ability to self-reflect (Millon, 1990, 1994, 2011; Millon, Weiss, & Millon, 2004). Although Millon did not structure Abstraction into his model for diagnosing and assessing personality disorders, these competencies do emerge as products of the preceding three bipolarities. Some initial ideas were informally proposed to incorporate these higher order mental processes into the forthcoming MCMI–IV, but were tabled prior to his death. This could be an area for future inquiry within his theory and instrumentation. The three primary motivating aims, then, give rise to a series of personality prototypes not entirely unlike the established personality disorder categories, although they are not limited by those constructs (Millon, 2011; Millon & Davis, 1996). Different configurations of motivating aim emphases across the three polarities represent different personality expressions. For example, an individual who is passively inclined on the adaptation polarity, with very little to no emphasis on the existence polarity, and moderately selffocused on the replication polarity, will likely evidence a personality pattern akin to what we now refer to as the schizoid personality. Avoidant personalities, who might evidence some similar, plainly observable behavioral features (e.g., lack of social engagement, withdrawal to an isolated environment), are very differently structured, with emphases toward the pain end of the existence polarity, and the active end of the adaptation polarity. In effect, this latter pattern exerts a large amount of energy maintaining environmental safety, despite having desires to integrate within the environment, whereas the former evidences little need in the social world. Similarly, distinct patterns might share mildly different (yet still distinct) underlying polarity structure. Narcissistic and antisocial prototypes both emphasize a strong leaning toward the self-end of the replication aim, but differ in their passivity versus activity, respectively, on the adaptation polarity. Although some interpersonal characteristics (e.g., interpersonal exploitiveness, lack of responsibility) are similar, the prototypes differ sharply in terms of their core perspective of what they must do in the world for needs fulfillment. In Millon’s conceptualization, narcissistic individuals feel entitled but believe that they generally do not need to actively pursue their desires, as what they want is simply forthcoming (although they might set up circumstances in which they indirectly get what they want). Antisocial individuals, on the other hand, are more likely to vigorously pursue what they see as their entitlements. Beyond this delineation of prototypes emanating from the basic motivating aims, the evolutionary theory specifies eight domains, four functional and four structural, representing expected personologic expression in facets of personality aligned with traditional psychological schools of thought.

Functional Domains The functional domains, according to Millon (2011), are expressive processes that occur as a coping transaction between the individual and their environment. They are generally observable as acts designed to regulate inner and outer life. They are as follows:

439 Expressive emotion: Formerly known as expressive acts, these are the outward behaviors arising from an affective state. Interpersonal conduct: The relational life and interactive style of the individual. This and the aforementioned expressive emotion make up the behavioral aspect of personality. Cognitive style: The quality and content of attention and focus characterized by the person, as well as his or her method of organizing and synthesizing information from the environment. This, along with self-image, make up a person’s phenomenology. Intrapsychic dynamics: Formerly known as regulatory mechanisms, this is the individual’s internal processes indirectly observable as acts of conflict resolution, needs gratification, and self-protection. These are largely analogous to defense mechanisms.

Structural Domains Millon (2011) described these domains as deeper, more “set” templates embedded within the personality and providing a “platform” for the functional domains. These are not as observable; therefore, they are mostly accessible to others based on inference and the person’s self-report. They are as follows: Self-image: Sameness or difference of an individual as compared to others, and the person’s reflection of sense of self-as-object. Intrapsychic content: Formerly known as object representations, this is the person’s general expectations of others, as imprinted from early experience. Intrapsychic architecture: Formerly known as morphologic organization, this is the organizing structures of the psyche. This inner architecture gives insight to the strength and cohesion of a personality. This, together with content and dynamics, represent intrapsychic aspects of the personality. Mood/temperament: This domain ties the body’s physical substrates to the workings of the psyche. This includes neuropsychological functioning, general energy and affect characteristics, and physical health effects on mental functioning. This domain, alone, represents the biophysical aspects of personality. These eight domains create uniform but heterogeneous dimensions consistent across all 15 prototypes (see Table 1). This differs from current categorical constructs that have become the norm since DSM–III in which a criteria set for a given diagnosis might, as mentioned previously, emphasize one or a small sampling of theoretical perspectives. Whereas one diagnosis may be described primarily by cognitive attributes, another may be largely captured by interpersonal observations. In contrast, Millon’s functional and structural domains provide for representation of each domain as part of a prototype’s criteria set. Because the same eight domains are present for each prototype, the prototypes become directly comparable to one another by domain. This creates a platform for admixtures of different personality prototypes, rather than a multiple diagnosis. An individual, for example, might evidence cognitions, a biophysical temperament, and defenses representative of one prototype, but behaviors, interpersonal conduct, and self-image of one to several others. Although

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Table 1.—Expressions of personality spectra across trait domains. Intrapsychic Trait domains

Expressive emotion

Spectrum disorders Schizoid Impassive Avoidant Fretful Melancholic Disconsolate Dependent Puerile Histrionic Dramatic Turbulent Impetuous Narcissistic Haughty Antisocial Impulsive Sadistic Precipitate Compulsive Disciplined Negativistic Embittered Masochistic Abstinent Schizotypal Peculiar

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Borderline Paranoid

Spasmodic Defensive

Interpersonal conduct

Cognitive style

Self-image

Content

Dynamics

Architecture

Unengaged Aversive Defenseless Submissive Attention-seeking High-spirited Exploitive Irresponsible Abrasive Courteous Contrary Acquiescent Secretive

Impoverished Distracted Fatalistic Naive Flight Scattered Expansive Nonconforming Dogmatic Constricted Cynical Diffident Autistic

Complacent Alienated Worthless Inept Gregarious Exalted Admirable Autonomous Combative Reliable Discontented Undeserving Estranged

Meager Vexatious Forsaken Immature Shallow Piecemeal Contrived Debased Pernicious Concealed Fluctuating Discredited Chaotic

Intellectualization Fantasy Asceticism Introjection Dissociation Magnification Rationalization Acting out Isolation Reaction formation Displacement Exaggeration Undoing

Undifferentiated Fragile Depleted Inchoate Disjointed Unsteady Spurious Unruly Eruptive Compartmentalized Divergent Inverted Fragmented

Paradoxical Provocative

Vacillating Mistrustful

Uncertain Inviolable

Incompatible Regression Unalterable Projection

there are combinations that are much more likely, as some attributes tend to have more of a meaningful relationship to some than to others, there is the logical possibility of 960 identifiable personality combinations drawn from 15 prototypes across eight domains. What is likely evident in the structure of this theory is the potential for these prototypal constructs to capture advantages of both categorical and dimensional methodologies. Although the prototypes resemble DSM–IV categories, they do not suffer from the same rigidity or limitations. A first advantage is that the theory, being generative, might provide the framework for as-yet not defined prototypes that could emerge in future studies in personality. Millon (2011) evidenced this by the inclusion of several prototypes not included in the main body of DSM–III through DSM–5. Melancholic (depressive), negativistic (passive-aggressive), masochistic (self-defeating), and sadistic (aggressive) prototypes have been included in the appendix of the past two manuals, and a newly identified turbulent prototype has been described in Millon’s (2011) latest writing and marked for inclusion in the upcoming MCMI–IV. Perhaps more germane to immediate developments in personality assessment and diagnosis, the domains, as well as the motivating aims, provide a structure for integrating and dimensionalizing personality constructs at a different level than that of current factorially oriented approaches (Widiger & Simonsen, 2005). As was emphasized by multiple participants in a roundtable discussion (Ganellen, Kreuger, Widiger, Bornstein, & Huprich, 2014), different models do not necessarily need to compete with one another as they measure similar constructs from different perspectives. Further, both convergence and divergence from one another could yield information integral to a more comprehensive understanding of the person. The unique contribution inherent in Millon’s model is its ability to connect trait-domain features (e.g., the eight functional and structural domains) directly to a unified and integrated explanatory system (motivating aims) that in turn directly guides assessment and intervention (Millon & Grossman, 2012). By creating comparability between

Split Inelastic

Mood/ temperament Apathetic Anguished Woeful Pacific Fickle Mercurial Insouciant Callous Hostile Solemn Irritable Dysphoric Distraught or insentient Labile Irascible

prototypes via this uniform criteria set, admixtures may then be conceptualized as true subtypes, rather than fitting criteria for more than one categorical diagnosis. This reflects the most common expression of personality, as it is the exception, not the rule, to find personality patterns in individuals that conform closely to a singular prototypal expression (Millon, Grossman, Millon, Meagher, & Ramnath, 2004). Further, examination of overlap in the polarity structure creates greater insight, leading to greater empathic understanding of an individual. In most instances, then, a person matches primarily with a particular prototype, but also bears traits and motivations indicative of another. For example, consider an individual primarily matching with a melancholic (depressive) prototype, but also bearing the expansive cognitive style of the narcissistic prototype, and the attention-seeking interpersonal conduct of a histrionic prototype. Combined with this person’s melancholic temperament, a likely presentation might be that of a voguish melancholic subtype, wherein the person frequently gains attention through gloomy, global predictions about the future, fueled by a self-declared ability to “see things that others are too blind or stupid to see.” In contrast, a primary melancholic pattern interspersed with facets of the dependent prototype will likely yield a quite different expression, with a person needing continuous direction and approval of another to manage and mitigate the disabling effects of characterologic melancholia. Although there are many implications for differences in treatment of these two subtypes, let’s just consider one core difference. The latter will definitely have an overarching treatment goal of diminishing reliance on others, whereas the former would likely benefit from ultimately gaining appreciation for others’ input. At the prototypal level, there are opportunities to consider overall counterbalancing of motivating aims in assessing and relating to motivational struggles with individuals. For example, consider the unusual combination of masochistic and antisocial prototypal features, admixing to a subtype. As much as orange resembles neither red nor yellow separately, the

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MILLON’S EVOLUTIONARY MODEL OF ASSESSMENT resultant subtype resembles someone highly distinct from either prototype alone. A deep sense of undeserving characterized by the masochistic passive-inverse pain polarity orientation is offset by the active-self, self-interested agenda of the antisocial. At times, the balance might work, albeit likely uncomfortably, but the combination of these features is more likely to create internal conflicts and problems in adjustment. Feeling justified in gratifying needs in an assertive or even aggressive manner, regardless of the cost to self or others, and at the same time needing to undermine self-worth (whether consciously or unconsciously), could produce considerable tension as well as self-destructive behavior. Not only is this invaluable information for the assessment clinician in describing personality attributes, but it lends itself to a new therapeutic dialogue. The treating clinician might then find empathic language capturing this struggle in a descriptive, dimensional, and ultimately less label-intensive manner. The last example highlights a deficit in most of the existing categorical and proposed dimensional models. With this deductive explanatory system, it is possible to identify and denote motivational conflicts at the higher order evolutionary polarity level, as well as underlying intrapsychic features at the functional or structural level. The extant DSM–5 categories, bearing the mandate of theoretical agnosticism, have been limited to observable, quantifiable criteria sets, a legacy of psychodynamic insight being purged from the manual as of the third edition. Likewise, inductive methodologies (e.g., factor analysis) aimed at uncovering latent dimensions are limited by the nature of their methods to observable phenomena and, indeed, proposed models embody this limitation. Yet, clinicians and individuals know that inner conflict exists. Deducing this conflict on theoretical grounds, then using an appropriate metric for hypothesis testing, fills an important gap.

COMPARISON WITH ESTABLISHED AND PROPOSED DSM–5 PERSONALITY CONSTRUCTS Despite Millon’s significant contribution to the DSM–IV task force (as well as its 1980 and 1987 predecessors, wherein he is often credited as a major architect of the multiaxial system and the Axis II categories), and the very close resemblance between personality disorder diagnostic categories and the prototypes of Millon’s theory, they are not, in fact, one and the same. In the traditional categories, there are approximately nine qualitative criteria per category; an individual needs to possess approximately half these criteria to qualify for a diagnosis. Although variations in criteria between individuals might account for significant heterogeneity between people similarly diagnosed (offhandedly creating something vaguely resembling dimensionality), it is more common for a given person to have a handful of traits of one, a handful of traits of another, and to be diagnosed with several personality disorders or a personality Disorder not otherwise specified (Millon, 2013). Lacking an explanatory system in which phenomena (traits, categories, or other criteria) are organized in a meaningful manner, there is nothing preventing the confusion and chaos of multiple diagnostic admixtures such as these, which ultimately leads to individuals meeting criteria for multiple or unspecified disorders based on confusion of criteria (Millon, 1990).

441 Another shortcoming of this criteria-to-category system is the lack of comparability of criteria sets. Like the evolutionary model, many of the factor-oriented models (e.g., Costa & McCrae, 1992; Harkness & McNulty, 1994; Livesley, 2006) are structured to include higher order concepts (generally the four or five overarching factors), with more face-valid, specific characteristics contained within each. This does provide a useful framework in which to organize potentially disparate traits and characteristics, and generally provides for a cleaner empirical picture than deductive prototypes or atheoretical categories. What it does not provide, however, is the system of explanatory principles and generative power, or a coherent means toward comparability of attributes attached to the specific structures and functions comprising a personality (Millon & Davis, 1996). Further, as illustrated before, the nature of inductive methodology limits assessment data to immediate observables, whereas much more lies beneath this level. Proponents of inductive methodologies have, however, demonstrated limitations of Millon’s model, and validational research for the evolutionary constructs have not been uniformly positive. An oft-cited limitation of both the theory and instrumentation (particularly the MCMI) has been the emphasis on personality pathology and the tendency to overpathologize personality constructs. Although Millon traditionally contended that personality exists on an adaptive to maladaptive continuum, efforts to examine Millon’s “normal” constructs have, at times, uncovered inconsistencies in applying polarity structure and expressed domains to the study of adaptive personality traits (e.g., McCrae, 2006; Mullins-Sweatt & Widiger, 2007). There is even some argument by Millon adherents that normal and abnormal evolutionary theory constructs might be qualitatively different, and that a four-factor structure (the three Millon polarities as factors, adding the full incorporation of a conflictedness factor that is already added on for several prototypes, and more fully engaging the pleasure end of the existence polarity) might more accurately capture adaptive functioning (Davis & Patterson, 2005). Future study from the perspective of the evolutionary model might more fully elucidate the relationship between adaptive and maladaptive patterns. Validational studies focused on the relationship between the MCMI and its underlying theory (in particular, the motivational aims) have not demonstrated consistency (Choca, 1999; O’Connor & Dyce, 1998; Retzlaff & Gibertini, 1987). Further, Mullins-Sweatt and Widiger (2007) found only weak support for the underlying theory using factor-analytic methods, sometimes evidencing results opposite to those the theory would predict. Others (e.g., Rossi et al., 2010) have noted discovery of an MCMI–III factor solution corroborating many of the current factor proposals, noting four domains converging with current dimensional proposals. A central difficulty in this line of inquiry is the appropriateness of traditional factor-analytic methodology in assessing constructs within Millon taxonomy and assessment. It is inherently a methodological mismatch to extend traditional factoranalytic techniques to account for theoretically identified dynamic conflicts and features in meaningful context with surface-observable traits. Confusion exists between latent roots identified via factor-analytic methodology, on the one hand, and the higher order prototypes on the other. In sum, these are not the same, and owing to the polythetic nature of shared

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442 attributes between these prototypes, they are not recoverable via these methods, as the prototypes are theoretical constructs developed using bipolar axes rather than a unidirectional descriptor (Strack & Millon, 2007). Although factor-analytic tools have been applicable to deciphering nuances at the domain level (e.g., Grossman, 2004), they have first required plainly observable data, or lower order domains already explicated by the theory (in both cases, the more observable of the functional-structural domains). Rossi et al. (2010) used a confirmatory factor analysis (CFA) methodology to bridge a gap between the MCMI–III’s theory and factorial domains consistent with DSM–5 proposals. Indeed, four of the five predominant factors were found, as stated previously. What did not emerge from this study, however, were elements constituting the more intrapsychically oriented nuances of the theory and the test. There are other methods that have not yet been substantively applied to Millon’s model or instrumentation that are more explicitly designed to illuminate theory, as well as polythetic or nonlinear characteristics (e.g., structural equation modeling, Rasch methodology). These tools, which allow for more flexible theoretical specificity owing to reliance on goodness of fit rather than specific factor loading, are more appropriate to assessing and even further developing both the theory and the assessment measures, and might provide further insight into how this model relates to current dimensional proposals and the future of personality assessment. Beyond the question of appropriateness of inductive versus deductive methods and measures, examination of the Alternative Model of Section III of the DSM–5 (American Psychiatric Association, 2013) yields the observation that the Alternative Model’s listing of traits and domains are already largely contained within Millon’s model. In the Alternative Model’s aspects of personality functioning (Criterion A), for example, identity, empathy, self-direction, and intimacy cover some of the same concepts as the three motivating aims of Millon’s model (e.g., self/other in identity/empathy, and in aspects of self-direction and intimacy), although pain/pleasure and active/passive seem to be connected more by inference than by direct analogy. What is not evident in the Alternative Model is how it corroborates detachment, imbalance, and conflict with core functioning such as identity and empathy. Likewise, subordinate traits drawn from the factorially derived DSM–5 domains of negative affect, detachment, antagonism, disinhibition, psychoticism (e.g., lability, withdrawal, grandiosity, etc.), expressed in the Alternative Model as Criterion B, are also largely contained within Millon’s functional and structural domains. An example might highlight how an extant personality disorder might be conceptualized in each model, and what attributes are illuminated within those conceptualizations. Consider the avoidant personality disorder, one that is a legacy of Millon’s early strong contention of the difference between activeand passive-detached (i.e., avoidant vs. schizoid) personality patterns. With the Alternative Model, a clinician might focus initially on functional deficits in intimacy and identity, noting the individual’s incapacity to form satisfactory social relations and reflect on themselves without distortion. Further examination of personality functioning might be illuminated by considering self-direction difficulties, wherein it becomes apparent that achievement is hampered by self-doubt, and by empathy distortions wherein the other person’s perceptions

GROSSMAN become the sole arbiter of interpersonal reality. Other factors bring personality traits such as anxiousness, perceptual dysregulation, and, probably most prominently, withdrawal, to light. Although this is not an exhaustive conceptualization, it does demonstrate how this clearly observable data might come to highlight relevant features. Suggesting its relationship to a given category (in this case, the avoidant personality disorder) allows for a clinical interpretation of the meaning and relationship between these observables but, in cases where there is no “match” to one of the six surviving personality disorder categories (noted in this system, then, as personality disorder–trait specified, or PD–TS), there is no particular guidance for the meaning of a particular trait, such as withdrawal. In contrast, Millon’s model for the avoidant personality disorder prototype primarily involves two imbalances in the system of motivating aims: (a) the strong emphasis on the pain end of the existence polarity, with no emphasis on pleasure, and (b) a strong emphasis on the active end of the adaptation polarity with no emphasis on passive. Taken together, this illustrates a basic motivation in which the individual continually enacts measures to remain psychologically safe. This can be further rounded out by how the individual maps in terms of self/other (replication strategy), which would likely be determined by what other prototypal patterns might be evident. This is further dimensionalized by the functional and structural aims (refer to Table 1) including likely prominent features such as “aversive” interpersonal conduct and “anguished” mood or temperament. What is further delineated in this system, however, are connections to underlying processes and conflicts. In a prototypal presentation, the theory notes that the aversive interpersonal quality (essentially enacting withdrawal) might be driven by fexatious intrapsychic content (object representations) and that the anguished temperament might be pacified by fantasy intrapsychic dynamics (defense mechanisms). This, too, is not exhaustive, but meant to illustrate this explanatory system linking observable traits to underlying processes. It also provides the ability to add meaning and context to a given feature. A feature such as withdrawal will have a different meaning and purpose with an avoidant presentation (where it prevents embarrassment or humiliation) than it will with a paranoid presentation (where it prevents perceived active attacks by others) or schizoid presentation (preference to being alone).

FURTHER CONSIDERATIONS As might be evident from his 1969 quote at the beginning of this article, Millon wished for his model to adapt to needs as our collective understanding of personality and psychology grows. From the perspective of degree of maladaptive functioning, Millon most recently broadened his bandwidth and created a schema for a more nuanced breakdown of level of functioning (Millon, 2011; Millon et al., in press). Across what is now a group of 15 personality prototypes (inclusive of the newly conceptualized turbulent pattern), Millon has added a spectrum component to his model, with indications as to the relative adaptiveness versus maladaptiveness of a given personality prototype (see Table 2). Although not entirely novel to this latest explication of the theory or the forthcoming MCMI–IV, Millon has now more fully explicated each

MILLON’S EVOLUTIONARY MODEL OF ASSESSMENT Table 2.—Personality spectra levels. Spectrum acronyma

Normal style

Abnormal type

Clinical disorder

AAS SRA DFM DAD SPH EET CEN ADA ADS RCC DRN AAM ESS UBC MPP

Apathetic Shy Dejected Deferential Sociable Ebullient Confident Aggrandizing Assertive Reliable Discontented Abused Eccentric Unstable Mistrustful

Asocial Reticent Forlorn Attached Pleasuring Exuberant Egotistical Devious Denigrating Constricted Resentful Aggrieved Schizotypal Borderline Paranoid

Schizoid Avoidant Melancholic Dependent Histrionic Turbulent Narcissistic Antisocial Sadistic Compulsive Negativistic Masochistic Schizophrenic Cyclophrenic Paraphrenic

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a Millon (2011) assigned an acronym for each prototype in the spectrum based on the first letter of each severity level description; for example, Schizoid spectrum (AAS) indicates apathetic style, asocial pattern, and schizoid personality disorder.

prototype, specifying three levels of personality functioning ranging from generally effective functioning to maladaptive functioning consistent with a clinical disorder. At the most adaptive end of each spectra, Millon describes a personality style. This level of functioning describes individuals who have a constellation of identifiable trait characteristics that hold together to reflect a prototypal pattern who usually manage affairs in their life reasonably well and who evidence at least a modicum of flexibility in their primary motivating aims. Individuals with a personality style who generally function effectively will exhibit strengths and vulnerabilities that might give rise to unique syndromal patterns in distress conditions. At the middle level of functioning, Millon identified personality types in which there is moderately less flexibility and adaptivity. These individuals might have episodic impairments in interpersonal interaction, self-reflection, temperament, and psychic control, creating distressing situations for themselves and those around them. Millon considered personality disorders to occur at the most maladaptive level of functioning. Individuals with personality disorders have particular areas of personality vulnerability, maladaptivity, inflexibility, and interpersonal difficulties that contribute to core conflicts, problematic relationships, and psychological distress, severely limiting these individuals in their activities of daily life. Each of the prototypes in the revised theory have been given a three-letter code to note its unique spectrum (e.g., the narcissistic spectrum is known as CEN, indicating the confident style, egotistic type, and narcissistic disorder). Although Millon frequently admonished the field to not become overly reliant on data-driven, empirical research methodology as the foundation for developing a model of personality (e.g., Millon, 2011; Millon & Davis, 1996; Millon & Grossman, 2012; Strack & Millon, 2007), he also explicitly advocated for empirical studies to test deductively derived hypotheses, as he recognized this was the core of true scientific methodology. The extant research focuses almost exclusively on the assessment instruments developed by Millon and his colleagues, but not on the underlying theory (Strack & Millon, 2007). In the late 1970s and throughout the 1980s, research efforts for the earlier MCMIs enjoyed a prolific

443 literature. Craig and Olson (2005) lamented that research on personality assessment measures, inclusive of the MCMIbased literature, has dwindled precipitously, and they speculate that this could possibly be due to economic factors. More specific to the MCMI, however, there seems to be a different reason. Millon often asserted that theory has always pushed science forward, and that methodology should assume the role of substantiating, not creating, new thought and new discovery. Although an elaborate, deductively derived system such as the evolutionary theory presents an elegant gestalt and a sensible basis on which to form conceptualization that is truly operational, any theory is only as valid as its evidence. Clinicians well-immersed in this system frequently provide strong anecdotal evidence of this methodology’s value. However, the call to reenergize and articulate a research agenda is crucial to substantiating this model as not only inclusive of much of the Alternative Model and dimensional proposals, but as providing a more thorough and complete taxonomy including better explication of less superficial traits and features, as well as the linkages among underlying processes, observable traits, and superordinate constructs (i.e., dimensional prototypes). A central, long-standing challenge has been the mismatch between statistical methodology commonly used in personality assessment and its applicability to a deductively derived theoretical system and its instrumentation. Exploratory factor analysis has been the tool of choice as used by researchers and critics, but it is limited by its nature to uncovering latent constructs (in this case, those constructs are already defined by the theory). In contrast, structural equation modeling, still a relative newcomer in contrast with older factorial methods and more explicitly capable of testing key propositions of the theory, shows promise as a means to more adequately address concerns brought up by those who have, to date, presented concerns with its constructs. Examination of the literature comparing different assessment modalities was enlightening in terms of explorations of adaptive personality assessment. Millon’s contention, as stated throughout, was that the path between adaptive and maladaptive personality functioning is on a continuum, and many of the same principles could be used within the theory to specify normal versus abnormal development and expression (Millon & Grossman, 2006). Multiple sources (e.g., Davis & Patterson, 2005; Mullins-Sweatt & Widiger, 2007) indicate that this might be an oversimplification. Davis and Patterson (2005) provided an interesting hypothesis in terms of an expanded evolutionary model, adding the element of conflictedness to the three basic motivating aims as its own domain, thereby creating a four-dimension structure. They argued that adaptive patterns, by nature, adhere more to the pleasure end of the existence aim than maladaptive personality functioning. Davis and Patterson’s hypotheses have yet to be tested, but do provide one well-articulated model to more adequately capture a wider bandwidth. Again, structural equation modeling shows promise as a means to examine Davis and Patterson’s model, among other theoretical developments. Future development for the taxonomy and, subsequently, assessment measures will likely require a comprehensive research agenda. Beyond developments now being incorporated into the MCMI–IV, further study is needed to clarify each prototypal construct as has been specified in the theory,

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444

GROSSMAN

building from both the functional and structural domains as well as the motivating aims. A possibility being considered is the construction of Rasch-based measures centered around each prototype but focused on the functional and structural domains. This could not only further substantiate the theory’s extant constructs, but could also delineate areas of convergence with the Alternative Model as well as point out unique variance outside this model. As similarities provide a level of convergent validity for proposed ideas, and uniquenesses (likely in the form of more intrapsychically oriented and conflictual constructs) are further explicated, a proposal for a more complete taxonomy might come to light incorporating the most contextual, pragmatic points of assessment. Virtually no empirical research has been conducted, to date, on the personality-guided or personalized model of case conceptualization and intervention that emanates from Millon’s theory and logically follows assessment based on this model (Millon, 1999a; Millon & Grossman, 2007a, 2007b, 2007c). This is lamentable, but given the aforementioned limitations of exploratory factor analysis, understandable. Its essential integrative structure is very elaborate, bearing elements of all the traditional psychotherapeutic approaches as they relate to facets (i.e., functional and structural domains) of personality. Evidence of its potential and success remains anecdotal. Systematized programs of research, again, in both quantitative (e.g., structural equation modeling for elements of case conceptualization, controlled comparative studies for intervention) and qualitative (e.g., case studies and meta-analyses) design structures, could contribute greatly to this model’s viability among intervention systems. Finally, several important points were mentioned in Ganellen’s aforementioned roundtable discussion related to common ground and complementarity between methodologies. These included, but were not limited to, the range of assessment domains, from adaptive to maladaptive patterns, the transference and countertransference effects between clinician and subject, and discrepancy analysis between multimethod measures vital to a true, comprehensive understanding of a person. As Bornstein stated in these proceedings, “There is no Truth with a capital ‘T’ in assessment” (Ganellen et al., 2014). We all have something to learn from one another, and this does not end with a particular measure or system of measurement proclaimed as the victor. The evolutionary theory, being an integrative construct incorporating all of these schools of thought, is well-poised to participate in these explorations, as are the family of Millon assessment instruments. It is my contention that this tradition will continue to find its place, offering its unique contribution, within the spectrum of methodologies of personality diagnosis and assessment well into the future.

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