psi logo Personalized Psychotherapeutic Intervention

The great philosophers and clinicians of the past viewed their task as creating a rationale that took into account all of the complexities of human nature—the biological, the phenomenological, the developmental, and so on. By contrast, modern conceptual thinkers have actively avoided this complex and broad vision. These theorists appear to favor one-dimensional schemas, conceptual frameworks that intentionally leave out much that may bear significantly on the reality of human life. Personalized psychotherapy joins with thinkers of the past and argue that no part of human nature should lie outside the scope of a clinician’s regard, e.g., the family and culture, neurobiological processes, unconscious memories, and so on.

We hope to lead the profession back to “reality” by exploring both the natural intricacy and diversity of the patients we treat. Despite their frequent brilliance, most schools of therapy have become inbred; more importantly, they persist in narrowing the clinician’s attention to just one or another facet of their patient’s psychological makeup, thereby wandering ever farther from human reality. They cease to represent the fullness of their patient’s lives, considering as significant only one of several psychic spheres—the unconscious, biochemical processes, or cognitive schemas, and so on. In effect, what has been taught to most fledgling therapists is an artificial reality, one which may have been formulated in its early stages as an original perspective and insightful methodology, but one which has drifted increasingly from its moorings over time, no longer anchored to the clinical reality from which it was abstracted.

If our wish takes root, a forthcoming series of books by Millon and Grossman, published by John Wiley and Company, serves as a revolutionary call, a renaissance that brings therapy back to the natural reality of patients’ lives. In line with the preceding, We hold to the proposition that the diagnostic categories that comprise our nosology (e.g., DSM-IV) are not composed of distinct disease entities or separable statistical factors; rather, they represent splendid fictions, arbitrary distinctions that can often mislead young therapists into making compartmentalized or, worse yet, manualized interventions. Fledgling therapists must learn that the symptoms and disorders we “diagnose” represent one or another segment of a complex of organically interwoven elements. The significance of each clinical component can best be grasped by reviewing a patient’s unique psychological experiences and his/her pattern of configurational dynamics, of which any specific component is but one part.

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Looking at a patient’s totality can present a bewildering if not chaotic array of possibilities, one which may drive even the most motivated young clinician to back off into a more manageable and simpler worldview, be it cognitive or pharmacologic, and so on. But, as we will contend, complexity need not be experienced as overwhelming; nor does it mean chaos, if we can create a logic and order to the treatment plan. This we have sought to do by illustrating, for example, that the systematic integration of Axis I syndromes and Axis II disorders, is not only feasible, but is one that is conducive to both briefer and more effective therapy. Of course, therapeutic concepts and methods can never achieve the precision and idealized model of the physical sciences. In our field we must deal with subtle variations and sequences, as well as constantly changing forces that comprise the natural state of human life.

As we trust will be evident, the scope of these books will not limit the therapeutic focus only to the treatment of personality disorders. We will attempt to show that all the clinical syndromes that comprise Axis I can be understood more clearly and treated more effectively when conceived as an outgrowth of a patient’s overall personality style. To say that depression is experienced and expressed differently from one patient to the next is a truism; so general a statement, however, will not suffice for a book such as this. Our task requires much more. These books provide extensive information and illustrations on how patients with different personality vulnerabilities perceive and cope with life’s stressors; and, with this body of knowledge in hand, therapists should be guided to undertake more precise and effective treatment plans. For example, a dependent person will often respond to a divorce situation with feelings of helplessness and hopelessness, whereas a narcissist, faced with similar circumstances, may respond in a disdainful and cavalier way. Even when both a dependent and a narcissist exhibit depressive symptoms in common, the precipitant of these symptoms will likely have been quite different; furthermore, treatment—its goals and methods—should likewise differ. In effect, similar symptoms do not call for the same treatment if the pattern of patient vulnerabilities and coping styles differ. In one case—dependents—the emotional turmoil may arise from their feelings of low self-esteem and their inability to function autonomously; in narcissists, depression may be the outcropping of failed cognitive denials, as well as a consequent collapse of their habitual interpersonal arrogance.

In our view, current debates regarding whether "technical eclecticism” or “integrative therapy" is the more suitable designation for our approach are both mistaken. These discussants have things backward, so to speak, because they start the task of intervention by focusing first on technique or methodology. Integration does not inhere in treatment methods or their theories, be they eclectic or otherwise. Integration inheres in the person, not in our theories or the modalities we prefer. It stems from the dynamics and interwoven character of the patient's traits and symptoms. Our task as therapists is not to see how we can blend intrinsically discordant models of therapeutic technique, but to match the integrated pattern of features that characterize each patient, and then to select treatment goals and tactics that mirror this pattern optimally. It is for this reason, among others, that we have chosen to employ the label "personalized therapy" to represent our brand of integrative treatment.

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Integration is an important concept in considering not only the psychotherapy of the individual case but also the role of psychotherapy in the broad sphere of clinical science. For the treatment of a particular patient to be integrated, the several elements of a clinical science should be integrated as well. One of the arguments advanced against technical eclecticism is that it explicitly insulates therapy from the broad context of clinical science. In contrast to eclecticism, where techniques are justified methodologically or empirically, integrative treatment reflects the logic of a comprehensive and relevant theory of human nature. Theories of this nature are inviting because they seek to encompass the full multidimensionality of human behavior; personalized therapy grows out of such a theory. Let us elaborate its rationale briefly.

Whether we work with "part functions" that focus on behaviors, or cognitions, or unconscious processes, or biological defects, and the like, or whether we address contextual systems that focus on the larger environment, the family, or the group, or the socioeconomic and political conditions of life, the crossover point, the place that links parts to contexts, is the person. The individual is the intersecting medium that brings them together. Persons, however, are more than just crossover mediums. As will be elaborated in this book, they are the only organically integrated system in the psychological domain, inherently created from birth as natural entities, rather than experience-derived gestalts constructed through cognitive attribution. Moreover, it is the person who lies at the heart of the therapeutic experience, the substantive being who gives meaning and coherence to symptoms and traits—be they behaviors, affects, or mechanisms—as well as that being, that singular entity, who gives life and expression to family interactions and social processes.

It is our contention that therapists should take cognizance of the person from the start, for the parts and the contexts take on different meanings, and call for different interventions in terms of the person to whom they are anchored. To focus on one social structure or one psychic form of expression, without understanding its undergirding or reference base is to engage in potentially misguided, if not random, therapeutic techniques.

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Personalized therapy insists on the primacy of the overarching gestalt of the whole person, one that gives coherence, provides an interactive framework, and creates an organic order among otherwise discrete clinical techniques. Each personality is a synthesized and substantive system: The whole is greater than the sum of its parts. The problems that our patients bring to us are an inextricably interwoven structure of behaviors, cognitions, and intrapsychic processes, bound together by feedback loops and serially unfolding concatenations that emerge at different times and in dynamic and changing configurations. The interpretation of one of Millon's psychological inventories, the MCMI, for example, does not proceed through a linear interpretation of its single scales. Instead, each scale contextualizes and transforms the meaning of the others in the profile. In parallel form, so should personalized therapy be conceived as a configuration of strategies and tactics in which each intervention technique is selected not only for its efficacy in resolving singular pathological features but also for its contribution to the overall constellation of treatment procedures, of which it is but one.

All psychic pathologies represent disorders for which the logic of the integrative mindset is the optimal therapeutic choice. The cohesion (or lack thereof) of complexly interwoven psychic structures and functions is what distinguishes our model of therapy from other clinical forms of treatment; it is the careful orchestration of diverse, yet synthesized techniques that mirror the characteristics of each patient’s psychological make-up that differentiates personalized psychotherapy from its integrative counterparts. The interwoven nature of the components comprising personalized treatment makes a multifaceted and synergistic approach a necessity. Therapies that conceptualize clinical disorders from a single perspective, be it psychodynamic, cognitive, behavior, or physiological, may be useful, and even necessary, but are not sufficient in themselves to undertake a therapy of the patient, disordered or not. As stated, the “revolution” we propose asserts that clinical disorders are not exclusively behavioral or cognitive or unconscious, that is, confined to particular expressive form. The overall pattern of a person’s traits and psychic expressions are systemic and multi-operational . No part of the system exists in complete isolation from the others. Every part is directly or indirectly tied to every other, such that there is an emergent synergism that accounts for a disorder’s clinical tenacity. Personality is “real”; it is a composite of intertwined elements whose totality must be reckoned with in all therapeutic enterprises. The key to treating our patients, therefore, lies in therapy that is designed to be as organismically complex as the person himself; this form of therapy should generate more than the sum of its parts. Difficult sounding as this may appear, we hope to otherwise demonstrate its ease and utility.

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Personalized therapy employs two basic strategies, the first I have termed "potentiated pairings." Here, treatment methods are combined simultaneously to overcome problematic characteristics that may be refractory to each technique if administered separately. These composites pull and push for change on several fronts, so that treatment is oriented to more than one expressive domain of clinical dysfunction. A currently popular form of treatment pairing is found in what is called “cognitive-behavioral” therapy. The second personalized procedure is labeled "catalytic sequences". Here, the order in which coordinated treatments are executed, is considered. Therapeutic combinations and progressions are designed to optimize the impact of changes in a manner that would be more effective than if the order were otherwise arranged. In a catalytic sequence, for example, one might seek first to alter a patient's stuttering by direct behavioral modification procedures which, if achieved, would facilitate the use of cognitive methods in producing self-image changes in confidence which, in its turn, would foster the utility of interpersonal techniques to effect social skill improvement. Personalized therapy is conceived, therefore, as a configuration of strategies and tactics in which each intervention technique is selected not only for its efficacy in resolving particular pathological difficulties, but also for its role in contributing to the overall constellation of treatment procedures, of which it is but one.

The logic for combining therapies has now become a central theme for a wide variety of health problems. A recent study of depression among the elderly has shown that those given both medication and psychotherapy recovered more than twice as frequently as did those who received either medication or psychotherapy alone. In treating AIDS, it has been found that a cocktail of three drugs in combination works appreciably better than any of the drugs alone; moreover, these data have held up with patients at different stages of the HIV disease. In difficulties such as smoking cessation, recent studies show that a combination of an antidepressant, nicotine replacement, and psychological counseling sharply increases (40-60%) the success of those who are trying to give up smoking, as compared to those who attempt cessation utilizing only one of these methods (5%). Diabetes is a disease in which any of several anatomic structures and physiochemical processes can go awry; it has now become a standard practice with these patients to administer two or more medications, each of which addresses one or another of the possible inherent defects. The goal is to cover all potentially contributing biophysical difficulties; the consequent drop in blood sugar levels among multi-treated patients is nothing less than miraculous. Recent studies demonstrate that the combination of smaller than usual dosages of two or more drugs for hypertension has proven much more effective than administering just one of the antihypertensives. The logic here, one no less applicable to mental disorders, is that the action of certain modality combinations broadens the range of efficacy to include a variety of potential clinical dysfunctions; together they complement each other and, most importantly, they produce a synergistic result in which the reduced dosage combination results in fewer side effects and a greater level of efficacy than each modality can do on its own.

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Eclectic combinations of several treatment modalities, such as those proposed by Lazarus, are a good start toward the goal of synergizing therapy, that is, to combine methods that are mutually reinforcing, hence strengthening what each modality can achieve separately. The logic for selecting modalities, however, should not be based on “school-oriented” habits, random choice, or superficial analyses, but rather on a knowledge of the inherent traits and psychic processes that characterize different personality styles or disorders. Whether we employ a cognitive modality first, followed by a behavioral, or a family-oriented, or an intrapsychic approach, should be determined by knowing the structure and the character of the patient’s personality makeup, knowledge that may be achieved by employing the MCMI-III with its new facet scales or the new MGFPDC instrument, both discussed in this website.

The combinational revolution in general health treatment has been proposed as a first-line approach to the treatment, not only of medical conditions, but of psychological disorders, as well. These books strongly favor this new model, proposing to guide not just any therapeutic combination, but one built on, and informed by, a thoughtful examination of all of the expressive features (domains) that characterize the person being treated—his/her cognitive distortions, interpersonal conduct, self-image, and the like. Just as medications for diabetes or hypertension are not randomly or habitually chosen, so, too, we in our field must recognize the several spheres of psychic function that characterize our patient’s difficulties. A focused assessment should enable us to identify which specific vulnerabilities and styles prove troublesome, and to understand how they synergistically relate in a pathological manner. With this knowledge as a guide, we can begin to approach our therapeutic task with a justifiably high measure of confidence. As health professionals in other fields have argued, informed combinational therapy is the “wave of the future.”

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