Journal of Psychotherapy Integration, Vol. 10, No.

1, 2000

Toward a New Model of Integrative Psychotherapy: Psychosynergy

Theodore Millon1,2

The goal of resynthesizing that which has been disconnected in our eld is what the author has designated as psychosynergy. This article seeks to advance our shared interest in the subject matter of psychotherapy. Particularly noted are efforts to reconnect the separate realms that give support to therapeutic practice, namely its undergirding scientic principles, its theoretically deduced personality and psychopathologic features, its classication format for organizing psychic pathology, its empirically grounded assessment instruments, and its integration of diverse therapeutic modalities. This overall goal stems from the authors belief that a synthesis of these components not only is possible, but will strengthen progress through mutual reinforcement and reciprocal enhancements.
KEY WORDS: therapy; integration; psychosynergy; personality.

Synergism represents the conjoining of normally separate venues, creating thereby a process of interrelatedness, and producing effects that successfully work together. Nature is intrinsically one, albeit one that we have disassembled for traditional and pragmatic reasons. Resynthesizing that which has been sundered in our eld is that to which I have attached the designation, psychosynergy. This article seeks to advance the synergistic integration of the comprehensive and diverse subject of psychotherapy. The authors belief is that the primary subject of psychological treatment is the person, and not disease, which reects the subject domain
1

University of Miami, Miami, Florida; Harvard University, Cambridge, Massachusetts; and The Institute for Advanced Studies in Personology and Psychopathology, Coral Gables, Florida. Correspondence should be directed to Theodore Millon c/o IASPP, 5400 SW 99th Terrace, Coral Gables, Florida 33156. 37
1053-0479/00/0300-0037$18.00/0 2000 Plenum Publishing Corporation

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of medicine. The essential elements that give substance to personalitythe fact that people exhibit distinctive and abiding characteristicshave survived through the ages, albeit under different rubrics and labels. This durability attests, at the very least, either to personalitys intuitive consonance with authentic observation, its intrinsic, if naive, human interest, or to its decidedly convincing utility. From a rather mundane and practical viewpoint, most mental health practitioners use their professional skills today in outpatient rather than inpatient settings. Their clients are no longer the severely disturbed state hospital psychotics, but ambulatory individuals seen in private ofces or community clinics; these clients are beset with personal stressors, social inadequacies, or interpersonal conicts, which are typically reported in symptoms such as anxiety, depression, or alcoholism, but which signify the outcroppings of longstanding vulnerabilities and maladaptive patterns of behaving, feeling, thinking, and relating: in other words, the individuals personality style. A few words should be said concerning the special role of recent third and fourth editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III and DSM-IV, respectively; American Psychiatric Association, 1980, 1994) in giving prominence to the personality disorders (Millon, 1986). With this ofcial system, personality not only gained a place of consequence among syndromal categories, but became central to its multiaxial schema. The logic for assigning personality its own axis (II) is more than a matter of differentiating syndromes of a more acute and dramatic form from those that may be overlooked by virtue of their longstanding and prosaic character. More relevant to this partitioning decision was the assertion that personality can serve synergistically as a substrate of affective vulnerabilities, cognitive styles, and behavioral dispositions from which clinicians can more fully grasp the meaning of their patients transient or orid Axis I disorders. In the recent DSMs, then, personality disorders of Axis II have not only attained a nosological status of prominence in their own right, but they have also been assigned a synergistic and contextual role that makes them essential to understanding clinical syndromes. There has been a marked shift in the focus of psychological therapies from that of surface symptoms to that of underlying personality functions. This reorientation reects an intriguing evolution that has been shared among diverse theories since the middle of this century. Auchincloss and Michels (1983) described this progression in an illuminating review of the analytical concept of character. They wrote, Today it is generally accepted that character disorders, not neurotic symptoms, are the primary indication for analysis. . . . Psychoanalysis (as a technique) and character

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analysis have become synonymous (p. 2). Recent contributions of ego, self, and object-relations theorists have extended the awareness of the highly varied consequences of early psychic difculties. Today, character structure is seen not only as a system of defensive operations, but as a complex organization of structures that are the focus of therapeutic attention and intervention. Similar shifts in emphasis are also evident in the recent writings of cognitive, behavioral, and interpersonal theorists. An inevitable part of the history of a relatively new science is that its constituent components progress at an uneven rate; some segments are highly advanced, while others struggle and lag behind. So it has been with the scientic elements of psychotherapy. As we move into the 21st century, it appears to me that efforts at coordinating the several components that comprise psychotherapy is long overdue, that is, that theory, classication, assessment, and therapy should become united and relate to one another in a systematic, or what I prefer to call, a synergistic way. Particularly relevant in this regard are efforts to coordinate the separate realms that comprise our eld, namely its relation to the universal laws of nature, its theories that represent these laws in its diverse subject domains, the classication schema that is derivable from these theories, the diagnostic assessment tools it constructs to identify and quantify the elements of the schema, and the therapeutic techniques by which it implements changes in its relevant subject realms. Rather than developing independently and being left to stand as autonomous and largely unconnected functions, a truly mature clinical science (Millon, 1996), one that is designed to create a synergistic bond among its elements, will embody the following explicit elements: 1. Universal scientic principles, that is, be grounded in the ubiquitous laws of nature, despite their varied forms of expression, providing thereby an undergirding framework for guiding and constructing subject-oriented theories. 2. Subject-oriented theories, that is, explanatory and heuristic conceptual schemas of personality and psychopathology that are consistent with established knowledge in both its own and related sciences, and from which reasonably accurate propositions concerning all clinical conditions can be both deduced and understood, enabling thereby the development of a formal classication system. 3. Classication of pathological syndromes and disorders, that is, a taxonomic nosology that has been derived logically from the theory, and provides a cohesive organization within which its major categories can readily be grouped and differentiated, permitting thereby the development of coordinated assessment instruments.

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4. Personality and clinical assessment instruments, that is, tools that are empirically grounded and sufciently sensitive quantitatively to enable the theorys propositions and hypotheses to be adequately investigated and evaluated, and the categories comprising its nosology to be readily identied (diagnosed) and measured (dimensionalized), specifying therefrom target areas for interventions. 5. Integrated therapeutic interventions, that is, planful strategies and modalities of treatment, designed in accord with the theory and oriented to modify problematic clinical characteristics, consonant with professional standards and social responsibilities. It is my belief that it is the coordination of these elements, that is, making them reciprocally enhancing and mutually reinforcing, that constitutes the essence of synergistic thinking. Working together, psychotherapeutic components may reect an overall combined knowledge that ends up being appreciably greater than the sum of their individual contributions. What should be aspired to is the integration of parts that have been disconnected this past century. Just as each person is an intrinsic unity, each component of pathology should not remain a separate element of a wideranging potpourri of unconnected parts. Rather, each element should be integrated into a gestalt, a coupled and synergistic unity in which the whole can become more informative and useful than its individual parts.

PRINCIPLES AND THEORIES: CONNECTING OUR SUBJECT TO EVOLUTIONARY THEORY To achieve synergistic goals, it will be necessary, I believe, to go beyond the current conceptual boundaries of psychology, and explore carefully reasoned, as well as intuitive hypotheses that draw their principles, if not their specic substance, from more established adjacent sciences. Not only may such steps bear new insightful observations, but they may provide insight into the structural synergies that exist throughout nature. Moreover, they should establish a foundation that can undergird and further guide our own disciplines explorations. Much of psychopathology, no less psychology as a whole, remains adrift, divorced from broader spheres of scientic knowledge, isolated from rmly grounded, if not universal principles, leading one to continue building the patchwork quilt of concepts and data domains that characterize our eld. Preoccupied with but a small part of the larger puzzle of nature, or fearing accusations of reductionism, many hesitate to draw on the rich possibilities found in other realms of scholarly pursuit (cosmology, evolutionary biology). With few exceptions, cohering

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concepts that would connect our subject to those of its sister sciences have not been developed (Millon, 1990). Despite the current profusion of new terminology, we seem trapped in (obsessed with?) horizontal renements. A search is needed for integrative schemas and cohesive constructs that link its seekers closely to relevant observations and laws developed in more advanced elds. The goalalbeit a rather grandiose oneis to refashion the patchwork quilt of our facet of science into a well-tailored and aesthetic tapestry that interweaves the many and diverse forms in which nature expresses itself. What better sphere is there within the psychological sciences to explore trait synergies than with the subject matter of personology? Persons are the only organically integrated systems in the psychological domain, evolved through the millennia and inherently created from birth as natural entities, rather than culture-bound and experience-derived gestalts. The intrinsic cohesion of persons is not merely a rhetorical construction, but an authentic substantive unity. Personologic features may often be dissonant, and may be partitioned conceptually for pragmatic or scientic purposes, but they are segments of an inseparable biopsychosocial entity. It is in both the spirit and substance of Darwins explanatory principles that the personologically oriented reader should consider the evolutionary proposals I have made. The principles employed are essentially the same as those which Darwin developed in seeking to explicate the origins of species. However, they are utilized to derive, not the origins of species, but the structure and style of each of the personality styles and disorders that have been formulated most clearly, but atheoretically on the basis of clinical observation alone (e.g., DSM-IV). Normal personality may best be conceived as representing the more-or-less distinctive ways of adaptive functioning that an organism of a particular species exhibits as it relates to its typical range of environments. Disorders of personality, so formulated, would represent maladaptive styles of functioning that can be traced to deciencies, imbalances, or conicts in a species capacity to relate to the environments it faces. What makes evolutionary theory as universal as I have proposed? Recent developments bridging ecological and evolutionary theory are well underway, and hence do offer some justication for extending their principles to human styles of adaptation. To provide a conceptual background from these sciences, and to furnish a rough model concerning personality disorders, I have identied three universal, and one distinctly human sphere in which evolutionary and ecological principles are demonstrated. They are labeled Existence, Adaptation, Replication, and Abstraction. The rst relates to the serendipitous transformation of random or less organized states into those possessing distinct structures of greater organization (life

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enhancement and life preservation); the second refers to homeostatic processes employed to sustain survival in open ecosystems (ecologic modication and ecologic accommodation); the third pertains to reproductive styles that maximize the diversication and selection of ecologically effective attributes (self-propagation and other nurturance); and the fourth, a distinctly human function, concerns the emergence of competencies that foster anticipatory planning and reasoned decision making (rational thought and emotional resonance). It is my belief that all human functioning, as with all spheres of nature, stems from universal principles of evolution that undergird innumerable variations. These evolutionary laws provide a framework that allows human beings, for example, to develop diverse forms of personality expression, while adhering to the same laws that meet lifes guidelines. It is these universal principles that all humans are born knowing and that permit children to adopt any one or another lifestyle. All creatures adopt styles of thought and behavior that invariably seek to fulll one or another combination of the very same polarities. The model seeks to provide an explanatory framework, one that utilizes a short list of principles to account for the numerous forms in which distinctive personalities develop. The task I have set forth is to articulate these explanatory laws, those shared elements that underlie all human functioning. At a fundamental level, all personality variations derive from the same mold. What has been most rewarding is that the threefold structure generates the same rich array of personality patterns that astute clinicians have derived from their observations. Although personalities can be exceptionally diverse, the clinician will be able to see that they are really variations of the same evolutionary themes.

CLASSIFICATION: DERIVING A SYNERGISTIC TAXONOMY OF ADAPTIVE AND MALADAPTIVE STYLES The concepts used to construct a mental health classication should be anchored to a theoretical framework. In fact, the goal of any science is a mode of comprehension in which all of the phenomena of a subject domain are brought within the boundaries of a limited set of principles. Einsteins search for the Unied Field Theory was an effort to bring the fundamental forces of naturegravity, magnetism, the strong and weak nuclear forcesinto a single explanatory framework. Similarly, whether assuming the role of therapist, theorist, or researcher, the goal in common is to understand how all persons, adaptive or not, are constructed by carving nature at its joints.

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There is a clear logic to classifying syndromes in medical disorders. Bodily changes wrought by infectious diseases and structural deterioration repeatedly display themselves in a reasonably uniform pattern of signs and symptoms that make sense in terms of how anatomic structures and physiological processes are altered and then dysfunction. Moreover, these biological changes provide a foundation not only for identifying the etiology and pathogenesis of these disorders, but also for anticipating their course and prognosis. Logic and fact together enable one to construct a rationale to explain why most medical syndromes express themselves in the signs and symptoms they do, as well as the sequences through which they unfold. Can the same be said for psychopathological classications? Is there logic, or perhaps evidence, for believing that certain forms of clinical expression (e.g., behaviors, cognitions, affects, mechanisms) cluster together as do medical syndromes; that is, not only covary frequently, but make sense as a coherently organized and reasonably distinctive group of characteristics? Are there theoretical and empirical justications for believing that the varied features of personality display a congurational unity and expressive consistency over time? Will the careful study of individuals reveal congruency among attributes such as overt behavior, intrapsychic functioning, and biophysical disposition? Is this coherence and stability of psychological functioning a valid phenomenon, that is, not merely imposed on observed data by virtue of clinical expectation or theoretical bias? There are reasons to believe that the answer to each of the preceding questions is yes. Stated briey and simply, the observations of covariant patterns of signs, symptoms, and traits may be traced to the fact that people possess relatively enduring biophysical dispositions, which give a consistent coloration to their experience, and that the range of experiences to which people are exposed throughout their lives is both limited and repetitive (Millon, 1969, 1981; Millon & Davis, 1996b, 2000). Given the limiting and shaping character of these biogenic and psychogenic factors, it should not be surprising that individuals develop clusters of prepotent and deeply ingrained behaviors, cognitions, and affects that clearly distinguish them from others of dissimilar backgrounds. Moreover, once a number of the components of a particular personality pattern are identied, knowledgeable clinicians can trace the presence of other, unobserved, but frequently correlated features comprising that pattern. A question that must be addressed concerning the nature of personological categories or dimensions may be phrased best as follows: Why does the possession of characteristic A increase the probability, appreciably beyond chance, of also possessing characteristics B, C, and so on? Put in a less abstract way, why do particular behaviors, attitudes, mechanisms, and so on covary in repetitive and recognizable ways rather than exhibit

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themselves in a more-or-less haphazard fashion? Put in an even more concrete way, why do behavioral defensiveness, interpersonal provocativeness, cognitive suspicion, affective irascibility, and excessive use of the projection mechanism cooccur in the same individual rather than be uncorrelated and randomly distributed among different individuals? The answers are, as implied above, that temperament and early experience simultaneously affect the development and nature of several emerging psychological structures and functions; that is, a wide range of behaviors, attitudes, affects, and mechanisms can be traced to the same origins, which thereby leads to their frequently observed covariance. Second, once an individual possesses these initial characteristics, they set in motion a series of derivative life experiences that shape the acquisition of new psychological attributes that are causally related to the characteristics that preceded them in the sequential chain. Common origins and successive linkages increase the probability that certain psychological characteristics will frequently be found to pair with specic others, which thereby results in repetitively observed clinical syndromes or personality pattern clusters. Illustrations of these reciprocal covariances and serially unfolding concatenations among longitudinal inuences (e.g., etiology) and concurrent attributes (e.g., signs, traits) may be found in Millon (1969, 1981, 1990) and Millon and Davis (1996b). The latent theoretical model I have formulated seeks to explicate the structure and styles of personality with reference to decient, imbalanced, or conicted modes of ecologic adaptation and reproductive strategy. Some readers will judge these conjectures persuasive; a few will consider them interesting, but essentially unconrmable, still others will nd little of merit in them. Whatever ones appraisal, the theoretical model may best be approached in the spirit in which it was formulatedan effort to bring together observations from different domains of science in the hope that scientic principles derived in adjacent elds can lead to a clearer understanding of their neighbors. The theoretical model I have based on evolutionary principles has generated several new personality categories, several of which have found their way into the DSM-III and DSM-IV (Kernberg, 1984). Drawing on the threefold polarity framework, a series of 11 personality prototypes and 3 severe variants were deduced, of which a few have proved to be original derivations in the sense that they had never been formulated as categories in prior mental health nosologies (e.g., portraying and coining the avoidant personality designation; Millon, 1969). Progressive research will determine if the network of concepts comprising this theory provides an optimal and valid structure for a comprehensive classication of clinical and personality pathology. At the very least, it contributes to the view

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that formal theory can lead to the deduction of new categories worthy of consensual verication. Of course, formal theory should not be pushed far beyond the data, and its derivations should be linked at all points to established clinical observations. Given the vast scope of personalities as well as the extent of knowledge still to be gathered, latent theories of classication are best kept limited today in both their focus and their specicity.

ASSESSMENT: DEVELOPING INSTRUMENTS THAT SYNERGIZE AXIS I AND AXIS II An historic and still frequently voiced complaint about diagnosis, be it based or not on the ofcial classication system, is its inutility for therapeutic purposes. Many clinicians, whatever their orientation, pay minimal attention to the possibility that diagnosis can inform the therapeutic philosophy and technique they employ. Synergistic assessment insists on the primacy of an overarching gestalt that gives coherence, provides an interactive framework, and creates an organic order that integrates the syndromes of Axis I with the disorders of Axis II. Each person becomes a synthesized and substantive whole that is greater than the sum of its multiaxial parts. The problems that our patients bring to us are an inextricably interwoven structure of behaviors, cognitions, intrapsychic processes, and so on, bound together by feedback loops and serially unfolding concatenations that emerge at different times and in dynamic and changing congurations, sometimes in the form of an Axis I syndrome, sometimes in the shape of an Axis II disorder, and sometimes in formations composed of both axes. The interpretation of the psychological inventories I have constructed such as the Millon Clinical Multiaxial Inventory (MCMI) does not proceed through a serial interpretation of its single scales. Instead, each scale contextualizes and transforms the meaning of the others in the prole. It should be noted that even mechanical tools such as the Minnesota Multiphasic Personality Inventory (MMPI) are now being interpreted primarily in terms of congural proles. No longer approached only as a set of separate scales, formerly segmented instruments are now being analyzed as congural integrations that possess clinical signicance and meaning as gestalt composites. Moreover, the former insistence that interpretation be anchored precisely to empirical correlates has given way to free-form clinical syntheses, including the dynamics of the unfairly maligned projectives. Personality formulations are no longer conceived as arbitrary sets of syndromal and trait scales that must rst be individually deduced and then

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pieced together, but as holistic or integrated congurations from the very start. Hence, I have sought to develop tools explicitly designed, for example, to diagnose and relate dysthymia in the borderline personality or generalized anxiety in the narcissistic personality. My own set of instruments, particularly the MCMI, represent this trend toward holistic personality tools, bridging and coupling both the DSM-IV Axis I clinical syndromes and Axis II personality disorders in a single inventory (Millon, 1977; Millon & Davis, 1995). The synergy of such assessment tools ows from their reciprocal clinical insights. To know that the patient is dysthymic is of value. Of greater value, however, is whether we know that the patient exhibits the core features of a histrionic personality with dysthymia, or the characteristics of an avoidant personality with dysthymia, and so on. The clinical domains of psychic functioning arise from the observation that psychopathology has been viewed from many different theoretical perspectives. Classical psychoanalytic theorists, for example, hold that personality is the expression of the vicissitudes of drives, while cognitive theorists holds that beliefs are central. The problem when attempting to coordinate such diverse perspectives is how to do so in a logical way which is consonant with the intrinsic organismic integrity of the person him/herself. Perhaps the best way to organize the domains of personality and psychopathology is to draw upon a distinction made in the biological sciences between structure and function. The basic science of anatomy investigates embedded and essentially permanent structures, which serve, for example, as substrates for mood and memory, while physiology examines underlying functions which regulate internal dynamics and external transactions. As an integrated totality, personality must depend on structural and functional domains, just as does any organism. In most cases, these domains parallel major approaches to the eld. Nothing is really new here, except the fact that these domains are presented in juxtaposition as a means of obtaining a complete representation of any given personality style, one which eschews the past dogmatisms of personality theory, just as psychotherapists have sought to break free of their own school-oriented past. The Expressive Acts domain represents the behavioral legacy of Thorndike, Skinner, and Hull, for example, while the Interpersonal Conduct domain represents the Interpersonal tradition, originating with Sullivan, and expressed today by Benjamin, Kiesler, and Wiggins, among others. The Cognitive Style domain is obviously intended to represent the cognitive tradition, of which Beck is the most notable modern exponent, while the Regulatory Mechanisms and Object Representations domains parallel the ideas of defense mechanisms and object relations of the psychodynamic school. All of these are legitimate approaches to personality, and through their very existence provide empirical support for the structural paradigm

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advanced above, that personality pathologies are best thought of as disorders of the entire matrix of the person. Unless we wish to return to a school-oriented and dogmatic past, we must be prepared to accept that each of these perspectives makes a legitimate claim on the content of personality. Similarly, if assessments are to be complete, it must seek forms of expression which address syndromes and disorders as pathologies that include each of these domains. The alternative is a reduction of this complex matrix to some singular perspective, be it behavioral, cognitive, or psychodynamic, or, in other words, to embrace again the past, to treat a part as if it was the whole.

PSYCHOTHERAPY: ORGANIZING A SYNERGISTIC PLAN FOR TREATMENT The cohesion of complexly interwoven psychic structures and functions is what distinguishes the disorders of the person from Axis I clinical syndromes; likewise, the orchestration of diverse, yet synthesized techniques of intervention is what differentiates synergistic from other variants of integrative psychotherapy (Millon, 1999). These two parallel constructs, emerging from different traditions and conceived in different venues, reect shared philosophical perspectives, one oriented toward the understanding of psychopathology, the other toward effecting its remediation. Although synergistic therapy can be applied to a variety of diverse clinical conditions, it would be wise to recognize that personality is that segment of psychopathology for which synergistic approaches are ideally and distinctively suitedin the same sense as behavioral techniques appear most efcacious in the modication of problematic actions, cognitive methods optimal for reframing phenomenological distortions, and intrapsychic techniques especially apt in resolving unconscious processes. Treatment itself should be synergistically organized; it ows through a series of bonds to each of the preceding component themes. Planning therapy reects the recommendations of specic tools for assessment; these assessments, in turn, have been constructed to represent and synthesize a multiaxial taxonomy, which, in turn, derives from a theory that accords with certain universal principles of nature. Our eld has been plagued (enriched?) by a grab bag of fascinating techniques. However, far from being a sign that psychotherapy has progressed, this variety represents a primitive history stage in which an initial task is to inventory what techniques exist and whether they work. Eclectic approaches may be genuinely impressive for their efcacy, but, if so, it is because they inadvertently tap into the latent organizing principles of na-

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tures structure, not because they are scientic in the sense of being generated by, or even coordinated to such deeper organizing principles. 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 naturethe 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 signicantly on the reality of human life. We join with thinkers of the past and argue that no part of human nature should lie outside the scope of a clinicians regard, e.g., the family and culture, neurobiological processes, unconscious memories, and so on. It is my hope that integrative therapies will lead us 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 clinicians attention to just one or another facet of their patients psychological makeup, thereby wandering ever farther from human reality. They cease to represent the fullness of their patients lives, considering as signicant only one of several psychic spheresthe unconscious, biochemical processes, or cognitive schemas, and so on. In effect, what has been taught to most edgling therapists is an articial reality, one which may have been formulated in its early stages as an original perspective and insightful methodology, but which has drifted increasingly from its moorings over time, no longer anchored to the clinical reality from which it was abstracted. If my wish takes root, this article should serve as a revolutionary call, heralding a renaissance that brings therapy back to the natural reality of patients lives. In line with the preceding, I 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 ctions, 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 signicance of each clinical component can best be grasped by reviewing a patients unique psychological experiences and his/her pattern of congurational dynamics, of which this component is but one part. Looking at a patients 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 I have recently contended

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(Millon, 1999), 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 I 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 conducive to both briefer and more effective therapy. My work does not limit its focus to the treatment of personality disorders. I have attempted 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 patients overall personality style. Current debates regarding whether technical eclecticism or integrative therapy is the more suitable designation for our approach are mistaken. These discussants have things backward, so to speak, because they start the task of intervention by focusing rst 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 patients 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 personality-guided synergistic therapy to represent our brand of integrative treatment. 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. It is the person who lies at the heart of the therapeutic experience, the substantive being who gives meaning and coherence to symptoms and traitsbe they behaviors, affects, or mechanismsas 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. As with synergistic assessment, personality-guided therapy demands that the focus of treatment must reside with the whole person as an integrated and substantive system, with the whole being greater than the sum

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of its parts. This focus lends congruity, provides a dynamic therapeutic structure, and creates an ingenuous order among otherwise disparate and haphazard clinical techniques. Our patients problems are an interwoven and variegated pattern of expressive acts, cognitive processes, and intrapsychic structures, each bound together by feedback mechanisms and continuously unfolding connections that emerge randomly and sporadically, often in unpredictable and continually mutable conformations. In much the same way the MCMI contextualizes the meaning of singular personality scales by virtue of its relationship with others in the overall prole, personalityguided therapy must be conceived as a conguration of strategies and tactics in which each intervention technique is selected not only for its efcacy 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 patients psychological makeup that differentiates personality-guided psychotherapy from its integrative counterparts. The interwoven nature of the components comprising personality-guided 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 sufcient in themselves to undertake a therapy of the patient, disordered or not. As stated, the revolution I propose asserts that clinical disorders are not exclusively behavioral or cognitive or unconscious, that is, conned to particular expressive form. The overall pattern of a persons traits and psychic expressions are systemic and multioperational. 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 disorders 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 herself or himself; this form of therapy should generate more than the sum of its parts. Difcult sounding as this may appear, I hope I have demonstrated its ease and utility in a recent book (Millon, 1999). Personality-guided synergism employs two basic strategies. The rst 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

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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 cognitivebehavioral therapy. The second synergistic 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 rst to alter a patients stuttering by direct behavioral modication procedures which, if achieved, would facilitate the use of cognitive methods in producing self-image changes in condence, which, in its turn, would foster the utility of interpersonal techniques to effect social skill improvement. Personality-guided therapy is conceived, therefore, as a conguration of strategies and tactics in which each intervention technique is selected not only for its efcacy in resolving particular pathological difculties, but also for its role in contributing to the overall constellation of treatment procedures, of which it is but one. As a general philosophy then, it seems that we should select our specic treatment techniques only as tactics to achieve strategic goals. Depending on the pathological domains to be modied and the overall treatment sequence one has in mind, the goals of therapy should be oriented toward the improvement of imbalances or deciencies by the use of techniques that are optimally suited to modify their expression in those clinical domains that are problematic. While the Axis I disorders are symptomatic in nature, and therefore presumably amenable to more focal and briefer interventions, personality traits are dispositional, specically dened as longstanding, pervasive, and actively resistant to outside inuences. As stated earlier, to treat personality is to wrangle with the ballast of a lifetime, to correct a developmental disorder of the entire matrix of the person, produced and perpetuated across years of functioning. Personality is multioperational and systemic. No part of the system exists in complete isolation. Instead, every part is directly or indirectly tied to every other, such that an emergent synergism lends the whole a clinical tenacity which makes personality a real thing to be reckoned with in any therapeutic enterprise. The key to treating personality and syndromal disorders lies in constructing congurations of therapy which are as organismically complex as the person him/herself. CLOSING COMMENT It is not that a variety of integrative therapies are inapplicable to focal pathologies, but rather that synergistic therapies are required for complex

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syndromes and personality disorders; it is the very interwoven nature of the components that makes a multifaceted and synthesized approach a necessity. In the future, it is hoped that the understanding of personality pathology will enable one to better understand the entire matrix of the persons psychic pathologies, both Axis I and Axis II. This should lead to a meaningful and useful schema for therapy, one that is as synergistic as are psychological disorders themselves. The empirical groundwork for a therapeutic approach must follow rather than precede its guiding principles, its undergirding theory, its assessment tools, or its diagnostic classications, the rst four components of a clinical science (Millon, 1996b). This article has offered an opportunity to outlined the overall rationale of personality-guided therapy, the nal constituent of the vefold scientic program that I have referred to recently as psychosynergy.

REFERENCES
American Psychiatric Association (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Auchincloss, E. L., & Michels, R. (1983). Psychoanalytic theory of character. In J. P. Frosch (Ed.), Current perspectives in personality disorders. Washington, DC: American Psychiatric Press. Clarkin, J., & Lenzenweger, M. (Eds.) (1995). Major theories of personality disorder. New York: Guilford Press. Kernberg, O. (1984). Severe personality disorders. New Haven, CT: Yale University Press. Millon, T. (1969). Modern psychopathology: A biosocial approach to maladaptive learning and functioning. Philadelphia, PA: Saunders. Millon, T. (1977). Millon Clinical Multiaxial Inventory, manual. Minneapolis, MN: National Computer Inventory and Computer Systems. Millon, T. (1981). Disorders of personality: DSM-III, axis II. New York: Wiley-Interscience. Millon, T. (1986). On the past and future of DSM-III. In T. Millon & G. L. Klerman (Eds.), Contemporary directions in psychopathology: Toward the DSM-IV. New York: Guilford Press. Millon, T. (1987a). Millon Clinical Multiaxial Inventory-II, manual. Minneapolis, MN: National Computer Systems. Millon, T. (1987b). On the nature of taxonomy in psychopathology. In C. Last & M. Hersen (Eds.), Issues in diagnostic research. New York: Plenum. Millon, T. (1988). Personologic psychotherapy: Ten commandments for a post-eclectic approach to integrative treatment. Psychotherapy, 25, 209219. Millon, T. (1990). Toward a new personology: An evolutionary model. New York: Wiley-Interscience. Millon, T. (1991a). Normality: What can we learn from evolutionary theory? In D. Offer and M. Sabshin (Eds.), Normality: Context and theory. New York: Basic Books. Millon, T. (1991b). Classication in psychopathology: Rationale, alternative & standards. Journal of Abnormal Psychology, 100, 245261. Millon, T. (1994). Millon Clinical Multiaxial Inventory-III, manual. Minneapolis, MN: National Computer Systems.

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Millon, T. (1996). Personality and psychopathology: Building a clinical science. New York: Wiley-Interscience. Millon, T. (1999). Personality-guided therapy. New York: Wiley-Interscience. Millon, T., & Davis, R. D. (1995). Putting Humpty-Dumpty together again: Using the MCMI in psychological assessment. In L. Beutler & M. Birren (Eds.), Integrative assessment of adult personality. New York: Guilford Press. Millon, T., & Davis, R. D. (1996a). An evolutionary theory of personality disorders. In J. Clarkin & M. Lenzenweger (Eds.), Major theories of personality disorder. New York: Guilford Press. Millon, T. (with Davis, R. D.). (1996b). Disorders of personality: DSM-IV and beyond (2nd ed.). New York: Wiley-Interscience. Millon, T., & Davis, R. D. (2000). Personality disorders in modern life. New York: Wiley-Interscience.