Beyond Traits: Personality As Intersubjective Themes

Nancy McWilliams

The author argues that research in the idiographic tradition is more conducive to

effective clinical work than the uncritical adoption of specific “evidence-based

therapies” for discrete symptomatic disorders. She views pressures on therapists

to adopt EBTs without consideration of individual differences and personal

subjectivity as the misapplication of a research paradigm to the clinical situation.

Reviewing some recent empirical work on individuality and therapeutic process,

she critiques efforts to formulate personality diagnosis on the basis of externally

observable traits without attention to internal experience, and she contends that

intrapsychic themes account for personality differences more powerfully than

traits, even when traits are construed dimensionally.

This paper is a version of a keynote speech given at the 2012 convention of the

Society for Personality Assessment, changed slightly for publication purposes. As I was

preparing for that talk, I found myself feeling a bit fraudulent. Because my doctorate was

in Personality and Social rather than Clinical Psychology, I was never formally trained in

psychological testing. Although I have a fair degree of familiarity with the Rorschach, the

TAT, the MMPI, the Wechsler, and the Myers-Briggs, and a passing knowledge of a few

other instruments, I never took courses in how to administer and interpret them. And

despite being an enthusiastic consumer of research, I am not a researcher. It is therefore

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easy for me to feel out of my depth when addressing seasoned personality assessors,

many of whom have spent decades studying psychological testing and its implications.

What I can offer, however, is the perspective of an experienced therapist whose

career reflects the conviction that good therapy involves adapting the treatment to each

unique patient rather than trying to adapt each patient to an idealized, ritualized, or non-

context-sensitive version of treatment. In some psychoanalytic cultures with which I am

familiar, "classical psychoanalysis" was typically seen as the best treatment, and one of

course wanted to give any patient "the best." Some supervisors would imply, in subtle

and not-so-subtle ways, that one's job was to fit the patient to that idealized technique

rather than to adapt a flexible, psychoanalytically informed treatment to the individual,

unique patient. It wasn't uncommon for students and analytic candidates to be told, for

example, "The patient is responding really well, but was what you did really analysis?" or

"The client's life has greatly improved, but you failed to analyze the transference!" That

always seemed crazy to me - a perverse mix-up between means and ends.

A contemporary version of a similar reversal of means and ends involves the

assumption that specific, empirically supported, manualized treatments are self-evidently

best for all patients who meet certain symptomatic criteria, irrespective of whether their

personalities are more hysterical or obsessional, whether they are more introverted or

extroverted, gay or straight, Italian or Chinese, or even whether their subjective

experience of their suffering is characterized by more self-definitional or more

communitarian elements (Blatt, 2008). As someone who was educated in the tradition of

Henry Murray's personology and Silvan Tomkins's affect theory, grounded in

psychoanalytic ego psychology and object relations ideas, and strongly influenced by

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master personality explicators such as David Shapiro, I feel a gut-level astonishment and

dismay at what this way of formulating psychotherapy leaves out.

Because practitioners began learning at least a century ago that individuals with

similar symptoms but different personalities cannot be given a "one-size-fits-all"

treatment, we developed a longstanding clinical tradition of attention to individual

differences in the people we try to help. Our clients experience our interventions

idiosyncratically depending on, among other factors, their temperaments, their

experiences with earlier caregivers, their attachment styles, and their individual defenses,

maturational issues, cognitive and emotional schemas, social and family contexts,

identifications, cultural and religious sensibilities, sexualities, and relational patterns.

Despite psychology's vast empirical literature on such individual differences, I worry that

the current tendency to treat a given symptom pattern as a thing-in-itself, rather than as an

expression of a client's complex and unique individuality, may produce a generation of

therapists whose main response to suffering is "there's a manual for that."

With no disrespect for the many valuable therapy manuals that have been

developed in recent years, or for the expansion of models that have enriched our options

to help our clients, I think that many contemporary thinkers have made what philosophers

call a "category mistake" with respect to the field of clinical practice. I have no doubt that

most practitioners believe that psychotherapy should be based on scientific research and

not just on clinical anecdote and the authority of admired supervisors. But therapy's being

based on research is different from its being conducted like research. Contemporary

therapists are being pressured to behave as if our work should be governed by the same

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practices that govern a certain kind of stringent research, namely, randomized controlled

trials. And what is considered “evidence” has been narrowed to RCTs.

To do randomized-controlled outcome research with methodological integrity,

one must operationalize one's concepts, select a homogeneous group of patients who

meet diagnostic criteria for a particular condition and yet lack comorbid problems, take

objective measures before and after a series of interventions, and manualize the treatment

to be sure each therapist in the research project is proceeding similarly. Given the

economic and practical realities of empirical research, one must usually delimit the

treatment artificially rather than leaving it open-ended so that each client can progress at

his or her individual pace.

To reason backwards from these research exigencies to the conclusion that

therapists, in working with complexly suffering people who are often filled with shame

for seeking help, should treat disorders as separable from personality and context, should

manualize their work, should define ahead of time the length of the treatment, and should

take objective measures before and after the therapy experience conflates the demands of

one field (empirical research) with the demands of another (applied clinical practice).

Parenthetically, I should note that most therapists believe that clients with uncomplicated,

discrete disorders that are not comorbid with any other problems exist only in the

imagination of some researchers.

We clinicians have traditionally defined our role as including our calling into

question, with our individual clients, some of the psychologically stressful or damaging

assumptions of our surrounding culture - especially the commercially driven pressures

that a mobile, mass society generates to consume products and to compete for narcissistic

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supplies. Increasingly, however, we are being asked to be instruments of that society, to

improve people's behavior only to the point where it is no longer inconvenient to the

larger community (McWilliams, 2005). The term "behavioral health" is replacing "mental

health" and "psychological health" as an organizing concept, as if the internal aspects of

experience are only incidental to an emotionally and psychologically satisfying life.

The current marginalization of personality issues, in favor of a focus on short-

term treatments for delimited disorder categories, based exclusively on the most overt

and obvious symptoms, is at least partly a result of the realities of current academic life,

in which the prompt amassing of a list of small research projects is more conducive to

tenure and promotion than longitudinal studies and longer-term, more complex

scholarship generally. It is also driven by the interests of pharmaceutical corporations,

who have a stake in defining mental and emotional difficulties as discrete symptoms that

their drugs can relieve handily. And most visibly, it reflects the interests of insurance

companies, who learned, after marketing their policies to employers as covering

"comprehensive mental health services," to exclude Axis II diagnoses from those

putatively comprehensive services, given that personalities do not change after a small,

inexpensive number of therapy sessions.

In addition, some aspects of the current, subtle devaluation of the ideographic

tradition in both psychotherapy and research derive, ironically, from psychologists'

worthy efforts to challenge the claims of drug companies to the effect that their chemicals

reduce mood disorders more effectively than therapy. When David Barlow, for example,

began his empirical studies of short-term cognitive-behavioral treatments for symptoms

of depression and anxiety, he was able to establish that, in general, therapy works as well

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as medication for DSM-defined mood disturbances (see, e.g., Barlow, 2007). And yet in

the process, he inevitably accepted the drug industry’s paradigm of isolated symptom and

targeted treatment, independent of personality and based on statistical averages.

We practitioners are now being told that the range and complexity of human

suffering should be defined by the inclusion and exclusion criteria of the studies done in

this original context. We are under pressure to redefine psychotherapy itself, to construe

it in terms of the pre-planned interventions developed for this type of study. Many in the

field (often researchers who don't themselves treat patients) would also have us discard

the strong but somewhat messier and more abstract-level evidence from meta-analyses of

more complex and open-ended therapies (see Shedler, 2010). In the process of the current

redefinitions of what is important to look at, as in so many aspects of contemporary

American life, the commercial world threatens to overwhelm good scholarship,

reasonable health care policies, and even common sense.

A couple of decades ago, most psychology textbooks included an incisive critique

of the "medical model" or "disease model" of conceptualizing problems in living.

Psychologists, readers were told, construed psychopathology with more sophistication

than this paradigm allowed. We considered the whole person, in that person’s context. In

recent decades, partly because of the exigencies of clinical research and the categories

that make sense to those who provide grants for it, and partly because clinicians can

collect insurance reimbursement for work that they frame in this way, we seem to have

uncritically endorsed the most mechanical and reductionist version of a medical model.

(Let me note here my discomfort with calling the categorical, descriptive psychiatry

approach - at least as it has been interpreted as grounds for targeting specific symptoms

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and equating their relief with overall good outcome - a “medical model.” No competent

physician would equate the reduction of observable symptoms with the cure of an

underlying disease. This shorthand may be a necessary way to operationalize therapeutic

progress for research purposes, but it misses some critical realities of clinical experience.)

As many investigators have shown empirically, the idea of matching brand-name

therapies to isolated disease entities, with no consideration of the personality in which

they appear, accounts for very little variance in treatment outcome. In contrast, the two

factors that do account for the lion's share of change in treatment are both personality

variables: first, the specific personalities of both the patient and the therapist, and second,

the quality of the therapeutic relationship, which expresses the interaction of their two

idiosyncratic subjectivities. I am referring here to analyses by researchers such as John

Norcross (e.g., 2002), Bruce Wampold (2001, 2010), Stanley Messer (e.g., Messer &

Wampold, 2002), Sidney Blatt (Blatt & Zuroff, 2005), Per-Einar Bindar (e.g., Bindar,

Holgersen & Nielsen, 2009), and many others. I am probably preaching to the choir in

reviewing these features of the contemporary mental health scene, which are dismaying

to anyone interested in personality issues, but which are particularly distressing to

therapists. As my cognitive-behaviorally oriented colleague, Milton Spett, recently

remarked, "We treat people, not disorders."

Contemporary neuroscientists tell us that even at the level of brain morphology

and chemistry, we are all unique. Geneticists are currently finding one after another area

in which our constitutional endowment and its epigenetic interaction with our interuterine

and post-natal environments determine our individuality. The diversity movement has

sensitized us to cultural differences in personality expression. The work of Rainer Krause

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and his colleagues (e.g., Anstadt, Merten, Ullrich & Krause, 1997; Merten, Anstadt,

Ullrich, Krause & Buchheim, 1996) on facial affect has established that we all have a

distinctive emotional signature as expressed by our facial configurations. Our faces give

testimony to our favored affects, and to habitual patterns of expressing them that match

our core relationship themes. In terms of general systems theory, we each have our own

idiosyncratic affective "fractal."

To illustrate this, Krause examined Everett Shostrom’s 1965 "Gloria" film

(“Three Approaches to Psychotherapy”) and analyzed the recurring facial patterns of Carl

Rogers, Fritz Perls, and Albert Ellis (Haviland-Jones, 2004). He found that Rogers's main

affect was interest/surprise, and that what he tended to tune in on with Gloria was

hostility. Ellis's face was more characterized by anger and contempt, and what he tended

to focus on with Gloria was her anxiety and fear. Perls's facial patterns were dominated

by shame and humiliation and defenses against those feelings, evidently as efforts to

control the affect of distress, which is what he tended to see in Gloria.

Krause has also done fascinating work, mostly published in German, videotaping

psychotherapy. He has discovered that in effective treatment, therapists behave with

"abnormal affect." Normal affect involves matching: When we interact with another

person, our face quickly mirrors the other's expressions. Krause examined therapist-

patient dyads, using clinicians of varying theoretical orientations, in which the patient had

failed to improve in two or more previous therapies. In those pairs in which both parties

agreed after treatment that there had been significant progress, what characterized the

facial affect of the therapist was not matching. He or she might "mark" the client's

emotional state with a brief, equivalent facial expression but then would quickly shift to

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showing another feeling, much as one sees in videos like those of Beatrice Beebe (see

Beebe & Lachmann, 2005), in which a parent marks the infant's emotional state and then

moves to another affect (as in, "Oh, you're unhappy? [brief facial mirroring of distress].

Maybe you're hungry and need to nurse [face showing anticipatory enjoyment].")

If the patient came in feeling ashamed, for example, the therapist's face might

show anger that someone had humiliated him or her. If the client came in angry, the

therapist's face might show curiosity/interest about the sources of the anger. When asked

how they accounted for their success, the clinicians all answered in terms of the

assumptions of their theoretical orientation, but what correlated empirically with the

therapeutic achievements was the therapist's capacity to be in the presence of intense and

often negative facial affects and to convey nonverbally that there is another way to feel

about what the patient reports (Merton, Anstadt, Ullrich, Krause, & Buchheim, 1996).

Extensive research on attachment, mostly done via the Strange Situation paradigm

and the Adult Attachment Interview, has identified some remarkably consistent patterns

underlying our individual relationships with others. I am thinking of the work of

Bowlby's students, Mary Ainsworth and Mary Main, but also Philip Shaver, Mario

Mikulincer, David Wallin, Jeremy Holmes, Karlen Lyons-Ruth, Stanley Tatkin, and

others. It has been clinically quite useful to appreciate our patients' differing attachment

styles and the particular attachment paradigm that gets activated with the therapist.

Before we had a concept of Type-D attachment (e.g., Liotti, 1999), for example, in which

the object of safety is also the object of fear (as expressed in confusing behaviors such as

a child's clinging to the mother and also biting her), it was harder to understand the

ongoing internal experience of our patients who had suffered early relational trauma.

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 Despite these newer, powerful ways of conceptualizing and appreciating

individual differences, therapists are feeling pervasive pressures to redefine ourselves, to

shift our self-definition from knowledgeable healer to technician (or “provider,” a term

with at least faint Orwellian overtones) who applies standard techniques to reified

conditions across the remarkable diversity of people who suffer them. This paradigm

shift, a painful pill for therapists to swallow, has had numerous unintended consequences.

I want to focus on one aspect of this subtle but profound change, the tendency, when we

do try to address personality phenomena, to consider them only or predominantly through

the lens of trait research. This is another area in which what is easily investigable by an

elegant empirical methodology can come to define a field that is much more complicated.

I appreciate the work of Lee Anna Clark and other trait researchers who

emphasize dimensionality rather than the unidimensional, categorical assumptions that

guided the original DSM paradigm shift (from DSM-II to DSM-III). Dimensional

formulations capture human experience better than neo-Kraepelinian, present-versus-

absent criteria-sets, a trope that has been particularly inapt when applied to personality

and its disorders. But at the same time, trait models, even dimensional ones, are

incompatible with the way seasoned clinicians think (Rottman, Kim, Ahn & Sanislow,

2011; Rottman, Ahn, Sanislow & Kim, 2009; Spitzer, First, Shedler, Westen & Skodol,

2008), and there are good reasons, not just resistance to change, for that incompatibility.

What I am worried about is a relative of a problem that Abraham Maslow

identified decades ago. He noted that when one has a really good instrument, it becomes

tempting to believe that anything worth talking about is what can be seen through that

instrument. We have very sophisticated instruments in current trait assessment

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procedures. I am concerned that what they can identify will define and constrict the fields

of both personality and psychotherapy. Jeffrey Singer (2005) seems to feel similarly. In

Personality and Psychotherapy, he reviews five-factor research and other trait

scholarship and applies it didactically to a patient named Jennifer, emphasizing what the

Revised NEO Personality Inventory can brilliantly tap into. But significantly, he adds:

We need to know more about how Jennifer employs defenses in her life to protect

against her vulnerability to stress and her proneness to anxiety and depression. . .

The NEO PI-R offers us a wide sampling of thoughts, behaviors, and potential

defenses, but it makes no causal links to explain how these different aspects of

Jennifer might be connected and in what situations or times they might be applied.

To approach knowledge of Jennifer's whole person, we need to turn to an analysis

of the where, when, and how of her personality, not simply the "what" that the

NEO PI-R provides (p. 46, emphasis his).

Two overall concerns have impelled my own current preoccupation with the

“where, when, and how” of personality and thus my choice of topic for an audience of

personality assessors. First, with the possible exception of the introversion-extroversion

polarity, I have not found the Big Five traits, about which there was much excitement

when I was in my early training in Personality, particularly relevant to my work as a

therapist. Many colleagues agree (see, e.g., Shedler et. al., 2010). Five-factor trait

research has been impressive, but not as applicable to psychological suffering, at least as

that suffering appears in my clinical office, as other ways of formulating reliable

individual differences. Kernberg and Caligor [1996, p. 115] went so far as to observe that

the five-factor model “has an eerie quality of unreality for the experienced clinician.”

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Second, I am worried about the possible unintended consequences of putting our primary

emphasis on traits, because in the current climate, I think that will lead to an

oversimplification and desiccation of psychotherapy.

Although trait-based scales do well at picking up more manifest aspects of

individual difference, they are less useful in accessing the here-and-now struggles that

beleaguer our clients. This observation is not an attack on the nomothetic tradition per se.

I appreciate trait-based instruments that illuminate key aspects of individuality, my most

recent enthusiasm being the recently developed Affective Neuroscience Personality

Scales (see Davis & Panksepp, 2011). I have two arguments to make, however, about the

limitations of construing personality predominantly in terms of traits, both of which

concern their clinical value. (I used to have three, one of which involved dimensionality,

but that is currently being addressed by many scholars.) One problem concerns the

limitations of descriptive as opposed to inferential approaches, and the other entails the

fact that traits express only one side of an internal tension or conflict that is more

important to understand than the traits themselves.

With respect to the first issue, trying to describe conditions only by their

externally observable or objective and measurable aspects at the expense of depicting

their subjectively experienced and inferred features, consider anxiety. For many years,

the DSM has defined anxiety by its overt manifestations, such as rapid heartbeat and

sweaty palms. But there is a long clinical tradition of disciplined naturalistic observation

about significant differences among types of anxiety and how they are experienced. We

discriminate between signal anxiety, moral anxiety, separation anxiety, post-traumatic

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anxiety, and annihilation anxiety, for example, and we craft our clinical interventions

differently depending on which kind we are inferring.

Jaak Panksepp's research in affective neuroscience (Panksepp, 2004; Panksepp &

Biven, 2012) supports the value of making such distinctions, even with respect to medical

treatments of anxiety. There are evidently at least two different neural networks in the

brain for anxiety-type feelings and behaviors, which Panksepp calls the PANIC system

and the FEAR system, respectively. The PANIC system deals with separation-distress

and social-attachment processes. Deep-brain stimulation neural mapping suggests that

when any young mammal emits its distinctive separation cry, the same part of the brain is

activated in the mother mammal as in the baby. This system manages what clinicians

have called separation anxiety. It is mediated by brain glutamate and Corticotrophin

Release Factor (CRF) systems and is inhibited by many brain social chemistries,

including endogenous opioids, oxytocin, and prolactin, along with general arousal

inhibitors such as serotonin (Swain, Lorberbaum, Korse & Strathearn, 2007). Hence,

distress of either anxiety or depression in this system tends to be responsive to the SSRIs.

The FEAR system, contrastingly, is the evolutionary legacy of our terror of

predation. The anxiety that people feel when their concerns are about destruction or self-

fragmentation, rather than separation and attachment, has in the clinical literature been

called "paranoid anxiety," "psychotic anxiety," or "annihilation anxiety" (Hurvich, 2003).

This anxious response arises in a different part of the brain, most notably the amygdala,

and is not as strongly modulated by the neurochemical systems that specifically control

separation distress. FEAR reactions are reduced neurochemically by benzodiazepines and

other "downer" drugs, including alcohol, which may be why our paranoid clients, who

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struggle chronically with this kind of anxiety, are so often unresponsive to SSRIs and

vulnerable to alcoholism and other substance use disorders.

Beyond the pharmacological implications of making such distinctions among

differing subjective experiences and meanings of anxiety, there are the psychotherapeutic

ones: A person suffering annihilation anxiety will not be comforted if a therapist,

assuming that anxiety in the client represents the separation fears that characterize the

therapist’s usual worries, comments on how much the patient needs a warm connection.

Thus, the post-DSM-III framing of anxiety as one phenomenon, manifested by

observable signs that miss the differences in the meaning of the anxiety to different

clients, has deprived clinicians of a rich source of help.

Such concerns apply similarly to depressive psychology. Sidney Blatt (e.g., Blatt

& Bers, 1993) has been studying for decades what the psychoanalytic community had

long construed as a clinically important distinction between two subjectively different

depressive experiences. The first is what the early analysts called "melancholia," which

more contemporary therapists tend to call "introjective depression." In that state of mind,

one feels morally bad, evil, contemptible, guilty, deserving of criticism. The second is

what my early mentors called more narcissistic or existential depression, more recently

termed "anaclitic" depression, in which the internal experience is "I'm alone, I'm empty,

I'm hungry, I need a relationship; life has no meaning; I feel existential despair." In either

of these subjective states, patients may have identical vegetative signs and affective

expressions and meet all the same criteria for a categorical DSM definition of depression.

I was trained that this distinction matters clinically, as follows: If one says

explicitly supportive things to an anaclitically depressed person, he or she will feel better.

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But I was warned not to do this with introjectively depressed individuals, as they would

feel I had not really understood them, that they had conned me into thinking they were

better than they were, they would feel inferior to me because my generosity of spirit

contrasted with their own felt badness, and they would get more depressed. I was taught,

in the language of Freud's structural model, that with these melancholic clients the way to

help them was not to support the ego but to attack the superego. What this looks like is to

say something along the lines of, "So what makes you so uniquely bad? Where did you

get that conceit?" Introjective patients in my experience are quite responsive to such

confrontations. They feel they deserve attack, and the therapist's criticism of their inflated

sense of badness can be assimilated precisely because the tone matches their sense that

they deserve criticism. But what the therapist is attacking, and trying to begin

deconstructing, is their self-attacking tendency.

Blatt has been interested for a long time in subjective disparities among those

suffering depression. One of his most interesting investigations was an analysis of the

ambitious NIMH Treatment of Depression Collaborative Research Program (TDCRP)

(Blatt & Zuroff, 2005). Like most "horse-race" studies in which patients are assigned to

different groups to see which therapeutic approach “wins,” the outcome showed no

significant differences among the treatment groups. But the findings from that study were

reported without differentiating among internal experiences of depression. Fortunately,

enough assessments had been done with the participants that Blatt could discriminate

more anaclitic from more introjective individuals and then examine their outcomes.

What he found was fascinating, and of significant value to clinical practice. The

anaclitically depressed participants got better quickly once the treatment started. There

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was no correlation between what the therapist said and their improvement; it seemed to

be the relationship itself that helped them. This is, of course, intuitively reasonable: If

one’s predominant subjective experience of depression is feeling desperately alone, a

therapeutic relationship immediately begins to mitigate that feeling. The bad news with

the anaclitic clients was that once the treatment was over, they tended to lose their gains

and to revert to feeling depressed.

The introjectively depressed participants, contrastingly, took considerably longer

to get better. And what the clinician said mattered. Patients' progress correlated with

whether or not the therapist confronted their self-hating cognitions. It did not matter

whether the practitioner did this from the perspective of cognitive therapy, challenging

irrational beliefs (e.g., Beck, 1987), or on the basis of psychodynamic ideas such as

Samson and Weiss's emphasis on confronting unconscious pathogenic cognitions

(Silberschatz, 2005). If the therapist pushed patients to rethink their self-criticism, they

began getting better. Although introjectively depressed participants took longer to

respond to treatment, they tended to maintain their gains afterward. Such findings have

much more relevance to clinical practice than statistical averages based on grouping

people according to their observable symptom pattern with no attention to the internal

meanings and subjective experiences of their problems.

In the context of considering depression, let me note the disappearance, as of

DSM-III (in which personality diagnoses were something of an afterthought), of the

depressive personality, or depressive-masochistic personality disorder (Kernberg, 1984).

This omission is another casualty of our looking at overt external phenomena rather than

ongoing internal experience. According to research by Shedler and Westen (Shedler &

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Westen, 2007; Westen, Shedler, Bradley & DeFife, 2012), characterological

depressiveness is the most common personality condition for which individuals seek

treatment. (According to research recently conducted in Australia [Hyde, 2009],

depressive personality – not necessarily personality disorder - is also the most common

kind of personality organization among psychotherapists. This finding tends not to

surprise clinicians.)

What applies to our understanding of anxiety and depression also applies to

personality. When the members of its task force on personality were working on the

Psychodynamic Diagnostic Manual (PDM Task Force, 2006), we realized that Blatt's

introjective-anaclitic polarity, which he has generalized beyond depression and renamed

as a "self-definition" versus "self-in-relation" orientation, could account for many

longstanding clinical observations about subtypes of personality. For example, there is

extensive writing about two versions of narcissism - distinctions between “oblivious” and

“hypervigilant” (Gabbard, 1989), “exhibitionistic” and “closeted” (Masterson, 1993),

“thick-skinned” and “thin-skinned” (Rosenfeld, 1987), “overt” and “covert” or “shy”

(Akhtar, 2000), or “arrogant” and “depressed/depleted” (McWilliams, 2011). Russ,

Shedler, Bradley, and Westen (2008) found these differences empirically, and thus

differentiated between “grandiose-malignant” and “fragile” narcissistic psychologies.

All such polarities capture a more self-definition versus a more self-in-relation

version of narcissism, respectively. Similarly, therapists have contrasted the “aggressive”

with the “passive-parasitic” psychopath (Henderson, 1939), the “flamboyant” with the

“inhibited” hysteric (Horowitz, 1991), and the “moral” with the “relational” masochist

(McWilliams, 2011; Reik, 1941). These differentiations have significant implications for

17
style and content of treatment. I should note that the self-definition/self-in-relation

polarity overlaps nicely with the Big Five trait of introversion/extroversion, but because it

involves inferred internal experience, it is more clinically useful.

Our capacity to work with clients of varying personality types has been

impoverished by efforts to define them by present-versus-absent traits. This is a problem

that the DSM-5 task force members have been struggling to correct, with their proposed

more dimensional approach to diagnosing personality disorders. But leaving the

dimensional issue aside for the moment, let us consider the problem of descriptive versus

inferential diagnosis. Consider the current DSM-IV criteria for Antisocial Personality

Disorder, or what we used to call psychopathy (a term I prefer because it refers to the

internal psychology of the person in question rather than the impact of that person's

behavior on others).

Failure to conform to social norms with respect to lawful behaviors

Deceitfulness

Impulsivity or failure to plan ahead

Irritability and aggressiveness

Reckless disregard for the safety of self and others

Consistent irresponsibility

Lack of remorse (1994, p. 650)

Note that DSM-III did not include that final criterion, which was added at the urging of

clinicians and researchers who saw lack of remorse as pathognomonic of psychopathic

psychology. It is the only internal criterion on the list.

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 These criteria are not exactly "wrong" (with the glaring exception of impulsivity:

Some psychopathic behavior is indeed impulsive, but some is planned and chillingly

predatory [Hare, 1999; Meloy, 2001]). I suspect that the impulsivity criterion represents a

projection of task force members, who may have been personally unable to imagine

carrying out heinous crimes with deliberation and care, and who assumed that if they had

committed such atrocities, it could only have been on impulse.) But there is much that is

missing, namely the internal world of the person in question.

What the list omits includes subjective phenomena such as the inability to love or

empathize, an orientation to people as objects rather than subjects, the organization of

self-esteem around the sense of power over others (evident in glee in "getting over" on

them [Bursten, 1973]), reliance on the defense of omnipotent control, and an inability to

experience nuanced affects. The empirically derived description of Westen, Shedler,

Bradley & DeFife (2012), which supports Cleckley’s (1941) original clinical

observations, emphasizes lack of remorse, lack of empathy, externalization as a defense,

and sadistic pleasure in aggression towards others. The DSM-IV criteria for Antisocial

Personality Disorder were normed on prison inmates. The manual thus, not surprisingly,

states that the disorder is more common among the urban poor (p. 647). People who get

sent to prison do tend to come from impoverished urban backgrounds, but the DSM

criteria ignore all the "Snakes in Suits" (Babiak & Hare, 2007) who had the means to

escape incarceration, whose psychopathy has worked for them rather than against them.

Defining Antisocial Personality Disorder by externally observable manifestations

and equating social effects with personality has led to our overdiagnosing as antisocial

those in poor and criminal subcultures, and to our underdiagnosing psychopathy in

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people with advantages. (I was recently told that Bernard Madoff was happy to learn that

he does not meet DSM criteria for Antisocial Personality Disorder, and he probably does

not.) These meditations are a way of making the point that externally observable, non-

inferential, non-subjectively oriented ways of describing personality leave out a vast

amount of what is most important to understand about individual experience, especially

about its implications for psychotherapy and other interventions.

Let me go to my second point, that personality differences are more intelligible in

terms of themes and tensions than in terms of traits. Attachment research, research on the

self-definition/self-in-relation polarity, and affect research like that of Krause and his

colleagues all bear on critical individual differences, but what they capture are processes

rather than entities, relational patterns rather than static traits. The effort to categorize

personality by the presence or absence of observable traits, even dimensional ones, is

clinically problematic. Therapists, perhaps because we are in ongoing intersubjective

relationships with specific individuals, tend to see personality as involving central themes

or schemas rather than traits (cf. McWilliams, 2011; Young, Klosko & Weishaar, 2006).

While I was working on this talk, a conversation took place on the

psychodynamic researchers listserv, in which Jonathan Shedler made the following

points, that I am condensing with his permission:

While I do think there is an important place for factor-analytically derived

dimensional trait models, I also believe that a dimensional trait approach of the

kind proposed by the DSM-5 committee is inherently problematic. This trait

model presumes (in Kuhnian terms, an untested, a priori, pre-theoretical

assumption) that personality is appropriately understood in terms of bipolar

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 dimensions - that people can be high or low on a given trait, but obviously they

cannot be both. However, psychodynamic understanding of personality is that it is

organized around themes (e.g., areas of preoccupation or conflict), not

dimensions. I would suggest, for example, that narcissistic personality is

organized around the theme of superiority versus inferiority. The essence of

narcissistic personality is neither superiority nor inferiority but the contradiction

itself - the simultaneous existence of both feelings of superiority and inferiority,

and the use of the former to ward off the latter. No bipolar "dimension" can

capture this contradiction. Where would you locate a narcissistic person on, say, a

self-esteem dimension? Should the person be high or low? Neither placement

captures the psychological phenomenon. (e-mail communication, 12/29/2011)

The arrogant, devaluing narcissistic person who falls into shame and self-loathing,

the meticulously neat obsessive-compulsive person who makes a terrible mess, the

withdrawn schizoid person who has moments of intense relatedness - all are clinically

familiar. Practitioners tend to differentiate between character types not by whether a

person is smug versus ashamed or neat versus messy or avoidant versus engaged, but

whether he or she is psychologically structured around, for example, the theme of self-

inflation versus humiliation, control versus dyscontrol, or distance versus closeness. To

the obsessive-compulsive person, closeness-distance issues are not centrally salient; to

the schizoid person, self-inflation versus shame is not a core preoccupation; to the

narcissistic person, order-disorder issues are peripheral, and so on. In the clinical

encounter, one sees traits and behaviors on both ends of any thematic continuum that

organizes the subjective experience characteristic of a particular personality.

21
 The Personality Disorders section of the current DSM ignores the issue of

intersubjective themes. Although it is true that, for example, individuals with a paranoid

personality structure can be accurately construed as having the traits of suspiciousness

and distrust, as per the DSM criteria for the personality disorder, they can also be

pathologically overtrusting, as in the phenomenon of the paranoid cult member who

sincerely believes in a leader's omnipotence or perfection. Paranoia is better understood,

as observers such as Harry Stack Sullivan and Leston Havens have noted, as a pathology

of and preoccupation with trust itself, rather than as a condition characterized by traits on

only one end of the trust-distrust polarity. In paranoid patients, it is common to see

extreme distrust and extreme absence of healthy suspicion alternating, depending on the

person's current situation.

Our recurrent difficulties conceptualizing a personality type that we once called

hysterical but now refer to as histrionic are relevant here. Central to the histrionic

person's subjective experience are preoccupations with gender, sexuality, and power.

Depending on the cultural and temporal context, the expression of such preoccupations

may appear hypersexual or asexual, or both, as in Kernberg's (1984) concept of pseudo-

hypersexuality. This mouthful describes the clinically familiar person who is seductive

and enticing but who fails to enjoy a fully orgasmic sexual experience. Nineteenth-

century descriptions of hysteria emphasized the neurasthenic, fainting, frail, modest

presentation of the conflict around gender, sexuality, and power. Contemporary Western

descriptions, including DSM-IV, emphasize seductiveness, self-dramatization, attention-

seeking, and exhibitionism. Does this mean we have been using the same term for

radically different psychologies? I doubt it. I think it means that the expressions of an

22
inner preoccupation differ depending on context. Another way of viewing this seemingly

paradoxical situation is that the trait of provocative sexualizing is much more closely

related to the trait of sexual inhibition than either is to uncomplicated sexual enjoyment.

Most experienced clinicians frame our interventions on the basis of observed

unconscious or, in more contemporarily acceptable parlance, "implicit" dynamic themes,

whether we call them internalized object relations (Fairbairn, 1952), repetitive structures

(French, 1958), inner working models (Bowlby, 1969), nuclear conflicts (Malan, 1976),

representations of interactions that have been generalized (Stern, 1985), fundamental

repetitive and maladaptive emotional structures (Dahl, 1988), internal relational models

(Aron, 1991), emotion schemas (Bucci, 1997), core conflictual relationship themes

(Luborsky & Crits-Cristoph, 1998), implicit relational knowing (Lyons-Ruth, 1999), or

personal schemas (Horowitz, 1998; Young, Klosko & Weishaar, 2006).

Although psychoanalytic therapists have had a longer period to elaborate on their

observations of such phenomena, this understanding is not an exclusively psychodynamic

position. As cognitive and behavioral therapies have developed and been applied in

diverse real-life clinical settings, the leaders of that practitioner community - therapists

such as Jeffrey Young, Marsha Linehan, and Jacqueline Persons - have emphasized the

same phenomena in the language of their own orientation. To understand such patterns

we therapists draw heavily from scientific research - on attachment, development,

neuroscience, personality, defense, and individual and systemic diversity of many kinds.

We also rely on a disciplined self-awareness, honed in personal therapy, and a deeply

idiographic sense of the patterns that go on between ourselves and each patient.

23
 Some of you have seen the recently released APA DVDs on "Three Approaches

to Psychotherapy: The Next Generation," modeled on the old "Gloria" film, in which

Judith Beck, Les Greenberg, and I all work with the same patient - a man in one DVD

and a woman in another. Trait and symptom-relief models miss the fact that the woman

we interviewed not only denied and avoided strong emotions; she also felt them

intensely. She was not only genuinely upbeat (with obvious traits of extroversion and

agreeableness); she was also deeply unhappy and self-critical and repeatedly enacted that

side of her inner tension. The man we interviewed not only shrank from intimate

attachment, he craved it, and the theme of closeness versus distance organized his

psychological experience in multiple pervasive ways. He did not simply have the

measurable trait of introversion; he had a conflict about emotional intimacy, and his

behavior expressed both sides of that conflict. I think any effective therapist of any

orientation would eventually have to appreciate such inner dynamisms.

Let me conclude with a plea to the psychological assessment community to

consider the value of understanding the subjective internal world of the client in all its

contradiction and complexity, along with a plea to contribute to scientific

conceptualizations of individuality that capture these clinically relevant aspects of

personality and make possible versions of psychotherapy that stand a chance of helping

our clients with what most deeply and recurrently ails them.

Acknowledgments

I am grateful to Kerry Gordon, Jaak Panksepp, and Jonathan Shedler for their help with

the published version of this talk.

24
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