Essentials of MCMI-IV Assessment [1 ed.] 1119236428, 9781119236429

Citation preview

Essentials of MCMI®-IV Assessment

Essentials of Psychological Assessment Series Series Editors, Alan S. Kaufman and Nadeen L. Kaufman Essentials of 16 PF ® Assessment by Heather E. P. Cattell and James M. Schuerger Essentials of ADHD Assessment for Children and Adolescents by Elizabeth P. Sparrow and Drew Erhardt Essentials of Assessing, Preventing, and Overcoming Reading Difficulties by David A. Kilpatrick Essentials of Assessment Report Writing by Elizabeth O. Lichtenberger, Nancy Mather, Nadeen L. Kaufman, and Alan S. Kaufman Essentials of Assessment with Brief Intelligence Tests by Susan R. Homack and Cecil R. Reynolds Essentials of Autism Spectrum Disorders Evaluation and Assessment by Celine A. Saulnier and Pamela E. Ventola Essentials of Bayley Scales of Infant Development–II Assessment by Maureen M. Black and Kathleen Matula Essentials of Behavioral Assessment by Michael C. Ramsay, Cecil R. Reynolds, and R. W. Kamphaus Essentials of Career Interest Assessment by Jeffrey P. Prince and Lisa J. Heiser Essentials of CAS Assessment by Jack A. Naglieri Essentials of Child and Adolescent Psychopathology, Second Edition by Linda Wilmshurst Essentials of Cognitive Assessment with KAIT and Other Kaufman Measures by Elizabeth O. Lichtenberger, Debra Y. Broadbooks, and Alan S. Kaufman Essentials of Conners Behavior Assessments™ by Elizabeth P. Sparrow Essentials of Creativity Assessment by James C. Kaufman, Jonathan A. Plucker, and John Baer Essentials of Cross-Battery Assessment, Third Edition by Dawn P. Flanagan, Samuel O. Ortiz, and Vincent C. Alfonso Essentials of DAS-II ® Assessment by Ron Dumont, John O. Willis, and Colin D. Elliott Essentials of Dyslexia Assessment and Intervention by Nancy Mather and Barbara J. Wendling Essentials of Evidence-Based Academic Interventions by Barbara J. Wendling and Nancy Mather Essentials of Executive Functions Assessment by George McCloskey and Lisa A. Perkins Essentials of Forensic Psychological Assessment, Second Edition by Marc J. Ackerman Essentials of Gifted Assessment by Steven I. Pfeiffer

Essentials of IDEA for Assessment Professionals by Guy McBride, Ron Dumont, and John O. Willis Essentials of Individual Achievement Assessment by Douglas K. Smith Essentials of Intellectual Disability Assessment and Identification by Alan W. Brue and Linda Wilmshurst Essentials of KABC-II Assessment by Alan S. Kaufman, Elizabeth O. Lichtenberger, Elaine Fletcher-Janzen, and Nadeen L. Kaufman Essentials of KTEA-3 and WIAT ®-III Assessment by Kristina C. Breaux and Elizabeth O. Lichtenberger Essentials of Millon™ Inventories Assessment, Third Edition by Stephen Strack Essentials of MMPI-A™ Assessment by Robert P. Archer and Radhika Krishnamurthy Essentials of MMPI-2® Assessment, Second Edition by David S. Nichols Essentials of Myers-Briggs Type Indicator ® Assessment, Second Edition by Naomi L. Quenk Essentials of NEPSY ®-II Assessment by Sally L. Kemp and Marit Korkman Essentials of Neuropsychological Assessment, Second Edition by Nancy Hebben and William Milberg Essentials of Nonverbal Assessment by Steve McCallum, Bruce Bracken, and John Wasserman Essentials of PAI ® Assessment by Leslie C. Morey Essentials of Planning, Selecting, and Tailoring Interventions for Unique Learners by Jennifer T. Mascolo, Vincent C. Alfonso, and Dawn P. Flanagan Essentials of Processing Assessment, Second Edition by Milton J. Dehn Essentials of Psychological Testing, Second Edition by Susana Urbina Essentials of Response to Intervention by Amanda M. VanDerHeyden and Matthew K. Burns Essentials of Rorschach® Assessment by Tara Rose, Michael P. Maloney and Nancy Kaser-Boyd Essentials of School Neuropsychological Assessment, Second Edition by Daniel C. Miller Essentials of Specific Learning Disability Identification by Dawn P. Flanagan and Vincent C. Alfonso

Essentials of Stanford-Binet Intelligence Scales (SB5) Assessment by Gale H. Roid and R. Andrew Barram Essentials of TAT and Other Storytelling Assessments, Second Edition by Hedwig Teglasi Essentials of Temperament Assessment by Diana Joyce Essentials of WAIS ®-IV Assessment, Second Edition by Elizabeth O. Lichtenberger and Alan S. Kaufman Essentials of WISC ®-V Assessment by Dawn P. Flanagan, Vincent C. Alfonso Essentials of WJ IV ® Cognitive Abilities Assessment by Fredrick A. Schrank, Scott L. Decker, and John M. Garruto

Essentials of WJ IV ® Tests of Achievement by Nancy Mather and Barbara J. Wendling Essentials of WMS ®-IV Assessment by Lisa W. Drozdick, James A. Holdnack, and Robin C. Hilsabeck Essentials of WNV ™ Assessment by Kimberly A. Brunnert, Jack A. Naglieri, and Steven T. Hardy-Braz Essentials of Working Memory Assessment and Intervention by Milton J. Dehn Essentials of WPPSI ™-IV Assessment by Susan Engi Raiford and Diane L. Coalson Essentials of WRAML2 and TOMAL-2 Assessment by Wayne Adams and Cecil R. Reynolds

Essentials of MCMI®-IV Assessment Seth Grossman Blaise Amendolace

Copyright © 2017 by John Wiley & Sons, Inc. All rights reserved. Published by John Wiley & Sons, Inc., Hoboken, New Jersey. Published simultaneously in Canada. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the publisher, or authorization through payment of the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax 978-646-8600, or on the Web at www.copyright.com. Requests to the publisher for permission should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, 201-748-6011, fax 201-748-6008, or online at www.wiley.com/go/permissions. Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Neither the publisher nor author shall be liable for any loss of profit or any other commercial damages, including but not limited to special, incidental, consequential, or other damages. Readers should be aware that Internet Web sites offered as citations and/or sources for further information may have changed or disappeared between the time this was written and when it is read. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold with the understanding that the publisher is not engaged in rendering professional services. If legal, accounting, medical, psychological or any other expert assistance is required, the services of a competent professional should be sought. For general information on our other products and services, please contact our Customer Care Department within the U.S. at 800-956-7739, outside the U.S. at 317-572-3986, or fax 317-572-4002. Wiley publishes in a variety of print and electronic formats and by print-on-demand. Some material included with standard print versions of this book may not be included in e-books or in print-on-demand. If this book refers to media such as a CD or DVD that is not included in the version you purchased, you may download this material at http://booksupport.wiley.com. For more information about Wiley products, visit www.wiley.com. Library of Congress Cataloging-in-Publication Data Names: Grossman, Seth, 1968- author. | Amendolace, Blaise, 1982- author. Title: Essentials of MCMI -IV assessment / Seth Grossman, Psy.D., Blaise Amendolace, Psy.D. Other titles: Essentials of psychological assessment series. Description: Hoboken, New Jersey : John Wiley & Sons, 2017. | Series: Essentials of psychological assessment series | Includes bibliographical references and index. Identifiers: LCCN 2016035910 (print) | LCCN 2016052631 (ebook) | ISBN 9781119236429 (pbk.) | ISBN 9781119236436 (pdf ) | ISBN 9781119236443 (epub) Subjects: LCSH: Millon Clinical Multiaxial Inventory—Handbooks, manuals, etc. Classification: LCC RC473.M47 G76 2017 (print) | LCC RC473.M47 (ebook) | DDC 616.89/075076—dc23 LC record available at https://lccn.loc.gov/2016035910

®

Cover design: Wiley Cover image: ©Greg Kuchik/Getty Images Printed in the United States of America FIRST EDITION

PB Printing

10 9 8 7 6 5 4 3 2 1

To our sons, Aiden and Lucca, Both of you provide the fire and light that allow us to push forward, always providing a why for any how. With all of our love, SG and BA

CONTENTS

One

List of Figures

xiii

List of Tables

xv

Series Preface

xvii

®

History and Development of the MCMI Through MCMI -IV

®

1

Construction of the Legacy MCMI Tests (MCMI, MCMI-II, MCMI-III) Development of the MCMI-IV Test Yourself

Two

®

MCMI -IV and Millon Evolutionary Theory

3 7 16

19

Personality as Focal Point in Clinical Assessment and Intervention An Evolutionary Model of Personality Motivating Aims Problematic Patterns in Motivating Aims Levels of Adaptiveness Structural and Functional Domains Applying Millon’s Evolutionary Theory to the MCMI-IV Test Yourself

Three

19 20 21 23 25 25 29 30

Administration and Scoring

33

Administration Scoring Test Yourself

33 35 38 ix

x CONTENTS

Four

Five

Six

Seven

Sections and Scales

41

Validity and Modifying Indices Noteworthy Responses Clinical Personality Patterns Severe Personality Pathology Clinical Syndromes Severe Clinical Syndromes Grossman Facet Scales Test Yourself

42 44 45 77 85 87 88 95

Interpretive Principles

97

Role of Personality in Assessment: A Recapitulation Building an Integrative MCMI-IV Interpretation Integrating the Overall Clinical Picture Test Yourself

97 99 107 107

Therapeutic Alliance Building

109

Introducing the MCMI-IV to the Examinee Preparing the Examinee for Feedback The Examiner’s Initial Preparation for Feedback Moving Away From Labels Understanding the Examinee’s Test-Taking Style (Modifying Indices) Language of the Theory = Language of Alliance 1: Individual Personality Scales Language of the Theory = Language of Alliance 2: Multiple Personality Scales Language of the Theory = Language of Alliance 3: Facet Scales Language of the Theory = Language of Alliance 4: Clinical Symptomology Test Yourself

110 111 111 112

®

Strengths and Weaknesses of the MCMI -IV

113 114 115 117 119 120

123

A. Jordan Wright Strengths Weaknesses

123 127

CONTENTS xi

Eight

Nine

Final Comment Test Yourself

133 135

Clinical Applications of the Millon Inventories

137

Key MCMI-IV Augmentation: Personality Spectra and Clinical Populations The MCMI-IV in Clinical Assessment Specific Assessment Applications With the MCMI Other Millon Inventories Test Yourself

137 139 142 144 148

Illustrative Case Reports

151

Case Example 1 Case Example 2

151 160

References

169

About the Authors

175

Index

177

LIST OF FIGURES

Figure 2.1 Figure 4.1 Figure 4.2 Figure 4.3 Figure 4.4 Figure 4.5 Figure 4.6 Figure 4.7 Figure 4.8 Figure 4.9 Figure 4.10 Figure 4.11 Figure 4.12 Figure 4.13 Figure 4.14 Figure 4.15 Figure 4.16 Figure 4.17 Figure 4.18 Figure 4.19 Figure 4.20 Figure 4.21 Figure 4.22

Motivating Aims of the Evolutionary Model Schizoid Motivating Aims Schizoid Domains Avoidant Motivating Aims Avoidant Domains Melancholic Motivating Aims Melancholic Domains Dependent Motivating Aims Dependent Domains Histrionic Motivating Aims Histrionic Domains Turbulent Motivating Aims Turbulent Domains Narcissistic Motivating Aims Narcissistic Domains Antisocial Motivating Aims Antisocial Domains Sadistic Motivating Aims Sadistic Domains Compulsive Motivating Aims Compulsive Domains Negativistic Motivating Aims Negativistic Domains

22 47 48 50 51 52 53 55 56 57 58 60 61 62 63 65 66 68 69 70 71 72 73 xiii

xiv LIST OF FIGURES

Figure 4.23 Figure 4.24 Figure 4.25 Figure 4.26 Figure 4.27 Figure 4.28 Figure 4.29 Figure 4.30 Figure 6.1 Figure 9.1 Figure 9.2 Figure 9.3 Figure 9.4

Masochistic Motivating Aims Masochistic Domains Schizotypal Motivating Aims Schizotypal Domains Borderline Motivating Aims Borderline Domains Paranoid Motivating Aims Paranoid Domains Motivating Aims of Scales 5 and 2A MCMI-IV Profile Page, Case Example 1 (Mitch) MCMI-IV Facet Page for Case Example 1 (Mitch) Profile Page for Case Example 2 (Valerie) Facet Page for Case Example 2 (Valerie)

75 76 78 79 80 81 83 84 116 154 155 162 163

LIST OF TABLES

Table 1.1 Table 1.2 Table 1.3 Table 1.4 Table 1.5 Table 2.1 Table 2.2 Table 4.1 Table 5.1 Table 8.1

Millon’s Original Eight Personality Prototypes Reliability of MCMI-IV Personality Scales Reliability of MCMI-IV Syndrome Scales Sensitivity and Specificity of MCMI-IV Personality Scales Sensitivity and Specificity of MCMI-IV Clinical Syndrome Scales Personality Levels Across Evolutionary Spectra Expression of Domains by Prototype Grossman Facet Scales Base Rate Anchor Points Objective and Projective Assessment Integration Guidelines

2 10 11 15 15 26 28 88 100 142

xv

SERIES PREFACE

I

n the Essentials of Psychological Assessment series, we have attempted to provide the reader with books that will deliver key practical information in the most efficient and accessible style. Many books in the series feature specific instruments in a variety of domains, such as cognition, personality, education, and neuropsychology. Other books, like Essentials of KTEA-3 and WIAT -III Assessment focus on crucial topics for professionals who are involved in anyway with assessment—topics such as specific reading disabilities, evidence-based interventions, or ADHD assessment. For the experienced professional, books in the series offer a concise yet thorough review of a test instrument or a specific area of expertise, including numerous tips for best practices. Students can turn to series books for a clear and concise overview of the important assessment tools, and key topics, in which they must become proficient to practice skillfully, efficiently, and ethically in their chosen fields. Wherever feasible, visual cues highlighting key points are utilized alongside systematic, step-by-step guidelines. Chapters are focused and succinct. Topics are organized for an easy understanding of the essential material related to a particular test or topic. Theory and research are continually woven into the fabric of each book, but always to enhance the practical application of the material, rather than to sidetrack or overwhelm readers. With this series, we aim to challenge and assist readers interested in psychological assessment to aspire to the highest level of competency by arming them with the tools they need for knowledgeable, informed practice. We have long been advocates of “intelligent” testing—the notion that numbers are meaningless unless they are brought to life by the clinical acumen and expertise of examiners. Assessment must be used to make a difference in the child’s or adult’s life, or why bother to test? All books in the series—whether devoted to specific tests or general topics—are consistent with this credo. We want this series to help our readers, novice and veteran alike, to benefit from the intelligent assessment approaches of the authors of each book.

®

xvii

xviii SERIES PREFACE

®

We are delighted to include Essentials of MCMI -IV Assessment in our series. This book articulates the considerable depth of Theodore Millon’s overarching theory of personality in a concise, accessible, and clinician-friendly form that is then directly applicable to MCMI-IV assessment and therapeutic applications. Going beyond the instrument’s traditional supportive role in providing incremental validity of personality and psychopathology diagnoses, the authors provide a historical view of our modern personality conceptualizations, and illustrate how the MCMI-IV can, through an integration of its theory and empirical qualities, inform the clinician about key personality variables that influence the onset, course, and resolution of psychological distress. They also provide insight into using the instrument’s findings therapeutically, from both traditional and collaborative modes of assessment and intervention. Further, the authors illustrate these methods both through a stepwise examination of theory and clinical practice, as well as MCMI-IV case examples. Finally, they cover the use of the instrument in different settings and applications, and describe the other Millon inventories that are specialized for use with child/adolescent, college, medical, and adaptive counseling populations. Alan S. Kaufman, PhD, and Nadeen L. Kaufman, EdD, Series Editors Yale Child Study Center, Yale University School of Medicine

Essentials of MCMI®-IV Assessment

One HISTORY AND DEVELOPMENT OF THE MCMI® THROUGH MCMI®-IV

T

o fully understand and operationalize the application and range of the Millon Clinical Multiaxial Inventory, Fourth Edition (MCMI-IV; Millon, Grossman, & Millon, 2015), it is useful to gain a working knowledge of its original intent and development in context with the time and challenges in the field of psychological assessment. This chapter will focus not only on the development of this most recent iteration of the instrument but also will highlight its evolution from its original form in context with advances in personality diagnosis, assessment, and intervention throughout the latter half of the 20th century. The MCMI-IV is a 195-item self-report inventory designed to articulate complex personality patterns in context with clinical symptomology, noteworthy concerns, and test-taking attitude in order to maximize therapeutic plans. The current, fourth generation of the instrument traces its roots back to the early 1960s, when Theodore Millon, then an associate professor at Lehigh University, a private university in the northeast United States, began contextualizing the personality study and research he had conducted throughout the early years of his career (Millon, 2002). Examining the characterologic prototypes described in the classic psychoanalytic literature, Millon noted the superbly articulated characterizations of personality styles, but he lamented the lack of comprehensiveness and consistency across these different patterns. A self-described “inclusive behaviorist” in his early career (Millon, 1990), Millon began blending his empirical background with his interest in integrative theory to attempt to construct an explanatory framework for basic personality constellations. He felt that this could, at once, describe core motivations of individuals and also provide a system for classification of personality variables. The driving force of this exercise was to make the case for personality as the central concern for clinical psychology, owing to its influence on, and ability to modulate, clinical symptomology. The fruits of this labor, manifest in Millon’s (1969) Modern 1

2 ESSENTIALS OF MCMI®-IV ASSESSMENT

Psychopathology, set the stage not only for the first Millon Clinical Multiaxial Inventory (MCMI; Millon, 1977) but also for the designation of personality on its own separate axis in the multiaxial systems of DSM-III through DSM-IV. Millon’s (1969) original template, described as a “biosocial-learning theory,” mapped a continuum from adaptive to maladaptive personality patterns and specified several distinct motivating forces when, combined with one another, gave rise to a series of personality prototypes evident among adaptive and maladaptive individuals. These motivational orientations emphasized social engagement and adaptation to the environment, drawn as opposing ends of a continuum. Social engagement was seen as engaged versus disengaged, whereas the adaptation continuum was described as active versus passive (that is, whether to act on an environment in order to suit the individual or to accept what the environment provides and change aspects of the self to fit in). This schema, when examined for different possible combinations, manifested eight prototypal personalities which largely coincided with identified problematic personality trends as seen in the literature and in the official psychiatric diagnostic system (see Table 1.1). Millon’s framework garnered the attention of key figures from the DSM leadership in the 1970s, and he was recruited to its personality disorders work group in which many of his conceptualizations were ultimately translated to its empirically based diagnostic criteria of the DSM-III (American Psychiatric Association [APA], 1980). Because Millon had specified a measurable framework for understanding personalities, he and his colleagues began exploring methods for doing this. Several attempts were made to map data points of existing instruments, such as the original MMPI (Hathaway & McKinley, 1940) and the Rorschach (Rorschach, 1921), to Millon’s personality constructs, but these efforts yielded inconsistent or incomplete results. Ultimately, Millon decided to formulate a new research-oriented instrument—the Millon-Illinois Self-Report Inventory Table 1.1 Millon’s Original Eight Personality Prototypes Relational Mode

Adaptive Mode

Detached

Passive: Schizoid Active: Avoidant Passive: Dependent Active: Histrionic Passive: Narcissistic Active: Antisocial Passive: Compulsive Active: Negativistic

Dependent Independent Ambivalent

HISTORY AND DEVELOPMENT OF THE MCMI® THROUGH MCMI®-IV

3

(MISRI)—which would be constructed with the explicit intent of measuring these personality prototypes. As his explorations expanded from academic and research settings to clinical use, measures for the major psychiatric disorders were added as a means to contextualize personality with major psychiatric disturbance. These additions were integrated into the original Millon Clinical Multiaxial Inventory (Millon, 1977). CONSTRUCTION OF THE LEGACY MCMI TESTS (MCMI, MCMI-II, MCMI-III)

Envisioned as a theoretically derived, empirically supported instrument, Millon chose to construct the original MCMI (as well as its predecessor, the MISRI) employing Loevinger’s (1957) classic three-stage model for objective test construction. In the first, Theoretical-Substantive stage, Millon and his colleagues developed more than 1,000 items written as either operational definitions of the theoretical constructs comprising the personality patterns or self-statements reflective of psychiatric symptomology. This initial stage was then followed by the Internal-Structural stage, in which this large item pool was administered to a developmental sample drawn from psychological and psychiatric clinics, inpatient and outpatient, across the United States. Classic psychometric measures were then applied to this sample to determine the adequacy of the items in terms of reliability (e.g., Cronbach’s alpha, repeated measures). Those items retained through the second phase were subsequently assessed in a third phase, the External-Criterion validation stage, wherein the surviving items DON’T FORGET were assessed for agreement with ....................................................... clinicians’ ratings of subjects and Theodore Millon designed his assesshow they corresponded with scales ment instruments to be theoretically derived and empirically validated on the new assessment, as well as measures. concordance with other instruments measuring similar constructs. The original MCMI featured eight primary personality scales corresponding to Millon’s eight personality styles, as well as three “severe” personality scales (Schizotypal, Cycloid [Borderline], and Paranoid) measuring personality prototypes conceived as more structurally compromised variants of the Basic Personality Patterns. Additionally, nine Clinical Syndrome scales measured classic psychopathology (e.g., depression, anxiety, alcohol abuse), and one validity scale was developed to detect random response patterns. In addition, the new instrument used Base Rate (BR) scores as an alternative to the commonly

4 ESSENTIALS OF MCMI®-IV ASSESSMENT

used T-score. The BR system, Millon argued, offered greater idiographic accuracy by rejecting the assumption that the prevalence rate for any given disorder is the same as the prevalence rate for any other disorder. The BR system, instead, referred to the prevalence rate (or base rate) of the disorder, setting a cutting point at a specified percentile of examinees for any of the disorders under consideration and using an iterative process to determine key scores and all score conversions (Wetzler, 1990). The MCMI rapidly became one of the most popular instruments used by clinical psychologists (Piotrowski & Keller, 1989; Piotrowski & Lubin, 1989, 1990). This was, in large part, because of its overlap with the personality disorders of the diagnostic system, offering clinicians a system in which they could further contextualize official diagnostic criteria via the explanatory principles embedded in Millon’s theory (Choca & Grossman, 2015). By the time of the original MCMI’s release in 1977, revisions to be introduced in DSM-III were imminent. There was much discussion about the possibility of adding the sadistic and the masochistic personality disorders to the DSM. Millon, who championed these additions, also added these two patterns to his theory and to the plans for the MCMI’s first major revision. The political landscape of the era was not in favor of these additions, because women and LGBT groups, in particular, opposed these inclusions because of concern regarding social and legal ramifications (Millon, 1981). Although the American Psychiatric Association ultimately voted against the additions and the prototypes were relegated to the DSM-III appendix for further consideration, Millon felt strongly about the importance and validity of these patterns for clinical applications, and they were incorporated into the MCMI-II (Millon, 1987). The MCMI-II also introduced a system of differential weights for items, reflective of their use as prototypal or supportive items for given scales. An item written specifically for a given scale was weighted; that is, it was given more than 1 raw score point (either 2 or 3) when endorsed for that scale. The same item, then, may have been used on another scale to measure a similar or contextually modified concept for that scale, but it was limited to a raw weight of 1. This system provided an economical means to explain similarities between different prototypes using minimal test content, but much like the sadistic and masochistic prototypes, it was not without its own controversy. Although these differential raw score weights made sense from a theoretical point of view, it added significantly to the complexity of scoring and gave rise to difficulties with discriminant validity (Retzlaff, 1991; Retzlaff, Sheehan, & Lorr, 1990; Streiner, Goldberg, & Miller, 1993; Streiner, & Miller, 1989; Widiger, Williams, Spitzer, & Frances, 1985). Less controversial, and arguably more beneficial, the MCMI-II also introduced three Modifying Indices, similar in scope to the MMPI validity scales. These

HISTORY AND DEVELOPMENT OF THE MCMI® THROUGH MCMI®-IV

5

three scales, Disclosure, Desirability, and Debasement, based on extant content, measured the examinee’s test-taking approach and added a dimension that further contextualized the person’s response to the challenges of self-reflection inherent in personality assessment. The end of the 1980s saw the most major theoretical revision in Millon’s DON’T FORGET career, culminating in a publication ....................................................... Millon’s theory was originally designed that tied core personality motivaas a biosocial-learning theory. In 1990, tions to evolutionary theory (Millon, he reconceptualized it as a more 1990). The new MCMI-II prototypes inclusive evolutionary theory. Most of had already added a discordant elethe original theory was incorporated into this new version, which provides ment to the theory that, similar to the guiding framework for all modthe other relational factors, featured ern Millon inventories, including the a passive variant (the self-defeating, MCMI-IV. masochistic personality) as well as an active variant (the forceful-aggressive, sadistic personality). This new dimension, along with the classic biosocial-learning schema of the eight basic prototypes, showed considerable overlap with Millon’s evolutionary proposals, and the existing personality patterns were reconceptualized as expressions of nature analogous to evolutionary phenomena of the natural world (e.g., Wilson, 1978). Subsequent publications based on the evolutionary theory included the second edition of Millon’s primary theory text, Disorders of Personality (Millon & Davis, 1996), as well as the next version of the instrument, the MCMI-III (Millon, 1994; Millon, Millon, & Davis, 1997). Chapter 2 details Millon’s evolutionary theory and its clinical application. Among other more nuanced changes incorporated into the revised theory and the MCMI-III (e.g., the impulsivity of the cycloid pattern being more fully fleshed out for its emotionality into the Borderline prototype), a new pattern, the depressive personality, was introduced and discussed as a possible addition to the upcoming DSM-IV (APA, 1994). Although the pattern was ultimately relegated to the appendix for future consideration, it has enjoyed recognition as an entity that is qualitatively distinct from both major depression and persistent depression/dysthymic disorder (e.g., Maddux & Johansson, 2014). Finally, in an effort to improve discriminant validity and parsimony, the weighting system for the MCMI-III was simplified. All items included on the MCMI-III, whether legacy or newly introduced, were designated as prototypal on only one scale and given a weight of 2 raw score points. They were then considered, based on theoretical consideration and intercorrelations, for inclusion as supplementary items for other scales (Jankowski, 2002; Millon, Millon, Davis, & Grossman, 2009).

6 ESSENTIALS OF MCMI®-IV ASSESSMENT

The mid-2000s also saw the first set of official facet scales published as part of the MCMI-III (Craig, 2005), an expansion of factorial ideas previously considered for the Millon inventories (e.g., Davis, 1993). Designed to reflect aspects of the evolutionary theory geared toward specific structural and functional domains, the Grossman Facet Scales provided a further breakdown of each of the primary personality scales along theoretical demarcations (Grossman, 2004; Millon, Millon, Davis, & Grossman, 2006a, 2006b). A final revision to the MCMI-III (Millon et al., 2009) updated the norms to the contemporary, mixed-gender standard, and introduced the Inconsistency scale to partner with and improve on the instrument’s validity measures. Millon’s final theoretical revision (2011) set the stage for the development of the current instrument, the MCMI-IV. Although the revision contained numerous enhancements and clarifications, two additions are most salient. First, this edition of the theory introduced another personality pattern, the Turbulent prototype, based on early psychoanalytic descriptions (e.g., Kraepelin, 1921; see also Boudry, 1983, and Carlson & Maniacci, 2012, for further discussion) as well as more current references in popular culture (e.g., Jamison, 2005). Second, the theory more fully articulated a wider bandwidth from adaptive to maladaptive levels of personality functioning. Although the evolutionary theory always specified a continuum, the revision sought to highlight characteristics at mild, moderate, and severe personologic pathology levels, designated as Style, Type, and Disorder, respectively.

Rapid Reference 1.1

...............................................................................................................

Millon Clinical Multiaxial Inventory-IV (MCMI-IV) Authors: Theodore Millon, PhD, DSc; Seth Grossman, PsyD; and Carrie Millon, PhD Publication date: 2015 Publisher: Pearson Clinical Assessments; 5601 Green Valley Drive, Bloomington, MN 55437 Copyright holder: Dicandrien, Inc. What the test measures: Personality patterns and domains (adaptive styles, abnormal traits, clinical disorders) in context with clinical psychopathology with individuals seeking clinical services Age range: 18 years and older Reading level: Fifth grade

HISTORY AND DEVELOPMENT OF THE MCMI® THROUGH MCMI®-IV

7

Average administration time: 30 to 40 minutes or less Norms: The instrument is normed on 1,547 clinical subjects (individuals seeking mental health services). Detailed normative information is available in the MCMI-IV examiner’s manual (Millon et al., 2015). Qualification of examiners: Purchase of MCMI-IV materials requires a C-level qualification as elaborated at www.pearsonclinical.com/psychology/ qualifications.html. Products and services: Examiner’s manual (digital and paper), paper-pencil test materials (for mail-in scoring), and administration and scoring services via digital platforms Q-Global (web-based) and Q-Local (local PC-based) are available through Pearson Clinical Assessments.

DEVELOPMENT OF THE MCMI-IV

The decision to develop a new version of the MCMI followed the historic precedent to keep the instrument aligned not only with the official diagnostic system, but with contemporary clinical needs as reflected by sociological changes. The manual for the last update to the MCMI-III (Millon et al., 2009) noted several of these trends, such as different concentrations of disorders and diagnoses, as well as a new standard for a combined-gender normative sample in several other instruments (prompting a renorming of the MCMI-III in its 4th edition). However, the authors agreed that there were substantive societal changes that could not be addressed by the MCMI-III renorming project alone, and Millon’s theory had been recently significantly updated (Millon, 2011). Therefore, the decision was made for the development of the next generation of the instrument, the MCMI-IV. Theoretical-Substantive Stage

With the most recent iteration of the theory completed and published, Millon began composing new items for use in the MCMI-IV. Consistent with methods used in the legacy MCMI instruments, a major focus was on construction of new items relevant to the new constructs in the theory and the instrument, as well as a review and revision of MCMI-III item pools reflective of the new instrument’s structures and scales. This new item content was derived from the theory as well as from the newly published DSM-V criteria (APA, 2013). This stage of development also saw a focus on contemporary social problems as well as concern for increased clinical focus on cognitive areas not generally associated with MCMI assessment, leading to several new noteworthy response categories and content (e.g., violence

8 ESSENTIALS OF MCMI®-IV ASSESSMENT

potential, ADHD). Across MCMI-III constructs maintained for the MCMI-IV, new item development focused on improving the psychometric properties of the scales as well as adding to the comprehensiveness of the constructs.

Rapid Reference 1.2

...............................................................................................................

Stages for Development: MCMI-IV 1. Theoretical-Substantive 2. Internal-Structural 3. External-Criterion

Members of the development team joined in this stage to scrutinize the newly formed item content, adding items in some cases and clarifying language across the new items. Their efforts led to the pilot study using a research form containing 245 new items administered to 449 individuals. Unlike prior iterations, this study included clinical and nonclinical subjects in an effort to examine the possibility of extending the traditionally clinically oriented measure to broader usage. Although this effort ultimately did not result in an instrument that could be this broadly administered, these data aided in shaping the larger clinical bandwidth reflective of the theory’s expansion to include different levels of pathology. This stage also helped ensure clarity of items as well as highlight early statistical trends. From the new item content, 106 items were retained to move on to the more formal item-tryout stage. The new items were added to the existing 175 items comprising the MCMI-III, resulting in a 281-item research form administered to a more targeted clinical group of 235 examinees. This group also completed two collateral measures: the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF; Ben-Porath & Tellegen, 2008) and the Brief Symptom Inventory (BSI; Derogatis, 1993). Additionally, administering clinicians were asked to complete a clinician’s rating form to specify their clinical assessment for each examinee. At this point, approximately 50 redundant or problematic items were replaced and several new items were added, primarily to aid comprehensiveness to several noteworthy response lists. The 109 new items retained after this stage were then translated into Spanish, as well as back-translated, to evaluate their usefulness and appropriateness for United States Spanish-speaking populations. Both an English and a Spanish final research form were assembled, composed of the MCMI-III in its entirety, as well as the 109 remaining new items, for administration in the standardization (internal-structural) stage.

HISTORY AND DEVELOPMENT OF THE MCMI® THROUGH MCMI®-IV

9

Internal-Structural Stage

Participation in the standardization efforts for the MCMI-IV was solicited by the publisher, targeting experienced MCMI-III users. For standardization, these clinicians administered the research form, including the 175 MCMI-III items, as well as the new items constructed specifically for MCMI-IV. This method, administered through the publisher’s online testing platform, was incorporated to provide the clinician and examinee with a valid MCMI-III profile for clinical use while subjecting new item content for standardization purposes. Examinees were administered the MCMI-III content first and were subsequently notified that the remaining items would not be used in their current clinical evaluation. During this process, clinicians were also asked to complete a clinician’s rating form, which described all MCMI-IV constructs, and instructed the clinician to rate the examinee on these constructs based on their clinical judgment. Standardization took place in fall 2014, with data analysis following this stage in spring 2015 to determine final item selection from MCMI-III and new item content as well as final scale composition. Primary selection factors included an item’s correlation with the targeted scale, representativeness of the clinical construct under consideration, and endorsement frequency. Items retained in this first round of analysis were then assigned as prototypal items for the target MCMI-IV scale and designated as carrying a weight of 2 raw score points for that scale. Items surviving this stage as prototypal were then subjected to covariance structure analysis (CSA; also referred to as confirmatory factor analysis). This statistical method was chosen for its ability to incorporate theoretical considerations in guiding scale composition without allowing the theory to predetermine this (Hoyle, 1991). The method led to a minor number of items being discarded from the prototypal pool. Items were then assessed for use as non-prototypal, or supportive, content on other primary personality or syndrome scales, where they would be designated with a raw score of 1 point. It is important to note, in this system of scale construction, that any given item may be used on several scales as a non-prototypal item, but they may only be used as a prototypal item on the single scale for which it was deliberately written. Criteria for inclusion as a supportive item on another scale included its relevance and additive value from theoretical and diagnostic perspectives, as well as its correlation with the target scale. Final Cronbach’s alpha measures were applied to each scale, which finalized the 195-item content of the MCMI-IV. Tables 1.2 and 1.3 present Cronbach’s alpha scores for the Personality and Clinical Syndrome scales, respectively. The Grossman Facet Scales, first introduced in the MCMI-III, were then constructed, primarily focusing on individual primary personality scale content. The

10 ESSENTIALS OF MCMI®-IV ASSESSMENT Table 1.2 Reliability of MCMI-IV Personality Scales Cronbach’s Alpha Clinical Personality Patterns 1 Schizoid (AASchd) 1.1 Interpersonally Unengaged 1.2 Meager Content 1.3 Temperamentally Apathetic 2A Avoidant (SRAvoid) 2A.1 Interpersonally Aversive 2A.2 Alienated Self-Image 2A.3 Vexatious Content 2B Melancholic (DFMelan) 2B.1 Cognitively Fatalistic 2B.2 Worthless Self-Image 2B.3 Temperamentally Woeful 3 Dependent (DADepn) 3.1 Expressively Puerile 3.2 Interpersonally Submissive 3.3 Inept Self-Image 4A Histrionic (SPHistr) 4A.1 Expressively Dramatic 4A.2 Interpersonally Attention-Seeking 4A.3 Temperamentally Fickle 4B Turbulent (EETurbu) 4B.1 Expressively Impetuous 4B.2 Interpersonally High-Spirited 4B.3 Exalted Self-Image 5 Narcissistic (CENarc) 5.1 Interpersonally Exploitive 5.2 Cognitively Expansive 5.3 Admirable Self-Image 6A Antisocial (ADAntis) 6A.1 Interpersonally Irresponsible 6A.2 Autonomous Self-Image 6A.3 Acting-Out Dynamics 6B Sadistic (ADSadis) 6B.1 Expressively Precipitate 6B.2 Interpersonally Abrasive 6B.3 Eruptive Architecture 7 Compulsive (RCComp) 7.1 Expressively Disciplined 7.2 Cognitively Constricted 7.3 Reliable Self-Image

.82 .73 .82 .80 .89 .80 .83 .83 .92 .82 .86 .87 .81 .81 .68 .77 .83 .70 .80 .83 .87 .81 .75 .77 .75 .74 .80 .63 .78 .68 .65 .77 .80 .82 .67 .81 .67 .67 .78 .69

HISTORY AND DEVELOPMENT OF THE MCMI® THROUGH MCMI®-IV

11

Table 1.2 (Continued) Cronbach’s Alpha 8A

8B

Severe Personality Pathology S

C

P

Negativistic (DRNegat) 8A.1 Expressively Embittered 8A.2 Discontented Self-Image 8A.3 Temperamentally Irritable Masochistic (AAMasoc) 8B.1 Undeserving Self-Image 8B.2 Inverted Architecture 8B.3 Temperamentally Dysphoric

.86 .77 .83 .85 .90 .87 .81 .79

Schizotypal (ESSchizoph) S.1 Cognitively Circumstantial S.2 Estranged Self-Image S.3 Chaotic Content Borderline (UBCycloph) C.1 Uncertain Self-Image C.2 Split Architecture C.3 Temperamentally Labile Paranoid (MPParaph) P.1 Expressively Defensive P.2 Cognitively Mistrustful P.3 Projection Dynamics

.89 .82 .85 .80 .91 .88 .85 .83 .84 .76 .71 .80

Table 1.3 Reliability of MCMI-IV Syndrome Scales Cronbach’s Alpha Clinical Syndromes A Generalized Anxiety (GENanx) H Somatic Symptom (SOMsym) N Bipolar Spectrum (BIPspe) D Persistent Depression (PERdep) B Alcohol Use (ALCuse) T Drug Use (DRGuse) R Post-Traumatic Stress (P-Tstr) Severe Clinical Syndromes SS Schizophrenic Spectrum (SCHspe) CC Major Depression (MAJdep) PP Delusional Disorder (DELdis)

.82 .84 .71 .93 .65 .83 .86 .86 .92 .81

12 ESSENTIALS OF MCMI®-IV ASSESSMENT

purpose of the facet scales is to offer more nuanced information regarding a given personality pattern, highlighting a person’s various traits such as cognition, self-image, temperament, and so on. Similar to the MCMI-III facets, the structure of the Grossman Facet Scales was conceived as an attempt to capture the most salient prototypal trait features as identified by the eight functional and structural domains of the theory (see Chapter 2 for a complete review of these domains). Of the eight domains, the theory posited that approximately three would be most salient for any given prototypal personality pattern, and the facet scales would identify the three most prominent traits present in each of the personality scales of the MCMI-IV. Three facets were identified for each of the 15 Clinical Personality Pattern scales and the Severe Personality Pathology scales, yielding a total of 45 facets, largely overlapping with the theory’s prediction of which facets are prominent for a given prototype. Construction of the MCMI-IV facet scales began with rational predictions about which items from a personality scale’s item pool would match with a trait domain specified as most salient by the theory, although some item content better coalesced with domains not predicted by the theory to be most prominent. This was followed by a CVA process, similar to that used to help form the primary scales, to improve the overall model fit. The final stage of facet development included examining related item content from other scales, using theoretical and correlational rationale to augment the facets, and calculating Cronbach’s alphas for each resultant scale. The sum total of all cases submitted for inclusion in the normative sample, through all phases of development, was 1,884. Following exclusion criteria (e.g., out-of-range validity measures, too many missing items), 1,547 cases were included for the final development and standardization sample for the MCMI-IV. This stratified sample sought to match with characteristics of United States and Canadian adults seeking therapeutic treatment with regard to age, race or ethnicity, setting, gender, geographic region, and education. The population in this sample, as is typical of help-seeking individuals in the United States and Canada, tends to favor white, college-educated adults in their mid-20s to -40s, and with good heterogeneity for marital status and geographic region. Inclusion of different races and ethnicities fell short of desired numbers owing to continued underrepresentation of minorities across clinical settings, but exceeded prior efforts for earlier MCMI normative samples. BR score conversions were calculated next. As stated previously, the BR system is an alternative to the popular T-score, because it does not assume a normal distribution in which an accurate reflection of the person can be gleaned from measuring a standard distance from a mean score. Instead, BR scores are anchored

HISTORY AND DEVELOPMENT OF THE MCMI® THROUGH MCMI®-IV

13

to specified prevalence rates of a characteristic or diagnosis. As with previous versions of the MCMI and other Millon inventories, the targeted anchor point is set at BR 75, with a further reference point at BR 85 (with an additional reference for personality scales at BR 60), with those points being interpretable similarly across scales. BR scores also are defined as representative of a continuum from adaptive to maladaptive characteristics and symptomology. For the personality scales, these anchor points may be generally interpreted as follows: BR 60–74 range: Personality style (generally adaptive with some prominent traits that may occasionally create concern) BR 75–84 range: Problematic personality type (noticeable constellation of personality attributes that may be more predictably problematic) BR 85+ range: Clinical personality disorder, with high likelihood of pervasive personality challenges at a more pronounced and impairing level For the Clinical Syndrome and Modifying Indices scales, the BR 75 and 85 anchor points may be generally interpreted as presence or prominence of the given construct, respectively. BR scores were derived from the clinician ratings of 938 examinees in the normative sample. These forms included DSM diagnostic information as well as severity ratings for all MCMI-IV primary scale constructs. For personality patterns, the percentage of the sample for which each pattern was diagnosed with a DSM diagnosis (when applicable), or a moderate to severe dysfunction was identified, was used as an anchor for an estimate of the base rate with which that pattern constitutes a problematic personality type in the population and was linked to a BR of 75. The percentage of those, then, who received a DSM diagnosis or severe dysfunction was used as the anchor point for the more pronounced BR rate of 85. Similar distinctions were used to establish the BR 75 and 85 anchor points for the Clinical Syndrome scales. The median raw score for a given scale’s distribution was assigned a BR of 60, whereas raw scores of 0 equated with BR 0, and BR 115 related to the maximum raw score for a scale. Linear interpolation was then used to complete the score table for each table. Different criteria were used to create the BR score transformations for the Modifying Indices and facet scales. For scales X (Disclosure), Y (Desirability), and Z (Debasement), the range was decreased to 0–100, and BRs were calculated to equate with designated extremes. For Scale X, a BR of 35 and 85 was set as the point at which the lowest 15% and highest 10% scored, respectively. The additional point of BR 75 was set at the next highest 15%. Scales Y and Z used BR 85 as anchored to the highest 5%, with BR 75 equating to the next 15%. These scales, too, used BR 35 as designating the lowest 15% or raw scores, with linear

14 ESSENTIALS OF MCMI®-IV ASSESSMENT

interpolation to complete the score set. The facet scales, likewise, feature a range from 0 to 100, similar to the Modifying Indices, and were tied to percentiles in the raw score distribution. External-Criterion Stage

The final stage of development for the MCMI-IV involved comparisons of examinee results with measures collected by both administering clinicians as well as via instruments measuring similar constructs. As mentioned, the MMPI-2-RF and BSI were administered to a portion of the developmental sample, and clinical rating forms were collected for 938 examinees in the standardization phase. Overall results of the comparative studies found meaningful relationships between the instruments. A majority of Clinical Syndrome constructs on both instruments were found to parallel considerably with MCMI-IV Clinical Syndrome scales, whereas there were generally low to moderate correlations between MMPI-2-RF scales and related MCMI-IV personality scales. This observation lends credence to the common perspective that the two instruments are best used complementarily, because they emphasize different areas of related clinical inquiry (Millon et al., 2015). Measures relevant to the clinician’s rating form focus on positive predictive power as measured through sensitivity and specificity for diagnoses and identified concerns. The MCMI-IV demonstrated adequate predictive power in these studies, with 15 of 25 measures, evidencing sensitivity ratings of above 0.5 and specificity values higher than sensitivity overall. Tables 1.4 and 1.5 present values for sensitivity and specificity for the Personality and Clinical Syndrome scales, respectively. See Millon et al. (2015) for a thorough review of validity data inclusive of these values and positive predictor values. By the end of the 20th century, Millon had become more focused on the application of assessment to intervention (Millon, 1999, 2002; Millon & Grossman, 2007a, 2007b, 2007c). Consistent with his 2011 text shift emphasizing the larger bandwidth of personality severity and adaptiveness across all 15 personality prototypes, the MCMI-IV vision was to focus on useful clinical information beyond the label or diagnosis and its applicability to intervention. In addition to the innovation of specifying a continuum of three ranges of personality functioning, a decision was made to create a new profile page as an alternative to the standard profile page, which would use Millon’s most recent abbreviations representative of the personality spectra in lieu of the classic labels (e.g., EETurbu in place of Turbulent). This is aligned with APA trends and directives toward greater openness in assessment as well as with some modalities’ encouragement of more direct

HISTORY AND DEVELOPMENT OF THE MCMI® THROUGH MCMI®-IV

15

Table 1.4 Sensitivity and Specificity of MCMI-IV Personality Scales Personality Scale Clinical Personality Patterns 1 Schizoid (AASchd) 2A Avoidant (SRAvoid) 2B Melancholic (DFMelan) 3 Dependent (DADepn) 4A Histrionic (SPHistr) 4B Turbulent (EETurbu) 5 Narcissistic (CENarc) 6A Antisocial (ADAntis) 6B Sadistic (ADSadis) 7 Compulsive (RCComp) 8A Negativistic (DRNegat) 8B Masochistic (AAMasoc) Severe Personality Pathology S Schizotypal (ESSchizoph) C Borderline (UBCycloph) P Paranoid (MPParaph)

Sensitivity

Specificity

.50 .68 .70 .56 .33 .63 .50 .49 .43 .30 .58 .22

.84 .65 .72 .75 .81 .87 .83 .87 .89 .84 .71 .85

.31 .46 .40

.91 .82 .80

Table 1.5 Sensitivity and Specificity of MCMI-IV Clinical Syndrome Scales Clinical Syndrome Scale Clinical Syndromes A Generalized Anxiety (GENanx) H Somatic Symptom (SOMsym) N Bipolar Spectrum (BIPspe) D Persistent Depression (PERdep) B Alcohol Use (ALCuse) T Drug Use (DRGuse) R Post-Traumatic Stress (P-Tstr) Severe Clinical Syndromes SS Schizophrenic Spectrum (SCHspe) CC Major Depression (MAJdep) PP Delusional Disorder (DELdis)

Sensitivity

Specificity

.72 .51 .58 .44 .68 .72 .62

.48 .75 .79 .82 .83 .90 .83

.33 .83 .50

.95 .67 .94

and collaborative feedback in psychological testing while avoiding misguidance of diagnostic labeling (e.g., Therapeutic Assessment). Also consistent with therapeutic utility, the MCMI-IV features an enhanced treatment guide tied more directly to the motivating aims of the evolutionary theory as well as explications of personality dimensions in a revised set of facet scales.

16 ESSENTIALS OF MCMI®-IV ASSESSMENT

TEST YOURSELF

............................................................................................................... 1. Millon’s theory was originally conceptualized explicitly using principles of evolution.

a. True b. False 2. The original MCMI (1977) contained how many personality scales?

a. b. c. d.

14 8 11 15

3. Originally introduced for the MCMI-III, the Grossman Facet Scales were designed to do which of the following?

a. To identify motivating aims corresponding to the evolutionary polarities of Millon’s theory b. To provide a further breakdown of each of the primary personality scales along theoretical demarcations c. To be derived factorially and represent a complementary theory of personality d. To denote expected clinical symptomology arising from personality patterns 4. The personality prototype introduced in Millon’s 2011 update to the theory, and included for the first time in the MCMI-IV, is which of the following patterns?

a. b. c. d.

Turbulent Self-Denigrating Forceful Melancholic

5. How many levels of functioning are identified on the MCMI-IV personality scales, and what are they called?

a. b. c. d.

2; flexible, inflexible 3; normal, abnormal, pathological 3; style, type, disorder 2; adaptive, maladaptive

6. The MCMI-IV is designed to be used with both clinical and nonclinical populations.

a. True b. False

HISTORY AND DEVELOPMENT OF THE MCMI® THROUGH MCMI®-IV

17

7. Which of the following is used as the primary interpretive metric on the MCMI-IV, and why?

a. The BR score; it is calculated by anchoring to several key percentile ranks and is therefore capable of estimating an individual’s standing in comparison with others in the normative population. b. The T-score; it is the most common and popular and the best understood of the various metrics used in modern assessment. c. The T-score; it adequately captures ranges of pathology and allows for distinctions along a standard deviation. d. The BR score; it does not assume a normal distribution of pathology and instead is anchored to estimates of prevalence of a given disorder. Answers: 1. b; 2. c; 3. b; 4. a; 5. c; 6. b; 7. d

Two MCMI®-IV AND MILLON EVOLUTIONARY THEORY

common misconception in MCMI-IV assessment is that owing to the considerable overlap in its constructs with official DSM criteria, there is relatively little to be gained from examining its generative theory. In other words, all that is necessary is that a clinician is well-versed in the official diagnostic system. Although this may be true for the most basic use of the MCMI-IV, in adding incremental validity to a diagnosis, this assumption leads to only the most basic level of interpretation and adds little to understanding or being able to assist the person therapeutically. Conversely, facility with Millon’s evolutionary theory adds a depth and relatedness to a clinician’s conceptualization of a given person, and it offers an explanatory framework for understanding not only the relationship of different personality traits to one another but also how these coalesced traits serve as the person’s psychological immune system (Millon, 2011). Furthermore, understanding an MCMI-IV profile on this deeper level offers important information in terms of how to create strong therapeutic alliances through a validating language of intervention embedded in the theory (see Chapter 6). It is recommended that the reader use this chapter as a primer on the theory, gain a basic understanding of its contents, and apply this knowledge to the information found in the more applied chapters of this book.

A

PERSONALITY AS FOCAL POINT IN CLINICAL ASSESSMENT AND INTERVENTION

Before reviewing Millon’s evolutionary theory, it may be useful to examine the role of personality in overall mental health. Most of the mental health enterprise focuses largely on symptom amelioration, with personal aspects such as age, gender, culture, socioeconomic status, and life circumstances making up the context that may play a role in modifying clinical expectations. Throughout his career, Millon advocated for personality to play a much more enhanced role in 19

20 ESSENTIALS OF MCMI®-IV ASSESSMENT

this endeavor, designing his instruments to be “personality-centric,” and DON’T FORGET ....................................................... focusing his theories on the centralMillon advocated for personality to ity of personologic functioning (Milbe seen as analogous to the physical lon, 2011; Millon & Davis, 1996). immune system; he encouraged cliniHis frequently stated analogy placed cians to focus on the effectiveness and psychology and medicine side by efficiency of this “psychological immune system” with regard to how it defended side, noting their evolution from against “infection” (via environmental primitive inroads to modern stanor situational concerns) and prevented dards, lamenting psychology’s “obses“symptoms” (depression, anxiety, etc.). sion” with symptom control. Drawing on the multiaxial systems of DSM-III through DSM-IV, Millon made comparisons between medicine’s timely progression of its focus from symptom treatment, through intervening on infectious processes, and on to targeted immunology. Through its modern history, Millon continued, psychology has remained mired in symptomology with occasional focus on infection (in this metaphor, life circumstances). To aim treatment at the personality level, Millon professed, was to strengthen the person’s psychological immune system (Millon, 1999; Millon & Grossman, 2007a, 2007b, 2007c). It is with this perspective in mind that the core focus of the Millon inventories is on personality functioning, with an ultimate intent of facilitating the therapeutic plans of the clinician. AN EVOLUTIONARY MODEL OF PERSONALITY

As introduced in Chapter 1, Millon began his explorations in personality using a biosocial-learning model. Although this system was generative of a comprehensive array of personality constellations and encouraging of a perspective that incorporated heterogeneous personality traits and variables, it was limited, by its nature, to integrating multiple perspectives from a framework within psychology (in this case, a behavioristic platform), thus unable to fully focus on multiple perspectives. Further, Millon felt that clinical psychology in general, and personology—the study of human personality—in particular, deserved an elevated status aligned with other sister sciences. Two central observations guided Millon’s paradigmatic shift toward aligning personality with evolutionary biology. The first observation related to Millon’s recognition that any given theory from within psychology proper, no matter its scientific rigor, is, by its nature, incomplete and distorted to favor its predilections. Further, any attempt to organize an integrative schema bridging disparate schools of thought (e.g., intrapsychic,

MCMI®-IV AND MILLON EVOLUTIONARY THEORY

21

biophysical, relational, etc.) will also demonstrate a clear bias because it must adopt a central point of view originating from one of these schools of thought. Moreover, an “internal” strategy such as this is unlikely to allow for full expression of all perspectives, something Millon felt to be essential in organizing the distinct elements that comprise a personality (Millon, 1969, 1990; Millon & Davis, 1996). Personality is not led by the unconscious, for example, with elements of biophysicality, phenomenology, and behavior organizing around intrapsychic phenomena. No one element will consistently lead for all individuals. For these reasons, Millon chose to look outside of psychology proper, to the neighboring sciences, to seek organizing principles hierarchically superior to the various psychological elements that would allow for equal expression among the schools of psychological inquiry (Grossman, 2004; Millon, 1990). Millon’s second observation reflected on the fact that humans and their personalities, as living organisms, shared basic motivational strategies with other natural beings of the living world. From large ecosystems (e.g., rainforests, food chains) to the smallest molecular structures (e.g., behavior of ions within single atoms), a minute number of explanatory laws could give rise to all basic expressions of natural phenomena. These common patterns were found throughout classical evolutionary theory literature (e.g., Darwin, 1859; Huxley, 1870; Spencer, 1870); moreover, Millon’s contemporaries in the adjacent science of evolutionary biology were positing connections between human social functioning and the larger expanses of biology (e.g., Wilson, 1978). As part of the natural world, then, personology held a natural place as a sister science, and explanation of human motivation could be delineated along the same evolutionary laws. In the current form of the theory (Millon, 2011), a series of 15 prototypes, detailed in Chapter 4, are derived, most of which align with the DSM-5 personality disorder diagnoses. Twelve of the patterns may be derived from a limited set of overarching principles, described in the following section, and three (Schizotypal, Borderline, and Paranoid) trend toward greater maladaptation, as seen in a form of structural compromise in the personality. MOTIVATING AIMS

The evolutionary theory posits three basic motivational strategies, termed motivating aims, all related directly to evolutionary processes (see Figure 2.1). When taken together, different patterns of emphasis, conflict, or other dynamics along these strategies derive each prototype of the taxonomy (and subsequently, each scale of the MCMI-IV). Each strategy was set up as polarity, with a range from one extreme to another. Simpler organisms of the living world, Millon

22 ESSENTIALS OF MCMI®-IV ASSESSMENT

Motivating Aims Existence Pleasure

Pain

(life enhancing)

(life sustaining)

Adaptation Passive

Active

(ecologically accommodating)

(ecologically modifying)

Replication Self

Other

(self-propagating)

(other-nurturing)

Figure 2.1 Motivating Aims of the Evolutionary Model

posited, could also be described using this schema, but in general, there would be much less dynamicism; that is, an organism such as a tree would simply be described via stable points on each of these continua. Humans and their personalities, however, would tend to show some movement and flexibility along these lines, because different situations and internal states would call for changes to these adaptive strategies. As human personality began showing more dysfunction, however, there would be less adaptivity and flexibility, and similar, often ineffective strategies would be used from situation to situation. The prototypes are each derived by examination of favored strategies across the three polarities, as follows: Survival strategy: At the most basic level, an organism must exist as a living entity. Strategies that allow for this range from those actions that would decrease the reality of threat and avoid those predators or situations that would hasten injury or demise (a pain-avoiding strategy) to actions aimed at seeking fulfillment in life without regard for potential costs (a pleasure-seeking strategy). Most adaptive individuals will have a preferred strategy somewhere along this continuum but will evidence a modicum of flexibility as needs arise. Less adaptive and maladaptive

MCMI®-IV AND MILLON EVOLUTIONARY THEORY

23

individuals will tend to become stagnant or fixated at their favored point on this continuum. Adaptation strategy: Assuming an organism is able to reasonably survive, it then must interface with its environment. This approach may range from exerting influence to change the environment to fit the individual’s need (an active-modifying strategy) to finding a suitable-enough environment and making personal changes toward a best fit (a passive-accommodating strategy). Again, the simpler organisms will likely fit one or the other pattern directly (e.g., in general, flora trend passively whereas fauna trend actively, with variations among members of each of those broad categories). Personalities that are adaptive, again, will have a favored but flexible strategy, and less healthy patterns will evidence concreteness or marked conflict. Replication strategy: Recognizing that any living entity will have a finite life span, successful species must find a way to regenerate. In the field of evolutionary biology, this polarity is represented by r-strategy versus K-strategy (e.g., mollusks such as oysters will lay multiple millions of eggs during the course of a lifetime and provide no further parenting because enough eggs will survive to adulthood; mammals have far fewer offspring and play a much larger role in nurturance). Translated to personality, this polarity is represented by self-propagating versus other-nurturing strategies, with relative adaptiveness defined similarly to the preceding two polarities. PROBLEMATIC PATTERNS IN MOTIVATING AIMS

Throughout this evolutionary schema, it is likely apparent that in general, an adaptive, healthy personality will demonstrate a good measure of definition along these polarities, acting largely in ways that evidence personal strength and resilience. A healthy individual may tend to favor certain strategies but will modify these in accordance with environmental and situational demands. For example, a deferential individual may tend to be more of a follower than a leader, may expend more energy in assessing personal ability, and may feel more secure with someone else than alone. These characteristics, when moderated, are neither adaptive nor maladaptive; the person can switch modes as necessary and show some level of initiative, strike out on his or her own, and so on, as a situation may require. This same pattern, on a more maladaptive level, however, will show a more pervasive fixedness, evidencing the strong passivity and other-orientedness of the dependent prototype. In this pattern, there could be difficulties in taking any initiative, insecurity in making any decision or acting

24 ESSENTIALS OF MCMI®-IV ASSESSMENT

in accord with personal skill, and feeling lost without a partner or significant other to give direction to life. There are several problematic processes demonstrable via the motivating aims that can affect adaptivity. Each of these processes impairs personologic flexibility and ability to meet circumstantial demands. These tendencies may manifest as part of a single prototype, wherein they will be specified by the theory, or they may find expression in admixtures of prototypal personalities, which is how most MCMI-IV profiles will appear with multiple scale elevations. These patterns are as follows: Disbalance: This is the simplest and most prevalent of these processes as well as that which most frequently defines a disordered personality. Simply put, this is a pattern in which a given personality strongly favors one side of the polarity structure over the other (e.g., a very passive individual, who shows little to no motivation to act on surroundings in order to modify life circumstances). In the prototypes, this pattern is most prominent in the emotionally extreme (e.g., Schizoid, Avoidant, Melancholic, Turbulent) and interpersonally imbalanced (e.g., Histrionic, Narcissistic, Antisocial, Dependent) personalities. Conflict: This process generally emanates from a desire to subjugate unwanted thoughts and feelings to the point where they will sometimes disappear from awareness, only to manifest again in even less desirable ways. Prototypal examples include self-other conflicts for the Compulsive and Negativistic patterns, in which denied or disavowed interpersonal feelings create an undercurrent of intrapsychic anger. This pattern is also present in the structurally compromised Borderline prototype, wherein conflictedness appears across all three motivating aims. Reversal: In this process, a motivating aim that is generally seen as straightforward is reversed into its opposite, thereby creating an inverse of expected motivations and the experience of a phenomena as its apparent opposite. Examples of these lie in the prototypal Sadistic and Masochistic patterns, wherein the pain motivation is reversed into a desired state or action, and the individual experiences enhancement or fulfillment via stimuli considered by most as noxious. Wavering: This process appears primarily in the Schizotypal prototype and appears across all its polarities. This represents a disintegration of usual motivating aims to the point where motivations become ill-defined and chaotic.

MCMI®-IV AND MILLON EVOLUTIONARY THEORY

ss Unalterable: Although any motivating aim may become more fixated than usual, the Paranoid prototype tends to evidence immovability across polarities. In this structural compromise, extant motivations become concretized, and the person tends to show severe resistance to any possibility for adapting polarity strategies.

25

DON’T FORGET

....................................................... Adaptive personalities will demonstrate a modicum of flexibility and clarity along the three evolutionary polarities. Less adaptive personality patterns demonstrate conflictedness, disbalance, fixedness, reversal, and wavering qualities; the more pronounced these difficulties, the more maladaptive the personality is expected to be.

LEVELS OF ADAPTIVENESS

The most recent update to the theory specifies three different adaptiveness levels across the 15 primary personality scales of the MCMI-IV, ranging from healthy to disordered and reflected on the MCMI-IV at specified Base Rate scores. Normal Style, the first of these three levels, reflects generally adaptive functioning, evidencing preferred strategies on the evolutionary polarities, but usually with adequate flexibility to change motivations as need arises. The moderate level along the functional to dysfunctional personality range comprises the Abnormal Type. At this level, the individual may be expected to predictably show vulnerability to repetitive stressors or impairments because of deficits in flexibility and adaptivity across motivating aims. Clinical Disorders, then, fall at the most maladaptive end and reflect individuals who chronically evidence functional personologic impairment, self-perpetuated vicious cycles of social and internal distress, and generally have a limited ability to satisfactorily function in a community. Table 2.1 presents each pattern of the spectrum in relation to these levels of severity and reiterates an acronym system initiated in Millon (2011) used in the alternative MCMI-IV profile. STRUCTURAL AND FUNCTIONAL DOMAINS

At a more molecular level, the evolutionary theory specifies expected expression in each of the personality prototypes. Similar to the DSM’s attempt to dimensionalize what are otherwise categorical constructs (e.g., Schizoid, Avoidant, etc.) by providing trait criteria wherein approximately half of any given criteria should be met for a given diagnosis, Millon’s theory operationalizes a trait-domain system

26 ESSENTIALS OF MCMI®-IV ASSESSMENT Table 2.1 Personality Levels Across Evolutionary Spectra Spectrum Acronym

Normal Style

Abnormal Type

Clinical Disorder

AASchd SRAvoid DFMelan DADepn SPHistr EETurbu CENarc ADAntis ADSadis RCComp DRNegat AAMasoc ESSchizoph UBCycloph MPParaph

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

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

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

so that what may appear to be categories are actually prototypes that are directly comparable to one another. Rather than having a criteria set that could be defined primarily by any one particular area of personality (thought process, behavior, etc.), each prototype of the theory has eight functional and structural domains. In this way, the categorical labels became true prototypes and provided for observations and measures that would more closely reflect persons as they actually are: admixtures of different personality prototypes. For example, a given person may have temperamental features typical of an avoidant prototype but interpersonal features more typical of a dependent prototype. The eight functional and structural domains are as follows: Expressive Emotion: A functional domain describing the objectively observable behaviors of an individual inferring an emotional need. Interpersonal Conduct: A functional domain reflecting how an individual interacts with others relationally. This and the aforementioned behavioral acts comprised the behavioral aspect of personality. Self-Image: A structural domain of personality representing an individual’s sense of self-as-object and his or her reflection of sameness or differentness from others. Cognitive Style: A functional domain that looks at the ways in which the individual allocates attention and focus and then processes and synthesizes information.

MCMI®-IV AND MILLON EVOLUTIONARY THEORY

27

Intrapsychic Content: This structural domain reflects the person’s general expectations of others as imprinted from early experience and along with cognitive style and self-image represent a person’s phenomenology. Intrapsychic Dynamic: Internal processes that give rise to this functional domain are representations of conflict resolution, need gratification, and self-protection. These are commonly known as defense mechanisms. Intrapsychic Architecture: Perhaps the most “structural” of all domains, this domain refers to the organizing principles and structures of the mind. The psyche’s architecture gives insight to the strength and cohesion of a personality. This and regulatory mechanisms represent intrapsychic aspects of the personality. Mood-Temperament: The strucss tural domain that ties in the body’s physical substrates to the workings of the psyche. This includes neuropsychological functioning, general energy and affect characteristics, and physical health effects on mental functioning. This domain, alone, represents the biophysical aspects of personality.

DON’T FORGET

....................................................... The system of functional and structural domains in Millon’s theory lends a level of comparability between personality prototypes; for example, an individual may evidence the expressive emotion of one prototype, the cognitive style of another, and the intrapsychic dynamics of a third.

As noted previously, a distinguishing advance in Millon’s evolutionary theory is its ability to create direct comparability with different persons. A common complaint to this day regarding the categorical structure of the DSM, inclusive of the DSM-5 (2013), is that it often forces clinicians to use more than one personality disorder label when a person does not cleanly fit the criteria, or it forces an unspecified personality diagnosis. Although there is substantial overlap with DSM criteria and the delineation of personality patterns under the theory, this was designed not to be the case with the prototypal system. A prototype is a theoretically derived textbook construct to which persons being assessed may be compared. It is actually highly unusual for a person to fit cleanly into one category alone (Millon, Grossman, Millon, Meagher, & Ramnath, 2004). Rather, a given person may match primarily with one prototype but evidence traits and features more typical of others. Because the domains of personality are comparable across prototypes, it is possible, and even likely, to see this manifest in highly individualized profiles (e.g., a person evidencing primarily Narcissistic patterns but with Depressive and Histrionic Features will be very different from

Expressive Emotion

Impassive

Fretful Disconsolate Puerile Dramatic

Impetuous

Haughty

Impulsive

Precipitate Disciplined

Embittered Abstinent Peculiar

Spasmodic Defensive

Domains

Schizoid

Avoidant Melancholic Dependent Histrionic

Turbulent

Narcissistic

Antisocial

Sadistic Compulsive

Negativistic Masochistic Schizotypal

Borderline Paranoid

Paradoxical Provocative

Contrary Acquiescent Secretive

Abrasive Courteous

Irresponsible

Exploitive

Aversive Defenseless Submissive AttentionSeeking High-Spirited

Unengaged

Interpersonal Conduct

Vacillating Mistrustful

Cynical Diffident Autistic

Nonconforming Dogmatic Constricted

Expansive

Scattered

Distracted Fatalistic Naive Flighty

Impoverished

Cognitive Style

Table 2.2 Expression of Domains by Prototype

Uncertain Inviolable

Discontented Undeserving Estranged

Combative Reliable

Autonomous

Admirable

Exalted

Alienated Worthless Inept Gregarious

Complacent

Self-Image

Trait

Incompatible Unalterable

Fluctuating Discredited Chaotic

Pernicious Concealed

Debased

Contrived

Piecemeal

Vexatious Forsaken Immature Shallow

Meager

Content

Regression Projection

Isolation Reaction Formation Displacement Exaggeration Undoing

Magnification Rationalization Acting-Out

Intellectualization Fantasy Asceticism Introjection Dissociation

Intrapsychic Dynamics

Split Inelastic

Eruptive Compartmentalized Divergent Inverted Fragmented

Unruly

Spurious

Unsteady

Undifferentiated Fragile Depleted Inchoate Disjointed

Architecture

Irritable Dysphoric Distraught or Insentient Labile Irascible

Hostile Solemn

Callous

Insouciant

Mercurial

Anguished Woeful Pacific Fickle

Apathetic

MoodTemperament

MCMI®-IV AND MILLON EVOLUTIONARY THEORY

29

a narcissistic pattern that evidences compulsive and dependent features). The domain structure is such that given the comparability of domains, we may see the former example (Narcissistic/Depressive/Histrionic admixture) as presenting as a kind of Nostradamus character when the person gains attention and possibly even acclaim for being highly pessimistic and “the only one who can see how bad things are.” Here we are seeing the woeful temperament of a Depressive prototype, the attention-seeking interpersonal conduct of a Histrionic prototype, and the expansive cognitive style of the Narcissist. Table 2.2 provides a table outlining domain expressions by prototype. From this reference, it is possible to see how co-elevations on the MCMI-IV may be compared at this level to provide more detailed, specific articulations of personality traits. APPLYING MILLON’S EVOLUTIONARY THEORY TO THE MCMI-IV

The aforementioned theoretical elements serve as building blocks to the central feature of the MCMI-IV—that is, its primary and facet personality scales. Each of the primary personality scales is conceptualized as a prototypal personality construct reflective of the motivating aims inherent in each prototype. Scale composition is derived from items that are written as operational statements reflective of the various functional and structural domains in each prototype, largely focusing on the domains best represented in a given prototype. The usefulness of the theory in assessment and, ultimately, in intervention, then, is manifold. First, a single personality scale, when elevated, offers considerable information beyond the label and the diagnostic criteria when applicable. The single elevation details aspects of the individual’s basic motivations, such as how geared he or she is, at least in part, to safety versus fulfillment, acting on or accepting circumstance, toward self-indulgence or other-nurturance, and discordant or otherwise conflicted. In multiple-scale elevations, as MCMI-IV protocols typically present, it is possible to isolate individual scales and then consider how these isolated elevations may blend to form further disbalance, conflicts, and the like between prototypal scales. Third, as domains are identified as salient via the Grossman Facet Scales and examination with the theory, specific trait expressions may offer insights into treatment approaches. Finally, with personologic insights gained from the personality scales, insights are possible in terms of how a given individual may express and experience a given syndromal complication. For example, a mixed persistent depression and anxiety (one of the most common presentations in clinical intervention) will be experienced very differently by a person displaying Histrionic and Negativistic patterns than by a person displaying Dependent and Avoidant patterns. Chapters 5 and 6, in particular, will offer considerable further detail in this regard.

30 ESSENTIALS OF MCMI®-IV ASSESSMENT

TEST YOURSELF

............................................................................................................... 1. The DSM personality disorder criteria are identical to those found on the MCMI-IV.

a. True b. False 2. An appropriate analogy for personality is to think of it as the psychological immune system.

a. True b. False 3. Which of the following represents Millon’s rationale for using evolutionary theory as an organizing framework for understanding, evaluating, and intervening with personality?

a. Human personalities share basic motivational aims with the natural, living world. b. The interrelationships among evolutionary polarities give greater understanding to the directives and conflicts of the individual. c. By tying a personality theory to a science outside of psychology proper (e.g., evolutionary biology), no one theory within (e.g., cognitive, existential, behavioral) may assume automatic primacy for factors other than the individual’s personality. d. All of the above. 4. Because organisms have finite lives, they must find ways to propagate their own species, which requires a strategic aim found on which polarity?

a. b. c. d.

Existence Replication Adaptation Abstraction

5. An organism that modifies an environment to make it suitable for its evolutionary aims is demonstrating which kind of strategy?

a. b. c. d.

Self-oriented Pleasure-oriented Other-oriented Active-oriented

6. Which of the following is the most common and simplest of motivational complications?

a. b. c. d.

Conflict Reversal Disbalance Conflict and Disbalance

MCMI®-IV AND MILLON EVOLUTIONARY THEORY

31

7. Which two domains are most closely related to an individual’s relational style?

a. b. c. d.

Intrapsychic Dynamics and Cognitive Style Interpersonal Conduct and Intrapsychic Dynamics Interpersonal Conduct and Intrapsychic Content Self-Image and Intrapsychic Content

8. Item content for the MCMI-IV is derived from the Functional-Structural domains as reflective of the motivating aims.

a. True b. False Answers: 1. b; 2. a; 3. d; 4. b; 5. d; 6. c; 7. c.; 8. b

Three ADMINISTRATION AND SCORING

ADMINISTRATION

Administration time for the MCMI-IV is expected to take between 25 and 30 minutes for most individuals. Test items have been measured by the Flesch-Kincaid Reading Index to be at a fifth-grade reading level. This brevity in administration, along with the simplicity of the item content, is anticipated to aid clinicians in balancing their time effectively with regard to integrating this comprehensive objective personality assessment with other clinical tasks, such as other clinical and assessment data, as appropriate. Its brevity is also anticipated to help reduce client fatigue and resistance in the testing process. As of this writing, the MCMI-IV can be administered in either English or Spanish using a digital or paper modality. Future language additions are expected to follow similar formats. In addition, the publisher offers audio recordings of the test items to be used with examinees who may need visual or reading accommodations for their administration. The MCMI-IV does not require any unique instructions beyond those that are explicitly detailed within the test materials, and most examinees do not require further clarification or explanation of the standardized prompts found in the digital and paper-and-pencil versions of the test.

Rapid Reference 3.1

...............................................................................................................

Keynotes of Administration and Scoring • Easily administered, true-false reporting format • Untimed administration, averaging 25 to 30 minutes for computer and paper-and-pencil administration (continued) 33

34 ESSENTIALS OF MCMI®-IV ASSESSMENT

• Appropriate for adults ages 18 and older • Fifth-grade reading level • All standardized instructions are provided on-screen via computer administrations or in the MCMI-IV manual for paper-and-pencil administrations • Score reporting includes raw score, Base Rate, and percentile rank scales. • Scoring is available only via computer; there is no longer a hand-scoring option. • Digital scoring yields either a profile report or an interpretive report.

Introducing the MCMI-IV to Examinees

Clinicians are encouraged to describe the MCMI-IV to each examinee as a brief inventory that is used to help clinicians understand individuals’ situation and problems, long-standing and immediate. The purpose of the assessment should be made clear to each examinee in order to increase motivation to answer items honestly and with personal investment. A metaphor that the authors often use to help examinees better understand the importance of honest self-disclosure is “garbage in, garbage out.” That is, when the purpose of the assessment is made clear, and the examinee has identified potential benefit from participation, it is important to explain that if examinees are dishonest in their self-report (garbage in), their results will likely be either invalid or inaccurate for their current condition (garbage out). In addition, it is important to encourage examinees to answer all items and consult with the clinician should they need assistance defining a word or clarifying the meaning of any particular item. Clinicians are encouraged to be available to answer any questions an examinee might have about the assessment process before, during, and after MCMI-IV administration. For full administrative guidelines, readers should consult the MCMI-IV manual and become familiar with the manual in its entirety prior to using the test. Should readers wish to assess populations that do not fit the general adult clinical criteria of the MCMI-IV but still desire to use Millon’s evolutionary theory to guide their treatment, there are several other measures that may meet those needs (Millon Adolescent Clinical Inventory [MACI]; Millon, Millon, Davis, & Grossman, 2006a; Millon Behavioral Medicine Diagnostic [MBMD]; Millon, Antoni, Millon, Minor, & Grossman, 2001; Millon College Counseling Inventory [MCCI]; Millon, Strack, Millon, & Grossman, 2006; Millon Index of Personality Styles-Revised [MIPS-R]; Millon, Weiss, & Millon, 2004; Millon Pre-Adolescent Clinical Inventory [M-PACI]; Millon, Tringone, Millon, & Grossman, 2005). Chapter 8 of this text provides more in-depth information regarding these series of tests.

ADMINISTRATION AND SCORING 35

Rapid Reference 3.2

...............................................................................................................

Framing the Assessment with Your Client • • • • •

Provide a clear rationale for test administration. Answer any questions the client may have prior to beginning the administration. Encourage honest responses in order to get the most accurate results. Encourage clients to answer all items if possible. Provide support and assistance throughout the administration to ensure that clients fully understand the items. • Use other Millon inventories when population or age-specific requirements are outside those specified for valid MCMI-IV administration.

SCORING

A notable change from MCMI-III is that the MCMI-IV scoring is now available via computer only using Pearson’s Q-global online scoring and reporting platform, Q-Local software, or by mailing in the paper-and-pencil response sheet to be computer scored. Hand scoring for the MCMI-IV is not available. As of the release of the instrument, the two report options for the MCMI-IV are a profile report with scores for each scale and listings of noteworthy responses along with a brief capsule summary of significant findings, and an interpretive report providing more extensive narratives directed toward personality description, clinical symptomology considerations, and treatment directives, in addition to all data included in the profile report. There is also an option to print the main profile page using abbreviations consistent with the test’s theory (Millon, 2011) rather than full personality and syndromal labels. This addition is provided to facilitate feedback, use the test results more therapeutically, and avoid unintended false-positive self-interpretations by the examinee.

™

®

Invalidity Considerations

The MCMI-IV is considered to be unscorable if 14 or more items have either been omitted or double-marked (with the latter situation potentially occurring only on paper-and-pencil administration). Any single scale on the MCMI-IV is considered to be unscorable if five or more items are omitted or double-marked. In both cases, the examiner is encouraged to correct the situation by providing the examinee with the clarification, support, and encouragement to facilitate a more thorough completion of the test.

36 ESSENTIALS OF MCMI®-IV ASSESSMENT

An MCMI-IV protocol is considered to be of questionable validity if the raw score on Scale V (Invalidity) is 1, if the raw score on Scale W (Inconsistency) is between 9 and 19, if the raw score on Scale X (Disclosure) is between 7 and 20 or between 61 and 114, or if Scale Y (Desirability) or Scale Z (Debasement) are extremely low or high. Similarly, an MCMI-IV is considered invalid if the raw score on Scale V is 2 or 3, if the raw score on scale W is 20 or greater, if the raw score on Scale X is less than 7 or greater than 114, or the Base Rate scores on Scales 1 through 8B are all less than 60. In these cases, there is an option to print an abbreviated report identifying the qualifying reason for test invalidity. In this instance, no scale scores or interpretive report will be generated.

Rapid Reference 3.3

...............................................................................................................

Conditions for MCMI-IV Validity to Be Questionable or Invalid 1. Scale V Raw Score (1-Questionable, 2-Invalid) 2. Scale W: Inconsistency (9–19 Questionable; 20+ Invalid)

Scale V Raw Score

0

1

2

0–8

OK

Questionable

Invalid

Questionable Invalid

Questionable Invalid

Invalid Invalid

Scale W Inconsistency 9–19 20–max

3. Disclosure (Scale X): Raw score < 6 or > 115 (Invalid) Possible underreporting: 7–20; possible overreporting: 61–114 (Questionable) 4. Extremes for (Y) Desirability or (Z) Debasement (Questionable) 5. No BR score above 60 for scales 1–8B (Invalid)

Base Rates

In keeping with Millon inventories tradition, elevations on most scales of the MCMI-IV profile are primarily interpretable in terms of a Base Rate (BR).

ADMINISTRATION AND SCORING 37

BR scores are a type of standardized score that differs from the more common T-scale (standard scale scores) scores seen in other comprehensive assessment measures. Both BR and T-scale scores are used to transform raw scores into a common metric unit to aid in comparison between groups. Unlike T-scores, the BR prevalence scores are created so that the percentage of the clinical population deemed diagnosable with a particular disorder falls (1) either at or above an established prevalence incidence threshold (e.g., clinical scales) or (2) at or above a known prevalence rate in each scale of the personality profile. BR scores attempt to capture the naturally occurring rate of a phenomenon (personality dysfunction) in a given population. BR scores are scaled to reflect the differing prevalence rates of the characteristics measured by the inventory and its unique scales. MCMI-IV BR scores range from 0 to 115, with 60 being the median score. A BR score of 75 is considered to be the cutoff for clinical significance, reflecting a statistically significant probability that the personality traits or specific disorder described within that scale are most likely present for the examinee. A BR score of 85 reflects a markedly high likelihood that those personality traits have manifested into a clearly definable disordered pattern. Although it has become common clinical practice to view significantly elevated scores on the MCMI as direct confirmation of the presence of psychiatric disorders and personality disorders specifically, it is important to remember that no personality test is 100% accurate. Individual differences among examinees, test-taking attitudes, test settings, cultural considerations, and current levels of functioning may all influence the accuracy of results. In addition, the clinician’s expertise in careful and accurate interpretation of the MCMI-IV must be considered prior to forming any diagnostic impressions or formal diagnosis.

Rapid Reference 3.4

............................................................................................................... BR scores, unlike T-scores, attempt to capture the naturally occurring rate of personality dysfunction in a given population. • MCMI-IV BR scores range from 0 to 115. • BR scores of 60 are the median score. • BR scores of 75 are considered the cutoff for clinical significance. • BR scores of 85 indicate the likely presence of diagnosable disorder. • Always consider contextual factors and holistic evaluation prior to arriving at any diagnostic labels as a result of MCMI-IV results.

38 ESSENTIALS OF MCMI®-IV ASSESSMENT

Base Rate Adjustments Following the conversion of raw test scores to BR scores, there are two possible adjustments that may be necessary in order to arrive at the final BR scores: the Disclosure Adjustment and the Anxiety/Major Depression Adjustment. Factoring the significance of either under- or overreporting current perceptions of psychopathology and distress, the Disclosure Adjustment uses the score on Scale X (Disclosure) to aid in providing a more accurate picture of the test-taker’s current level of functioning. The Anxiety/Major Depression Adjustment factors the likelihood that the accuracy of self-reporting is significantly affected by a test-taker’s acute state of markedly anxious or depressive symptomatology. The five Personality Pattern scales that are directly affected by this adjustment are Scales 2A (Avoidant), 2B (Melancholic), 8B (Masochistic), S (Schizotypal), and C (Borderline) because of the presumed high frequency of intrapsychic turmoil present within these patterns. Percentile Rank Scores

Percentile rank scores, a very common reporting metric on many psychiatric and cognitive assessments, are provided for the MCMI-IV scales. Although not as directly interpretable as BR scores, which are tied to an estimate of prevalence for a specified disorder, many clinicians may find these useful to gauge an individual’s standing on a particular measure relative to other individuals within the standardization sample. What is important to note in examining percentile rank scores is that psychiatric-personality distributions do not follow a normal curve as do other common psychological measures, such as measures of cognition. Therefore, percentile ranks and BR scores do not correspond uniformly between scales. It may be expected that these scores correspond most closely at the level of BR 75, because percentages are used to establish this clinical demarcation, but significant differences may occur because a BR score deviates further from this threshold.

TEST YOURSELF

............................................................................................................... 1. How long does it take to administer the MCMI-IV? 2. In addition to computer scoring, hand-scoring options have been made available for the MCMI-IV.

a. True b. False

ADMINISTRATION AND SCORING 39

3. At which Base Rate score would you consider it a high likelihood that an examinee meets criteria for a diagnosable psychiatric disorder?

a. b. c. d.

50 60 75 85

4. When using MCMI-IV results to aid in diagnosis and treatment planning, which other factors should you consider prior to making your decision?

a. b. c. d. e.

Individual differences among examinees Test-taking attitudes and test settings Cultural considerations Current level of functioning All of the above

5. What are the only two possible BR adjustments that can be made on the MCMI-IV? Answers: 1. 25 to 30 minutes; 2. a; 3. d; 4. e; 5. Disclosure and Anxiety/Major Depression adjustments

Four SECTIONS AND SCALES

P

rior to interpretation of MCMI-IV results, clinicians must become familiar with the different sections, scales, and subscales of the test instrument. In addition, knowledge of the meaning and creation of each scale is highly encouraged for accurate interpretation. Each prior iteration of the MCMI has attempted to further explore and expand the applications of Millon’s theory, and the MCMI-IV attempts to make the connection between theory and practical experience more intuitive and expansive for the clinician. The following section and scale definitions will aid clinicians in orgaDON’T FORGET nizing the MCMI-IV within a struc....................................................... tured, conceptual framework. First, Each of the 15 personality pattern clinicians must look to the Validity scales is accompanied by three distinct and Modifying Indices in order to Grossman Facet Scales to aid the examiner in a more nuanced and specific assess the level of confidence in the interpretation of significant elevations. accuracy of the test findings. Second, they must look toward the highest Base Rate (BR) score elevations on the Severe Personality Pathology Patterns, Clinical Personality Patterns, Severe Clinical Syndromes scales, and then finally the Clinical Syndrome scales in order to more accurately identify the core personality structure and expression of the examinee. Finally, in order to arrive at the most accurate, comprehensive, and clinically useful picture of an examinee’s current personality structure, clinicians must identify the corresponding elevations on each Grossman Facet Scale to arrive at a complete interpretation. Each of the Severe Personality and Clinical Personality Pattern scales’ interpretive sections will be broken down to content related to the motivating aims of the examinee, his or her most likely or most clinically relevant forms of personality expression, and treatment considerations for the clinician. The motivating aims sections will provide clarity and specificity with regard to the 41

42 ESSENTIALS OF MCMI®-IV ASSESSMENT

unique organization of the three-polarity structure as formulated by Millon’s evolutionary theory (Millon, 2011; see Chapter 2 of this Essentials volume for review). The personality expression section will provide an in-depth description of the personologic domains for each scale, focusing on the most clinically useful, common, and conceptually meaningful representations of each personality style. Treatment considerations will provide a brief overview of what clinicians may encounter in treatment when working with individuals who manifest these identified personality patterns. VALIDITY AND MODIFYING INDICES

Having a framework to best understand the accuracy of a self-report personality measure is critical in ensuring the utility of any test results. The validity of MCMI-IV results may be overtly or covertly influenced by a number of factors, including but not limited to random responding, low motivation to participate in the assessment, intentional misrepresentation of current or past experience, reading difficulty, and lack of understanding of the purpose of the assessment. When low motivation, overt resistance, or difficulty conveying the potential utility of participation in the MCMI-IV is believed to be a factor prior to test administration, we strongly encourage clinicians to review Chapter 6 (“Therapeutic Alliance Building”) in this book in order to better prepare clients for an optimal assessment experience. The MCMI-IV is equipped with validity and random response indicators (Scales V and W), as well as impression management scales, which are collectively referred to as Modifying Indices (Scales X, Y, and Z). Rapid Reference 4.1 provides an overview of the the Validity scales and Modifying Indices. Invalidity (Scale V)

Scale V (Invalidity) of the MCMI-IV is composed of three items that the vast majority of individuals would never accurately endorse in the affirmative (e.g., “I was on the front cover of several magazines last year.”). If any of the three items within this scale are endorsed in the affirmative, it raises concerns about the client’s level of motivation, ability to understand test items, and marked lack of attention to the content of test items. Clinicians must be mindful of the many different potential reasons for random responding and attempt to have examinees clarify when any of the three items within this scale are endorsed. Inconsistency (Scale W)

The MCMI-IV designates 25 statistically and semantically related item pairs for Scale W (Inconsistency), which attempts to determine the level of consistency in

SECTIONS AND SCALES 43

item responses. Although Scale V attempts to identify examinees’ overall approach and ability to adequately participate in the assessment, Scale W seeks to identify significant patterns of random responding that would adversely affect the utility of test data. Corresponding items are usually composed of content prompting examinees to answer similar questions about themselves and are worded either in the affirmative or negative with regard to any given personality characteristic. Although minute differences in syntax on occasion may give reason for a particular examinee to answer item pairs in opposition to one another, it is believed that a motivated, engaged, and accurately self-disclosing examinee will answer the vast majority of these items in the expected direction throughout a given test administration. Disclosure Index (Scale X)

The Disclosure Index (Scale X), the next index that may signify problematic response behavior, is designed to indicate whether the examinee was inclined to be honest and self-disclosing or defensive and secretive. This scale is usually the first of the three Modifying Indices that clinicians examine when assessing whether MCMI-IV test findings represent an accurate self-report from an examinee. When interpreted in conjunction with Scales Y and Z, the cumulative findings provide the clearest picture of an examinee’s test-taking attitude. Desirability Index (Scale Y)

The Desirability Index (Scale Y) assesses the degree to which the examinee’s results may have been affected by his or her inclination to appear socially attractive, morally virtuous, or emotionally well composed. Although this scale can be used to gain insight into an examinee’s attempt to “fake good,” it may be more clinically appropriate to interpret scores on this scale as a conscious denial of personality dysfunction or perceived minor personality flaws. Debasement Index (Scale Z)

The Debasement Index (Scale Z) generally reflects tendencies that are opposite of those reflected in Scale Y. Specifically, information gathered from this scale helps to identify attempts by an examinee to appear more psychopathological, devalued, or impaired. Through the endorsement of items that suggest the presence of more intense emotional experiences and personal difficulties than would typically be endorsed by a clinical population, it is essential for clinicians to explore the possibility of high scores on this scale as a cry for help when their actual experience corresponds to elevations on this index.

44 ESSENTIALS OF MCMI®-IV ASSESSMENT

Rapid Reference 4.1

...............................................................................................................

List of Validity and Modifying Indices Invalidity (Scale V) Inconsistency (Scale W) Disclosure (Scale X) Desirability (Scale Y) Debasement (Scale Z)

NOTEWORTHY RESPONSES

The MCMI-IV continues the convention of providing a series of critical items for a given examinee. The 13 categories comprising the noteworthy responses section (see Rapid Reference 4.2) are composed of specific items, some written specifically for this category and some derived from scale items. These categories are not scored; rather, they are simple listings of critical items. In the MCMI-IV, this section has been expanded considerably. The well-known use of this section is to flag examinees who might present an imminent harm or liability, and several new categories (e.g., Violence Potential) have been added to address social concerns that have become more prevalent since the publication of the MCMI-III. Additionally, several new categories now comprise another focus area—that of common clinical concerns for which the MCMI-IV is not the optimal instrument (e.g., TBI, ADHD, ASD) but in which certain overlapping MCMI-IV items (e.g., from the Schizoid, Schizotypal, Bipolar, and other scales) may point to the need for a differential diagnosis using instruments more adequately measuring these diagnoses.

Rapid Reference 4.2

...............................................................................................................

Noteworthy Response Categories Differentials

Red Flags

Adult ADHD Autism Spectrum Eating Disorder Health Preoccupied Prescription Drug Abuse TBI

Childhood Abuse Emotional Dyscontrol Explosively Angry Interpersonally Alienated Self-Destructive Potential Self-Injurious Behavior/Tendency Vengefully Prone

SECTIONS AND SCALES 45

CLINICAL PERSONALITY PATTERNS

Millon’s evolutionary theory provides a framework for understanding personality functioning that arises from the individual’s adherence to his or her specific configuration of three evolutionary polarities (referred to collectively as motivating aims) of mental life: pleasure-pain, active-passive, and self-other. These patterns, in turn, are generative of each of the MCMI-IV personality scales (Clinical Personality Patterns as well as Severe Personality Pathology, covered in the next section). Twelve of the 15 identified personality patterns on the MCMI-IV reflect the basic Clinical Personality Patterns prototypes that are derived from disbalances or single discordances reflected in Millon’s motivating aims. These identified personality prototypes, formulated as textbook models to which examinees may be compared, reflect core characteristics of individual personologic functioning, and these characteristics are believed to be more pervasive and fixed as the individual exhibits more disordered and psychopathological patterns. Further, the most recent update to Millon’s theory (Millon, 2011) detailed a system of spectra, delineating each prototype into three degrees of functioning from adaptive to maladaptive. Each of these is represented alongside the more familiar prototypal label (e.g., Avoidant) by an abbreviation representing this spectrum (e.g., the Avoidant prototype is broken down into Shy style, Reticent type, and Avoidant clinical disorder, represented by the abbreviation, SRAvoid) (see Rapid Reference 4.3 for an overview of the Clinical Personality Patterns and Severe Personality Pathology scales, as well as Table 2.1 in Chapter 2 for a complete listing of these spectra). In part dependent on this level of functioning, these personologic ways of being can be so ingrained into the individual’s lifestyle that his or her level of insight into the role that these patterns play in his or her life may be very low. It is further believed that during times of stress, transition, or persistent adversity, less adaptive personality attributes may naturally become more present and deleterious to the overall functioning of even higher-functioning individuals. The MCMI-IV has added a new Clinical Personality Pattern, the Turbulent prototype (Scale 4B), which further contributes to this wide breadth of the clinicians’ overall understanding of an individual’s personality functioning.

Rapid Reference 4.3

...............................................................................................................

List of Clinical and Severe Clinical Personality Patterns Clinical Personality Patterns Schizoid (AASchd, Scale 1) Avoidant (SRAvoid, Scale 2A)

(continued)

46 ESSENTIALS OF MCMI®-IV ASSESSMENT

Melancholic (DFMelan, Scale 2B) Dependent (DADepn, Scale 3) Histrionic (SPHistr, Scale 4A) Turbulent (EETurbu, Scale 4B) Narcissistic (CENarc, Scale 5) Antisocial (ADAntis, Scale 6A) Sadistic (ADSadis, Scale 6B) Compulsive (RCComp, Scale 7) Negativistic (DRNegat, Scale 8A) Masochistic (AAMasoc, Scale 8B) Severe Personality Pathology Schizotypal (EESchioph, Scale S) Borderline (UBCycloph, Scale C) Paranoid (MPParaph, Scale P)

Notably, although some individuals may match fairly consistently with a single prototype as reflected Most valid MCMI-IV profiles will have on a given personality scale, and their the presence of multiple significantly MCMI-IV profile may exhibit a single elevated scales, requiring the examiner elevation, this is the exception and not to integrate several expressions of personality functioning into one complete the rule. Typical MCMI-IV profiles description. feature several personality scale elevations, and their interpretation should involve an integration of these patterns, rather than a consideration of separate and distinct personality patterns, disorders, or diagnoses. Each of the following Clinical Personality Patterns have the ability to provide clinicians with an abundance of information regarding the overall psychological functioning of an individual. In addition to providing narrative general descriptions of each scale, corresponding motivating aims, overall personality expression, and treatment considerations, the reader will also be provided with two visual aids to help better understand the motivating aims and personologic domains for each personality pattern. The first figure provided for each personality pattern will aid in clearly delineating exactly where a given personality pattern manifests itself along the evolutionary polarity continuum, hence clarifying the starting

DON’T FORGET .......................................................

SECTIONS AND SCALES 47

point of any interpretation of the identified personality pattern. The second figure provided for each personality pattern will explicitly identify the eight personologic domains, four functional and four structural, that help to provide more breadth and depth to the overall interpretation. For each pictorial representation of the personologic domains, the three shaded domains represent the corresponding Grossman Facet Scales for each parent personality pattern. In addition, the larger the circle for each descriptor, the more common or intrinsic the presence of that domain is considered to be for the identified personality pattern. Schizoid (Scale 1)

The Passive-Detached pattern found within the Schizoid scale is characterized by social impassivity, lack of emotional reactivity, and a marked difficulty experiencing strong emotions. Human relationships tend to be of minimal importance or significance for these individuals, because they typically do not experience strong emotions that may otherwise support a stronger attachment and desire to connect with others. Motivating Aims Expressing a marked deficiency in either the pleasure or pain polarity, individuals who score high on the Schizoid scale lack an important connection to emotion that likely negatively affects their ability to connect with others, themselves, or their life experiences in general. Without those emotional motivators, they tend to take a clearly passive approach to their lives (Figure 4.1). AASchd (Schizoid) Spectrum Millon Evolutionary Model MCMI-IV: Scale 1 Pleasure

Pain

Passive

Active

Self

Other

Figure 4.1 Schizoid Motivating Aims

Weak on Polarity Average on Polarity Strong on Polarity

48 ESSENTIALS OF MCMI®-IV ASSESSMENT

Personality Expression Apathy, interpersonal disengagement, and insufficient intrapsychic depth tend be hallmarks of the Schizoid personality. Whether because of potential neurological deficits, genetic predispositions, or learned interpersonal patterns, their diminished capacity to deeply enjoy life usually translates into more solitary existences. They have marked difficulty understanding others and themselves, in large part because of their excessively disorganized and diffuse intrapsychic topography. In addition, they often have an inability to experience any intense emotions, whether they are prosocial or destructive in nature. Emotionally, they tend to remain at a baseline that precludes them from experiencing intimate, close connections with others and also prevents them from experiencing intense feelings of anger or rage when they believe they have been wronged. They often appear to be disengaged and inattentive and are just as likely to be focused on their inner world as they are to be engaged in a daydream. Typically, they behave in an easygoing manner, because their lack of strong convictions or certainty regarding what they believe is right makes them more susceptible to act in accordance with others’ values and beliefs (Figure 4.2). In extreme cases, individuals with a Schizoid personality pattern may experience depersonalization. Although remaining physically present in the external world, they often appear to be mentally checked out. Their marked lack of emotional reactivity to external and internal stimuli often presents as odd and

Personologic Domains: AASchd Spectrum Impassive Expressive Emotion

Complacent

Intellectualization

Self-Image

Intrapsychic Dynamics

Unengaged Interpersonal Conduct

Apathetic Mood/Temperament

Meager Impoverished Cognitive Style

Figure 4.2 Schizoid Domains

Intrapsychic Content

Undifferentiated Intrapsychic Architecture

SECTIONS AND SCALES 49

makes those around them experience a certain level of discomfort and, potentially, concern. Regardless, these individuals tend to view themselves as distant and disconnected entities from their intrapsychic experiences. Despite their prominent self-focus, their thoughts and feelings provide little solace, comfort, or direction to their existence. Not only are these individuals’ internal processes poorly defined and disorganized but also their inability to relate to others further serves to establish them as a kind of recluse in society. Treatment Implications Individuals with high elevations on the Schizoid scale have a moderately or markedly poor prognostic outlook, depending on the severity of the elevation. Their emotional and interpersonal deficits tend to be chronic and pervasive, and they often have little to no intrinsic motivation to change. Coupled with their already low level of energy, clinicians can most likely expect individuals who are not willing to put significant effort into their treatment both inside and outside of sessions. Oftentimes lacking insight into the nature of their difficulties and being content with their current quality of life, these individuals rarely seek out or experience success in therapy. Because of a marked lack of internal motivation, the role of contextual factors in their motivation to change and willingness to actively participate in therapy remain a critical aspect of the initial assessment conducted with these individuals. Avoidant (Scale 2A)

The Active-Detached pattern found with the Avoidant scale is characterized by a hypervigilance, mistrust, or fear of others. These individuals have learned to avoid the pain that they associate with relationships by actively withdrawing from social contact and connection. Despite desires to relate, they have developed a rigid belief system, most likely based on past experiences, that encourages them to keep others at an emotional arms’ length, with the intention of never allowing others to have the potential to hurt them in the future. Motivating Aims Demonstrating a clear conflict within the pleasure-pain polarity, individuals who score high on the Avoidant scale experience a diminished ability to experience pleasure while concurrently experiencing an extraordinary sensitivity and predilection to intrapsychic distress. They are often frustrated with their life; they do not usually experience extreme highs because of a lack of risk taking and a consistent state of hypervigilance, which is exacerbated by their constant avoidance of potentially harmful stimuli (Figure 4.3).

50 ESSENTIALS OF MCMI®-IV ASSESSMENT

SRAvoid (Avoidant) Prototype Millon Evolutionary Model MCMI-IV: Scale 2A Pleasure

Pain

Passive

Active

Self

Other

Weak on Polarity Average on Polarity Strong on Polarity

Figure 4.3 Avoidant Motivating Aims

Personality Expression Avoidant personality styles tend to be marked with poor self-worth, significant levels of anxiety, and an overwhelming sense of inadequacy and social ineptitude. Individuals who score high on this scale often tend to internalize blame, and they use these often-distorted attributions to further reinforce a harsh and ever-present self-critic. However, they may also possess a strong desire to engage and connect with others on deeper, more intimate levels. Unfortunately, their uneasy and oftentimes odd interpersonal style typically leads others to reject, ridicule, or shun them altogether. This common response from others serves to exacerbate their already hardwired belief that they are not good enough for, or worthy of, interpersonally meaningful relationships (Figure 4.4). In an attempt to reach some form of reprieve or escape from their harsh, critical inner world, individuals with an Avoidant personality style turn to their rich fantasy world in order to gain distance from the pain caused by constant self-degradation. The strength of their unwanted emotional experiences often disrupts their desire to successfully navigate unwanted thoughts and beliefs, and they are often left back where they started following an intense emotional experience. Learning to repress or compartmentalize the majority of their feelings might seem like the only solution. When their level of life dissatisfaction transcends the interand intrapersonal domains, they often adopt a nonchalant, unemotional, and apathetic outward appearance that attempts to mask their internal distress. Although this personality pattern can take on several distinct forms (see the accompanying Grossman Facet Scales), the overwhelming characteristic in each

SECTIONS AND SCALES 51

Personologic Domains: SRAvoid Spectrum Fretful Expressive Emotion

Aversive Interpersonal Conduct

Distracted Cognitive Style

Alienated Self-Image

Fragile Intrapsychic Architecture

Fantasy Intrapsychic Dynamics

Anguished Mood/Temperament

Vexatious Intrapsychic Content

Figure 4.4 Avoidant Domains

of these presentations is a pervasive and active withdrawal from external realities. Constantly being concerned with being humiliated or rejected by others, these emotionally anxious individuals have learned to distance themselves from others as a means of protection and perceived safety. Historically, there is a high likelihood that these individuals experienced parental rejection and deprecation, slowed or irregular social maturation, or peer group alienation at key times during their development. Treatment Implications Because of the pervasive and entrenched nature of their maladaptive personality patterns, coupled with a usual lack of supportive and caring environments, the prognosis for individuals with Avoidant personality pattern is extremely poor. As a clinician working with these individuals, you can expect high rates of dropout and extremely high defenses. Regardless of the inherent safety in the therapeutic relationship, Avoidant individuals will be much less likely to reveal their true beliefs, emotions, and experiences because they will most likely have difficulty trusting that even their therapist will treat them with kindness and acceptance. However, with a great deal of patience, clear communication regarding treatment goals and progress, and the provision of a stable, consistent space for these individuals to lower their defenses, a strong working alliance may be forged, and therapeutic gains may be experienced.

52 ESSENTIALS OF MCMI®-IV ASSESSMENT

Melancholic (Scale 2B)

Although Schizoid individuals display marked difficulty experiencing strong emotions, and Avoidant individuals attempt to adapt their lifestyles to avoid undesired strong emotional experiences, individuals with a prominent Melancholic personality pattern hold to the belief that emotional pain is permanent, deserved, and unchangeable. Oftentimes viewed by others as cynical or pessimistic, individuals with this personality pattern have difficulty viewing themselves and others outside of the frame of their perceived undesired emotional stalemate. Motivating Aims Intrapsychic pain seems to be the primary motivating factor, which ultimately reinforces a passive acceptance of current life situations. Although they may elicit prosocial or adaptive behaviors occasionally, they are constantly reminded of past hurts, perceived failures, and an overall sense of helplessness concerning their future. Oftentimes, they end up simply resigning themselves to the status quo of their existence (Figure 4.5). Personality Expression Chronic feelings of sadness and depression are the hallmark of the melancholic presentation. Individuals who score high on this scale tend to lack joy in their lives, frequently ruminate on perceived or real losses from their past, and maintain a sense of despair about their future. Their pessimism, coupled with a daily experience of emotional pain and suffering, lead them to expect the worst, and they rarely believe they deserve anything different. Oftentimes, they believe that they have either missed out on, or have already lost, whatever opportunity they had to DFMelan (Melancholic) Spectrum Millon Evolutionary Model MCMI-IV: Scale 2B Pleasure

Pain

Passive

Active

Self

Other

Figure 4.5 Melancholic Motivating Aims

Weak on Polarity Average on Polarity Strong on Polarity

SECTIONS AND SCALES 53

Personologic Domains: DFMelan Spectrum Forsaken

Depleted

Intrapsychic Content

Intrapsychic Architecture

Pessimistic Cognitive Style

Woeful Mood/Temperament

Worthless

Disconsolate

Self-Image

Expressive Emotion

Asceticism Intrapsychic Dynamics

Defenseless Interpersonal Conduct

Figure 4.6 Melancholic Domains

find happiness in their lives. Other times, they demonstrate a marked inability to see the good in their current situations, regardless of the external quality of their relationships or life circumstances (Figure 4.6). Interpersonally, they tend to demonstrate marked difficulties advocating for themselves, either because of their belief that they are not worth it or simply because of their extremely low levels of energy and motivation. They tend to engender feelings of sympathy from others. However, they tend to present themselves relationally in one of two ways: being overly acquiescent and passive or extremely needy and demanding. With both presentations, the common goal is to seek nurturance and validation from others in order to create a better developed sense of security and fulfillment. Unfortunately, these styles of relating are usually accompanied by clear acclamation of their worthlessness and perceived reinforcement of their inability to function like “normal people.” Although they crave affection and support, should they receive them from others they tend to reciprocate in ways that are not equal in scope or in depth. Should they not receive affection and support from others, they tend to withdraw and engage in marked self-condemnation and feelings of guilt and shame for not being deserving. Although environmental factors most likely played a significant role in these individuals establishing such a rigid and self-defeated view of themselves and their world, there are strong biological predispositions to their personality style that cannot be ignored. And although external solutions to their problems and concerns can seem quite clear to others looking in, these individuals maintain

54 ESSENTIALS OF MCMI®-IV ASSESSMENT

an almost defiant attachment to their disheartened outlook. Depending on the severity of the elevation, suicidal thoughts, hopelessness, and lack of adaptive coping skills may also be present. Historically, there is a high likelihood that they experienced early loss of emotional support from caretakers, loss of a realistic sense of self, adoption of learned helplessness, or unconscious re-creation of past experiences of suffering. Treatment Implications Although most individuals who fall C A U T I O N .................................................... within the Melancholic personality structure have accepted their painful Individuals who receive a BR score of life experiences as unchangeable, 85 or higher on the Melancholic scale oftentimes their motivation to partypically warrant a more thorough and explicit risk assessment following testticipate in treatment comes as result ing to ensure their safety. of a recent traumatic experience, unexpected reaction to a new life transition, or at the behest of their family, friends, or colleagues. It is easy for the clinician to focus exclusively on the current symptoms of depression, but it would be well-advised to ensure that a thorough history be taken on the extent and onset of their Melancholic personality style. Oftentimes, clients’ current symptoms are merely a recurring pattern of emotional reactivity that can be traced back to earlier periods in their lives. Years of experience have reinforced these individuals’ belief that even though things may be okay in their lives currently, feelings of despair and dysphoria are waiting for them around the corner. Depending on the severity of the elevation, the presence of hopelessness, lack of social support, and level of chronicity, frequent and explicit risk assessment may be a necessary component of treatment with these individuals because suicidality is common in more severe presentations.

Dependent (Scale 3)

The Passive-Other pattern identified in the Dependent scale is noted for an individual’s lack of autonomy and self-efficacy. Individuals scoring high on this scale display a marked difficulty establishing a healthy balance of self- and other fulfillment in their relationships. They gravitate toward relationships in which they believe they can rely on another person for emotional support, direction, and reassurance, regardless of the quality. Oftentimes, these individuals become so accustomed to playing a passive role in relationships that their own sense of self becomes unclear or unimportant to them.

SECTIONS AND SCALES 55

DADepn (Dependent) Spectrum Millon Evolutionary Model MCMI-IV: Scale 3 Pleasure

Pain

Passive

Active

Self

Other

Weak on Polarity Average on Polarity Strong on Polarity

Figure 4.7 Dependent Motivating Aims

Motivating Aims Exhibiting a clear and marked passive reliance on others’ behaviors to bring about fulfillment in their lives, these individuals rarely experience a consistent state of pleasure or pain. By focusing so extensively and rigidly on the expectations, approval, and support from others, they tend to have a vague sense of self and ambiguity regarding their own morality and personal beliefs (Figure 4.7). Personality Expression Individuals with high elevations on the Dependent scale have come to believe that their happiness, security, and self-confidence are a direct result of the kindness of others. As a result, they tend to become strongly bonded with those whom they have identified as bearers of happiness and fulfillment, and they display a strong need for support and attention. This marked need for approval and affection tends to leave these individuals sacrificing their own values, desires, and other life goals in the service of ensuring that others do not abandon, reject, or remove themselves from their lives on any level. They maintain a constant pacifism, rarely taking sides on contentious issues and avoiding social conflict at all cost (Figure 4.8). The entirety of their interpersonal style and presentation lacks confidence, often evidenced by slouched posture, ultra-conservative dress, and reluctance to spontaneously participate in social interaction. They maintain a markedly inept self-image and believe that they are weak and fragile needing others to provide safety and security in their lives. Regardless of past accomplishments or successes, these individuals routinely latch on to perceived personal flaws or situational factors that diminish the importance or significance of those past success. Their tendency to see themselves as having little to no value further reinforces the way

56 ESSENTIALS OF MCMI®-IV ASSESSMENT

Personologic Domains: DADepn Spectrum Immature

Pacific Mood/Temperament

Intrapsychic Content

Inchoate

Submissive

Inept

Interpersonal Conduct

Self-Image

Naive Puerile

Cognitive Style

Intrapsychic Architecture

Introjection Intrapsychic Dynamics

Expressive Emotion

Figure 4.8 Dependent Domains

in which others approach them, usually eliciting more support and kindness from new relationships in their lives. However, others tend to grow tired and frustrated with the Dependent individual’s constant need for direction and reassurance, and this pattern often leads to resentment and frustration in longer-term relationships. Dependent individuals are often left reinforcing the narrative that they are not worthy of love and affection through consistent refusal to take responsibility for their actions. Developmentally, these individuals have most likely experienced a series of events in which there was excessive attachment learning and an avoidance or inability to learn independent prosocial behaviors. Oftentimes, there is a history of parental attachment that is marked by overprotection and lack of personal freedom. As these individuals grow into adulthood, they likely have a history of engaging in clinging social behaviors as well as an active avoidance of stereotypically adult behaviors. Treatment Implications There is a high probability that individuals with the Dependent personality pattern had a supportive relationship with at least one primary caretaker in their lives, thus providing them with a learned ability to trust in the safety of well-defined relationships. Therefore, the prognosis for these individuals is generally good, because they can be expected to be cooperative, engaged, and receptive to various treatment approaches. By nature, these individuals seek out and enjoy

SECTIONS AND SCALES 57

close relationships to aid them in feeling safe and secure. This information should provide relief and caution to their would-be therapist, because the development of rapport will most likely occur rapidly. However, it is advised that you use your clinical judgment and knowledge of this personality pattern to determine if the client’s behavior is attributed to pathologically related modes of interpersonal compliance or genuine therapeutic gains. Histrionic (Scale 4A)

The Active-Other motivational pattern identified in the Histrionic scale demonstrates an individual’s desire to be loved and attended to at any cost. Manipulation and learned socially desirable behaviors work together to help Histrionic individuals appear confident and self-assured to others. However, underneath the surface, these individuals need constant reassurance and validation from external sources in order to maintain any acceptable level of functioning. Motivating Aims Shifting from the passive orientation of the Dependent scale, the primary motivations for individuals scoring high on the Histrionic scale are extremely active behaviors in the pursuit of acceptance and nurturance from others. Similarly, they do not have a clearly defined predilection toward pleasure or pain, so these individuals tend to continually seek reassurance from others, because they have marked difficulty feeling safe and secure without recurrent external validation (Figure 4.9). SPHistr (Histrionic) Spectrum Millon Evolutionary Model MCMI-IV: Scale 4A Pleasure

Pain

Passive

Active

Self

Other

Figure 4.9 Histrionic Motivating Aims

Weak on Polarity Average on Polarity Strong on Polarity

58 ESSENTIALS OF MCMI®-IV ASSESSMENT

Personality Expression Individuals who score high on the Histrionic scale engage in persistent attention seeking, overly dramatic expression of emotion, and superficially charismatic lifestyles. They tend to be impatient, impulsive, and experience intense emotional states followed by periods of rapid boredom and futility. They demonstrate an interpersonal seductiveness that serves to illicit a high degree of praise and external validation. However, once they detect the waning or disappearance of that external validation, they will often resort to overly dramatic displays and childlike exhibitionism to ensure that the spotlight remains firmly on them. They expend a great deal of energy attempting to win over others and rarely feel satisfied for extended periods of time (Figure 4.10). A significant barrier for Histrionic personalities in gaining appropriate insight and awareness of their maladaptive behavioral patterns is their marked avoidance of introspection or self-reflection. This results in a blatant lack of self-awareness that is further perpetuated by their almost obsessive focus on external stimuli. As a result, they may become overly suggestible, excessively focused on fleeting or superficial events, and experience difficulty in solidifying a clear, accurate picture of their own sense of self. They are often characterized as being flighty in interpersonal relationships, most likely because of their constant desire for Personologic Domains: SPHistr Spectrum

Dramatic Expressive Emotion

Dissociation

Gregarious

Intrapsychic Dynamics

Self-Image

Attention-Seeking

Fickle

Interpersonal Conduct

Flighty Cognitive Style

Figure 4.10 Histrionic Domains

Mood/Temperament

Shallow Intrapsychic Content

Disjointed Intrapsychic Architecture

SECTIONS AND SCALES 59

new distractions that take them further away from identifying and accepting their actual personality structure. By keeping interactions at a surface level, they attempt to prevent anyone else from seeing them for their true selves. An additional source of confusion and frustration for others who may want to connect with Histrionic personalities is their tendency to be extremely fickle, erratic, and extreme in their emotional expression, leaving others to wonder about the genuine motivation behind their behaviors. Treatment Implications Individuals with Histrionic personality patterns rarely seek therapy, and REMEMBER ....................................................... when they do, they are often lookOne of the most significant differences ing for their therapist to provide them between the Dependent and Histrionic the approval and audience that they Personality Patterns is the Dependent’s are currently missing in their lives. passive orientation and the Histrionic’s active orientation toward attaining love Should clients begin to attain the and affection from others. social rewards they previously experienced, they are likely to drop out of treatment without much warning. It is often helpful to identify this tendency at the onset of treatment and create specific goals that serve to reinforce the many potential benefits of continued and completed psychotherapy. In addition, significant ups and downs in long-term relationships are expected, because their need for continual external validation and interpersonal excitement becomes less frequent or present because of familiarity and routine.

Turbulent (Scale 4B)

The Active-Pleasure-Seeking pattern of the Turbulent scale helps to add to the breadth of the MCMI-IV, because this scale provides insight into the one Clinical Personality Pattern that emphasizes the “pleasure” end of the “pleasure-pain” continuum of Millon’s theory. Many individuals who score high on the Turbulent scale are relatively well-adjusted, vigorously pursue goals in life, exhibit an adaptive outlook on the future, and hold a strong interest in connecting with others. However, these positive characteristics have natural limits, beyond which these individuals become alienating and misattuned to others and their environment, as well as emotionally and physically depleting of themselves. At times, their high levels of energy can appear to be hypomanic in nature. Maintaining this high energy level or unrelenting emotional intensity becomes increasingly more difficult and may ultimately lead to depressive exhaustion. Believing that

60 ESSENTIALS OF MCMI®-IV ASSESSMENT

EETurbu (Turbulent) Spectrum Millon Evolutionary Model MCMI-IV: Scale 4B Pleasure

Pain

Passive

Active

Self

Other

Weak on Polarity Average on Polarity Strong on Polarity

Figure 4.11 Turbulent Motivating Aims

they have the ability to be all things to all people, they tend to experience marked difficulty managing setbacks in life, because their strong emotional experience likely clouds their judgment and perception of themselves and their environment. Motivating Aims This is the only scale of the 15 total personality patterns that primarily emphasizes the pleasure orientation as its main motivator. Individuals who score high on the Turbulent scale expend a great deal of energy, time, and creativity toward feeling happy and fulfilled. Their sense of fulfillment does not necessarily come from their own happiness, but they oftentimes experience personal satisfaction even when advocating for others (Figure 4.11). Personality Expression Individuals who score high on the Turbulent scale are typically enthusiastic, animated, and idealistic. Oftentimes, they become scattered in their thinking, because they are inundated with thoughts about how to better meet their needs or reassess their goals. They usually demonstrate a great deal of emotional excitability and forceful energy. They tend to maintain what appears to be restless activity and can oftentimes be socially intrusive because of their strong desire to engage with others. At times, they can experience so much excitement and intense emotion that they seem to be bursting out of their own skin in a futile attempt to become more engaged with their surroundings (Figure 4.12). Turbulent individuals are fidgety, extremely animated, and over-the-top in physical mannerisms. They often display an excessive use of idiosyncratic gestures (e.g., winking, providing a thumbs-up, or excessive nodding), attempting

SECTIONS AND SCALES 61

Personologic Domains: EETurbu Spectrum

Impetuous

High-Spirited

Expressive Emotion

Interpersonal Conduct

Mercurial

Unsteady Intrapsychic Architecture

Scattered

Mood/Temperament

Cognitive Style

Piecemeal Intrapsychic Content

Exalted

Magnification Intrapsychic Dynamics

Self-Image

Figure 4.12 Turbulent Domains

to get others actively involved in their up-tempo interpersonal style. REMEMBER Although they are usually extremely ....................................................... The Turbulent scale is the only Clinical productive throughout the day, the Personality Pattern that demonstrates a quality of their efforts is not usually in strong pull on the pleasure side of the line with their expectations. Despite pleasure-pain evolutionary polarity. any real or imagined setbacks, these individuals maintain a positive, highspirited outlook on life. Of note, their high level of energy is usually met with severe and chronic sleep difficulties. Historically, these individuals usually report experiencing overwhelmingly happy childhood experiences. However, there may be cases when further investigation reveals the presence of markedly painful experiences, loss of a loved one, and an underlying fear of abandonment. Treatment Implications The high level of optimism, self-assurance, and ability to keep moving in spite of external obstacles make Turbulent individuals much less likely to seek out treatment. However, should they lack the practical skills to succeed in their current areas of functioning, whether it be relational, occupational, or something else,

62 ESSENTIALS OF MCMI®-IV ASSESSMENT

they are much more likely to seek guidance and support. Their inflated sense of self-worth, lack of interpersonal awareness, and deeply buried experiences of depression and anxiety may serve to be ideal foci for treatment planning and goal setting at the onset of therapy. Usually possessing a deep reservoir of positivity and belief in their own potential, these individuals will most likely be self-starters and highly engaged clients. Narcissistic (Scale 5)

The Passive-Independent pattern of the Narcissistic prototype is marked by an ability to experience fulfillment simply by focusing on the self. This egotistic self-involvement tends to create feelings of superiority that are often unmatched by that individual’s actual circumstances. Regardless of external feedback or validation, these individuals maintain a sense of artificially high well-being that prevents them from connecting with others on deeper, more genuine levels. Maintenance of this inflated sense of self-worth is often managed (consciously or unconsciously) through the exploitation and manipulation of others. Motivating Aims Exhibiting a markedly passive reliance on the self, these individuals have learned to develop a rigid and naive belief structure that typically places their own importance, ability, and overall worth above all others. By removing the need for external validation from their lives, they tend to vacillate between genuinely feeling content and unsatisfied (Figure 4.13). CENarc (Narcissistic) Spectrum Millon Evolutionary Model MCMI-IV: Scale 5 Pleasure

Pain

Passive

Active

Self

Other

Figure 4.13 Narcissistic Motivating Aims

Weak on Polarity Average on Polarity Strong on Polarity

SECTIONS AND SCALES 63

Personality Expression Individuals who score high on the Narcissistic scale focus on themselves as the center of their own existence, with a marked indifference to the ideas, beliefs, and values of others. For them, simply being who they are is enough for them to feel satisfied and content in life. They do not necessarily have to achieve or accomplish anything significant in order to maintain their overinflated sense of self-worth. They tend to engage passively with the world, because their expectation is that others will help them regardless of whether they themselves provide anything in return. Their marked lack of empathy and intellectualized way of delivering sympathy tend to round out their personality presentation (Figure 4.14). The overt presentation of most narcissists is one of a cool, calm, and collected nature. This seemingly easygoing demeanor is usually interpreted as either self-confidence or arrogance, depending on the observer. However, it is not uncommon for these individuals to behave in a pretentious, exclusive, and overtly arrogant manner in order to clearly establish their intellectual and ideological superiority to those surrounding them. They tend to exploit others, take them for granted, and quickly move on to new relationships when they feel that others

Personologic Domains: CENarc Spectrum

Haughty Expressive Emotion

Rationalization

Exploitive

Cognitive Style

Mood/Temperament

Admirable

Interpersonal Conduct

Expansive

Insouciant

Intrapsychic Dynamics

Self-Image

Contrived Intrapsychic Content

Figure 4.14 Narcissistic Domains

Spurious Intrapsychic Architecture

64 ESSENTIALS OF MCMI®-IV ASSESSMENT

have served their identified purpose. Not only do they lack empathy but also they are often accompanied by a marked sense of entitlement that precludes them from understanding why anyone would ever disagree with them or refuse to do what they request. Should these individuals have their inflated sense of self-importance threatened by someone whom they deem a worthy adversary or denied what they believe is owed to them, they become extremely susceptible to narcissistic injury. These injuries are often followed by outbursts highlighted by rage, immature coping strategies, and purposeful malice. They may act cutthroat when they sense that their extremely fragile sense of self is being confronted, and they will do whatever they think they have to in order to preserve their superior status. Historically, potential factors that may have contributed to the development of this style include parental overvaluation and indulgence, being the only child or having first male status, or excessive periods of social alienation that prevented them from honing their ability to experience empathy. Treatment Implications Although some individuals who seek therapy do so at the request of others in their life who have grown frustrated or have been hurt by the unwanted and irksome interpersonal manifestations of their personality functioning, Narcissistic personalities usually do not seek treatment unless they believe that something is off. Usually, a strong blow to their pride will enact a tailspin of depressive experiences that are confusing and frustrating for these individuals. Their lack of accurate insight usually leaves them ill-prepared to face the difficulties of sitting with unwanted emotions. They usually present very cogent arguments to help explain how others are responsible for their current situation, and they will most likely believe and find ways to prove that they are more intelligent and superior than their therapist. At the onset of treatment, it is helpful to allow these individuals to talk about themselves at great length, helping them restore a sense of confidence in their abilities and history. However, it is strongly encouraged to establish a clear framework that enables gradual delivery of objective feedback regarding the interpersonal process being experienced in the room so that these individuals may learn how to appropriately identify and accept the perceptions and values of others. Antisocial (Scale 6A)

The Active-Independent pattern found in the Antisocial prototype typically manifests in persons who have little to no regard for the well-being of others,

SECTIONS AND SCALES 65

because they believe self-preservation and autonomy must be upheld by any means necessary. A learned mistrust of others and cynical attitude toward the world fuel their patterns of duplicitous and often harmful behaviors toward others. They tend to believe that the maintenance of autonomy and the use of hostile, unlimited behavioral tactics are the only reliable ways of thriving, while disallowing mistreatment or victimization from others. Motivating Aims The marked active-self orientation, coupled with a tendency to seek out pleasure, creates a significant amount of external conflict for individuals who score high on the Antisocial scale. Armed with a marked disregard for social norms and high level of intrinsic motivation to attain what they wish at any cost, people with this personality pattern are often accompanied by a history of unlawful or boundary-violating behaviors (Figure 4.15). Personality Expression Individuals who score high on the Antisocial scale tend to be impulsive, irresponsible, and lack empathy or sympathy for others. They have adopted a cynical attitude regarding the motivation of others, and they firmly believe that they are entitled to what they want, when they want it. They have learned that much of what they have accomplished in life has come from direct, oftentimes aggressive, and socially inappropriate self-advocacy. Over time, they usually grow more comfortable using intimidation, rule breaking, and antagonistic behaviors as the norm rather than the exception. They desire autonomy and oftentimes ruminate about ways to exact revenge on those whom they believe have attempted or succeeded

ADAntis (Antisocial) Spectrum Millon Evolutionary Model MCMI-IV: Scale 6A Pleasure

Pain

Passive

Active

Self

Other

Figure 4.15 Antisocial Motivating Aims

Weak on Polarity Average on Polarity Strong on Polarity

66 ESSENTIALS OF MCMI®-IV ASSESSMENT

Personologic Domains: ADAntis Spectrum

Autonomous Self-Image

Acting-Out Intrapsychic Dynamic

Deviant Cognitive Style

Debased Intrapsychic Content

Irresponsible Interpersonal Conduct

Unruly

Impulsive Expressive Emotion

Callous

Intrapsychic Architecture Mood/Temperament

Figure 4.16 Antisocial Domains

at harming them. They believe that they were or are provided with little to no genuine affection and assert that they must always be on guard against potential attacks and cruelty from others (Figure 4.16). The outward appearance of the Antisocial personality may look physically intimidating, off-putting, or generally precarious. However, it is important to note that a more conventional, safe, and welcoming surface-level presentation may mislead others into missing the obvious presence of Antisocial behavioral patterns. Most of these individuals are untrustworthy and unreliable in their close relationships. They frequently disappoint others who care for them, and at times they appear to experience a sense of pleasure when engaging in deceitful, manipulative, or defiant behaviors. When dealing with these individuals, it can often feel like playing a game of tug-of-war. However, in this game, Antisocial personalities will repeatedly break the rules to ensure that they win in ways in which they believe they deserve. Having learned that they can trust only themselves, these individuals rarely maintain a sense of loyalty or dutifulness. They use people as a means to an end, usually creating situations in which they can make others feel the pain, embarrassment, and frustration that they have felt previously in their lives. These individuals usually lack remorse or guilt for their actions. At times, they can act extremely charming and persuasive, but this is usually a means for them to attain what they want when other strategies have failed. Oftentimes, they become very skilled liars, and they are able to create markedly detailed and interesting stories to help support their false claims. They have a penchant for identifying the

SECTIONS AND SCALES 67

weaknesses in others and subsequently attack or use those weaknesses to achieve their own personal goals. Historically, these individuals may have experienced early parental indifference or absence, poor parental role models, or recurrent experiences of trust or boundary violations.

CAUTION .................................................... Individuals who score higher than BR 85 on the Antisocial scale may have significant legal histories or strong tendencies to break the law and societal rules. It is important to identify clear boundaries when working with these individuals for their safety and the safety of the clinician.

Treatment Implications Typically, these individuals will seek out therapy services only when they are forced to as a condition of their relationship, employer, or other mandated avenue. The therapist can expect high levels of resistance, aggression, and immature acting-out behaviors. Because of the marked lack of insight or desire to change their behavior, these clients tend to be extremely difficult when attempting to establish rapport and genuine buy-in for active therapy participation. One of the more useful ways to approach these individuals is to routinely connect their history of antisocial behavior to the personal real-world consequences that they have inevitably created. If the therapist elects to focus on the task of empathy building too early on in treatment, these clients will most likely not care enough about consequences to others to be truly motivated to change their behaviors.

Sadistic (Scale 6B)

Unlike the Antisocial pattern, the Sadistic prototype is characterized by an active orientation toward inflicting pain on others that is operationalized inversely as a pleasure-oriented motivating aim. By demonstrating their perceived power, they find not only solace and security but also satisfaction and pleasure by humiliating others and making clear attempts to invalidate their feelings and experience. These individuals often maintain an ability to appear well adjusted on the outside, but their underlying tendency to push other people’s buttons, create interpersonal discord, and aggressively dominate relationships becomes evident over time. Motivating Aims Individuals who score high on the Sadistic scale derive pleasure by actively seeking to create and inflict painful situations on others. This reversal of the pleasure-pain polarity leans heavily toward pain as the primary mechanism that influences their active interpersonal style (Figure 4.17).

68 ESSENTIALS OF MCMI®-IV ASSESSMENT

ADSadis (Sadistic) Spectrum Millon Evolutionary Model MCMI-IV: Scale 6B Pleasure

Pain

Passive

Active

Self

Other

Weak on Polarity Average on Polarity Strong on Polarity Reversal on Polarity

Figure 4.17 Sadistic Motivating Aims

Personality Expression Individuals who score high on the Sadistic scale have found that the infliction of pain and suffering on others is what provides them the most joy and pleasure in their lives. This is an aggressively oriented personality that usually seeks out and engages in frequent arguments with others. Although most others engage in arguments for the sake of proving their point, the end goal for these individuals is to bring humiliation, degradation, or emotional uneasiness to their identified adversary. As a result, many people tend to avoid Sadistic personalities, because they can often sense, or overtly observe, their vicious, unrelenting, and markedly rigid interpersonal patterns (Figure 4.18). Although they do not necessarily lack empathy, these personalities tend to disregard the feelings of others as trivial and, at times, laughable. Their marked insensitivity toward others is likely connected to their strong drive to identify and exploit the perceived weaknesses of others for their own personal gain. Basically, without attaching to an emotional connection with others, they are better able to take advantage of others in increasingly more cruel and manipulative ways. The intrapsychic dynamics of the Sadistic personality are often useful guide points to better understand how they maintain such a combative and callous lifestyle. In order to protect their sense of self-righteousness, they tend to employ several defenses so that the actual painful consequences of their behaviors are never truly internalized or accepted. Additionally, these individuals usually learn that they cannot act aggressively, cruelly, and impulsively in all areas of their lives or else they would ultimately suffer their own severe and irreversible consequences. Therefore, the most common defense strategies employed tend

SECTIONS AND SCALES 69

Personologic Domains: SASadis Spectrum

Precipitate Expressive Emotion

Combative Self-Image

Eruptive Intrapsychic Architecture

Abrasive Interpersonal Conduct

Hostile Mood/Temperament

Isolation Intrapsychic Dynamics

Dogmatic

Pernicious

Cognitive Style

Intrapsychic Content

Figure 4.18 Sadistic Domains

to be rationalization, sublimation, and projection. Depending on the unique presentation and history of the individual, many will use one or several of these defense strategies more than the others. Historically, these individuals may have experienced parental hostility, lack of connection to conventional norms or values, or significant past hurts in varied relationships. Treatment Implications Because in part of their rigid belief system, lack of care for others, and tendency to find others who will tolerate their behaviors, the overall prognosis for these individuals is poor. Oftentimes, they lack insight into the cause and effect of their personality structure. In addition, should they arrive at a more accurate level of insight, they typically do not care enough to change any of their core behaviors. It is suggested that the therapist helps to reduce the client’s active self-focus, increase interpersonal sensitivity, and practice more socially appropriate ways to manage his or her emotions. Compulsive (Scale 7)

The Passive-Ambivalent pattern found in the Compulsive personality is based on a conflict between hostility toward others and a fear of social disapproval. Over time, they learn to reconcile this conflict with overcompliance to societal

70 ESSENTIALS OF MCMI®-IV ASSESSMENT

norms and expectations, while experiencing an underlying anger, resentment, and frustration with the status quo. Although these underlying experiences may bubble to the surface in times of stress, Compulsive individuals tend to maintain the appearance of overt passivity and compliance throughout the majority of their lives. Motivating Aims The Compulsive scale presents a clear conflict between the self and other polarities as evidenced by the overall ambivalence that these individuals struggle with in everyday decision making. Encompassing a strong passivity in appearance and functioning, they oftentimes experience a strong desire to break the rules and make decisions connected to their own personal reactions. However, they oftentimes defer to the desires or wants of others when ultimately choosing a course of action (Figure 4.19). Personality Expression Individuals who score high on the Compulsive scale are overly rigid, obsessive, and perfectionistic in their thoughts and actions. They often develop routines and approaches to life that are methodical, detailed, and logic-focused. Should their self-created structure or routine be disrupted, they usually respond with exasperation and annoyance. They are dutiful and reliable, and they have marked difficulty accepting others for their perceived lack of organization, discipline, and logical thinking. Emotions come last, if at all, when making decisions. Over time, they have learned creative ways to subdue or avoid their emotional experience at the service of increased logical functioning (Figure 4.20). Interpersonally, they usually behave in accordance with explicit social norms, preferring to interact with others in a formal, polite, and prescribed manner. RCComp (Compulsive) Spectrum Millon Evolutionary Model MCMI-IV: Scale 7 Pleasure

Pain

Passive

Active

Self

Other

Weak on Polarity Average on Polarity Strong on Polarity Conflict on Polarity

Figure 4.19 Compulsive Motivating Aims

SECTIONS AND SCALES 71

Personologic Domains: RCComp Spectrum

Reliable

Constricted

Reaction-Formation

Self-Image

Cognitive Style

Intrapsychic Dynamics

Compartmentalized Intrapsychic Architecture

Respectful

Interpersonal Conduct

Disciplined Expressive Emotion

Concealed Intrapsychic Content

Solemn Mood/Temperament

Figure 4.20 Compulsive Domains

They display utmost respect and deference to authority figures, while expecting the same treatment from others whom they have identified as being subordinate to them. Underneath that veneer, they tend to operate from a markedly rigid set of ethics and morality. Although these values usually do not deviate very far from societal norms, their day-to-day routine is usually rife with idiosyncratic and markedly inflexible ways of being. Oftentimes, they believe that they have developed the most effective, efficient, and productive ways of completing tasks, and they do not elicit or integrate feedback from others. The psyche of the Compulsive personality is rife with unwanted memories, feelings, and other private events that these individuals work hard at avoiding. Should past or current experiences provide contradictory evidence to their well-established belief system, whether on a large or small scale, they have developed explicit and reliable ways to filter that content out of their awareness. Typically, these individuals employ the psychodynamic defenses of reaction formation, sublimation, and projective identification when faced with contradictory stimuli. Historically, these individuals may have had overcontrolling parents, always relied on rules and laws for a sense of safety, or developed a hypercritical conscience that determined unrealistic expectations for their behavior. Treatment Implications Unwanted or uncomfortable psychophysiological experiences often precipitate these individuals’ participation in therapy. Following a physician’s evaluation and learning that their current condition is likely psychosomatic, they are more likely

72 ESSENTIALS OF MCMI®-IV ASSESSMENT

to buy in and become engaged in the therapy process. Their marked level of defense and avoidance regarding their emotional world should usually be the initial focus of targeted treatment interventions. A suggested specific goal would be to aid these individuals in accepting the totality of their experience, focusing on self-compassion and holistic decision making, which includes logic and emotion. Negativistic (Scale 8A)

The Active-Ambivalent pattern found in the Negativistic personality represents an inability to resolve internal conflicts similar to the pattern found within the Compulsive personality. However, Negativistic individuals tend to be much more aware of their ambivalence, because their passive-aggressive style intrudes into everyday life with more overt behaviors that appear to be equally extreme on both sides of the spectrum. These individuals are constantly experiencing intrapsychic turmoil because of their inability to resolve the ongoing conflict between their rigid belief system and their vacillating emotional experience. Bouts of destructive anger and stubbornness are usually followed by experiences of guilt and shame. Motivating Aims The primary motivating factors of the Negativistic personality are shown in an intense conflict within the self-other polarity, ultimately favoring more of a self-focus when a potential balance cannot be achieved. When their needs are not being met, they tend to act erratically and passive-aggressively. However, their extremely active style usually produces more difficulties and uncertainties in their life because they usually resort to more immature coping strategies (Figure 4.21). DRNegat (Negativistic) Spectrum Millon Evolutionary Model MCMI-IV: Scale 8A Pleasure

Pain

Passive

Active

Self

Other

Weak on Polarity Average on Polarity Strong on Polarity Conflict on Polarity

Figure 4.21 Negativistic Motivating Aims

SECTIONS AND SCALES 73

Personality Expression Individuals who score high on the Negativistic scale typically have mood instability, a pessimistic outlook on life, and a markedly low frustration tolerance. They have come to rely on passive-aggressive behaviors to get what they want, because they have never developed more workable or prosocial strategies to manage distress or frustration. They are often seen as being irritable, stubborn, and markedly judgmental. Their personal relationships are typified by patterns of arguments, disappointments, and lack of insight into why others do not respond to them in preferred ways. Although they tend to approach others with impatience, inflexibility, and erratic behaviors, they tend to experience feelings of guilt and remorse when they learn that others have been negatively affected by their actions (Figure 4.22). Their self-view is one of discontent, with Negativistic personalities constantly comparing themselves to others, usually identifying the ways that others had it easier or better than they did. They are cynical, envious, and resentful of others. They are rarely satisfied, and they develop confusing and contradictory views regarding what constitutes success, depending on whether they or others achieve a particular goal. A primary struggle for these individuals is the constant vacillation

Personologic Domains: DRNegat Spectrum

Embittered

Contrary

Expressive Emotion

Interpersonal Conduct

Displacement Intrapsychic Dynamics

Irritable

Discontented

Mood/Temperament

Self-Image

Vacillating

Skeptical

Divergent

Intrapsychic Content

Cognitive Style

Intrapsychic Architecture

Figure 4.22 Negativistic Domains

74 ESSENTIALS OF MCMI®-IV ASSESSMENT

between feelings of guilt and resentment toward others, which leads to their markedly erratic and interpersonally frustrating way of managing stress. They typically employ displacement as their main way of coping, because it is much easier for them to focus on the perceived flaws of others than to accept and change their own personal weaknesses. Most Negativistic personalities maintain a misanthropic view and approach to the world. They tend to complain about many different aspects of their experience and have marked difficulty keeping those complaints private. Even when things might be working in their favor, they tend to find the perceived fault or predict the inevitable failure of a given situation. They often require a great deal of emotional energy to engage with, and most others usually stop spending time with them without providing them feedback regarding the impact of their cynical, critical, and overly negative interpersonal style. Historically, these individuals may have experienced uneven or interrupted maturation, parental inconsistency, contradictory family communications, or family schisms. Treatment Implications Oftentimes, Negativistic personalities enter into therapy via provocation or insistence from family members, friends, or coworkers who have reached their limits dealing with their emotionally draining interpersonal style. They usually present very childlike, blaming others, refusing to take responsibility for their actions, and being markedly obstinate. Progress in therapy is usually rare, because they demonstrate marked difficulty viewing their therapist as a collaborator and not another antagonist who wants to change them. It is critically important that treatment focuses on clearly establishing the boundaries and nature of the therapeutic relationship and assisting clients to create more balance and flexibility in the ways they approach life internally and externally. Masochistic (Scale 8B)

Masochistic individuals are typically competent and capable, but they have adopted a rigid core belief about their value and self-efficacy. They are disproportionally self-demeaning and markedly harsh self-critics. They tend to create difficulties for themselves based on the fear that success will result in rejection or further personal devaluation, effectively undermining themselves or putting themselves in harm’s way. Oftentimes they explicitly give permission and encourage others to exploit, take advantage, or punish them. Masochistic individuals believe that they deserve maltreatment. Shame plays a large role in their decision making, and their overly critical and negative self-appraisals are reinforced when they are made to feel “less than.”

SECTIONS AND SCALES 75

AAMasoc (Masochistic) Spectrum Millon Evolutionary Model MCMI-IV: Scale 8B Pleasure

Pain

Passive

Active

Self

Other

Weak on Polarity Average on Polarity Strong on Polarity Reversal on Polarity

Figure 4.23 Masochistic Motivating Aims

Motivating Aims The tumultuous presentation of individuals who score high on the Masochistic scale is primarily affected by the reversal in their pain-pleasure polarity. Oftentimes, painful experiences have become the expected and desired form of engagement, with these individuals adopting a markedly passive role in order to attain their goals. With their own well-being and safety not typically factoring in to their relationships, they tend to rely more on others for nurturance and support (Figure 4.23). Personality Expression An overwhelming pull to be self-defeating in thoughts and behaviors is the hallmark of individuals who score high on the Masochistic scale. They have internalized the firm belief that they are undeserving of love and affection, and as a result, they behave in ways that inevitably reinforce that belief. Specifically, they tend to place themselves in punishing, shameful, or self-disparaging situations in order to provide further support for their self-pitying narrative. By frequently engaging in self-sacrifice, they hope to elicit guilt in others. However, regardless of others’ response to their behaviors, they maintain a marked level of persistence and commitment to the task of inflicting pain and suffering on themselves (Figure 4.24). When they engage in self-reflection, they tend to distort the accuracy of their experiences to meet the desired outcome of reinforcing their strongly held belief that they were either responsible for their perceived failures or their circumstances would not have allowed for any other possible outcome. New situations or relationships provide minimal solace to these individuals, because

76 ESSENTIALS OF MCMI®-IV ASSESSMENT

Personologic Domains: AAMasoc Spectrum

Abstinent Expressive Emotion

Deferential Interpersonal Conduct

Dysphoric

Exaggeration Intrapsychic Dynamics

Undeserving

Mood/Temperament

Inverted Intrapsychic Architecture

Self-Image

Diffident Cognitive Style

Discredited Intrapsychic Structure

Figure 4.24 Masochistic Domains

they have already concluded that things will never change for the better and others will not genuinely care for them. Oftentimes, they can acknowledge that there are others in their life who do care for them, but they tend to provide vague explanations as to why those people might be acting out of sympathy as opposed to genuine affection. Their emotional world is quite overwhelming and confusing. They may vacillate from feelings of anxious apprehension one minute to feelings of intense suffering the next. This suffering is not primarily intended to draw sympathy from others but serves to reinforce their own personal beliefs regarding self-worth and deservedness. However, they often use the responses of others to further validate their distorted self-concept. For example, a significant concern among this population is their tendency to solicit disapproval from others in order to unabashedly accept full blame and invite outside criticisms regarding their interpersonal behavior or style. Historically, these individuals may have experienced times when physical pain and pleasure were difficult to differentiate because of early childhood abuse, inconsistent or punishment-focused parenting styles, or developing an overreliance on others at the expense of the self. Treatment Implications Although these individuals tend to exhibit broad-based personality dysfunction, the main arena that seems to be consistently and most severely affected is the

SECTIONS AND SCALES 77

interpersonal domain. Fortunately, therapy provides an ideal scenario to help these individuals learn more adaptive interpersonal skills, gain insight into the way their behaviors affect others, and for the therapist to share his or her process for therapeutic gains. These individuals often lack the experience of interpersonal success, usually adopting the role of victim in all of their interactions. Suffering usually becomes their identity. Therefore, a potential therapist would benefit from aiding these clients in clarifying their values, identifying more adaptive and healthy life goals, and preparing for a potential self-reinvention in the process. SEVERE PERSONALITY PATHOLOGY

The following three Severe Personality Patterns differentiate themselves from the preceding Basic Personality Patterns because of their marked cognitive instability, abnormal emotional reactivity (or lack thereof ), and interpersonal difficulties. The Severe Personality Patterns aid in identifying those clients whose core personality is structurally compromised, as evidenced by unintegrated, conflicted, or immovable coping patterns. These personality patterns—Schizotypal, Borderline, and Paranoid— REMEMBER have been formulated in the theory ....................................................... The three Severe Personality Patterns to represent more advanced stages of (Schizotypal, Borderline, and Paranoid) personality pathology. Reflecting an represent the more structurally cominsidious and slow deterioration of the promised, disintegrated personality patterns on the MCMI-IV. personality structure, these differ from the Basic Personality Patterns by several criteria, especially deficits in social competence and frequent (but usually reversible) psychotic episodes. Less integrated in terms of personality organization and less effective in coping than their milder counterparts, they are particularly vulnerable to the everyday strains of life. Schizotypal (Scale S)

Characterized by odd and eccentric thinking patterns on the low end and psychotic thought processes on the high end, the Schizotypal personality pattern is a clear departure from accurate reality testing. Often, their unique way of viewing the world, themselves, and others contributes to marked difficulty initiating, maintaining, or enjoying interpersonal relationships.

78 ESSENTIALS OF MCMI®-IV ASSESSMENT

ESSchizoph (Schizotypal) Spectrum Millon Evolutionary Model MCMI-IV: Scale S Pleasure

Pain

Passive

Active

Self

Other

Weak on Polarity Average on Polarity Strong on Polarity Wavering on Polarity

Figure 4.25 Schizotypal Motivating Aims

Motivating Aims Because of their lack of clear motivation or identification with any of the six potential evolutionary polarities, individuals who score high on the Schizotypal scale tend to have markedly disorganized, odd, and ineffective personality structures. Through this intrapsychic confusion, they often regress to modes of being that relegate them to lead more solitary and monotonous lives, most likely as a means to experience some form of experiential stability (Figure 4.25). Personality Expression Alienation and detachment from themselves and others characterizes the core identity of individuals who score high on the Schizotypal scale. They often lack appropriate social skills, in large part because of their inability to arrive at a consistent and clear idea of social norms and theory of mind. They tend to misinterpret external and internal stimuli and often engage in decision making using illogical, odd, and maladaptive thought processes. These individuals usually have an awareness of their peculiar presentation, and they oftentimes vacillate among feelings of sadness, apathy, and resignation. Of note, these individuals usually take on a predominantly active or passive approach to their lives (Figure 4.26). These individuals usually experience marked difficulties participating in society, oftentimes having difficulty maintaining employment and relationships with others. Their reality testing is often faulty, and in more severe cases, it may actually include experiences of overt psychosis including hallucinations, delusions, and extremely bizarre behaviors. Possessing minimal levels of motivation or drive, these individuals become increasingly detached from social situations and rely more heavily on the instability and ineffectiveness of their own thought processes to try to make sense of the world.

SECTIONS AND SCALES 79

Personologic Domains: ESSchizoph Spectrum Distraught or Insentient

Estranged

Mood/Temperament

Self-Image

Circumstantial

Eccentric

Cognitive Style

Fragmented Intrapsychic Architecture

Undoing Intrapsychic Dynamics

Expressive Emotion

Secretive Interpersonal Conduct

Chaotic Intrapsychic Content

Figure 4.26 Schizotypal Domains

As a result of their atypical beliefs, paranoid tendencies, and past interpersonal failures, they tend to maintain a secretive lifestyle that breeds curiosity and concern from others. Lacking the ability to experience the safety and comfort found in healthy relationships, they have learned to withdraw, remain increasingly to themselves, and oftentimes maintain very few connections or attachments. Even so, these attachments are usually maintained out of necessity or habit. In direct relation to their history of interpersonal difficulties and failures, they developed a markedly estranged self-image that is further perpetuated by the frequent use of self-illusions, depersonalization, and rich fantasy. Historically, these individuals may have experienced rejection, degradation, and humiliation without having appropriate support structures that aided them in navigating their uncomfortable resulting affective experiences. Treatment Implications Although individuals with Schizotypal personalities are easier to identify than some other personality patterns, the difficulty lies in differentiating their presentation from a more acute and severe diagnosis of schizophrenia. In general, the overall severity and duration of their presentations should aid the clinician in making this distinction. On accurately identifying the client’s condition as schizotypal, it is highly suggested that therapists be more explicit and directive in their work. These individuals often need grounding, clear reality testing, and didactic exposure to basic concepts of emotional intelligence, problem solving,

80 ESSENTIALS OF MCMI®-IV ASSESSMENT

and the impact of their unique personality structure on all aspects of their life and functioning. Borderline (Scale C)

Borderline personality patterns might best be understood as markedly deteriorated versions of certain Clinical Personality Patterns. The intense and oftentimes unpredictable nature of their emotional experience leads to a series of erratic and risky decisions that ultimately create more instability in their lives as a whole. The level of risk is high for these individuals, because they tend to engage in self-harm in an attempt to either balance their unwanted emotional experiences or make grand gestures to gain affection or approval from others. Motivating Aims Although the Schizotypal personality experiences ambivalence across each of the three polarities, the Borderline scale indicates the presence of a constant state of conflict in each of the three polarities. Never feeling a sense of genuine safety or security, these individuals vacillate strongly and frequently between attempts at creating more balance and attaching to others in their life. Their internal conflict is usually predicated on a long-standing fear of abandonment, and they often create situations that leave those closest to them feeling confused, hurt, and yet still drawn to remain in their lives (Figure 4.27). Personality Expression Individuals who score high on the Borderline scale experience a marked and vacillating imbalance between their primary drives and motivations. They tend to UBCycloph (Borderline) Spectrum Millon Evolutionary Model MCMI-IV: Scale C Pleasure

Pain

Passive

Active

Self

Other

Figure 4.27 Borderline Motivating Aims

Weak on Polarity Average on Polarity Strong on Polarity Conflict on Polarity

SECTIONS AND SCALES 81

Personologic Domains: UBCycloph Spectrum Incompatible

Regression

Intrapsychic Content

Intrapsychic Dynamics

Capricious

Paradoxical

Uncertain

Interpersonal Conduct

Spasmodic Expressive Emotions

Cognitive Style

Self-Image

Split Intrapsychic Architecture

Labile Mood/Temperament

Figure 4.28 Borderline Domains

be in constant fear of abandonment, wrestle with guilt and shame regarding past behaviors, and experience intense and unpredictable changes in mood and behavior. Oftentimes, these individuals experience intense moods that do not have a clear connection to any environmental or external factors. These often unexpected and severe mood swings can be coupled with recurring periods of dejection and apathy, often interspersed with spells of anger, anxiety, or euphoria. The unpredictable nature of their personality tends to create difficulty and conflict in most areas of their functioning (Figure 4.28). Although their primary motivation is to receive love from and remain attached to others, they behave in an interpersonally paradoxical style. At times, they can be unpredictably antagonistic, manipulative, and impulsive. Other times, they may act obsessively interested, caring, and devout. However, they usually come to expect abandonment in relationships, and oftentimes they create situations that drive others away so that they can fulfill this self-prophecy. By testing the limits of most of their close relationships, they inevitably facilitate exactly what they do not wish would occur: others leaving them. However, they tend to go to great lengths to keep those closest to them in their lives. In extreme situations, they will threaten self-harm or suicide to convince someone to remain in a relationship with them.

82 ESSENTIALS OF MCMI®-IV ASSESSMENT

A significant difficulty for these individuals is the lack of a secure and consistent footing with regard to the way they view themselves, others, and the world. One day, they may find themselves believing that they can take on the world. The next day, they may believe that they are worthless and will not amount to much. Feeling scattered and unclear about their motives, intentions, and values, they tend to regress back to childlike states of relating to the world, or in severe cases, quasi-psychotic thought processes. Historically, these individuals may have experienced childhood abuse or neglect, societal inconsistencies and mixed messages, or unhealthy attachment to a caregiver. Treatment Implications Individuals with Borderline personalC A U T I O N .................................................... ity patterns are notoriously difficult to work with in therapy. Their tendency Because of the high likelihood of either to vacillate between loving and hata history of or current self-harm behaviors in individuals who score over ing their therapist, coupled with an BR 85 on the Borderline scale, it is increased likelihood to use self-harm highly advised to conduct a thorough as a coping strategy, serves to make and explicit risk assessment with your the course of therapy markedly unpreexaminee following a positive score on dictable and potentially high risk. this scale. Therapists tend to experience a heavy emotional load when working with these individuals, and it is encouraged to focus on therapist self-care throughout treatment with these individuals. Clear boundaries, expectations, and treatment goals are essential. Therapists can expect that these individuals will test the limits in treatment, and they should be prepared to react therapeutically, yet firmly. It is often helpful to establish a more holistic approach that includes individual therapy, skills-based and support groups, and on-call crisis services that individuals can access throughout their time in treatment. Paranoid (Scale P)

The hallmark thinking style of the Paranoid personality is rigid, disorganized, and suspicious. They constantly fear the loss of their self-determination and are markedly averse to integrating outside sources of influence or new information into their personal belief systems. Their extreme hypervigilance, cynical mistrust of others, and uncompromising interpersonal styles create social difficulties in most, if not all, of their relationships.

SECTIONS AND SCALES 83

MPParaph (Paranoid) Spectrum Millon Evolutionary Model MCMI-IV: Scale P

Pleasure

Pain

Passive

Active

Weak on Polarity Average on Polarity Strong on Polarity

Self

Other

Unalterable Polarity Orientation

Figure 4.29 Paranoid Motivating Aims

Motivating Aims One of the most uncompromising polarity orientations, the Paranoid scale identifies those individuals who are markedly defensive, suspicious, and rigid in their approach to life. Although they oftentimes exhibit low frustration tolerance, are easily activated, and display maladaptive interpersonal styles, they tend to resort to their creativity to help them cope with the world. By creating an elaborate inner world that oftentimes only they can truly understand or accept, they inadvertently prevent the possibility of learning from experience, others, or any external stimuli (Figure 4.29). Personality Expression Individuals who score high on the Paranoid scale operate with a marked distrust of others and fear of losing their autonomy. Oftentimes, these characteristics are accompanied by hostility, low frustration tolerance, and the presence of extremely rigid belief systems. They maintain a constant state of hypervigilance that usually leads to misinterpretation of external stimuli and overreaction or odd reactions as a result. In severe cases, they may also experience psychotic-like experiences, usually of a delusional nature (Figure 4.30). Paranoid personalities despise being dependent on others, not because of the assumption of weakness and inability to keep themselves safe but primarily because they are unable to trust anyone fully. To expose oneself to a vulnerable, trusting relationship is akin to leaving oneself completely undefended against acts of intimate betrayal and inevitable disappointment, hence their tendency

84 ESSENTIALS OF MCMI®-IV ASSESSMENT

Personologic Domains: MPParaph Spectrum

Irascible

Inviolable

Mood/Temperament

Projection

Self-Image

Intrapsychic Dynamics

Mistrustful

Defensive

Cognitive Style

Expressive Emotion

Unalterable Inelastic

Provocative

Intrapsychic Architecture

Interpersonal Conduct

Intrapsychic Content

Figure 4.30 Paranoid Domains

to create rich inner worlds composed of rigid beliefs and rules for everyday behavior. As foolish as they believe it is to trust someone else, these personalities believe that it is far worse to ever relinquish their self-control and lose their autonomy. Paranoid personalities tend to engage in provocative interpersonal behaviors, which make the probability of engaging in genuine, intimate relationships extremely poor. They tend to hold grudges with or without logical explanation, act argumentatively toward others, and develop deep resentments toward those whom they believe have attained their successes unfairly or with excessive assistance from others. Their tendency to believe that others did not earn their share in life and that they themselves were purposefully and unjustly prevented from experiencing success because of malicious external forces can potentially lead them to decompensate in risky ways. This may play out with the presence of overt aggression in the form of physically violent acts. Historically, these individuals were likely to have experienced child abuse or neglect, parental overcontrol, or being treated like a social outcast from an early age. Treatment Implications Prognosis for these individuals is markedly poor, mostly because of their deeply ingrained and pervasive attitudes and beliefs. They likely come into therapy experiencing dysfunction across all areas of functioning, but they rarely feel

SECTIONS AND SCALES 85

motivated to change or improve any aspect of their personal life. They will attempt to convince their therapist to adapt their unique and often odd view of the world or simply write off the process altogether. Focusing on their drive for autonomy, it is advised to develop treatment goals that aid these individuals in becoming more self-sustaining via identification of specific ways to increase adaptive intrapersonal behaviors, such as mindfulness strategies. CLINICAL SYNDROMES

The Clinical Syndrome scales aid the examiner in gaining better understanding of the more temporary and clear-cut states that accompany the presence of the more chronic and stable patterns found in Clinical and Severe Personality Patterns. Regardless of how severe the elevations are within these scales, they are of most use to the examiner as additional, clarifying data points to help better and more comprehensively explain the examinee’s elevation(s) on the preceding personality pattern scales. Rapid Reference 4.4 provides an overview of the Clinical Syndromes scales, as well as the Severe Syndromes scales. Generalized Anxiety (Scale A) The Generalized Anxiety scale identifies the presence of intrusive, recurring, and oftentimes fearful thoughts. Their overanalytical and future-oriented disposition coupled with uncomfortable physiological experiences usually lead individuals with high scores on this scale to experience ineffectiveness in several areas of their functioning. Somatic Symptom (Scale H) When seeking clarification on the nature of physiological concerns found within elevations on other MCMI-IV scales, the Somatic Symptom scale aids the examiner in determining the increased likelihood of a more classic psychosomatic presentation. Oftentimes, individuals who score high on this scale use their physical experience or fear of illness and physical ailment as an unworkable outlet for their intrapsychic pain and dissatisfaction. Bipolar Spectrum (Scale N) The Bipolar Spectrum scale provides a helpful tool in identifying the presence of manic symptoms, which can range from flight of ideas and inflated sense of self-worth to disorganized psychotic experiences. The lower the elevation on this scale, the more likely that the examinee is currently experiencing a hypomanic or cyclothymic state. The higher the elevation, the more likely the examinee is experiencing a classically manic presentation with marked and potentially routine mood swings.

86 ESSENTIALS OF MCMI®-IV ASSESSMENT

Persistent Depression (Scale D) Potentially adding more elaboration to the personality style identified in the Melancholic personality, the Persistent Depression scale helps to identify a pronounced experience of defeat, apathy, and helplessness in individuals. High scores indicate patterns of overall ineffectiveness in problem solving, planning, and interpersonal functioning, mostly because of the extent of learned helplessness that seems to become more entrenched in their personality as time passes. Alcohol Use (Scale B) The Alcohol Use scale is a straightforward self-reporting of current or recent alcohol abuse or dependence. Elevations on this scale indicate a more purposeful disclosure of their experience, because the items that comprise this scale are straightforward and explicit. Drug Use (Scale T) Similarly to the Alcohol Use scale, the Drug Use scale is a highly face-valid scale that indicates an intentional disclosure of problematic drug use when elevated. High scores on this scale are usually associated with a history of poor decision making, real-world and costly consequences, and a pattern of habitual boundary violations. Post-Traumatic Stress (Scale R) The Post-Traumatic Stress scale aids in identifying the presence of avoidance, excessive fear, and intrusive private events as related to a directly or vicariously experienced traumatic event. Oftentimes, intense emotionality and ultra-realistic flashbacks or nightmares coincide to create a marked state of discomfort when exposed to trauma-related stimuli.

Rapid Reference 4.4

...............................................................................................................

Clinical Syndrome and Severe Clinical Syndrome Scales Clinical Syndrome Scales Generalized Anxiety (Scale A) Somatic Symptom (Scale H) Bipolar Spectrum (Scale N) Persistent Depression (Scale D) Alcohol Use (Scale B)

SECTIONS AND SCALES 87

Drug Use (Scale T) Post-Traumatic Stress (Scale R) Severe Clinical Syndromes Schizophrenic Spectrum (Scale SS) Major Depression (Scale CC) Delusional (Scale PP)

SEVERE CLINICAL SYNDROMES

The Severe Clinical Syndrome scales present three distinct and intrapersonally maladaptive presentations that are usually cause for more focal clinical concern. Whether because of the disorganized or distorted thinking styles or the oftentimes marked inability to adequately function in society, elevations on these scales indicate a need for more focused and multilayered risk assessment when examinees experience higher elevations. Schizophrenic Spectrum (Scale SS) The presence of clearly definable hallucinations and delusions are just one likely experience of individuals who score high on the Schizophrenic Spectrum scale. Inappropriate emotional outbursts, unpredictable interpersonal behavior, and markedly disorganized and scattered thinking are hallmarks of this presentation. These individuals are difficult to read and connect with, because their external presentation is often odd, incongruent with their internal reality, and generally off-putting. Major Depression (Scale CC) The Major Depression scale helps to identify individuals experiencing classical clinical depression. These individuals usually experience a persistent depressed mood, pessimistic views of the world and their place in it, sleep and appetite difficulties, suicidality, and lethargy. They usually experience concern, dismay, or resignation concerning their belief that things in their life will never change. At times, these individuals may experience interpersonal disappointment because of their tendency to focus on the perceived flaws in themselves, their hopeless attitude, and difficulty experiencing joy across various situations. Delusional (Scale PP) The Delusional scale aids in identifying individuals with marked impairments in reality testing, coupled with an interpersonally aggressive and intimidating style.

88 ESSENTIALS OF MCMI®-IV ASSESSMENT

High scores on this scale indicate the presence of clearly articulated and tightly held irrational beliefs that ultimately lead to interpersonal alienation and suspiciousness. If these beliefs are challenged directly, the usual response is extreme defensiveness, anger, and unwarranted reassurance that they are privy to beliefs that others simply are not able to understand or unwilling to accept as truth. GROSSMAN FACET SCALES

The Grossman Facet Scales were developed to aid the examiner in detecting the nuances and specific presentation of the 15 primary personality scales. They provide an added layer of confidence in the identification of the examinee’s true expression of personality functioning. Three corresponding facet scales were identified across the 15 primary personality scales, creating a total of 45 total facet scales. They serve to further expand on the depth and breadth found in Millon’s evolutionary theory as it pertains to the clinical practice of personality assessment (Millon, 2011; Millon & Grossman, 2007c, 2012). Table 4.1 Grossman Facet Scales Primary Scale

Facet Scale

1. Schizoid (AASchd)

1.1 Interpersonally Unengaged

2A. Avoidant (SRAvoid)

Func- Structional tural Description X

1.2 Meager Content

X

1.3 Temperamentally Apathetic

X

2A.1 Interpersonally Aversive

2A.2 Alienated Self-Image

X

X

Indifferent, unresponsive to others, favoring solitary activities and a peripheral social role; tend to neither desire nor enjoy close relationships Lacking in internalized object representations; largely devoid of early perceptions and relationship templates Experiencing and exhibiting little affect and generally reporting weak affection and erotic need; emotions, when recognized, tend to have an intellectualized quality Desirous of acceptance but loath to get involved unless assured of psychic safety; tending to distance from relationships owing to belief they will be shamed or humiliated Perceives self as socially inadequate, unappealing, and vacuous, and fearful of rejection, which tends to justify isolative existence

SECTIONS AND SCALES 89

Table 4.1 (Continued) Primary Scale

Facet Scale

Func- Structional tural Description

2A.3 Vexatious Content

2B. Melancholic 2B.1 Cognitively (DFMelan) Fatalistic

3. Dependent (DADepn)

X

X

2B.2 Worthless Self-Image

X

2B.3 Temperamentally Woeful

X

3.1 Expressively Puerile

X

3.2. Interpersonally Submissive

X

3.3. Inept Self-Image

X

Templates of early relations intensely conflict-ridden and troublesome and are easily activated by subtle triggers; lack of gratification structure creates vulnerability because of lack of defenses to deflect stressors Tendency toward defeatist attitudes, bleak outlooks, and future pessimism; colorizes current events in absolute negativity and terms of doom Self-judging as insignificant and without intrinsic value; vulnerable to dejected states with little provocation and believes self to be deserving of derogation, resulting in overwhelming guilt Joyless, tearful, worrisome disposition that undergirds guilt-ridden tendencies; relations with others and involvement with activities are mechanical and unenjoyable Lacking in mature confidence leading to a behavioral set marked by docility and withdrawal from expected adult initiative; seeks childlike roles in which to feel support and nurturance Seeks subordinate relations in order to quell anxiety of lack of self-initiative; comfortable and reassured by compliant and placating role to others Views self as fragile, incapable, and incompetent; self-disparagement in this regard may have little basis in reality but expression of self-image elicits support of more dominant and directed individuals (continued )

90 ESSENTIALS OF MCMI®-IV ASSESSMENT Table 4.1 (Continued) Primary Scale

Facet Scale

4A. Histrionic 4A.1 Expressively (SPHistr) Dramatic

4A.2 Interpersonally Attention-Seeking

Func- Structional tural Description X

X

4A.3 Temperamentally Fickle

4B. Turbulent 4B.1 Expressively (EETurbu) Impetuous

4B.2 Interpersonally High-Spirited

X

X

X

4B.3 Exalted Self-Image

5. Narcissistic (CENarc)

5.1 Interpersonally Exploitive

X

X

Provocative, fetching, and excitable in behavior, producing volatile and theatrical expressions of wide-ranging but short-lived emotional states Solicitous of praise, attention, and reassurance from multiple others; tends to use flirtatious and seductive interpersonal machinations to gain attention Heightened emotional responsiveness producing heterogeneous expressions of affect from positive to negative that is switched with unusual variability and ease; temperament tends to have low threshold for reactiveness Excitable, zealous, and animated behavioral set evidencing tirelessness and restlessness; high energy may be unfocused, scattered, and ultimately pointless or assaultive because energy fails to create achievement Animated, seductive, and engaging interpersonal interactions typical and often without appropriate boundaries; may be experienced as overbearing, insistent, and intrusive by others Self-portrait is one of dynamicism, boldness, and ambitiousness, with little reality testing for demand placed on self or others Assumes others are extensions of self and free to be used for his or her needs; no acknowledgment of reciprocal responsibility; indulgent of personal agenda without regard to others’ needs

SECTIONS AND SCALES 91

Table 4.1 (Continued) Primary Scale

Facet Scale 5.2 Cognitively Expansive

Func- Structional tural Description X

5.3 Admirable Self-Image

6A. Antisocial 6A.1 Interpersonally (ADAntis) Irresponsible

X

X

6A.2 Autonomous Self-Image

6B. Sadistic (ADSadis)

X

6A.3 Acting-Out Dynamics

X

6B.1 Expressively Precipitate

X

6B.2 Interpersonally Abrasive

X

Awash in self-glorifying fantasies, imagination without pragmatism or reality constraint, and illusive and dishonest with self-presentation Views self as unique and deserving of admiration without achievement; experienced by others as egotistical, haughty, and grandiose Unreliable, unable, or unwilling to meet obligations; transgresses societal expectations with regard to how he or she treats others; deceptive in transactions and intrusive in relationships Intentionally negates social contracts because belief in self is geared to not acknowledging need for other people; others are seen only as assets but are ultimately unnecessary Inner tensions give way to malevolent acts committed without guilt or remorse; underlying belief is “victimize or be victimized,” with no other need to rationalize unconstrained thoughts, statements, or actions Prone to argumentativeness and contentiousness, instigating altercations with sudden emotional outbursts that can be attacking and vindictive in nature; seeks dominance in conflict Fulfillment seeking including intimidation, humiliation, and shaming of others; means of intimidation may be verbal, physical, or sexual in nature (continued )

92 ESSENTIALS OF MCMI®-IV ASSESSMENT Table 4.1 (Continued) Primary Scale

7. Compulsive (RCComp)

Facet Scale

Func- Structional tural Description

6B.3 Eruptive Architecture

X

7.1 Expressively Disciplined

X

7.2 Cognitively Constricted

X

7.3 Reliable Self-Image

8A. Negativistic 8A.1 Expressively (DRNegat) Embittered

X

X

8A.2 Discontented Self-Image

X

8A.3 Temperamentally Irritable

X

Inner aggressions that seep through intrapsychic world without warning in abrupt outbursts beyond personal control; early experiences of psychic pain serve as quick-touch triggers that erupt in affect, generally deliberately controlled but consistently vulnerable Creates structure and discipline in acts and drives, and disallows affect to act on purpose; tendency to be formal and perfectionistic in all tasks, frequently unwittingly complicating responsibilities owing to split-off affect Obedient to rules, social responsibilities, and perceived morality; evidences a rigidness in interpretation of societal guidelines and expectations; troubled by unfamiliar or alternative conventions Self-view is of industry, discipline, and devotion to responsibility; disavowed of need to recharge in social or leisure activities; fearful of condemnation in the event of failure to meet expectations Resentfulness giving rise to procrastination, irksomeness, and contrary behaviors that resist fulfilling expectations of others; can display satisfaction and gratification in undermining others Sees self as jinxed and demeaned by others; believes self to be unable to be understood in relationships; expresses envy and bitterness at others’ perceived good fortunes Affective disposition grumpy, sulky, impatient, and obstinate; generally shows little frustration tolerance, giving rise to bitterness and discontent

SECTIONS AND SCALES 93

Table 4.1 (Continued) Primary Scale

Facet Scale

Func- Structional tural Description

8B. Masochistic 8B.1 Undeserving (AAMasoc) Self-Image

S. Schizotypal (ESShizoph)

X

8B.2 Inverted Architecture

X

8B.3 Temperamentally Dysphoric

X

S.1 Cognitively Circumstantial

X

S.2 Estranged Self-Image

X

S.3 Chaotic Content

X

C. Borderline C.1 Uncertain (UBCycloph) Self-Image

X

Sees self as unworthy, shameful, and debased; magnification of faults creates a harsh self-judgment in which positive feedback is rejected as unreliable and fulfillment is found when able to validate unworthiness with pain and disapproval Reversal of sensibility in which pain and pleasure are experienced as their opposites; repetition of inverted motivation and feeling gives rise to transposed needs gratification, self-sabotage Apprehensiveness dominating affective set, revealing an array of negative states from anguish to mournful; wistfulness in expression can at times be used willfully to induce guilt Cognitive set filled with irrelevancies, magical thinking, daydreams, and circumstantial narrative; odd beliefs result in alienation from others Inability to gauge reactions and expressions from others leading to a sense of personal confusion, emptiness, disconnected affect in which personal experience becomes increasingly remote Early object representations jumbled and incongruous; erratic narratives and uncoordinated impulses produce an inefficient template for regulating interpersonal needs Sense of personal identity confused, tenuous, and scattered, regulated only by adopting ill-fitting absolutes of self-contrition and punishment, activated by easily experienced self-uncertainty (continued )

94 ESSENTIALS OF MCMI®-IV ASSESSMENT Table 4.1 (Continued) Primary Scale

Facet Scale

Func- Structional tural Description

C.2 Split Architecture

X

C.3 Temperamentally Labile

X

P. Paranoid P.1 Expressively (MPParaph) Defensive

X

P.2 Cognitively Mistrustful

X

P.3 Projection Dynamics

X

Inner structure incongruent and segmented, and shifts in focus experienced as abrupt and oppositional; attempts at ordering memories, perceptions, and feelings ineffectively achieved by disavowing uncertainty in action and adopting absolute, black-and-white actions Instability of affect pervading presentation in mood sets that frequently contrast external cues; wavering of feelings producing swings from dysphoria to anger to anxiousness Displaying vigilance and guardedness in anticipation of malicious interactions, even in the absence of interaction; tenacity in seeking sense of control and self-righteousness Mental set occupied by a filter that interprets even innocuous events as threatening to sense of self; interprets signs of manipulation and deceit at minimal to no provocation; distortions and magnifications of everyday exchanges lead to continuous misinterpretations of circumstances Self-righteousness giving rise to disavowal of and blindness to any possible negative trait; any unwanted characteristic reattributed to others on detecting even their most inconsequential deficiency; projections often taking the form of attack, seeking humiliation, and deprecation of any adversary

SECTIONS AND SCALES 95

TEST YOURSELF

............................................................................................................... 1. If an examinee endorses one or more items on Scale V (Invalidity), his or her protocol is likely to invalid.

a. True b. False 2. Information gathered from this scale helps to identify attempts by an examinee to appear more psychopathological, devalued, or impaired.

a. b. c. d.

Debasement Disclosure Desirability Inconsistency

3. This Clinical Personality Pattern pulls strongly on the pain and active polarities, with an average pull on the self-other continuum.

a. b. c. d.

Masochistic Antisocial Avoidant Compulsive

4. Shifting from the passive orientation of the Dependent scale, the primary motivations for individuals scoring high on this scale are extremely active behaviors in the pursuit of acceptance and nurturance from others.

a. b. c. d.

Histrionic Turbulent Sadistic Antisocial

5. According to the evolutionary polarity model, which Severe Clinical Personality scale experiences a conflict across all three polarities?

a. b. c. d.

Schizotypal Borderline Paranoid Depressive

6. Newly added to the MCMI-IV, this active-pleasure-seeking Clinical Personality Pattern helps to add breadth to the MCMI-IV, because this scale provides insight into the one Clinical Personality Pattern that emphasizes the pleasure end of the pleasure-pain continuum of Millon’s theory.

a. b. c. d.

Superficial Passive-Aggressive Turbulent Neurotic (continued)

96 ESSENTIALS OF MCMI®-IV ASSESSMENT

7. This Clinical Personality Pattern was once considered for inclusion in the DSM in the form of Passive-Aggressive Personality Disorder.

a. b. c. d.

Masochistic Negativistic Borderline Melancholic

8. Which Clinical Syndrome scale provides a helpful tool in identifying the presence of manic symptoms that can range from flight of ideas and inflated sense of self-worth to disorganized psychotic experiences?

a. b. c. d.

Drug Use Bipolar Generalized Anxiety Somatic Symptom

9. Each of the following Grossman Facet Scales help to further clarify and more accurately describe the Melancholic Personality Pattern, except for which of the following?

a. b. c. d.

Interpersonally Devoid Cognitively Fatalistic Worthless Self-Image Temperamentally Woeful

Answers: 1. a; 2. a; 3. c; 4. a; 5. b; 6. c; 7. b; 8. b; 9. a

Five INTERPRETIVE PRINCIPLES

I

n Chapter 4, we detailed the scales of the MCMI-IV as they are defined by the theory, and, when applicable, as they overlap with the official DSM diagnostic system. Understanding these scales in isolation is an important step in gaining fluency with the MCMI-IV, because this information serves as the raw materials of a well-rounded and comprehensive interpretation. While Chapter 4 focused on detailing textbook examples of personality and clinical models, this chapter will focus on integrating multiple prototypal scales and standard clinical constructs into a composite picture, with the aim of reflecting important aspects of the examinee in reality.

ROLE OF PERSONALITY IN ASSESSMENT: A RECAPITULATION

Personality is rarely the presenting clinical concern in and of itself. It may also be said that a person rarely enters treatment and proclaims, “I have a personality disorder that I need to treat” (in those or similar words). There will be the occasional person sent by a significant other or a person who must be assessed for a personality diagnosis because of a legal matter, but a person seeking treatment for a personality concern is a relatively rare occurrence. Usually, presenting distress is more syndrome-oriented, and the person is not thinking about his or her personality as a relevant consideration. Yet, it often is. Chapter 2 described the role of personality among other clinical phenomenon in a theoretical manner. Prior to examining the steps involved in interpreting and contextualizing MCMI-IV data, a few words to recap the role of personality, this time with a more clinical focus, may be helpful. No two people will ever experience the same depression, anxiety, addiction, trauma, grief, or any other psychological event in precisely the same way. In fact, no two people with the same general personality diagnosis will have an identical experience with these phenomena. Everyone’s perceptions, unconscious, 97

98 ESSENTIALS OF MCMI®-IV ASSESSMENT

behaviors, and temperament plays a role in shaping the severity, extent, effect, and overall nature of any psychological disturbance. Although no assessment or even formal battery will be able to detail all of the highly idiographic differences between even two very similar individuals, a competent and comprehensive personality evaluation will likely yield useful and relevant information in terms of how a given personality mediates psychological experience. Our aim in this chapter is to coordinate, contextualize, and, when appropriate, blend data from the MCMI-IV into a useful composite picture that sheds light on a person’s experience. In painting this picture, it is important to understand that knowledge of the constructs in the instrument is imperative to understanding what constructs mean in context with one another. Particularly with personality prototypes, the presence of motivating aims and trait constellations from different prototypes in the same person, which is the most common presentation, yields a very distinct personality. Single elevations are a relative rarity, and even when they do occur, a person will not match perfectly with textbook descriptions or theoretical predictions. Deviations from the theory are the rule, not the exception, but the theoretical constructs provide vital points of reference. A useful analogy to understanding personality blends is the color wheel DON’T FORGET ....................................................... (for this example, we will use the primary colors red, yellow, and blue Personality prototypes, as represent[RYB]). RYB are but three perceivable ed by the personality scales of the MCMI-IV, are analogous to a primary colors, yet their various combinations, color wheel. Whereas most priin various amounts, can produce a mary color models delineate three spectrum of thousands of color variprimary colors that, when combined, ants. To take a simple example from may yield thousands of identifiable this metaphor: You would not look at colors, there are 15 personality prototypes that may admix to an infinite the color purple and label it as red or spectrum of personalities. blue, although it is widely known that these two colors, in approximately equal amounts and as they appear in their primary form, blend to create purple. What is identified is an entity unique and distinct from its components. It maintains the core material of the original two colors, but the blending changes the appearance entirely. A similar process occurs with human personality. There are countless possible traits and characteristics and many methods for describing what we perceive in human personality. The current method takes the approach of using 15 primary colors (that is, the primary personality scales), inclusive of their motivating aims,

INTERPRETIVE PRINCIPLES 99

structure, and facets as identified by the functional and structural personologic domains, and attempts to reflect an examinee using this data. For example, a person who produces a profile with 2A (Avoidant) and 2B (Melancholic) elevations may exhibit characteristics of each prototype, but this personality constellation will be qualitatively and quantitatively different from either alone. Further, the personality structure will be affected in unique ways. Recall that both prototypes appear strong on the pain end of the survival polarity, but they are opposites (one active, one passive) on the adaptation polarity. This opposition may create a conflict for the person, who would feel ambivalence regarding remaining guarded and controlling for possible psychic pain (as would a prototypal Avoidant) versus simply giving in and expecting to be vulnerable to psychic pain (as would a prototypal Melancholic). This presentation, then, evidences unique problems with either prototype. A similar but not as complex perspective may be used with the clinical syndromes as well. A well-known phenomenon is “double depression,” which is composed of an underlying Persistent Depressive Disorder (formerly referred to as Dysthymic Disorder) and a superimposed, current Major Depressive Disorder in the same person. The resulting combination resembles many aspects of the two-component disorders, but it is unique from those as well. Other combinations of syndromal disorders are common as well, and they have implications when combined. A particular strength of the MCMI-IV approach is the potential to contextualize personality and syndromal information. After forming the examinee’s personality and syndromal composite pictures, it is important to look at these two composites together, along with validity and noteworthy concerns and reports from other sources (other testing, collateral information, etc.). What will emerge is a deeper, contextual understanding of who this person is, where this person has come from, what immediate stressors are present, and what distress experience is relevant to this person. The following steps will help build this overall picture. BUILDING AN INTEGRATIVE MCMI-IV INTERPRETATION

The process of assembling the many data points of an MCMI-IV profile involves a recommended sequence, the ability to contextualize disparate information, and a sensitivity to, but not an obsession with, specific score quantities. Table 5.1 may be used as a reminder of significant anchor points that assist in qualifying score elevations.

100 ESSENTIALS OF MCMI®-IV ASSESSMENT Table 5.1 Base Rate Anchor Points Base Rate

60

75

85

Personality Scale Clinical Syndrome Modifying Index/Facet Scale

Style Median sample score Interpretable

Type Presence Presence

Disorder Prominence Prominence

Review Sources of Collateral Information

In order to appropriately interpret any test-related information in a manner relevant to an individual, the examiner should learn as much about the person’s life context as is practical. This is good practice regardless of what instruments may be used, but this is particularly important with an instrument that focuses on core aspects of personality. Should a highly unexpected result appear, this information will be useful to understand the outstanding elevation. Consider this real-life example: An elite, Olympic athlete in active training was administered the MCMI-III by one of the authors (SG) and, despite appearances of humility, self-awareness, and regard for others, produced a BR 115 on scale 5 (NarciDON’T FORGET ....................................................... ssistic). In the collaborative feedback session, the examinee was able to Following the suggested sequence of relate this apparent aberrant result in interpretation (Severe Personality the context of the rigorous training pathology before Clinical Personality Patterns; Severe Clinical Syndromes and common practice of “psyching before Basic Clinical Syndromes) faciliourselves up before competition to tates colorization, or an ability to see fully believe we’re ‘all that.’” Although the effects of more pronounced malsome narcissistic qualities were uncovadaptive traits or pathology on basic ered and reviewed in feedback, the personality and syndromal patterns. extremely high elevation was a clear distortion. Review Validity Data

Similar to any psychological instrument, the examiner will want to ensure that overt response-style distortions that would negate the protocol are not present in the produced MCMI-IV profile (computerized scoring will alert the clinician to this, when applicable). Additionally, the examiner will want to know how any anomalies, even those considered subtle, may affect the overall picture. See Rapid Reference 5.1 for a quick overview of the validity data process, including the following issues.

INTERPRETIVE PRINCIPLES 101

Review of Scales V (Invalidity) and W (Inconsistency): Scale V includes three highly unlikely items that the vast majority of respondents would not legitimately endorse in the affirmative. If one of these items is endorsed, the profile should be questioned, and if two or three are endorsed, the profile should not be interpreted further. Similarly, Scale W (Inconsistency) is composed of 25 statistically and semantically related item pairs from the clinical content. Although there are plausible reasons as to why an examinee may endorse item pairs in unexpected directions, the majority of these should be endorsed as expected. If 9 to 19 item pairs are scored unusually, the profile should be considered questionable. If 20 or more pairs are scored unusually, the profile should be considered invalid. Review of Scales X (Disclosure), Y (Desirability), and Z (Debasement): These three scales, taken together, provide information related to the test-taking attitude of the examinee and may serve, in some cases, to provide the basis for automatic score adjustments (see Chapter 3). On Scale X, the only MCMI-IV scale that is fully interpretable for low and high scores, an examinee is likely underreporting and avoiding being forthcoming with important clinical information at a raw score of 20; at a raw score of 6, the profile should be considered invalid because the respondent did not provide enough information. On the other end, a raw score above 60 may indicate overreporting or overemphasizing complaints, and a raw score over 114 invalidates the profile. Scales Y and Z do not provide absolute cutoffs for invalid profiles, but general MCMI-IV guidelines for considering problematic elevations should be employed (i.e., at BR 75 and 85, as with the clinical scales). Scale Y, Desirability, measures a respondent’s attempt to portray hisor herself favorably, virtuously, or unrealistically emotionally healthy, whereas Scale Z, Debasement, measures the opposite tendency, portraying oneself disfavorably, impaired, or psychopathological. Each, if elevated, has implications in context with other clinical elevations. An elevated Scale Y, for example, has very different meaning when accompanied by a high 6A (Antisocial) elevation than with a high 3 (Dependent) elevation. Further, clinicians should be alert to the possibility of moderately high elevations on Scales Y and Z. This incongruence, assuming it is legitimately produced, may indicate ambivalence about reporting personally troublesome matters while also experiencing significant emotional pain.

102 ESSENTIALS OF MCMI®-IV ASSESSMENT

Rapid Reference 5.1

...............................................................................................................

Validity Data 1. Scale V Raw Score (Three unusual items) 2. Scale W: Inconsistency

Scale V

Scale W

Raw Score

0

1

2

0–8

OK

Questionable

Invalid

9–19

Questionable

Questionable

Invalid

20–max

Invalid

Invalid

Invalid

3. Disclosure (X): Raw score < 6, or > 115 (Invalid) Possible underreporting: 7–20; possible overreporting: 61–114 4. Extremes for (Y) Desirability, and/or (Z) Debasement

Review Noteworthy Responses

The 13 noteworthy response categories are reviewed next. The purpose of these responses is twofold: First, this data set contains several categories representing red flags or immediate concerns in which the clinician will wish to be alerted to the potential for harm to self or others. Any endorsed response in these item sets warrants appropriate clinical attention, although none should automatically indicate the need for immediate intervention. Second, the noteworthy response category set now also includes several differential diagnostic categories (such as ADHD and ASD). These are categories for which the MCMI-IV is not an adequate measure but for which some of the MCMI-IV clinical or personality scales share some symptomology. Used in this way, a clinician may be alerted to the potential need to differentiate a classic psychiatric syndrome or personality pattern against one of the noteworthy response disorders (e.g., Schizotypal Personality Patterns versus Autism Spectrum Disorder). Assess Severe Personality Pathology

In assessing personality scales, Retzlaff (1996) first proposed a method for the MCMI-III that we are endorsing and expanding on as part of our recommended interpretive sequence. In order to incorporate structural anomalies present in the three Severe Personality Patterns—Schizotypal, Borderline, and

INTERPRETIVE PRINCIPLES 103

Paranoid—these scales should be examined before assessing the Basic Personality Patterns (Scales 1–8B). In this examination, a primary consideration is how the theory, via the “Motivating Aims” (see Chapter 4), structures each scale. With the Severe Personality Patterns, in general, the theory lays emphasis on the structural integrity of each construct, with each showing compromise and lack of coherence in the personality system because of polarity wavering (Schizotypal), polarity conflict (Borderline), or unalterable polarities (Paranoid). The guidelines for examining these scales are as follows: 1. If one or more of the scales S, C, or P are among the highest two to three elevations across all personality scales, those high-elevated scales should be considered for possible diagnostic implications and interpreted as a primary elevation. This means, for example, that if Scale C (Borderline) is the first or second highest elevation along with Scale 8A (Negativistic), the Borderline scale should be co-interpreted directly with Scale 8A, given similar weight, and may be considered supportive of, but not determinative of, a diagnosis of Borderline Personality Disorder. 2. If one or more of the scales S, C, or P are elevated above BR 60, but not among the highest two to three elevations across all scales, the elevated scale(s) (S, C, P) should be assessed for contribution as a modifier of other more highly elevated scales. Although the S, C, or P scale in this scenario will not likely be considered for a given diagnosis, its effects, as specified in the theory, should be considered in terms of any potential personality structural compromise. As an example, let’s say a given profile evidences a very high 4B/5 (Turbulent/Narcissistic) elevation, with both scores above 85. If the profile also includes an elevated S, C, or P (let’s say BR 64 for any of these), the elevation may affect the interpretation as follows: a. Elevation on Scale S: The Wavering/Disintegrating effect on the motivating aims across all polarity dimensions may create a more chaotic presentation with this otherwise narcissistically guarded, energetic, and ambitious person evidencing lack of focus and an alienation from and misattunement to others. b. Elevation on Scale C: Owing to pervasive conflicts across all polarities, this elevation may indicate fragility of personality cohesion, and any unusual stressors may create intense and unpredictable lability. c. Elevation on Scale P: In this scenario, the immutability across polarities is likely to present in an unrealistically determined, unalterable agenda in which any outside doubt is met with projection and guardedness.

104 ESSENTIALS OF MCMI®-IV ASSESSMENT

3. No elevations over BR 60 on Scales S, C, P: These scales may be disregarded for the current profile, and the clinician should move on to a more straightforward interpretation of Clinical Personality Patterns, Scales 1–8B. Assess Clinical Personality Patterns (Scales 1–8B)

Keeping in mind any elevations on Scales S, C, or P, the next stage of interpretation involves the Clinical Personality Pattern scales. In this section, each high score elevation is examined separately, with primary focus on the highest two to three scale scores. When examining these scales, as with the Severe Personality Pathology, it is as important to consider the structure of the construct as defined by the theory (the “Motivating Aims”; see Chapter 4) as it is to look at the diagnostic criteria from the DSM-5, when applicable. Polarity disbalance, conflict, and discord in each prototype offer key information in terms of how different parts of personality gather and value different evolutionary motivations. The descriptions in Chapter 4, focused on prototypal information, provide excellent keys to understanding each elevation in isolation. For the unusual profile in which there is a single highly elevated score across personality scales, this level of inquiry, along with understanding the elevation in context with information provided by the examinee and other sources of information, may be sufficient. However, this is the exception, not the rule. Most profiles will feature multiple elevations. As per the prior discussion, which used the color wheel as a metaphor for how prototypal personality patterns (primary colors) coalesce into subtypes (secondary colors), the next part of the interpretive process involves an understanding of each prototype as well as a dynamic view as to how two or more prototypal patterns may manifest together. Ninety of the most common subtypes are described in Millon’s (2011) Disorders of Personality; many more are possible. This is an area of MCMI-IV interpretation that involves clinical practice and skill building to become fluent in assessing these combinations and relating your results to the examinee’s presentation and other sources of information. Here are several useful guidelines: 1. Matching/aligning polarities: Examination of several prototypes represented by elevated scale scores may yield more than one matching polarity description. For example, if Scales 3 (Dependent) and 4A (Histrionic) are elevated, both prototypes feature a strong emphasis on the “Other” end of the Replication polarity. It is likely, especially if there are no other major elevations in opposition to this, that this examinee places an even more distinct emphasis on using relationships with others for self-definition. 2. Opposing polarities: In some combinations, two elevated scales will represent prototypes wherein a polarity continuum will highlight opposing

INTERPRETIVE PRINCIPLES 105

ends of the continuum. In these instances, the clinician must examine the meaning of this difference. Oftentimes, this relates to current level of functioning. When not distressed, a simple difference such as this may indicate an ability to modulate between motivational strategies, but under distress, this may highlight a conflict. In the same example with a co-elevation of the Dependent and Histrionic scales, although the Replication strategy matches (both emphasizing “Other”), the Adaptation strategy is opposed (Dependent being a “Passive” strategy and Histrionic being an “Active” one). It is possible that, when this person is not experiencing unusual pressure, the two differing emphases may balance one another, and the person may be able to switch between adjusting to expectations and acting on the environment as outside cues arise. However, in more distress, the same personality structure may create a conflict in which the person feels ambivalence as to whether to draw attention (act on the environment) or fly under the radar (passively fit in). 3. Combinations in which one or more prototypes feature a single conflict or discordance: These situations often highlight the need to assess whether the prototypal amalgam exacerbates or subdues the prototypal conflict or discord. For example, Scale 2A (Avoidant) and Scale 6B (Sadistic) are structured similarly, with each oriented toward an “Active Pain” motivating strategy. Of course, their outward expression is very different, but their core motivations may be similar. The key difference is the reversal on “Pain” for the Sadistic, wherein this person reorients the focus on pain to deflect psychic pain outward onto others. Wherein a single Sadistic elevation may be reflective of a person less aware of his or her own psychic pain experience, the combination likely reflects an individual well aware of his or her struggle with social acceptance, possibly being more conscious of his or her strategy to hurt others as a means of deflection. 4. Combinations involving Scales S, C, or P: A determination will need to be made as to whether an elevation on one of these three scales represents a probable co-elevation with other scales contending for a diagnostic assignment or whether a more moderate elevation (above BR 60; more significantly separated from other higher elevations) serves mainly to colorize the more elevated scales. See the discussion in the prior section for a more detailed review of this process. Although there may be many scales elevated beyond a BR of 60, key interpretive information should be focused on the highest of these scales. In some instances, an elevated scale that is not among the highest scores will contribute some meaningful colorization to the overall profile, but primary consideration

106 ESSENTIALS OF MCMI®-IV ASSESSMENT

should still be focused on the highest elevations. For example, a profile may feature a cluster of high scores, perhaps BRs in the 80s, for Scales 1 (Schizoid), 2A (Avoidant), and 3 (Dependent), with a secondary score of Scale 6B (Sadistic) at a BR of 67. In this example, most of the motivation and key personologic information will be found in the solitude, fear of rejection, and self-uncertainty in the first three scales. However, Scale 6B adds an important colorization in that it may speak to this person’s chosen defense of presenting a kind of “meanness” in their interactions. Exploration of this scale with examinees may lead to an understanding that owing to their fears, they are more comforted by leading people to believe in their unfriendliness and causticness. Integrate Grossman Facet Scales

Once the clinician has formulated the overall personality framework, focus may shift to more finite, molecular specifications as detailed by the Grossman Facet Scales. To review, these scales are derived from the three out of eight most prominent structural and functional domains in each prototypal scale (see Chapter 4), and they largely match with those predicted to be most prominent within the theory. Although which three out of eight domains may differ among prototypal scales, the eight domains are consistent across all prototypes and scales. Assessment of facet scales is a relatively straightforward process. First, priority is given to facet scales, as a general rule, in order of the primary scale elevations. The highest three primary scale scores are shown in descending order graphically on page 2 of the profile report, with the full listing of all facet scales below that graph. In some instances, the same domain may be elevated on two different primary scales, with two different descriptions. The clinician will need to determine, based on primary scale elevation, facet scale elevation, and clinical presentation, which of the two descriptions (or whether a combination of both descriptions) is most appropriate. Facet scales are best seen as clinical hypothesis builders, not diagnostic in their own right, but they are useful in helping determine specific problem areas and linking these challenges to treatment approaches. Chapter 6 details this process. Examine Severe Syndrome and Clinical Syndrome Scales

After completing MCMI-IV assessment of personality variables, attention is turned to the syndromal scales, beginning, as was the case with personality scales, with the Severe Syndromes (Scales SS [Schizophrenic Spectrum], CC [Major Depression], and PP [Delusional Disorder]). The rationale is similar to that of the personality scales, although the interpretation is generally more straightforward. These three

INTERPRETIVE PRINCIPLES 107

scales may serve to colorize and combine with the Clinical Syndrome scales in meaningful ways. A moderate Scale SS elevation, for example, will affect the meaning of a high elevation on Scale A (Generalized Anxiety) or Scale R (Post-Traumatic Stress) in terms of reality testing and dissociative experience, even in the absence of a Schizophrenia diagnostic consideration. Although combinations between the more basic Clinical Syndrome scales are common as well and create modified meanings resulting from these combinations, beginning with the more severe variants helps to contextualize these varying levels of psychopathology. INTEGRATING THE OVERALL CLINICAL PICTURE

A major consideration in MCMI-IV assessment is the relatedness of the varying sections of the instrument and how one section modifies or colorizes another. Following the aforementioned sequence, by its inherent process, highlights the relationships between Personality and Clinical Syndrome, validity and response style and personologic data, noteworthy responses and clinical status, and so on. The interpretive sequence is designed to be a stepwise, cumulative process wherein a heterogeneous but unified reflection of the person, his or her response to assessment, current level of distress, presenting psychiatric difficulties, and possible alternative explanations for psychological status emerge. The astute clinician will be mindful, throughout this process, of (1) who this person is, based on primary and facet scale data; (2) what his or her response is to the unusual situation of being assessed in such a personal manner, based on validity and modifying index data; and (3) how his or her personality and personal experiences affect any present syndromal psychopathology based on noteworthy responses and clinical syndromal data.

TEST YOURSELF

............................................................................................................... 1. Two or more score elevations are the most common profile configurations, and they are best interpreted as admixtures of the personality prototypes from which they are composed.

a. True b. False 2. It is generally most accurate to begin interpretation of each clinical section of the MCMI-IV (personality and syndrome sections) by examining the basic patterns and then incorporating the more severe patterns.

a. True b. False (continued)

108 ESSENTIALS OF MCMI®-IV ASSESSMENT

3. Identify the suggested interpretive sequence, following review of relevant clinical information from other sources (interview, other test data, etc.).

a. Modifying Indices, Noteworthy Response, Clinical Personality Patterns, Severe Personality Pathology, Grossman Facet Scales, Clinical Syndromes, Severe Clinical Syndromes b. Noteworthy Responses, Modifying Indices, Grossman Facet Scales, Severe Personality Pathology, Severe Clinical Syndromes, Clinical Personality Patterns, Clinical Syndromes c. Modifying Indices, Noteworthy Responses, Grossman Facet Scales, Severe Personality Pathology, Clinical Personality Patterns, Severe Clinical Syndromes, Clinical Syndromes d. Modifying Indices, Noteworthy Responses, Severe Personality Pathology, Clinical Personality Patterns, Grossman Facet Scales, Severe Clinical Syndromes, Clinical Syndromes 4. On the MCMI-IV clinical scales, which of the following is NOT a Clinical Syndrome?

a. b. c. d.

Eating Disorders Bipolar Spectrum Persistent Depression Post-Traumatic Stress

5. When Scale S, C, or P is elevated above BR 60, but moderately less than other scales from 1–8B, it may signify which of the following?

a. The elevation on this single severe personality scale should be considered foremost in determining diagnosis without regard for other higher elevations. b. Although it may or may not be considered for the primary diagnosis, an elevation on one of these Severe Personality scales may colorize interpretation of other personality patterns by representing a structural compromise in the personality. c. The elevation on the Severe Personality scale should be disqualified entirely in terms of diagnosis, but it may still colorize interpretation of other personality patterns by representing a structural compromise in the personality. d. The elevated Severe Personality scale should be considered for colorization of other personality patterns by representing a structural compromise in the personality, but only if it is among the top three elevations. 6. When a co-elevation of two personality scales reveals opposing emphases on a single evolutionary polarity (e.g., one pattern emphasizes “PassiveAccommodating” and the other emphasizes “Active-Modifying” on the adaptation polarity), it often signifies at least a periodic conflict in motivation, particularly when the individual is distressed.

a. True b. False Answers: 1. a; 2. b; 3. d; 4. a; 5. b; 6. a

Six THERAPEUTIC ALLIANCE BUILDING

T

his chapter illuminates the process of relating MCMI-IV assessment findings to the examinee from personal characteristics through experienced distress. The use of psychological assessment to facilitate therapeutic alliance building has been well established (Ackerman, Hilsenroth, Baity, & Blagys, 2000). From the first interaction the examiner has with the examinee, there are many opportunities to improve overall outcomes and potential benefit of the testing process. Often, clinicians overlook the importance of therapeutic alliance building because of overreliance on valid test findings to provide the crux of the assessment experience. We aim to identify several ways to improve the overall experience for the examiner and examinee while enhancing the therapeutic utility for all involved. In addition, we will highlight specific ways that integrating Millon’s evolutionary theory into the approach for test feedback delivery may aid clinicians in further interweaving theoretical concepts with clinical practice. Throughout this chapter’s discussion, we will illustrate alliance-building suggestions drawn from MCMI-IV score elevations by using a hypothetical score combination of Scale 5 (CENarc/Narcissistic) and Scale 2A (SRAvoid/Avoidant), which has appeared, albeit infrequently, in our clinical experience. Although this pattern has been seen in clinical practice on legacy MCMI instruments alone, it more frequently appears as a combination in which one elevation (usually Scale 5: Narcissistic) appears on the MCMI, whereas a projective measure (e.g., the Rorschach) more typically captures aspects of characterologic avoidance. We generally encourage the use of several instruments, as appropriate and feasible, and specifically suggest a combination of objective and projective methods that may then more comprehensively capture more defended and less defended characteristics and complaints. For current illustrative purposes, however, we assume that an MCMI-IV, used without other assessment methods, captured both of these elevations within the BR 75–85 range, with the Narcissistic scale slightly 109

110 ESSENTIALS OF MCMI®-IV ASSESSMENT

more elevated, and with no further significant personality elevations. We will further assume a high (BR 85+) elevation on Severe Clinical Syndrome Scale CC (Major Depression) and a moderately high elevation (BR 75–84) on Clinical Syndrome Scale A (Generalized Anxiety), with no further Clinical Syndrome elevations. Finally, we will assume moderately high elevations (BR 75–84) on both Modifying Indices Desirability (Scale Y) and Debasement (Scale Z), with a somewhat lower elevation (BR < 60) on Disclosure (Scale X) with no significant scores on Scales V (Invalidity) and W (Inconsistency). For this example, we are also deliberately deemphasizing precise MCMI-IV scores in order to focus more specifically on the therapeutic alliance, with the recognition that a greater level of precision, particularly for diagnostic purposes, is expected in actual clinical practice. Chapter 5 details the sequence of interpretation and provides guidelines for examining individual and multiple elevations throughout the sections and scales of the MCMI-IV in order to come to an integrated clinical picture. In this chapter, we will focus only on immediately significant information to illustrate several alliance-building techniques. The current example for this chapter, as indicated in the prior paragraph, features information from four MCMI-IV sections: Modifying Indices, Clinical Personality Patterns (no Severe Personality Pathology was elevated), Severe Clinical Syndromes, and Clinical Syndromes (See Rapid Reference 6.1). INTRODUCING THE MCMI-IV TO THE EXAMINEE

In addition to abiding by the standardized administration guidelines outlined in the MCMI-IV manual, which are consistent with current guidelines for testing (AERA, APA, & NCME, 2014), it is highly suggested that the examiner go above and beyond the standard instructions to help their examinees feel safe, become knowledgeable, and feel like a collaborative participant in the assessment process. Whether the MCMI-IV administration will occur via digital or paper-and-pencil format, it is suggested that examiners use Finn’s (1996) approach to using formal assessment measures as therapeutic interventions in their own right and adopt a perspective that assessments be seen as “empathy magnifiers.” This includes the perspective that the examiner assumes the role of “expert on the tests,” who then encourages the examinee to assume the role of “expert on yourself.” A particular focus is suggested with regard to explaining how test results can specifically aid the client in meeting treatment goals, being astutely attuned to his or her experience in the room, and offering support and guidance throughout the process as appropriate.

THERAPEUTIC ALLIANCE BUILDING

111

Rapid Reference 6.1

...............................................................................................................

Hypothetical Score Elevations for This Chapter • Moderately elevated Desirability scale (75+); low-moderate Debasement scale (BR 60+) • No significant endorsements on noteworthy responses • Personality scales 2A (SRAvoid) and 5 (CENarc) in the BR 75–85 range, with scale 5 moderately higher • Syndromal scales: Scale CC (Major Depression) in BR 85+ range; Scale A (Generalized Anxiety) in BR 75+ range

PREPARING THE EXAMINEE FOR FEEDBACK

As previously inferred, assessment feedback sessions are often perceived by the examinee as sterile, impersonal, and truncated. The vast amount of information provided by a valid and significantly elevated MCMI-IV profile enables the examiner to share extremely poignant and sensitive information about an examinee’s functioning in a conceptually and contextually focused delivery. It is important to inform examinees about the nature of feedback sessions so that they may feel more prepared to listen, process, and ask questions about their test results. By explicitly inviting questions and reactions from examinees, it is expected that the information being delivered will be more likely to be integrated into their lives and appreciated overall. THE EXAMINER’S INITIAL PREPARATION FOR FEEDBACK

In preparing for a feedback session, it is useful to not only examine results and their meanings in accordance with the underlying theory but also to imagine hearing these results as if they were your own. This is particularly true for an instrument such as the MCMI-IV, in which results are organized in psychiatric diagnostic terms. This information should be disseminated transparently but not insensitively. To facilitate clear information and maintain the ability to explain psychiatric data in language useful to the client, it is highly recommended that clinicians make use of the alternative profile page (accessible in digital administrations by selecting “Abbreviate Scale Names” from the print menu of either the Q-Local or Q-Global systems) and sharing this graphic printout with the

112 ESSENTIALS OF MCMI®-IV ASSESSMENT

examinee during feedback. More detail on this process will follow in a subsequent section. MOVING AWAY FROM LABELS

Although the MCMI-IV is a well-established and psychometrically sound instrument that can aid clinicians in clarifying or ruling out certain diagnoses, insensitively conveyed labels may cause clients to become overly focused on the diagnostic lingo provided and lose sight of how the contextual richness of the feedback information provided may help them truly understand themselves, others, and the world much more clearly. Although the use of professional language, which may seem like psycho-jargon to clients, aids clinicians in communicating with other professionals, we believe that clients have the opportunity to benefit much more when we take the time to connect theory to test findings and test findings to common language. It is with this perspective in mind that the authors of the MCMI-IV decided to develop an optional alternative profile page. Similar to the legacy MCMI inventories, the default option for printing profile pages, in the profile report and interpretive report options, is to print these pages with the standard labels (Schizoid, Avoidant, Melancholic, etc.). This printout is the most straightforward and easily used for many clinicians in organizing MCMI-IV data into a more comprehensive assessment. However, clinical experience has demonstrated that when the profile pages are shared with examinees, there is a natural inclination for the examinee to observe elevations and labels together and to possibly draw false conclusions. This tendency has also been demonstrated with other objective instruments, such as the MMPI, whose tradition of using scale numbers rather than labels is now long and well established (Domino & Domino, 2006). Because most clinicians are not as familiar with the MCMI-IV scale numbers, and because the theory update introduced an abbreviation schema aligning with the personality spectra (Millon, 2011), the decision was made to offer this same schema on the MCMI-IV, with Clinical and Severe Personality scale abbreviations derived from the theory. A similar schema for the Clinical and Severe Syndrome scales was developed to mirror the personality scales. With some basic study and familiarity of the scale names and their associated abbreviations, which, in the personality scales also reflect the varying degrees of adaptiveness (e.g., the CENarc spectrum outlining the Confident Style, Egotistical Type, and Narcissistic Disorder), the examiner is given considerable clinical control over results dissemination, rather than having to explain back a diagnostic category about which the examinee may or may not have anecdotal but

THERAPEUTIC ALLIANCE BUILDING

113

incomplete knowledge. This sets the stage for better elaboration of results in descriptive rather than categorical or clinical terms. It also opens the feedback discussion to information drawn from the underlying theory. Similar to the contextual organization found in Chapter 4, we will outline how to organize and communicate test findings beginning with Modifying Indices to understand the person’s test-taking approach, then moving to personologic motivating aims (polarities) as catalysts for the therapeutic relationship, shifting subsequently to dynamic personality scale interpretation as a guide to case conceptualization, using the facet scales to focus intervention on trait domains, and, finally, incorporating the syndrome scale elevation(s) as a treatment goal guide. UNDERSTANDING THE EXAMINEE’S TEST-TAKING STYLE (MODIFYING INDICES)

Experienced assessors know that the person’s comfort level in disclosing information, as well as his or her style of presentation (presenting a healthy, likeable image versus demonstrating symptomology), can be just as important as the more nuanced information found in the personality and clinical scales. In our current example, we are assuming no anomalies for Scales V and W (more directly measuring validity of the protocol) and are not immediately directed to a more tertiary intervention or more comprehensive differential diagnosis as a function of the noteworthy responses, although we have taken note of this individual’s endorsement of one “Self-Destructive Potential” and one “Vengefully Prone” item, both of which may be explored during feedback. This person, however, has endorsed sufficient items included on Scale Y (Desirability) and Scale Z (Debasement) Modifying Indices to produce moderately high elevations on both—an unusual finding. Scale X (Disclosure) was endorsed to a moderate degree but lower than the other two Modifying Indices and not significant enough to warrant any direct assumptions about this person’s tendency to over- or underreport. With this configuration, the examiner may wish to contemplate this unusual mix: This person has acknowledged positive and negative self-impressions to a fairly significant degree. A valid and potentially engaging line of questioning following the administration may involve asking this person what gains he or she might expect from the information this test might reveal, as well as what the person may have noticed about him- or herself while completing the MCMI-IV. This inquiry is likely to produce some conflicting information that may add important perspective to the personality and syndromal findings. A mix such as this is likely to reveal significant uncertainties in how this person makes impressions with others as well as some confusion in typical defenses. As feedback

114 ESSENTIALS OF MCMI®-IV ASSESSMENT

continues, the examiner may want to check in with some degree of immediacy as this examinee evidences reactions to more positive and more negative findings, noting variance in discomfort and relief or relaxation as results are discussed. LANGUAGE OF THE THEORY = LANGUAGE OF ALLIANCE 1: INDIVIDUAL PERSONALITY SCALES

Effective feedback relies strongly on the examiner’s facility for translating the categorical or clinical information of the MCMI-IV into more dimensional or descriptive constructs. Consider, for example, a single elevation on Scale 3 (Dependent). Traditional modes of feedback frequently sound something similar to “These elevations reflect how you may be similar to [or “responded similarly to,” in more collaborative terms] dependent individuals.” We suggest, however, that it is more helpful, disarming, and therapeutic to draw from the theory’s motivating aims for a given personality. Using theoretical language to construct this more descriptive feedback, this client would benefit from this information delivered along the lines of “You tend to take [or more collaboratively, “You responded similarly to people who take …”] a more passive role in relationships, often relying on others to provide direction and a sense of safety.” By focusing on the dynamic within this personality structure that pulls strongly on the passive and other evolutionary polarities, the clinician is able to communicate the manifestation of the dependent personality without emphasizing the categorical label. In this chapter’s primary example, we will be conveying a difficult set of information in this unusual combination of personality elevations. The slightly higher elevation on Scale 5 (CENarc, Narcissistic spectrum) indicates an Egotistical type, though somewhat subthreshold for consideration of Narcissistic Personality Disorder. Here, the examiner will want to look at and contemplate the theoretical construction of this spectra. Part of this individual’s personality will likely reflect the CENarc spectrum’s polarity construction (passive adaptation/self-nurturing). Prototypically, this pattern tends to manifest a kind of confidence (deservedly or otherwise) that “the universe will be there for me; I don’t have to really engage my specialness to get the good things coming to me,” among other features. However, this personality configuration also includes a similarly elevated Scale 2A (SRAvoid, Avoidant spectrum), which is quite different. This part of the person’s evolutionary-polarity manifestation is very actively adapted and focused intensely on pain (more clearly: pain avoidance) with a likely tendency to feel considerable interpersonal vulnerability. A prototypal Avoidant personality may relate to a statement such as, “People who elevate on this scale seem to expend

THERAPEUTIC ALLIANCE BUILDING

115

a lot of energy defending themselves, making sure they don’t fall prey to other’s demeaning ways.” LANGUAGE OF THE THEORY = LANGUAGE OF ALLIANCE 2: MULTIPLE PERSONALITY SCALES

It is likely self-evident by the foregoing focus on the dynamic interpretaDON’T FORGET tion of a particular personality pattern ....................................................... Most MCMI-IV protocols will be that the examiner’s next task will be composed of several personality scale to describe several personality scales configurations meant to be interpreted in context with one another. Rememtogether. Use the analogy of the color ber, most valid MCMI-IV protocols wheel to arrive at admixtures of personality scales. are likely to have multiple scale elevations. It may be useful, once again, to consider the color wheel analogy. By combining prototypal personality patterns (primary colors), you may then derive a much wider spectrum of secondary colors and further admixtures (multiple scale elevations creating subtypes). This begins, however, with considering the relative contribution of each prototypal pattern. When describing the personality expression of one specific scale, it may be helpful to preface or explain certain findings by stating, “If this said everything about you … but it, of course, doesn’t.” Examiners should be mindful of occurrences when evolutionary polarities may align, complement, or conflict with each other. During those instances, it may be helpful to inform the examinee that “at times, these tendencies may balance each other out, but other times, you may find yourself feeling stuck or caught up in an attempt to find what way of being works best for you in a given moment.” To return to our example: It is likely difficult to fathom how an individual might score similarly on two markedly different prototype scales. Referring to Figure 6.1, several conflicting data points emerge. Perhaps most striking is the conflict between active and passive adaptation modes. Contextually, the passive mode of the Scale 5 (CENarc) elevation, indicating a self-assurance that all will be well, is in stark contrast to the active mode of self-protection evident in the Scale 2A (SRAvoid) elevation. Feedback will be in good part determined by the overall presentation and objective observation, but it should offer opportunities for the examinee to describe how a found conflict may affect him or her ideographically. An inquiry may be delivered, for example, by using these theoretical clues to frame feedback along the lines of “You seem to show two tendencies that I need your input on to understand what they mean to you. They seem to be

116 ESSENTIALS OF MCMI®-IV ASSESSMENT

Pleasure

Pain

Pleasure

Pain

Passive

Active

Passive

Active

Self

Other

Self

Other

Scale 5: CENarc

Scale 2A: SRAvoid Weak on Polarity Average on Polarity Strong on Polarity

Figure 6.1 Motivating Aims of Scales 5 and 2A

contradictory. On the one hand, you responded similarly to those who don’t feel a strong need for concern for things that happen around you, kind of like, ‘I’ll be fine; I can handle everything without breaking a sweat.’ On the other hand, the test picked up an equally strong tendency to feel less self-assured, less relaxed, more vigilant with the world around you, and maybe even more self-protective. Help me understand this.” Assuming the results are valid and that there is at least a modicum of openness about this person’s interpersonal concerns, the examinee is then invited to respond, explore, and reconsider means of dealing with environmental challenges. Although there are a number of possibilities, the most common response to this finding is that the individual has, over time, assumed something of an Egotistic/ Narcissistic posture or even a devil-may-care attitude as their active defense. However, it’s been going on for enough time that it has become somewhat second nature, although it is unwittingly emotionally exhausting to maintain. As this understanding becomes clearer, the person may begin to make connections to presenting anxious or depressive referral concerns, described in a subsequent section. This analysis is not necessarily limited to only the most salient disbalance, conflict, or any other anomaly that emerges from examining elevations together. In the current example, other possible points to consider may involve the survival (pain-pleasure) polarity, wherein the individual struggles to maintain the air of insouciance suggested by the simply “moderate” orientations on both polarities on the Scale 5 elevation, while simultaneously masking perceived threats (high pain orientation) and pulling energy away from life-enhancement (pleasure-oriented) tasks and goals. Further, this person may start to sense a feeling of aloneness and alienation on the replication (self-other) polarity while really desiring mutually satisfying relationships.

THERAPEUTIC ALLIANCE BUILDING

117

Consider, as well, that this example does not include any elevations (BR 60 or higher) on the Severe Personality Pathology scales. If it had, these would be considered first in organizing interpretation and feedback, although these might not be divulged first. For example, if this combination would have also seen even a secondary elevation on Scale P (the Paranoid spectrum, or MPParaph) in the range of BR 60–74, it would be a good indicator that this person’s ingrained personality patterns have become more immovable and rigid and that preferred modes of motivation (i.e., the 2A/5 elevations) are likely to be very guarded and defended. The evaluator might further expect some level of deflection of responsibility for complaints. Should this elevation be higher (BR 75+), there would be a stronger likelihood of complications even more central to a Paranoid personality. Theory language feedback cues would be even more critical in this circumstance, possibly beginning with validation of the difficulty of accepting alternative perspectives. LANGUAGE OF THE THEORY = LANGUAGE OF ALLIANCE 3: FACET SCALES

This building-block process of understanding and subsequently relating DON’T FORGET MCMI-IV information to the exam- ....................................................... The Grossman Facet Scales correinee in a manner that builds a spond to the most salient three of the therapeutic alliance continues with eight functional and structural domains integration of the Grossman Facet of each primary personality scale. Scales. The facet score data provides descriptions from the eight functional and structural domains of the 15 primary personality scales. Remember, too, that the facet scales correspond to the three most salient personologic domains for each prototypal patterns and that different facet configurations across elevated scales will yield valuable information related to focused areas of personologic concern. Our 2A/5 (SRAvoid/CENarc) elevation example presents the possibility of six facet scales in one of a number of possible elevations: For Scale 2A: Aversive Interpersonal Conduct; Alienated Self-Image; Vexatious Intrapsychic Content For Scale 5: Exploitive Interpersonal Conduct, Expansive Cognitive Style; Admirable Self-Image Although facet elevations are not limited to those found under these highest primary scale elevations under consideration (any facet scores for a primary scale

118 ESSENTIALS OF MCMI®-IV ASSESSMENT

elevated over BR 60 may be interpretable), we will limit our discussion to these six for the current demonstration. We will presume that Alienated Self-Image, Expansive Cognitive Style, and Vexatious Intrapsychic Content were the highest of the facet score elevations. After introducing the various dynamics of the multiple primary scale elevations and helping the examinee come to a modicum of understanding regarding those personality phenomena, the examiner can then begin to pinpoint aspects of the facet scores and how they may relate to current distress. The primary scale discussion often creates openings for this; in fact, the examinee may disclose some of these characteristics spontaneously. For example, the examinee in this example may respond to a deeper understanding of the “armor” of egotism defending uncertainty by disclosing that “people haven’t always been nice to me.” This may provide the desired opening for the clinician to introduce the Vexatious Intrapsychic Content and Alienated Self-Image facet scales. Another way to further link facet score findings to more practical utility for examinees is to help them understand which approaches to psychotherapy may best suit their unique personality pattern composition and to explain some basic tenets of the approaches that emerge. Rapid Reference 6.2 is a non-exhaustive list of therapies that logically correspond to the functional or structural domains of personality and, therefore, information gleaned from the facet scales. This approach lends a degree of comfort to the examinee in that the data points relate not only to explanation of personal characteristics but also are further linked to transparent, understandable means of mental health improvement. In considering Rapid Reference 6.2, one caveat is in order. Although these domain or therapy combinations often correspond directly to effective approaches for the identified domain, these examples should be used as a guide rather than a manualized approach. Different individuals will still evidence better response to other treatment approaches based on a number of factors. For example, an individual such as the one from the chapter’s example may show a most significant elevation on the Aversive Interpersonal Conduct facet scale but may not be as amenable to a more behaviorally based interpersonal therapy. Further examination may indicate that a related domain, Fantasy Intrapsychic Mechanism (part of the SRAvoid spectrum but not represented by a Grossman Facet Scale), plays the most important role in this person’s interpersonal distress, perhaps by imagining a different interpersonal reality and assumed role. In this regard, an approach focusing on early object templates (more of a psychodynamic approach) may be better suited prior to actualizing the interpersonal conduct more behaviorally.

THERAPEUTIC ALLIANCE BUILDING

119

Rapid Reference 6.2

...............................................................................................................

Domain-Oriented Therapeutic Modalities Behavioral/Expressive Emotion Interpersonal Conduct Cognitive Style Self-Image Intrapsychic Dynamics Intrapsychic Content Intrapsychic Architecture Mood-Temperament

ACT, DBT, Experiential Interpersonal, Family, Group CBT, REBT, MBCT, CBASP Humanistic/Existential Psychodynamic, Psychoanalytic, TLDP Relational, Trans/Countertransferential Insight-Oriented Pharmacologic/Physiological, Mind-Body

LANGUAGE OF THE THEORY = LANGUAGE OF ALLIANCE 4: CLINICAL SYMPTOMOLOGY

Finally, we suggest that the examiner help the examinee understand how his or her distinct personality pattern may relate to his or her referral question or immediate distress. We are discussing this component of alliance building last because we suggest the examiner move through the interpretive sequence in which personality is considered before symptomology as per the sequence described in Chapter 5. However, it is important to note that this information, specifically, may be best placed elsewhere in the feedback sequence, depending on several factors (e.g., salience of experienced distress or referral question, openness to personality information, etc.). Some examinees may be more or less interested in understanding themselves in relation to the need for the assessment; this should be ascertained from the clinical interview and behavioral observations throughout the assessment. Generally, those more interested in self-examination may be more amenable to getting the foundation of the personality information first, then moving on to how it applies to their concerns. However, this is often not the case, particularly when a person is highly focused on a given distress. These individuals tend to respond best by validating the distress first and introducing the Clinical Syndrome scales at the outset of feedback. Most individuals, however, fall somewhere in between, and they may benefit most by interweaving syndrome scale information with personality data. Following the interpretive sequence in organizing information is useful in this regard, because it lends colorization to the syndrome scales by gaining in personologic understanding first.

120 ESSENTIALS OF MCMI®-IV ASSESSMENT

Again, let us assume that the person in our current example is not overwhelmed by syndromal concerns but expresses a moderate desire to get to the point. In this case, the aforementioned interweaving would be the best fit. In isolation, most clinicians are familiar with a combined acute onset of major depression with a more globalized anxiousness, as the Clinical Syndrome scales indicate. A blind read of these disturbances would likely bring to mind, non-exhaustively, a severe downturn in mood or affect, loss of energy and motivation, disturbances in activities of daily living, combined with an overactive mind, general sense of dread, worry about realistic and intangible threats, and so on. Some of these and other symptoms may manifest in this person, but their meaning and expression are likely to change, given the personality profile. We have established, thus far, that this person exhibits a conflict in how to relate to others and meet challenges. Specifically, this individual has created something of an egotistical persona that disallows others to see the real person. Instead of allowing any vulnerability, which is essential to deeper relations, there is a kind of personal campaign invoking others’ praise and awe. Unlike a pure Narcissist, however, Scale 2A elevation suggests greater awareness of how unsustainable the persona really is, and likely this person regularly wonders when the humiliation of discovery of the ugly truth will occur. In the meantime, the persona becomes more deeply ingrained, and, to this person, the perceived harshness of inevitably exposing weakness grows. Integrating the facet scale information (e.g., Alienated Self-Image, Expansive Cognitive Style, Vexatious Interpersonal Content) further highlights the efforts (and the reasons) behind the manifest concerns and the defenses that have kept them at bay. The relationship between these motivating forces and clinical symptomology then becomes clearer and more understandable. By interweaving statements directly relating the personologic dynamics with presenting concerns, the examiner gains a closer perspective to this person’s inner narrative and can help set the stage for reconstructing that narrative in a more self-sympathetic manner.

TEST YOURSELF

............................................................................................................... 1. Because most objective tests are empirically derived, it is best to use the MCMI-IV in isolation to achieve clear and focused results.

a. True b. False 2. The presence of even a moderate elevation on Scales S (ESSchizoph, Schizotypal spectrum), C (UBCycloph, Borderline spectrum), and/or

THERAPEUTIC ALLIANCE BUILDING

121

P (MPParaph, Paranoid spectrum) will do what to the information found in all other personality scales?

a. b. c. d.

Negate Diagnostically supersede Colorize and lend context to b and c

3. According to Finn (1996), test instruments should be seen as which of the following?

a. b. c. d.

Diagnostic determiners Empathy magnifiers An alternative to psychotherapy The examiner’s toolbox to dispute a client’s self-limiting belief system

4. A co-elevation on Modifying Indices Scale Y (Desirability) and Scale Z (Debasement) indicates which of the following?

a. A possibility that the examinee feels conflicted in terms of exposing vulnerability and presenting favorably b. An invalid protocol, because no clear test-taking response pattern can be determined c. The likelihood of a need for crisis stabilization, because it is indicative of noncohesiveness in personality d. a and c 5. Primary and Severe Personality scale information should always be presented first to ensure therapeutic alliance building.

a. True b. False 6. When relaying personality scale score elevations, it is generally best to begin by doing which of the following?

a. Describing each score elevation separately with common language cues suggested by theory, then using an inquiry process with the examinee to understand how they relate to one another b. Combining all score elevations and directly relaying the combined information c. Using the elevated scales’ labels to ascertain the examinee’s colloquial understanding of them, then modifying that understanding accordingly d. Describing all of the motivating aims of the theory and then relaying which ones are relevant to the examinee’s protocol 7. Facet scale scores become interpretable only when the related primary scale is elevated at a BR of 75 or above.

a. True b. False (continued)

122 ESSENTIALS OF MCMI®-IV ASSESSMENT

8. Clinical Syndrome/Severe Syndrome scales are best understood as which of the following?

a. Discrete entities consistent with the empirical criteria of the DSM-V, unaltered by co-elevations with other Clinical Syndrome or Personality scales of the MCMI-IV b. Moderately overlapping with DSM-V criteria sets but theoretically derived in accordance with Millon’s evolutionary theory c. The focal point of MCMI-IV assessment d. Measures coinciding in large part to DSM-V criteria but modified in interpretation based on overall MCMI-IV data Answers: 1: b; 2: c; 3: b; 4: a; 5: b; 6: a; 7: b; 8: d

Seven STRENGTHS AND WEAKNESSES OF THE MCMI®-IV

A. Jordan Wright

T

he Millon Clinical Multiaxial Inventory, Fourth Edition, is a useful, important instrument in the assessment of personality and clinical functioning. As one of relatively few widely used, broad-based instruments to understand individuals’ functioning, it certainly stands out in multiple ways and contributes significantly to multimodal assessments. Although this edition of the test is new, it carries with it a rich and fruitful history of research examination and evidence for its reliability, validity, and utility, much of which easily transfers to the new instrument; however, the reader should be cautioned that the basis for this chapter is a combination of scrutiny of the MCMI-IV and information from previous editions of the test. Although the test includes scales of symptoms related to syndromes such as Anxiety and Depression, the MCMI-IV aims to assess signs and symptoms related to longer-standing personality patterns and disorders, which align with Millon’s (and often, but not always, the DSM-5’s) conceptualization of personality functioning. The descriptions of scales and subscales are intended to aid in interpretation that is not always easy but is meant to be useful in understanding underlying patterns, issues, conflicts, strengths, and dynamics of personality. STRENGTHS

The MCMI-IV is an exceptionally broad-band measure that carries the ambitious task of integrating a grand theory of personality with modern empirical testing standards. Beyond this, it provides information aimed at contextualizing long-standing personologic patterns with related symptomatology in a way that lends depth and relatedness to each. It seeks to accomplish these important 123

124 ESSENTIALS OF MCMI®-IV ASSESSMENT

assessment tasks through a unique development strategy incorporating this blend of theory, empiricism, and pragmatism. Test Development

The method for developing the MCMI (originally) attempted to balance three different important influences: theoretical concerns, based on Theodore Millon’s dynamic concepts of personality functioning; concerns of structure internal to the test itself; and external concerns based on real-world criteria. The result of balancing the three influences (though admittedly the measure, especially in its current form, seems more heavily weighted toward theoretical considerations) is a measure that satisfies multiple needs, from practical (linking to actual DSM diagnoses) to complexly clinical (describing internal states related to long-standing personality patterns). Further, the use of Base Rate (BR) scores, rather than straightforward T-scores or scaled scores, is an innovation that has been widely (though not unanimously) praised conceptually. With MCMI-IV, the measure saw a development that is in fact more aligned with Millon’s (2011) theoretical framework of personality functioning than the previous editions of the measure. In addition to adding the Exuberant/Turbulent Personality Disorder scale to round out the alignment with Millon’s proposed styles, the developers of the new version have attempted (in alignment with Millon’s theories) to clarify that the test measures not just pathological personality functioning but also styles and traits related to different personality constructs. They have done this by reformulating each personality scale along a continuum from normal (functional, adaptive) to abnormal (dysfunctional, maladaptive). The development of new items to expand the test’s scope and update it and the large and diverse (in background and treatment settings) standardization sample continue the incorporation of theoretical, internal, and external (criterion) influences on test development. Practical Issues

The MCMI-IV has a host of practical benefits. It is significantly shorter than its primary, comparable tests (the MMPI and the PAI), with a fifth-grade reading level, and yet it provides a wide range and depth of information. The measure provides information on symptomatology related to clinical syndromes and diagnoses, such as Substance Abuse, Anxiety, Depression, and Thought Disorder, but it also provides information on the more enduring, long-standing patterns and potential disorders of personality functioning. Although symptoms related to syndromes and disorders are important to know (and indeed some other measures are superior to the MCMI at highlighting and describing them), personality

STRENGTHS AND WEAKNESSES OF THE MCMI®-IV

125

functioning is too easily overlooked. This is frequently the case for many reasons, including the fact that clinical symptoms are often more ego-dystonic (salient and disruptive to the client), whereas personality patterns and problems are often more ego-syntonic (aligned with how clients see themselves and their “normal” functioning). This makes clinical symptoms more visible and distressing, whereas personality traits and patterns are often more hidden. The MCMI-IV simply will not allow clinicians to overlook personality functioning, perhaps the greatest strength the test has. Perhaps one of the MCMI-IV’s greatest practical benefits is its demonstrated diagnostic efficiency for personality disorders. In studies that compared BR scores at or above either 75 or 85 to clinician-rated diagnoses of specific disorders, many of the scales proved well aligned with clinician ratings, with positive predictive power estimates ranging between .30 and .68 (Millon, Grossman, & Millon, 2015). Although this is a psychometric strength of the measure, it is also a practical strength, because the test proves a useful, efficient screener for specific personality disorders (in addition to its more clinical descriptive use as part of a larger assessment). Psychometric Properties

The psychometric properties reported in the MCMI-IV manual (Millon et al., 2015) are on the whole quite solid. Individual scales’ internal consistency, for example, are generally good to excellent, with a few in the questionable range (e.g., Alcohol Use is a .65). Especially for personality patterns and disorders, which should be more stable over time, test-retest reliability is important. Although the test-retest interval was quite low (a median of 13 days), the reported test-retest reliability statistics were quite good, ranging from .73 to .85. The MCMI-III had similarly good test-retest reliabilities, even over longer periods of time (see Craig, 1999). The test developers compared the MCMI-IV to multiple other measures of personality and clinical functioning in order to establish criterion-based validity. Theoretically expected associations are generally pretty supportive of the MCMI-IV. For example, the Depression subscale on the Brief Symptom Inventory was quite strongly associated with the Major Depression and Persistent Depression subscales of the MCMI-IV (.75 and .77, respectively). Similarly, some of the personality scales were moderately associated (as expected) with several scales on the MMPI-2-RF, such as the Paranoid scale on the MCMI-IV having a .58 correlation with RC6 (Ideas of Persecution) on the MMPI-2-RF and the Antisocial and Sadistic scales on the MCMI-IV having a .64 and .47 correlations with RC4 (Antisocial Behavior) on the MMPI-2-RF. Although these criteria share method variance (they, similar to the MCMI-IV, are self-report inventories),

126 ESSENTIALS OF MCMI®-IV ASSESSMENT

these findings are still supportive of the MCMI-IV measuring what it purports to measure. Similar studies were supportive of the MCMI-III when comparing scales to the Beck Depression Inventory, the General Behavior Inventory, the State-Trait Anxiety Inventory, the Symptom Checklist-90, the MMPI-2, and others (see Millon, 1994, 1997; Millon, Millon, Davis, & Grossman, 2006b). Factor analytic studies evaluating the structure of the scales of the MCMI have been performed extensively on previous versions of the test, and these kinds of analyses will inevitably and necessarily be conducted on the MCMI-IV. In general, these studies have supported how items contribute to the general scale structure of the measure (see, for example, Choca & Van Denburg, 2004; Retzlaff, Lorr, & Hyer, 1989). Different factor analytic studies have determined different optimal factor structures, including eight-factor solutions (Millon, 1987), three-factor solutions (Craig & Bivens, 1998), and four-factor solutions (Rossi, Elklit, & Simonsen, 2010), all centered on major psychopathological and personality constructs. How the MCMI-IV will fare in factor analyses on multiple large samples remains to be seen. Interpretation

Perhaps the greatest strength of the MCMI-IV is its theory-driven focus on personality patterns. Many self-report inventories provide an account of current and past symptoms related to clinical disorders such as Depression and Anxiety. And even more now, with the DSM-5 no longer separating personality disorders from other clinical disorders, these are seen as analogs of largely biologically based, psychopharmacologically treatable disorders. The field is moving more and more toward understanding personality disorders as another clinical syndrome; this understanding has benefits, such as the basic assumption that they are treatable, which research has shown they certainly are. However, Millon’s understanding of personality as the context in which behaviors or symptoms occur remains a compelling and fruitful theory. The idea that the same set of circumstances occurring to two different people with two different personality types will elicit different behavioral responses and symptoms is no stretch of the imagination. Personality functioning (and personality disorders) as a descriptive (and predictive) way of understanding symptomatology (and other clinical disorders) remains a basic assumption throughout much of the clinical field. The MCMI-IV is structured in a way that aligns with and supports this theory. The personality scales (the Clinical Personality Patterns and Severe Personality Pathology scales) are set up to help clinicians understand dynamic interplays among different personality systems, such as interpersonal patterns, self-image,

STRENGTHS AND WEAKNESSES OF THE MCMI®-IV

127

mood-temperament, style of expressing emotion, and the intrapsychic structure (architecture) and content, among others. This is a much more nuanced, difficult-to-understand, and potentially clinically fruitful set of information than most self-report inventories aim to provide. Further, with more focus from the MCMI-IV team on the actual clinical relevance of personality scale findings (in the form of actual therapeutic feedback that can be directly generated as a result of elevations on particular scales), the link between MCMI-IV findings and therapeutic interventions will be quite strong. Understanding an individual’s personality dynamics can often lead to more thoughtful, deeper clinical work than simply understanding their expressed emotions, and for those who truly understand how to interpret it, the MCMI-IV provides a strong, theoretically driven measure of those dynamics. WEAKNESSES

A measure that takes on the ambitious task of describing personality functioning (in addition to clinical syndromes) will necessarily have some drawbacks. The field of personality psychology itself has not fully agreed on what components make up personality, and the DSM-5 seems to have distinguished personality functioning from personality disorders, which are no longer segregated on Axis II in a way that distinguishes them from other clinical syndromes such as Depression, Anxiety, and Substance Use disorders. Personality is simply difficult to define, and no measure could be the definitive evaluation of personality while the definition of personality is still debated. The MCMI-IV is based on a single (quite compelling) theory of personality (Millon, 2011). Even personality disorders, which are much more clearly defined by the DSM-5, are difficult to assess, and there is no current best practice in the assessment of personality disorders with which the MCMI-IV can be compared. Interrater agreement of clinicians with interview data diagnosing personality disorders is shockingly low (median kappa = .25; Perry, 1992), and diagnoses made using more formal instruments (including the previous versions of the MCMI) tend to have low agreement (Miller, Streiner, & Parkinson, 1992; Streiner & Miller, 1990), making it difficult to evaluate how well the MCMI performs in the diagnosis. Test Development

The development team for the MCMI has worked hard to maintain currency and relevance with the DSM, which has continued to make it useful in DSM diagnosis. However, it has also meant the relatively frequent updates and pretty

128 ESSENTIALS OF MCMI®-IV ASSESSMENT

significant changes to the measure (about every 10 years or so), especially in comparison to other broad-based measures such as the MMPI-2 and the PAI. Frequent updates, and especially significant changes to the measure, limit the amount of research that can be done on the instrument itself in order to build a strong evidence base. Although arguments can be made for the application of research evidence from previous versions of the test to newer versions (as is done in this chapter), there is simply a strong limitation when discussing the evidence of a test that does not have as much empirical scrutiny on the very version being discussed. The most significant empirical criticism of the MCMI-IV (and its previous versions) is the issue of item overlap. Theory supports the use of item overlap: certain signs, symptoms, beliefs, behaviors, and attitudes cross boundaries of different syndromes, disorders, and personality types. As such, any one item could theoretically be related to elevation on different scales. However, for measurement purposes, this is not a clean process; elevation in one scale will necessarily mean elevation in another that shares items, even if an individual does not exhibit clinical signs or symptoms of both disorders. Additionally, scales could be seen as assessing redundant constructs, if they are not distinct and clear enough to have unique items. Successive versions of the MCMI have certainly decreased the numbers of item overlap. Although the MCMI-III used its 175 items 440 times on scales, the MCMI-IV uses its 195 items only 392 times on scales. Although the result seems to have decreased the interscale correlations on the MCMI-IV (all are below .90, with only three above .80: Avoidant-Melancholic, Histrionic-Turbulent, and Masochistic-Melancholic), even these levels of correlation suggest that the constructs measured by different scales are extremely highly overlapping. Practical Issues

The greatest practical weakness of the MCMI-IV comes from the strongly theoretical nature of the instrument, which in and of itself can be seen as one of the test’s strengths. The weakness comes from the way scales and facet scales are named. Although some hold practical relevance (e.g., the Schizoid scale holds meaning for those who understand Schizoid Personality Disorder, and the newer title of Apathetic-Asocial-Schizoid makes intuitive sense for the continuum from less to more pathological along that dimension, albeit still quite negatively focused), many of the names are simply too esoteric to make interpretation quick and easy, even for quite experienced clinicians. On the level of scales, some examples include the new Unstable-Borderline-Cyclophrenic

STRENGTHS AND WEAKNESSES OF THE MCMI®-IV

129

and Mistrustful-Paranoid-Paraphrenic scales. Although the terms borderline and paranoid hold specific meaning in the field, the terms cyclophrenic and paraphrenic are highly specific to Millon’s (2011) theories and are not easily and readily translatable in the interpreter’s mind (even those with deep knowledge and understanding of Millon’s theories will find that many terms do not easily and quickly trigger interpretive descriptions). Even more esoteric are names of the overwhelming majority of the facet scales. Millon (in his 2011 book and, subsequently, in alignment with Millon’s theory, the test developers) worked hard to make these scale components pithy. However, the result of the short and packed-with-meaning phrases is the severe use of jargon. Examples include Vexatious Intrapsychic Content, Fatalistic Cognitive Style, and Puerile Expressive Emotion, none of which make interpretation easy for the clinician. They also have the side effect of making the measure seem overly psychodynamic, with seemingly less utility for diagnostic purposes. These facet scales not only do not lend themselves to easy and quick interpretation but also the names at times seem to set extremely difficult-to-understand distinctions; for example, it can be difficult to differentiate interpretively between a self-image that is Admirable (as on the Narcissistic scale) and one that is Exalted (as on the Turbulent scale). When it comes to the practical speed and ease of interpretations, the names given to scales and subscales certainly serves as a significant weakness of the MCMI-IV. Psychometric Properties

One significant difficulty in the assessment of personality functioning (and personality disorders), especially with the use of single-administration instruments such as the MCMI-IV, is the distinction between state and trait. Theoretically, personality disorders (and certainly descriptions of overall personality functioning) should relate more to traits than to states, which are more related to behaviors and clinical syndromes and symptoms. How can a measure given at a single moment in time, though, truly evaluate traits divorced from the current state of the individual being assessed? Previous versions of the MCMI seemed to fall prey to this difficulty; for example, in a study (Reich & Noyes, 1987) comparing significant elevations (and thus personality disorder estimates) in clients during and recovering from depressed episodes, those who were acutely depressed had 50% more personality disorder estimates (significant elevations) than those in recovery. Moreover, many, including the test developers, have found that the personality (supposedly trait) scales are no more stable over time than the clinical (supposedly state) scales, including for the MCMI-IV (Craig, 1999; Millon, 1994, 1997; Millon et al., 2006b, 2015).

130 ESSENTIALS OF MCMI®-IV ASSESSMENT

In a discussion of the demonstrated validity of the MCMI, there has been a relatively heated debate about whether the measure meets the Daubert criteria for admissibility into court for forensic purposes. To date, this debate has not been resolved, and it certainly is not resolved for the new version of the test, which has not yet undergone nearly as much psychometric scrutiny as its predecessors. Retzlaff (1996) determined that the positive predictive power (ability to correctly diagnose an intended disorder when compared to clinician ratings) was disconcertingly low for the personality disorder scales, and Rogers, Salekin, and Sewell (1999) found problems with convergent validities, which were often lower than discriminant validity associations. However, Retzlaff (1996, 2000) discussed the predictive power problem within the context of flawed methodology in studies to construct validity of the measure. Additionally, Dyer and McCann (2000) pointed out that the measures used in the Rogers et al. (1999) study may not accurately reflect the overall purpose (and construct validity) of the test. That is, the study compared the MCMI to other tests of personality; Dyer and McCann argue that the true test of the MCMI is to compare results to non-test methods of diagnosis, because that is the true purpose of the test (rather than to relate to other tests). Even in their response to this criticism, Rogers, Salekin, and Sewell (2000) cite methodological problems with validation studies (rather than methodologically sound studies that showed lack of validity). This is an important distinction, because failing to reach the minimum threshold of proving validity is quite different than proving invalidity. Further work needs to be conducted on establishing the construct validity of the personality disorder scales. Although, as stated previously in the practical strengths section, the diagnostic efficiency of the MCMI-IV for personality disorders is strong. Gibeau and Choca (2005) found that the diagnostic efficiency and accuracy of the MCMI-III (not the MCMI-IV) in detecting syndromes (not personality disorders), compared to clinician ratings, were mixed. Although the Substance Abuse and PTSD scales were particularly in concert with clinician ratings, the Thought Disorder and Delusional Disorder scales were relatively weak in agreeing with clinician-rated diagnoses. Interestingly, some research (again on the MCMI-III, not the MCMI-IV) has suggested that using raw scores, not BR scores, may be preferable in the interpretation of the Clinical Syndrome scales, because these might better correlate with a structured interview–based diagnosis (Hesse, Guldager, & Holm Linneberg, 2012). It is important to note that the BR scores were still adequate in their relation to the interview-based diagnoses. A significant criticism of previous versions of the MCMI is the implication that it overdiagnoses and overpathologizes, overly categorizing individuals in the significant or clinical range (e.g., Flynn, McCann, & Fairbank, 1995; Wetzler, 1990), with some research finding up to 60% more personality disorder diagnoses

STRENGTHS AND WEAKNESSES OF THE MCMI®-IV

131

than structured interviews of similar individuals. At least in part to blame is the pathological naming of the scales (see the “Interpretation” discussion that follows). Using a cutoff score on a scale called, for example, Narcissistic in order to make a clinical decision about whether or not an individual has a personality disorder is tempting (because the name suggests significant elevation should be usable to diagnose Narcissistic Personality Disorder), but it is likely misguided. Although diagnostically efficient, the MCMI-IV should not be used alone in diagnostic decision making. Self-report instruments simply have too many potential weaknesses (including, but not limited to, motivated and unmotivated response bias). When nonclinical populations take the MCMI, it is still tempting to interpret even BR scores below 75 in pathological terms (and at times the computer interpretations can reinforce this), with focus on negative aspects of each scale without consideration for their potentially positive components. The new scale formulations that attempt to remind clinicians that these scales relate to styles and patterns may help, though the names still imply a BR of 85 or higher is related to presence of the pathology itself. Additionally, caution should be taken when assessing individuals with potential psychotic disorders, because research has suggested that previous versions of the MCMI have performed poorly with this population (Craig, 1999). Interpretation

There are several weaknesses in interpreting the MCMI-IV. In addition to the overemphasis of the negative components of the different personality scales, without the necessary attention to the positive and adaptive components of each of the scales, as well as the potential for overpathologizing, the major weaknesses have to do with two areas that represent seeming lack of commitment in decisions by the test developers (though these decisions are heavily aligned with Millon’s 2011 book). First, the test does not clearly reside, theoretically and structurally, in the DSM-5 or in the theories of Millon (though it certainly leans in the latter direction). That is, some of the diagnostic criteria built into the MCMI-IV are quite closely tied to the DSM-5, whereas others are much more closely tied to the theories of Millon. This can lead to interpretive confusion when using the MCMI-IV to contribute to diagnostic decisions. For example, the Antisocial scale includes items similar to the very behaviorally oriented diagnostic criteria in the DSM-5 for Antisocial Personality Disorder, but it also includes many more dynamic and underlying issues, such as an underdeveloped conscience. Further muddying the use of the MCMI-IV in the case of diagnosing Antisocial Personality Disorder is how to balance the application of the Antisocial scale and the Sadistic scale. Again, having scales that align (certainly in name and often in criteria) to DSM-5

132 ESSENTIALS OF MCMI®-IV ASSESSMENT

diagnoses can be useful, but the fact that the MCMI-IV included these without committing wholly to it makes it more difficult to use in diagnostic decision making, at the same time not eschewing diagnostic labels in favor of the more dimensional and dynamic models proposed by Millon. In actuality, even high elevations on certain scales that are linked to DSM-5 personality disorders may indicate styles and tendencies that, under the right circumstances, may not be pathological (and may even be advantageous). Extreme elevation on the Histrionic scale, for example, may relate to the personality style of a great actor or a charismatic and personable high-level executive. Clinicians should be cautioned not to be too quick to make any diagnostic decisions based on MCMI-IV scales, even when the scale names may tempt them to do so. Also because of the divided allegiance to the DSM-5 and to Millon’s theories, it can at times be confusing to figure out where interpretive material originated. Interpretive material comes from all three of the sources of test development (cited in “Test Development” in the “Strengths” section): Millon’s theories, the DSM (external), and empirical studies of the measure itself (internal). The interpretive material has developed over time, somewhat organically balancing these three influences. However, this makes it difficult to judge the evidence base of interpretive statements; that is, for any single interpretive statement, it is unclear whether it came from empirical validity studies or developed out of Millon’s theories. Especially with esoteric names for scales and in particular facet scales, clinicians must contend with whether interpretations were simply conceptually derived and may in fact be out of date or obsolete or if they were empirically derived and continue to be current. Millon (1992) himself stated that accurate interpretation depends on “the overall validity of the inventory, the adequacy of the theory that provides the logic underlying the separate scales, the skill of the clinician, and the interpreter’s experience with relevant populations” (p. 424), highlighting the need for care in interpreting what can on the surface seem like straightforward data that emerge from the measure. The second area of weakness that relates to a seeming lack of commitment on the part of the test developers (in alignment with Millon’s 2011 book) is the prudent but somewhat weak attempt to rename scales in a less pathological, more dimensional way. The renaming represents a strong move on the part of the test to steer clinicians away from purely pathological interpretations of scales and to a more dimensional, nuanced understanding of personality styles that have adaptive, positive components (even at elevated levels) and less adaptive components. However, the test did not commit to this change (making it an option, in addition to the more traditional, pathological names). Additionally, the nomenclature chosen to represent these dimensional renamings is complicated and non-intuitive. If given the option between referring to the Narcissistic scale

STRENGTHS AND WEAKNESSES OF THE MCMI®-IV

133

and the CENarc, whether in informal conversation with colleagues or in more formal report writing, clinicians will undoubtedly choose the former. Although the names of the scales may seem semantic and less important than scale content, they do represent embedded and implicit understandings about what the scales truly represent. Offering an alternative to the pathological titles is a good move, but making them complicated, non-intuitive, and non-user-friendly will necessarily drive clinicians back to the traditional, pathological names (along with pushing them back toward the more pathological understanding of the scales). FINAL COMMENT

Despite its weaknesses, the MCMI-IV is extremely useful as a clinical assessment tool. It has made improvements over the previous versions of the test, such as reducing item overlap somewhat and aligning more directly to Millon’s (2011) theories. The ability to describe so many different components, adaptive and maladaptive, of personality continues to distinguish the MCMI-IV as a unique contributor to the field of assessment. Clinicians are encouraged, however, to integrate the use of the MCMI-IV with data from additional sources and not to make definitive diagnostic or clinical decisions based on the measure alone.

Rapid Reference 7.1

...............................................................................................................

Summary of Strengths and Weaknesses of the MCMI-IV Strengths

Weaknesses

Test Development • Balance of theoretical, internal (test structure), and external (criterion) influences on original test development • Updated items to make the test more contemporary and to broaden its scope • Inclusion of the Exuberant/ Turbulent scale • Renaming of scales to reflect the continuum from normal personality characteristics to pathological personality disorders

• Relatively frequent updates, meaning less time for adequate empirical scrutiny of each version of the test • Significant item overlap, leading to potentially redundant scales and potentially spuriously elevated scales

(continued)

134 ESSENTIALS OF MCMI®-IV ASSESSMENT

Strengths

Weaknesses

Practical Issues • Brief administration • Fifth-grade reading level • Description of personality functioning, in addition to signs and symptoms related to clinical syndromes • Diagnostically efficient with regard to personality disorders

• Scale and facet scale names heavily rely on theoretical jargon, making them difficult to interpret and for some difficult to distinguish from one another

Psychometric Properties • Generally good to excellent internal consistency of scales • Adequate test-retest reliability for personality scales • Good criterion-based validity in relation to other conceptually similar measures • Strong factor analytic evidence for previous versions of the test (with more research needed specifically on the MCMI-IV)

• Difficulty distinguishing traits from states, with the impact of current state on personality pattern (trait) scale elevations unclear • Contention about previous versions of the measure’s diagnostic validity, with debate about methodology and emphasis on whether or not the MCMI meets the Daubert criteria for admissibility into court for forensic purposes • Mixed validity findings for previous versions of the test related specifically to the Clinical Syndrome (not Personality Pattern) scales • Previous versions often criticized as overpathologizing and overdiagnosing individuals • Previous versions of the test found to perform poorly in assessing individuals with potential psychotic disorders

STRENGTHS AND WEAKNESSES OF THE MCMI®-IV

Strengths

135

Weaknesses

Interpretation • Theory-driven focus on personality patterns and disorders • Efforts to make scale interpretation more dimensional along continua from less to more pathological or maladaptive • Efforts to link personality scale findings with therapeutic feedback and clinical intervention

• Overemphasis of negative components of personality patterns • Mixed conformity to and divergence from the DSM-5 leads to difficulty knowing how much emphasis to put on MCMI-IV findings for diagnostic decision-making purposes • Divided allegiance to the DSM-5, Millon’s theories, and empirical validity studies makes unclear where interpretive material was derived • Seeming lack of commitment to the renaming of scales to emphasize their dimensional nature, as well as the clumsy nomenclature chosen for these new names, makes an implicit shift in assessors’ understanding of these scales difficult

TEST YOURSELF

............................................................................................................... 1. One weakness of the MCMI-IV is its overreliance on Millon’s theories of personality functioning.

a. True b. False 2. Which of the following are strengths of the MCMI-IV?

a. b. c. d.

Its clear and ready link to the DSM-5 Its ability to describe subtle and nuanced aspects of personality functioning Its easy-to-use facet scale names Its commitment to emphasizing for all users the dimensional renaming of the personality scales (continued)

136 ESSENTIALS OF MCMI®-IV ASSESSMENT

3. Although the MCMI-IV has decreased the amount significantly, the stillhigh level of item overlap makes no conceptual sense when considering the different personality disorders.

a. True b. False 4. Although longer than its previous versions, the MCMI-IV remains one of the briefer broad-based measures of clinical and personality functioning.

a. True b. False 5. Clinicians should take special precaution when interpreting the MCMI-IV results for individuals with which of the following potential conditions?

a. b. c. d.

Personality disorders Suicidal tendency Sociopathy Psychotic disorders

Answers: 1. a; 2. b; 3. b; 4. a; 5. d

Eight CLINICAL APPLICATIONS OF THE MILLON INVENTORIES

n this chapter, we will explore several areas of Millon inventories application. We will begin by looking at the theory’s influence on the range of the MCMI-IV and how this latest version of the instrument may be most beneficially used in context with other instruments in a full battery assessment. Next, we will examine specific applications that have historically drawn attention to the use of the MCMI-III (Millon, Millon, Davis, & Grossman, 2009) and prior MCMI versions and how these areas may relate to the new MCMI-IV assessment. Finally, we will review the sister Millon inventories for their application in different populations and challenges.

I

KEY MCMI-IV AUGMENTATION: PERSONALITY SPECTRA AND CLINICAL POPULATIONS

A primary consideration in using the MCMI-IV or its predecessors has DON’T FORGET always been the matter of the correct- ....................................................... Although the MCMI-IV has broadened ness of its use to the examinee’s its measurable range of personality population and referral question. functioning to more adaptive patterns, The MCMI instruments have always it should not be used as a normal perbeen intended for adult clinical and sonality measure for general counseling or other nonclinical purposes. psychiatric use; the authors directly discourage the test’s use as a normal personality measure or for general life counseling or coaching, encouraging the use of the Millon Index of Personality Styles-Revised (MIPS-R; Millon, Weiss, & Millon, 2004, discussed later in this chapter) or other applicable measures directly designed for these tasks. In developing the MCMI-IV, some thought was given to expanding the range of the new instrument to include the MIPS-R bandwidth of adaptive personality, but this idea was discarded because the 137

138 ESSENTIALS OF MCMI®-IV ASSESSMENT

developing instrument demonstrated a loss of focus on clinical specificity in this early developmental stage, showing that an attempt to measure everything led to a loss of adequate specific measurement (Millon, Grossman, & Millon, 2015). However, changes in Millon’s (2011) update to his theory introduced a paradigm wherein clinical presentation was more inclusive of adaptive personologic functioning. The prior iteration of the evolutionary theory (Millon, 1990; Millon & Davis, 1996) did describe a continuum of adaptive to maladaptive personality, primarily by specifying an adaptive range by one label and the corresponding maladaptive range by another (generally the more familiar psychiatric Axis II labels). This range, however, was inferred but not deliberately applied to the MCMI-III, leaving some question as to the appropriateness of the instrument for a given presentation. Several observations and solutions related to clinical judgment for the presence of a personality disorder have been useful in gauging the appropriateness of legacy MCMI instruments (e.g., Bornstein, 1998; Turkat, 1990). In our view, however, the conundrum is clarified by this most recent iteration of the theory and the instrument. As described throughout this book, Millon’s (2011) reconceptualization of the evolutionary theory proffered an expanded bandwidth of personologic functioning that could be described in three continuous ranges (see Chapter 2 for a full discussion); these are now directly and deliberately referenced from theory to instrumentation in the MCMI-IV. The most adaptive range (Style, BR 60–74) captures attributes of a person who generally functions well, evidences at least a modicum of flexibility in basic personality motivations, and demonstrates generally well-moderated characteristics that nonetheless are related to less-moderated characteristics of the parallel personality disorder (e.g., “confidence” rather than Narcissism, “sociability” rather than Histrionic, etc.). In the absence of a syndromal complaint, the person scoring in this range may gain some insight into his or her personologic functioning (albeit through a clinically oriented lens), but could be overpathologized by a clinician who is not adequately versed in the theory. With the presence or onset of a syndromal complaint, however (e.g., onset of a marked adjustment disorder, generalized anxiety, depression, etc.), there is a degree of perspective and relatedness between personality and syndrome as assessed with the MCMI-IV. It may then be possible to ascertain how the personality style affects the onset and course of the syndromal complaint and how treatment may be augmented by this insight. This will be incrementally true of persons scoring in the Type range (BR 75–84) and Disorder range (BR 85+) of the personality scales, with increasing personality dysfunction playing a more impactful role in the clinical presentation.

CLINICAL APPLICATIONS OF THE MILLON INVENTORIES

139

Rapid Reference 8.1

............................................................................................................... The personality spectrum is broken down into three ranges of functioning corresponding to designated BR scores on the MCMI-IV: • Normal Style (BR 60–74) • Abnormal Type (BR 75–84) • Clinical Disorder (BR 85+)

It may be said, then, that the MCMI-IV must still be considered a clinical instrument; its lens remains focused on increments of personality dysfunction and psychopathology. However, owing mostly to theoretical specificity, the instrument is designed to more adequately capture the floor of this range, whereas its predecessors were not deliberately designed to do so. The instrument also benefited in this regard from the inclusion of some collected pilot-phase normative data (approximately 235 mixed clinical and nonclinical subjects; a small percentage of the total 1,884 cases collected before exclusion criteria finalized the total normative sample to 1,547 cases; Millon et al., 2015). Although research efforts related to the MCMI-IV are just beginning at the time of this writing, these developments help contextualize the following discussions regarding the MCMI-IV placement in assessments as well as provide insights to challenges previously identified with earlier MCMI instruments. THE MCMI-IV IN CLINICAL ASSESSMENT

The MCMI-IV, as just indicated, is not designed to be a test directed toward nonclinical counseling purposes or as a measure of normal personality. It can, however, augment treatment planning and psychotherapy as a standalone measure and in conjunction with other assessments. Chapters 5 and 6 detail interpretive procedures and augmentations to the clinical alliance that can help assessors maximize the clinical utility of the instrument. In considering the MCMI-IV’s place in context with a more comprehensive battery, a few words may be helpful. Burisch (1984) described three major traditions for constructing objective (item-driven) tests: External-Criterion (e.g., the MMPI family of instruments), Inductive-Statistical (e.g., the NEO and the 16PF), and Deductive-Rational (e.g., the Millon inventories). Each has their strengths and non-strengths by virtue of their test construction method as well as the specific measures they employ. Deductive measures by their nature, including the Millon inventories, tend to stand apart from the other two methods, both of which subscribe to empirically

140 ESSENTIALS OF MCMI®-IV ASSESSMENT

derived methodologies. Neither of the other two methods is theory-initiated; if any consideration is given for theory, it follows empirical measurement. Therefore, these other methods do not implicitly offer an explanatory framework for how their various measures relate to one another. Deductive construction, by contrast, begins with theory and is thereafter empirically validated, allowing for the inherent explanatory principles to add depth and relatedness to the constructs it portends to measure by using the scientific method of hypothesis testing via empirical means. This method holds two key advantages. First, a given isolated feature benefits from additional meaning when it is theoretically related to other features within the construct. For example, the DSM-5 research criteria for future directions for personality disorders identify the act of withdrawal as a key but isolated feature in its atheoretical, alternative factorial model (APA, 2013), and its relationship to other features is nonspecific. In Millon’s conception, withdrawal means different things within different constructs: In the prototypal Schizoid construct, withdrawal is a preference; in the prototypal Avoidant construct, it is an act associated with protection from humiliation; in the prototypal Paranoid construct, it is a protection from attack. The second advantage is that, in assessment, a deductively derived objective personality instrument holds a special place among other assessments, somewhere between statistically derived instruments and projective measures. Although it conforms to, and to an extent is limited by, the nature of self-report instruments (e.g., largely dependent on a person’s self-awareness), it can infer some of the less conscious personologic data by inference in a manner similar to projective instruments. The liability for deductive construction, then, is that more classical or common statistical methodologies have historically been a poor fit for a theory as complex, nuanced, and, at times, inferential as Millon’s evolutionary theory and, subsequently, the Millon inventories (Grossman, 2015). In the MCMI-IV, this shortfall has begun to be addressed by the introduction of newer, SEM-based statistical measures that are more conducive to verifying and guiding theory (e.g., AMOS; Arbuckle, 2006) and, therefore, more able to enhance empirical verification of the primary and facet personality scale compositions.

Rapid Reference 8.2

............................................................................................................... Three traditions of objective, item-driven self-report inventories and familiar examples of each: External-Criterion (MMPI instruments) Inductive-Statistical (NEO and 16PF) Deductive-Rational (Millon inventories)

CLINICAL APPLICATIONS OF THE MILLON INVENTORIES

141

Different types of psychological instruments are, by their type and design, known to tap into and detail different aspects of psychological information about a person. The most obvious distinction, of course, would be the difference between neuropsychological and cognitive-academic tests versus clinical– psychiatrically oriented instruments. Among clinical-psychiatric instruments, however, the methodologic differences are clear but the content differences may not be as intuitive. Although it does seem obvious that projective measures (e.g., the Rorschach, the TAT, picture drawings, etc.) may tap less conscious content whereas objective measures are focused on data in the individual’s awareness, it may not be as obvious that these different methodologies and their comparisons in reviewing a test battery may have considerable implications in terms of a person’s functioning (Finn, 2007). Disregarding specific elevations and score combinations, a “good” MMPI-2 and a “bad” Rorschach may indicate a tendency to hold it together in most social circumstances despite considerable inner turmoil, for example, whereas a “good” Rorschach and a “bad” MMPI-2 may indicate more of a need for social support, attention, and help while not adequately employing inner resources. It has been said, informally, that the MCMI falls “somewhere between an MMPI and a Rorschach” in this regard (Choca, 1999, 2004). Whereas the MMPI-2 and MMPI-2 RF excel in deciphering test-taking approaches and provide excellent empirical correlates to 2- and 3-point clinical elevations, the MCMI-IV excels at identifying finite data points and inferring, through theory, connections to less conscious, more intrapsychically oriented processes (Millon, 2011). Further, the theory enables distinctions in meaning of certain psychological phenomena based on personality composition. For instance, the concept of avoidance may be picked up by atheoretical instruments, but they often do not contextualize this in a meaningful and purposeful way. The MCMI-IV, however, lends a context; avoidance will relate to a preference for someone with a strong Scale 1 (AASchd, Schizoid spectrum) elevation, a fear of humiliation for someone with a strong Scale 2A (SRAvoid, Avoidant spectrum) elevation, and a strategy to avert attack for someone with a strong Scale P (MPParaph, Paranoid spectrum) elevation (Grossman, 2015). The use of the MCMI-IV in the context of other objective and projective instruments, then, can be seen as one that helps connect concepts between more overtly observable and more inferential data. Table 8.1 offers a general guideline to assist in integrating these different instruments. In relationship to other objective inventories, we suggest that the MCMI-IV be used in an integrative manner with other assessments. The use of the MCMI-IV with the MMPI-2 (and presumably, MMPI-2 RF) is commonplace; a general observation on their use together in a comprehensive assessment is that the MMPI instruments tend to view personality through the lens of clinical

142 ESSENTIALS OF MCMI®-IV ASSESSMENT Table 8.1 Objective and Projective Assessment Integration Guidelines Less Pathological Projective Less Pathological Objective

More Pathological Objective

More Pathological Projective

Low to moderate pathology; Tendency to deny symptomology, current concerns may be more strident defenses, “stay strong” transient, situation-specific, and despite greater levels of inner so on or lowered disclosure style turmoil, generally higher desirability, split affect, intellectualization Reactivity may be elevated, Less integration and cohesion, tendency may be to draw may sense depleted resources attention to real distress, may but be unaware or unclear of have untapped resources or how distress works; more adequate coping but favors chaotic, displaced thought, extraversion in challenges action, emotion

symptomology, whereas the MCMI-IV views symptomology through the lens of personality (Antoni, 2008). Both perspectives are advantageous in ascertaining the full nature of a given presentation. Similar illumination is likely to be found with the MCMI-IV and many other objective instruments. SPECIFIC ASSESSMENT APPLICATIONS WITH THE MCMI

Although the next section on other Millon inventories details considerations of the other Millon assessments with targeted populations, this section briefly explores current and historic use of the MCMI in the context of specific assessment challenges, wherein the MCMI-IV or its predecessors have been used, in some cases controversially. ss Collaborative and therapeutic assessment: This approach DON’T FORGET ....................................................... to assessment is likely most simAdaptation of the MCMI-IV for colilar to traditional full battery laborative and therapeutic assessment assessment, but it differs in key may help clarify therapeutic material for assumptions and procedures. assessment feedback. Although the primary intent of traditional assessment is the provision of information for treatment planning, placement, status determination, and future psychotherapy, the collaborative approach has, at its core, the intention of being therapeutic in its own right (Finn, Fischer, & Handler, 2012). Currently, neither the

CLINICAL APPLICATIONS OF THE MILLON INVENTORIES

143

MCMI-IV nor the MCMI-III has been widely adopted or studied for use in collaborative modes of assessment, although both of the authors have employed both versions in this mode and are currently gathering case materials to more fully explore the MCMI-IV for this use. We believe it to be a good fit for this application, particularly in assisting determination of Levels 1, 2, and 3 information in feedback (Finn, 2007) as well as in therapeutic alliance building as described in Chapter 6. Expert testimony and criminal proceedings: The MCMI-III has been widely used in criminal proceedings from early-phase confessions to court procedures determining status to testify and levels of culpability (NGRI, etc.). This practice has not been without controversy, because the initial MCMI-III validity study evidenced key failings for specific scales in terms of meeting Daubert v. Merrell Dow Pharmaceuticals (92–102; 509 U.S. 579., 1993) precedent criteria (see Dyer & McCann, 2000; Retzlaff, 2000; Rogers, Salekin, & Sewell, 1999; for a review of this issue). Shortly after the initial publication of the MCMI-III in 1994, it was determined that the original validity study was flawed, leading to a revalidation of the instrument (Davis, Wenger, & Guzman, 1997) that indicated, well in advance of the Rogers et al. (1999) critique, that the instrument did, indeed, meet Daubert criteria. The MCMI-IV sensitivity-specificity criteria are comparable to the MCMI-III (Millon et al., 2015), and it is anticipated that the MCMI-IV will ultimately succeed the MCMI-III for expert testimony and criminal proceedings. Corrections: Historically, the ss MCMI has been used widely DON’T FORGET ....................................................... in correctional settings to As of this publication, the MCMI-IV assist psychologists and corhas not yet been normed on a dedrections professionals manage icated corrections population, unlike inmates, augment security, and the MCMI-III’s 2003 Corrections Report. provide treatment directives. Although both are acceptable for this purpose, the clinician will need to make The MCMI-III introduced the determination as to which version the Corrections Report and a best suits its application. corrections-specific normative group (Millon, Millon, & Davis, 2003) in order to tailor the assessment specifically for this application. The MCMI-IV has not yet announced similar plans. Ethically, the MCMI-III Corrections Report and the MCMI-IV standard administration may be used for corrections purposes, because the 2003 publication

144 ESSENTIALS OF MCMI®-IV ASSESSMENT

remains valid, but the revised instrument has several new measures that may be useful to this population (e.g., Vengefully Prone noteworthy responses, Turbulent Personality Pattern). Clinicians in these settings will need to employ their clinical judgment as to continued use of the MCMI-III Corrections Report versus adopting the MCMI-IV. Family law: Perhaps the most controversial use of the MCMI, historically, has been in family law application (Quinnell & Bow, 2001), particularly in determination of child custody. The historic argument has been that of making assumptions regarding a litigant’s mental state prior to testing, inclusive of personality disorders. Because the instrument is normed on a treatment-seeking clinical population, the normative group is legally distinct from litigants; however, it is often clinically similar to those involved in these disputes, particularly given the MCMI-IV’s lower clinical floor. The clinician will need to become familiar with both sides of this issue before deciding to use the MCMI-IV for this purpose. It is also advised that the assessor make at least a preliminary determination in terms of the likelihood of a litigant’s clinical need before employing the assessment. Cognitive, psychoeducational, ss and neuropsychological DON’T FORGET ....................................................... applications: Comprehensive Objective inventories such as the assessments focusing on cogMCMI-IV are useful in understanding nition and neuropsychological overlap of personality and neurocognianomalies depend on rule-outs tive traits and symptoms. of alternative explanations. For this reason, a valid measure of emotional and personality variables is necessary to demonstrate that a deficit is not better explained by an emotional issue. A distinction for the MCMI-IV is that it focuses largely on long-standing personality functioning, thus providing differentials among personality, immediate emotional dysfunction, and cognitive measures. Additionally, the recently added noteworthy response categories of ADHD, TBI, and ASD, though not comprehensively assessed by the MCMI-IV, may assist the clinician in understanding overlap of personality, psychiatric, and cognitive variables. OTHER MILLON INVENTORIES

All of the Millon inventories share similar three-stage (Loevinger, 1957) deductive test construction, and all personality measures are derived from Millon’s theories

CLINICAL APPLICATIONS OF THE MILLON INVENTORIES

145

(Millon, 1969, 1981, 1990, 2011; Millon & Davis, 1996). In most instances, the personality scales share their numbering schema with the MCMI-IV, although not all scales are represented on all measures. The two exceptions to this are the Millon Pre-Adolescent Clinical Inventory (M-PACI; Millon, Tringone, Millon, & Grossman, 2005) and the Millon Index of Personality Styles-Revised (MIPS-R; Millon et al., 2004). Both of these, however, do use theoretical personality constructs in a manner that is intuitive to those with a modicum of familiarity with the theory. For this reason, a similar interpretation and alliance-building strategy, as described throughout this book, may be employed when assessing personality patterns, as well as relating other clinical information provided by these measures to personality function and dysfunction. A more comprehensive review of each of these instruments may be found in Strack (2008), Essentials of Millon Inventories Assessment (3rd ed.). M-PACI and MACI—Pre-Adolescent and Adolescent Populations

The Millon Adolescent Clinical Inventory (MACI; Millon et al., 2006a) is designed to assess personality and clinical symptomology in a manner similar to the MCMI-IV, but was developed for adolescents ages 13 to 19 (there is intentional overlap in age with the MCMI-IV; the clinician is charged with determining which measure is more appropriate, based on maturity of the examinee). In addition to the two major sections of personality and symptomology, the test features another major section, “Expressed Concerns,” which comprise specific areas of subjective distress as observed in adolescents (e.g., Identity Diffusion, Body Disapproval). The assessment is composed of 160 true-false items that contribute to Modifying Indices, Personality Patterns, Expressed Concerns, and Clinical Syndromes. Normative subgroups are divided into younger and older adolescents. The MACI test, first published in 1993, also was updated to include a set of Grossman Facet Scales that are parallel in source and structure, but not entirely identical, to those found on the MCMI-III and MCMI-IV. Of note, the Personality Patterns, although reflective of those found on the MCMI, are constructed and labeled as moderately maladaptive, not using the terminology of DSM personality disorders (e.g., Introversive, Inhibited, Doleful, etc.); Scale 4B (Turbulent on the MCMI-IV) is not included, because it had not yet been developed at the time of the MACI’s construction; and Scales S and P (Schizotypal and Paranoid on the MCMI-IV) are not included, because their moderate counterparts were not evident in the normative population. At the time of this writing, the MACI is being approved for a major future update, which will likely be designated as the MACI-II.

146 ESSENTIALS OF MCMI®-IV ASSESSMENT

Rapid Reference 8.3

...............................................................................................................

Other Millon Inventories The members of the Millon family of instruments adhere to Millon’s theory, and many tenets of MCMI-IV interpretation are applicable to these other instruments, particularly with regard to personality or coping style sections. These instruments include the following: • MACI: Millon Adolescent Clinical Inventory (clinical instrument for ages 13–19) • MBMD: Millon Behavioral Medicine Diagnostic (adult medical psychology measure) • MCCI: Millon College Counseling Inventory (clinical instrument for college students) • MIPS-R: Millon Index of Personality Styles-Revised (normal personality measure) • M-PACI: Millon Pre-Adolescent Clinical Inventory (clinical instrument for ages 9–12)

The Millon Pre-Adolescent Clinical Inventory (M-PACI; Millon, Tringone, et al., 2005) grew out of the MACI in recognition of a need for a similar assessment for 9- to 12-year-olds. At 97 true-false items, the assessment is the shortest of the Millon inventories and produces a profile featuring 14 profile scales in two sections (Emerging Personality Patterns and Current Clinical Signs). Although the personality scale number designations do not correspond with most of the other Millon inventories scales (they are instead ordered in groups according to increasing problematic qualities), the constructs and labels are consistent with the subclinical characterizations of these personality patterns in the theory. Therefore, interpretive and feedback strategies, adjusted for age appropriateness, are similar, as well, to those described throughout this book. Note, however, that these Emerging Personality Patterns do not include moderate parallels of several of the MCMI-IV personality scales, because these were not yet distinguishable in the normative population for this age range. MBMD—Medical and Health Psychology Applications

The Millon Behavioral Medical Diagnostic (MBMD; Millon, Antoni, Millon, Minor, & Grossman, 2001) is an updated version of one of the first behavioral medicine assessments, the Millon Behavioral Health Inventory (MBHI; Millon,

CLINICAL APPLICATIONS OF THE MILLON INVENTORIES

147

Green, & Meagher, 1982). The updated 165-item assessment, reflective of considerable advances since the pioneering of the behavioral health field, includes four major clinical sections that are analogous to the concept of personality and psychopathology in medicine and psychology (Coping Styles and Stress Moderators representing longer-range ways of being; Psychiatric Indications and Treatment Prognostics representing more acute onset concepts). Additionally, there are indicators for negative health habits, Modifying Indices, and a cumulative treatment guide. Similar to MCMI-IV assessment, the Coping Styles are reflective of the theory’s personality patterns, and they share the numbering system for Scales 1–8B (with the exception of Scale 4B, because the Turbulent pattern had not yet been developed). These Coping Styles are constructed to be adaptive variants of the MCMI Personality Patterns and relate to how different persons manage the onset of health concerns. In a similar manner to the clinical instruments, the coping styles colorize most of the other interpretive information. In addition to a general medical population, there are specialized norms and reports for bariatric and pain patients. MCCI—College Counseling

Perhaps most closely related to the MACI, the Millon College Counseling Inventory (MCCI; Millon, Strack, Millon, & Grossman, 2006) is designed to target concerns that have become apparent as expressed by contemporary college and university students. Intended for use within a college counseling setting, the MCCI is structured similar to the MACI in terms of sections, but it is the only Millon instrument using a five-tier Likert-style item set. Personality styles are parallel to the MACI and MCMI (with the exception of the absence of Scale 6B, Sadistic, because it did not appear consistently in the college normative population, and Scale 4B, Turbulent, which had not yet been developed). In a similar manner to the MCMI-IV, the instrument encourages a multi-domain approach, using similar interpretive and feedback strategies to the MCMI-IV but incorporating not only clinical signs but also expressed concerns relevant to college-experienced distress. The 150-item test is appropriate for use with college students ages 16 to 40 presenting at college counseling settings. MIPS-R—Adaptive (Normal) Personality

The most distinct of the Millon inventories is the MIPS-R, which, in its 180-item format, measures several domains of normal-adaptive personality styles. Based on Millon’s evolutionary theory, similar to all Millon inventories, but expanding

148 ESSENTIALS OF MCMI®-IV ASSESSMENT

into the fourth Motivating Aim domain, Abstraction, the assessment goes beyond Basic Personality Patterns and examines Jungian cognitive modes (Jung, 1959) and behavioral patterns. The substantive scales are broken down into 12 pairs representing opposite concepts across three domains. The first, Motivating Styles, is reflective of the motivating aims from which the MCMI-IV and other personality scales are derived (e.g., Pleasure-Enhancing versus Pain-Avoiding, etc.). The second group is termed Thought-Guiding Styles and is reflective of Jungian cognitive modes (e.g., Externally versus Internally Focused). The third group is termed Behaving Styles and corresponds to several of the familiar Millon personality prototypes (e.g., Asocial/Withdrawing versus Gregarious/Outgoing). The assessment also features several validity indicators and a measure to detect the possibility of a clinical presentation.

TEST YOURSELF

............................................................................................................... 1. The MCMI-III and its corresponding iteration of the underlying theory inferred _____ ranges of personality functionality versus dysfunction; the MCMI-IV delineates _____ adaptive versus maladaptive levels.

a. b. c. d.

3; 4 2; 3 3; 2 4; 3

2. Which of the following aspects of the MCMI-IV are useful in helping to determine the order in which feedback information is delivered as well as in suggesting therapeutic direction?

a. b. c. d.

Motivating aims Personologic aims and facet scores Clinical symptomology All of the above

3. The MCMI-IV may be used in most forensic settings without regard to its clinical appropriateness for the specified application.

a. True b. False 4. The MCMI-III Corrections Report and the MCMI-IV may be appropriate for assessing criminals in a corrections setting.

a. True b. False 5. The MCMI-III was criticized and ultimately found unable to adequately meet Daubert (1993) criteria.

a. True b. False

CLINICAL APPLICATIONS OF THE MILLON INVENTORIES

149

6. Which psychological measure is appropriate for assessing psychological factors in medical treatment?

a. b. c. d.

MCCI M-PACI MBMD MIPS-R

7. Some Millon inventories do not include one or more of the theoretically specified personality patterns because there was lack of sufficient evidence (few subjects) of those pattern(s) in the referenced normative sample.

a. True b. False Answers: 1. b; 2. d; 3. b; 4. a; 5. b; 6. c; 7. a

Nine ILLUSTRATIVE CASE REPORTS

lthough a single valid and reliable assessment instrument such as the MCMI-IV may yield information valuable to a targeted clinical challenge, the accepted standard of care as specified in the current American Psychological Association Ethical Code of Psychologists and Code of Conduct (APA, 2010) discourages blind interpretations in actual clinical applications. Although acceptable for training purposes in order to familiarize the user with a given instrument’s measures and features, it cannot be overstated that the individual’s context, worldview, background, and presenting difficulties (along with data from a clinical interview as well as other testing materials, as available) must be integrated with the information gathered through any psychological assessment instrument. This chapter provides two illustrative cases to demonstrate this integration of MCMI-IV data with relevant background information. The case material presented includes test data based partially on one author’s (SG) past administration of the MCMI-III, further adapted to represent MCMI-IV responses. However, all background information, inclusive of setting, identifying information, case history, and details regarding presenting challenges have been altered and do not represent the original cases.

A

CASE EXAMPLE 1 Reason for Referral

Mitch is a 25-year-old, Caucasian, heterosexual, single, cisgender male who was referred to his university’s counseling center by the Dean of Students’ office because he exhibited disruptive and malevolent behaviors in his current political science class. He is at risk for being expelled from the university because of a history of violations to the university’s student code of conduct. The Dean of Students’ office is requesting that Mitch participate in a psychological evaluation 151

152 ESSENTIALS OF MCMI®-IV ASSESSMENT

to help determine his current level of functioning and to identify potential treatment recommendations. Background Information

Mitch was born in Fort Lauderdale, Florida, via natural birth with no reported complications. His parents, who remain married, are both employed at a local accounting firm. Mitch’s father is 49 years old and his mother is 48 years old, both identify as European American. Mitch’s father reported having a history of clinical depression, participating in counseling at two separate times in his adult life. Mitch has one sibling, a 22-year-old sister with no mental health history. Mitch identified being raised in an upper-middle-class socioeconomic status, attending private schools throughout his childhood. Mitch reported having a strong social support network and several close friends that he has had since early childhood. He denied making any new friends since graduating from high school. Mitch currently works approximately 30 hours per week as a waiter at a local restaurant. He reported watching local sports teams for leisure and spending most of his free time working, going to school, or going to the gym. He denied having any concerns regarding his social life. Mitch reported first experiencing mental health difficulties at age seven, when he was diagnosed with Attention Deficit Hyperactivity Disorder following multiple parent-teacher conferences regarding his poor behavior in class. Mitch identified a history of impulsivity and rule-breaking behavior that ultimately led to him being arrested when he was 15 years old for trespassing on a private golf course with friends. Mitch denied having any malicious intent, and he explained that he was just having fun with his friends. Mitch reported first drinking alcohol at age 13, and drinking approximately one to two times per month throughout high school. He denied any other drug use, but reported experimenting with marijuana four to five times while in high school. On entering college at 18 years old, he reported drinking alcohol three to four times per week, and “blacking out” from alcohol abuse approximately one time per month. When he was 21 years old, he was arrested for driving under the influence of alcohol and was able to participate in a court-mandated probation program for first-time offenders. Currently, he reported drinking alcohol approximately one time per week, and denied any difficulties with abuse or dependence. Mitch is currently participating in once-weekly outpatient counseling with a community provider. He reported seeking counseling following his girlfriend breaking up with him 3 months ago and being referred by a friend. He reported having difficulty taking responsibility for the breakup, although his ex-girlfriend

ILLUSTRATIVE CASE REPORTS 153

informed him that she would have stayed together with him if he participated in counseling earlier to help him better manage his anger and learn how to open up more. Mitch reported that he is unsure if the counseling has helped him, because he has only been to three sessions thus far. Behavioral Observations

Mitch arrived 20 minutes late for the testing session. His mood was moderately agitated and his affect was congruent. He appeared to be able to focus and concentrate as needed. Level of insight appeared to be poor and judgment seemed questionable. Mitch provided brief answers to most of the questions asked. He frequently checked his cellphone and reported wanting to complete the testing as soon as possible. Initially, rapport was difficult to establish, because he reported that he did not want to participate in testing. Following a discussion clarifying the purpose of testing, the use of test results, and the potential personal utility of interpretive feedback, Mitch appeared to be more relaxed and cooperative. Test Findings

(See Figure 9.1) (See Figure 9.2) Test Validity

Mitch appeared to answer items in an open, consistent, and straightforward manner. Although his score on the Disclosure scale may indicate mild overreporting or an overemphasis of presenting concerns, his Desirability and Debasement scale scores were found to be within the expected range. Therefore, this profile is considered valid, and the information provided is believed to be an accurate description of Mitch’s personality functioning. Noteworthy Responses

Mitch endorsed noteworthy items in the following areas: emotional dyscontrol, explosively angry, self-destructive potential, and vengefully prone. In addition, he endorsed two items that loaded on the Adult ADHD category. Although the MCMI-IV is not an appropriate measure to use when attempting to accurately diagnose ADHD in adults, Mitch’s response style within this category helps to provide a clearer picture of his overall personality functioning while identifying potential areas that may warrant additional testing and evaluation.

154 ESSENTIALS OF MCMI®-IV ASSESSMENT

MCMI-IV Interpretive Report Page X

Valid Report

MILLON CLINICAL MULTIAXIAL INVENTORY-IV PROFILE SUMMARY HIGH-POINT CODE = 6A 8B 2A

INVALIDITY (V) = 0 INCONSISTENCY (W) = 4 Score Raw BR

VALIDITY

X Y Z

Compulsive Negativistic Masochistic Severe Personality Pathology Schizotypal Borderline Paranoid

Raw

Severe Clinical Syndromes Schizophrenic Spectrum

PR

Profile of BR Scores 75 Average

100 High

65 59 42

Profile of BR Scores BR 0

60

75 Style

1 2A 2B 3 4A 4B 5

10 15 10 5 7 11 10

66 78 56 47 31 52 81

68 78 65 50 38 60 71

6A 6B

14 7

95 69

85 65

7

11

27

44

8A 8B

10 20

67 94

67 81

S

13

79

67

C P

13 5

76 58

70 62

Raw

Score PR

PSYCHOPATHOLOGY Clinical Syndromes Generalized Anxiety Somatic Symptom Bipolar Spectrum Persistent Depression Alcohol Use Drug Use Post-Traumatic Stress

104 13 3

Score

PERSONALITY

Antisocial Sadistic

35 Low

Modifying Indices Disclosure Desirability Debasement

Clinical Personality Patterns Schizoid Avoidant Melancholic Dependent Histrionic Turbulent Narcissistic

0

85 Type

115

Disorder

Profile of BR Scores BR 0

60

75

85

115

Present Prominent A H N D B T R

4 0 8 5 5 7 2

44 17 70 34 92 84 43

60 0 68 42 85 75 40 61

SS

8

59

Major Depression

CC

0

18

0

Delusional

PP

2

70

62

Figure 9.1 MCMI-IV Profile Page, Case Example 1 (Mitch)

ILLUSTRATIVE CASE REPORTS 155

MCMI-IV Interpretive Report Page X

Valid Report

MILLON CLINICAL MULTIAXIAL INVENTORY-IV PROFILE SUMMARY FACET SCORES FOR PROMINENT PERSONALITY SCALES

Antisocial Interpersonally Irresponsible Autonomous Self-Image Acting-Out Dynamics Masochistic

Profile of BR Scores

Score

FACET SCALES

Raw

PR

BR

35

75

100 Interpretable

6A 6A.1 6A.2 6A.3

1 5 7

39 91 96

30 75 85

8B

Undeserving Self-Image

8B.1

3

56

63

Inverted Architecture

8B.2

8

98

85

Temperamentally Dysphoric

8B.3

3

38

45 75

Avoidant

0

2A

Interpersonally Aversive

2A.1

5

69

Alienated Self-Image

2A.2

0

16

0

Vexatious Content

2A.3

4

73

75

GROSSMAN FACET SCALE SCORES RAW PR 1 1.1 1.2 1.3 2A 2A.1 2A.2 2A.3 2B 2B.1 2B.2 2B.3 3 3.1 3.2 3.3 4A 4A.1 4A.2 4A.3 4B 4B.1 4B.2 4B.3 5 5.1 5.2 5.3 6A 6A.1 6A.2 6A.3

Schizoid Interpersonally Unengaged Meager Content Temperamentally Apathetic Avoidant Interpersonally Aversive Alienated Self-Image Vexatious Content Melancholic Cognitively Fatalistic Worthless Self-Image Temperamentally Woeful Dependent Expressively Puerile Interpersonally Submissive Inept Self-Image Histrionic Expressively Dramatic Interpersonally Attention-Seeking Temperamentally Fickle Turbulent Expressively Impetuous Interpersonally High-Spirited Exalted Self-Image Narcissistic Interpersonally Exploitive Cognitively Expansive Admirable Self-Image Antisocial Interpersonally Irresponsible Autonomous Self-Image Acting-Out Dynamics

RAW PR

BR

2 2 1

46 40 38

60 40 30

5 0 4

69 16 73

75 0 75

0 2 0

12 61 18

0 68 0

2 1 1

41 46 30

40 60 30

2 2 4

64 18 40

40 65 48

4 1 2

64 16 25

65 15 30

5 3 1

88 36 64

75 36 60

1 5 7

39 91 96

30 75 85

6B 6B.1 6B.2 6B.3 7 7.1 7.2 7.3 8A 8A.1 8A.2 8A.3 8B 8B.1 8B.2 8B.3 S S.1 S.2 S.3 C C.1 C.2 C.3 P P.1 P.2 P.3

Sadistic Expressively Precipitate Interpersonally Abrasive Eruptive Architecture Compulsive Expressively Disciplined Cognitively Constricted Reliable Self-Image Negativistic Expressively Embittered Discontented Self-Image Temperamentally Irritable Masochistic Undeserving Self-Image Inverted Architecture Temperamentally Dysphoric Schizotypal Cognitively Circumstantial Estranged Self-Image Chaotic Content Borderline Uncertain Self-Image Split Architecture Temperamentally Labile Paranoid Expressively Defensive Cognitively Mistrustful Projection Dynamics

Figure 9.2 MCMI-IV Facet Page for Case Example 1 (Mitch)

BR

3 1 5

69 46 93

63 60 75

3 4 1

35 39 2

45 48 10

1 2 5

44 40 81

60 40 75

3 8 3

56 98 38

63 85 45

1 5 1

31 73 53

20 66 60

0 9 3

5 96 65

0 85 64

2 0 1

51 30 53

60 0 60

156 ESSENTIALS OF MCMI®-IV ASSESSMENT

Severe Personality Pathology

All three of the Severe Personality Pathology scales on Mitch’s profile were found to be higher than BR 60, but were not among the highest two to three elevations across all scales. Therefore, their elevations will aid in modifying the personality expression descriptions of the more significantly elevated Clinical Personality Pattern scales in the next section. Overall, the elevations on these scales indicate that Mitch’s personality shows structural compromise and has most likely lacked cohesiveness when attempting to integrate his various motivating aims and unique personality characteristics.

Clinical Personality Patterns

Although Mitch’s profile demonstrated several elevations across the Clinical Personality Patterns, the three patterns with the highest BR scores will serve to provide the clearest picture of his current personality functioning. Specifically, his highest elevation on Scale 6A (ADAntis; Antisocial spectrum), which at BR 85 places this score in the disorder range, will serve as the starting point for this interpretation, with interpretive data from Scale 8B (AAMasoc; Masochistic spectrum; BR 81) and Scale 2A (SRAvoid; Avoidant spectrum; BR 78), providing more specific colorization of Mitch’s unique personality expression. The contradiction between the motivating aims of Mitch’s three highest elevations informs the assessor that Mitch’s personality expression is expected and unique in several ways: • His elevation on Scale 2A (ADAntis) indicates a strong pull toward active and self-polarities. Mitch tends to act in accordance with what he believes is right, regardless of how it affects others. • His elevation on Scale 8B (AAMasoc) indicates that Mitch’s relationship to pleasure (life-enhancement) is confusing to him and others. His tendency to think of his own needs and desires first, without regard for others’ well-being, tends to leave him feeling emotionally unsatisfied. • His elevation on Scale 2A (SRAvoid) indicates a strong pull toward active pain avoidance. Mitch tends to purposefully hide his internal struggle from others, most likely because of underlying feelings of shame and fear of embarrassment. Mitch’s predominant active orientation on the active-passive polarity informs the assessor that he most likely engages in decision making without factoring in much collateral information. For example, Mitch does not seem to learn much from past

ILLUSTRATIVE CASE REPORTS 157

mistakes, and he is much more focused on immediate gratification when engaging in decision making. Mitch tends to be impulsive and irresponsible, vacillating between lacking empathy for others and feeling guilty about his actions. He engages in a marked internal struggle between feeling entitled to what he wants while consistently grappling with the belief that he deserves nothing. He is unsure if he can ever attain what he wants without hurting himself or others in the process. He most likely picks his fights haphazardly, rarely weighing the pros and cons of active hostility versus passive withdrawal. When Mitch chooses to be actively hostile toward others, he most likely demonstrates a propensity to be ruthless in his verbal attacks and determined to win arguments at all costs. When he chooses to withdraw, he most likely does so in a passive-aggressive style, which leaves others questioning the motives behind his behavior. For Mitch, his experience of feeling immediate gratification following an outburst or attack on others leaves him feeling confused, because he most likely does not get what he wants interpersonally or intrapersonally over the long run. Mitch’s track record of poor decision making and, ultimately, perceived external attribution of undesired life situations has left him with a markedly cynical attitude toward others and the world. Mitch manifests an almost childlike conceptualization of relationships. He tends to believe that if he does not get what he wants in a given situation, he will ultimately get what he wants by acting out and making it so. In the moment, he may experience satisfaction in verbally degrading another person, brashly and aggressively arguing a point or potentially engaging in physical altercations to prove his worthiness. The fleeting sense of accomplishment and self-efficacy that Mitch experiences following his acting-out behaviors is most likely met with just as powerful experiences of internal self-deprecation and a strong desire to isolate himself from others. Although Mitch’s attempts to connect with others are met with expected hostility and frustration, Mitch has come to expect this style of interpersonal engagement as commonplace and unavoidable. Although Mitch’s outward appearance leads others to believe that he is self-assured and oftentimes smug, he is frequently overwhelmed by self-defeating thoughts and shame regarding his past behavior. He has internalized the belief that others cannot and will not provide him with love and affection, but he does not seriously consider changing his own behaviors to potentially engender the nurturance from others that he craves. His tendency to artfully distort the accuracy of his experiences to either validate his cynical worldview or denigrate himself fails to provide him with strong anecdotal evidence to help convince him to change his behaviors. As a result, he is markedly rigid and unwavering in his morality and belief in what is right. His inflexibility extends

158 ESSENTIALS OF MCMI®-IV ASSESSMENT

outward and inward; just as he is unwilling to give others the benefit of the doubt, he has also formed an unwavering and markedly pejorative view of himself. Grossman Facet Scales

Recall that the facet scales help to provide clarity and elaboration to significant elevations on the Clinical Personality Pattern scales. Although each primary scale contains three unique facet scales, we are only looking at the significantly elevated facet scales from the identified elevated primary scales. Antisocial • Acting-Out Dynamics (BR=85): Inner tensions give way to malevolent acts committed without guilt or remorse. Underlying belief is “victimize or be victimized,” with no other need to rationalize unconstrained thoughts, statements, or actions. • Autonomous Self-Image (BR=75): Intentionally negates social contracts because belief in self is geared to not acknowledging need for other people; others are seen only as assets but ultimately unnecessary. Masochistic • Inverted Architecture (BR=85): Reversal of sensibility in which pain and pleasure are experienced as their opposites. Repetition of inverted motivation and feeling gives rise to transposed needs gratification, self-sabotage. Avoidant • Interpersonally Aversive (BR=75): Desirous of acceptance but loathe to get involved unless assured of psychic safety. Tending to distance from relationships owing to belief he will be shamed or humiliated. • Vexatious Content (BR=75): Templates of early relations are intensely conflict-ridden and troublesome and are easily activated by subtle triggers; lack of gratification structure creates vulnerability because of lack of defenses to deflect stressors. Mitch’s facet scale elevations help to better understand the motivations behind his impulsive behaviors and the resulting emotional conflict they create. His marked lack of empathy seems intrinsically connected to his identification as a victim and his reluctance to explore the impact of his actions on others. Severe Syndrome Scales

There were no significant elevations on any of the three Severe Clinical Syndrome scales on Mitch’s profile, so no information can be gathered from this area.

ILLUSTRATIVE CASE REPORTS 159

Clinical Symptomatology

Mitch was found to have significant elevations on two scales within the Clinical Syndromes section: Alcohol Use (BR 85) and Drug Use (BR 75). Because both of these scales are considered to be highly face valid, they inform the assessor that Mitch demonstrates an openness regarding his substance use history. In addition, they highlight Mitch’s use of substances as a coping mechanism, albeit one that has most likely lead to him experiencing undesired consequences in his life. Furthermore, we can posit that Mitch’s use of alcohol and illicit substances further supports the presence of rule-breaking behaviors in addition to him having identified his use of substances as helping him navigate uncomfortable feelings of guilt and thoughts of self-destructiveness.

Diagnostic Considerations

Mitch’s MCMI-IV profile indicates the likely presence of Antisocial Personality Disorder, as outlined within DSM-5. However, because of his unique profile constellation, several other disorders should be considered when attempting to accurately diagnose Mitch. The assessor would want to examine the possibility of Narcissistic Personality Disorder and Borderline Personality Disorder, because these are frequently co-occurring conditions with Antisocial Personality Disorder. Regarding clinical disorders, the assessor would want to carefully examine for the presence of Anxiety, Depressive, and Substance Use disorders, because these have all been found to be highly comorbid with presentations of Antisocial Personality Patterns. Regarding Mitch’s profile, specifically, the assessor would want to explore the significance of his alcohol use in the context of his presenting concerns and personality expression.

Treatment Considerations

Mitch’s current participation in outpatient therapy is a positive prognostic indicator. Typically, individuals with similar MCMI-IV profiles will seek out therapy services only when they are forced to as a condition of their relationship, employer, or other mandated avenue. Although this personality assessment was mandated by his university, Mitch’s willingness to engage in therapy prior to any mandate serves to abate any concerns a potential therapist might have regarding his reluctance to entertain the idea of counseling as treatment. Mitch’s therapist, however, may expect high levels of resistance, aggression, and immature acting-out behaviors in session. Because of his marked lack of insight and desire

160 ESSENTIALS OF MCMI®-IV ASSESSMENT

to change his behavior, a considerable amount of time must be devoted to rapport building and clear demonstration of the therapist understanding Mitch’s unique worldview. A major point of entry would be to help provide Mitch with a clear description of the conflict between the ADAntis and AAMasoc patterns; namely, Mitch experiences clear desiring of what he wants, but simultaneously he believes that he doesn’t deserve anything, much less what he wants. Another useful way to approach Mitch is to routinely connect his history of acting-out behaviors to the personal real-world consequences that they have inevitably created. By shifting from a personal responsibility framework to a focus on experiencing desired, healthy interpersonal interactions within the therapy room, the therapist can better align with Mitch. By taking a nonjudgmental stance in therapy, identifying potential malicious intent from all possible vantage points, and then highlighting more adaptive ways of responding, the therapist would be best equipped to help Mitch learn how to approach situations outside of therapy in similar ways. CASE EXAMPLE 2 Reason for Referral

Valerie is a 41-year-old, Venezuelan American, bisexual, married, cisgender female who was referred for testing by her fertility specialist because of her having a history of chronic fatigue, irritability, and interpersonal dissatisfaction. She and her husband, according to her, “always seem to come up with a reason for being at each other’s throats.” Although Valerie and her husband have been medically evaluated for reproductive anomalies, none have been identified. Therefore, Valerie would like assistance in identifying potential psychological factors that may be contributing to her reproductive difficulties. Background Information

Valerie was born in Venezuela, where she lived until the age of 10. She reported that her parents were married following the news that her mother was pregnant with Valerie. In addition, she has two younger siblings, a brother who is 1 year younger and a sister who is 3 years younger. Her father is an international businessman who frequently traveled long periods of time for work throughout her childhood. Valerie described her relationship with her father as “ok, when he was there.” Her mother was a stay-at-home parent. In addition, she reported being raised with her maternal grandmother living in their home. She reported relocating to the United States with her family at age 10 because of her father procuring a

ILLUSTRATIVE CASE REPORTS 161

more stable employment opportunity in Philadelphia, Pennsylvania. She reported living in a suburban area outside of Philadelphia with her family until she graduated high school. She described her childhood in Venezuela as being “nonexistent.” She explained that she was expected to help with chores and childcare from the age of 5. Specifically, she reported having to help clean the family house, prepare meals, and tend to her younger siblings. She reported living in a small, three-bedroom house in which her parents had one bedroom, her grandmother had one bedroom, and the three children shared one bedroom. On moving to the United States, she reported experiencing a significant and desired shift in her family’s socioeconomic status. She reported moving to an affluent suburb, living in a large house with ample accommodations for each family member, and not having financial concerns. Valerie reported improving her relationship with her father once they arrived in the United States, while noticing increased conflict and anger toward her mother. She reported similarly connecting more with the boys in her high school and not making friends with other girls easily. She provided several critical comments and specific examples of being “betrayed” by other female classmates throughout high school. However, once she attended college, she reported getting along with both men and women, and she began to explore her sexuality. She reported being sexually and romantically attracted to men and women, but she mostly dated men. She reported engaging in a series of tumultuous and emotionally volatile relationships throughout her 20s. She reported meeting her husband via an online dating site when she was 30 years old and marrying him within six months of meeting him. Valerie’s husband is 12 years older and is a successful, practicing neurosurgeon. They have been trying to get pregnant for the past four years and are currently contemplating in-vitro fertilization as a next step. Behavioral Observations

Valerie’s mood was euthymic and her affect was appropriate to the situation. She was observed to be cooperative, engaged, and motivated throughout the testing session. Valerie appeared to be comfortable throughout the testing session as evidenced by her asking several questions, requesting breaks, and providing feedback to the assessor. At times, Valerie would ask the assessor personal questions regarding family life and politics. However, Valerie was easily redirected to the task at hand, and this redirection did not seem to negatively affect the testing session or the quality of her participation. She completed the test administration in approximately 30 minutes.

162 ESSENTIALS OF MCMI®-IV ASSESSMENT

Test Findings

MCMI-IV Interpretive Report Page X

Valid Report

MILLON CLINICAL MULTIAXIAL INVENTORY-IV PROFILE SUMMARY HIGH-POINT CODE = C 8A 6A

INVALIDITY (V) = 0 INCONSISTENCY (W) = 2 Score

VALIDITY

Raw X Y Z

PERSONALITY

Antisocial Sadistic Compulsive Negativistic Masochistic Severe Personality Pathology Schizotypal Borderline Paranoid

Raw

Severe Clinical Syndromes Schizophrenic Spectrum

35

75

78 7 21

Score PR

100

Average

High

89 35 81

BR 0

Profile of BR Scores 60 75 Style

1 2A 2B 3 4A 4B 5

8 13 17 12 5 8 4

56 72 76 82 20 41 44

62 75 78 77 30 45 48

6A 6B

14 8

96 74

85 66

7

3

2

12

8A 8B

23 16

98 85

93 73

S

10

68

64

C P

23 8

98 73

95 68

Raw

Score PR

PSYCHOPATHOLOGY Clinical Syndromes Generalized Anxiety Somatic Symptom Bipolar Spectrum Persistent Depression Alcohol Use Drug Use Post-Traumatic Stress

Profile of BR Scores 0 Low

Modifying Indices Disclosure Desirability Debasement

Clinical Personality Patterns Schizoid Avoidant Melancholic Dependent Histrionic Turbulent Narcissistic

BR

BR 0

Type

Profile of BR Scores 60 75

85

115

Disorder

85

115

Present Prominent A H N D B T R

6 7 5 25 5 6 3

57 59 49 96 92 82 52

78 63 60 103 82 72 60

SS

13

81

67

Major Depression

CC

14

77

85

Delusional

PP

1

57

60

Figure 9.3 Profile Page for Case Example 2 (Valerie)

ILLUSTRATIVE CASE REPORTS 163

MCMI-IV Interpretive Report Page X

Valid Report

MILLON CLINICAL MULTIAXIAL INVENTORY-IV PROFILE SUMMARY FACET SCORES FOR PROMINENT PERSONALITY SCALES FACET SCALES Borderline Uncertain Self-Image Split Architecture Temperamentally Labile Negativistic

Raw

Score PR

Profile of BR Scores BR

35

75

100 Interpretable

C C.1 C.2 C.3

7 11 3

91 100 65

80 95 64

8A

Expressively Embittered

8A.1

4

79

75

Discontented Self-Image

8A.2

9

94

82

Temperamentally Irritable

8A.3

1

45

60

Antisocial

0

6A

Interpersonally Irresponsible

6A.1

6

96

85

Autonomous Self-Image

6A.2

5

91

75

Acting-Out Dynamics

6A.3

4

86

71

GROSSMAN FACET SCALE SCORES RAW PR 1 1.1 1.2 1.3 2A 2A.1 2A.2 2A.3 2B 2B.1 2B.2 2B.3 3 3.1 3.2 3.3 4A 4A.1 4A.2 4A.3 4B 4B.1 4B.2 4B.3 5 5.1 5.2 5.3 6A 6A.1 6A.2 6A.3

Schizoid Interpersonally Unengaged Meager Content Temperamentally Apathetic Avoidant Interpersonally Aversive Alienated Self-Image Vexatious Content Melancholic Cognitively Fatalistic Worthless Self-Image Temperamentally Woeful Dependent Expressively Puerile Interpersonally Submissive Inept Self-Image Histrionic Expressively Dramatic Interpersonally Attention-Seeking Temperamentally Fickle Turbulent Expressively Impetuous Interpersonally High-Spirited Exalted Self-Image Narcissistic Interpersonally Exploitive Cognitively Expansive Admirable Self-Image Antisocial Interpersonally Irresponsible Autonomous Self-Image Acting-Out Dynamics

RAW PR

BR

1 2 1

31 40 38

30 40 30

1 3 4

20 56 73

20 65 75

3 0 4

45 33 68

60 0 70

0 2 7

15 64 94

0 68 85

1 6 0

46 58 4

60 65 0

4 1 5

64 16 59

65 15 68

7 3 1

97 36 63

90 36 60

6 5 4

96 91 86

85 75 71

6B 6B.1 6B.2 6B.3 7 7.1 7.2 7.3 8A 8A.1 8A.2 8A.3 8B 8B.1 8B.2 8B.3 S S.1 S.2 S.3 C C.1 C.2 C.3 P P.1 P.2 P.3

Sadistic Expressively Precipitate Interpersonally Abrasive Eruptive Architecture Compulsive Expressively Disciplined Cognitively Constricted Reliable Self-Image Negativistic Expressively Embittered Discontented Self-Image Temperamentally Irritable Masochistic Undeserving Self-Image Inverted Architecture Temperamentally Dysphoric Schizotypal Cognitively Circumstantial Estranged Self-Image Chaotic Content Borderline Uncertain Self-Image Split Architecture Temperamentally Labile Paranoid Expressively Defensive Cognitively Mistrustful Projection Dynamics

Figure 9.4 Facet Page for Case Example 2 (Valerie)

BR

3 1 5

69 46 93

63 60 75

0 3 1

2 29 2

0 36 10

4 9 1

79 94 45

75 82 60

3 2 3

56 56 38

63 60 45

2 3 1

43 58 53

40 62 60

7 11 3

91 100 65

80 95 64

2 3 2

51 79 67

60 70 64

164 ESSENTIALS OF MCMI®-IV ASSESSMENT

Test Validity

Valerie appeared to answer items in an open, consistent, and straight-forward manner. Although her score on Scale X (Disclosure) indicates a probable overreporting of symptoms, her score on Scale Z (Debasement) indicates the presence of more intense emotional experiences and personal difficulties than would typically be endorsed by a clinical population. Given that Scales V and W were unremarkable and Scale Y fell within the average range, Valerie’s presenting concerns and her history of marked relational difficulties are believed to be an accurate description of Valerie’s personality functioning.

Noteworthy Responses

Valerie endorsed noteworthy responses in the following areas: emotional dyscontrol, self-destructive potential, and self-injurious behavior or tendency. However, she denied engaging in self-harm on more overt items. In addition, her profile was significant in the health preoccupation and eating disorder differentials. Although Valerie’s reason for referral was related to current health concerns, this is the first area in which eating concerns is showing up in her overall personality functioning. Therefore, it is important to consider this cluster of behaviors when conceptualizing Valerie’s current personality expression.

Severe Personality Pathology

Of the three Severe Personality Pathology scales, Valerie’s BR 95 on Scale C (UBCycloph; Borderline spectrum) is her highest scale elevation among the personality patterns and pathology scales. Her elevation on this scale will be the foundation for the interpretation of her overall profile. The significant polarity conflicts present within the motivating aims of the Borderline Personality Pattern create a general sense of vulnerability and fear that is usually accompanied by strong, frequent, but poorly integrated attempts at creating more balance and attachment to others in her life. Valerie’s internal conflict is likely predicated on a long-standing fear of abandonment, and she most likely creates situations that leave those closest to her feeling confused, hurt, and yet still drawn to remain in her life. Because Valerie’s MCMI-IV profile demonstrated two Clinical Personality Pattern scales with BR ≥ 85 (Negativistic and Antisocial), as well as significant elevations on Severe Clinical Syndromes and Clinical Syndrome scales, her high-point elevation on the Borderline scale will serve as a mediating factor in the interpretation of the following sections and scales.

ILLUSTRATIVE CASE REPORTS 165

Clinical Personality Patterns

With the Borderline scale elevation serving as a foundation, Valerie’s next two highest and significantly elevated Clinical Personality Pattern scale elevations provide the next interpretive material to incorporate into her overall personality interpretation. Although Valerie’s profile demonstrated BR elevations above 60 on eight other personality patterns, her three highest scores will serve to provide the most accurate picture of her personality. Her scores on Scale 8A (DRNegat; Negativistic spectrum; BR 93) and Scale 6A (ADAntis; Antisocial spectrum; BR 85) help to better inform how her core Borderline personality structure manifests in her unique presentation. Let’s explore the motivating aims of these two personality patterns. • Her elevation on Scale 8A (DRNegat) indicates an active-ambivalent pattern that tends to lead to difficulties effectively resolving internal and interpersonal conflicts. Valerie most likely experiences internal distress because of her inability to resolve the ongoing conflict between her rigid belief system and her unpredictable emotional experience. • Her elevation on Scale 6A (ADAntis) indicates a strong pull toward the active and self-polarities. Valerie tends to engage in frequent boundary-violating behaviors, because her motivation to attain what she wants is a priority in her life, regardless of how it affects others. Valerie tends to experience intense and frequent mood swings, often without provocation. She has learned to expect instability in her internal and external worlds. She has resigned herself to a life of conflict and has learned several maladaptive coping strategies to use when navigating unwanted or uncomfortable situations. Her cynicism and rigid belief system prevent her from being able to flexibly adapt to life’s stressors. As a result, she frequently blames external factors for her misfortunes and often holds grudges and forms unshakeable opinions of others when she believes she has been slighted. Although Valerie does display a strong desire to connect with others, there are several factors that prevent her from being able to engage in healthy adult relationships. First, she tends to identify and focus much of her attention on the most problematic or concerning aspects of a situation, according to her perception. Whether there is a perceived or actual threat in her environment, she will always identify the worst-case scenario. If others see a situation differently, Valerie most likely writes them off as being naive or ignorant. In addition, when things are not working out the way that Valerie had hoped, or believes that they should, she most likely acts out in excessively immature ways. Her coping strategies are the second factor preventing Valerie from having healthy

166 ESSENTIALS OF MCMI®-IV ASSESSMENT

relationships. Her argumentative, brash, and, at times, overly aggressive style of conflict resolution tends to leave others confused, hurt, and not wanting to engage with Valerie in the future. Valerie has adopted a win-at-all-cost philosophy to arguing, and when overtly aggressive means do not accomplish her goal, she will rely on more passive-aggressive behaviors to assert her dominance in a situation. Last, Valerie’s constant fear of abandonment and low self-worth lead to her questioning the motives of anyone who may display an interest in getting to know her or cultivate a relationship with her. If Valerie’s brash demeanor has not pushed others away, her constant questioning, paranoia, and challenging others’ intentions tend to create hostile relational patterns that leave others emotionally drained following an encounter with Valerie. Grossman Facet Scales

Although each primary scale contains three unique facet scales, we are only looking at the significantly elevated facet scales from the identified elevated primary scales. Borderline • Split Architecture (BR=95): Inner structure is incongruent and segmented and shifts in focus are experienced as abrupt and oppositional; attempts at ordering memories, perceptions, and feelings are ineffectively achieved by disavowing uncertainty in action and adopting absolute, black-and-white actions. • Uncertain Self-Image (BR=80): Sense of personal identity is confused, tenuous, and scattered, regulated only by adopting ill-fitting absolutes of self-contrition and punishment, activated by easily experienced self-uncertainty. Negativistic • Expressively Embittered (BR=75): Resentfulness gives rise to procrastination, irksomeness, and contrary behaviors that resist fulfilling expectations of others; can display satisfaction and gratification in undermining others. • Discontented Self-Image (BR=82): Sees self as jinxed and demeaned by others; believes self as unable to be understood in relationships; expresses envy and bitterness at others’ perceived good fortunes. Antisocial • Interpersonally Irresponsible (BR=85): Unreliable, unable, or unwilling to meet obligations; transgresses societal expectations with regard to how they treat others; deceptive in transactions and intrusive in relationships.

ILLUSTRATIVE CASE REPORTS 167

• Autonomous Self-Image (BR=75): Intentionally negates social contracts because belief in self is geared to not acknowledging need for other people; others are seen only as assets but ultimately unnecessary. Severe Syndrome Scales

Valerie had one significant elevation within the Severe Clinical Syndromes cluster on the Major Depression scale (BR 85). Although this elevation helps to further validate the pessimism-cynicism previously identified, it also helps to clarify the nature of Valerie’s mood swings. Specifically, Valerie most likely spends more time experiencing the unwanted, uncomfortable, and oftentimes hopeless experience of classical clinical depression. Although she tends to vacillate in her mood, she appears to have a marked predilection toward sadness and difficulty experiencing joy in situations that most others would consider to be worthwhile. Clinical Symptomatology

Valerie’s profile had three significant elevations among the Clinical Syndromes scales, with the Persistent Depression scale (BR=103) being the highest elevation. The Persistent Depression scale helps to identify Valerie’s pronounced experience of defeat, apathy, and helplessness. Valerie demonstrates patterns of overall ineffectiveness in problem solving, planning, and interpersonal functioning, mostly because of the extent that learned helplessness has become entrenched in her personality over time. Her next highest elevation on the Alcohol Use scale (BR 82) indicate a more purposeful disclosure of her experience, highlighting the use and abuse of alcohol as a maladaptive coping strategy. Last, her elevation on the Generalized Anxiety scale (BR 78) identifies the presence of intrusive, recurring, and fearful thoughts. Although Valerie’s elevations on the Major Depression and Persistent Depression scales identify her tendency to ruminate over undesired experiences from her past, she also experiences overanalytical and future-oriented worry coupled with uncomfortable physiological experiences. Diagnostic Considerations

Valerie’s MCMI-IV profile indicates the likely presence of Borderline Personality Disorder, as outlined within DSM-5. However, because of her unique profile constellation, several other disorders should be considered when attempting to accurately diagnose Valerie. Other Cluster B disorders should be considered in this presentation, such as Antisocial Personality Disorder. In addition, because of her

168 ESSENTIALS OF MCMI®-IV ASSESSMENT

complex presentation, Valerie may exhibit behaviors and histories in accordance with several personality disorders, so further and more specific diagnostic interviews may be important to accurately arrive at a diagnosis in this area. Regarding clinical disorders, Valerie most likely meets criteria for a mood disorder, in addition to her personality disorder pathology. Specifically, she most likely meets criteria for Major Depressive Disorder, Persistent Depressive Disorder, or some other Unspecified Depressive Disorder. It will be of the utmost importance to rule out her alcohol use as either a symptom or coping strategy of or within her established diagnoses, or whether or not her substance use warrants its own diagnosis. Similarly, it may be helpful to rule out anxiety disorders, specifically Post-Traumatic Stress Disorder, because many individuals struggling with Cluster B personality disorders have reported histories of past abuse or neglect. Treatment Considerations

Individuals with Valerie’s personality patterns are notoriously difficult to work with in therapy. Their tendency to vacillate between loving and hating their therapist, coupled with their increased likelihood to use self-harm as a coping strategy, serve to make the course of therapy markedly unpredictable. Even though Valerie did not overtly endorse self-harm on her MCMI-IV, her risk should be evaluated during every meeting until she and her therapist agree that she has the resources to adaptively cope with life’s stressors. Valerie’s therapist can expect high levels of resistance, aggression, and immature acting-out behaviors. Because of her marked lack of insight and desire to change her behavior, it might be extremely difficult to establish rapport and gain genuine buy-in for active therapy participation. Therapists tend to experience a heavy emotional load when working with clients such as Valerie, and they are encouraged to focus on therapist self-care throughout treatment with these individuals. Clear boundaries, expectations, and treatment goals are essential. Therapists can expect Valerie to test the limits in treatment, and they should be prepared to react therapeutically, yet firmly. It is suggested to establish a more holistic approach that includes individual therapy, skills-based or support groups, and on-call crisis services that Valerie can access throughout her time in treatment.

REFERENCES

Ackerman, S. J., Hilsenroth, M. J., Baity, M. R., & Blagys, M. D. (2000). Interaction of therapeutic process and alliance during psychological assessment. Journal of Personality Assessment, 75(1), 82–109. American Educational Research Association, American Psychological Association, & National Council on Measurement in Education (AERA, APA, & NCME). (2014). Standards for educational and psychological testing. Washington, DC: Authors. American Psychiatric Association (APA). (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington, DC: Author. American Psychiatric Association (APA). (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. American Psychological Association (APA). (2010). American Psychological Association ethical principles of psychologists and code of conduct. Washington, DC: Author. American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author. Antoni, M. (2008). Studies relating the MCMI and the MMPI. In T. Millon & C. Bloom (Eds.), The Millon inventories: A practitioner’s guide to personalized assessment (pp. 157–176). New York: Guilford. Arbuckle, J. L. (2006). AMOS (Version 6.0) [Computer software]. Chicago, IL: Small Waters. Ben-Porath, Y., & Tellegen, A. (2008). MMPI-2-RF manual for administration, scoring and interpretation. Minneapolis, MN: University of Minnesota Press. Bornstein, R. F. (1998). Reconceptualizing personality disorder diagnosis in the DSM-V: The discriminant validity challenge. Clinical Psychology: Science and Practice, 5, 333–343. Boudry, F. (1983). The evolution of the concept of character in Freud’s writings. Journal of the American Psychoanalytic Association, 31, 3–31. Burisch, M. (1984). Approaches to personality inventory construction: A comparison of merits. American Psychologist, 39, 214–227. Carlson, J., & Maniacci, M. P. (2012). Alfred Adler revisited . New York, NY: Routledge/Taylor & Francis. Choca, J. P. (1999). Evolution of Millon’s personality prototypes. Journal of Personality Assessment, 72, 353–364. Choca, J. P. (2004). Interpretative guide to the Millon Clinical Multiaxial Inventory (3rd ed.). Washington, DC: American Psychological Association. 169

170 REFERENCES Choca, J. P., & Grossman, S. (2015). Evolution of the Millon Clinical Multiaxial Inventory. Journal of Personality Assessment, 97 , 541–549. Choca, J. P., & Van Denburg, E. (2004). Interpretive guide to the Millon Clinical Multiaxial Inventory (3rd ed.). Washington, DC: American Psychological Association. Craig, R. J. (1999). Overview and status of the Millon Clinical Multiaxial Inventory. Journal of Personality Assessment, 72, 390–406. Craig, R. J. (2005) New directions in interpreting the Millon Clinical Multiaxial Inventory. New York, NY: Wiley. Craig, R. J., & Bivens, A. (1998). Factor structure of the MCMI-III. Journal of Personality Assessment, 70, 190–196. Darwin, C. R. (1859). On the origin of species by means of natural selection. London, UK: Murray. Davis, R. D. (1993). Development of content scales for the Millon Adolescent Clinical Inventory. Unpublished master’s thesis, University of Miami, Miami, FL. Davis, R. D., Wenger, A., & Guzman, A. (1997). Validation of the MCMI-III. In T. Millon (Ed.), The Millon inventories: Clinical and personality assessment (pp. 327–359). New York, NY: Guilford. Derogatis, L. (1993). Brief Symptom Inventory (BSI) manual. Minneapolis, MN: National Computer Systems. Domino, G., & Domino, M. L. (2006). Psychological testing: An introduction. Cambridge, UK: Cambridge University Press. Dyer, F. J., & McCann, J. T. (2000). The Millon clinical inventories, research critical of their forensic application, and Daubert criteria. Law and Human Behavior, 24, 487–497. Finn, S. E. (1996). Manual for using the MMPI-2 as a therapeutic intervention. Minneapolis, MN: University of Minnesota Press. Finn, S. E. (2007). In our client’s shoes: Theory and technique of therapeutic assessment. Mahwah, NJ: Erlbaum. Finn, S. E., Fischer, C. T., & Handler, L. (Eds.). (2012). Collaborative/therapeutic assessment: A casebook and guide. Hoboken, NJ: Wiley. Flynn, P. M., McCann, J. T., & Fairbank, J. A. (1995). Issues in the assessment of personality disorder and substance abuse using the Millon Clinical Multiaxial Inventory (MCMI-II). Journal of Clinical Psychology, 51, 415–421. Gibeau, P., & Choca, J. (2005). The diagnostic efficiency of the MCMI-III in the detection of Axis I disorders. In R. J. Craig (Ed.), New directions in interpreting the Millon Clinical Multiaxial Inventory-III (MCMI-III) (pp. 272–283). Hoboken, NJ: Wiley. Grossman, S. D. (2004). Facets of personality: A proposal for the development of MCMI-III content scales (Doctoral dissertation, Carlos Albizu University). Dissertation Abstracts International, 65, 5401. Grossman, S. D. (2015). Millon’s evolutionary model of personality assessment: A case for categorical/dimensional prototypes. Journal of Personality Assessment, 97 , 436–445. Hathaway, S. R., & McKinley, J. C. (1940). A multiphasic personality schedule (Minnesota): I. Construction of the schedule. Journal of Psychology, 10, 249–254.

REFERENCES 171

Hesse, M., Guldager, S., & Holm Linneberg, I. (2012). Convergent validity of MCMI-III clinical syndrome scales. British Journal of Clinical Psychology, 51(2), 172–184. Hoyle, R. H. (1991). Evaluating measurement models in clinical research: Covariance structure analysis of latent variable models of self-conception. Journal of Consulting and Clinical Psychology, 59, 67–76. Huxley, T. H. (1870). Mr. Darwin’s critics. Contemporary Review, 18, 443–476. Jamison, K. A. (2005). Exuberance (The passion for life). New York, NY: Knopf. Jankowski, D. (2002). Beginner’s guide for the MCMI-III . Washington, DC: American Psychological Association. Jung, C. G. (1959). The basic writings of C. G. Jung. New York, NY: Random House. Kraepelin, E. (1921). Manic-depressive insanity and paranoia. Edinburgh, Scotland: Livingstone. Loevinger, J. (1957). Objective tests as instruments of psychological theory. Psychological Reports, 3, 635–694. Maddux, R. E., & Johansson, H. (2014). A case of depressive personality disorder: Aligning theory, practice, and clinical research. Personality Disorders: Theory, Research and Treatment, 5, 117–124. Miller, H. R., Streiner, D. L., & Parkinson, A. (1992). Maximum likelihood estimates of the ability of the MMPI and the MCMI personality disorder scales and the SIDP to identify personality disorders. Journal of Personality Assessment, 59, 1–13. Millon, T. (1969). Modern psychopathology. Philadelphia, PA: Saunders. Millon, T. (1977). Millon Clinical Multiaxial Inventory. Minneapolis, MN: National Computer Systems. Millon, T. (1981). Disorders of personality: DSM-III, axis II . New York, NY: Wiley. Millon, T. (1987). Manual for the MCMI-II . Minneapolis, MN: National Computer Systems. Millon, T. (1990). Toward a new personology: An evolutionary model. New York, NY: Wiley. Millon, T. (1992). Millon Clinical Multiaxial Inventory: I & II. Journal of Counseling and Development, 70, 422–426. Millon, T. (1994). Millon Clinical Multiaxial Inventory-III (MCMI-III manual). Minneapolis, MN: National Computer Systems. Millon, T. (1997). Millon Clinical Multiaxial Inventory-III manual (2nd ed.). Minneapolis, MN: National Computer Systems. Millon, T. (1999). Personality-guided therapy. New York, NY: Wiley. Millon, T. (2002). A blessed and charmed personal odyssey. Journal of Personality Assessment, 79, 171–194. Millon, T. (2011). Disorders of personality: Introducing a DSM-ICD spectrum from normal to abnormal. Hoboken, NJ: Wiley. Millon, T., Antoni, M., Millon, C., Minor, S., & Grossman, S. (2001). Millon Behavioral Medicine Diagnostic (MBMD) manual. Minneapolis, MN: Pearson Assessments. Millon, T., & Davis, R. D. (1996). Disorders of personality: DSM-IV and beyond. New York, NY: Wiley.

172 REFERENCES Millon, T., Green, C., & Meagher, R. (1982). Millon Behavioral Health Inventory (MBHI) manual. Minneapolis, MN: National Computer Systems. Millon, T., & Grossman, S. D. (2007a). Moderating severe personality disorders: A personalized psychotherapy approach. Hoboken, NJ: Wiley. Millon, T., & Grossman, S. D. (2007b). Overcoming resistant personality disorders: A personalized psychotherapy approach. Hoboken, NJ: Wiley. Millon, T., & Grossman, S. D. (2007c). Resolving difficult clinical syndromes: A personalized psychotherapy approach. Hoboken, NJ: Wiley. Millon, T. & Grossman, S. D. (2012). Personalized psychotherapy: The unification and customization of trait-oriented treatments. Journal of Unified Psychotherapy and Clinical Science, 1, (1) 61–86. Millon, T., Grossman, S., & Millon, C. (2015). Millon Clinical Multiaxial Inventory-IV manual. Minneapolis, MN: Pearson Assessments. Millon, T., Grossman, S., Millon, C., Meagher, S., & Ramnath, R. (2004). Personality disorders in modern life. Hoboken, NJ: Wiley. Millon, T., Millon, C., & Davis, R. (1997). Millon Clinical Multiaxial Inventory-III (MCMI-III) manual (2nd ed.). Minneapolis, MN: National Computer Systems. Millon, T., Millon, C., & Davis, R. (2003). Millon Clinical Multiaxial Inventory-III (MCMI-III): Corrections report manual. Minneapolis, MN: Pearson Assessments. Millon, T., Millon, C., Davis, R., & Grossman, S. (2006a). Millon Adolescent Clinical Inventory (MACI) manual (2nd ed.). Minneapolis, MN: Pearson Assessments. Millon, T., Millon, C., Davis, R., & Grossman, S. (2006b). Millon Clinical Multiaxial Inventory-III (MCMI-III) manual (3rd ed.). Minneapolis, MN: Pearson Assessments. Millon, T., Millon, C., Davis, R., & Grossman, S. (2009). Millon Clinical Multiaxial Inventory-III (MCMI-III) manual (4th ed.). Minneapolis, MN: PsychCorp/Pearson Assessments. Millon, T., Strack, S., Millon, C., & Grossman, S. (2006). Millon College Counseling Inventory (MCCI). Minneapolis, MN: Pearson Assessments. Millon, T., Tringone, R., Millon, C., & Grossman, S. (2005). Millon Pre-Adolescent Clinical Inventory (M-PACI) manual. Minneapolis, MN: Pearson Assessments. Millon, T., Weiss, L., & Millon, C. (2004). Millon Index of Personality Styles-Revised (MIPS-R) manual. Minneapolis, MN: NCS Pearson. Perry, J. C. (1992). Problems and considerations in the valid assessment of personality disorders. American Journal of Psychiatry, 149, 1645–1653. Piotrowski, C., & Keller, J. W. (1989). Psychological testing in outpatient mental health facilities: A national study. Professional Psychology: Research and Practice, 20, 423–425. Piotrowski, C., & Lubin, B. (1989). Assessment practices of Division 38 practitioners. Health Psychologist, 11, 1. Piotrowski, C., & Lubin, B. (1990). Assessment practices of health psychologists: Survey of APA Division 38 clinicians. Professional Psychology: Research and Practice, 21, 99–106. Quinnell, F. A., & Bow, J. N. (2001). Psychological tests used in child custody evaluations. Behavioral Sciences and the Law, 19, 491–501.

REFERENCES 173

Reich, J. H., & Noyes, R. (1987). A comparison of DSM-III personality disorders in acutely ill panic and depressed patients. Journal of Anxiety Disorders, 1, 123–131. Retzlaff, P. D. (1991, August). MCMI-II scoring challenges: Multi-weight items and site specific algorithms. Paper presented at the 99th Annual Convention of the American Psychological Association, San Francisco, CA. Retzlaff, P. D. (1996). MCMI-III diagnostic validity: Bad test or bad validity study? Journal of Personality Assessment, 66 , 431–437. Retzlaff, P. D. (2000). Comment on the validity of the MCMI-III. Law and Human Behavior, 24, 499–500. Retzlaff, P. D., Lorr, M., & Hyer, L. (1989). An MCMI-II item-level component analysis: Personality and clinical factors. Unpublished manuscript. Retzlaff, P. D., Sheehan, E. P., & Lorr, M. (1990). MCMI-II scoring: Weighted and unweighted algorithms. Journal of Personality Assessment, 55, 219–223. Rogers, R., Salekin, R. T., & Sewell, K. W. (1999). Validation of the Millon Clinical Multiaxial Inventories for Axis-II disorders: Does it meet the Daubert standard? Law and Human Behavior, 23, 423–443. Rogers, R., Salekin, R. T., & Sewell, K. W. (2000). The MCMI-III and the Daubert standard: Separating rhetoric from reality. Law and Human Behavior, 24(4), 501–506. Rorschach, H. (1921). Psychodiagnostik. Berne, Switzerland: Hans Huber. Rossi, G., Elklit, A., & Simonsen, E. (2010). Empirical evidence for a four factor framework of personality disorder organization: Multigroup confirmatory factor analysis of the Millon Clinical Multiaxial Inventory-III personality disorder scales across Belgian and Danish data samples. Journal of Personality Disorders, 24, 128–150. Spencer, H. (1870). The principles of psychology. London, UK: Williams and Norgate. Strack, S. (Ed.). (2008). Essentials of Millon inventories assessment (3rd ed.). Hoboken, NJ: Wiley. Streiner, D. L., Goldberg, J. O., & Miller, H. R. (1993). MCMI-II item weights: Their lack of effectiveness. Journal of Personality Assessment, 60, 471–476. Streiner, D. L., & Miller, H. R. (1989). The MCMI-II: How much better than the MCMI? Journal of Personality Assessment, 53, 81–84. Streiner, D. L., & Miller, H. R. (1990). Maximum likelihood estimates of the accuracy of four diagnostic techniques. Educational and Psychological Measurement, 50, 653–662. Turkat, I. D. (1990). The personality disorders: A psychological approach to clinical management. New York: Pergamon Press. Wetzler, S. (1990). The Millon Clinical Multiaxial Inventory (MCMI): A review. Journal of Personality Assessment, 55, 445–464. Widiger, T. A., Williams, J. B. W., Spitzer, R. L., & Frances, A. (1985). The MCMI as a measure of DSM-III. Journal of Personality Assessment, 49, 366–378. Wilson, E. O. (1978). On human nature. Cambridge, MA: Harvard University Press.

ABOUT THE AUTHORS

Seth Grossman, Psy.D., is the chief coauthor of the MCMI-IV and the founder and clinical director of The Center for Psychological Fitness, a multispecialist group practice in the Fort Lauderdale, Florida, region, where he oversees a group of clinicians working in diverse clinical areas. He is also a consulting psychologist and clinical faculty member at the Florida International University Herbert M. Wertheim College of Medicine, Counseling and Wellness Center. He is a member of the American Psychological Association and the Society for Personality Assessment. In the past few years, Dr. Grossman has extended his role with the Millon inventories, having been mentored for many years by the late Dr. Theodore Millon, the world-renowned personality theorist and personality assessment author. The MCMI-IV clinical assessment was completed under Dr. Grossman’s leadership following Dr. Millon’s passing. Over the course of nearly two decades, Dr. Grossman has coauthored many Millon textbooks, journal articles, and personality tests. An early highlight of his contribution to the assessment field was the construction of the Grossman Facet Scales, first introduced in the MCMI-III and MACI and now updated for the MCMI-IV. Dr. Grossman is a featured presenter and Millon inventories instructor in many clinical and professional settings nationally and internationally. Blaise Amendolace, Psy.D., is currently the interim clinical director at Florida Atlantic University’s Counseling and Psychological Services (FAU CAPS). He is also the assessment coordinator at FAU CAPS, focusing on the administration and supervision of therapeutic personality assessment. He is an adjunct faculty member at FAU, Lynn University, and Florida Institute of Technology, where he earned his doctoral degree learning under the direct supervision of Radhika Krishnamurthy, PsyD. He is an active member of the Society for Personality Assessment, Association of Contextual Behavioral Science, and the Florida Psychological Association, having been awarded the Outstanding Early Career Psychologist award in 2013. In addition, he maintains a private practice at The Center for Psychological Fitness in Cooper City, Florida. 175

176 ABOUT THE AUTHORS

A. Jordan Wright, Ph.D., ABAP (contributing author), is a diplomate in assessment psychology and a fellow of the American Academy of Assessment Psychology and the Society for Personality Assessment. He received his MA in Psychology in Education from Teachers College and his Ph.D. in Clinical Psychology from Columbia University. He is on faculty at Empire State College, State University of New York, where he coordinates the human development department and the psychology curriculum statewide. He is the author of Conducting Psychological Assessment: A Guide for Practitioners (Wiley, 2010) and the coauthor of the Handbook of Psychological Assessment, Sixth Edition (Wiley, 2016).

INDEX

A AAMasoc Spectrum, 74–77, 93, 158, 167 AASchd Spectrum, 10, 15, 26, 45, 47–49, 88, 106 abandonment fear, 61, 80–81, 164–166 Abbreviated Scale Names, 111 Abnormal Type, 25–26, 138–139 abrasive conduct, 10, 28, 69, 91 acting-out, 10, 28, 66–67, 91, 157–160 Acting-Out Dynamics, 158 Active-Ambivalent Pattern. See Negativistic Personality Pattern Active-Detached Pattern. See Avoidant Personality Pattern Active-Independent Pattern. See Antisocial Personality Pattern Active-Modifying strategy, 22–23 Active-Other Motivational Pattern. See Histrionic Personality Pattern Active-Pleasure-Seeking Pattern. See Turbulent Personality Pattern ADAntis Spectrum, 64–67, 91, 101, 156, 165 adaptation strategy, 22–23 ADHD. See Attention Deficit Hyperactivity Disorder administration, of MCMI-IV, 33–34 Admirable Self-Image, 10, 28, 63, 91, 117, 129 ADSadis Spectrum, 67–69, 91–92, 105

Alcohol Use scale, 86–87, 152, 167 Alienated Self-Image, 51, 64, 78, 88, 93, 103, 116, 117–118 aligning polarities, 104 alliance building, 109 feedback preparation, 111–112 introducing MCMI-IV, 110 label avoidance, 112–113 test-taking style, 113–120 American Psychiatric Association (APA), 2, 4 American Psychological Association Ethical Code of Psychologists and Code of Conduct, 151 antagonistic interpersonal style, 65, 81 Antisocial Personality Pattern, 64–67, 91, 101, 131 in case report, 156, 158, 165–166 anxiety. See Generalized Anxiety scale Anxiety Adjustment factors, 38 APA. See American Psychiatric Association apathetic temperament, 10, 26, 28, 48, 50, 88 Apathetic-Asocial-Schizoid scale, 128. See also Grossman Facet Scales ASD. See autism spectrum disorder assessment application with MCMI, 142–144 integration guidelines, 142 overall picture, 107 role of personality, 97–107 177

178 INDEX

Attention Deficit Hyperactivity Disorder (ADHD), 7–8, 102, 144, 152, 153 attention-seeking, 10, 28–29, 58, 90 autism spectrum disorder (ASD), 102, 144 Autonomous Self-Image, 10, 28, 66, 91, 158, 167 Aversive Interpersonal Conduct, 10, 28, 51, 88, 117–118, 158 Avoidant Personality Pattern, 49–51, 88–89, 99, 105, 109, 114–117 in case report, 156 B Base Rate (BR) system, 3–4, 12–14 85 or higher, 54, 67, 82, 100, 103, 110, 131, 138–139 in case report, 158–159, 164–167 adjustments, 38 anchor points, 100 development, 124 MCMI-IV scores, 36–38 Beck Depression Inventory, 126 biosocial-learning theory, 2 Bipolar Spectrum scale, 85–86 Borderline Personality Pattern, 80–82, 93–94, 102–105 in case report, 166–167 BR. See Base Rate system Brief Symptom Inventory (BSI), 8, 125 C case reports background information, 152, 160–161 behavioral observations, 153, 161

clinical personality pattern, 156, 165–166 clinical symptomatology, 159, 167 diagnostic considerations, 159, 167–168 facet page, 155, 163 Grossman Facet Scale, 158, 166–167 noteworthy responses, 153, 164 profile page, 154, 162 referral reason, 151–152, 160 severe personality pathology, 156, 164 severe syndrome scale, 167 test validity, 153, 164 treatment considerations, 159–160, 168 CENarc Spectrum, 62–64, 90–91, 109, 114–117 chaotic intrapsychic content, 11, 24, 28, 79, 93, 103, 142 child custody, 144 childhood abuse, 44, 76, 82 circumstantial cognitive-style, 11, 24, 78, 93 Clinical Disorders, 25–26, 138–139 Clinical Personality Patterns, 10–11, 12, 45–47 Antisocial, 64–67, 91, 101, 131, 156, 158, 165–166 assessing, 104–106 Avoidant, 49–51, 88–89, 99, 105, 109, 114–117, 156 in case reports, 156, 165–166 Compulsive, 69–72, 92 Dependent, 54–57, 89, 101, 104–105, 114 Histrionic, 57–59, 90, 104–105 Masochistic, 74–77, 93, 158, 167 Melancholic, 52–54, 89, 99

INDEX 179

Narcissistic, 62–64, 90–91, 100, 109, 114–117 Negativistic, 72–74, 92, 103, 165–166 Sadistic, 67–69, 91–92, 105 Schizoid, 10, 15, 26, 45, 47–49, 88, 106 Turbulent, 59–62, 90, 103, 124, 143–144 Clinical Symptomology, 119–120 case report, 159 Clinical Syndromes, 9, 11, 15 Alcohol Use, 86–87, 152, 167 Bipolar Spectrum, 85–86 BR anchor point, 13 Drug Use, 86–87, 152 examining, 106–107 Generalized Anxiety, 85–86, 107, 110, 167 Persistent Depression, 86, 99, 124, 167 Post-Traumatic Stress, 86–87, 107 Somatic Symptom, 85–86 Cluster B personality, 168 Cognitive Style Expansive, 10, 28, 91, 117–118, 120 Fatalistic, 129 introduction to, 26–28 Mistrustful, 11, 26, 28, 46, 65, 84, 94, 129 Pessimistic, 29, 52–53, 73, 87 collaborative assessment, 142–143 collateral information, 100 color wheel analogy, 98, 115 combination prototypes, 105 Compulsive Personality Pattern, 69–72, 92 confirmatory factor analysis. See covariance structure analysis

constricted cognition, 10, 26, 28, 71, 92 correctional settings, 143–144 Corrections Report (Millon, Millon & Davis), 143–144 court-mandated program, 97, 152 covariance structure analysis (CSA), 9 criminal proceedings, 143 Cronbach’s alpha scores, 9, 10–11 CSA. See covariance structure analysis cynical attitude, 28, 52, 65, 73–74, 82, 157 D DADpen Spectrum, 54–57, 89, 101, 104–105, 114 Daubert criteria, 143 Davis, Roger, 5 Debasement scale, 13, 42–44, 101–102, 110, 113, 164 Deductive-Rational inventory, 139–140 defensive emotion, 11, 28, 43, 83–84, 88, 94 Delusional Disorder scale, 87–88, 106–107 Dependent Personality Pattern, 54–57, 89, 101, 104–105, 114 depression, 86, 99, 124, 167. See also Major Depression scale Desirability scale, 13, 42–44, 101–102, 110, 113 DFMelan Spectrum, 52–54, 89, 99 differentials, 44 disciplined emotion, 10, 28, 70–71, 92 Disclosure scale, 13, 38, 42–44, 101–102, 110, 113, 164 Discontented Self-Image, 11, 26, 28, 73, 92, 166 disintegrating effect, 24–25, 77, 103 disorders. See Clinical Disorders

180 INDEX

Disorders of Personality (Millon), 104 Disorders of Personality (Millon & Davis), 5 Domain-Oriented Therapeutic Modalities, 119 Domains, by scale antisocial, 65–67 avoidant, 50–51 borderline, 80–82 compulsive, 70–71 dependent, 55–56 histrionic, 58–59 masochistic, 75–76 melancholic, 52–54 narcissistic, 63–64 negativistic, 73–74 paranoid, 83–84 sadistic, 68–69 schizoid, 48 schizotypal, 78–79 turbulent, 60–61 double depression, 99 dramatic emotion, 10, 28, 58, 90 DRNegat Spectrum, 72–74, 92 Drug Use scale, 86–87, 152 DSM-5 criteria, 7 evolutionary theory, 27–29 to MCMI-IV, 126–127, 131–132 DSM-III criteria, 2 dysphoric temperament, 11, 28, 76, 93 Dysthymic Disorder, 99 E EESchizoph Spectrum, 77–80, 93 EETurbu Spectrum, 59–62, 90, 103, 124, 143–144 embittered emotion, 11, 28, 73, 92, 166 eruptive architecture, 10, 28, 69, 92

Essentials of Millon Inventories Assessment (Strack), 145 Estranged Self-Image, 11, 28, 79, 93 Ethical Code of Psychologists and Code of Conduct, 151 evolutionary theory. See also Millon Evolutionary Model compared to DSM-5, 27–29 model of personality, 20–21 origin of MCMI-IV, 29 Exalted Self-Image, 10, 28, 61, 90, 129 examinee alliance building, 109–112 feedback from MCMI-IV, 111 introducing MCMI-IV, 110 label avoidance, 112–113 overall picture, 107 role of personality, 97–107 test-taking style, 113–120 Expansive Cognitive Style, 10, 28, 91, 117–118, 120 expert testimony, 143 exploitive conduct, 10, 28, 63, 90, 117 Expressive emotion, 26 External-Criterion inventory, 3, 8, 14–15, 139–140 F family law, 144 Fantasy Intrapsychic Mechanism, 118 Fatalistic Cognitive Style, 129 fickle temperament, 10, 28, 58–59, 90 G General Behavior Inventory, 126 Generalized Anxiety scale, 85–86, 107, 110 in case report, 167

INDEX 181

Grossman, Seth, 6. See also Grossman Facet Scales Grossman Facet Scales, 9–12, 29, 88–94 case report, 158 integrating, 106 language of alliance, 117–119 to MACI, 145 H health applications, 146–147 high-spirit conduct, 10, 28, 61, 90 Histrionic Personality Pattern, 57–59, 90, 104–105 hostile temperament, 28, 65, 69, 157, 166 I immune system, 19–20 impetuous expression, 10, 28, 61, 90 inclusive behaviorist, 1 Inconsistency, 42–44, 101–102, 110 Inductive-Statistical inventory, 139–140 Inept Self-Image, 10, 28, 55–56, 89 integrative interpretation, 99–100 Internal-Structural stage, 3, 9–14 interpersonal aversion, 10, 28, 51, 88, 117–118, 158 conduct, 25–29 imbalance, 24 irresponsibility, 10, 28, 65–66, 91, 157, 166 interpretive principles of personality, 97–107 intrapsychic architecture, 11, 25–29, 76, 81, 93–94, 158, 166 Intrapsychic dynamic, 25–29

Invalidity, 35–36, 42–44, 101–102, 110 inverted intrapsychic architecture, 11, 28, 76, 93, 158 irresponsible conduct, 10, 28, 65–66, 91, 157, 166 irritable temperament, 11, 28, 73, 92 K K-strategy, 23 L labile temperament, 11, 28, 81, 94 language of alliance clinical symptomology, 119–120 facets scale, 117–119 individual personality scale, 114–115 multiple personality scale, 115–117 legally mandated testing, 97, 152 Lehigh University, 1 Loevinger, Jane, 3 M MACI. See Millon Adolescent Clinical Inventory Major Depression Adjustment, 38 Major Depression scale, 87, 106–107, 110 manipulative interpersonal style, 66, 68, 81 Masochistic Personality Pattern, 74–77, 93 in case report, 158, 167 matching polarities, 104 MBHI. See Millon Behavioral Health Inventory MBMD. See Millon Behavioral Medicine Diagnostic

182 INDEX

MCCI. See Millon College Counseling Inventory MCMI. See Millon Clinical Multiaxial Inventory MCMI-II. See Millon Clinical Multiaxial Inventory, Second Edition MCMI-III. See Millon Clinical Multiaxial Inventory, Third Edition MCMI-IV. See Millon Clinical Multiaxial Inventory, Fourth Edition medical applications, 146–147 Melancholic Personality Pattern, 52–54, 89, 99 Millon, Carrie, 6 Millon, Theodore, 104, 124 evolutionary theory, 19–21 MCMI-IV development, 1–15 personality prototypes, 2–3 theories of, 132–133 Millon Adolescent Clinical Inventory (MACI), 145–146 Millon Behavioral Health Inventory (MBHI), 146–147 Millon Behavioral Medicine Diagnostic (MBMD), 34, 146–147 Millon Clinical Multiaxial Inventory (MCMI) construction, 3–6 development, 124, 127–128 history, 1–3 introducing, 34 Millon Clinical Multiaxial Inventory, Fourth Edition (MCMI-IV). See also case reports; Millon Evolutionary Model administration, 33–34 augmentation, 137–139

base rates, 36–38 in clinical assessment, 139–142 development, 7 to DSM-5, 126–127, 131–132 history, 1–3 inconsistency, 42–44, 101–102, 110 integrative interpretation, 99–100 Internal-Structural stage, 8, 9–14 interpretation, 126–127, 131–133, 135 introduction to examinees, 34–35 invalidity, 35–36, 42–44, 101–102, 110 modifying indices, 42–44 noteworthy responses, 44, 102 personality scales reliability, 10–11 practical issues, 124–125, 128–129, 134 psychometric properties, 125–126, 129–130, 134 reference details, 6–7 reliability, 13, 38, 42–44, 101–102, 110, 113, 164 scoring, 35–38 strengths, 123–127, 133–135 test development, 124, 127–128, 133 Theoretical-Substantive stage, 7–8, 14–15 validity, 13, 42–44, 101–102, 110, 113, 164 weaknesses, 127–135 Millon Clinical Multiaxial Inventory, Second Edition (MCMI-II), 4–5 Millon Clinical Multiaxial Inventory, Third Edition (MCMI-III), 5–6, 125–126, 130, 137–138 Corrections Report, 143–144

INDEX 183

Millon College Counseling Inventory (MCCI), 34, 146–147 Millon Evolutionary Model, 140 Scale 1, 47–49, 88, 106 Scale 2A, 49–51, 88–89, 99, 105, 109, 114–117, 156 Scale 2B, 52–54, 89, 99 Scale 3, 54–57, 89, 101, 104–105, 114 Scale 4A, 57–59, 90, 104–105 Scale 4B, 59–62, 90, 103, 124, 143–144 Scale 5, 62–64, 90–91, 100, 109, 114–117 Scale 6A, 64–67, 91, 101, 156, 165 Scale 6B, 67–69, 91–92, 105 Scale 7, 69–72, 92 Scale 8A, 72–74, 92, 103, 165 Scale 8B, 74–77, 93, 156 Scale C, 80–82, 93–94, 102–105, 166–167 Scale P, 82–85, 94, 102–104, 105, 116–117 Scale S, 77–80, 93, 102–105 Millon Index of Personality Styles-Revised (MIPS-R), 34, 137–138, 145, 146–148 Millon Pre-Adolescent Clinical Inventory (M-PACI), 34, 145, 146 Millon-Illinois Self-Report Inventory (MISRI), 2–3 Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF), 8, 126 minority ethnicities, 12 MIPS-R. See Millon Index of Personality Styles-Revised

MISRI. See Millon-Illinois Self-Report Inventory Mistrustful Cognitive Style, 11, 26, 28, 46, 65, 84, 94, 129 Mistrustful-Paranoid-Paraphrenic scale, 128–129. See also Grossman Facet Scales MMPI-2-RF. See Minnesota Multiphasic Personality Inventory-2 Restructured Form Modern Psychopathology (Millon), 1–2 Modifying Indices scale, 41–44 BR anchor point, 13 examinee test-taking style, 113–120 introduction, 4–5 Mood-temperament, 25–29 motivating aims, 21–23 antisocial, 65 Avoidant, 49–50 borderline, 80 compulsive, 70 dependent, 55 histrionic, 57 masochistic, 75 melancholic, 52–53 narcissistic, 62 negativistic, 72 paranoid, 83 problematic patterns in, 23–25 sadistic, 67–68 schizoid, 47 schizotypal, 78 turbulent, 60 M-PACI. See Millon Pre-Adolescent Clinical Inventory MPParaph Spectrum, 82–85, 94

184 INDEX

N Narcissistic Personality Pattern, 62–64, 90–91, 100, 109, 114–117 Negativistic Personality Pattern, 72–74, 92 in case report, 165–166 neurocognitive application, 144 Normal Style, 25–26, 138–139 noteworthy responses, 44, 102, 153, 164 O opposing polarities, 104–105 other-nurturing strategy, 22–23 P pain-pleasure polarity, 45, 49, 59, 61, 75, 116 Paranoid Personality Pattern, 82–85, 94 parenting-styles, 23, 47, 51, 64, 67, 69, 71, 76, 84, 152, 160–161 passive-accommodating strategy, 22–23 passive-aggressive strategy, 72–73, 157, 166. See also Negativistic Personality Pattern Passive-Ambivalent Pattern. See Compulsive Personality Pattern Passive-Detached Pattern. See Schizoid Personality Pattern Passive-Independent Pattern. See Narcissistic Personality Pattern Passive-Other Pattern. See Dependent Personality Pattern pathological objective, 142 Pearson Clinical Assessments, 7 Pearson’s Q-global® scoring, 35 percentile rank score, 38

Persistent Depression scale, 86, 99, 124, 167 in case report, 167 personality adaptiveness, 25 in clinical assessment, 19–20 evolutionary model, 20–21 expression antisocial, 65–67 avoidant, 50–51 borderline, 80–82 compulsive, 70–71 dependent, 55–56 histrionic, 58–59 masochistic, 75–76 melancholic, 52–54 narcissistic, 63–64 negativistic, 73–74 paranoid, 83–84 sadistic, 68–69 schizoid, 48–49 schizotypal, 78–79 turbulent, 60–61 motivating aims of, 21–23 problematic patterns, 23–25 overall clinical picture, 107 prototypes, 2–3 role in assessment of, 97–107 spectra, 137–139 personality level Abnormal Type, 25–26 Clinical Disorder, 25–26, 138–139 Normal Style, 25–26 Personality scale, 9, 10–11 sensitivity and specificity, 15 personologic domains. See Domains, by scale Pessimistic Cognitive Style, 29, 52–53, 73, 87

INDEX 185

pleasure-oriented, 67, 116 pleasure-pain polarity, 45, 49, 59, 61, 75, 116 Post-Traumatic Stress scale, 86–87, 107 precipitate emotion, 10, 28, 69, 91 psychoeducational application, 144 psychosis, 78 puerile emotion, 10, 28, 56, 89, 129 Q Q-global scoring, 35 Q-Local software, 35 R RCComp Spectrum, 69–72, 92 red flags, 44 Reliable Self-Image, 10, 26, 28, 70–71, 91, 92 replication strategy, 22–23 Rorschach, 2, 109, 141 r-strategy, 23 S Sadistic Personality Pattern, 67–69, 91–92, 105 safety, of clinician, 67, 82, 168 Scale 1 (Schizoid), 10, 15, 26, 45, 47–49, 88, 106 Scale 2A (Avoidant), 49–51, 88–89, 99, 105, 109, 114–117 in case report, 156 Scale 2B (Melancholic), 52–54, 89, 99 Scale 3 (Dependent), 54–57, 89, 101, 104–105, 114 Scale 4A (Histrionic), 57–59, 90, 104–105

Scale 4B (Turbulent), 59–62, 90, 103, 124, 143–144 Scale 5 (Narcissistic), 62–64, 90–91, 100, 109, 114–117 Scale 6A (Antisocial), 64–67, 91, 101, 131 in case report, 156, 158, 165–166 Scale 6B (Sadistic), 67–69, 91–92, 105 Scale 7 (Compulsive), 69–72, 92 Scale 8A (Negativistic), 72–74, 92, 103 in case report, 165–166 Scale 8B (Masochistic), 74–77, 93 in case report, 156, 167 Scale A (Generalized Anxiety), 85–86, 107, 110, 167 Scale B (Alcohol Use), 86–87, 152, 167 Scale C (Borderline), 80–82, 93–94, 102–105, 166–167 Scale CC (Major Depression), 87, 106–107, 110 Scale D (Persistent Depression), 86, 99, 124, 167 Scale H (Somatic Symptom), 85–86 Scale N (Bipolar Spectrum), 85–86 Scale P (Paranoid), 82–85, 94, 102–105, 116–117 Scale PP (Delusional Disorder), 87–88, 106–107 Scale R (Post-Traumatic Stress), 86–87, 107 Scale S (Schizotypal), 77–80, 93, 102–105 Scale SS (Schizophrenic Spectrum), 87, 106–107 Scale T (Drug Use), 86–87, 152 Scale V (Invalidity), 36, 42–44, 101–102, 110 Scale W (Inconsistency), 42–44, 101–102, 110

186 INDEX

Scale X (Disclosure), 13, 38, 42–44, 101–102, 110, 113 in case report, 164 Scale Y (Desirability), 13, 42–44, 101–102, 110, 113 Scale Z (Debasement), 13, 42–44, 101–102, 110, 113 in case report, 164 Schizoid Personality Pattern, 10, 15, 26, 45, 47–49, 88, 106 Schizophrenic Spectrum scale, 87, 106–107 Schizotypal Personality Pattern, 77–80, 93, 102–105 scoring, 35–38, 41–42 self-care of therapist, 67, 82, 168 self-destructive potential, 113 self-harm, 80–82, 164, 168 Self-Image overview, 25–29 self-propagating strategy, 22–23 sensitivity and specificity, of MCMI-IV, 14, 15 Severe Clinical Syndromes, 11, 15, 87–88 case report, 158 Delusional Disorder, 87–88, 106–107 examining, 106–107 Major Depression, 87, 106–107, 110 Schizophrenic Spectrum, 87, 106–107 Severe Personality Pathology, 11, 12, 15 assessing, 102–104 Borderline, 80–82, 93–94, 102–105, 166–167 Paranoid, 82–85, 94, 102–105, 116–117 Schizotypal, 77–80, 93, 102–105 Somatic Symptom scale, 85–86

Spanish language translation, 8 specificity. See sensitivity and specificity SPHistr Spectrum, 57–59, 90 split intrapsychic architecture, 11, 28, 81, 94, 166 SRAvoid Spectrum, 49–51, 88–89, 99, 105, 109, 114–117, 156 State-Trait Anxiety Inventory, 126 Strack, Stephen, 145 submissive conduct, 10, 28, 56, 89 substance abuse, 124 suicidal, 54, 81, 87 survival strategy, 22–23 Symptom Checklist-90, 126 Syndromes. See Clinical Syndromes; Severe Clinical Syndromes T test questions, by chapter alliance building, 120–122 clinical applications, 148–149 evolutionary theory, 30–31 history and development of MCMI-IV, 16–17 interpretive principles, 107–108 MCMI-IV scoring, 38–39 MCMI-IV strengths and weaknesses, 135–136 scores and scales, 95–96 Theoretical-Substantive stage, 3 therapeutic assessment, 142 therapist self-care, 67, 82, 168 Thought Disorder, 124, 130 three-stage model, 3 trait-domain system, 25–29 treatment implications antisocial, 67 avoidant, 51 borderline, 82

INDEX 187

in case report, 159–160, 168 compulsive, 71–72 dependent, 56–57 histrionic, 59 masochistic, 76–77 melancholic, 54 narcissistic, 64 negativistic, 74 paranoid, 84–85 sadistic, 69 schizoid, 49 schizotypal, 79–80 turbulent, 61–62 T-score, 3–4, 124 Turbulent Personality Pattern, 59–62, 90, 103, 124, 143–144 U UBCycloph Spectrum, 80–82, 93–94 unalterable intrapsychic content, 28, 83–84 Uncertain Self-Image, 11, 28, 81, 93, 106, 118, 166

Undeserving Self-Image, 11, 28, 75–76, 93 unengaged conduct, 10, 28, 48, 88 Unstable-Borderline-Cyclophrenic scale, 128–129. See also Grossman Facet Scales V validity. See also Invalidity of case report, 153, 164 reviewing scores of, 100–102 scales of, 35–36, 42–44 vengefully prone, 113, 143–144 Vexatious Interpersonal Content, 117–118, 129, 158 W wavering, 24–25, 103 withdrawal, 140 woeful temperament, 10, 28–29, 53, 89 women, 4 Worthless Self-Image, 10, 28, 53, 82, 89

WILEY END USER LICENSE AGREEMENT Go to www.wiley.com/go/eula to access Wiley’s ebook EULA.