by Theodore Millon, Carrie M. Millon, Sarah Meagher, Seth Grossman, and Rowena Ramnath
John Wiley & Sons, 2004
Review by Roy Sugarman, Ph.D. on Dec 7th 2004
Millon, of the Mutiaxial Inventory
fame, has said of personalities that they are like impressionist paintings in
that each is at a distance easily accessed, but up close there is a bewildering
complexity. Jeff Magnavita, (a fitting name, given the analogy) in his
foreword, notes that this book lays the groundwork for the construction of a
working model of human personality dysfunction, as well as normal functioning.
If true, this would be a relief, given that mental health professionals are not
regarded as terribly accurate when it comes to assessing normality, and perhaps
we stand too close to the painting so to speak. We certainly are capable of
finding pathology in most circumstances, as for instance in the notorious Chelmsford
Hospital matter in Australia, without always looking for the context markers
that would say otherwise (see pg 72, with reference to interpersonal
Culture is another bedeviling
factor, and only 6 pages of the 600-odd actually deal with this, always by
using a window as a form of focusing on such issues throughout the book. The
DSM-IV is by its nature part of the Universalist school of thought, which holds
that these described disorders may be thought of as universal. Millon deals
with this briefly, as others have done, without commenting on the eye of the diagnoser-beholder:
the book's focus so often reverts to the evolutionary underpinnings of
personality, related to survival, adaptation and replication, but never
certainly from the perspective of an ideational Darwinism, where most of our
interactions come to nothing, as Russ Barkley would have it.
Nowhere does one see a satisfactory
discussion of the kind of perspective that the eye of the viewer of the
painting might bring, and one might add to Millon that the eye of the beholder
brings to the cumulative whole of the painting what the beholder wants
to see, within the viewer's paradigm, not from a Universalist perspective, but
culture specific. One of my famous painter friends always responds to queries:
"What do you want to see" or "What do you want it to be?"
As discussed by Millon, nosological categories have their value, not
definitive, but guiding in what they tell us to look at, an epistemology of
personality investigation, and that is what Millon sets out to do for us here,
and well enough to make this a classic work for post-grads.
Millon's influence is thus,
historically, quite large, and in the foreword anyway he is characterised as
being a major driver in the quest for a 'personology', an epistemology of
personality one imagines, defining what one should be looking at in a
To this end the book embarks by
examining the historical foundations of the biology or psychodynamics of the
putative disorders, and then the more contemporary views. This latter takes the
form of an examination of the interpersonal, cognitive, traits/factors, and
then the abovementioned evolutionary-neurodevelopmental perspectives.
Having 'romanced' all of these
perspectives, Millon says somewhat cynically (and probably correctly) that
psychology will always regard the latest 'fad' as the last word on the
subject. Perhaps it's not the latest fad, but the latest DSM, with some
disorders coming and going, like masochism, sadism, and so on.
In keeping with the painting
metaphor used above, Millon writes that we are left with a 'patchwork quilt'
that fails to converge on an integrated view of personality (page 58). The
alternative to a more integrated view would be 'an uncomfortable eclecticism'
of 'unassimilated partial views'. Later in this discussion we again see the emergence
of the survival, adaptation and replication view taken in one of the early
focused 'culture' windows referred to above. This results then in a discussion
of the domains of personality, which is clearly an attempt to converge the 'fads'
of personality into a more usable format, or at least one that is more
heuristically useful anyway, as the DSM's have set out to be.
The final format above leads Millon
to hold that psychological health is dependent on the fit between the entire
configuration of the person's characteristics and potentials with those of the
environments in which the person functions (page 73), more than a passing
reference to culture here. I note he goes on to say "Behaviors experienced
as pleasurable are generally repeated…..while those experienced as painful….are
not repeated" which of course ignores aspects of intrinsic motivation that
are coming to the fore after Ryan and Deci's work for instance. We may indeed
embark on painful pathways if there is a reward inside us for pursuing such a
course, with the fundamental attribution errors of others outside us making it
clear they think there is something wrong with us in doing so.
For instance, why do men, the
stereotype goes, resist asking others for instructions when they are clearly lost,
with wifey and kids in tow, all demanding daddy stop and ask? The answer
really is that finding out where to go (extrinsic reward) is nowhere nearly as
internally rewarding as toughing it out and emerging at your destination with
only yourself and your amazing capacity for exploration and self-determination
to blame (intrinsic reward), no matter how painful that might be to others,
especially those sweating in the car who hate your latest Neil Young CD. Daddy
is a PD! Daddy is a PD! It really is all in the context both internally and
externally….is it not?
If all behavior has a purpose, and
this internal purpose, hidden from sight, may promote the idea that such
behavior indicates that within this behavioral entity resides a 'horrible
person', then the personality disorders as a whole would indicate a determined
and collated set of fundamental attribution errors. For instance, a person with
a sense of entitlement, always irritable, who cannot tolerate team approaches
and touchy-feely committees, and who is adamant their way is probably correct,
given their experience, full of rationalizations and disdainful of regulations
which stunt creativity, is probably more likely to be from a certain country,
or profession, rather than from a diagnostic category such as antisocial or
narcissistic. It depends where you stand, and these categories are thus
predisposing professionals to label many characteristics as pathological. The
above person however, in many societies that value such characteristics, would
be seen as a creative leader with drive, ambition, single mindedness of
purpose, and do well. In a more British and colonial system, they would have to
have Royalty in their blood, or be sent to Coventry or simply sabotaged by the
others (see Millon deal with this on pages 151-155).
I cannot get away from the idea, at
this stage, that only some must regard some concatenations of personality
features as undesirable. My trainees then describe these characters as 'horrible
people'. Such attribution errors are common in responses to gender roles that
are resistant to stereotypy, page 81: masquerading gender roles as madness may
be to locate falsely (a fundamental attribution error, I think) within persons
all of the ludicrous cognitive and behavioral limitations that actually reside
in gender roles and stratification.
The development of the personality
disorders section then proceeds with a discussion that, of course, these are
not disorders in the medical sense: they are seen as theoretical constructs
employed to represent varied styles or patterns in which the personality system
functions in a maladaptive way in relation to its environment. This by now is
better language for me to evaluate and use in my paradigms:
When the alternative strategies
employed to achieve goals, relate to others, and cope with stress are few in
number and rigidly practiced (adaptive inflexibility); when habitual
perceptions, needs, and behaviors perpetuate and intensify pre-existing
difficulties (vicious circles); and when the person tends to lack resilience
under conditions of stress (tenuous stability), we speak of a clinically
maladaptive personality pattern (pages 77-78)
Another issue that arises then is
that of my favorite hobbyhorse, namely that "a huge percentage of women
diagnosed as personality disordered have histories of sexual and physical abuse"
(page 82). Given that the developing brain is exquisitely sensitive to
stresses, and changes are noted in the limbic and other areas, with resultant
changes in the hypothalamic-pituitary-adrenal axis in response to such abuse,
this contention appears to have much merit, but is still neglected in history
taking, or ignored, in some areas in which I work, as being part of the
etiology; rather, there is a tendency to conform to the attribution error in
its most fundamental guise, and label the person as horrible, and treat them
In my training since the '80's,
there was the push-of-war between psychiatry and psychology as to who would
treat the Axis II group, largely not regarded as suffering from a mental
illness and hence not a deserved target of mental health intervention. Recent
articles in the British Journal of Psychiatry have brought up just this issue,
prompting my previous boss to close our hospital wards to anyone with
Borderline Personality Disorder: a professor in psychiatry, he regarded such
patients as not mentally ill.
Their anxiety, bipolarity,
depressions etc were all felt to be secondary to the 'thing' of their
personality disorder, a derangement of character rather than of mind or brain,
whereas of course it is both of the latter that lead to the former derangement
of character. Deciding on treatment, and then procuring it for them remains
The window on gender notes:
Our conceptualizations are fuzzy,
our samples are biased, our measures are biased, and our clinicians fall prey
to their own biases. The question of what to do is even more difficult to
address (pg 83).
Perhaps then, my boss was right to deny access to a toxic
Despite Millon's efforts, there is
thus far to go in creating a science or a neuroepistemology for personology.
Chapter Four takes this on, but only after an exhaustive Chapter Three that
examines the multitude of theories relating to how the disordered phenotype
Here one sees the emergence of the
true genius of Millon and of his scholarly approach, and he and his colleagues
are most thorough in examining the issues of testing, assessment and diagnosis
in all their theoretical and practical vicissitudes.
The psychotherapy section of this
chapter only begins thus after almost twenty pages, which tells you how
thorough they have been. A discussion around brief therapies, common factors
of therapies, and technical eclecticism leads to the idea of synergistic
therapy, one of Millon's own, with each intervention both targeted at a single
aspect of the person, but also at the global outcome. Personality is thus a
functional-structural system, and targeted as such by synergistic therapies
rather than a particular approach. In this way, one could use two approaches
together where either in isolation would not work (a potentiation of pairing)
or rather use a sequenced series of approaches chosen as a kind of filibuster.
Assessment and therapy are thus seen as continuous with personality in an
integrated way, the theme of this book.
Chapter Five onwards focuses on
individual disorders, beginning with the Antisocial. Apart from the
introductory discussions, the clinical aspects of normality versus abnormal in
the eyes of the professional comprise the most important part of the
discussion. We all, I am sure, have a morbid fascination with the Hannibal
Lector style of brilliant villain, there are many more amongst us who are less
grossly abnormal, but who still do not represent the Judeo-Christian ideal of a
human. These former would include the adventurer and the dissenting
personality, who I described above as the individual who goes their own
path with resentment of the restraints of the 'pack', and who 'finesse' their
way through life rather than slog, or follow the road most often travelled by
others. There are also variants on the antisocial, such as the covetous, or
the humiliation-sensitive reputation-defender. Again, various approaches,
concluding with the environment neuro-developmental perspectives are described
and evaluated. As expected, the therapy section is slim.
The rest of the chapters follow the
same extensive, intense framework
Finally, attention is given to the 'other'
disorders in the backrooms of the DSM-IV.
Millon and colleagues have thus
successfully updated the bible of personality disorder reference material, and
there is nothing quite like it out there. I remain with my reservations about
his testing equipment, as using it with brain-injured populations or
distinguishing those having gone through trauma from other groups leads to
However, I do not have to estimate
that this book will become a classic reference, mostly for those in the
postgraduate zones of endeavor, since the first edition already is.
There is no real application for
medication here, and that I suppose is correct, and the treatment side is thin,
again, reflecting on sad reality.
However, with insights and research
such as this from Millon and his colleagues, things are not looking that dim.
© 2004 Roy Sugarman
PhD, Clinical Director: Clinical Therapies Programme, Principal Psychologist:
South West Sydney Area Health Service, Conjoint Senior Lecturer in
Psychiatry, University of New South Wales, Australia.