8a
C. Emily Durbin
Roche and Ansell (this volume) offer a model that integrates the basic descriptive literature on interpersonal behavior in personality disorders (PDs) with literature on interpersonal psychotherapy (CIIT) for patients with personality pathology. Their argument for the utility of this model includes the following key claims: (1) all interpersonal behavior can be captured by its space on the dimensions of agency and communion, and individual PDs are characterized by tendencies to occupy specific areas in these spaces; (2) the types of problems in interpersonal interactions typical of persons with personality pathology cannot be understood solely as emerging from problems with one interpersonal process (complementarity), but from the specificity of the region of interpersonal space occupied by these persons’ behaviors and the impairments this can create; and (3) knowing the specifics of the patterns of problematic interpersonal behavior and the nuances of how these behaviors emerge in response to behaviors from interaction partners can help therapists design strategies for treating personality pathology.
In this commentary, I offer some thoughts about these pieces of their argument and some suggestions for reconsideration and further exploration. The richness and breadth of the literature on individual differences in interpersonal styles provides an elegant model for organizing a large body of evidence regarding persistent patterns of interpersonal behavior and their implications for psychological functioning and adjustment. The simplicity of these models and their intuitive application to understanding therapist–patient interactions are appealing. In their chapter, Roche and Ansell aim to add specificity and nuance to this model in an attempt to concretize how the model can inform therapeutic practice with those who present with personality pathology. This is a worthy goal, both because specific recommendations are more readily translatable and lend themselves to empirical test of their efficacy and also because the therapeutic context provides an interesting one in which predictions made by an interpersonal model of personality functioning can be tested. My impression is that, in attempting to consider more fine-grained processes, some of the practical utility of these models’ simplicity is obscured. Focusing on fleshing out the nuances of distinct interpersonal styles in different PDs may be less productive than other strategies for building a therapeutic model, such as identifying common mechanisms as a basis for intervention strategies or elucidating distinctions between the varying challenges patients face across relationships of disparate kinds.
Interpersonal Styles Don’t Need to Be Unique to Particular PD Categories to Be Informative for Treatment
The authors argue that the utility of the interpersonal model for informing treatment of personality pathology lies in both the ubiquity of interpersonal problems in PDs and in the specificity with which each PD manifests particular problematic interpersonal styles. For example, they state that “Interpersonal models are especially appealing to the study of personality disorders because all are characterized by interpersonal dysfunction, and yet each specific personality disorder contains its own specific style of pathology” (p. 173 in the previous chapter by Roche). Much of their argument about the utility of these models for informing treatment matching and selecting treatment targets and techniques rests on this claim of specificity. I am not convinced that the empirical literature outlining the kinds of nuance that Roche and Ansell emphasize is sufficiently developed to support these kinds of distinctions, and wonder if more effort in other directions could provide some of the detail and specificity they are seeking to provide. Moreover, given high rates of comorbidity across PDs (and between PDs and other psychopathology) and evidence that their covariance is partially attributable to common personality trait factors (Kotov et al., 2011; Krueger & Markon, 2014), arguments built on a high degree of uniqueness across PDs are facing stiff headwinds. Evidence that correlates of different PDs – such as their characteristic interpersonal styles (rather than their diagnostic criteria) – have discriminant validity and treatment utility would be an important contribution to the literature, but the evidence to date in support of this premise seems underdeveloped.
In a comprehensive meta-analysis cited by Roche and Ansell, we (Wilson, Stroud, & Durbin, 2017) found that the individual PDs included in DSM-IV and DSM-5 showed discriminant validity in their profile of exhibited interpersonal problems. This discriminant validity took the form of somewhat distinctive profiles of elevation across the eight interpersonal styles that populate the interpersonal circumplex, such that the peak scale elevation and rank ordering of elevations varied across the different PDs (with the exception of obsessive-compulsive and dependent PDs, which were less distinctive). This lends support for Roche and Ansell’s argument that there are predictable variations in how interpersonal problems manifest across persons with personality pathology that could form the basis for developing targeted techniques for behavior change with these populations. However, it is always worth considering what is gained by adopting a more granular conceptual model in terms of how the model performs when it is used for applied purposes. How many different techniques for different kinds of interpersonal presentations are warranted, and what is the magnitude of uniqueness needed to support the development of new techniques? The fact that there are identifiable differences in profiles across PDs is not itself evidence that the specific information that distinguishes them is in fact the most productive way to conceptualize either the causes of these problems or how they may be most effectively treated. There is likely a limit to the degree to which treatment developers (and ultimately clinicians) will be able to articulate, validate, and employ strategies to address patterns of uniqueness defined by profiles across the eight octants of the circumplex.
If you look at the results of our meta-analysis with a viewpoint that is less granular, many PDs that share symptom features and conceptual space tended to occupy similar quadrants of the interpersonal circumplex, indicating that they could also be thought of as variations within a broader theme of problematic interpersonal behavior. There may be some utility to considering the ways in which different PDs share common interpersonal problems, as these may indicate core challenges that could be addressed in a treatment program for many different PDs that commonly co-occur. In our meta-analysis, the one interpersonal style/octant that was elevated in common across all PDs was vindictiveness. This quadrant includes elements of suspicion, distrust, stewing over hurts and slights, punishing or hurting others to redeem the self, using competition as a means of defeating others, and being self-serving to the detriment of acknowledging the needs and promoting the well-being of others. What are the specific treatment recommendations for addressing this negatively affectively laden style with prominent cognitive distortions and ruminations about self–other relations? I would be interested to hear how the CIIT approach would be used to enact behavior change on this style common across PDs. Would targeting this style common across PDs, which seems likely to be a barrier to openness to a therapeutic relationship, be an effective strategy for initiating interpersonal change?
Important Specificity May Reside in Relationship Context, Instead of (or in Addition to) the Interpersonal Profile
Roche and Ansell focus on the nuances of distinct patterns of interpersonal problems that characterize the person with personality pathology, foregrounding the trait-like elements of interpersonal behavior and localizing the target of treatment within the person’s characteristic mode of relating to other people. In the background, however, lies a critical element that is probably very important for understanding and helping those with personality pathology improve their social adjustment, namely relationship contexts. Patients may come to treatment with a longstanding pattern of problematic ways of behaving in multiple relationships (a “forest” that the clinician is likely more skilled at discerning from the patient’s history and presenting problems than is the patient). However, people also come to treatment with highly contextualized relationship problems: they worry they chose the wrong marital partner, they are estranged from a sibling, they have struggled to maintain adult friendships after leaving college, etc. Problematic interpersonal styles influence their lives by playing out in the context of these important relationships and self-defining relationship struggles. The particularities of these relationship problems have personal meaning and implications that extend beyond their representation as exemplars of the person’s characteristic stylistic problems. People are motivated to change longstanding beliefs about other people and to explore uncomfortable and new interpersonal spaces because doing so may help to resolve the issues in these very relationships.
In our meta-analysis, we found evidence that PDs are associated with functioning in key adult interpersonal domains (family, peer, parent–child, and romantic partner relationships), as one would expect for patterns thought to have a broad impact on interpersonal functioning in general. More tellingly, though, we showed that these different relationship contexts are not equivalent; the degree to which different PDs were associated with problems in functioning varied across the different relationships domains. For example, among all the PDs, only borderline PD showed significant impairment in the romantic relationship domain. It seems critical that any therapeutic approach aiming to change characteristic interpersonal styles not treat them as fungible across relationship contexts. Rather, interventions should seek to understand how people’s behavior in a particular relationship context contributes to the quality of that relationship and how the way in which someone interacts with another person is tied to both the meaning of that relationship and the individual’s broader life goals.
Different relationships obviously afford different kinds of interpersonal behavior, with some relationships constraining what behaviors will be viewed as normative or adaptive, and other relationships allowing a wider variety of behaviors. For example, successful parenting takes a different kind of give-and-take than a successful romantic relationship. Conveying warmth and nurturance means different things when done in the context of a friendship than one’s family of origin. Most people are simultaneously managing being in many different kinds of relationships at once. The variability across them could pose differential challenges for people whose characteristic interpersonal styles are dysfunctional or rigid. It is important to consider that people with personality dysfunction may struggle differentially across relationship domains – some relationships may be intact while others are severely damaged or nonexistent. Understanding this will help us to consider how relationship roles interact with styles to determine the quality of and satisfaction with relationships, as well as to identify ways to generalize patients’ existing strengths in one context (e.g., their ability to be assertive in one relationship domain) to additional relational contexts. It is also important to consider that the patient–therapist relationship has its own structure and role guidelines that influence the behaviors typically expressed within this relationship, as well as the ways in which interventions focused on this relationship do or do not readily translate to new behaviors in relationship contexts that are structurally different from the patient–therapist relationship.
What Is the Goal of Therapy Informed by Interpersonal Styles? Changes in Relationship Quality/Satisfaction, “Normalization” of Interpersonal Styles, or Something Else?
Roche and Ansell describe CIIT as building upon an understanding of a “normative pattern for how interpersonal exchanges unfold over time” (p. 175 in the previous chapter), particularly the principle of complementarity, and refer specifically to a treatment technique that aims at “facilitating a healthy exchange of dominance within the therapy session, along with some closeness/distance pulls on communion (without occupying the extremes of those pulls, i.e., total enmeshment vs. rejection)” (p. 179 in the previous chapter). For all their interest in specificity, this leaves some lacking in terms of offering a working definition of what amounts to a “healthy exchange of dominance.” Further, it seems there are many opportunities for empirical work to help validate such working definitions and to test whether the predictions Roche and Ansell make about how one interaction partner can move another into a new interpersonal space hold. At a broader level, it would be important to know what this model defines as a positive treatment outcome, how change in interpersonal styles would be assessed, and what types of validation would provide support for this model as a conceptual framework for both interpersonal behavior change and improving mental health outcomes.
A potentially fruitful area of exploration would be to examine how the patterns of interpersonal behavior observed in interaction dyads can be used to understand the particular mechanics of how those with interpersonal problems are behaving in interactions and how that behavior is being received. As Roche and Ansell note, not all interpersonal behavior is complementary and non-complementary behavior can be adaptive. So, what defines a problematic interpersonal style without reference to external criteria by which a behavior is deemed “adaptive”? If someone is experiencing few problems in their key relationships, should a therapist address their interpersonal style? If someone is struggling with an important relationship but is unremarkable in their interpersonal style, what is the recommended treatment approach?
Summary
The model described by Roche and Ansell has the potential to inform new questions about how interpersonal models can be deployed to address the relationship problems common to people with personality dysfunction. Whereas they focus in particular on the distinctions across different interpersonal styles and the properties of how these styles contribute to patterns of interactions across people, the model could benefit from (1) considering areas of commonality in addition to differences across both PDs and styles; (2) placing these considerations within the broader context of relationship context and roles; and (3) mapping out an agenda for delineating what constitute normative interpersonal processes, how to measure them, and how to identify techniques that address patterns that are non-normative.
References
Kotov, R., Ruggero, C. J., Krueger, R. F., Watson, D., Yuan, Q., & Zimmerman, M. (2011). New dimensions in the quantitative classification of mental illness. Archives of General Psychiatry, 68, 1003–1011.
Krueger, R. F., & Markon, K. E. (2014). The role of the DSM-5 personality trait model in moving toward a quantitative and empirically based approach to classifying personality and psychopathology. Annual Review of Clinical Psychology, 10, 477–501.
Wilson, S., Stroud, C. B., & Durbin, C. E. (2017). Interpersonal dysfunction in personality disorders: A meta-analytic review. Psychological Bulletin, 143(7), 677–734.