19b
Whitney R. Ringwald, Elizabeth A. Edershile, William C. Woods, and Aidan G. C. Wright
Bach and Presnall-Shvorin’s proposal for trait-informed treatment represents an important step towards translating emergent, empirically driven models of personality pathology into clinical applications. Given the problematically large gap between the bench and bedside in personality psychopathology, connecting the two, as Bach and Presnall-Shvorin suggest, is imperative. In support of their effort to refine interventions by systematic consideration of individual differences, we wish to emphasize the necessity of integrating stable and dynamic features of personality by identifying underlying mechanistic processes. Many of the authors’ recommendations are predicated on assumed relationships between traits and associated behavioral manifestations, and we suggest that a unifying, mechanistic model would clarify and validate these recommendations. In this commentary, we present promising theoretical frameworks, relevant research, and needed future directions for our mutual imperative to improve available treatments through scientific understanding. In particular, scientific models that articulate the processes occurring between dispositional and behavioral manifestations are needed (e.g., DeYoung, 2015; Fleeson & Jayawickreme, 2015; Wright, 2011).
We share the same concerns with current categorical diagnostic nosologies expressed by Bach and Presnall-Shvorin, and agree with their endorsement of a dimensional model of personality traits. Factor analytic studies of personality pathology structure have consistently produced variants of the five-factor maladaptive trait model put forth by Bach and Presnall-Shvorin, and have failed to support traditional, discrete criterion clusters (e.g., Aslinger, Manuck, Pilkonis, Simms, & Wright, 2018; Conway, Hammen, & Brennan, 2012; O’Connor, 2005; Wright et al., 2012). Defining pathological traits dimensionally more accurately accounts for marked heterogeneity in symptom presentation and begins to resolve issues of comorbidity among personality disorders (Hopwood et al., 2018). A dimensional approach to conceptualizing personality pathology is substantiated by evidence of concordance between established basic trait models and maladaptive trait models. Situating maladaptive traits into a broader understanding of personality provides a fruitful foundation for future research.
As stated by the authors, because traits represent general behavioral tendencies, they are relevant for understanding the daily life of an individual and, therefore, necessitate treatment considerations. Indeed, in research using intensive, repeated measurements of behavior and affect, dispositional traits are associated with daily trait-related manifestations with considerable specificity (Fleeson, 2001; Wright & Simms, 2016). Bach and Presnall-Shvorin’s theoretical stance is based on an understanding that traits are more probabilistic than deterministic and are not maladaptive per se; rather, the maladaptive behavioral manifestations of a trait are the most appropriate therapeutic targets.
This intuitively compelling notion that there are both relatively fixed aspects of personality and aspects that are more variable and amenable to change has recently been quantitatively evaluated and supported. A series of factor analyses suggest that the structure of personality pathology is comprised of a general PD “severity” factor and statistically independent personality “styles” (Hopwood et al., 2011; Jahng et al., 2011; Oltmanns, Smith, Oltmanns, & Widiger, 2018; Sharp et al., 2015; Williams, Scalco, & Simms, 2018; Wright, Hopwood, Skodol, & Morey, 2016). Further, general PD severity is strongly associated with psychosocial outcomes and declines rapidly over time in naturalistic studies, whereas PD style is less predictive of outcomes (c.f., Jahng et al., 2011) and tends to be more stable over time (Woods, Edershile, Wright, & Lenzenweger, 2019; Wright et al., 2016). These data suggest, as the authors put forth, that not every trait is an equal candidate for intervention, and identification of those dimensions of personality that contribute to dysfunction and can be modified will allow clinicians to direct resources more effectively. At the same time, identifying those dimensions of personality that represent mostly fixed individual differences, so-called specific or stylistic factors, can inform treatment planning in terms of expectations, goals, and interventions. That these specific factors are not nearly as predictive of psychiatric distress as the general PD factor (Hopwood et al., 2011; Williams et al., 2018; Wright et al., 2016; but see Jahng et al., 2011) suggests an approach to treatment that regards individual differences as intrinsic assets rather than solely liabilities.
Understanding psychopathology in terms of static descriptions of averaged tendencies provides an incomplete account limited in predictive power and clinical utility (Beltz, Wright, Sprague, & Molenaar, 2016; Scott et al., 2017; Wright, Beltz, Gates, Molenaar, & Simms, 2015). Human behavior, emotion, the transactional relationships between people and between a person and her or his environment, and the complex psychological mechanisms that mediate these relationships, are dynamic processes. Knowing a person’s traits describes a likely collection of behavioral responses but says nothing reliable about why and when that person will engage in those behaviors and, therefore, reveals little about fundamental aspects of human experience and what contributes to the dysfunctional patterns that bring a client to treatment.
It is reasonable to infer the motivations or phenomenology associated with different traits as these authors have done, and, as a measure of central tendency, these trait-informed inferences may prove to be accurate much of the time. However, we propose that, absent a comprehensive mechanistic model that links traits to trait-relevant behavior, such conclusions regarding causal processes are confined to speculation and could inhibit therapeutic progress. To illustrate how these limitations could unfold in the clinical setting, we present a brief case example.
Imagine Patient X who is profoundly fearful of rejection and abandonment. To prevent the seemingly inevitable pain and conflict of relationships, she now completely avoids them. This patient has had no close friendships or romantic partners for years and expresses no interest in developing intimacy. She appears high in the trait of detachment. Therefore, based on trait-informed model logic, the focus of treatment would be helping her “accept” her lack of normative interest in relationships. Yet, this patient is naturally oriented towards relationships and craves connection, but has adapted her behavior to protect herself. Her detachment serves a regulatory function that is unaccounted for by a descriptive, trait-level assessment but would be an indispensable insight for her treatment provider. Indeed, her characteristic behavior reflects her relationship insecurity, a separate trait from a different domain.
As demonstrated by this example, a model of psychopathology that moves beyond description to one that elucidates underlying causal processes is needed to complete a clinical portrait. This would also accommodate the many cases where observed maladaptive behavior and motivating goals align. Whereas we find many of the recommended approaches put forth by Bach and Presnall-Shvorin to be sensible and likely effective in many cases, greater impact could be achieved with a cohesive theoretical and empirical rationale to account for the mechanistic relationship between traits and trait-relevant expressions. As the authors suggest, the identified maladaptive traits correspond to putatively extreme variants of basic traits (e.g., Widiger & Trull, 2007), yet extremity is not a precondition for dysfunction. Evaluation of impairment cannot be made on the basis of traits alone but must be qualified by specific domains of dysfunction. We propose integrating insights from a framework such as the cybernetic theory of personality and psychopathology (DeYoung, 2015; DeYoung & Krueger, 2018) to operationalize causation and meaningfully define maladaptation.
A complete review of this theory can be found elsewhere (DeYoung & Krueger, 2018), but we will highlight how this model could complement and extend Bach and Presnall-Shvorin’s recommendations for treatment. DeYoung and Krueger propose that psychopathology be defined by the failure of characteristic adaptations to move a person towards her or his psychological goals. Characteristic adaptations are those interpretations and strategies that a person develops in response to the demands of life to meet her or his needs. Returning to the case of Patient X, the patient had adapted to her experiences of rejection and perceived abandonment by disengaging from relationships. Conceptualizing her personality mechanistically would allow a clinician to identify that her withdrawal behavior functions to meet her psychological goal of avoiding pain at the expense of failing to meet concurrent goals of companionship. Disentangling dysfunctional mechanisms from personality traits provides a system for specifying the appropriate point of intervention. In cybernetic terms, a clinician would help the example patient replace her current, problematic characteristic adaptations with ones that minimize the conflict between her psychological goals. For instance, she may work on improving emotion regulation to attenuate her responses to perceived slights so that relationships are more satisfying – an approach that differs from that indicated from an exclusively surface-level trait-informed treatment.
Measuring latent, dynamic features of clinical phenomena to empirically substantiate these theoretically coherent and face-valid ideas has proven elusive but will be necessary for clarifying personality structure in a way that is useful for guiding treatment recommendations. We enthusiastically support individualizing treatment and assert that these efforts cannot solely rely on references to population averages (i.e., individual differences in traits), but require idiographic data (Wright et al., 2019). A promising methodological approach for capturing the function of individual behavior is the use of ambulatory assessment (Stone & Shiffman, 1994). Through repeated measurement of participants’ emotions, cognitions, and actions in their daily life, a more ecologically valid, personalized characterization of personality expression can be achieved. Such rich, contextualized data can also reveal environmental contingencies of pathological responses, which, as underscored by Bach and Presnall-Shvorin, are important in trait-informed treatment.
For instance, using ecological momentary assessment, Wright et al. (2017) examined the links among participants’ self-reported affect, behavior, and perceptions of others’ behavior to identify specific social circumstances that prompt narcissistic behavior. Namely, people higher in narcissistic features tend to respond more aggressively to perceived dominance in others – a response mediated by negative affect, suggesting a regulatory function. These data provide a far more nuanced and clinically meaningful account of personality pathology than can be provided by trait-level descriptions.
The extensive body of work on personality traits continues to be relevant; indeed, trait models have been shown to strongly predict most major life outcomes (Ozer & Benet-Martinez, 2006). However, empirical advances that allow for more granular characterization at the within-person level will make possible a hierarchical, mechanistic model of personality that can more accurately differentiate between what personality is and what it does. Building on the trait-informed model with greater understanding of the function of trait expressions and those contextual variables that maintain pathology can lead to better assessment methods and more meaningful diagnostic schemata. Further, given the extensive work on personality traits, understanding dynamic processes and how these processes relate to trait dimensions will make for a rich body of literature, maximizing possibilities to connect this literature to clinical application. As for Bach and Presnall-Shvorin’s important imperatives to increase patient participation and strengthen therapeutic rapport, appreciation for the function of maladaptive behavior is integral for validating the patient’s experience and deciding on treatment goals.
Assimilation of traits and dynamic processes of personality into a single framework would provide a generalizable structure flexible enough to adapt extant treatment approaches to individual problems. A fuller understanding of causal mechanisms could potentially bolster efforts to identify agents of change in different therapeutic models and make treatment more efficient. Bach and Presnall-Shvorin conceptually match interventions to personality trait expressions – a task we suggest could be made more systematic through cybernetic evaluation and an appreciation of the basic structure of personality processes. We wish to acknowledge the significance of the authors’ contributions towards translating dimensional trait models into treatment and hope to support their effort by encouraging incorporation of dynamic elements of personality for even greater precision in the treatment of psychopathology.
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