Psy 615

Personality Analysis

Prior to beginning work on this assignment, review Chapter 3 in your textbook and the HumanMetrics Jung Typology Test website, and read the Choca (1999), Paris (2005), and Westen (1998) articles.

For this assignment, choose a historically important figure or a character from a movie, novel, or TV show, then address the following in your paper:

  • Examine your figure or character from the perspective of Jung’s theoretical approach to personality and describe your chosen figure or character based on the dichotomous facets of personality as defined by Jung.
  • Evaluate the current Myers-Briggs Type Indicator (MBTI) personality instrument, which is based on Jung’s theories, and provide your impression of your chosen figure or character through the major facets of the MBTI.
  • Analyze how ethical issues might affect the implementation of MBTI personality assessment in the setting native to your chosen figure or character.
  • Assess the MBTI and its use to provide results on your chosen figure or character and describe the efficacy and reliability of this assessment as it relates to your chosen person.
  • Summarize and present your opinion about how well this theory describes the person in question. Provide research to support your claims.

The Personality Analysis

  • Must be three to five double-spaced pages in length (not including title and references pages) and formatted according to APA style as outlined in the Ashford Writing Center (Links to an external site.)Links to an external site..
  • Must include a separate title page with the following:
    • Title of paper
    • Student’s name
    • Course name and number
    • Instructor’s name
    • Date submitted
  • Must address the topic of the paper with critical thought.
  • Must use at least three peer-reviewed sources, including a minimum of three from the Ashford University Library.  These may include the required articles for the assignment.
  • Must document all sources in APA style as outlined in the Ashford Writing Center.
  • Must include a separate references page that is formatted according to APA style as outlined in the Ashford Writing Center.

CASE FORMULATION A N D PERSONALITY DIAGNOSIS: TWO

PROCESSES O R ONE? DREW WESTEN

Clinical formulation and diagnostic formulation often seem like en- tirely separate, if not contradictory, enterprises, particularly with respect to the assessment of personality and its pathology. Clinical case formulation always presupposes a theory of personality because the questions one asks and the hypotheses one forms about a patient’s personality depend on what one thinks personality is and how it relates to overt symptomatology. The categories and criteria embodied in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric As- sociation, 1994), by contrast, were deliberately selected to be as theory neutral as possible. As a result, clinicians, who always operate from theory, often find them irrelevant to clinical formulation and practice. Does it matter whether a patient meets criteria for histrionic personality disorder or only manifests four of the requisite criteria?

In this chapter I argue that one of the problems with the current diagnostic system is precisely that it separates the processes of formulation and diagnosis, that this drives a wedge between clinical practice and re- search, that this need not be the case, and that quantified clinical judg-

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http://dx.doi.org/10.1037/10307-004 Making Diagnosis Meaningful: Enhancing Evaluation and Treatment of Psychological Disorders, edited by J. W. Barron Copyright © 1998 American Psychological Association. All rights reserved.

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ments can in fact be translated into clinically and empirically valid per- sonality diagnoses. I begin by addressing some of the costs and benefits of diagnosis, focusing on the diagnosis of personality and personality disorders. I then suggest that the link between case formulation and diagnosis is functional dulgnosis (i.e., assessment of discrete but interacting personality functions) and suggest three questions that organize a systematic case for- mulation: What are the person’s motives; psychological resources; and ex- perience of the self, others, and relationships? A fourth related question is, How is each of these aspects of the person’s personality developed? I con- clude with a brief discussion of a psychometric procedure for translating reliable clinical judgments about personality functioning into diagnoses, which can be adapted for clinical practice in a way that systematizes and organizes clinical thinking rather than overrides it for the purpose of ar- riving at what may seem like an arbitrary diagnostic categorization.

W H Y DIAGNOSE? THE COSTS AND BENEFITS OF DIAGNOSING PERSONALITY

I begin with a case example, which I use throughout the chapter to illustrate some of the relevant issues. Throughout the chapter, the case description and formulation are indented, so that by the end of the chapter the reader can assess the adequacy of the model of case formulation being proposed by rereading the material in italics as if it were an initial evalu- ation summary. For simplicity, I describe the patient at the beginning of treatment.

The patient, Mr. D., was a man in his early 20s who came to treatment for lifelong problems with depression, anxiety, and feelings of inade- quacy. Mr. D. was a kind, introspective, sensitive man who nevertheless had tremendous difficulty making friends and interacting comfortably with people. He was constantly worried that he would misspeak, would ruminate after conversations about what he had said and the way he was perceived, and had only one or two friends with whom he could interact comfortably. Sex for Mr. D. was fraught with conflict. He was in a 2-year relationship with a woman who was emotionally and phys- ically distant, whom he saw twice a month and with whom he rarely had sex. Before her, his sexual experiences all had been anxiety pro- voking and short-lived in every sense. His associations to memories of these sexual experiences were replete with classically Freudian imagery, such as his fantasy that he would “accidentally” touch the woman’s anus and be repulsed, that her vagina seemed “torn up,” and that his desire was really for a man. Mr. D. came from a working-class family in Boston and had lost his father, a police officer, when his father was killed in a gunfight when Mr. D. was 4 years old. He was reared by his mother and later a stepfather, who seemed relatively kind and benign.

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He described his mother as basically loving, but she herself had a his- tory of depression that seemed more chronic than episodic.

Using the DSM-IV, Mr. D. would not receive a personality disorder (PD) diagnosis, even though he clearly had enduring, maladaptive ways of thinking, feeling, and behaving (i.e., the kinds of personality problems that require therapeutic attention). On Axis I he meets criteria for dysthymic disorder, has subclinical symptoms of an anxiety disorder, and could be diagnosed with a male erectile disorder. On Axis I1 he would come close to meeting criteria for depressive personality disorder, which is not an of- ficial diagnosis. He has some avoidant features but clearly does not meet criteria for that disorder. Using the two axes, then, one can capture much of his depression, some of his anxiety, some of his social anxiety, and a description of some of his sexual problems. The interconnections among these problems, however, cannot be captured; they appear as discrete symp- toms. His chart diagnosis would be nondescriptive:

Axis I: dysthymic disorder; male erectile disorder; r/o anxiety dis- order not otherwise specified; Axis 11: deferred; Axis Ill: deferred; Axis IV: social isolation, job dissatisfaction; Axis V (Global Assessment of Functioning): 65.

I believe this is a relatively typical case in terms of what the DSM-IV captures and fails to capture.

The Problems of Diagnosis

Diagnosis, particularly as embodied in the DSM approach, has a num- ber of problems, costs, and limitations. One with which every introductory psychology student is familiar is the problem of labeling. The classic version of this concern was the labeling theories of the 1960s, which focused on the stigma of psychiatric diagnosis, notably schizophrenia. A more contem- porary concern is that labels activate schemas, and schemas carry conno- tations that can lead clinicians to see what they expect or to react affec- tively to patients diagnosed with disorders for which they have particular countertransference problems (e.g., the reactions of many clinicians to pa- tients with borderline personality disorder [BPD]). Additionally, diagnosis today is frequently used in the service of anxiety reduction by psychiatric residents and other mental health professionals who are not being ade- quately trained to understand their patients’ dynamics and instead are com- pensating by focusing their attention o n finding the right category into which to place their patients. These problems associated with psychiatric labeling, however, point more to problems with clinicians and training than with diagnosis per se. They suggest that as clinicians we need to be

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aware of schematic biases and our issues with particular kinds of patients, address difficulties we might have in sitting with “not knowing,” and avoid training programs that teach about categories instead of people.

Other problems, however, are more serious. One is the “so what” question. Suppose we decide that Mr. D. has a dysthymic disorder, and perhaps make the diagnosis of depressive personality disorder even though it is currently only in the appendix to the diagnostic manual. Clinically, what does this add to the knowledge, garnered in the first 5 min of the first interview, that he has been depressed most of his life? Does it guide us psychotherapeutically? Does it suggest a particular medication? Suppose, instead, we decide that he has an avoidant personality disorder with de- pressive features rather than a depressive personality disorder with avoidant features. So what? These are the kinds of diagnostic questions on which most PD research is currently focused, which is probably why most clini- cians, sadly, do not read PD research.

Another related problem is the issue of comorbidity. The DSM ap- proach, following a model that does pass the “so what” test in other areas of medicine (e.g., knowing that a patient has hypothyroidism rather than anemia has clear treatment implications), places individuals into catego- ries. The problem for the classification of PDs is the high comorbidity of PDs both within and across the two axes. With respect to Axis I comor- bidity, empirically, a substantial percentage of patients with Axis I1 disor- ders are comorbid for Axis I pathology and vice versa (Green & Curtis, 1988; Shea, Glass, Pilkonis, Watkins, & Docherty, 1987). The whole notion of Axis I-Axis I1 “comorbidity” may be largely artifactual, brought about by an artificial distinction between one axis originally intended to be more episodic and biogenic and the other more chronic and psycho- genic. Unfortunately, nature was not so kind as to separate episodic, bio- logical disorders from chronic, psychological or “functional” pathology. Schizophrenia and bipolar disorder are the best examples of disorders with high heritability, but schizophrenia is often chronic, as are some forms of bipolar disorder, and relapse in each is related in part to psychosocial var- iables such as the amount of hostile criticism and overinvolvement patients receive from their families (Hooley, 1987; Miklowitz et al., 1991). Fur- thermore, many of the PDs undoubtedly have biological diatheses, partic- ularly schizotypal PD, which appears to be best categorized as a schizo- phrenic spectrum disorder and is found in the biological relatives of schizophrenic patients.

In this respect, consider Mr. D. Does it really make sense to scatter his symptomatology over two axes, like ashes over the Grand Canyon? All the problems with which he presented are chronic, but the extent to which they reflect biological or environmental etiological factors is unclear. Mak- ing matters more complicated, many aspects of his pathology are not rep- resented on either Axis, such as his sexual conflicts, his passivity, and his

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chronic feelings of inferiority that do not appear to be part of any particular PD and are found in many patients who have personality problems not severe enough to merit a n Axis I1 diagnosis. Indeed, this latter point rep- resents another clear problem with Axis 11, which fails to include or cat- egorize a large percentage of psychotherapy patients with “neurotic” per- sonality pathology that slips between the axes (for empirical data, see Westen, 1997a). In a recent study, Westen and Arkowitz (1998) found that fully 60% of patients treated in clinical practice for enduring maladaptive personality patterns cannot be diagnosed on Axis 11.

Within Axis 11, comorbidity is even more of a problem. Research consistently shows that most patients with PDs fit criteria for multiple disorders (Bell & Jackson, 1992; Morey, 1988; Oldham et al., 1992), so that if a patient has any PD, h e o r she likely receives three or four PD diagnoses, a t least with the research instruments widely in use. This has led some observers (Widiger & Frances, 1994) to suggest a shift from cat- egorical to dimensional diagnosis. This could be accomplished by giving the patient a rating for each PD, leading to a diagnostic profile rather than a categorical diagnosis (e.g., on a scale from 1 to 7, Mr. D. would receive a 6 on depressive PD, a 3 on avoidant PD, a 1 o n BPD, etc.). Alternatively, as Widiger and Frances and others have proposed, Axis I1 could be aban- doned in favor of rating patients using the Five Factor Model (FFM) of personality (Goldberg, 1993; John, 1990; McCrae & Costa, 1990). The FFM was derived from self-reports and distinguishes five dimensions of per- sonality o n which individuals vary: neuroticism, extraversion, conscien- tiousness, agreeableness, and openness to experience. From this perspective, people with PDs are nothing but individuals who fall o n the extreme ends of these dimensions. Mr. D. would no longer receive a diagnosis of de- pressive PD with avoidant features; instead, he would score high on neu- roticism and introversion.

From a clinical perspective, neither the current categorical model nor the dimensional alternative seems to provide a n adequate solution to the problem of personality diagnosis. In fact, each seems to confound a sub- stantive issue with a scaling issue. clinically, the question is not, Does the patient cross the threshold for avoidant PD? or How high does the patient score on neuroticism? T h e relevant clinical question is, Under what circumstances do which cognitive, affective, motivational, and be- havioral patterns and their interactions get triggered in ways that lead to distress for the patient or those around him or her? As I show later, this is a functional question, not a scaling question, and it is one that neither Axis I1 nor the FFM (particularly with its reliance on self-reports) is pre- pared to answer. It is a question that deals with the dynamic interaction of psychological processes, intrapsychically and intersystemically. Both cat- egorical and dimensional diagnostic systems share a major problem of trait theories criticized years ago by Mischel (1968) with which personality psy-

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chologists have wrestled for nearly three decades (e.g., Funder & Colvin, 1991; Kenrick & Funder, 1988), namely that t h e y fail to specify the elic- iting conditions for personality processes and instead describe traits as qual- ities that are relatively fixed over time and across situations. Clinically, many patients have problems with authority, but these do not emerge with cats, dogs, peers, or subordinates and cannot easily be summarized with adjectives on a checklist or with categorical diagnoses.

The Benefits of Diagnosis

These are some strong arguments against diagnosis, particularly as instantiated in the DSM-lV. Diagnosis also, however, has considerable benefits. One is communication between clinicians. To describe a patient with a 10-page discursive evaluation summary is not parsimonious, nor can clinicians learn about more general processes typical of certain types of patients (e.g., those with BPD, antisocial PD, anorexia, etc.) without some form of categorization. Elimination of diagnosis would result in articles with titles such as, “Developmental History in Patients Who Show Evidence of Splitting, Difficulty Maintaining Relationships, Self-Mutilation, Inconstant Representations, Poorly Modulated Affect, and Sundry Other Symptoms.” Clearly, diagnosis allows communication among mental health profession- als about patients who share certain features, however fuzzy the categories are around the edges.

A second benefit has to do with communication with patients. As clinicians, we rarely present our patients with a diagnosis. Rather, if we provide initial diagnostic feedback at all (which I believe we should), we offer a brief narrative, clinical formulation at the end of an evaluation period, which describes what we have seen and what we think might be helpful. For example, after spending three sessions with a patient with BPD, I might say something along the following lines:

I t seems like we’ve identified some central issues for us to work on. One is that you often feel overwhelmed, like your feelings are out of control. When you feel this way, sometimes you’ll break off a relation- ship that you’ll later wish you hadn’t, sometimes you’ll cut yourself, and sometimes you’ll drink too much. A second issue is that deep down, you seem like you don’t really trust that people will love you and treat you well. And this seems related to your feelings about yourself-when you feel bad about yourself, you feel totally bad, like there’s nothing about you but badness and that you don’t deserve any better.

This can be useful to patients because it takes what feels like a morass of feelings, symptoms, and concerns and puts them into a manageable, co- herent form and lets them know that the clinician has some understanding of them and how to proceed.

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On some occasions, however, actually telling a patient his or her diagnosis can be therapeutically indicated. This is often the case with pa- tients with posttraumatic stress disorder, who frequently fear t h e y are going crazy and have n o idea that their symptoms are a typical, understandable, and treatable response to psychological trauma. Although using a diagnos- tic label is rarely indicated with PD patients, who will generally feel labeled rather than understood (and for good reason), in some cases giving the patient a diagnosis can be helpful. When I was nearing the end of my internship many years ago, I was assigned a severely disturbed borderline patient for evaluation and brief treatment (because I was leaving the agency). She presented with a foot-high stack of psychiatric records since the time of her initial contacts with mental health professionals as a run- away 20 years earlier. I knew she had written away for all prior records and that she would do the same with anything I wrote, so I decided to go over my evaluation summary with her, including the diagnosis. It was one of the most therapeutic encounters I have ever had with a patient with BPD. She was struck not only by the dynamic interpretations of a series of events from her history but also by the fact that she was not alone and crazy and that a class of people existed who shared similar problems. Her first re- sponse after the session was to go to the bookstore, to buy some books o n BPD (she found Kemberg especially helpful), and to learn about herself.

Third, diagnosis is essential with some disorders, such as schizophrenia or bipolar disorder, for which treatment decisions depend on accurate di- agnosis. A diagnosis of BPD can be useful as well because the presence of this PD has predictive value v i s – h i s the use of various medications for depression (see, e.g., Gunderson, 1986). Knowing whether a patient who has behaved antisocially actually has the constellation of variables associ- ated with antisocial PD or is acting out a neurotic conflict also is clinically important.

A fourth way in which diagnosis is useful is for research purposes, which should ultimately feed back into clinical knowledge. A case in point is the etiology of BPD. For years the only etiological theories were based on reconstructions in psychoanalytic treatment, notably Kernberg’s ( 1975) suggestion that patients with borderline personality organization have a constitutional overabundance of aggressive drive and several less clearly specified hypotheses about pathogenic mother-child interactions in the preoedipal years (e.g., Mahler, Pine, & Bergman, 1975). Once the third edition of the DSM created a PD axis, however, measures began to arise to operationalize diagnoses, notably BPD, which led to research relevant to its etiology. On the basis of this research, clinicians now know that a history of sexual abuse is unusually common in the developmental histories of patients with BPD (Herman, Perry, & Van der Kolk, 1989; Ogata et al., 1990; Westen, Ludolph, Misle, et al., 1990) and that it probably contrib- utes, along with Constitutional factors and the quality of attachment rela-

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tionships in childhood, to the development of the disorder. Without a diagnosis, we might well be continuing to argue about whether sexual abuse plays any role in the disorder, with no basis for choosing among competing theories except for the authority of those who expound them.

Diagnosis has one final utility: It is impossible to do without. Diag- nosis is simply a technical form of categorization, and people cannot nav- igate their way through the world without concepts and categories. Any therapist who claims simply to sit with the patient and experience the person “as he or she is” is cognitively naive. Schemas can lead us astray, but they are essential for thought. Clinicians have to be able to tell whether a patient is psychotic, and they use all kinds of implicit and ex- plicit rules to do so. This is simply how the human brain works. Categories represent observed (or taught) regularities in the world. Without them, every case would be entirely new, and clinicians would have to reinvent a theory of personality for every patient. Even the most stalwart constructiv- ists implicitly assess the way their patients feel, how they handle their feelings, the extent to which they have a good hold on reality, and so forth. This implies assimilation of aspects of patients’ behavior to preex- isting schemas. The question is how to make those schemas clinically useful and more likely to sharpen our understanding of our patients rather than obscure who they are.

FUNCTIONAL ASSESSMENT OF PERSONALITY

The issue, then, is not whether to give up diagnosis but how to re- frame the diagnostic process so that it is maximally useful. O n e way to make diagnosis more meaningful when assessing personality is to begin with a functional messment, or functional diagnosis-an assessment of how the individual tends to function cognitively, affectively, and behaviorally under certain conditions relevant to psychological and social adaptation. This means assessing pathology as well as health because helping a patient re- quires knowledge of his or her adaptive capacities as well as areas of dys- function. T h e kinds of descriptive diagnoses made o n Axis I1 can and should be derivative of a functional assessment because once a clini- cian has thoroughly assessed a patient’s personality functioning, a simple prototype-matching procedure can automatically produce a descriptive di- agnosis.

Elsewhere (Westen, 1995, 1996) I have argued that three sets of var- iables, defined by three questions, provide a relatively comprehensive road- map of personality that can guide personality assessment: First, what does the individual wish for, fear, and value and to what extent are these mo- tives conscious and mutually compatible? Second, what are the individual’s

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psychological resources for adapting to internal and external demands? Third, what is the individual’s capacity for engaging in intimate relation- ships, and how does the individual experience the self, others, and rela- tionships? The interaction of the processes included under these three broad rubrics defines the individual’s personality, as he or she pursues mo- tives and responds to experiences with characteristic ways of thinking, feel- ing, and behaving. From a clinical perspective, a fourth question is devel- opmental: How did these various processes emerge, and a t what junctures and in what ways did development go awry?

This view of personality is dynamic and systemic in two senses. First, it views personality as the interaction of psychological processes activated under specific conditions, not as the possession of certain traits to particular degrees. One can, and should, be able to measure each of the variables defined by the model, but assigning people to static categories o r ascribing to them relatively static traits is not the goal of assessment because doing so misses the dynamics at the heart of the patient’s personality functioning. Second, this view does not consider situational demands as being entirely independent of personality characteristics. The environment people expe- rience is not generally independent of their actions (see Wachtel, 1987), and the way they respond is often conditional, depending in part on the presence of certain activating conditions, not automatically and inflexibly elicited regardless of the circumstances (Westen, 199713).

In this section, I flesh out each of these questions and the variables that constitute them (see Exhibit 4.1), again using Mr. D. as an example. Although delineation of these variables drew extensively from research across personality, clinical, and developmental psychology, the first three questions address, respectively, the concerns of classical psychoanalytic the- ory; ego psychology; and object relations theory, relational theories, and self psychology. The fourth cuts across all three. All four questions, al- though theory laden, are close to clinical data and together represent a codification of the kind of assessment most skilled clinicians intuitively make, although the effort here is to systematize those dimensions in a way that is both clinically and empirically sound.

Question 1: What Does the Person Wish for, Fear, and Value, and to what Extent Are These Motives Conscious and Mutually Compatible?

The first question regards motivation: What does the individual wish for, fear, and value? To put it another way, what representations of desired, feared, and valued states has the patient come to associate with a substan- tial enough degree of affect that these representations guide behavior as goal states? These affectively imbued representations can be conscious, un-

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EXHIBIT 4.1 Domains of Personality Functioning in a Comprehensive Assessment I. Motives

a. Fears b. Wishes c. Values d. Conflicts among fears, wishes, and values e. Consciousness of dominant motives f. Notable compromise formations

11. Psychological resources a. Cognitive functions

1. Intellectual functioning, verbal and nonverbal skills, memory 2. Cognitive style 3. Coherence or disorder of thought processes 4. Expectancies and belief systems

b. Affective experience 1. Intensity of affective experience 2. Variability or lability of affect 3. Tendency to experience positive and negative affect 4. Tendency to experience particular affects 5. Consciousness of affective experience 6. Capacity for experiencing ambivalent emotions

c. Affect regulation 1. Conscious coping strategies 2. Defenses 3. Repertoire of affect-regulatory behavior

d. Behavioral resources 111. Experience of the self and others and capacity for relatedness

a. Cognitive structure of representations of self and others 1. Complexity 2. Differentiation of different representations from each other 3. Integration of diverse elements

b. Affect tone of relationship schemas c. Capacity for emotional investment in relationships d. Capacity for investment in values and moral standards e. Understanding of social causality f. Dominant interpersonal concerns: chronically activated interpersonal

g. Management of aggressive impulses h. Social skills and interpersonal behavior i. Self-structure

wishes, fears, and schemas

1. Sense of self-continuity or coherence; sense of self as a thinker, feeler,

2. Conscious and unconscious representations 3. Self-with-other schemas 4. Self-esteem 5. Feared, wished-for, ought, and ideal self-representations 6. Self-presentation 7. Identity

IV. Development a. Developmental level (maturity) of various psychological processes b. Temperament c. Salient developmental experiences

and agent; experience of self as being continuous over time

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conscious, or somewhere in between (such as acknowledged but only in alternation, or recognized with considerable clinical probing and support), and they may be congruent or conflicting. T h e y also may be combined to produce compromise formations (see Brenner, 1982), which simultaneously address multiple motives, some or all of which may be unconscious. Recent empirical evidence (summarized by Westen, in press; see Bargh, 1997; McClelland, Koestner, & Weinberger, 1989) supports the long-held clinical view that motives can be either conscious or unconscious, that conscious motives can differ substantially from their unconscious counterparts, and that motives (e-g., the desire to perceive the self accurately and the desire to maximize self-esteem) can conflict and be combined unconsciously to produce compromise responses.

A comprehensive assessment of a n individual’s motivational structure would, of course, be impossible because it would involve mapping every connection between thought and feeling in the individual’s mind; rather, the major aim of assessment of this domain of personality is to understand the broad sweep of his or her recurring motives, particularly those involved in symptom formation and maintenance:

Mr. D. was tom by competing motives to succeed and to fail. On the one hand, he desperately wanted to succeed, in part to match up to a fantasy ideal of his dead father, in part to please his mother and step- father, and in part simply because he had internalized much of the achievement orientation of U S . culture. On the other hand, he ap- peared compelled to find ways to fail, and careful examination of his motives in such circumstances led to wishes to be passive and cared for, fears that he would fail that led him to avoid efforts to succeed that seemed to him “doomed,” and conflicts around his masculinity [apparently related in part to his father’s death at a young age] that left him reluctant to take on a more “agentic” role that he associated with manliness [and ultimately death].

Mr. D. was equally conflicted about his relational wishes. On the one hand, he wanted to be closer to people, but he was frightened that he would be rejected and was afraid of his own anger in relationships. Thus, instead of actually engaging with people, he would often have a running commentary with them in his mind, often filled with ag- gressive content, which served as a compromise among his wishes to connect, his wishes to express his rage at what felt like constant re- jection and humiliation, and his fears of getting involved. Sex was a particular battleground for conflicting motives for Mr. D., who once again wanted to connect emotionally, wanted to satisfy his physical desires, and wanted to feel like a man but was paralyzed by conflicting motives. As noted earlier, he associated female genitals with danger and was both drawn to and repulsed by anal fantasies. [I am not speak- ing theoretically here; he was explicit in describing those fantasies and corresponding fears, with no suggestion necessary on my part.] He also

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had homosexual fantasies that would sometimes intrude during mo- ments of arousal, which was distressing to him.

Question 2: What Psychological Resources (Cognitive, Affective, and Behavioral Dispositions) Does the Individual Have at His or Her Disposal?

The second question includes several subdimensions, largely centering on the individual’s cognitive and affective patterns. The first set of dimen- sions pertains to the cognitive resources at the individual’s disposal. When clinicians assess patients, they try to evaluate several aspects of cognitive functioning. One is intellectual functioning, such as the degree to which the individual can process information efficiently using verbal and visual modes. Contemporary theories of intelligence emphasize multiple intelli- gences and the uses to which people put their intellectual processes in solving problems (Chen & Gardner, 1997; Gardner, 1983; Stemberg, 1985, 1997). Clinical assessment of intelligence similarly entails a functional as- sessment of the way individuals think relative to the tasks that confront them. A dynamically informed cognitive assessment also focuses on the role of motives in channeling intellectual processes, on the extent to which the individual’s affects disrupt them, and in general on the interaction of affect, motivation, and reasoning.

Another cognitive variable is cognitive style (Shapiro, 1965), such as the global, impressionistic, hysterical style that usually co-occurs with de- fenses such as repression, pseudonafvet6, or denial of obvious but unpleas- ant ideas, and the analytical, miss-the-forest-for-the-trees, obsessional style, which is usually accompanied by defenses such as intellectualization and inattention to affect. Similar concepts of cognitive style emerged indepen- dently in other empirical literatures, such as research on field dependence (Berry, 1976), although a dynamic understanding focuses more on cognitive-affective interactions. An additional cognitive variable, first studied by psychoanalytic ego psychologists, is the degree to which an in- dividual’s thought processes are intact or disordered (see Allison, Blatt, & Zimet, 1968; Johnston & Holzman, 1979; Rapaport, Gill, & Schafer, 1945). Finally, cognitive assessment requires attention to cognitive content as well as process, that is, to prominent schemas and beliefs (see, e.g., Beck, 1976, 1993; Weiss & Sampson, 1986). Cognitive therapists pay attention to the more conscious aspects of these schemas, whereas psychodynamic clinicians attend more to unconscious schemas or representations, although the focus of psychodynamic clinicians on such cognitive processes is often obscured by their use of the word fantasies to refer to all manner of psy- chological contents, from the wishful beliefs most people colloquially un- derstand as fantasies, to childhood constructions of reality such as “my father died because I got angry at him.” (To the extent that these cognitive

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contents encode interpersonal information, t h e y attain a salience high- lighted by the third broad question, to be discussed shortly.) Research that distinguishes explicit thought and memory (consciously retrievable and ma- nipulable information) from implicit cognitive processes (such as infor- mation encoded along associational networks, which is inkcessible to con- sciousness; see Holyoak & Spellman, 1993; Schacter, 1992) suggests the need for careful attention to cognitive processes at different levels of con- sciousness because the two systems of thought (implicit and explicit, un- conscious and conscious) are psychologically and neurologically distinct (see Westen, in press).

Another domain of psychological resources is composed of the indi- vidual’s chronic affective tendencies. Individuals differ in a number of af- fective dimensions, many of which have been studied empirically, including affective lability (i.e., the extent to which they fluctuate from one emo- tional state to another), affect intensity (i.e., the extent to which emotions are strong; Larsen & Diener, 1987), the extent to which they chronically experience pleasant and unpleasant affects (Buss & Plomin, 1984), the extent to which they experience specific affects such as shame and guilt (see Watson & Clark, 1992; Watson & Tellegen, 1985; Westen, 1994), their comfort with conscious awareness of affect (see Pennebaker, 1989), and, as emphasized by Kemberg (1975, 1984) and subsequently examined empirically (e.g., Baker, Silk, Westen, Nigg, & Lohr, 1992; Sincoff, 1992), their ability to recognize and experience conflicting affective states and appraisals simultaneously (i.e., the capacity for ambivalence).

A n important domain of affective functioning that is currently re- ceiving more widespread attention by psychologists is affect regulation, which refers to the conscious and unconscious procedures used to maximize pleasant and minimize unpleasant emotions (see Dozier & Kobak, 1992; Mayer, Salovey, Gomberg-Kaufman, & Blainey, 1991; Westen, 1985, 1994; Westen, Muderrisoglu, Fowler, Shedler, & Koren, 1997). People regulate affects in many ways, using conscious coping strategies (e.g., anticipation, cognitive reframing, self-disnaction, suppression, humor, etc.), unconscious defenses (see Perry & Cooper, 1989; Vaillant, 1992), and behaviors aimed at altering reality to eliminate a n aversive situation or a t altering the affect directly (e.g., by ingesting drugs o r alcohol; Haan, 1977).