The Role of Personality in Psychotherapy for Anxiety and ... · PDF file2000). Far less...

The Role of Personality in Psychotherapy for Anxiety

and Depression

Richard E. Zinbarg,1 Amanda A. Uliaszek,2 and

Jonathan M. Adler2

1Northwestern University and The Family Institute

at Northwestern University2Northwestern University

ABSTRACT A trait approach to personality has many implications forpsychotherapy. Given that traits contribute to the expression of symp-toms of common psychiatric disorders, are moderately heritable, and rel-atively stable (yet also dynamic to some extent), long-term change insymptoms is possible but is likely to be limited. Analogous to the mannerin which genes set the reaction range for phenotype, standing on certaintraits may set the patient’s ‘‘therapeutic range.’’ On the other hand, someof the same traits that may limit the depth of therapeutic benefits mightalso increase their breadth. In addition, taking the patient’s standing ondifferent traits into account can inform the choice of therapeutic strategyand targets and can affect the formation of the therapeutic alliance andcompliance with self-help exercises. Finally, other aspects of personalitybeyond traits, such as ego development and narrative identity, also ap-pear to have important implications for psychotherapy.

A great deal of theory and research has focused on the implicationsof personality traits for the development and course of psychopa-

thology. Indeed, questions concerning the associations between per-sonality traits and the development and course of psychopathology

were a central focus of the research programs developed by H. J.Eysenck (e.g., 1967) and J. A. Gray (e.g., Gray & McNaughton,

Preparation of this article was supported by the Patricia M. Nielsen Research Chair of

the Family Institute at Northwestern University and by National Institutes of Health

Grant R01-MH65652-01 to Richard E. Zinbarg.

Correspondence concerning this article should be addressed to Richard Zinbarg,

Department of Psychology, Northwestern University, 2029 Sheridan Rd., Evanston,

IL 60208-2710; E-mail: [email protected].

Journal of Personality 76:6, December 2008r 2008, Copyright the AuthorsJournal compilation r 2008, Wiley Periodicals, Inc.DOI: 10.1111/j.1467-6494.2008.00534.x

i:/BWUS/JOPY/534/[email protected]

2000). Far less attention has been paid, however, to implications that

personality traits have for psychotherapy. Yet a trait approach topersonality has great potential to be useful in the psychological

clinic. In this article, we explore the implications of personality traitsfor prognosis: choosing therapeutic strategies, identifying therapeu-

tic targets, deciding whether medications are necessary, developingthe therapeutic alliance, and ensuring compliance with between-ses-

sion practice/self-help exercises.Our primary focus is on four questions regarding the nature of

personality traits and the relationship between personality traits andpsychopathology. Two considerations guided our selection of ques-tions to focus on. First, we believe that, relative to other questions

we considered, these four questions either have more fundamentalimplications for psychotherapy or have been mistakenly taken to

have such implications by laypeople and even experts in some cases.Second, given our commitment to empirically informed psychother-

apy, we also limited ourselves to questions for which personalityscience has provided relatively firm answers.

The first, and most fundamental, of our four questions is ‘‘Dopersonality traits contribute to the development, maintenance, and/or expression of psychopathology?’’ If the answer to this question is

‘‘No,’’ then the implications of personality traits for psychotherapywould seem to be limited to whether certain traits might influence the

therapeutic alliance or other aspects of the therapeutic process suchas patient compliance. On the other hand, if traits do contribute to

the development and/or maintenance of psychiatric symptoms, thencharacteristics of traits such as their degree of mutability would seem

to be central to considerations of patient prognosis.Our second question is ‘‘How stable are personality traits?’’

This question bears directly on mutability and therefore prog-nosis. For example, if traits contributing to symptoms are perfectlystable, it would seem that prognosis would be rather grim in many

cases.Our third question is ‘‘How heritable are personality traits?’’ As

one’s genotype is invariant, it is assumed by some patients whom wework with—and perhaps by some therapists and researchers—that if

much of the reliable variance in traits contributing to symptoms isheritable, then the prognosis for most psychotherapy cases would be

rather grim, whereas biological interventions stand a better chanceof working and are perhaps even necessary.

1650 Zinbarg, Uliaszek, & Adler

The final question we consider is ‘‘Are personality traits hierar-

chically structured?’’ If so, an important task confronting psycho-therapists and their patients is to determine which levels of the

hierarchy are the most relevant for each aspect of treatment planningand implementation.

In this article, we discuss the literatures bearing on the four ques-tions posed above. After answering these questions, we discuss their

implications for psychotherapy including challenging what we be-lieve are two commonly held myths about personality and psycho-

therapy: that trait vulnerability factors cannot be altered bypsychotherapy and that medications are necessary for symptom re-duction. Given our expertise in anxiety and unipolar depressive dis-

orders, almost all of our examples involve the treatment of thesedisorders. Finally, we will also briefly consider psychotherapeutic

implications of aspects of personality beyond traits.The current diagnostic system of the American Psychiatric Asso-

ciation posts several distinct acute clinical syndromes that are seen asreflecting deviations from the individual’s usual functioning and col-

lectively comprise the Axis I disorders. It is important to note thataccording to this system, the Axis I disorders are distinct from per-sonality disorders that collectively comprise the Axis II disorders

and are believed to be more chronic and encompass the individual’susual ways of interacting with the world. Given the distinct bound-

aries posited in the diagnostic system and that we focus only on thetreatment of Axis I internalizing disorders, it might be thought that

our hypotheses are necessarily limited to these disorders. Nonethe-less, we believe that many of the hypotheses we discuss also apply to

other disorders, including many of the Axis II disorders. The reasonwe say this is that empirical evidence exists that greatly blurs the

boundary between Axis I and Axis II. First, Axis I and Axis II dis-orders are highly co-occurring. Those with a Cluster B or Cluster Cpersonality disorder have a significantly greater chance of also hav-

ing a mood or anxiety disorder (e.g., Coid, Yang, Tyrer, Roberts, &Ullrich, 2006; Lenzenweger, 2006). Second, some mood and anxiety

disorders and Axis II disorders (particularly in Cluster C) share spe-cific symptoms (e.g., social phobia and avoidant personality disor-

der, dysthymia, and depressive personality disorder), furtherblurring the Axis I-Axis II boundary (Krueger,

2005). Third, mood and anxiety disorders are associated with thesame personality traits that characterize at least some personality

Personality Traits and Psychotherapy 1651

disorders (Widiger, 2003). Finally, Axis I and Axis II disorders are

not distinguishable in many important ways, including stability, ageof onset, degree of insight, or genetic versus psychosocial etiology

(e.g., Krueger, 2005; Widiger, 2003).Treatment response may be one of the areas where there may be

important differences between Axis I and Axis II. Because there aremany more treatment studies of Axis I than Axis II, this continues to

be an area of debate (Beck, Freeman, & Davis, 2004; Krueger, 2005).While several uncontrolled clinical reports and single-case design

studies yield positive results for cognitive-behavioral therapy across9 of 10 personality disorders (excluding schizotypal), controlledtreatment studies seem to exist only for antisocial, avoidant, and

borderline personality disorder (Beck et al., 2004). These studieshave yielded mixed results; at worst, treatment results in little change

in symptomatology (e.g., those with antisocial personality disorderwho were not depressed; Luborsky, McLellan, Woody, O’Brien, &

Auerbach, 1985); at best, treatment results in a reduction of serioussymptoms (for example, in dialectical behavior therapy for border-

line personality disorder; Linehan, Armstrong, Suarez, Allmon, &Heard, 1991). Some researchers are particularly optimistic aboutthese results, especially those involving dialectical behavior therapy

for borderline personality disorder (Krueger, 2005; Livesley, 2004).However, it is important to note that this therapy consists of 1 year

of intensive treatment (much longer than many treatments of Axis Idisorders) and often results in only moderate overall improvement,

as opposed to complete recovery or high end-state functioning that ismore commonly seen in treatments of anxiety (e.g., Borkovec &

Whisman, 1996) and depressive disorders (e.g., Jacobson et al.,1996). Even though there appears to be a mean difference between

Axis I and Axis II disorders in treatment responses, however, themany similarities between them suggest to us that the many of thepsychotherapeutic implications of traits we discuss will also apply to

Axis II disorders.

Four Basic Questions About the Nature of Personality Traits

Do personality traits contribute to the development, maintenance, and/or expression of psychiatric disorders?

Several theorists have hypothesized a trait vulnerability factor com-mon to most, if not all, of the internalizing disorders (e.g., Cloninger,


1986; Eysenck, 1967; Fowles, 1993; Gray & McNaughton, 2000;

Tellegen, 1985). This trait is defined slightly differently and givendifferent labels by different theorists—harm avoidance (Cloninger),

neuroticism (Eysenck), trait anxiety or behavioral inhibition systemsensitivity (Fowles, Gray) and negative affectivity (Tellegen). How-

ever, in our opinion, the conceptual and empirical overlap amongthese conceptualizations far outweighs the differences, and a discus-

sion of the subtle differences among these conceptualizations is be-yond the scope of this article. Each of these conceptualizations

implies a trait disposition to experience negative affect. The termneuroticism (N) will be used hereafter to acknowledge Eysenck’s pi-oneering work and to be consistent with the emergence of the Big

Five model of personality—which includes N, Introversion/Extr-aversion (I), Conscientiousness (C), Agreeableness (A), and Open-

ness to experience (O)—as the dominant model of personality traitstructure (e.g., Goldberg, 1993; Watson, Clark, & Chmielewski,

2008).In factor-analytic terminology, the hypothesis of a common risk

factor implies that there should be a general factor that is common todepression and all of the anxiety disorders. Indeed, evidence for such ageneral factor has consistently been obtained across samples seeking

psychiatric treatment (e.g., Zinbarg & Barlow, 1996), epidemiologicalsamples (e.g., Fergusson, Horwood, & Boden, 2006; Krueger, 1999;

Krueger, Caspi, Moffitt, & Silva, 1998; Vollebergh et al., 2001) and ina large, multinational sample comprising consumers of general health

care service centers (Krueger, Chentsova-Dutton, Markon, Goldberg,& Ormel, 2003). There is also evidence not only of a general factor in

cross-sectional analyses but also in longitudinal analyses (Fergusonet al., 2006; also see Gregory et al., 2007).

Though the evidence regarding the general factor common to theAxis I internalizing disorders is consistent with the hypothesis thatthere is a risk factor common to all of these disorders, there is an

alternative explanation that these results are not capable of rulingout. That is, it is possible that the second-order factor may have

arisen entirely as a consequence of demoralization resulting fromdeveloping an internalizing disorder rather than from a variable of

etiologic significance (Frank, 1961; Link & Dohrenwend, 1980).Evidence with some bearing on this alternative explanation has

come from multivariate, behavior-genetic studies conducted byKendler and his colleagues (e.g., Hettema, Prescott, Myers, Neale,


& Kendler, 2005; Kendler, Prescott, Myers, & Neale, 2003). These

results suggest strongly that a genetic factor is largely responsible forthe pattern of symptom covariance that results in the frequently co-

occurring symptoms of internalizing disorders. Furthermore, it seemslikely that the genetic factor is at least partly, if not entirely, related to

the vulnerability to these disorders. Indeed, data we review next fromlongitudinal studies demonstrate that N and related traits (e.g., be-

havioral inhibition and anxiety sensitivity) do prospectively predictthe onset of new episodes of MDD and anxiety disorders (for a more

detailed discussion of the studies on the phenotypic and geneticstructure of the internalizing disorders, see Zinbarg & Yoon, 2008).

Clark, Watson, and Mineka (1994) reviewed several longitudinal

studies showing N to be a predictor of both subsequent diagnosesand chronicity of major depression. Since that review, studies re-

ported by Hayward, Killen, Kraemer, and Taylor (2000), Kendlerand colleagues (e.g., Kendler, Kuhn, & Prescott, 2004), and Krueger,

Caspi, Moffitt, Silva, and McGee (1996) obtained results consistentwith the conclusions arrived at by Clark et al. (1994). Krueger et al.

also found that N is an especially good marker of risk for multiplediagnoses of emotional disorders.

For anxiety disorders, Clark et al. (1994) also reviewed evidence

that N is a risk factor for the development of post-traumatic stressdisorder. Additional longitudinal studies have shown that children

high on behavioral inhibition (thought to be a precursor to, andfacet of, N; Turner, Beidel, & Wolff, 1996) are at greater risk for the

development of multiple phobias and other anxiety disorders in laterchildhood (Biederman et al., 1990, 1993; Hirschfeld et al., 1992) and

social phobia in adolescence (Hayward, Killen, Kraemer, & Taylor,1998; Schwartz, Snidman, & Kagan, 1999). Hayward et al. (2000)

also found N to be a predictor of panic attacks in a 4-year prospec-tive study of adolescents. Thus, extant data are consistent with thehypothesis that N is a marker of vulnerability for both major de-

pression and anxiety disorders.Other studies have focused on more narrow facets of N. For ex-

ample, negative beliefs about the consequences of experiencing anx-iety, known as anxiety sensitivity (AS; Reiss, 1980), are believed to

be facets of N that confer vulnerability for panic attacks and panicdisorder and, to a lesser degree, other anxiety disorders. Laboratory

studies supporting a role for AS in panic attacks entail panic prov-ocation procedures. In nonclinical samples, AS predicts subjective


distress and reported symptomatology in response to CO2 inhalation

(Forsyth, Palav, & Duff, 1999), and hyperventilation (Sturges,Goetsch, Ridley, & Whittal, 1998), even after partialing trait anxi-

ety (Rapee & Medoro, 1994). Several longitudinal studies now indi-cate that AS is a marker of vulnerability for the onset of panic

attacks over 1- to 4-year intervals in adolescents (Hayward et al.,2000), college students (e.g., Li & Zinbarg, 2007), and community

samples with specific phobias or no anxiety disorders (Ehlers, 1995).In addition, AS predicted the development of worry about panic

(and anxiety more generally), during an acute military stressor (i.e., 5weeks of basic training), even after partialing history of panic attacksand trait anxiety (e.g., Schmidt et al., 1999). Finally, whereas the

clinical/practical importance of AS in symptom genesis has beenquestioned based on small effect size estimates (Schmidt, Lerew, &

Jackson, 1999), Li and Zinbarg (2007) demonstrated that when AS ismeasured properly (i.e., in accordance with its hierarchical structure)

it predicts meaningful proportions of variance in the onset of panic.Given that low positive affect (PA) or anhedonia is relatively spe-

cific to depression (e.g., Clark & Watson, 1991), Fowles (1993) andothers hypothesized low positive emotionality (PEM) to be a trait-vulnerability marker for depression. Despite different labels for this

marker— PEM (Tellegen, 1985) and Introversion (I; DePue & Ia-cono, 1989)—similarities in these conceptualizations, in our view,

outweigh the differences, and a discussion of the subtle differencesamong these conceptualizations is beyond the scope of this article.

We will refer to this trait as I, again to acknowledge Eysenck’spioneering work and to be consistent with the Big Five model of

personality. Several longitudinal studies suggest that I is a predictorof subsequent depressive symptoms (e.g., Levenson, Aldwin, Bosse,

& Spiro, 1988; Holahan & Moos, 1991) and diagnoses (Hirschfeldet al., 1989; Krueger et al., 1996), but other studies did not replicatethese findings (e.g., Gershuny & Sher, 1988; Kendler et al., 1993).

Gershuny and Sher (1998) found that I interacted with N in theprediction of symptoms of depression although Jorm et al. (2000)

failed to replicate this interactive effect. A more consistent finding isthat I has been shown to be positively associated with the chronicity

of the course of major depression (Clark et al., 1994). There is alsoevidence that children at risk of depression by virtue of having a

mother with a history of depression are low on observational mea-sures of PEM (Durbin, Klein, Hayden, Buckley, & Moerk, 2005).


Structural modeling studies have also been informative about the

relationship between normal and abnormal traits or characteristics.O’Connor (2002) meta-analyzed dozens of correlation and factor

loading matrices published in English-language journals over the past50 years. This included data on 37 measures, both normal (e.g., 16

Personality Factor Questionnaire, California Psychological Inven-tory) and abnormal (e.g., Beck Depression Inventory, MMPI) in con-

tent and with clinical and nonclinical populations. The resultsindicated that the same number of components existed in the mea-

sures for both clinical and nonclinical populations, with the factorstructure looking essentially the same for the two groups. Anotherstudy completed a meta-analysis on 77 samples from 52 studies

examining five different personality measures (Markon, Krueger, &Watson, 2005). Markon, Krueger, and Watson (2005) also found an

integrated model of normal and abnormal personality, which theythen replicated in a sample of college-age participants. Thus, these

two meta-analyses converge in suggesting that psychopathologysymptoms can often be explained as extreme variants of normal traits.

Similar structural questions have been studied in the area ofpersonality disorders (PDs). O’Connor and Dyce (2001) reported afive-factor structure of PDs. Importantly, normal and abnormal

personalities were distinguishable only by vector length, a measureof rigidity, and extremity of the trait. Miller, Lynam, Widiger, and

Leukefeld (2001) also reported results that support the contentionthat psychopathy can be understood as extreme standing on several

Big Five personality factors, most notably extremely low A and ex-tremely low C. One possible exception to the conclusion that PD

symptoms can be explained as variants of normal traits is the evi-dence presented by Watson, Clark, and Chmielewski (2008) that

the Big Five needs to be expanded to incorporate a dimension—Oddity—relevant for the symptoms related primarily to the ClusterA PDs. On the other hand, Watson et al. (2008) also review evidence

that the Big Five personality factors (with the exception of Open-ness) provide an adequate basis for the assessment of the character-

istics related to the Cluster B and Cluster C PDs.In concluding this section, it is clear that N-related and I-related

traits are markers of mechanisms that contribute to the developmentand/or maintenance of anxiety and depressive disorders. Whereas

there is a need for longitudinal research testing whether other traitsare markers for risk of other disorders, cross-sectional research on


structural models suggests that four of the five Big Five personality

factors (i.e., all but Openness) might contribute to the development,maintenance, and/or expression of PDs.

How stable are traits?

McCrae and Costa (1996) concluded that much research has shown

that normal personality traits tend to remain relatively stable through-out a person’s lifetime. Consistent with this, a recent study by Watson

and Humrichouse (2006) found rank-order stability in the .7 range (withlittle variability across different traits) for a 2-year interval for both self-

and spouse ratings. Hampson and Goldberg (2006) found similar esti-mates of .70–.79 (.85–.98 corrected for unreliability) over 2.8 years in anadult sample. Indeed, based on the observation that the asymptotic

values (as retest intervals lengthen) of adult trait temporal stability co-efficients are above zero, Fraley and Roberts (2005) concluded that

there must be a constant factor contributing to trait scores over time.At the same time, it is important to note that a well-accepted prin-

ciple among researchers in this area is that the longer the retest inter-val, the lower the level of rank-order stability (e.g., Roberts &

DelVecchio, 2000). For example, Hampson and Goldberg also re-ported very modest temporal stability coefficients over a 40-year in-terval spanning elementary school and midlife including values of .16

for O, .08 for A, and .00 for N. Though it is almost certain that highervalues would have been obtained if the 40-year retest interval had

spanned early adulthood to older adulthood (e.g., Fraley & Roberts,2005; Roberts & DelVecchio, 2000). Other studies have also demon-

strated moderating variables that are associated with changes in per-sonality, at least in the period of adolescence to young adulthood. For

example, the introduction of a controlled stressor (12-month exposureto an intercultural environment) can decrease personality vulnerabil-

ity in terms of trait anxiety, locus of control, and defensiveness (An-drews, Page, & Neilson, 1993). Another study showed that one’s workexperience, including success, power, satisfaction, and security in

young adulthood can modify basic personality dimensions, particu-larly N and E (Roberts, Caspi, & Moffitt, 2003). These results illus-

trate the point that personality traits, though relatively stable in theshort- and midterm, are far from immutable.

Results have consistently shown that N and I scores significantlyincrease (sometimes up to one standard deviation) during a depres-


sive episode (see Costa, Bagby, Herbst, & McCrae, 2005; Ormel,

Oldehinkel, & Vollebergh, 2004; Santor, Bagby, & Joffe, 1997). Thishas caused much confusion and controversy among personality

researchers, with some concluding that personality measures aresystematically biased by acute depression, therefore questioning the

validity and usefulness of personality assessment during depressiveepisodes (e.g., Hirschfeld, Klerman, Clayton, & Keller, 1983). Other

researchers have proposed that it is erroneous to believe that per-sonality traits are immutable but that the changes in trait scores that

occur during a depressive episode represents a ‘‘true’’ change in per-sonality (Costa et al., 2005). Widiger and Trull (1992) discuss a thirdpossibility of a spectrum relationship in which both personality and

disorder stem from common causes and vary together.While this debate is not yet settled, sophisticated methodological

techniques may make it possible to do so in the future. Thus, a studymight use informant reporting to rule out the possibility that re-

porting bias is entirely responsible for the changes in trait scoresduring a depressive episode. Of course, it is possible that the ob-

served changes reflect both reporting bias and true trait or spectrumchange. Teasing apart the trait change and spectrum change expla-nations is probably more challenging, and a full discussion of this

issue is beyond the scope of this article. Briefly, though, the crux ofthe difference seems to be that the trait change explanation implies

that N and depressive episodes are related yet distinct constructs,whereas the spectrum explanation implies that although they reflect

a single trait, they reflect different location parameters along thistrait. Thus, one could use confirmatory factor analysis for categor-

ical items—equivalent to multidimensional Item Response Theoryanalysis (e.g., Muthen, 1984; Takane & de Leeuw, 1987—to test

whether a diagnosis of depression and symptoms of depression de-fine a separable factor from that defined by items tapping N. Cer-tainly, regardless of how this debate is ultimately resolved, the

evidence regarding changes in trait scores associated with depres-sive episodes is consistent with the conclusion based on trait stability

studies in nonclinical samples that traits are not immutable.

How heritable are traits?

Behavioral genetic research has yielded consistent results indicatinga moderate heritable component of traits. There appears to be little


differential heritability across traits with estimates falling in the

moderate range of .20 to .60 (e.g., Jang, McCrae, Angleitner, Riem-ann, & Livesley, 1998; Keller, Coventry, Heath, & Martin, 2005;

Loehlin, Neiderhiser, & Reiss, 2003; Saudino & Plomin, 1996).Shared environment (e.g., parenting style, socioeconomic status,

neighborhood) accounts for, at most, a small portion of variancein most traits (e.g., McCrae, Jang, Livesley, Riemann, & Angleitner,

2001; Saudino, Plomin, & Defries, 1996). However, some studieshave found that larger shared environmental effects are sometimes

found when variables that moderate heritability are modeled (Krue-ger, South, Johnson, & Iacono, this issue). Nonshared environmen-tal effects (e.g., peer group influence, birth order effects, accidents,

illnesses) for personality traits are estimated to fall between .4 to .8(e.g., Saudino & Plomin, 1996). It is important to remember that

nonshared environment is computed as a residual score, which in-cludes the variance, if any, associated with the interaction of the ge-

notype by shared environment, systematic method variance, randomerror variance, and nonadditive genetic effects.

Also, pertinent to this discussion is the heritability of psychopa-thology, with a focus on depressive and anxiety disorders. Researchhas shown that major depressive disorder (MDD) has a heritability

estimate of approximately .4–.5, with the remaining varianceaccounted for by nonshared environmental effects (for review, see

Levinson, 2005; Sullivan, Neale, & Kendler, 2000). Behavioral ge-netic analyses of anxiety disorders yield similar results, with esti-

mates of heritability generally ranging from .3–.4 (see Hettema,Neale, & Kendler, 2001). Again, common environmental effects were

nil, with nonshared environmental effects accounting for 60–70% ofthe variance. As mentioned above, multivariate behavior-genetic

studies suggest at least one genetic factor common to MDD and theanxiety disorders (e.g., Hettema et al., 2005; Hettema, Neale, Myers,Prescott, & Kendler, 2006; Kendler et al., 2003). Moreover, N

appears to be related to one of these common genetic factors (e.g.,Hettema et al., 2006). For example, the association between N and

MDD results largely from shared genetic factors; approximately50% of the genetic effects on MDD are shared with N (Kendler,

Gatz, Gardner, & Pedersen, 2006). For GAD, this number is ap-proximately 35% (MacKintosh et al., 2006).

Behavioral genetic research not only studies the varianceaccounted for by genetics and the environment within traits, but


the covariation between traits. Multivariate factor analyses have

been completed on genetic correlations of groups of traits, leadingbehavioral genetic research to support two-, three-, four-, and five-

factor models of personality (Krueger & Johnson, 2007). Thisresearch also supports personality structure at the individual facet

level beneath the Big Five ( Jang et al., 1998). Taken together, thisevidence suggests that genetic influences on personality traits are not

confined to one specific level of the personality hierarchy but affectthe entire hierarchy and all of its levels. The phenotypic structure of

personality traits, as discussed below, appears to mirror this hierar-chical organization (Krueger & Johnson, 2007).

Are personality traits hierarchically structured?

As noted earlier, the dominant model of normal personality traitstructure is the Big Five (e.g., Goldberg, 1993). Many theorists have

represented and emphasized the hierarchical structure of the BigFive (e.g., Costa & McCrae, 1997; Digman, 1997; Eysenck, 1947;

Watson et al., 2008). Importantly, though different researchers haveendorsed what might appear to be different structural models, Mark-

on, Krueger and Watson (2005) present evidence that the structuresput forward by these different theorists can be integrated and un-derstood as focusing on different levels of the same hierarchical

structure. Costa and McCrae (1997) present the Big Five at thehighest level of the hierarchy, with each Big Five factor comprised of

six lower order facets. Digman (1997) presents a five-level hierarchywith the fourth level consisting of the Big Five, with two additional

factors, a (comprised of A, N, and C) and b (comprised of O and I),at Level 5. Levels 1–3 in the Digman model are those proposed by

Eysenck (1947): Level 3 is facets of the Big Five, Level 2 is habitualresponses, and Level 1 is specific responses to situational cues.

Eysenck (1992) advocated that Level 4 (represented by the BigFive in Digman’s model) consists of only three factors: I, N, andpsychoticism (P). In Eysenck’s model, A and C reside on Level 3, as

facets of P.Based on both theory (e.g., Lilienfeld, Turner, & Jacob, 1993) and

empirical evidence (e.g., McNally, 1996; Zinbarg & Barlow, 1996;Zinbarg, Barlow, & Brown, 1997; Zinbarg, Brown, Barlow, &

Rapee, 2001), we view N-spectrum traits as comprising a four-tieredhierarchy with N as a fourth-order trait that is related to the general


tendency to react with negative affect to stressful stimuli. (It is worth

noting, however, that we agree with Livesley, 2007, that we see noreason why nature should be ordered so neatly that all five Big Five

traits comprise structures with the same numbers of levels or thesame number of facets per level.) Trait anxiety is a third-order facet

of N related to the slightly less general tendency to react anxiously topotentially threatening stimuli (with trait depression and hostility

being examples of other third-order facets of N). AS is a second-order facet (perhaps corresponding to Eysenck’s habitual response

level) of trait anxiety related to the more specific tendency to reactanxiously to one’s own anxiety. Finally, AS is divisible into threefirst-order facets (corresponding to Eysenck’s level of specific re-

sponses to particular cues) relating to concerns about different do-mains: (a) AS-Physical Concerns (fear of the physical sensations of

anxiety related to the belief that they will result in physical catas-trophe), (b) AS-Mental Incapacitation Concerns (fear of the mental

and emotional manifestations of anxiety related to the belief thatthey will result in emotional catastrophe), (c) AS-Social Concerns

(fear of publicly observable sensations of anxiety related to the beliefthat they will result in social catastrophe). Whereas AS tends to beelevated in all anxiety disorders and major depression, profiles across

the first-order facets of AS appear to be useful for discriminatingamong these disorders (Zinbarg et al., 1997).

Hierarchical models are important for studying personalityand related constructs, partly because of the ‘‘bandwidth/fidelity

trade-off ’’ (Cronbach & Gleser, 1957). This refers to the notion thatbroad constructs (those at the top of a hierarchy) are useful in

predicting diverse behaviors at moderate levels of accuracy, whilenarrow constructs (those at the bottom of a hierarchy) are useful at

predicting a limited range of behaviors at a high level of accuracy.This might imply that a personality construct should ideally bestudied at different levels of breadth (Hampson, John, & Goldberg,

1986). However, some researchers have identified a ‘‘basic level’’ ofpersonality traits, which they considered to be the most useful and

informative level. In a study by John, Hampson, and Goldberg(1991) this level consisted of the highest level of the hierarchy that is

still behaviorally descriptive, the third level of a four-level hierarchy.This level was preferred by John and colleagues over the more ab-

stract superordinate levels and the more basic and specific subordi-nate levels, illustrating a good compromise between bandwidth


and fidelity. When it comes to implications for psychotherapy, how-

ever, it seems to us that different levels of the hierarchy each havetheir own contributions to make. Our discussion of treatment

planning to follow draws heavily on the second and first levels. Incontrast, our discussion of the breadth of therapeutic benefits is most

germane to the third and fourth levels.

Myths Based on the Evidence Bearing on One or More of the Four

Basic Questions About the Nature of Personality Traits

Trait vulnerability factors cannot be altered by psychotherapy

Some researchers seem to have either implicitly or explicitly assumedthat trait vulnerability factors cannot be altered by psychotherapy.

For example, Mathews, Mogg, Kentish, and M. Eysenck (1995)suggest that their finding that cognitive-behavioral therapy (CBT)

for generalized anxiety disorder (GAD) reduced an informationprocessing bias is ‘‘consistent with two alternative views: either that

cognitive bias depends on current state factors such as mood, or thatvigilance represents an enduring characteristic that becomes appar-

ent only when vulnerable Ss are under stress’’ (p. 302). Clearly, animplicit assumption underlying this argument is that trait vulnera-bilities can’t be altered by psychotherapy (ergo, any characteristic,

such as an information-processing bias, which appears to have beenaltered by therapy must neither be a trait vulnerability factor nor

have been altered but rather is one not currently being expressed). Inturn, this implicit assumption seems likely to stem from thinking of

traits as being immutable. Notably absent from this discussion is thepossibility that threat-processing biases are trait vulnerability mark-

ers that are relatively enduring but not immutable and that, there-fore, are at least partly modifiable by experiences such as therapy. In

contrast, the literature cited above clearly shows that traits can bevulnerability factors that are relatively enduring but far from im-mutable. Given the mutability of traits, we believe they can be mod-

ified to some degree by therapy.Consistent with our belief, there are several studies that have pro-

vided evidence for a change in personality trait scores over the courseof therapy, with most concentrating on the Big Five traits over the

course of treatment for depression (e.g., Clark, Vittengl, Kraft, &Jarrett, 2003; De Fruyt, Van Leeuwen, Bagby, Rolland, & Rouillon,


2006; Du, Bakish, Ravindran, & Hrdina, 2002). As mentioned ear-

lier, the major finding is that N and I scores tend to decrease over thecourse of treatment for depression. This has been supported regard-

less of whether the treatment is psychotherapy (Clark et al., 2003) orpsychotropic medication (Bagby, Levitan, Kennedy, Levitt, & Joffe,

1999; Costa et al., 2005; Du et al., 2002; Santor et al., 1997). More-over, whereas most of the medication studies failed to include the use

of a placebo control group, we are aware of at least one exceptionthat did find greater personality change associated with the active

medication than with a placebo (Tang, DeRubeis, Hollon, Shelton,& Schalet, in preparation).

The basic effect, that of the change in N and I scores, is fairly

consistent among studies (although De Fruyt et al., 2006, foundonly a change in N), and there are two other important findings from

this body of research. First, though some studies have notedthat change in personality traits is correlated with change in depres-

sion (e.g., Clark et al., 2003; Du et al., 2002), other studies havefound that personality trait change occurs largely independent of

change in depression. From these studies we might conclude thattreatment for depression can have a significant effect on personalitytraits, independent of the effect the treatment has on depression

(De Fruyt et al., 2006; Santor et al., 1997; Tang et al., in prepara-tion). Second, studies have also demonstrated that personality trait

variables not only demonstrate absolute change in the form ofdecreasing N and I but also rank order stability (De Fruyt et al.,

2006; Santor et al., 1997). We interpret these results to implythat (a) the rank order stability found in these studies reflects

a constant source of variance in personality traits thatremains unchanged throughout adulthood (see Fraley & Roberts,

2005), and (b) the absolute change in personality trait measures seenthroughout depression treatment represents an actual altering of thetraits of N and I (for an alternative view, see Clark et al., 2003).

Medications are necessary for symptom reduction

Some of our patients (and according to their accounts, some of their

psychiatrists and former psychotherapists) hold the belief that theheritability of traits likely involved in the development, maintenance,

and/or expression of common psychiatric disorders implies that med-ications are necessary for successful treatment. A simple version of


this argument might go something like this: if there is a biological

basis to psychopathology, then effective treatment must also involvea biological intervention. A more sophisticated version might recog-

nize that traits associated with symptoms are not immutable but as-sume that the genetic influences on these traits are and will continue

to produce symptoms if not addressed directly (i.e., biologically). In-deed, it is certainly true that the genotype remains constant over the

lifespan and will not be altered by psychotherapy. Yet bothversions of this argument are fallacious for four reasons.

First, heritability estimates are far from perfect. Thus, the envi-ronment clearly does influence traits even if the shared environmentdoes not.

Second, despite the fact that genotype remains constant over thelife span, heritability estimates can, and sometimes do, change as a

function of age perhaps due to variability in gene expression overtime and/or to gene-environment transactional processes (e.g.,

McGue, Bouchard, Iacono, & Lykken, 1993; Plomin & Spinath,2004). Similarly, estimates of the influence of the shared, familial

environment can, and sometimes do, change as a function of ageprobably due to the potency of more recent environment influencesrelative to more distal environmental influences (McGue et al., 1993;

Plomin & Spinath, 2004). That is, genetic influences are clearly notconstant over time.

Third, heritability estimates are specific to the range of environ-ments represented in the samples they are based on. Even if the range

of sampled environments is large, heritability estimates still onlyrepresent an average of these without any information regarding

the effect of a specific environment. For example, Krueger andcolleagues (this issue) found that genetic shared environmental and

nonshared environmental effects were moderated by the participantsperception of their parental relationship. That is, when participantsrated the relationship low in Regard, this diminished genetic effect

and enhanced nonshared environmental effects. When participantsrated the relationship high in Conflict, this diminished the genetic

effect and enhanced shared environmental effects. It is possible thatwith further advances in psychotherapeutic theory and technique

that psychotherapies for some conditions will represent systematicenvironmental perturbations larger than any represented in extant

behavioral genetic studies and large enough to lead to larger traitdifferences than those obtained to date.


Finally, we know that experience changes the structure of the

brain (e.g., Merzenich, 1998). Thus, psychotherapy is capable ofleading to brain reorganization such that medications are not

necessary even to effect changes in the biological bases of traits.

Psychotherapeutic Implications of the Research Bearing on the

Four Basic Questions About the Nature of Personality Traits

If the basic research findings concerning the nature of traits doesnot support the inferences that trait vulnerability factors cannot be

altered by psychotherapy or that medication is necessary, whatthen are the implications of this research? We next turn our atten-

tion to some of the implications that we believe traits can have forpsychotherapy.

Prognosis: The depth of psychotherapeutic benefits

Given that personality traits such as N, AS, and I appear to be in-

volved in the development or maintenance of symptoms, the pa-tient’s standing on these traits may place constraints either on the

amount of therapeutic improvement he or she might experience oron the durability of such improvements. Indeed, if these traits hadbeen shown to be entirely heritable and perfectly temporally stable in

test-retest studies, then it might seem reasonable to argue that thebenefits of psychotherapy would be fleeting at best. Even then, how-

ever, if few participants in the studies producing the perfect herita-bility and stability coefficients had been in psychotherapy, such an

argument would not be unassailable. Fortunately, we do not need todebate such issues as it is clear that traits are not immutable given

that they are neither completely stable nor entirely heritable. Thus,whereas some might argue that if traits are involved in symptom

development, maintenance, and/or expression then long-termchange in symptoms as a result of psychotherapy would be impos-sible, such a view is clearly not warranted by the evidence. That is,

given that traits are not immutable, the fact that there are trait in-fluences on symptom development, maintenance, and/or expression

certainly does not imply that long-term change in symptoms shouldbe impossible.

What then are the psychotherapeutic implications of the findingsthat personality traits are partially heritable and of those that led


Fraley and Roberts (2005) to conclude that there is a factor (i.e.,

one’s genotype) that provides a constant contribution to variance inpersonality traits? These findings are certainly consistent with our

belief that the benefits of psychotherapy are likely to be at leastsomewhat limited in magnitude both in terms of effects on symptoms

and on traits (for a related discussion, see Harkness & Lilienfeld,1997). That is, the evidence suggests that there is a limit to the ben-

efits of even the most effective of our currently available treatments.For example, in a trial of CBT for GAD Zinbarg, Lee, and Yoon

(2007) obtained large effect sizes (on average symptom scores atpost-test in the treatment group were 1.48 standard deviations (SDs)lower than in the wait-list group and 1.71 SDs lower than their own

pretest scores). Despite these statistically large effects, the clinicalsignificance of the findings were much more limited. Only 50% of the

patients achieved high end-state functioning (i.e., being broughtwithin 1 SD of the normal mean) on four of five outcome measures,

and we are not aware of any studies that have obtained meaningfullybetter high-end state functioning results with GAD. Moreover, con-

sistent with the findings cited above that whereas N and I tend todecrease during treatment they often remain elevated relative to thenormal population (Costa et al., 2005; De Fruyt et al., 2006; Du

et al., 2002), none of the patients scored more than a half of a SDbelow the normal mean on at least four of the measures.

Thus, it is possible to bring patients who begin therapy withsymptom scores outside of the normal distributions back into the

normal range as a result of therapy. We also believe it is possible toimprove on our current therapies such that even higher proportions

of our patients might achieve this high end-state functioning status inthe future. However, we do not think it is realistic to expect to bring

many high N patients to the low end of either symptom distributionsor the N distribution as a result of psychotherapy. In an analogousfashion to the manner in which genes set the ‘‘reaction range’’

(Gottesman, 1963) for phenotype, we offer the speculation thatstanding on a trait such as N may be said to set the patient’s

‘‘therapeutic range.’’A weak version of the ‘‘therapeutic range’’ hypothesis does not

necessarily predict that pretreatment personality predicts the amountof improvement a patient experiences. Rather, it may be that most

patients will begin therapy with high enough elevations on N(or other relevant traits) that they all have a somewhat restricted


‘‘therapeutic range’’ and/or a restricted statistical range of trait

scores. (That is, it may be that there is an asymptotic functionbetween N and ‘‘therapeutic range’’ such that further increases in N

above some threshold value are not associated with further decreasesin ‘‘therapeutic range.’’) Thus, a weak version merely predicts that

very few patients will ever be brought more than approximately ahalf of a SD below the normal mean on a majority of outcome

measures.Interestingly, however, some (though certainly not all) studies

have shown that pretreatment personality traits have an impact ontreatment outcome consistent with a stronger version of the ‘‘ther-apeutic range’’ hypothesis. For example, some researchers have ex-

plored the role of one facet of N—perfectionism—as measured bythe Dysfunctional Attitudes Scale (DAS; Weissman & Beck, 1978) in

the Treatment of Depression Collaborative Research Program(TDCRP). Over the course of treatment, patients with high to mod-

erate levels of perfectionism at pretreatment made no significanttherapeutic gain after the eighth treatment session (Blatt & Zuroff,

2005). Using video recordings of a sampling of treatment sessionsand a measure that codes therapist and patient participation in thetherapeutic alliance (Krupnick et al., 1996), results indicated that

perfectionist patients showed a disengagement in therapy after theeighth treatment session (Shahar, Blatt, Zuroff, Krupnick, & Sotsky,

2004; Zuroff et al., 2000). One possible explanation of these results isthat these patients may have tended to apply their perfectionistic

beliefs to the therapy, which would be certainly be consistent with atrait perspective. If so, and if this tendency to apply perfectionistic

standards to their work in therapy were not treated directly, it wouldhave left the patients vulnerable to feeling they were ‘‘failing’’ in

therapy and hopeless. Hopelessness about therapy, in turn, would beexpected to lead to disengagement (but see Shahar et al., 2004, for analternative explanation).

Some might argue that the nonzero heritability estimates of per-sonality traits and the tendency for temporal stability coefficients to

asymptote at values above zero (as the follow-up interval increases)necessarily dictates that the upper limit to therapeutic benefit must

fall short of bringing patients to the low end of symptom and trait-risk factor distributions. If so, we believe such an argument would be

just as logically fallacious—and for many of the same reasons—asthe arguments that traits cannot be altered by psychotherapy or that


medications are necessary. Also, as in an example provided by

Hampson and Goldberg (2006) of the number of hair follicles persquare centimeter of scalp in men, characteristics with even higher

heritabilities than personality traits undergo radical changes. That is,if men with genetically determined ‘‘thick’’ hair can, and sometimes

do, go bald, then genetic influences on traits do not preclude radicalchange in standing on a trait. Thus, though we believe bringing

patients to the low end of symptom and trait-risk factor distributionsis unlikely, it is not logically impossible.

To summarize, we believe it is logically fallacious to argueagainst the possibility of therapy leading to radical change inpersonality traits based on evidence of their temporal stability and

heritability. At the same time, we believe that until good evidence forsuch radical transformation is presented, it is best (and certainly

most realistic) for patients and therapists alike to set more modestexpectations for therapy given that many of the traits that contribute

to seeking psychotherapy in the first place may limit a patient’s‘‘therapeutic range.’’

Prognosis: The breadth of psychotherapeutic benefits

Despite the limits to the depth of change we can realistically expectfrom psychotherapy, we believe the personality trait literature gives

us more reason to be optimistic about the breadth of change. That is,the fact that there appear to be broad risk factors that confer risk for

many forms of psychopathology offers some hope that when therapyis beneficial, it might have broad effects beyond the specifically tar-

geted symptoms. To the extent that psychotherapy focused on theprincipal diagnosis leads to some reduction in one of those broad

factors, then we should expect improvement in comorbid conditionseven if they are not explicitly targeted in treatment.

To illustrate this point, consider the case of N and internaliz-ing disorders. As discussed above, N appears to be a broad riskfactor for MDD and the anxiety disorders. Thus, psychotherapy

for any one of these disorders that produces change in one or morethe processes (e.g., biases in the processing of threatening and/or

ambiguous information, physiological hyper-reactivity, avoidancebehaviors) that likely link N to symptoms should also be associated

with reductions in symptoms of comorbid anxiety disorders orMDD that aren’t explicitly targeted in the therapy. Indeed, whereas


there is a need for more research on the impact of psychotherapy

on comorbid conditions, the available evidence in the literatureon CBT for anxiety disorders supports the expectation of broad

improvement that extends to comorbid conditions not explicitlytargeted in therapy (Borkovec, Abel, & Newman, 1995; Brown &

Barlow, 1992).

Therapeutic strategy and targets

The bandwidth/fidelity trade-off may have specific implications inthe clinical setting, especially in terms of treatment planning. First,

personality trait measures can identify higher order traits that arerelated to a wide range of thoughts, feelings, and behaviors that maybe causing distress in the patient (e.g., high N and high I) or that

might interfere with treatment (e.g., low C, low or extremely high A).They give the therapist a broad, general view of how a patient thinks,

feels, and behaves. The therapist now has a starting point fromwhich to begin to understand the patient, develop strategies for

building a strong alliance, and think of possible interventions thatwill be useful. For example, a therapist should be wary of a highly

agreeable patient for signs of false enthusiasm or possible alliancetears that the patient does not verbalize because he or she is overlymotivated to please the therapist (Miller, 1991; Muten, 1991). Sim-

ilarly, a therapist should be prepared to be highly reinforcing of alow-conscientious patient for homework completion. However, spe-

cific treatment planning based solely on the higher order traits maybe unwise; closer examination of lower order facets will predict pa-

tients’ behaviors with higher accuracy, allowing for a more specifictreatment plan. Therefore, a second step involves examination of

lower order facets to more specifically tailor a therapeutic approach.The lower order facets that comprise a higher order factor are often

distinct enough in kind to warrant different treatment approaches.In other instances, lower order facets may not be this distinct butmay be distinct enough to inform the choice of the specific target that

a treatment approach is applied to. In general, it is likely that a per-son scoring high on one facet of a higher order factor will score high

on the rest. A closer examination of the facets, however, may revealinformative data about the specific patient.

Let us also take the example of Introversion. A therapist with twopatients who are extremely introverted might deem them both to be


better candidates for individual therapy than for group therapy (es-

pecially if the therapy group were relatively unstructured, in whichcase their participation would be expected to be minimal; for a re-

lated discussion see Miller, 1991). Consistent with this, Ogrodniczuk,Piper, Joyce, McCallum, and Rosie (2003) found that I and N were

related to poor outcome in outpatient group therapy, whereas O andA were related to good outcome. However, each patient might have

a distinct I facet profile that is informative to treatment planning.For example, Patient #1 is especially low on the I facets of warmth

and gregariousness but average on the I facet of trait positiveemotionality. In contrast to his average standing on trait positiveemotionality, however, he is especially low on a measure of current

state positive emotions, indicating an anhedonic depressive state inan individual who has at least average capacity for pleasure. A

treatment plan might focus on behavioral activation (e.g., Martell,Addis, & Jacobson, 2001). On the other hand, Patient #2 is especially

low on the I facets of assertiveness and excitement seeking, indicat-ing that this person avoids situations that might involve

increased emotional arousal, even if the end result is potentiallyrewarding. A treatment plan might focus on assertiveness trainingand behavioral exposures to increase tolerance of emotional arousal.

Another example involves N. A therapist, noting that there aretwo patients high on the higher order trait of N, might first hypoth-

esize that these people are especially likely to have a mood or anxietydisorder, be prone to experiencing negative affect, and might benefit

from CBT. However, closer examination of their N facet profilesmay indicate that different therapeutic approaches are necessary.

Patient #3 is especially elevated on the anxiety and self-consciousnessfacets, indicating that cognitive restructuring and behavioral expo-

sures should be aimed at fear of evaluation. Patient #4 is especiallyelevated on the impulsiveness and angry hostility facets, indicatingthat relaxation training and anger management training might

be helpful.A third example involves simultaneous consideration of I facets

and N facets. Patients #5 and #6 are both high on N, with especiallyhigh elevations on the anxiety facet, thereby suggesting that expo-

sure therapy may be beneficial. Patient #5 has at least average scoreson the I facet of PEM, whereas Patient #6 is low on the I facet of

PEM. Thus, one might be able to facilitate the exposure therapyfor Patient #5 with motivation interviewing techniques designed


to increase approach motivation for exposures (Zinbarg, 1998). In

contrast, such an approach might be of more limited value forPatient #6, and the therapist should instead focus primarily on

decreasing avoidance motivation via cognitive restructuring tofacilitate the exposure therapy.

A fourth example involves the second-order and first-order facetsin our four-tiered N hierarchy. Patients #7 and #8 are both high not

only on the fourth-order trait of N but are also both high on thethird-order facet of anxiety. Thus, they would both be likely to ben-

efit from CBT including exposure therapy. However, Patient #7 isalso high on the second-order facet of AS and the first-order facet ofAS-Physical Concerns, whereas Patient #8 is not. Rather, in addition

to an elevation on the third-order facet of trait anxiety, Patient #8 isalso high on the second-order facet of Specific Fears and the first-

order facet of Fear of Heights. Thus, exposure would be indicatedfor both patients, but for Patient #7 we would recommend inter-

oceptive exposure whereas we would obviously recommend either invivo or virtual exposure to heights for Patient #8 (see Zinbarg et al.,

1997). From these oversimplified examples, one can see how anunderstanding of the hierarchical structure of personality and utili-zation of personality measures that take this structure into account

can be helpful for treatment planning.

Alliance

There is evidence that even in CBT, which emphasizes specific ther-apeutic techniques and deemphasizes the importance of the thera-

peutic relationship relative to many other schools of psychotherapy,the strength of the therapeutic alliance is a predictor of outcome

(e.g., Castonguay et al., 1996; Klein et al., 2003; Krupnick et al.,1996; Loeb et al., 2005). Thus, the patient’s standing on A might be

expected to predict outcome as mediated by its impact on thetherapeutic alliance (Miller, 1991). Consistent with this hypothesis,Gurtman (1996) found that the patient’s standing on hostile-dom-

inance predicts poor therapeutic alliance and outcome. This associ-ation might be moderated, however, by therapist skill at working

with disagreeable patients or by amount of attention to alliancebuilding paid by the therapist. That is, disagreeable patients should

require greater interpersonal skill, greater skill at repairing allianceruptures, and/or effort on the part of the therapist to achieve the


same level of benefit compared with agreeable patients with equally

severe initial symptoms.

Compliance

The best available evidence suggests that compliance with self-helpexercises in between sessions is a predictor of outcome in CBT (e.g.,

Addis & Jacobson, 2000; Burns & Spangler, 2000; Kazantis, Deane,& Ronan, 2000). Thus, the patient’s standing on C, A, and O at

initial assessment might be expected to predict outcome as mediatedby compliance with self-help exercises (Miller, 1991). Knowledge of a

patient’s C level could be useful to a therapist in order to build inextra structure when negotiating self-help exercises with a low C

patient (negotiating not only what exercises the patient will work onbetween sessions but also when and what external cues will be used

to remind the patient when it is time to work on a given exercise).Note that we use the verb negotiating rather than assigning; we be-lieve it is always best practice to adopt a collaborative stance and

offer a menu of choices when it comes to self-help exercises. Knowl-edge of a patient’s A level could be helpful, however, to encourage a

therapist to be particularly mindful of these principles from theoutset of therapy with a highly disagreeable patient (Miller, 1991).

Finally, as most self-help exercises will involve the patient experi-menting with behaviors, cognitions, or feelings, O may also be re-

lated to compliance (McCrae, 1991; Miller, 1991). Thus, knowledgeof a patient’s O level could help a therapist adopt a more incrementalapproach to negotiating self-help exercises to gradually build up to

responses that deviate more and more from the patient’s usual rep-ertoire.

Beyond Traits

It is worth mentioning that there are components of personality be-yond traits that have important implications for psychotherapy. Oneincreasingly influential theory of personality suggests that traits form

the foundation or ‘‘dispositional signature’’ of personality (Mc-Adams, 1995, p. 372), onto which are added two other distinct lev-

els of personality: characteristic adaptations and narrative identity(e.g., McAdams, 1995, 2001; McAdams & Pals, 2006). Characteristic

adaptations include a wide range of dynamic motivational, social-cognitive, and developmental aspects of human individuality. These


components of personality are contextualized within situations and

evolve over time. In addition, people vary with respect to the lifestories that they construct to provide their lives with a sense of unity

and purpose and to make meaning out of their experiences, a level ofpersonality termed narrative identity (e.g., McAdams, 1995, 2001;

Singer, 2004). These three levels of personality are sometimes relatedto each other in predictable ways, and sometimes they are not, sug-

gesting that characteristic adaptations and narrative identity are notsimply emergent properties of traits (e.g., McAdams, 1995; Mc-

Adams & Pals, 2006). Individual differences at each of these addi-tional levels of personality have also been studied in relation to psy-chotherapy. Indeed, Singer (2005), adopting and expanding upon

this three-level approach to personality, strongly advocates that tak-ing all components of personality into account, what he calls an

‘‘integrative, person based personality psychology, forms a scientificand ethical basis for the treatment of individuals in psychotherapy’’

(p. 158). Westen, Gabbard, and Blagov (2006) echo this assertion intheir claim that a multileveled conception of personality structure

should serve as a context for understanding psychopathology andtherefore treatment. A comprehensive overview of these literatures iswell beyond the scope of the present article, but for completeness it is

important to acknowledge certain key findings that incorporate theseother levels of personality.

Characteristic adaptations–Ego development

One characteristic adaptation that has implications for psychother-

apy is ego development (ED). ED is a life span developmental con-struct that concerns the complexity individuals use when making

meaning out of their experiences (e.g., Loevinger, 1976; Westenberg& Block, 1993). Individuals’ stage of ED does not tend to show

strong correlation with their profile of dispositional traits, althoughED is sometimes observed to correlate with the trait of Openness(Westenberg & Block, 1993). We have selected ED as an example

because it is an important, if sometimes overlooked, characteristicadaptation among those that have been operationalized well for sys-

tematic empirical study (Westen, Gabbard, & Blagov, 2006). (Forexample, a PsychInfo search for ego development yielded 2,897 re-

sults, while searches for other characteristic adaptations, such as at-tachment, yielded many more [17,855].) There are at least three ways


in which the study of ED can inform the study and practice of psy-

chotherapy.First, King and her colleagues (e.g., King & Napa, 1998) found

that lay conceptions of ‘‘the good life’’ include both subjective well-being as well as leading a life of complex meaning (high ED). They

therefore suggest that clinicians broaden their conception of the de-sired outcomes of therapy to include an increase in the nuance and

depth of a client’s self-understanding. Ego stage is unlikely to berelated to the client’s trait profile, while their level of happiness might

be predicted by neuroticism and extraversion.Second, a client’s stage of ED has implications for their treatment.

Dill and Noam (1990) found that individuals at higher stages of ED

tended to request psychodynamic, insight-oriented therapy, whereasindividuals at lower stages of ED tended to request more behavioral

treatments and triage-type interventions that focused on immediateproblem solving. As behavior therapy has become increasingly inte-

grated with cognitive techniques and theory (e.g., Zinbarg, 1990),however, CBT may have gained some ground in preferences among

those at higher stages of ED since the time that Dill and Noamcollected their data, especially among those aware of the emphasison meaning in contemporary CBT. Once in treatment, theory

suggests that individuals at varying stages of ED might also bringdifferent concerns to therapy. For example, Noam (1998) suggests

that each stage of ED might bring with it certain specific vulnera-bilities that could not be predicted from knowing the client’s trait

profile.Finally, variation in ED is related to the stories clients tell about

their treatment experience, above and beyond that explained bytraits (e.g., Adler & McAdams, 2007, in press). For example, Adler,

Wagner, and McAdams (2007) found that ED was significantly pos-itively correlated with the coherence of individuals’ stories abouttheir experiences in therapy, even after partialing O. As an increase

in coherence of narratives over the course of treatment may correlatewith outcome (e.g., Baerger & McAdams, 1999; Foa, Molnar, &

Cashman, 1995), therapists might do well to assist their clients atlower stages of ED to develop more coherent narratives. Thus, ED, a

relatively stable construct in the adult years, may build upon traits’contribution to the development and maintenance of psychiatric

disorders by influencing their expression in individuals at differentED stages and may suggest varying treatment strategies.


Narrative identity

There has been increasing theoretical and empirical attention paid to

the relationship between narrative identity and psychotherapy be-yond the influence of traits as well, leading some to declare ‘‘narra-

tive as a nontrivial point of convergence for the therapy field’’(Angus & McLeod, 2004, p. 373; see also Singer, 2005). There is also

evidence that narrative themes relate to psychopathology even afterpartialing relevant personality traits. For example, Adler, Kissel,

and McAdams (2006) found that the narrative theme of contami-nation was strongly related to individuals’ depression and low lifesatisfaction, even partialing N. Within the narrative tradition, psy-

chotherapy has been conceived of in two ways: as a process that isfundamentally concerned with modifying people’s self-narratives

(e.g., White & Epston, 1990) and also as an important source ofpersonality development that must itself get storied and incorpo-

rated into one’s evolving sense of self (e.g., Lieblich, 2004).The first perspective holds that, regardless of the specific content

of the treatment, therapy is, in essence, about helping clients modifytheir self-stories. This viewpoint has led to the development of ther-apeutic techniques that are explicitly focused on clients’ self-narra-

tives (e.g., White & Epston, 1990). In addition, various componentsof clients’ narratives have been operationalized as important process

and outcome indices, independent of traditional symptom-basedmeasures (e.g., Hayes, Beevers, Feldman, Laurenceau, & Perlman,

2005; Lysaker, Lancaster, & Lysaker, 2003). For example, Lysakerand colleagues (2003) found that the coherence of the personal

narratives of adults with schizophrenia increased over the courseof treatment. While certain traits might predispose people to craft

certain types of stories about their lives, the themes assessed at thelevel of narrative identity have been shown to be correlated withcertain forms of psychopathology, such as depression, after partial-

ing traits like N (Adler et al., 2006).From the second perspective, the experience of going to therapy is

itself conceived of as an important event that must be incorporatedinto the client’s evolving self-story (e.g., Lieblich, 2004). In a classic

work on psychotherapy, Frank (1961) suggested that weaving the‘‘myth’’ of the therapeutic experience is fundamental to the individ-

ual’s continued optimal functioning once treatment has ended(p. 327). Yet there are significant individual differences in the


narration of psychotherapy and these differences correlate with vari-

ations in mental health (e.g., Adler, Wagner et al., 2007; Baerger &McAdams, 1999). For example, Adler and McAdams (2007, in

press) found that individuals high in psychological well-being (com-pared to those low) tended to recall their therapy as the story of a

victorious battle from the past, wherein a personal problem rises tobecome (temporarily) a fierce antagonist, only to be defeated once

and for all by a reenergized self (for a related discussion of clientagency, see Combs & Freedman, 2004). In doing CBT for anxiety,

our experience suggests that for many patients it is important totransform a self-story of being cowardly because of the experience ofintense anxiety to one of being courageous because of action in the

face of anxiety. The thematic content of clients’ narratives and theirevolution over treatment cannot be predicted well from their trait

profiles, yet they serve an important psychological function (e.g.,Frank, 1961).

CONCLUSION

We have argued that taking personality into account may be usefulfor psychotherapists and psychotherapy researchers. Specifically, in-dividual differences in personality traits as well as personality con-

structs beyond traits such as ego development and narrative identityappear to have implications for such diverse aspects of psychother-

apy as prognosis, treatment-seeking preferences, choice of therapeu-tic strategies, the focus of therapeutic interventions, and the ways in

which clients regard their treatment and narrate their experiences intherapy. Clearly, many of the implications we have drawn involve

some degree or other of speculation. It is just as clear to us, however,that our conjectures are imminently testable. Thus, time and empir-

ical studies will tell which of the hypotheses generated here are validor clinically useful and which are not.

Given that the principles of learning theory provide the concep-

tual foundation for behavior therapy and that much of Eysenck’swork centered around hypothesized effects of heritable traits in

moderating learning processes and outcomes (e.g., Eysenck, 1967), itis certainly the case that the perspective adopted here is far more

consistent with the Eysenckian/European school of behavior therapythan the school that developed in the United States in the 1950s


(Krueger & Piasecki, 2002). A potentially interesting historical note,

however, is that whereas Eysenck in many ways pioneered the mod-ern study of traits (e.g., Eysenck, 1947), the trait-psychopathology

interface (e.g., Eysenck, 1944), behavior therapy (e.g., Eysenck,1959, 1960a), and the study of the efficacy of psychotherapy (e.g.,

Eysenck, 1952), we are not aware of much research conducted byEysenck himself at the trait-psychotherapy interface. In fact,

whereas a PsycINFO search yielded 663 publications authored orcoauthored by Eysenck, including 360 hits using the keyword

personality and another 82 using the keywords psychotherapy andbehavior therapy, we are aware of only three articles or chapters inwhich he explicitly discussed the implications of traits for psycho-

therapy (Eysenck, 1960b, 1969, 1985). Regardless of the ultimate fateof many of our conjectures, we are convinced that further merging of

these two research streams pioneered by Eysenck will lead toenhanced understanding and improved practice of psychotherapy.

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