Instrument name. The Millon Clinical Multiaxial Inventory (MCMI-III), in its third edition, was developed by Theodore Millon (1977, 1996, 1997a, b).
Type of instrument. The MCMI-III is a standardized personality inventory that includes 24 clinical scales and 4 scales concerning reliability and validity.
Eleven clinical scales measure clinical personality patterns and three indi- cate severe personality patterns, with very high scores similar to DSM-IV- TR personality disorders. Moderate clinical personality pattern scores reflect personality traits, while a slightly elevated score represents personal- ity features. Seven scales assess DSM-IV-TR, Axis I, clinical syndromes (i.e., anxiety; somatoform; bipolar; dysthymia; alcohol dependence; drug depen- dence; and posttraumatic stress disorder) and three reflect serious clinical syndromes (i.e., thought disorder, major depression, and delusional disor- der).
Use–target audience. This instrument is used for assessing and making treat- ment decisions in adults (18 years and older), focusing on personality style and disorders, unique among tests. An adolescent version, the Millon Ado- lescent Clinical Inventory (MACI), is available and has been normed on 13 to 19 year olds.
Multicultural. English and Spanish versions are available. Computer-generated interpretive reports are available only in English.
Ease and time of administration. The inventory consists of 175 statements about personality and behavior to which the individual responds “true” or
“false” as applied to him or her. It can be completed in 20 to 30 minutes and
may be taken directly on a computer or in paper format. An eighth-grade reading level is specified.
Scoring procedure. Computer scoring of the 28 scales takes only a few minutes to provide a simple profile with minimal interpretive comments or a full interpretive report.
Reliability. Moderate levels of reliability have been noted. Test–retest reliabili- ties have been reported in a range from .67–.91 to .67–.69 for 1 year as well as an internal consistency of .80 (Groth–Marnat, 1999).
Validity. Although the positive predictive power of the MCMI-II ranged between .30 and .80, predictive values for the MCMI-III were not reported in the test manual (Millon, 1997a).
Availability and source. This inventory can be obtained from Pearson Assess- ments (formerly National Computer Systems, Inc.).
Comment. The MCMI-III, developed empirically from a theoretical base, has accrued over 600 references, including a number of books. Over the course of a quarter of a century it has reached an established place among clini- cians, including those working with couples in whom DSM-IV Axis I and II issues are suspected in one or both partners.
Using the MCMI-III With Couples
At the present time, the MCMI-III is the only major and widely used psycho- logical inventory that assesses qualities of personality styles and personality disorders within the context of an empirically derived theory consistent with DSM-IV-TR. This makes it a core instrument for a comprehensive assessment battery. Even used alone for screening, the inventory is extremely useful in arriving at hypotheses about the personality structure and interactive pattern of the underlying the immediate conflicts, overt anxiety, and depressive, or acting-out, features that partners present with in couples therapy.
The Process of Couple MCMI-III Analysis
1. Check for satisfactory validity and response style scores.
2. Next, note significant scores on the profile of each spouse so that indica- tions of personality styles/disorders and any clinical syndromes are compared with other information collected, such as the clinical interview and previous records or collateral data. Beyond comparing family history of psychiatric and substance dependence, information on the partners’
family-of-origin histories, attraction to each other, and courting history can be usefully compared with their scores on the 14 personality style/
disorders scales.
3. After completing this overall analysis, an in-depth analysis of the person- alities and interaction patterns needs to be undertaken. This can be done with the help of Millon’s MCMI-III Manual (1997a) or Millon’s Disorders
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EFFECTIVE USEOF PSYCHOLOGICAL TESTSWITH COUPLESAND FAMILIES 73 of Personality (1996). With couple interpretations, it is particularly important to look at the behavioral level, that is, expressive behavior and interpersonal behavior. From this level, inferences can be systematically drawn about linkages with features or domains falling at other levels.
These levels include the polarities of pleasure–pain, active–passive, and self–other. Identifying where couples fall with reference to these polarities (especially self–other) and their personality styles/disorders can be most clinically useful in understanding the homeostatic function of these balances. This is because the couple or family system tends to make adjustments to maintain the status quo, thereby preserving the relation- ships between individuals that meet some individual needs. This analysis permits a more detailed description of the interactive pattern of the per- sonality expressions of the couple, and provides the basis for planning and therapeutic treatment, which can be sharpened by reference to personality-guided therapy (Millon, 1999). A detailed example of this analysis process applied to the dependent/narcissistic couple may be found in Nurse’s (1997) chapter in The Disordered Couple. See also Nurse’s chapter in The Millon Inventories (Millon, 1997b), which provides illustrations of the process.
Prototypic MCMI-III Couple Relational Patterns
This section briefly describes six MCMI-III couple relationship patterns com- monly seen in outpatient treatment settings.
Narcissistic Male/Histrionic Female
Males with a very high score on the Narcissistic scale (5) may act in an arro- gant fashion with a tendency irresponsibly to ignore social norms and stan- dards. They may show little empathy and act in an interpersonally exploitive manner, seemingly unaware of the negative impact on others. These males may have self-glorifying fantasies of success, yet may move from job to job always looking for employment that meets how they think they should be treated. Yet, narcissistic males maintain a cool aura, seemingly not shaken by anything. However, it is particularly important on this scale to determine whether a high score represents a style or a disorder (Craig, 1999). With a narcissistic style, subtle attitudes may be reflective in a moderate way of these characteristics, except under pressure when the attitudes and behaviors can become significantly more pronounced.
Females in this relational pattern often show a marked peak on the Histri- onic scale (4). They convey an engaging, fleeting, and often theatrical atti- tude, conveying a high level of excitement and activity. Histrionics seek to be the center of attention, developing ways of being socially stimulating, but they
avoid reflecting on even fleeting unwanted emotions, seeking to deny contra- dictory feelings as they are constantly in action. At a level of style they may be dramatic and energetic but can enter more into relationships. Given the frequent lack of any symptoms evident on the MCMI clinical syndrome scale scores, some with slight scale elevations appear to have simply histrionic fea- tures and are up-beat and free from indications of maladjustment. If an elevation on the Compulsive scale (7) occurs, their general emotional style is likely to be balanced by some capacity to be organized, thorough, and conscientious, while remaining expressive and outgoing as reflected in a moderately elevated histrionic scale score. This pattern suggests a person functioning relatively effectively.
In the couple relationship, the truly histrionic female will likely be attracted to the narcissistic male because of his sureness, command, and interest in her. He is likely to be attracted to her because of her apparent attraction to him and his own fantasies of how enhanced his life would be and how others will see him with her on his arm. They are likely to become disillusioned, periodically fight, and sometimes even triangulate a child or other individual in a struggle to gain power and make up for what they do not have with each other.
Because these patterns represent some gender stereotypes, it may be use- ful for the couple to be seen by a male/female cotherapy team. Each therapist in individual sessions prior to some of the couple sessions could prepare his or her same-gendered client by acknowledging strengths and achievements coupled with setting structured goals. For the female, these sessions could include practicing on channeling/controlling feeling expressions; for the male, they could focus on empathy practice (with the therapist avoiding mirroring, which serves to reinforce narcissism). For the more moderate, normal-appearing histrionic/narcissistic couple, it may be that that couple difficulties lie in relationship problems more than in the personality structure of either.
Compulsive Female/Dependent–Avoidant Male
Females with a high elevation on the Compulsive scale (7) appear excessively disciplined and maintain a highly structured, organized life. They see them- selves as conscientious, devoted to thoroughness, and fearful of not doing things in the best possible way. They maintain an inner world that is cogni- tively constricted (i.e., narrow and rule bound, anticipating that others will behave similarly). Sometimes using reaction formation as a major defense, they appear super-reasonable, not dealing with contrary feelings, and fearful of underlying feelings such as anger. Although their lives may be full of tension and tight control of emotions, research suggests that an elevated compulsive score may indicate more conscientiousness than compulsivity (Craig, 1999), an effective and rewarded style in many environments.
EFFECTIVE USEOF PSYCHOLOGICAL TESTSWITH COUPLESAND FAMILIES 75 Males with an elevation on the Dependent (3) and Avoidant (2A) scales have a need for close relationships but hesitate about approaching others out of a fear of rejection. Their style is interpersonally submissive but not expressive.
They may be seen as cognitively naive, avoiding confrontation; sometimes they experience themselves as weak and alienated. They may feel a need to become involved with, if not devoted to, others; they introject others’ views and maintain relationships through the use of fantasy in order to avoid signif- icant anxiety. At a level of personality style, moderate level scores point to a person with a significant emotional neediness who, because of the importance of relationships, is hesitant to take action without being sure of acceptance.
Couples therapy with couples demonstrating more pronounced score patterns such as these needs to proceed slowly and often needs to be accom- panied with individual sessions. Conjoint sessions must appeal to the female’s need to do the right thing and the male’s need for a close relationship with reassurance of acceptance. In couple sessions the goal is for the male to become more assertive and capitalize on his abilities developed outside the home and to become more active in the home. The goal for the female is mod- ify her sometimes too conscientious pattern so as to be in more control of it, thus turning it to positive use and being less constricted by it, and to move from being passive and only (restrictively) nurturing others to paying increased attention to her own needs as well as those of others.
Narcissistic Male/Narcissistic Female
As noted earlier, males with a marked peak on the Narcissistic scale (5) may act in an arrogant, condescending fashion with a tendency irresponsibly to ignore social norms and standards. They may show little empathy and act in an interpersonally exploitive manner, seemingly unaware of the negative impact on others. They view themselves as special and have fantasies of love and success that drive them to high levels of achievement, yet they may repress and/or reshape affect and distort facts to maintain their self-illusions in the face of failures. Typically, they maintain a cool aura of self-possessed optimism unless their confidence is shaken.
Females with very high elevations on the Narcissistic scale (5) may present much as narcissistic males. They are interested in others in large part for what they can gain from them in terms of their own self-esteem, and thus they can behave amorously. Nevertheless, they tend to be self-deceptive, self- centered, and rationalize; until their confidence is shaken, they present with a cool, imperturbable demeanor.
As a couple, narcissistic males and females tend to have similar blind spots: repressing and denying the same negative aspects of their personalities.
This means that they cannot easily confront each other without being aware of similar self-aggrandizing traits in themselves. Although they believed earlier in their relationship that they were “made for each other” because they
reflected each other, with the arrival of a child or other shifts in their inter- personal balance, each misses the other’s focused attention. Their intense attachment can switch from positive to negative, blaming each other and pointing out the negative parts of the other’s personality, and thereby warding off confronting themselves with their own experiences of deprivation and recognition of their short-comings. By recognizing the couple’s interlocking narcissistic styles, a couple therapist can more easily avoid responding nega- tively to these individuals’ self-focused approaches to life and instead can support their effectiveness while gently helping them gain more actual empathy with each other. A couple demonstrating narcissistic styles (rather than disorders) may have developed a broader base and a better interpersonal connection, giving the therapist a platform to assist them in building a sounder marriage relationship despite the arrival of a child, loss of a job, illness, or other unbal- ancing occurrence.
Histrionic–Narcissistic Female/Compulsive Male
In this profile, the Histrionic pattern (Scale 4), mixed with Narcissistic features (Scale 5) of superiority and entitlement, increases the possibility of irresponsible, acting-out behavior considerably beyond that of the prototypical histrionic personality disorder in females. These individuals tend to be attracted to Compulsive (Scale 7), that is, conscientious, males whom they view as stable, goal oriented, and secure. However, with time they experience such men as boring and rigid. These females may have sought out other types of relationships, but after being wounded, may have retreated to safe kinds of husband–father relationships with a compulsive male in order to lick their wounds.
Males with a compulsive or conscientious personality (Scale 7) are likely to have been excited and attracted to these affectively dominated females whom they typically view as intriguing, colorful, and vivacious. Yet, with the passage of time and relational demands, these males become disconcerted with their partners, whom they now view as flighty, irresponsible, and supremely selfish and vain.
Relationally, these females will be the source of feeling expressiveness in the relationship, while these males will be the voice of reason. Couple therapy stressing improved communication could focus on having these couples get to know each other as specific, unique individuals. Unfortunately, without the ben- efit of couples therapy or other corrective experiences, neither partner is likely to move beyond these limiting roles without expressing his or her humanity.
Antisocial Female/Antisocial–Narcissistic Male
Clinicians inexperienced with the MCMI-III may improperly conclude that both partners are antisocial or psychopathic personalities because of elevated
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EFFECTIVE USEOF PSYCHOLOGICAL TESTSWITH COUPLESAND FAMILIES 77 6A Scales. In keeping with Millon’s clinical formulation of this scale as primarily a measure of aggression, such scale elevations (particularly at a moderate level) reflect the competitive, aggressive attitude and style associated with successful entrepreneurs. These are the “antisocial” style individuals who are likely to come in for couple therapy. It would be surprising if true psycho- paths, who comprise only a minority of antisocial personality disorders, came for therapy.
Couples with this pattern who show up for therapy typically take risks, exploit (usually within the limits of the law), and shade the truth to meet their own needs. Yet, they view themselves as law-abiding individuals. When they become involved in close romantic relationships, they can carry some of these antisocial qualities into that relationship. Thus, they can be competitive and can view their relationship as a game in which they match wits with each other. They may admire each other’s ability to succeed in business; however, they can be tough, argumentative, and insensitive to each other’s feelings.
With this couple, an imbalance can be anticipated because of the male’s narcissistic (Scale 5) entitlement. His partner will become incensed at his self- centeredness. When she finds ways to puncture his confident front, he may respond with hurt, rage, and vindictiveness. Their motivation for coming for couples therapy is probably so that each can gain an advantage over the other.
When the therapist does not express judgment of who is right, they can impa- tiently join in turning on the therapist, only to seek a new one. Therapists need to be aware that this therapy could be the first stage in a long divorce battle in which neither gives because winning is everything for them.
Dependent Male/Dependent Female
Dependent partners (Scale 3) tend to be so “nice” to each other that they inev- itably tread lightly in their relationship. Unfortunately, treading lightly allows little opportunity for openly dealing with their problems. Consequently, problem solving only appears to occur when one partner quickly acquiesces in order to avoid being criticized. At some level, each partner may be looking for a good parent and thus may develop considerable resentment, although he tends to squelch this; if irritation comes out unexpectedly, he may hurriedly apologize.
Each partner has the capacity to be kind, loving, and caring with each other. If they begin to develop personally outside the relationship—through work experiences, for instance—and maintain their same way of couple relating, this dissonance in their lives may bring them to couples therapy. By helping each recognize his growing resentment and assisting each in learning to com- municate his feelings, the therapist can help these needy people experience developing together. When dependent style couples seek help, the therapist needs to discover what has unbalanced their relationship, for example, the growth of one, a new child, a promotion, a relationship external to the mar- riage, and so forth.
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Summary
The MCMI-III uniquely provides informational, descriptive hypotheses about personality structure as well as syndromal indications. The MCMI-III profile helps the couples therapist draw understandable hypotheses about the couple relationship and interactive pattern in guiding planning for interventions.