Assessing Adolescents with the MACI: Using the Millon Adolescent Clinical Invetory / Edition 1

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Overview

Assessing Adolescents with the MACI is an interpretive guide for using the Millon Adolescent Clinical Inventory—the most widely used personality assessment test for adolescents. The first book devoted exclusively to the MACI, this resource will prove a helpful guide for understanding the test, interpreting the results in clinical evaluation, and making appropriate recommendations for treatment and care management.

Unlike other assessment tests developed for adults and adapted for adolescents, the MACI was created to address the unique concerns, pressures, and situations of adolescents. The MACI is also constructed using an underlying theory of personality and psychopathology. The MACI is a 160-item, 31-scale self report inventory that was designed to assess personality styles, significant problems or concerns, and clinical symptoms in adolescents. Using a true false format, the MACI surveys a wide range of personality characteristics and clinical symptoms that tend to be a focus in psychological evaluations of teenagers that either have or are suspected of having emotional or behavioral difficulties.

While multi-scale personality inventories such as the MACI are useful for improving the clinician's understanding of an adolescent's personality and clinical symptoms, there are other reasons for using such instruments. The MACI can be used to formulate diagnostic hypotheses, confirm clinical diagnoses, formulate treatment plans, or assist in decision making surrounding case management and disposition planning. The MACI can be used as an outcome measure to evaluate changes in an adolescent's functioning as a result of treatment and intervention. Of course, the MACI can also be used in research studies to investigate a range of issues that pertain to adolescent psychopathology, personality, and treatment response.

Drawing on a broad range of sources, including data in the MACI manual, published research studies, unpublished research, theoretical literature, and his own experience with the test, Joseph McCann lays the groundwork for the basis of the test and then offers an exhaustive exploration of all facets of the test. Recognizing both the strengths and weaknesses of the MACI, McCann offers a balanced and comprehensive resource on this vital assessment tool.

"This book fills an important gap in the clinical literature . . . Joseph McCann, author of this first full text on the MACI, is the best known workshop presenter on the topic. Assessment with the MACI will enable the student and the clinician to develop a sophisticated basis for disentangling the many variations among youngsters, to assess both their assets and liabilities, to determine the presence of clinical disorders, and, most importantly, to provide a full picture that can serve as the basis for making decisions regarding each adolescent's welfare, that is, to be able to outline a logical course of treatment which may prove more optimally efficacious. It will guide the reader to transform the raw MACI test data, coordinate these data with the history of the youngster's experience, as well as with observational and interview information, facilitating interpretive syntheses and providing thereby a basis to help link assessment to psychotherapy. This text is insightful and comprehensive, a work of inestimable value to both practicing clinicians and students." —Theodore Millon, from the Foreword.

The book contains black-and-white illustrations.

Assessing Adolescents with the MACI is an interpretive guide for using the Millon Adolescent Clinical Inventory Test­the most widely-used personality assessment test for adolescents. The MACI, designed for mental health professionals, holds many advantages over its main competitor, the MMPI-A, as it is pitched at a lower reading level, shorter in length, offers better internal consistency, and is grounded in a comprehensive theory of psychopathology.

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Editorial Reviews

From The Critics
Reviewer: Tony A. Fletcher, PsyD (Rush University Medical Center)
Description: This is the first full-length book to address the evaluative value of the Millon Adolescent Clinical Inventory (MACI). This resource accumulates the current research and the clinical expertise of the foremost workshop presenter of the MACI in an in-depth text that addresses the clinical usefulness of the most widely used adolescent test of personality and psychopathology.
Purpose: The purpose is to provide a guide for understanding the MACI's interpretive value in clinical evaluations and an aid in appropriate treatment and management. The author's intention is to provide a comprehensive text for teaching the development and application of the MACI. This is an important, timely, and much needed understanding of the Millon Adolescent Clinical Inventory for addressing personality traits, which contributes to the understanding of patient's overall personality characteristics and clinical syndromes.
Audience: This book is written for graduate course study in personality assessment and will be an invaluable resource for the practicing professional who works with adolescents. The author is a leading expert in the development and utility of the MACI and gives practical applications of this instrument's personality pattern scales.
Features: The book includes clinical case vignettes that help to round out the MACI's clinical uses. There are sufficient tables and figures that aid in the discussion of the use of the MACI. The references give merit to MACI credibility and utility as a personality instrument.
Assessment: This is an extremely useful interpretive guide to the MACI and is a must-read for any clinician who evaluates adolescents. It brings together theoretical concepts and clinical applicability, and connects them with real-world clinical issues to aid in appropriate diagnosis and treatment of adolescent populations.
Tony A. Fletcher
This is the first full-length book to address the evaluative value of the Millon Adolescent Clinical Inventory (MACI). This resource accumulates the current research and the clinical expertise of the foremost workshop presenter of the MACI in an in-depth text that addresses the clinical usefulness of the most widely used adolescent test of personality and psychopathology. The purpose is to provide a guide for understanding the MACI's interpretive value in clinical evaluations and an aid in appropriate treatment and management. The author's intention is to provide a comprehensive text for teaching the development and application of the MACI. This is an important, timely, and much needed understanding of the Millon Adolescent Clinical Inventory for addressing personality traits, which contributes to the understanding of patient's overall personality characteristics and clinical syndromes. This book is written for graduate course study in personality assessment and will be an invaluable resource for the practicing professional who works with adolescents. The author is a leading expert in the development and utility of the MACI and gives practical applications of this instrument's personality pattern scales. The book includes clinical case vignettes that help to round out the MACI's clinical uses. There are sufficient tables and figures that aid in the discussion of the use of the MACI. The references give merit to MACI credibility and utility as a personality instrument. This is an extremely useful interpretive guide to the MACI and is a must-read for any clinician who evaluates adolescents. It brings together theoretical concepts and clinical applicability, and connects them withreal-world clinical issues to aid in appropriate diagnosis and treatment of adolescent populations.

4 Stars! from Doody
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Product Details

  • ISBN-13: 9780471326199
  • Publisher: Wiley, John & Sons, Incorporated
  • Publication date: 3/8/1999
  • Edition number: 1
  • Pages: 238
  • Product dimensions: 6.50 (w) x 9.53 (h) x 0.98 (d)

Meet the Author

JOSEPH T. McCANN, PsyD, JD, has a private clinical and forensic psychology practice in Binghamton, New York, and has collaborated on the MACI with Theodore Millon, the author of the test. Dr. McCann is also the author of Malingering and Deception in Adolescents and Forensic Assessment with the Millon Inventories.

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Table of Contents

Basic Issues and Theoretical Foundations.

Development of the MACI.

Profile Features and Psychometric Characteristics.

Assessing Profile Validity.

Personality Patterns Scales.

Expressed Concerns Scales.

Clinical Syndromes Scales.

Integrating the MACI Profile.

Special Diagnostic and Assessment Issues.

Clinical Applications.

Treatment Planning with the MACI.

Appendices.

References.

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First Chapter

Assessing Adolescents with the MACI: Using the Millon Adolescent Clinical Inventory
Joseph T. McCann
0-471-32619-4

(NOTE: The figures and/or tables mentioned in this sample chapter do not appear on the web version.)
Basic Issues and Theoretical Foundations

The past decade has not been particularly kind to teenagers because many alarming trends have received a great deal of media attention. During the 1997-1998 academic year, five schools became sites of tragedy when a student opened fire with a weapon on a group of teachers or classmates. In Mississippi, a teenager shot and killed two girls, one of whom had broken up with him earlier. In Kentucky, a 14-year-old shot and killed three students and wounded five others for reasons that were never made clear in media coverage. In Arkansas, an 11-year-old and 13-year-old student lured teachers and peers outside a middle school by pulling a fire alarm and then shot at them; in the end, four students and a teacher were killed. Although national statistics have shown a decline in violent crime overall in recent years, the data mask an alarming increase in violent crime perpetrated by teenagers. According to statistics published by the Federal Bureau of Investigation (1993), the arrest rate for violent crime rose 45% among teenagers between 1988 and 1992. Although juvenile homicide apparently dropped 30% between 1994 to 1996, more than 2,000 juvenile homicides were still reported in 1996 (Schiraldi, 1998).
Criminal violence is not the only concern for young people in this country. Over a 30-year period going back to 1957, the overall suicide rate for people age 15 to 24 tripled (Berman & Jobes, 1991). After a peak suicide rate in the late 1970s, suicide among young people appears to have leveled off, but the rate remains high nevertheless, with about 12 suicide deaths per 100,000. These statistics point to an increased demand for assessing and treating the mental health problems of adolescents. Where inpatient and outpatient clinics once focused on adults, and the occasional child or adolescent, there are now specialized outpatient clinics and inpatient hospital units, residential treatment programs, and substance abuse units that focus on adolescents.
The mental health problems of adolescents and their increasing involvement in the criminal justice system have created a pressing need for accurate and useful methods for assessing adolescent personality and psychopathology. This book presents information on clinical use of the Millon Adolescent Clinical Inventory (MACI; Millon, Millon, & Davis, 1993), including an overview of the instrument's development, approaches to interpretation, and use of the test results for developing treatment plans for adolescents receiving mental health services. This chapter provides a brief overview of the MACI, followed by a discussion of general issues that set forth a context in which both novice and experienced MACI users can understand how to utilize the results from this psychological test.
The first portion of this chapter provides a brief summary of the MACI, including its format and foundations. This section is followed by an overview of adolescent development and the assessment of psychopathology in adolescence. A complete analysis of these issues is beyond the scope of this chapter; however, this discussion points out the unique psychological processes that occur in this critical period of development. The chapter then closes with a summary of Theodore Millon's theory of personality and psychopathology. An understanding of this theoretical model is critical to the interpretation of MACI test results because the theory served as a guiding framework for development of the instrument. Moreover, the theory is a major source of information for interpretation of the MACI.

OVERVIEW OF THE MACI
The MACI is a 160-item, 31-scale self-report inventory designed to assess personality styles, significant problems or concerns, and clinical symptoms in adolescents. Using a true-false format, the MACI surveys a wide range of personality characteristics and clinical symptoms that tend to be a focus in psychological evaluations of teenagers who either have or are suspected of having emotional or behavioral difficulties. Responses of adolescents on the MACI items are scored and individual scales are plotted in a profile as illustrated in Figure 1.1. The MACI can be used in several settings to evaluate the psychological status of adolescents: inpatient and outpatient mental health clinics; residential treatment centers; correctional facilities; and educational institutions where professionals suspect psychological difficulties are affecting a teenager's school performance.
Multiscale personality inventories such as the MACI are designed to improve the clinician's understanding of an adolescent's personality and clinical symptoms, but there are other reasons for using such instruments. The MACI can be helpful in formulating diagnostic hypotheses, confirming clinical diagnoses, formulating treatment plans, or making decisions about case management and disposition planning. In addition, the MACI can be used as an outcome measure to evaluate changes in an adolescent's functioning as a result of treatment and intervention. The MACI can also be effective in research studies to investigate a range of issues that pertain to adolescent psychopathology, personality, and treatment response.
In the following chapters, numerous issues will be discussed on development of the MACI, its psychometric properties, interpretation of results, and its use in assessing a wide range of diagnostic and treatment issues. However, some basic principles are relevant to understanding the full range of applications of the test and warrant discussion here. The MACI is based on an approach to test development that departs from the way clinicians approached adolescent assessment a decade ago. Traditionally, adolescents were often viewed as "miniadults": personality assessment instruments developed on adult populations were administered to adolescents with the adoption of specific age-referenced norms. However, some problems, social pressures, and developmental considerations are unique to adolescents, and adult personality measures tend not to capture these issues. The MACI was developed specifically for adolescents and the item content and scales were designed with these unique issues in mind. In addition, the MACI, like its adult counterpart the Millon Clinical Multiaxial Inventory-III (MCMI-III; Millon, Davis, & Millon, 1997), is based on a comprehensive theory of personality and psychopathology (Millon, 1969, 1981, 1990; Millon & Davis, 1994). Many clinical assessment instruments are not necessarily grounded in a comprehensive theoretical model; however, the theory developed by the MACI author, Theodore Millon, offers a logical, coherent, and internally consistent model for developing item content, scale composition, and a general framework for understanding test results. Therefore, the theoretical model can inform test interpretation in the same way that psychometric properties and research results can inform the interpretive process.
In light of these issues, it is important to recognize the unique problems that adolescents encounter and the underlying theory of personality and psychopathology on which the MACI rests. The remainder of this chapter describes these issues and will provide MACI users with a context for understanding the material in the remainder of this book.

ADOLESCENT DEVELOPMENT
In everyday language use, adolescence is a term that generally refers to the teenage years. However, strict chronological age can be problematic in defining when specifically adolescence occurs. Among most people who study this period of development, there is a consensus that adolescence is a stage of considerable transition. As noted by Coleman (1992):
The transition, it is believed, results from the operation of a number of pressures. Some of these, in particular the physiological and emotional pressures, are internal; while other pressures, which originate from peers, parents, teachers, and society at large, are external to the young person. Sometimes these external pressures carry the individual towards maturity at a faster rate than he or she would prefer, while on other occasions they act as a brake, holding the adolescent back from the freedom and independence which he or she believes to be a legitimate right. It is the interplay of these forces which, in the final analysis, contributes more than anything to the success or failure of the transition from childhood to maturity. (pp. 10-11)
This observation by Coleman captures the many different pressures and struggles that characterize adolescence. Biological, psychological, and social pressures contribute to the tension between independence and dependence on the family.
There are many ways to define adolescence (Petersen, 1988). Chronological age is one means, but this approach is limited because it does not fully identify this period's developmental aspects. If one assumes the teenage years of 13 to 19 define adolescence, then these age parameters do not encompass other essential features. Puberty is often a biological marker that is used to mark the onset of adolescence; however, some teenagers reach puberty prior to age 13 while others may have a delayed onset. Thus, chronological age is not often an accurate marker. Other gauges have included specific grade levels (e.g., junior and senior high school), cognitive factors such as the onset of formal operations, or the structure of an individual's social environment (e.g., involvement with certain peer groups, leaving the parental home). Some have viewed adolescence broadly as encompassing the second decade of life (Petersen, 1988).
In this book, adolescence is generally conceptualized as the teenage years from 13 to 19. Although this definition has limitations, it also defines the age range for which the MACI can be appropriately utilized. Within the developmental stage of adolescence, several factors are significant. The transitional nature of this period creates a tension between adequate adjustment and turmoil. This conflict is characterized in the quotation from Coleman's (1992) work cited at the beginning of this section. Moreover, it is implicit in this characterization of adolescence as a transitional period that a certain degree of emotional and psychological upheaval is to be expected. Despite these challenges, evidence supports the conclusion that whereas most teenagers can cope with the demands and turmoil of adolescence, some cannot and come to the attention of the mental health or juvenile justice system (Petersen, 1988).
Adolescents can potentially experience problems with adjustment in several areas of functioning. In the biological realm, adolescents experience physical changes related to puberty, and marked changes in hormonal activity bring on increased sexual interest and tension. Therefore, adolescents can experience concerns about their physical development, sexuality, and body image. Some of these concerns may be transient and relatively common, but others may reflect psychological discomfort and maladjustment. In the psychological realm, adolescents face changes in identity, self-concept, and cognitive maturity in response to gradually increasing demands to select a career path and set of life goals. Again, these challenges may be relatively common, but in some cases the adolescent may develop marked discomfort or confusion about his or her identity or self-worth. In the social realm, adolescents face tension between developing greater interests with peers or adopting group norms and the demand to maintain some emotional and financial dependence on parents. This tension again can be the source of normal conflict between the adolescent and the family, but it can also escalate into marked disturbances such as insecurity among peers, oppositional or defiant acting-out, or a lack of empathy toward others.
The unique challenges of adolescence dictate that the assessment of adolescents must include measures that take these issues into account. In many respects, the MACI addresses these issues by including scales that measure concerns that are of most salience in the lives of adolescents.

ASSESSING ADOLESCENT PSYCHOPATHOLOGY
It should come as no surprise that the transition's adolescence and the turmoil that characterizes this stage of development create unique challenges for the clinician who is assessing for psychopathology. The Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV; American Psychiatric Association, 1994) constitutes the most widely adopted diagnostic framework in clinical practice and is therefore a useful starting point for analyzing the diagnosis of psychopathology, or mental disorders, in adolescents.
The DSM-IV defines a mental disorder as "a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress . . . or disability . . . or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom" (p. xxi). This definition emphasizes that the behavioral or psychological syndrome must be a source of distress for the person or a cause of some impairment in functioning and not merely a deviation from normality. With respect to diagnosing a mental disorder in adolescents, the DSM-IV approach makes two general provisions that offer some guidelines. The first is the identification of specific disorders that are usually diagnosed during infancy, childhood, or adolescence and the second is a special section of "Specific Culture, Age, and Gender Features" for other disorders that may be diagnosed in children, adolescents, or adults (e. g., major depression). Despite these provisions, there are still difficulties associated with the practice of diagnosing psychopathology in adolescents.
Although specific disorders in DSM-IV are identified as being first diagnosed in childhood and adolescence (e.g., conduct disorder, oppositional defiant disorder, mental retardation), sometimes these disturbances are not identified until adulthood. For example, attention deficit hyperactivity disorder is included in the "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence," but in some cases the symptoms may not be accurately identified as being due to this condition until much later in life, even though the individual might have had some difficulties in childhood or adolescence. Also, the DSM-IV notes that the identification of specific disorders as having their onset in childhood or adolescence should not prevent clinicians from exploring other diagnoses that may be present in young people (e.g., major depression, posttraumatic stress disorder, schizophrenia). In those disorders that are found throughout the DSM-IV, the clinician must thus attend to the particular age features outlined for a specific disturbance.
The DSM-IV makes a number of provisions for diagnosing disorders in adolescence based on factors such as the specific age of the individual, the duration of time that symptoms should be present, and the expected age of onset for a particular form of psychopathology. Moreover, many of these provisions take into account research findings on the manifestation of psychopathology in adolescents. For example, antisocial personality disorder has as one of its criteria that the diagnosis cannot be made unless the person is at least 18 years of age. If a teenager below the age of 18 exhibits symptoms such as antisocial acting-out, chronic impulsivity, violation of the rights of other people, and similar features associated with antisocial personality, then a diagnosis of conduct disorder is appropriate. Moreover, DSM-IV notes that conduct disorder is an appropriate diagnosis only when "the behavior in question is symptomatic of an underlying dysfunction within the individual and not simply a reaction to the immediate social context" (American Psychiatric Association, 1994, p. 88). More importantly, research shows that conduct disorder in adolescence does not predict antisocial personality disorder in adulthood because some forms of adolescent antisocial behavior are limited to this phase of development, whereas other forms of such behavior are indicative of a life course of antisocial disturbance (Moffitt, 1993).
Another provision made by DSM-IV that is relevant to use of the MACI in clinical assessment is the specific caution made about diagnosing personality disorders in adolescents. Widiger and his colleagues (Widiger, Mangine, Corbitt, Ellis, & Thomas, 1995) urge caution in making personality disorder diagnoses in adolescents because many personality traits do not stabilize until the third decade of life and personality disorder diagnoses show limited stability from adolescence into early adulthood. As such, DSM-IV permits the diagnosis of all personality disorders except antisocial in children or adolescents, so long as "the individual's particular maladaptive personality traits appear to be pervasive, persistent, and unlikely to be limited to a particular developmental stage or an episode of an Axis I disorder" (American Psychiatric Association, 1994, p. 631). Moreover, the DSM-IV requires that the features of a personality disorder must be present for at least one year before making a diagnosis.
The overall structure of the MACI reflects this level of caution, as well as the controversy surrounding personality disorder diagnosis in adolescents. In particular, the Personality Patterns scales have names that reflect intermediate levels of disturbance. Although each of these scales parallels a specific DSM personality disorder, the scale names do not directly reflect these diagnoses as do the names of the personality scales on the adult version of the Millon inventories, the MCMI-III. Thus, Scale 1 on the MACI, while based on the construct of schizoid personality disorder, is called Introversive; Scale 2 on the MACI is named Inhibited instead of Avoidant, and so on. This subtle name alteration reminds MACI users that although the scales are designed to measure disturbed personality traits, judicious use of the scales and a conservative approach to diagnosis of personality disorders in adolescents are warranted.
In light of the challenges that arise when assessing psychopathology in adolescence, it is extremely helpful to have some guiding framework for making a diagnosis. The literature on adolescent psychopathology and specific diagnostic criteria as outlined in DSM-IV help to inform the assessment process. Instruments specifically designed for adolescents, such as the MACI, are another useful source of information. A unique aspect of the MACI is that it is based not only on traditional psychometric principles, but also on a comprehensive theory of personality and psychopathology. An understanding of this theoretical framework is necessary for a full appreciation of the MACI's development and for interpreting the test results. The remainder of this chapter describes the theoretical model on which the MACI rests. For readers who want a more detailed review of Theodore Millon's theory, Millon and Davis (1994) provide the most comprehensive and updated presentation.

MILLON'S THEORETICAL MODEL
The human personality can be studied and defined in many ways including descriptive or explanatory perspectives that focus on psychological, social, and biological factors. The theoretical approach to personality and psychopathology developed by Theodore Millon is a comprehensive and integrative approach to personality that is biopsychosocial in nature. Originally formulated within a social learning model (Millon, 1969, 1981), the theory has expanded into an evolutionary one (Millon, 1990; Millon & Davis, 1994) in which the underlying constructs and principles are rooted in evolutionary theory and reflect many of the principles found in all sciences.
The most basic notion is the principle that individual personality traits lie along a continuum from normal traits and styles, to intermediate levels of disturbance, to abnormality involving disorders of personality. A central framework used to describe this continuum includes the concept of three dimensions, or polarities, each defining a separate aspect of human personality. The first polarity consists of pain versus pleasure and refers to the notion that human existence is directed toward maximizing pleasurable or life-enhancing experiences, and minimizing painful or life-threatening experiences. As such, individuals are generally oriented to seek out pleasure and minimize discomfort. A second polarity consists of active versus passive and refers to the typical ways of behaving that permit the person to seek out pleasure and minimize pain. The two ways of achieving pleasure include active means, such as manipulating and changing one's environment, and passive means such as accommodating and adapting to one's environment. The third polarity is self versus other and represents the source of reinforcing or life-enhancing experiences. This polarity recognizes the social nature of human existence in that some life-enhancing experiences come about through the self, such as getting what one wants or having one's needs met; and some experiences involve others, such as performing altruistic acts or having close interpersonal relationships. At the heart of this theory is the notion that normal functioning involves flexibility and adaptability because the person has a healthy balance between all these polarities. That is, flexibility exists between self and others and the capacity to be active or passive as the situation requires. Moreover, the normal personality is characterized by a clear focus on maximizing pleasurable life experiences and coping effectively with painful situations.
Disturbances in personality arise when the person becomes more rigid in a particular approach to coping, perpetuates vicious cycles in which the same difficulties arise in the person's life, and there is greater susceptibility to psychological distress or decompensation. Moreover, clinical symptoms such as anxiety, depression, or thought disorder are viewed as extensions of personality disturbances. Using the three polarities, Millon outlines five disruptions that can occur in the person's functioning that give rise to personality disturbances and psychopathology. The first disruption can arise in the person's instrumental style of coping in that he or she becomes fixated on either an active or a passive mode of coping. The second disruption in functioning can arise in the source of the person's life-enhancing experience when there is an excessive reliance on either the self (independent) or others (dependent). The three other disruptions all arise in the pain versus pleasure polarity. The person can be detached, with an unwillingness or inability to experience pleasure in life. Another disruption can occur when the individual reverses the polarities of pain and pleasure, deriving pleasure from experiences that are normally painful and pain in situations that are normally pleasurable; this disruption is called a discordant personality pattern. The other disruption occurring in the pain versus pleasure realm is the ambivalent pattern whereby the person is conflicted between seeking out self-oriented versus other-oriented experiences.
These disturbances in polarities can be used to form a 2 (active-passive) x 5 (independent-dependent-discordant-ambivalent-detached) table that represents 11 basic personality styles. Table 1.1 outlines each of these styles with the labels reflecting intermediate levels of disturbance and the corresponding DSM personality disorder in parentheses. The active-independent personality is characterized by manipulation and self-centered acting-out that is represented in the unruly personality, corresponding to the antisocial personality disorder. The passive-independent style is characterized by a lack of empathy for others, feelings of entitlement, and grandiosity that define the egotistic personality, or the narcissistic personality disorder. Active-dependent personality is defined by gregariousness, attention-seeking, and emotionality that is meant to draw attention to one's self and to make others want to be around the person; this dramatizing style corresponds to the histrionic personality disorder. The passive-dependent personality is characterized by submissiveness, passivity, and inadequacy and reflects a submissive style that parallels the dependent personality disorder. The active-discordant style is characterized by hostile acting-out, the intentional infliction of pain, either verbally or physically, and excessive efforts to exert power over others; this forceful style corresponds to the sadistic personality disorder. Passive-discordant types are self-loathing and pessimistic, and they feel deserving of their suffering and unhappiness; this self-demeaning type corresponds to the self-defeating personality disorder. The active-ambivalent personality experiences excessive irritability and moodiness, skepticism, and oppositional behavior; this style corresponds to the negativistic personality disorder. Passive-ambivalent types are conflicted and overcompensate by adopting a rigid adherence to rules and order, tight controls over emotions, and inflexibility; this conforming style corresponds to the compulsive personality disorder. In the detached personality type, there is an active variant that is characterized by withdrawal from others, heightened social anxiety, and the expectation of rejection and ridicule by others; this inhibited type corresponds to the avoidant personality disorder. Finally, there are two variants of the passive-detached style. The introversive style, corresponding to the schizoid personality disorder, is characterized by bland emotions, a lack of interest in relationships, and a lethargic and unemotional demeanor. The doleful style, corresponding to the depressive personality disorder, is characterized by pessimism, hopelessness, and chronic unhappiness. The major distinguishing feature between these two passive-detached types is that the introversive style is generally devoid of any emotional experience whereas the doleful style passively accepts a painful and dysphoric existence.
Millon also conceptualizes three personality disorders, the schizotypal, borderline, and paranoid, as severe variants of the more basic personality disorders. These three disorders are considered more severe because of the manifestation of transient psychotic episodes, severe disruption in identity, and more extreme levels of emotional dysregulation. Only the borderline personality is represented on the MACI because of the wide clinical interest in borderline disturbances in adolescents. The other two severe personality disorders are not represented on the MACI due to the low prevalence of these disturbances in the clinical sample that made up the instrument's normative sample.
The theoretical framework outlined here and schematically displayed in Table 1.1 has direct application to the clinical interpretation of the MACI. The individual scales on the MACI profile are arranged in accordance with this theoretical framework. In Figure 1.1, Scales 1, 2A, and 2B are arranged side by side and correspond to the inhibited, introversive, and doleful personalities; all three of these scales thus reflect the detached personality types in Millon's theory. Scales 3 and 4 in Figure 1.1 represent the submissive and dramatizing personality styles and also correspond to the dependent types. Scales 5 and 6A represent the egotistic and unruly personalities, which have the independent polarity disruption as the unifying theme. Scales 7 and 8A represent the conforming and oppositional personalities and have the ambivalent polarity disruption as their unifying theme. Only the two discordant types, forceful and self-demeaning, are placed next to scales that have similar behavioral and clinical presentations, but do not comprise a discordant dimension in side-by-side scales.
This arrangement of the MACI scales has some practical implications for interpretation because some MACI profiles with multiple scale elevations can be understood using the theoretical framework. If Scales 1, 2A, and 2B are all elevated, a general social detachment and lack of pleasure in life is represented in the profile. If Scales 2A and 2B are elevated, but Scale 1 is not, then social detachment associated with painful emotional experiences is being tapped. Likewise, if Scales 5 and 6A are elevated, the MACI profile is reflecting a general self-centeredness that may be manifest in both entitlement and expectation of special treatment as well as manipulative and antisocial acting-out. Because the discordant and ambivalent types experience conflict either in the nature or source of reinforcement, Scales 6B, 7, 8A, and 8B reflect a cluster of scales that reveal how the adolescent deals with internal conflict and tension. This issue is discussed in Chapter 5.
Another important concept in Millon's theory of personality is the prototypal model of individual personality types. A prototype represents a common set of features or characteristics describing members of a category that constitutes an ideal standard to evaluate individuals in the real world (Everly, 1995). What makes the prototypal model useful is that it provides different domains of personality to allow for the heterogeneity among people in actual practice. For example, clinicians rarely encounter a "pure" narcissistic or antisocial personality disorder; rather, people represent mixes and blends of personality styles, or two individuals with a specific personality disorder (e. g., narcissistic) may manifest different clusters of traits of the disorder.
The concept of domain of personality is important because it provides the basis for understanding the different personality styles discussed earlier. Millon defines two general features of personality: structural and functional. Structural attributes of personality "represent a deeply embedded and relatively enduring template of imprinted memories, attitudes, needs, fears, conflicts, and so on that guide experience and transform the nature of ongoing life events" (Millon & Davis, 1994, p. 144). Functional attributes of personality "represent dynamic processes that transpire within the intrapsychic world and between the individual's self and psychosocial environment" (p. 141). These structural and functional domains of personality are then organized at four levels: behavioral, phenomenological, intrapsychic, and biophysical.
The behavioral level of personality domains represents those aspects that deal with what a person does and what can be directly observed. The two domains of personality at this level are expressive acts and interpersonal conduct. Expressive acts are "readily observable by others" and "enable the clinician to define, through inference, valuable qualities of the patient's overall characterological presentation" (Everly, 1995, p. 29). Interpersonal conduct is "the way one relates to others" and "allows the clinician to declare qualities of personal competence, self-esteem," and needs for affiliation (p. 29). Both expressive acts and interpersonal conduct are functional attributes of personality.
At the phenomenological level, there are three domains of personality. These have the common theme of deciding how the person experiences him-or herself in the world. The three domains at this level are cognitive style, object representations, and self-image. Cognitive style represents how people "perceive events, focus their attention, process information, organize their thoughts, and communicate their reactions and ideas to others" (Everly, 1995, p. 30). Object representations constitute "an inner imprint, a structural residue composed of memories, attitudes, and affects" that are products of significant experiences with others and which guide perceptions and reactions to current life events (p. 30). Self-image refers to the perception that people have of themselves and their consistent image of who they are. Of these three domains of personality, cognitive style is a functional attribute and object representations and self-image are both structural attributes.
The intrapsychic level of functioning encompasses two domains of personality representing unconscious processes that reflect how the person deals with internal conflict. The two domains at the intrapsychic level are regulatory mechanisms and morphologic organization. Regulatory mechanisms are internal psychological processes that provide self-protection, self-defense, need gratification, and conflict resolution when the person experiences internal or external psychological threats; they are generally inferred and unobserved features of the personality. Morphologic organization refers to the general configuration of the internal psychic structure, including the degree of cohesiveness, balance, and tension that exists among the internal personality structures. The regulatory mechanisms constitute a functional attribute of personality, whereas morphologic organization is a structural component of personality.
The fourth level of data on personality functioning is the biophysical level, which encompasses one domain, namely mood or temperament. This is a structural attribute and represents the persistent moods and emotional features that occur in a wide range of experiences and across various relationships.
In all, eight domains of personality are organized around the two general themes of the dynamic nature of the domain (i.e., structural and functional) and the level of data they represent (i.e., behavioral, phenomenological, intrapsychic, and biophysical). This domain model permits a description of each personality style in Millon's prototypal approach to be defined at each of these levels. In Appendix A, each of the personality styles measured by the MACI Personality Patterns scales is presented along with the individual domains for each personality style. These descriptions represent Millon's theoretical prototypic descriptions of each personality style at each level and domain of personality. More importantly, these tables in Appendix A can serve as reference materials when interpreting the MACI Personality Patterns scales. When an elevation occurs on a particular scale, the table for that scale can be consulted to generate diagnostic and clinical hypotheses.

SUMMARY
Many challenges occur in the assessment of adolescents. Because this transitional period of development sometimes requires unique provisions when assessing psychopathology in young people, clinicians must have specialized techniques and instruments to assess the most significant concerns and difficulties of adolescence. The Millon Adolescent Clinical Inventory (MACI) was designed specifically for adolescents and is a theory-based instrument with a wide range of applications. This chapter provides a general overview of the issues relevant to adolescent development and the assessment of psychopathology in teenagers. In addition, it summarizes Millon's theory of personality and psychopathology, which served as the guiding framework for developing the MACI. The text stresses the relevance of adolescent development and assessment and the principles in Millon's theory to clinical use of the MACI. This introductory chapter thus gives a context for the material presented in the remaining chapters.

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