Whatever happened to interpersonal diagnosis? A psychosocial alternative to DSM-III

Whatever Happened to Interpersonal Diagnosis?

A Psychosocial Alternative to DSM-III

CLINTON W. McLEMORE Fuller Theological SeminaryGraduate School of Psychology

LORNA SMITH BENJAMIN Department oj PsychiatryUniversity of Wisconsin, andWisconsin Psychiatric Institute

ABSTRACT: Concerns about the scientific and clinicalshortcomings of the pending DSM-III lead the authorsto propose that psychology consolidate its knowledgein the form of an interpersonal behavior taxonomy.A substantial body oj literature suggests that the mostuseful asspects of current psychiatric diagnostic sche-mata are psychosocial in nature and that most diag-noses of "functional mental disorders" are made, albeitimplicitly, on the basis of observed interpersonal be-havior. This article includes a review of social be-havior coding models suitable for clinical use and adiscussion of how Benjamin's structural analysis ofsocial behavior could be used for developing an inter-personal nosology. The authors highlight the clinicaland scientific advantages of such a nosology over tra-ditional psychiatric nomenclature. They also illus-trate the application of the Benjamin model to clinicalpractice with a brief case history and give a specificexample of how a DSM-III diagnosis might be trans-lated into this model.

The third edition of the American Psychiatric As-sociation's Diagnostic and Statistical Manual ofMental Disorders (DSM-III) has now been draftedand, barring major setbacks, will be in general useby 1980. It will be much more comprehensivethan its predecessor, the current DSM-II (Ameri-can Psychiatric Association, 1968), in that de-scriptions of the clinical entities have been sub-stantially expanded and, beyond this, the entireformat for diagnosis has been revamped (Schacht& Nathan, 1977). No longer will a clinician sim-ply select the one or two categories into which thepatient or client seems to fit best. Instead, it willbe necessary to relate explicitly the primary di-agnostic axis, based on presenting dysfunction, toother features also termed axes.

The five axes that will be referenced in diagnos-ing an individual are (1) clinical psychiatric syn-dromes and other conditions, (2) personality dis-

Vol. 34, No. 1, 17-34

orders (adult) and specific developmental disorders(children and adolescents), (3) nonmental medicaldisorders, (4) severity of psychosocial stresses, and(5) highest level of adaptive functioning in thepast year. This new form of specification, or as itsdesigners call it, multiaxial diagnostic system, doesin fact defuse some of the frequently cited criti-cisms of the existing scheme of nomenclature: Thecurrent practice of focusing on psychiatric symp-toms in isolation from their psychological sub-structure in personality is certainly lessened byrelating those symptoms to more enduring aspectsof personality; establishing current level of func-tioning in relation to maximum personal effective-ness attained in the recent past places diagnosis ina time perspective manifestly useful for prognos-tication and, thus, for planning treatments; andalthough the committee charged with the job ofrevision assiduously avoided commitment to a par-ticular etiological theory (Schacht & Nathan,1977; Millon, Note 1), DSM-HI allows for mul-tiple etiologies by coding current environmentalprecipitants as well as physiological ailments andby distinguishing tentatively between physical andnonphysical causes. The reader interested in acollection of recent symposium papers on nosology,written largely by physicians, is referred to thevolume edited by Rakoff, Stancer, and Kedward(1977), entitled Psychiatric Diagnosis.

We would like to express appreciation to Robert C.Carson, David C. Cerling, Ralph Mason Dreger, Arnold P.Goldstein, Phyllis P. Hart, Eric N. Jacobsen, Alvin R.Mahrer, Albert R. Marston, William T. McKinney, Jr.,Thomas Schacht, Philip A. Smith, and Charles J. Wallacefor their constructive comments on various aspects of thematerial presented in this article.

Requests for reprints and related materials should besent to Lorna Smith Benjamin, Department of Psychiatry,Clinical Sciences Center, Madison, Wisconsin 53792.

AMERICAN PSYCHOLOGIST • JANUARY 1979 • 17Copyright 1979 by the American Psychological Association, Inc.

0003-066X/ 79/3401-0017$00.75

Despite improvements promised by DSM-III,there is still reason for considerable concern onthe part of behavioral scientists. Concerns relatingto sociopolitical impact and the boundaries of pro-fessional territory were recently expressed bySchacht and Nathan (1977) in their article "ButIs It Good for the Psychologists?" The presentarticle focuses not on these issues but on the sci-entific viability and actual clinical utility of DSM-III. It also presents concrete recommendationson how psychology might go about developing itsown nosological system, one that would be faithfulto both the formal canons and the informal as-sumptions of our discipline. Below, we proposea psychosocial nosology, specifically, an interper-sonal behavior classification system.

Let us survey some of the shortcomings of DSM-III. As in the past, diagnosis still rests partly onimpressionistic clinical judgment, including, for ex-ample, global ratings of the "severity" of psycho-social stresses and of the patient's highest level ofadaptive functioning during the past year. Sec-ond, the system still categorizes human beings interms of illness very broadly defined. Finally, andmost importantly, DSM-III shows near total neg-lect of social psychological variables and inter-personal behavior. We submit that rigorous andsystematic description of social behavior is uniquelycritical to effective definition and treatment of theproblems that bring most individuals for psychi-atric or psychological consultation.

The history of the interpersonal diagnosis ofpersonality, from its roots in the theoretical writ-ings of the neo-Freudians (Erikson, 1950; Fromm,1941; Homey, 194S; Sullivan, 1947) to contem-porary research developments, reveals that forsome time now behavioral scientists have been inpossession of the concepts and methodologies nec-essary to create a truly psychosocial taxonomy ofpersonality function and dysfunction. Such a cre-ative venture, however, has yet to capture theimagination of either psychologists or psychia-trists, although the establishment of an APA-sponsored Commission on Psychodiagnosis hasbeen advocated (Zubin, Note 2) and recentlyimplemented (Note 3). In the following pages,we attempt to demonstrate that interpersonal be-havior may be the most useful basis for a classifi-cation system.

Over a decade ago, H. B. Adams (1964) putforward a similar suggestion in an American Psy-chologist article entitled " 'Mental Illness' or In-terpersonal Behavior?" Drawing on a large num-

ber of studies, including the MMPI research ofJackson and Messick (1961) and Welsh (19S6),Adams pointed out the considerable extent towhich indices of psychopathology and social be-havior overlap. Carson (1969) put it this way:

Personality disorder, if the term is to have any meaning,is a matter of how one behaves (including what one says)in the presence of others; its definition is public andsocial in nature. . . . Often, of course, irregular or unusualbehavior is determined in part by ... internal emotionalstates, (p. 225)

Such determinative emotional states, as a matterof course, are inferred from what an individualdoes or says or from what others report aboutwhat he or she does or says.

There are in fact common clusters of behaviorsthat are associated with certain diagnostic labels,and these indeed have both prognostic and thera-peutic implications. These include whether theclient will prove receptive to insight-oriented in-terventions, the extent to which he or she will at-tempt to manipulate the therapist, how much ofa suicide or homicide risk exists, probabilities ofother kinds of acting out, and so on. Some ofthese behavioral implications are essentially inter-personal. For example, if the diagnostic label"schizophrenia, paranoid type" is applicable onthe basis of criteria presented in DSM-III(29S.3X), there will be evidence of disturbancesin thought, perception, affect, sense of self, voli-tion, relationship to the external world (with-drawal), and motor behavior, as well as delusionsor hallucinations of a persecutory or grandiosenature and/or delusions of jealousness. One medi-cal implication will be that antipsychotic drugsshould probably be prescribed. Some of the im-plications of this diagnosis to the interpersonallyoriented therapist are that the treatment relation-ship, if it is to succeed, can be expected to last along time; there will be extreme difficulty in es-tablishing a trusting relationship between the ther-apist and the patient; there will likely be episodesof angry outbursts, some of which may be directedtoward the therapist; there may be social contextsin which the person continues to function nor-mally; the person's early family history will prob-ably include at least one controlling, accusing par-ent; and the family milieu of the patient may haveincluded much mind reading and subtle but im-portant interpersonal nuance. The example showsthat in addition to indicating what medicationsmay be useful in ameliorating the paranoia, eventhe DSM classification has a number of interper-

18 • JANUARY 1979 • AMERICAN PSYCHOLOGIST

Figure 1. Classification of interpersonal behavior into 16 mechanisms or reflexes. Eachof the 16 interpersonal variables is illustrated by sample behaviors. The inner circlepresents illustrations of adaptive reflexes, for example, for Variable A, manage. The centerring indicates the type of behavior that this interpersonal reflex tends to pull from theother one. Thus we see that the person who uses Reflex A tends to provoke others toobedience, and so forth. These findings involve two-way interpersonal phenomena (whatthe subject does and what the other does back) and are therefore less reliable than theother interpersonal codes presented in this figure. The next circle illustrates extreme orrigid reflexes, for example, dominates. The perimeter of the circle is divided into eightgeneral categories employed in interpersonal diagnosis. Each category has a moderate(adaptive) and an extreme (pathological) intensity, for example, managerial-autocratic.(Figure and caption are from Interpersonal Diagnosis of Personality: A Functional Theoryand Methodology for Personality Evaluation by Timothy Leary. New York: Ronald Press,19S7, p. 65. Copyright 1957 by Ronald Press, Division of John Wiley & Sons, Inc. Re-printed by permission.)

sonal implications, which may be the ones of mostuse to the psychological therapist. By interper-personal we mean that which one person does,overtly or covertly, in relation to another personwho, in some sense, is the object of this behavior(see Leary, 1957, p. 4).

In this article we argue that psychology's nosol-ogy should focus on these interpersonal behaviors.Such an interpersonal taxonomy would not onlyhelp us understand and treat psychological difficul-ties but might also help identify constructive fac-tors in human development and thereby enhanceefforts to prevent the appearance of behavior dis-orders in the first place.

Background to Interpersonal Diagnosis

The concept of interpersonal diagnosis was mostelaborated by Timothy Leary, who spent nearly adecade with the Kaiser Foundation in Oaklandbefore accepting an appointment at Harvard.Leary's expulsion from Harvard was national newsfor some time, owing to the fact that by continuingto advocate the use of psychedelic chemicals, Learyseemed to flout the norms of both his professionand his university. That episode adversely af-fected a brilliant research career that includeddetailed, careful study of ways to dimensionalizesocial behavior. In his classic book, Leary (19S7)

AMERICAN PSYCHOLOGIST • JANUARY 1979 • 19

TABLE 1

Hypothetical Relationships Between Interpersonal and Psychiatric Categories

Variablecode

Interpersonal mode ofadjustment Interpersonal type of maladjustment

Standard psychiatric equivalent ofinterpersonal type of maladjustment

AP Executive, forceful, respectedpersonality

BC Independent, competitivepersonality

I)E Blunt, frank, critical, uncon-ventional personality

I'G Realistic, skepticalpersonality

/// Modest, sensitive personality

JK Respectful, trustfulpersonality

LM Bland, conventional, friendly,agreeable personality

NO Popular, responsiblepersonality

Managing, autocratic, power-orientedpersonality

Narcissistic, exploitive personality

Aggressive, sadistic personality

Passively resistant, bitter, distrustfulpersonality

Passive, submissive, self-punishing,masochistic personality

Docile, dependent personality

Naive, "sweet," overconformingpersonality

Hypernormal, hyperpopular, compulsivelygenerous personality

No psychiatric equivalent(Compulsive personality?)

No psychiatric equivalent(Counterphobic? Manic?)

Psychopathic, sadisticpersonality

Schizoid personality

Masochistic, psychasthenic,obsessive personality

Neurasthenic, mixed neurosis,anxiety neurosis, anxietyhysteria, phobic personality

Hysterical personality

Psychosomatic personality

Note. From "Interpersonal Diagnosis: Some Problems of Methodology and Validation" by Timothy Leary and Hubert S. Coffey, Journal ofAbnormal and Social Psychology, 1955, 50, 110-124. Copyright 1955 by the American Psychological Association. Reprinted by permission.

presented the notion of a "functional concept of much the same sequence" (p. 829). Earlier theynersonalirv"r had suggested.personality":

Since the neurotic interpersonal intensities tend to overlapsome aspects of the non-interpersonal psychiatric cate-gories, we have close to hand a solution for the problemof what to do with these latter less functional terms.The process of redefining them begins to take place auto-matically. Most of the popular diagnostic labels havevague, undefined but fairly effective functional power.They have interpersonal correlates. To be skeptical, real-istic and reserved is generally an adaptive interpersonalpattern. To be inflexibly distrustful and withdrawn isinvariably maladjustive. Many psychiatrists would callit schizoid. Thus we see the possibilities of redefining theclassical language of administrative psychiatry in the inter-personal terms. This preserves the usefulness of the olderterminology while sharpening its denotative power, (p. 57)

Leary constructed a classification system knownas the interpersonal circle, a circular array of socialbehavior variables built around two orthogonalaxes (love-hate and dominance-submission), tech-nically known as a circumplex (Guttman, 1966).Figure 1 is a reproduction of the interpersonalcircle; the caption description is as it appeared inLeary's (19S7) book.

Lorr and McNair (1963, 1965) critically re-searched the Leary circle and attempted to expandit. Their investigations were thorough and me-thodologically impressive. In 196S, Lorr and Mc-Nair noted, "The [Leary] categories are mostsimilar to those presented here and conform to

had suggested,

The value of the schema for clinical diagnosis is worthyof mention. Leary and Coffey (19S5) have found im-portant relations between their check list and certainclinical categories. . . . The descriptive profile of inter-personal behavior is ... especially relevant to therapistssince the profile suggests hypotheses concerning person-ality defenses, methods of handling anxiety, interpersonalresponsivity, and the like. (Lorr & McNair, 1%3, p. 74)

Lorr has published a number of other studies (e.g.,Lorr, Bishop, & McNair, 1965) relevant to ourdiscussion.

Leary's suggestions for relating interpersonalclassifications to standard psychiatric diagnosticnomenclature are outlined in Table 1, taken fromLeary and Coffey (1955, p. 119). Note that theysupplied interpersonal terms corresponding, for ex-ample, to schizoid personality: passively resistant,bitter, distrustful.

Leary (1957) called his approach to psycho-diagnosis "dynamic behaviorism" (p. vi), the valueof which he claimed lies "in its emphasis on thecomplexity and variety of human nature and onthe objectivity and clarity of empirical proceduresit sets forth for multi-level diagnosis" (page v).Leary elaborated five levels of personality: (1)public communication, (2) conscious communica-tion, (3) private perception, (4) unexpressed sig-


INTERPERSONAL

OTHER

Uncanngly let go 128Forget 127

Ignore, pretend not lh«re 126Neglect interests, needs 125

Illogical initiation 124Abandon, leave in lurch 123

Starve, cut out 122Angry dismiss, reject 121 «

Annihilating Attack 130 -Approach menacingly (31

Rip off, dram 132Punish, take fevenge 133Delude, divert, mitlead 134

Accuse, blame 135

120 Endorse frwdom

118 Encourage separate identity117 You can do it fine

116 Carefully, (airly considerMS Friendly listen

114 Show empaihrc understanding113 Confirm as OK as is

112 Stroke, soothe, calm111 Warmly welcome110 Tender sexuality

141 Friendly invite142 Provide for, nurture

143 Protect, back up

Put down, act superior 136Intrude, block, restrict 137

144 Sensible analysis- 145 Constructive stimulate

- 146 Pamper, overindulge147 Benevolent monitor, reminduo, uiuiin, renrtci u/ -̂ — — •»

Enforce conformity 138 L- -I '48 Specify what's best

Manage, control 140

220 Frwly com* and go

SELF

Go own separate way 228Defy, do opposite 227

Will off. nonditdose 226Busy with own thing 225

Noncontingtnt reaction 224Detach, weep alona 223

Refuse assistance, cart 222Flee, ncapt, withdraw 221

Deipant* promt 230Wary, fearful 231Sacrifice greatly 232

App«ate, tcurry 233Uncomprehending agree 234

Whine, defend, justify 236Sulk, act put upon 236Apathetic compliance 237

Follow rules, proper 238

218 Own identity, standard!217 Aliart on own

216 "Put card$ on the table"215 Openly disclose, reveal

214 Clearly express213 Enthusiastic showing

212 Relax, flow, enjoy211 Joyful approach210 Ecstatic miponia

241 Follow, maintain contact242 Accept caretaking

243 Ask, trust, count on244 Accept reason

246 Take in, learn from246 Cling, depend

247 Defer, overconform248 Submerge into role

YiaM. ubmit, givt In 240

320 HappY-jo-lucky

INTRAPSYCHIC Drift with the moment 328Neglect options 327

Fantasy, dream 326Neglect own potential 325

Undefined, unknown self 324. Reckless 323

Of Ignore own basic needs 322__ __ Reject, dismiss self 321UTrlBK Torture, annihilate wlf 330

to SELF Menace to self 331Dram, overburden self 332

Vengeful self punish 333Deceive, divert self 334Guilt, blame, bad self 335

Doubt, put self down 336Restrain, hold back self 337

Force propriety 338

318 Let nature unfold317 Let self do it, confident

316 Balanced self acceptance316 Explore, listen to inner self

314 Integrated, solid core313 Pleased with self

312 Stroke, soothe self311 Entertain, enjoy self

310 Low. dwriih self

341 Seek best for self342 Nurture, restore self

343 Protect self344 Examine, analyze self

346 Practice, become accomplished346 Self pamper, indulge

347 Benevolent eye on self'348 Force ideal identity

Control, manage Hlf 340

Figure 2. Most recent revision (1978) of Benjamin's (1974) "chart of social behavior."The top surface (diamond) depicts interpersonal behaviors for which the focus is on theother person, and the middle surface displays interpersonal behaviors for which the focusis on thes self. On each surface, the horizontal axis is affiliation and the vertical axis isinterdependence. Opposite behaviors appear directly across from each other on the samesurface (e.g., Chart Point 115, "friendly explore, listen," is the opposite of 13S, "accuse,blame"). Complementary behaviors, those that tend to draw or prompt each other, areat corresponding positions on these two surfaces. The behavior complementary to "accuse,blame" is therefore "whine, defend, justify" (235). Antidotes are complements of oppo-sites. Thus, the antidote to "whine, defend, justify" is the complement of "openly dis-close, reveal" (215), namely, "friendly explore, listen" (115). The bottom surface por-trays what happens when behaviors represented on the top surface are turned inward.Note that the Benjamin model, unlike Leary's interpersonal circle, depicts an entire spec-trum of behaviors (mapped onto the top halves of the two interpersonal surfaces) in-volving the giving and taking of autonomy, either friendly or hostile, since dominance andsubmission are depicted as complementary forms of high interdependence. (From "Struc-tural Analysis of Differentiation Failure" by Lorna S. Benjamin, Psychiatry, in press. Copy-right 1979 by the William Alanson White Psychiatric Foundation. Reprinted by per-mission.)


Endorse f reedom

INTERPERSONAL

OTHER

0

Annihilating a t tack Tender sexuality

Manage, controlFreely coma and 20

SELF

IS)

Desperate protest Ecstat ic response

Yield, submit, give in

INTRAPSYCHICIntro ject

olOTHER

toSELF

Torture, annihilate self

Happy-go-lucky

Love, cherish sell

Control, manage self

Figure 3. Benjamin's chart reduced to quadrants.(From "Structural Analysis of Differentiation Failure"by Lorna S. Benjamin, Psychiatry, in press. Copy-right 1979 by the William Alanson White PsychiatricFoundation. Reprinted by permission.)

nificant omissions, and (S) values (the ego ideal).He devised different measures for each level andwas careful to distinguish inference from behav-ioral observation. According to Leary, his inter-personal system is dynamic in two senses: First,it concerns itself with "the impact one person hasor makes in interaction with others"; second, itallows for "the interaction of psychological pres-sures among the different levels of personality"(Leary, 1957, p. vi).

Carson (1969) used a simplified version ofLeary's circle to develop a system for coding socialbehavior into four quadrants, the clinical value ofwhich he illustrated throughout his book on per-sonality and psychotherapy. Several other socialbehavior coding systems, some based on observa-tions of children, have been published (e.g., Becker& Krug, 1964; Borgatta, Cottrell, & Mann, 19S8;Schaefer, 1965). Orford (1976) offered a bookentitled The Social Psychology of Mental Disorder,

which contains essays written from the interactionposition on such subjects as marital compatibility,therapy research, and psychodiagnosis. Volumesby Argyle (1969), Cashdan (1973), Duncan andFiske (1977), and Endler and Magnusson (1976)also suggest the importance of coding social inter-actions.

Interpersonal Translation of the DSM

To demonstrate the potential value of interper-sonal conceptualizations in clinical practice, espe-cially in diagnosis and treatment planning, webriefly describe how a recently published modelof social behavior might be impressed into clinicalservice. Benjamin (1974) used both clinical andnonclinical literature to develop a psychologicallysophisticated and clinically useful model of socialbehavior known as the structural analysis of socialbehavior (SASB). Though it was generally com-patible with the models of Leary (1957) and Car-son (1969), Benjamin extended these and otherprior models in the directions of explicitness (andthus of precision) and of molecularity (see Figure2 ) .

Developed over the course of several revisions,based on autocorrelations, circumplex analysis, andfactor analyses, Benjamin's SASB model has stoodup well to empirical test (see Benjamin, 1974,1977, Note 4). As with Leary's circle, the hori-zontal axis in all three diamonds is affiliation(love-hate). The vertical axis is interdependence,with maximum interdependence at the bottom ofeach diamond and maximum independence at thetop. Because of its detailed structure, the SASBmodel has desirable versatility on the molar-mo-lecular dimension, in that all 72 interpersonalchart points on the first two surfaces can eitherbe used or be collapsed into two sets of fourcomplementary quadrants (see Figure 3). Notethat the top half of each of the top two sur-faces represents behavior not saturated with con-trol, either in the sense of dominance (controllingthe other) or submission (being controlled by theother). This allows for the charting of a wholerange of behaviors not capable of being mappedonto the Leary circle.

Limitations of space preclude explication of thedetails of the SASB structure and many of itsapplications. There are, however, four major ad-vantages related to the fact that the model wasconstructed using mathematical logic and a largenumber of empirical analyses: (1) Opposite be-


haviors are defined at 180° angles; for example,the opposite of 114 (show empathic understand-ing) is 134 (delude, divert, mislead). (2) Com-plementary behaviors, those that tend to draweach other, are defined and can be used to showwhat interpersonal behavior can be expected toaccompany what other interpersonal behavior; forexample, 214 (clearly express oneself) is the com-plement of 114 (show empathic understanding),and 234 (uncomprehending agreement, a kind ofhostile submission) is the complement of beingeffectively misled by 134 (delude, divert, mis-lead). (3) Antitheses can be specified; that is,the model prescribes what behavior to enact inorder to draw out the opposite of what is athand, specifically the opposite of its complement.For example, if someone is diverting and mislead-ing the therapist (a form of hostile power), theantithetical behavior would be 214, such as thestatement, "I'd like to believe what you're sayingbut I'm having a little trouble" (friendly auton-omy). In an affiliative relationship, this kind of /statement seems to draw the deceiver toward de-veloping more understanding of the speaker. Ifthe nodal point in the relationship is hostile, how-ever, there would be increasing attempts at de-ception and hostile control. In terms of the model,augmented deceit is the deceiver's antithesis to thebenevolent person's gesture to put the relationshipon more respectful and friendly grounds. (4)Finally, the Benjamin model explicitly translatesthe psychoanalytic idea of introjection into geo-metric terms and, in so doing, specifies ways inwhich interpersonal experiences affect one's treat-ment of oneself. The third (bottom) diamond ofFigure 3 thus indicates what happens if the be-haviors charted on the top diamond are turnedinward. If a child has a parent who routinelyuses hostile power, for example, blaming (ChartPoint 135), and the child turns the hostile powerinward, he or she becomes guilty (Chart Point335). A constructive encounter with a benevolenttherapist who shows empathic understanding (114)may reverse this trend toward self-blame and intime result in the introjection of the therapist'sgood will (314, integrated, solid core).

In these examples, we generally assume that theobjective behavioral stimulus and the respondent'sperception of that stimulus—Murray's alpha andbeta presses—correspond. In treating the ques-tion of what exactly the real stimulus is, whatSigmund Koch (1964) eruditely discussed as the"stimulus problem," one winds up in a dilemma:

To say that the stimulus is the physical event(say, 500 footcandles of light) seems to bypassthe mediating events of perception, and to relyon how the individual actually perceives this physi-cal event (say, what he or she sees while lookingin the direction of the light source) is to give upthe hope of direct measurement. No easy solutionpresents itself. "Radical behaviorists" willinglysacrifice subjectivity and staunch "phenomenolo-gists" gladly give up objectivity. Our solution isto use a model that may be applied to either ofthe two domains, depending on the source of thespecific data mapped onto it (seeNatsoulas, 1978).

The principles of opposites, complements, an-titheses, and introjects apply consistently amongall 108 points of the model. These features givethe model considerable power: in the generationof hypotheses about etiology; in aiding our under-standing of how current life situations affect be-havior of the person in question, which is relevantto the recent state-trait controversy (Mischel,1968, 1973); and in therapeutic goal setting (Ben-jamin, 1977).

It should be reiterated that models such as thoseof Leary and Benjamin may be used simply forclassification and that predictions about which be-haviors tend to follow which other behaviors dur-ing dyadic interaction may be ignored, if con-venient, without damage to the classification pro-cess itself. Predictions are specific and thereforemay be useful ultimately in coming to understandetiology, but etiological hypotheses deriving fromthe social models need not be accepted in orderto use them in a nosological system. It would beour expectation, moreover, that failure of comple-mentarity, for example, could in itself turn out tobe a diagnostic indicator (see Benjamin, 1974, pp.416-418, for elaboration).

Reliability and Related Matters

"The first question in evaluating any classificationschema is the reliability of the system" (H. E.Adams, Doster, & Calhoun, 1977, p. 50). Nu-merous studies have highlighted the unreliabilityof traditional psychiatric diagnosis (e.g., Ward,Beck, Mendelson, Mock, & Erbaugh, 1962; Zigler& Phillips, 1961a, 1961b; Zubin 1967), leadingAdams et al. (1977) to remark that "a 'patient'sdiagnosis reveals surprisingly little informationabout his behavior" (p. 50). The question of con-cern, at this juncture, has to do with the 'relia-bility of interpersonal diagnosis.


Behavioral observations are mapped onto theLeary circle by means of a deceptively simple 128-item checklist (LaForge & Suczek, 19SS). Thisdevice can be used for what Leary called Level 1("public communication") or Level 2 ("consciousdescription") observations, that is, for ratings byothers or for self-reports. The fourth and finalversion of the Interpersonal Check List was theproduct of a substantial amount of carefully doneresearch (see Leary, 19S7, pp. 453-463). Itemswere added or deleted during the revisions in orderto ensure that they were as unambiguous as pos-sible, that the distribution of item "intensities"was comparable throughout the circle, and thatthe effects of various response biases (e.g., ac-quiescence and social desirability) were minimized.Detailed presentation of reliability data wouldtake us beyond the scope of this article, but somegeneral information may prove useful. Stabilityof the Interpersonal Check List seems fairly good.In 1959, Shopler (cited in Lake, Miles, & Earle,1973, p. 116) studied 5-month test-retest relia-bilities. For Level 1, dominance summary scoresyielded a stability coefficient of .74, and love sum-mary scores yielded a coefficient of .72. For Level2, the reliability coefficients were .95 and .62, re-spectively. Other data (Leary, 1957, p. 461) gave2-week self-report average reliabilities of .78 foroctants and .73 for sixteenths on the circle. Leary(1957) noted, "Because this sample is a somewhathomogeneous all-female group [obese persons],these correlations are not likely to be larger thanones obtained with other groups" (p. 461). Afterreviewing these and other data, Lake, Miles, andEarle (1973) stated, "Given that such reliabilitiesare based on 4-item and 8-item scales, they aresurprisingly high" (p. 116). The highly respectedMeasures of Social Psychological Attitudes (Rob-inson & Shaver, 1969) reported that predictionsrelating to construct validation of the Leary modelhad stood up well to empirical test (p. 136). Itcited the Leary checklist as offering "great prom-ise" (p. 135) but as not yet having received "suf-ficient response from other researchers" (p. 137).This response still had not materialized 4 yearslater, so the revised edition of this volume (Rob-inson & Shaver, 1973) lists the checklist in asection on rarely used instruments, without criticalreview.

Reliabilities for the newer Benjamin SASBmodel are quite encouraging. Test-retest reliabili-ties for dimensional ratings of the SASB itemshave ranged from .85 to .93, and interrater relia-

bilities for judgments of psychotherapy transac-tion segments in terms of the model fell in exactlythe same range (Benjamin, Note 4, Note 5).Because of the nature of both the Leary and Ben-jamin models, reliability in the sense of consistencymay be more critical than reliability in the senseof stability. Both Leary (1957, p. 461) andBenjamin (1974, pp. 416-419) made this verypoint. In its most general meaning, reliabilitymay be said to be the absence of error variance.As Fiske and Rice (1955) noted, therefore, sta-bility over time is usually high when internal con-sistency is high. Predicted patterns of internalcorrelations have generally been borne out for theLeary circle (Leary, 1957, pp. 461-462; see Lorrand McNair, 1963, 1965, for related information)and even more impressively for the SASB model(Benjamin, 1974).

An extensive autocorrelational analysis (Benja-min, 1974, pp. 416-417) revealed that the averagePearson r between obtained autocorrelations andpredicted (inverted normal curve) values is high.In one sample of normals it was .92, and in an-other sample, .97. It is interesting that the valuesobtained with corresponding psychiatric patientsamples were .68 and .81, leading Benjamin (1974)to comment,

Without exception, for every set of ratings, the averageinternal consistency was greater in the normal samplethan in the psychiatric sample. The idea that reliabilityis a property of people as well as of scales has beenexpressed by others (Jackson, 1971, p. 243) and similarly,lack of order (Foa, 1968) or reliability (Hersch &Scheibe, 1967) has previously been seen as reflecting psy-chopathology. (p. 417)

Benjamin (1974) discussed how "unstable unpre-dictable interpersonal postures" may relate toambivalence (pp. 417, 418) and also gave a clini-cal example of how serious disturbance may occa-sionally reflect itself in high internal consistency.To use consistency of interpersonal behavior as adiagnostic indicator, complex norms would haveto be developed, especially because such consist-ency is sometimes associated with psychologicaldisturbance.

As is indicated earlier in this article, the SASBmodel has been extensively tested through circum-plex analysis, factor analysis, and autocorrelationalmethods (see Benjamin, 1974, for an extended dis-cussion of its initial validation). The model hasbeen revised (in 1976 and 1978) on the basis ofseveral further analyses (Benjamin, Note 4), in-cluding additional factor analyses and an elabo-rate dimensionalized rating procedure. It has been


demonstrated that the SASB surfaces can be re-generated quite nicely from item factor loadings.These and other results (see Benjamin, 1974,1977) lend strong support to the construct validityof the model.

One final issue must be addressed. To whatextent are interpersonal ratings affected by re-sponse biases, specifically by acquiescence tenden-cies and social desirability distortions? The for-mer are controlled for in both the Leary and Ben-jamin models by ensuring that acquiescence effectsare highly likely to cancel out (see Leary, 1957,pp. 459, 460, and Benjamin, 1974, p. 419). Socialdesirability responding, the attempt to make one-self or someone else look good on ratings, is po-tentially more troublesome, and Leary (1957) con-trolled for it through very careful item selection.The heart of the issue is whether social desira-bility responding represents a contamination, asource of unwanted systematic bias, or whether itis intrinsic to what one is actually intending tomeasure and therefore ought not to be arbitrarilyeliminated. Citing the work of Heilbrun (1964)and that of Cole, Getting, and Miskimins (1969),Benjamin (1974) suggested that "deviation fromsocial desirability may itself be 'pathology' " (p.423). Benjamin (1977, p. 405) took pains todistinguish between social desirability as an arti-fact and as clinically meaningful defensiveness andto relate this distinction to the settings in whichthe SASB model is used. The reader is referredto Benjamin (1974, pp. 419-423) for detailedtreatment of these issues.

The Place of Interpersonal Diagnosis inClinical Psychology and PsychiatryPsychologists are in an ideal position to provideclinicians of all academic backgrounds with arigorous behavioral taxonomy. We have arguedthat a very useful taxonomy would be one basedon interpersonal functioning, with the additionalprovision that interpersonal experiences may beinternalized (introjected). A person may treathimself or herself as an object to be loved andnourished, hated and deprived, and so forth. Al-though these sorts of self-focused behaviors cus-tomarily cannot be observed directly but must beinferred (see bottom surface of Benjamin's model,Figures 2 and 3), they are still clinically impor-tant. The behavior, verbal or motoric, of anacutely suicidal person without ties to a singleliving person may still be classified in the SASBmodel (Chart Point 330).

H. E. Adams et al. (1977) proposed an elabo-rate psychological response classification system(PRCS) constructed around six interacting sys-tems: motoric, perceptual, biological, cognitive,emotional, and social. Such a proposal is de-signed to be "simple, coherent, and exhaustive"(H. E. Adams et al., 1977, p. 67). Their sug-gestion has much to recommend it, for example,it may be used as a format for "all theories" (e.g.,psychopathology, personality), but it may bestretching a point to call it simple. By design, itdoes not specify the clinical implications of vari-ous combinations of responses from the six sub-categories:

The PRCS does not try to solve the dilemma of theDSM-II by spelling out more specifically the combinationof symptoms to be found in syndromes presumed toexist, or by empirical study of the correlates of sympto-matic behavior. (H. E. Adams et al., 1977, pp. 63-64)

A comprehensive catalogue of all such combina-tions would, of course, be huge. Add to this thepossibilities of weighted combinations and of non-linear functions, and the implications are stagger-ing. This astronomical number of possible "syn-dromes" could be reduced to a smaller subset,presumably those most clinically useful, but suchreduction would probably be difficult and, to asignificant degree, arbitrary. At the same time,treating separately the 39 response categories sub-sumed under the six response systems would seemto work against the very thing the PRCS was de-signed to facilitate, understanding of the personas an integrated (or distintegrated) entity.

The stance of the interpersonal diagnostician isto treat the social category as a window throughwhich to view the other domains of functioning.To the interpersonal nosologist, those motoric, per-ceptual, cognitive, emotional, and biological pro-cesses that affect or derive from social behaviorare the ones of principal interest, again with thecaveat that the object of one's social behavior maybe oneself. That psychiatric labeling originatedas a means of categorizing social behavior hasbeen suggested by Sharma (1970, p. 251) who,citing Szasz (1966), concluded, "It is social andinterpersonal behavior that is classified and diag-nosed." To the extent this is true, it suggeststhe importance that human beings, including (andperhaps especially) mental health professionals,attach to the kinds of behaviors we have beendiscussing. Moreover, it would seem that socialbehavior, regardless of its causes or correlates, ismore directly accessible to the psychologist's (psy-


chotherapist's) interventions than, say, emotionalstates, and that change in several of the other fiveresponse systems may effectively be brought aboutby alterations in interpersonal behavior. This, ofcourse, was Sullivan's (1947) innovative thesis.

To determine, in the majority of cases, that aparticular person needs hospitalization or medica-tion requires no elaborate nosology. These areusually matters of routine psychiatric management.When you get to the complicated business of howone person (the therapist) is best advised to be-have toward another person (the client) in orderto bring about an improvement in the latter's life(successful psychotherapy), the availability of anadequate nosology becomes critical. The clearspecification of what is wrong implies treatmentgoals, which in turn may suggest procedures forachieving these goals.

The mental status examination is primarily in-tended to help make basic decisions about clinicalmanagement. As the clinician evaluates orienta-tion, mood, thought, judgment, insight, and so on,the focus is generally on such questions as "Is thisperson psychotic? Will this individual benefitfrom phenothiazines? How likely is acting out?"The information generated by a mental status ex-amination about what specific behaviors needchanging, and exactly how to accomplish this, issketchy at best. Although the psychiatric man-agement questions to which we referred aboveneed to be answered, a scientific nosology can po-tentially go far beyond such matters.

A person's behavior could probably be crudelymapped onto a chart, such as Figure 3, in aboutthe same time it takes to do the mental statusevaluation. In fact, the two could be done con-currently. Such a global use of the SASB modelwould trade off precision for practicality, with theinevitable result that reliability would decrease.Still, even for a person about to be hospitalized,there might be great value in a brief chart notesuch as "Tends to relate through hostile compli-ance. Staff should avoid responding with punish-ment or other forms of hostile power, like criti-cism." This second sentence, of course, derivesfrom the theoretical postulates of the SASB struc-ture. It should be noted in passing that suchremediation prescriptions are not necessarily re-lated logically to etiology; that is, the patient'shostile compliance might, in the extreme case, beorganically based, perhaps secondary to a bio-chemically induced depression. Hostile powerexerted by others, in this case the ward staff, might

still exacerbate the patient's maladaptive inter-personal behavior.

More elaborate interpersonal assessment proce-dures might include completion of SASB question-naire ratings on the client by the therapist ordiagnostician, family members, an employer, andof course the client. In the ideal, they would alsoinclude ratings of these significant others. Thiswould provide information on the interpersonalenvironment to which the client is routinely re-sponding. Note that these procedures allow forobjective Level 1 assessments (by others, i.e., theclient rating a significant other or vice versa) andfor subjective Level 2 evaluations (by the personunder study, i.e., self-ratings by the client or by asignificant other). By using a computer, all ofthese can be quickly scored, tabulated, and dis-played or printed out for the clinician (see Ben-jamin, 1977, for extended discussion of how thesemethods may be used clinically).

In an article that purports to offer an alterna-tive to traditional diagnosis, one important butdifficult question must be confronted: Should theDSM be supplemented or replaced—are the pro-posed alternative and the DSM mutually exclu-sive? Over 20 years ago, Leary (19S7) madethese comments:

It seems quite possible that within a few decades theslowly evolving laws of pragmatic usage will establishinterpersonal concepts as a popular and useful diagnosticlanguage. Two possibilities suggest themselves here—thefirst is that direct interpersonal terms will replace thedisorganized nosology of present-day psychiatry; the sec-ond is that the current terms will be redefined in inter-personal terms, (p. 56)

Any resolution of the issue at this point would bepremature and would probably reflect bias morethan knowledge. The following statement by Car-son (1969) is relevant:

The limits of the interpersonal approach to neurotic symp-toms are not precisely known at this time, and it must beacknowledged that certain types of classical (althoughactually quite rare) symptomatic behaviors—such as com-pulsive hand-washing—are not readily accounted for inany obvious way within a strictly interpersonal frame-work. In general, however, it can be said that the analy-sis of specific neurotic symptoms in terms of their inter-personal function will often yield data essential to theirfull understanding, (pp. 246-247)

H. E. Adams et al. (1977) remarked, "The mostsalient reason we could find or others have givenfor retaining the [DSM | is the void that wouldremain by its absence. . . . The issue then iswhether psychology as a science is capable of fill-ing this void" (p. 69).


We believe the answer is yes. We also believethat as a profession we should move judiciously,being careful to substantiate whatever claims wemake. Perhaps the best course of action would beto put our energies into developing the type ofnosology proposed here, to begin to use it rou-tinely, and to trust that utility itself will indicatethe best approach or combination of approachesin the long run. It remains to be demonstratedwhether DSM-III will be any more valuable as anaid to actually helping people than would a soundmethod of interpersonal diagnosis. Our guess isthat it may be a good deal less!

H. E. Adams et al. (1977) wrote, "An impor-tant question is whether the presenting symptomsor a particular diagnosis are useful in the selec-tion of a treatment program or other psychiatricdecisions. . . . According to Bannister, Salmon, andLeiberman (1964) the answer is no" (p. 52).They went on to say, "Since clinical decisions suchas correct treatment programs are among the majorpurposes of a classification system in abnormalpsychology, it would appear that . . . the currentclassification system is largely meaningless" (p.53). Eight years earlier, Carson (1969, p. 224)came to essentially the same conclusion.

Begelman (1976, pp. 23-24), in a helpful chap-ter on behavioral classification, summarized ninesomewhat overlapping criticisms of the DSM, de-rived from a long list of published articles andbooks. Table 2 lists these criticisms, along withcomments on how they relate to the sort of tax-onomy we are suggesting. Some of the critiqueslisted in Table 2 (e.g., No. 8) are less applicableto DSM-III than to its predecessors, but the readermay still find these comparisons of interest. Thereare other criticisms of the DSM, and there areother comments we would like to have made butdid not in order to keep the table within manage-able scope. The "medical model," for example,means many things, but space limitations precludeanything like a complete treatment of these issueshere.

A Clinical Example

Benjamin (1977) presented a detailed descriptionof the "Structural Analysis of a Family in Ther-apy." This case report is of special interest be-cause the treatment relationship extended for 3years, through the course of which SASB chartingswere done regularly. In Journal of Consulting andClinical Psychology, the author stated, "The pres-

ent naturalistic application is offered to illustratethe use of the [SASB] model for more precisemeasurement and understanding of ... changesthat occur during psychotherapy" (p. 391). Inintroducing the clinical material, Benjamin (1977)made these additional comments: "The data . . .are analyzed by a specific (operationalized) pro-cedure, and the output is expressed in a way thatis interpretable by the subject as well as by the-therapist" (p. 392). This last statement relates,of course, to the issue of informed consent. A fewsentences later, Benjamin remarked, " [The SASBdiagnostic] method offers a promising beginningtoward describing the process of therapeutic changethrough objectifying and quantifying that whichhas seemed vital to the clinician but elusive tothe researcher" (p. 392).

The presenting problem was the behavior of anout-of-control, S-year-old, firstborn son describedas extremely abusive toward his mother, who re-garded him as a "little monster." His typicaleveryday behavioral repertoire included kicking,swearing, and threatening to kill her (Benjamin,1977, p. 395), and when the family came fortreatment the mother and child were steadfastlylocked into a hostile power struggle. Behaviortherapy, including home visits, had previously beentried under the direction of a team of behaviormodification specialists, but "the parents reportedthat the treatment seemed to make the problemworse" (p. 395). It is not our purpose here toevaluate the relative merits of various therapeuticprocedures, but it does seem appropriate to makea few comments on why traditional behavioralmanagement may have proved ineffective. Themother was relating to the son through power,often hostile power, but he resisted her control andresponded with even more hostile power of hisown. Contingency management may have beenperceived by the boy as just so much more hostilecontrol, especially if the mother had communicatedthat she saw behavior therapy methods as a wayof "winning," an orientation that would have beencharacteristic of her (Benjamin, 1977, p. 398).Successful treatment involved collecting multiplesources of SASB ratings on family members, in-cluding grandparents, introducing this informationinto the therapy process, and eventually gettingthe mother to replace hostile control with its oppo-site, friendly emancipation. Benjamin (1977, p.398) noted that the mother had been resistant tothe idea that "her son was not basically bad orwrong but rather just an ordinary human being


TABLE 2

Interpersonal Diagnosis and Criticisms of the DSM

Criticisms(from Begelman, 1976)

Comparison withinterpersonal nosology

1. Overreliance on the"medical model"

2. Stigmatization of thosediagnosed, especially theinstitutionalized

3. Incorporation of debatabletheoretical notions

4. Inadequate reliabilityand validity

Interpersonal diagnosis treatsreports and observations ofsocial behavior as its unitsof analysis and thus in noway fosters a belief in"disease processes"; it atleast implicitly suggestscontinuity between thenormal and the abnormal,and though it does notnecessitate adherence to anyparticular etiological theory,it easily lends itself tolearning formulations ofpathogenesis and therapy(what many interpersonaltheorists would rather termdevelopment and remediation)

Although virtually any set ofconceptual categories canbe imbued with value at-tributes, interpersonal de-scription is relatively freeof Stigmatization, whereasDSM categories seem toencourage the view that theperson is his disease ("Mr.Jones is a schizophrenic";H. E. Adams et al., 1977,p. 49); social behavioralresponse characteristics arenot taken to be dispositional(intrinsic to the nature ofthe individual)

Since all nosologies are es-sentially theoretical, andnearly all theoretical notionsare potentially debatable,there is little to be said hereexcept that an interpersonalnosology is eminently re-searchable (testable)

Though the reliability oftraditional diagnostic labelsis notoriously low, we dis-cuss elsewhere in this articlethe rather respectable reli-ability of interpersonal as-sessment, along with issuesrelated to construct valida-tion ; determinations ofcriterion-oriented validitymust be made with referenceto specific contexts (e.g., howwell an interpersonal tax-onomy predicts responses toparticular treatments)



5. Little value for prognoses,specifications of treat-ment, or predictions ofgeneral behavior

6. Dehumanization of thetherapist-clientrelationship

7. Inconsistencies incategorical groupings

8. Biases toward pathology(e.g., diagnosing in termsof the most "severe"behaviors evident in casesof "mixedsymptomatology")

When contrasted with theDSM, interpersonal assess-ment would seem strong inthese domains; the inter-personal models allow foreither situation-specific orgeneralized behavioral pre-dictions (the validity of theformer will of course behigher; cf. Mischel, 1968,1973); of perhaps evengreater potential value arethe clear implications fortreatment specified by aninterpersonal evaluation(see Dimond, Havens, &Jones, 1978, for a relevantdiscussion)

All classification systems, tothe extent that they resultin the objectification of theclient, may be said to de-humanize the therapist-client relationship; by con-trast with the DSM, how-ever, interpersonal tax-onomies do not imply anyqualitative distinction (e.g.,sick vs. well, ordered vs. dis-ordered) between the clientand the clinician, at leastinsofar as both manifestnearly all interpersonal be-haviors in varying degrees

Such inconsistencies do notarise in interpersonal tax-onomies, which are explicitlyconstructed around inter-nally consistent models ofhuman behavior

Since an interpersonal no-sology is not a collection ofheterogeneous entities, thisproblem does not emerge; itcould, but need not, arisewhen the interpersonaldiagnostician is comparingan individual's responses to,say, a friend or employer(which may be relativelyfunctional) with those to aspouse or parent (whichmay be relativelydysfunctional)


TABLE 2—(Continued)


9. Presumptions ofhomogeneity amongindividuals similarlylabeled


Diagnostic labels will probablyalways function somewhatas stereotypes (H. E.Adams et al., 1977, p. 54),and therefore the presump-tion of homogeneity withincategories is perhaps in-escapable; the crucial issuebecomes how narrow orbroad to make nosologicalcategories (or dimensions);interpersonal taxonomieshave the highly desirableproperty of flexibility on


9. (continued)


what Cronbach (1970, pp.179-182) has called the"bandwidth-fidelity" di-mension, the trade-off be-tween breadth of coverageand precision of measure-ment—Consider the molec-ularity of the Benjaminmodel versus the relativemolarity of the Leary circle;consider also that the formermay be collapsed into asmall number of quadrants '

responding to contingencies." Eventually shecame to see that hostile power was reinforcing herson's misbehavior; that is, her hostile control in-creased the probability of his hostile countercon-trol. Of relevance to this case study, in view ofthe boy's manifest behavioral "hyperactivity," isa comment by Orford (1976): "Even when thebasic etiology of a condition can be explained ingenetic terms, social psychological factors maystill play an important role in modifying the formand course of the condition" (p. 48). Naturally,it is not known whether or not this child was inany significant way organically impaired, but ifso, Orford's comment is noteworthy. The centralpoints to be made here are that the SASB modelfacilitated (a) explicit charting of the child's be-havior disturbance, (b) clear specification of treat-ment goals, (c) detailed elaboration of the socialcontext of the problem, (d) reconstruction of thedevelopmental history of this context across gen-erations, (e) ongoing monitoring of change overtime, and (f) reasonably objective criteria for im-provement and success. Bejamin's model also sug-gested a direction for treatment by specifying theantidote to what was initially happening betweenmother and son.

Since our primary concern in this article is withdiagnosis, it may prove helpful to give a specificexample of how DSM-III and the SASB modelmay be related. Benjamin (Note 6) has postu-lated a number of relationships between specificDSM-III categories and interpersonal behaviorsportrayed on the SASB chart surfaces. Here, forillustrative purposes, we briefly outline the hy-pothesized interpersonal correlates of a paranoiddisturbance in both mild and severe forms. Re-

call that earlier in this article we discussed someof the interpersonal implications of the paranoiddiagnosis. The formal diagnosis to be discussed is301.00, "paranoid personality disorder." DSM-III (Note 7) defines personality disorders in gen-eral as

deeply ingrained, inflexible, maladaptive patterns of re-lating to, perceiving and thinking about the environmentand oneself that are of sufficient severity to cause eithersignificant impairment in adaptive functioning or sub-jective distress. Thus, they are pervasive personalitytraits and 'are exhibited in a wide range of importantsocial and personal contexts, (p. K:l)

For the specific personality disorder of 301.00,DSM-III (Note 7) includes these descriptors:

pervasive and longstanding suspiciousness and mistrust ofpeople in general. . . . [Such persons] are hypersensitiveand easily slighted. . . . [They] are hypervigilant and takeprecautions against any perceived threat [in the face ofwhich] they show a tendency to "counterattack." . . .Their affective experience is restricted and they . . . areviewed as hostile, (pp. K:3-K:4)

Figure 4 presents the postulated SASB equivalentsof 301.00. Milder forms of the disorder arecharted on the "focus on self" surface, and themore severe forms, in which there tends to beovert attack and revenge, are charted on the "focuson other" surface. We are currently conductinglarge-scale investigations to validate and refinethese sorts of clinical hypotheses, which haveevolved out of converging sources of information,including empirical data and clinical interviews.

Traits and Situations

Diagnostic and statistical manuals clearly presup-pose the existence of traits, and indeed Leary's


OTHERAngtv dumiH. teiecl 131

Annihilating attack 130 —j-Approach menacingly 'i'

Rip of!, diPumth, take it

SELF

Figure 4. Example of a DSM-III diagnosis mappedonto Benjamin's model. The formal diagnosis is301.00, "paranoid personality disorder." Mild formsof the disorder are represented on the "focus on self"surface and are characterized by flight, escape, andwithdrawal. More extreme forms are portrayed onthe "focus on other" surface and are characterized byovert aggression.

pioneer efforts to relate interpersonal descriptionsto standard diagnostic categories appear to as-sume cross-situational consistency, although Leary(1957, p. 60) did stress the importance of measur-ing behavior in its "functional context." Argu-ments to the contrary (Mischel, 1968, 1973), thereis a fair amount of evidence in support of traitconceptualizations (e.g., Huba & Hamilton, 1976).

Questionnaires coordinated to the SASB modelrequire respondents to characterize specific rela-tionships at specific points in time. When showna computer-generated patterning of questionnaireratings, patients have frequently given confirmingresponses such as, "Oh yes, that was really trueabout him," or "I never thought that I marriedmy mother, but I see I really have" (see Benja-min, 1977). This suggests a fair amount of sta-bility in interpersonal posture, at least in a givenrelationship at a given period of time, and thiscan often be recognized by both the clinician andthe client, as is indicated by Benjamin's (1974,1977) work with psychiatric samples.

An adequate nosology must, however, encom-pass the fact that one can behave differently acrosssituations (see Pervin, 1976). Application of aninterpersonal model such as Benjamin's to different

relationships and situations allows for such situa-tional specificity. For example, interpersonal anal-ysis may characterize a husband as relating to hiswife via hostile submission, which may parallelreports of how his father related to his mother.Yet this same husband may be affectionately con-trolling toward his children. A thorough inter-personal analysis would include characterizationsof persons in relation to spouse, employer, friends,specific children, strangers, and parents duringspecific periods of time. As is discussed above,interpersonal diagnosis can be done impressionisti-cally, which would be least reliable, or in a highlysystematic fashion. We hypothesize that it canfavorably compare with DSM-III at any level ofspecificity.

Perceptions, Cognitions, Emotions, andInterpersonal Behavior

Processes of perception, cognition, and emotionmight also be addressed in an interpersonal nos-ology (Weiner, 1974), and Benjamin (Note 8)has begun to develop models of cognition and af-fect coordinated to the SASB structure. Theextent to which a particular patient's self-reportsof interpersonal behavior differ from reports bysignificant others is in itself potentially usefulclinical information. In his 1957 book, Learyextensively discussed the implications of such in-terlevel discrepancies in personality assessment.Although the phenomena of transference can bedescribed by learning theorists as (normal) gen-eralization, and parataxic distortion can be relatedto recent work on (normal) orienting mechanisms,distortions in the perception of interpersonal be-havior, whether one's own or another person's, maybe intrinsically pathological. A recent clinicalexamination of errors in target persons' reports ofspouses' behavior has been offered by Gottman,Notarius, Markman, Bank, Yoppi, and Rubin(1976). They documented the intuitively reason-able idea that distressed marriages are character-ized by more negative behavioral reciprocity thanare nondistressed marriages. This suggests theoperation of self-fulfilling prophecies and, moregenerally, of complex attribution processes. Whatone attributes to and expects from the world, one islikely to get (Carson, in press).

The interpersonal models posit that certain be-haviors prompt, or draw, certain others, which iswhat interpersonal theorists mean by "behavioralcomplementarity." According to Benjamin's model,


for example, if one anticipates punishment (ChartPoint 133), one tends to become appeasing (233),and too many apologies (233) draw out moreabuse (133). Naturally, responses to expectedpunishment can vary widely. One can fight backin anticipation, or such appeasement as one offersmay be ingenuine. The model simply predictswhat is most likely to occur, especially once a re-lationship has stabilized. Carson (in press, p. 26)notes that the competitive person "does not ap-preciate his [sic] own contribution to his experi-ence of competitiveness in others. Hence, he tendsto conclude that the world is just that way; heexpects hostility from others" and gets it.

Sociologists have related the self-fulfilling pro-phecy idea to paranoid symptomatology. In 1962,Lemert reviewed Cameron's (1943) formulationof the paranoid pseudocommunity:

Paranoid persons are those whose inadequate social learn-ing lends them in situations of unusual stress to incom-petent social reaction. . . . His reactions to this supposedcommunity of response which he sees loaded with threatto himself bring him into open conflict with the actualcommunity and lead to his temporary or permanent iso-lation from its affairs. The real community, which isunable to share in his attitudes and reactions, takes actionsthrough forcible restraint or retaliation after the paranoidperson bursts into defensive or vengeful activity. (Lem-ert, 1962, p. 2)

Although Cameron termed the community pseudo-,Lemert argued that its reactions to the paranoid'shostile behavior may in fact be quite real. Cam-eron and Lemert provided insight into the inter-actions among the patient's perceptions, the socialmilieu, and the symptomatology. Under ideal cir-cumstances, the interpersonal diagnostician wouldgather information from a variety of sources andthereby attempt to understand these processes forthe person under study.

Bridging Clinical Concepts andEmpirical Research

Throughout this article, we have argued that psy-chology is in possession of the tools with which todevise a scientifically sound nosology. This nosol-ogy would encompass the full spectrum of inter-personal behaviors and would thus be useful forthe description of normal personality as well aspsychopathology. It would also be capable ofclearly distinguishing one level of measurementfrom another, for example, self-reports from re-ports given by others such as the spouse and, ofcourse, the clinician. In addition, while avoiding

any necessary endorsement of a particular etiologi-cal theory, the proposed nosology would be pre-scriptive in that it would specify remedial goalsand strategies, and it might greatly reduce the stig-matization currently associated with diagnosis.All of these features are desirable, but the onethat may prove most important in the long runis the extent to which a rigorous interpersonalnosology would facilitate research. H. E. Adamset al. (1977) appropriately remarked,

Much research effort has been wasted in attempts to dif-ferentiate groups on the basis of different diagnostic labels.It should be much more fruitful to look instead at spe-cific disturbances of response patterns and examine theiretiology, correlates, and modification, (p. 68)

One promising way of impressing interpersonalcoding schemas into such research is to study be-havioral contingencies, in particular the conditionalprobabilities that Person A will respond with be-haviors FI, F2 + . . . ¥„ when Person B performsbehavior Xl,X~2+ . . . Xn.

Although his work has generated controversy(Buchwald, Coyne, & Cole, 1978; Costello, 1978;Depue & Monroe, 1978), Seligman (1975) hasproduced evidence to suggest that noncontingentexperience leads to a sense of helplessness, whichin turn is associated with depression. The opera-tional way to study contingency is through thecareful enumeration of sequence. This has beenrecognized in the clinical literature for some time.Jay Haley (1963) suggested,

What is potentially most scientific about the interpersonalapproach is its emphasis upon observable data. The waysin which people interact with each other can be observed.. . . What is lacking in the interpersonal approach is thesystematic descriptive system differentiating the deviantfrom normal ways in which people interact with eachother. An ideal classification of interpersonal relationswould indicate types of psychopathology or differentiaterelationships into classes, according to the presence orabsence of certain readily observable sequences in the in-teraction. If such an ideal system is developed, it wouldnot only clarify diagnosis, currently based upon an anti-quated system, but also clarify the etiology of psycho-pathology. If one says that a patient is withdrawn fromreality, one says nothing about the processes which pro-voked this withdrawal, (p. 87)

More recently, Haley (1976, pp. 100-128) notedthe circularity of certain behavioral sequences, es-pecially within the family, and stated that "whodoes what in response to whom" is indicative ofwhat he terms "hierarchy," a concept closely akinto the dominance construct in the interpersonalbehavior models.

Markov equations have been used to analyze


behavior sequences coded onto the SASB surfaces.Benjamin (Note 9) wrote,

There have been few formal efforts to consider sequencingin the study of the process of psychotherapy. It is con-ceivable that this omission has led to the failure, forexample, to distinguish "pathological" from "normal" fami-lies (e.g., Frank, 1965). Both may "encourage independ-ence," show "noncontrolling warmth" and both may in-voke guilt and use punishment. The difference may lie inthe sequencing . . . in pathological families expressions ofunderstanding can be immediately followed by inductionof guilt, and expressions of independence, by restraint.. . . In normal families quite the opposite may occur:dependency may be punished and followed by rejectionand independence may be followed by noncontrollingwarmth.

Clearly, the detailed study of behavioral sequencesis a research tool that is too cumbersome for rou-tine clinical use. Still, such investigations seempromising and serve as an example of how the gapbetween the clinic and the laboratory may bepartially bridged by a rigorous taxonomy of socialbehavior.

Conclusion

We have proposed an interpersonal nosology andhave suggested a general method for translatingtraditional diagnostic categories into psychosocialterms, consistent with the assumptions and pro-cedures of behavioral science. Construction ofsuch a nosology will be a long and complicatedjob, requiring the collaboration of many. We haveattempted to sketch the sorts of issues that mustbe addressed in order to construct a taxonomy thatwill accomplish what it is supposed to and willreflect both the rigors of good science and thepresent data base of psychology. Such a nosologyshould be benign, representative of the human con-text in which the person functions, and flexibleenough to be used at various levels of generality.

It is clear that a good deal of work will beneeded to fully document relationships betweeninterpersonal behavior and standard psychiatriccategories, but it is also evident that the selectionof a traditional diagnosis for a particular individ-ual is frequently based on reports or observationsof social performance, a point made over and overagain in the literature. Sophisticated and well-researched models of social behavior have beenpublished during the past 25 years. It is appro-priate that their utility for psychodiagnosis be ex-plored, with a view toward evolving a taxonomicsystem for psychological dysfunction that is in-ternally consistent, psychometrically sound, opera-

tionally stated, comprehensive to the extent thatall existing psychiatric diagnoses of demonstrablevalue are translatable into it, and perhaps mostimportant of all, avoids continued endorsement ofa disease conceptualization of abnormality by be-ing explicitly constructed in terms of psychosocialbehaviors.

Some researchers (e.g., Blashfield, 1973) havebegun to explore the relationships among tradi-tional psychiatric diagnoses, using methods likehierarchical cluster analysis. A psychologicallyrobust nosology yielding clear implications fortreatment may have to be built around a unifyingdescriptive schema. Given that the process ofdiagnosis is largely a social one, that interpersonaleffectiveness has been viewed as crucially impor-tant by theorists as divergent as behaviorists (e.g.,Eisler, 1976) and dynamicists (e.g., Sullivan,1947), that social behavior may be taken as akind of common denominator of higher phylo-genetic functioning, and that psychologists haveaccumulated an impressive body of literature onpsychosocial functioning, it seems appropriate andtimely for behavioral scientists to construct a com-prehensive interpersonal taxonomy.

REFERENCE NOTES

1. Millon, T. Progress report on the proposed draft ofDSM-III. In A. R. Mahrer (Chair), Psychologicaltaxonomy: An alternative to DSM. Symposium pre-sented at the meeting of the American PsychologicalAssociation, San Francisco, August 1977.

2. Zubin, J. Proposal for an APA sponsored task forceon psychodiagnosis. In A. H. Mahrer (Chair), Psycho-logical taxonomy: An alternative to DSM. Symposiumpresented at the meeting of the American PsychologicalAssociation, San Francisco, August 1977.

3. The American Psychological Association has commis-sioned a task force on diagnosis (Wilbur E. Morley,Chair).

4. Benjamin, L. S. Update on the reliability and validityof the structural analysis of social behavior. Unpub-lished manuscript, 1978. (Available from Lorna SmithBenjamin, Department of Psychiatry, Clinical SciencesCenter, Madison, Wisconsin 53792.)

5. Benjamin, L. S. Using structural analysis for codingvideotaped or typed scripts of social interaction. Un-published manuscript, 1976.

6. Benjamin, L. S. Relation of interpersonal behavior tosome diagnostic categories as presented in DSM-III.Unpublished manuscript, 1978.

7. Task Force on Nomenclature and Statistics, AmericanPsychiatric Association. Diagnostic and statistical man-ual of mental disorders (3rd ed.; draft version of Janu-ary 15, 1978). (Available from Task Force on Nomen-clature and Statistics, American Psychiatric Association,722 West 168 Street, New York, New York 10032.)

8. Benjamin, L. S. Toward models of the dimensions ofaffect and cognition. Unpublished manuscript, 1978.


9. Benjamin, L. S. Use of Markov chains in the struc-tural analysis of a pathological mother-son conversa-tion. Unpublished manuscript, 1977.

REFERENCES

Adams, H. B. "Mental illness" or interpersonal behavior?American Psychologist, 1964, 19, 191-197.

Adams, H. E., Doster, J. A., & Calhoun, K. S. A psycho-logically based system of response classification. In A.R. Ciminero, K. S. Calhoun, & H. E. Adams (Eds.),Handbook of behavioral assessment. New York: Wiley,1977.

American Psychiatric Association. Diagnostic and statis-tical manual of mental disorders (2nd ed.). Washing-ton, D.C.: Author, 1968.

Argyle, M. Social interaction. Chicago: Aldine, 1969.Bannister, D., Salmon, P., & Leiberman, D. M. Diagno-

sis-treatment relationships in psychiatry: A statisticalanalysis. British Journal of Psychiatry, 1964, 110, 726-732.

Becker, W. C., & Krug, R. S. A circumplex model forsocial behavior in children. Child Development, 1964,34, 371-396.

Begelman, D. A. Behavioral classification. In M. Hersen& A. E. Bellack (Eds.), Behavioral assessment: A prac-tical handbook. New York: Pergamon Press, 1976.

Benjamin, L. S. Structural analysis of social behavior.Psychological Review, 1974, 81, 392-42S.

Benjamin, L. S. Structural analysis of a family in ther-apy. Journal of Consulting and Clinical Psychology,1977, 45, 391-406.

Benjamin, L. S. Structural analysis of differentiationfailure. Psychiatry, in press.

Blashfield, R. An evaluation of the DSM-II classifica-tion of schizophrenia as a nomenclature. Journal ofAbnormal Psychology, 1973, 82, 382-389.

Borgatta, E. F., Cottrell, L. S., Jr., & Mann, J. M. Thespectrum of individual interaction characteristics: Aninterdimensional analysis. Psychological Reports, 1958,4, 279-319.

Buchwald, A. M., Coyne, J. C., & Cole, C. S. A criticalevaluation of the learned helplessness model of depres-sion. Journal of Abnormal Psychology, 1978, 87, 180-193.

Cameron, N. The paranoid pseudo-community. Ameri-can Journal of Sociology, 1943, 49, 32-38.

Carson, R. C. Interaction concepts of personality. Chi-cago: Aldine, 1969.

Carson, R. C. Personality and exchange in developingrelationships. In T. L. Huston & R. L. Burgess (Eds.),Social exchange in developing relationships. New York:Academic Press, in press.

Cashdan, S. Interactional psychotherapy: Stages andstrategies in behavioral change. New York: Grune &Stratton, 1973.

Cole, C. W., Getting, E. R., & Miskimins, R. W. Self-concept therapy for adolescent females. Journal ofAbnormal Psychology, 1969, 74, 642-645.

Costello, C. G. A critical review of Seligman's laboratoryexperiments on learned helplessness and depression inhumans. Journal of Abnormal Psychology, 1978, 87,21-31.

Cronbach, L. J. Essentials of psychological testing (3rded.). New York: Harper & Row, 1970.

Depue, R. A., & Monroe, S. M. Learned helplessness inthe perspective of the depressive disorders: Conceptualand definitional issues. Journal of Abnormal Psychol-ogy, 1978, 87, 3-20.

Dimond, R. E., Havens, R. A., & Jones, A. C. A con-ceptual framework for the practice of prescriptive ec-lecticism in psychotherapy. American Psychologist,1978, 33, 239-248.

Duncan, S., & Fiske, D. W. Face-to-face interaction:Research, methods, and theory. Hillsdale, N.J.: Hal-sted Press, 1977.

Eisler, R. M. Behavioral assessment of social skills. InM. Hersen & A. S. Bellack (Eds.), Behavioral assess-ment: A practical handbook. New York: PergamonPress, 1976.

Endler, N. S., & Magnusson, D. (Eds.). Interactionalpsychology and personality. Washington, D. C.: Hemi-sphere, 1976.

Erikson, E. H. Childhood and society. New York: Nor-ton, 1950.

Fiske, D. W., & Rice, L. Intra-individual response vari-ability. Psychological Bulletin, 1955, 52, 217-250.

Foa, U. G. Three kinds of behavioral changes. Psycho-logical Bulletin, 1968, 70, 460-473.

Frank, G. H. The role of the family in the developmentof psychopathology. Psychological Bulletin, 1965, 64,191-205.

Fromm, E. Escape from freedom. New York: Farrar &Rinehart, 1941.

Gottman, J., Notarius, C., Markman, H., Bank, S., Yoppi,B., & Rubin, M. E. Behavioral exchange theory andmarital decision making. Journal of/ Personality andSocial Psychology, 1976, 34, 14-23.

Guttman, L. Order analysis of correlation matrices. InR. B. Cattell (Ed.), Handbook of multivariate experi-mental psychology. Chicago: Rand McNally, 1966.

Haley, J. Strategies of psychotherapy. New York: Grune& Stratton, 1963.

Haley, J. Problem-solving therapy. San Francisco: Jos-sey-Bass, 1976.

Heilbrun, A. B., Jr. Social learning theory, social de-sirability, and the MMPI. Psychological Bulletin, 1964,61, 337-387.

Hersch, P. D., & Scheibe, K. E. Reliability and validityof internal-external control as a personality dimension.Journal of Consulting Psychology, 1967, 31, 609-613.

Horney, K. Our inner conflicts. New York: Norton,1945.

Huba, G. J., & Hamilton, D. L. On the generality oftrait relationships: Some analyses based on Fiske'spaper. Psychological Bulletin, 1976, 83, 868-876.

Jackson, D. N. The dynamics of structural personalitytests: 1971. Psychological Review, 1971, 78, 229-248.

Jackson, D. N., & Messick, S. Acquiescence and desira-bility as response determinants on the MMPI. Educa-tional and Psychological Measurement, 1961, 21, 771-790.

Koch, S. Psychology and emerging conceptions of knowl-edge as unitary. In T. W. Wann (Ed.), Behaviorismand phenomenology: Contrasting bases for modern psy-chology. Chicago: University of Chicago Press, 1964.

LaForge, R., & Suczek, R. The interpersonal dimensionof personality: III. An interpersonal check list. Jour-nal of Personality, 1955, 24, 94-112.

Lake, D. G., Miles, M. B., & Earle, R. B., Jr. Measuringhuman behavior: Tools for the assessment of socialfunctioning. New York: Teachers College Press, 1973.

Leary, T. Interpersonal diagnosis of personality: A func-tional theory and methodology for personality evalua-tion. New York: Ronald Press, 1957.

Leary, T., & Coffey, H. S. Interpersonal diagnosis: Someproblems of methodology and validation. Journal ofAbnormal and Social Psychology, 1955, 50, 110-124.


Lemert, E. M. Paranoia and the dynamics of exclusion.Sociometry, 1962, 25, 2-20.

Lorr, M., Bishop, P. F., & McNair, D. M. Interpersonaltypes among psychiatric patients. Journal of Abnormaland Social Psychology, 1965, 70, 468-472.

Lorr, M., & McNair, D. M. An interpersonal behaviorcircle. Journal oj Abnormal and Social Psychology,1963, 67, 68-75.

Lorr, M., & McNair, D. M. Expansion of the inter-personal behavior circle. Journal of Personality andSocial Psychology, 1965, 2, 823-830.

Mischel, W. Personality and assessment. New York:Wiley, 1968.

Mischel, W. Toward a cognitive social learning recon-ceptualization of personality. Psychological Review,1973, 80, 252-283.

Natsoulas, T. Residual subjectivity. American Psycholo-gist, 1978, 33, 269-283.

Orford, J. The social psychology oj menial disorder.Baltimore, Md.: Penguin Books, 1976.

Pervin, L. A. A free-response description approach tothe analysis of person-situation interaction. Journaloj Personality and Social Psychology, 1976, 34, 465-474.

Rakoff, V. M., Stancer, H. C., & Kedward, H. B. (Eds.).Psychiatric diagnosis. New York: Brunner/Mazel, 1977.

Robinson, J. P., & Shaver, P. R. Measures of social psy-chological attitudes. Ann Arbor: University of Michi-gan, Institute for Social Research, 1969.

Robinson, J. P., & Shaver, P. R. Measures of social psy-chological attitudes (Rev. ed.). Ann Arbor: Univer-sity of Michigan, Institute for Social'Research, 1973.

Schacht, T., & Nathan, P. But is it good for the psy-chologists? Appraisal and status of DSM-III. Ameri-can Psychologist, 1977, 32, 1017-1025.

Schaefer, E. S. A configurational analysis of children'sreports of parent behavior. Journal oj ConsultingPsychology, 1965, 29, 552-557.

Seligman, M. Helplessness: On depression and death.San Francisco: Freeman, 1975.

Sharma, S. L. A historical background of the develop-ment of nosology in psychiatry and psychology. Ameri-can Psychologist, 1970, 25, 248-253.

Sullivan, H. S. Conceptions oj modern psychiatry. NewYork: Norton, 1947.

Szasz, T. S. The psychiatric classification of behavior:A strategy of personal constraint. In L. Eron (Ed.),The classification of behavior disorders. Chicago: Al-dine, 1966.

Ward, C. H., Beck, A. T., Mendelson, M., Mock, J. E.,& Erbaugh, J. K. The psychiatric nomenclature: Rea-sons for diagnostic disagreement. Archives of GeneralPsychiatry, 1962, 7, 198-205.

Weiner, B. (Ed.). Cognitive views oj human motivation.New York: Academic Press, 1974.

Welsh, G. S. Factor Dimensions A and R. In G. S.Welsh & W. G. Dahlstrom (Eds.), Basic readings onthe MMPI in psychology and medicine. Minneapolis:University of Minnesota Press, 1956.

Zigler, E., & Phillips, L. Psychiatric diagnosis and symp-tomatology. Journal oj Abnormal and Social Psychol-ogy, 1961, 63, 69-75. (a)

Zigler, E., & Phillips, L. Psychiatric diagnosis: A critique.Journal oj Abnormal and Social Psychology, 1961, 63,607-618. (b)

Zubin, J. Classification of the behavior disorders. InP. R. Farnsworth (Ed.), Annual review oj psychology(Vol. 18). Palo Alto, Calif.: Annual Reviews, 1967.

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Documents

Whatever happened to interpersonal diagnosis? A psychosocial alternative to DSM-III