Journal of personality assessment 57, 415-433
Miller, T. R (1991)
The psychotherapeutic utility of the five-factor model of personality: A clinician’s experience

In this article is suggested that

• Neuroticism influences the intensity and duration of the patient’s distress
• Extraversion influences the patient’s enthusiasm for treatement
• Openness influences the patient’s reactions to the therapist’s interventions
• Agreeableness influences the patient’s reaction to the person of the therapists
• Conscientiousness influences the patient’s willingness to do the work of psychotherapy

The clinical value of a taxonomy of personality

The five-factor model is a descriptive, taxonomic trait theory.

Trait theory is immediately helpful to the clinician in three particular ways

• It helps the therapist anticipate and understand the client’s private experience, because trait measures give a useful portrait of the client’s feelings and needs
• It helps the therapist understand and anticipate the problems presented in treatment
• It helps the therapist formulate a practical treatment plan and anticipate the opportunities and pitfalls for treatment

In real life, patients express all five factors simultaneously.

The five factors in clinical context

Neuroticism (N)

Clinical presentation

N influences the intensity and persistence of the patient’s distress.

Treatment implications

A therapist needs to know where his or her patient stands on the N domain in order to interpret a presenting problem, intake diagnosis or social history.

• Low on N
  The problem is more likely to be a reaction to a severe stressor of recent oneset
  A good treatment focus might be a relatively isolated self-defeating behaviour pattern or a strong emotional reaction to a recent stressor
• High on N
  The presenting problem is likely to mesh with a pattern of tension, worry and dysphoria woven throughout the patient’s life.
  It makes sense for treatment to focus on generic difficulties.
  Setting clear and realistic treatment goals may be particularly important for high N patients, who may be further demoralized by the frustration of unrealistic expectations of treatment.

Outcome expectations

Treatment can be conceptualized without the premise that N must be or can be substantially reduced.
N scores probably change slightly at best, due mostly to moderate changes on one or two of the facet scales.
N scores at the beginning of treatment give some useful predictive information about the client’s adjustment at the end of therapy.

Extraverstion (E)

Clinical presentation

E influences the client’s enthusiasm for the process of psychotherapy and his or her expressiveness in treatment.

• High E patients
  More likely to be cheerful, to laugh and joke about their presenting complains, and to assert their opinions to the therapist
  Experience emotions with greater intensity
  At the outset of treatment, they are more likely to hit the ground running
• Low E patients
  Less likely to be cheerful
  Experience emotions with lesser intensity

Extremes of E indicate the form that complaints and symptoms are likely to take, not the likelihood that symptoms will arise or that functioning will be impaired.

Treatment implications

E likely accounts for the distinction between patients who eagerly anticipate each succeeding session and patients who seem to dread each one.

• Extraverts are gregarious and like to talk
• Introverts do not

Most systems of psychotherapy involve considerable conversation.
Low E patients rarely find themselves brimming over which words they must spill.

Outcome expectations

It may be that a certain minimum level of E is necessary to give clients the vigour and hope to cooperate with therapy and benefit from it.

E is a strong predictor of well-being.

Openness (O)

Clinical presentation

O influences the client’s reaction to the interventions offered by the therapist.

• Low O psychotherapy patients
  Closed
• High O patients
  Likely to be perceived by therapists as good patients
  Readily fantasize and symbolize

Therapists who understand the O domain will be less likely to make potential harmful value judgements about low O clients or themselves.

Extreme O can have disadvantages
Very high N, very high O patients may reify their own metaphors.

Treatment implications

Psychotherapy can be understood as the process of finding novel solutions to familiar problems.
Treatment methods can be rank-ordered according to the degree to which they require novel behaviour and thinking from the client.
This openness to novel experience is reflected in the client’s O score.
Therapies that rely on emotional support are easily tolerated by individuals who are closed to experience.

Outcome expectations

The relationship between O and treatment outcome will turn out to be complex.
Clinician’s biasses against O.

Agreeableness (A)

Clinical presentation

A influences the client’s subjective reaction to the therapist, just as it influences the nature of the client’s relationship with other people.

• High A
  Want to be liked
• Low A
  Want to be admired or to achieve interpersonal influence

The presenting complains of high A and low A do not differ dramatically.
It seems that high A patients have been victimized or exploited by others in the past.
Low A people often do complain of victimization or excessive naivete, because they vividly remember every time they have lost the advantage in some kind of an interpersonal power struggle.

Treatment implications

It is useful to know where clients stand on A in the earliest stages of treatment.
If they are low in A, you can expect skepticism, sensitivity to minor failures of empathy, and slowness in developing a collaborative relationship.
High A people tend to present the opposite kind of transference phenomena.

Outcome expectations

In general, very low A patients are probably more likely to initiate early and unsatisfactory treatment termination.

Conscientiousness (C)

Clinical presentation

People who score high on C are more likely to make an effort, tolerate discomfort, and to delay gratification of impulses and desires.
Low C scores may have a previously unexpected relationship with the nature and severity of psychopathology. Or high C people may prefer to solve their own problems.

Treatment implications

A mismatch between effort and desire will become apparent in psychotherapy.
Patients with low C will still want to be relieved of their symptoms and problems in living, but are less likely to make an effort to change their behaviour, or endure psychological or physical discomfort even when they recognize the desirability of doing so.

Low C might represent one of the absolute limits of the power of psychotherapy.

Outcome expectations

C is correlated with a good outcome.