Applying HiTOP (a DSM alternative) to Clinical Practice with Dr. Robert Krueger

In part 2, Dan and Dr. Krueger discuss the importance of understanding personality in the context of psychopathology, emphasizing the HiTOP model's integration of personality traits and symptoms. Dr. Krueger explores the clinical utility of psychopathology profiles, the need for a dimensional approach to psychopathology, and the relevance of interpersonal factors in personality disorders. The conversation also touches on the challenges of implementing the HiTOP model in clinical practice, the significance of therapeutic assessment, and the ongoing evolution of treatment protocols. 

Special Guest: Dr. Robert Krueger

Episode Links
HiTOP Model in an image

Original HiTOP Article

HiTOP Self-Report Measures

Sample HiTOP Clinical Assessment Profile

ARCS Institute

Official HiTOP Website

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[Music] Broadcasting from the most beautiful city in the world, I'm your host, Dr. Dan Cox, a professor of counseling psychology at the University of British Columbia. Welcome to Psychotherapy and Applied Psychology, where we dive deep with the world's leading applied psychology researchers to uncover practical insights pull back the curtain and hopefully have some fun along the way. If you find this show useful, it'd be much appreciated, if you shared it with someone else, you might enjoy it too. Dan could be more excited to welcome back one of the world's authorities on mental health diagnoses. In talking with my guest, cutting edge researcher, that is at the forefront of using mathematics and other methods for understanding psychiatric diagnoses, I was struck by how much he considers the clinicians and patients experience in his work. In this conversation, you'll learn about how personality is integrated into the high-top model of psychopathology and what using the high-top modeling clinical practice looks like. The episode begins with my guest talking about how personality is embedded within the high-top model. So, without further ado, it is my pleasure to welcome back my very special guest, Dr. Bob Kruger. Part of the reason that high-top looks the way it does is because personality really is kind of the infrastructure for psychopathological presentations. And again, there's a lot of literature that speaks to that basic assertion I just made. But psychopathology is taking place in the context of a person's basic, this positional major and set up. So that's, I think, where the clinical utility comes in for me. I have a hard time thinking about a case without understanding the personality of the case, if that makes sense. Who is this person? What are their basic, this positional features? And it's always the case with psychopathology that's the way in which people experience problems in the context of what they're basically like. As they encounter the world, their personality that's intersecting with the things that happen to them or the things that they do to the world, like are being driven by their dispositions. And again, that's not to say that personality is fixed and I'm changing and totally 100% heritable or whatever you might say. I think these things are sort of, you know, not, that is not possible to work with personality clinically. I think that's another misunderstanding that people often have. So I just want to kind of call that out, right? Like, I think personality is kind of the key construct in clinical case conceptualization. That's part of the reason high top is organized the way it is. Personality is relevant beyond the personality disorders, which is a whole set for matter. And if you get to know the personality of the person, you have a much better handle on, who am I dealing with here? So yeah, I can try to make that as vivid as I can, right? Like using a specific kind of case example that I often use, workshops, right? You encounter two patients, both clearly meet criteria for major depressive episode, right? And that's the presenting complaint, right? They're coming in because they're depressed. They're having problems with, you know, sleeping and eating and engagement and being able to go to work for school, right? Kind of classic depressive presentations. And that's why they're there. Imagine one of those people is like the sweetest person you never meet, right? So they lack all those antagonistic features. One of them, and they have similar levels of depression, is really antagonistic, difficult to get along with. Oftentimes, you know, finds until the odds of other people. I mean, you know, you can say like, well, they both have depression, so I'm going to do CBT for depression. But that's going to go really differently for those two cases. I mean, I mean, this is an example. There was a time when I was seeing two people who were like this, and that part is part of how the light bulb came on for me. It's like, oh, right with the one guy that I was saying, very, very kind, very sweet, appreciated all my efforts. I got some medical referral things to happen that were super helpful to him. Right? Like just like everything I did was very much appreciated. He would do his homework, right? And, you know, that was great, right? Because you had, you know, and of course, the essence of effective psychotherapy is I'm sure we would agree is like the relationship, right? So we built this strong relationship and it was straightforward to do it. Okay, then the other guy, like it doesn't matter. Like, maybe you should try some homework. I don't like this homework. This is stupid. This is a waste of time. Right? Like nothing's going to help me. Life is hopeless. Right? And I don't really like you. I never really liked any of my therapist. You guys are just in this for the money after all. That's a very different presentation. Right? That's a very different kind of person to try to work with because you've got to work around work with that basic hostility. Right? That essential antagonism. That the person carries with them in their approach to the world versus the other person who's, you know, lacking those qualities. If anything, like has the opposite quality of being very agreeable, like easy to get along with. Very interested in smoothing over social circumstances. So maybe that example helps, right? Because I, you know, once you start to see that stuff clinically, it becomes clear to me that you've got to understand personality. Because it's the context in which psychophevality is occurring. Both of those people were very depressed and had a clear and similar presenting complaint, having to do with how depression was affecting their willy defunction and some clear treatment goals surrounding them. But there are different personalities affected how you had to proceed. Because you're not just going to get somebody who's antagonistic to do homework or whatever, or you engage with, you know, the treatment protocol. Even if that protocol is well laid out, it's going to be a much bigger challenge. So that's, that's the essence of what I want to convey about, you know, like dimensionality of these things. And also the kind of the multi dimensionality, like you need a personality profile. And, you know, why I think it's very clinically useful to understand the way personality affects presentations. And then be able to like pivot and modify your approaches of therapist to recognize, you know, those kinds of personality differences. So in the high top model personality is brought into the, I don't know if you even diagnosis is the right word, but it's brought in. And then in the in the in the system, the words, their traits and their components, right. That is sort of the two terms that are used in the high top framework to talk about sort of, we would traditionally think of as symptoms, I guess, and more personality. Yeah. And so I think that that is, that setup is meant to recognize that some things are more like symptoms in that they're kind of focal behavioral tendencies that might come and go more readily. And some things are more like traits in that they're more like dispositional tendencies that kind of carry more across time and circumstances. So something like self-harm, right, or specific kinds of eating behaviors, specific kinds of sexual problems, right. These are more like behavioral clusters. And certain other kinds of things like the aforementioned examples of this inhibition and antagonism, more like dispositional things, personality. And then you need both concepts to make sense of psychopathology because traditionally psychopathological concepts contain elements of both, right. They contain things that are more like dispositions of traits and tendencies and they contain things that are more like behavioral problems, but more focal nature. So to make that all work, right, you kind of need both things within the model. And I think that's how high top tries to handle that fact. Like that some things that are part of psychology are more like behavioral clusters, right, of specific kind of problem behaviors that the clinician might be presented with and some things are more like dispositional tendencies. It's not the say that this distinction isn't fuzzy, right, there are overlapping aspects to this. And in fact, some high top colleagues have argued that to the extent of the behavior for cis them, it's a trade, right. Like that's one way to handle that. To the distinction, whereas to the extent that the behavior is time varying, it's less trade-like. But, you know, practically speaking as a clinician, you got to pay attention to both those things, I think. Sometimes, right, the presenting plane is really a very focal behavioral problem. And then that's what you mean, deal with primarily. And that might be a situation where personality might interfere, but might be less centrally relevant. Then a much more, well, frankly, like behavioral kind of perspective, like what's the problem behavior? Let's do a functional analysis of what's supporting this problem behavior and try to intervene on that level. Sometimes I think that can be fairly effective and you don't need to bring in a lot of broader dispositional stuff. But even there is the person going to cooperate with the behavioral intervention? Well, again, I guess even there, personality is going to come into play. You know, right, like to get somebody to do something, like exposure and response you mentioned or something like this or whatever, like they got a cooperate. You know, the classic axiom, right? They're not going to change without, you know, like being willing to change or being willing to engage with the therapy. Like, giving people engaged is a big part of the whole battle, right, in effect, with psychotherapies. They have to connect with you, you have to establish a good working relationship, and then they have to engage. So I guess even for focal behavioral problems, the person might come in there, like a sexual complaint or something that's very behavioral. Just kind of thing of examples of like there's a really, really specific behavior thing I want to change about myself. Like, it's still in the context of like who is this person and how easily can I act with this person? Right? I guess that's my point. Like, you kind of need both to get back to kind of, I think what you were asking me about, which is like, I top kind of has both these behavioral syndrome type elements and these kind of dis-positional trait type elements. I think that's because psychopethology as it presents in the clinic has both elements. So do you think we should retain or get rid of the distinction between the personality disorders and the disorders we're talking about now? Yeah, that's a really great question. It's been a question of great interest recently in the literature. And I think it requires some retasting, maybe what we mean by personality disorder. So like, it's all these constructs floating around with this psychopethology. We've talked a lot about personality today. Now you've introduced personality disorder, right, which adds the word disorder to the concept of personality. And I think if you look at kind of like the DSM and ask, well, what makes these syndromes personality disorders as opposed to mental disorders? It used to be that without access one and access two DSM five did away with the multi-axial thing, but traditionally people I think still talk about access one and access to disorders as the mental disorders and personality disorders, right? When you look at like, what's in that personality disorders chapter? What kind of features of presentations are described there that aren't described in the other parts as much? It's interpersonal stuff. Right, so when in that kind of like happens clinically too when people say like, this person is a personality kind of flavor, there's probably personality disorder present. They mean this interpersonal stuff that's present, right? That isn't so much present when people who don't have a personality disorder. So some colleagues of mine like Aiden Wright and his, you know, colleagues that have proposed that you could think about these as the interpersonal disorders. Rather than the personality disorders because personality is relevant to all of psychopathology. But the things that have traditionally been called personality disorders are really more like interpersonal kinds of problems. So I think that's a compelling way of recasting what this is about and then what gets tricky is like, well, interpersonal stuff is present in a lot of psychopathology. So is the distinction even really all that relevant? And I guess I come back to certain concepts are hard to be rid of. Like I mean, I'm the editor of the Journal of Personality Disorders. I guess I have some endorsement of the concept of personality disorders. I've heard of this, but of course this is an enterprise I inherited from people who came before me. So like, am I going to like have some campaigns and limit the concept of personality disorders? I thought I got particularly well because it's a concept that's been there for a long time. But I think thinking about what we meant by personality disorders might have been more like presentations where interpersonal difficulties are really at the fore. And I'm really relevant to the case presentation. That might be a better way of thinking about what do you mean by personality disorders? Because again, personality is relevant to all of psychopathology. So maybe that helps to answer your question, which is like, should we get rid of the distinction? I think we should recognize the personality, right? Is it the core of a lot of psychopathology that's going to be helpful clinically to get that idea across? And then ask, you know, our interpersonal factor, the key aspect of the presentation. Because then that might call for the kinds of approaches that have traditionally been classified under the personality disorders. The way that you're describing it, it almost sounds like another dimension that we would have a. Interpersonal factors or interpersonal dysfunction or whatever it is as a separate access. So that's kind of how they have that's how the alternative model of personality disorders, which we talked about in our previous conversation kind of handles that right in the AMP. There's personality variation, which is criterion B in that model. And there's interpersonal difficulties, which also have self manifestations, right? So these things are kind of conjoined psychologically, like people with difficulty conceptualizing other people in coherent and adaptive ways. Also often have difficulty conceptualizing themselves in coherent and adaptive ways, but self other pathologies kind of a psychologically coherent construct. That makes sense, if I say that way, like that, that had its origins in psychodynamic theory, maybe obviously, but, you know, self other conceptualization, like object religions, like the ability to think about yourself, other people in coherent and adaptive ways. That's criterion A in the AMP. So yeah, the AMPD model, I think, handles it the way you just described. The high top model isn't as explicit about that distinction because some of that interpersonal stuff is sitting along with the personality trait stuff. And that's an ongoing area of discussion research, right? Like how much can you really separate out? It's called criterion A, self, you know, other problems from criterion B, more dispositional trait type problems. Can you really separate the amount? I think that I can appreciate the distinction psychologically, clinically, because it really has to do with like everybody has a personality and they're going to have quirks. But the criterion A stuff is like, okay, that's what we meant by personality disorders, right? There's just there are serious issues with being able to conceptualize self another in a coherent and adaptive way, which requires a very different therapeutic approach. Because those are people who aren't going to be able to form a therapeutic relationship with readily these kinds of things come before, right? In terms of how you have to work with them clinically. So it's a bit complex, right? When I'm trying to describe there and there's, you know, different models out there in the literature. But I think to get back into your question, you know, should we dispense with the idea of personality disorders versus other disorders? I think we need to recast maybe what that meant in the first place as, you know, presentations. Like so, I mean, going to say as personalities are clinical presentations where self other disturbance is very prominent in the clinical picture. Right? There's a prominent aspect of dealing with this person where the commission comes to realize that the person has, you know, notable challenges in having a coherent sense of who they are, how they relate to other people. You know, like coherent ideas about the motives of other people who are working mental models of self another like if you don't have that stuff. Then those are going to personal kinds of problems that are going to pass and that's not relevant to every case. When it is relevance, that's what we meant by the personality disorders in the first place is what I think is going on, you know, in the clinic, essentially. In the high top model, are there any, are there any threshold effects? So do you think about these. What's the word I should do? I should use the word symptoms severity, which I use. Do we think about the symptoms? Maybe like this stuff that this the raw meat like the stuff that people. Do you think that those, yeah, the severity of that is that a purely linear sort of, you know, as it gets higher, it gets more challenging, or are there thresholds or cutoffs where it sort of seems like, okay, now this is where a person's really struggling, right? Sort of how we think about sort of like we hear talking about earlier, when you hit the magic number of five, then you have the disorder, but something more empirically based. Yeah, no, that's a fantastic question. It's something I've been, I've thought about for many, many years and tried to work on some publications about this. So long story short, there are pretty sophisticated statistical approaches that can be taken to ask whether a collection of what's called symptoms, right, or criteria, or, you know, essential clinical features, symptoms probably works for this. Right, whether those things are organized empirically in such a way that there is some discrete aspect of that distribution versus that it's moving continuous, right? So we've done things like this many, many other colleagues and things like this, right? So there's a set of statistical tools that you can use. If you have a data set that contains a list of these symptoms on people to ask whether the distributions are continuous or discrete or have discrete type features, right? Or aren't smoothly continuous in various ways. And that literature is pretty consistent in saying it's very rare to encounter non-smooth discrete features. That makes sense, like that's rarely encountered in data. It's more typical to conclude from this model-hitting exercise that things are continuous. So that's another basis for the assigned different basis for the high-top approach. Now, that doesn't mean you can't set practical color offs, but they would be well understood as having a practical aspect of them not a scientific aspect. But that makes sense. And that happens all the time in medicine, but that's not rare in medicine. People with lots of classical examples, right? Blood pressure is a classical example. Right, there's a point at which that becomes, that's a continuous variable right here. It's a solid can die, solid blood pressure or continuous variables. But as everybody knows, I'm going to the doctor. They measure that continuously, but then there's a point where they're like,"Oh, you might have hypertension." Right? And we might want to prescribe data blockers or something like this, right? That's practical because the risk, right, for undesirable effects like the stroke, or much enhanced at certain levels of this continuous variable of blood pressure. So it's meaningful to talk about hypertension based on having a certain level of blood pressure. That's clinically useful and meaningful. There's some threshold there, but they're set on a practical basis. No one's claiming that blood pressure has to scrape features in its distribution. What's being said is that there's a certain level of blood pressure beyond which we know clinically that the risks of, you know, really unpleasant things happening like a stroke are much enhanced. So that's the way to begin thinking about this in psychotherapy, like the underlying symptom structures are pretty continuous. But for practical purposes, we can say, "We do this in two or two anyway." Like, this is the level of depression where the person can't do stuff they really want me to be doing, like going to work with school. You know, there are levels, right, and that's where the social impact occurs. That's a practical distinction, not a scientific one, which doesn't mean we can't make a distinction. Just recognize depression is continuous. But there's a level, right, beyond which it really does require some kind of intervention because the person's not functioning. So that would be reasonable to say that it's associated, like so if we're using depression or whatever, that it's association with various outcomes would be non-linear. That like above certain thresholds is when we would see that just the example you gave, right, difficulty at work. And if we said, you know, unemployment or losing a job or whatever, that there are at the whatever we're saying are the lower levels, the odds of that happening are because of this, because of the depression are somewhere very minimal. Then at a certain threshold, now it starts to be that, you know, it starts to become like, "All right, sometimes people do have trouble at work because of this." Then you hit a higher level, then this is often people have trouble at work because of this. Yeah, and that's likely to be pretty smooth and continuous too, right? So people have studied that as well. Basically, this is the regression, right? Like the statistical relationship between the predictor and the outcome, or the predictor is psychology symptom, you know, amount. And the outcome is something like, you know, a bill will be awarded. You rarely see that that has some kind of non-linear aspect to it. So people try to study that too, and that looks pretty continuous. So again, like there's a practical place to set it, even if the data are pretty continuous. Because, you know, the probability of really not being able to function is a linear function of how many symptoms. I mean, you know, we can admit that that's continuous, that's fine. And we can say like, "Okay, as a field, like we get together and say that, you know, practice guidelines are such that this level, you know, is the place at which the undesirable effects become more likely than not." Like we can do it that way, right? Greater than 50%. Right? Yeah, again, that's somewhat arbitrary, but also practically useful. That's the point I'm getting trying to convey. Even if everything is smooth and continuous, there are practical aspects. And that's the basis we could use to set thresholds. And just say like, that's, it's set there for practical reasons. The science is that it's smoothly continuous, but this is the point where the clinicians really start paying attention, because the probability of adverse events is greater, than it was at a level below that, enough so, that really that's where you pay attention. Yeah, and the other point I guess I could convey is that this is always in clinical settings. People again do this intuitively. A kind of a triaging kind of thing that people do. Right? So like, I spent a lot of time in my training in drug and alcohol type settings. It's always like this. By which I mean like, okay, the person has some difficulties and good social supports. And there's no real medical complications of like alcohol dependence, right? You might be able to do, you know, outpatient approaches to detox that could be kind of effective. Okay, the presentation is more severe than that and they've managed to, you know, really like lose their social supports. Well, then maybe a partial hospital is in some kind of approaches. Okay, like, and there's no medical complications. Right? Like, let's say you have that kind of presentation, but there's not good social supports. It's kind of a medium level severity, right? Well, then like, partial hospital, maybe that's the way it goes. Okay, this, and then at this extreme, right? This person has no social supports. They've been bringing heavily for years. Maybe there's some initial signs of warranty course of cause. They might have peripheral neuropathy. I mean, you got to start them on vitamin supplements immediately. And, you know, you might want to detox them in an inpatient way because there's possible medical complications that could be really severe. That's, that's inpatient. You see what I'm saying? Like, there's a continuum, there's a continuum intervention intensity that corresponds fairly naturally to a continual symptom presentation. And, and that's how it works anyway, right? Like, that, no, it would be weird to think about like, okay, our, our alcohol dependence treatment unit. Either treats people or dozens. Like, as it's implied by a diagnosis, right? Like, you either make criteria for alcohol dependence and we throw the kitchen sink at you and your inpatient from on. Or we send you home. Nobody does this, right? Like, that's not how these things work. Practically speaking, there's a, there's a graded degree of intervention intensity that corresponds to the graded degree of symptom presentation and severity and, you know, associated effects of the problem. So, I mean, I think really like getting back to the point of this whole discussion, like the high top kind of thing is like, okay, we know this. Let's not pretend that there's a bunch of categories where we know there aren't. Let's try to develop more scientifically based approaches that, like naturally to these practical things we can do to, to be effective, clinically, which often have a graded intensity aspect of it. Just naturally. So, on the on the high top website, which I'll link to, there are several measures that have been developed to assess disorder of psychopethology based on the high top model. If you were talking to a clinician who said, hey, could you point me in the direction of one or two tools? Because I want to try this in practice or work, you see how this works with a client. What would be the one or two tools you would point them towards? Yeah, so high top now has some assessment measures that are available that are, I think, connected on the website. So that might be one tool where you could use the high top assessment. It's called the high top SR. Kind of try to use that. Try to interpret that clinic. We see if that gives you something useful. And also we have a clinician network that's developed, right, that should be linked up there on the website. Join the clinician network, connect with the network with other people trying to do this stuff in applied ways. And so, with the, I think it's helpful, you know, with the high top SR, where that tool is. And I'll link this as well. So what the tell me if I'm wrong, what the clinician gets is they get and use this word earlier, they get this profile. Well, there'll be these, you know, three or so general categories. And then underneath of each one of those are a bunch of sort of subcategories. And then you get this, it reminded me of an MMPI profile is what it reminded me of where you get you get this score, right, on each of these subfactors. And so you can see by looking across this client's profile, sort of at the higher level factors, where maybe there are some elevations. So if it's, for example, if they have a whole bunch of scores that are high on externalizing and low on internalizing, you can start to immediately say, Oh, okay, this person is more of an externalizer than an internalizer, right, so that gives you clinical information. But then there's also these subfactors underneath of that, that would be terms that most of us would probably be more used to seeing in the DSM, like subcategories within the DSM, where you're going to see those elevations or not on that profile. Yeah, yeah, that's the kind of information that is conveyed by that. And the hope is that that's more clinically useful than just diagnosis, present absence. So that's a way to kind of engage directly with the model in a clinical setting. Right. So one of the things, and we were talking about earlier about this consortium, and one of the things that I thought was very cool that I'd love for you to talk a little bit about is. So you guys kind of created a bunch of rules for lack of a better term about how we're going to move forward with this thing. And part of that is for folks who want to propose changes to the high top model. So I was wondering if you could talk about that process a little bit. Yeah, no, I mean, so that's something that many high toppers, to be going, "I don't know what this is," I said this stuff into my head. Let's call them high toppers. The members of the consortium are pretty invested in it. Wait, did you just come up with that? I think it needs to stick. I think that's kind of, you guys need like t-shirts or pins or mugs or something. I'm a high topper. I love a high topper. Yeah, we have a high top society now, which is linked to on the web page. And at our most recent society, meaning we had our first swag. So I have a high top chip clip now. So your official society was here with chip. I think everybody knows. So that's kind of fun. Yeah, and t-shirts would be good. So yeah, there's a high top society too. There's the consortium, which is the scientific branch of high top. But there's a society too that people can belong to and pay dues to and come to our meetings. We have yearly meetings. So that's on the web page too. That's another way to engage with the high top enterprise. Right, join the society. Beyond the society newsletter, come to the meetings, present your work, and connect with people that you've got a conference. That's a good way to engage with the group. And then what were we talking about? A lot of them. So the process of proposing changes to the high top model. Yeah, so there's a revision group. My colleague, Mary Forbes, who's at McCory, in Australia, leads that group. And they put together paper describing a systematic approach to proposing changes. So there's a template for proposing changes like a way of assembling the evidence. But then that committee would consider, if you said we should change something out of the model. Like the name of something or where it's located or whatever. Yeah, there's a process for engaging with the model. So yeah, that is a thing that the consortium is attempting to develop. Because that's always a challenge with these things, right? Like these models can become readily ossified, like kind of fixed in place, kind of stuck. Right, certainly that's an issue with the DSM, as we've been discussing. Like that can tell you it's stuck. Because there's various political forces and practical reasons to not mess with it. So high top could suffer the same fate, of course. So there's been some sensitivity to trying to have a dynamic process where it's not changing at random, right, or based on the whims of a few people. But a systematic process for proposing changes is for that to be considered by the committee that handles, you know, revisions. So the revisions work, right, that handles this. Yeah, it struck me, it sort of looking at it and seeing that revision, and I think there was a paper that you all have written that sort of specifies how that goes. But it just really struck me again that like you're not part, you know, you're not part of like the infrastructure of some pre-existing organization, where this sort of thing would be, you know, sort of like how the American Psychiatric Association has with, you know, that, that, but you develop sort of this, these rigorous set of standards and expectations for folks to propose changes to the model. It's just struck me as impressive and really thoughtful. And again, you know, I don't think you have any full-time staff that are working. You know, I mean, it's just sort of a lot of effort. Yeah, it is. That's Mary Forbes for you, right? Like she was the person who really directed that and led it. So she's the person who felt that was important and kind of led the effort to pull that together. I think along with Eden Wright, it was part of that too, it was part of the revision's work group, one of the co-chairs. But yeah, that's, it's a good thing that you're alluding to, which is that there have been a lot of selfless people involved, devoting a lot of time and effort to be endeavor. I guess because they believe in what it's about. So yeah, that's been gratifying again, like it's the where I used before. That's how that feels to me. It's like it's cool. The colleagues are like, we want to engage with this and contribute to it. So that's been great to see. So I'm wondering if you could talk just a little bit more and you sort of started to earlier about the what this would look like or where you all are thinking about going with this clinically. You know, we have this, if nothing else, large literature on, you know, whether they're randomized control trials or other sorts of trials, looking at specific treatments for specific problems and that's organized in all sorts of different ways. But we have decades of work looking at this based on the existing DSM classification. And now we have this new model. Right. So again, there's a clinical applications work group within the high top that's published some papers about this. So that's one place to go for some resources for how you might apply this clinically. And I think, you know, the basic scheme is that there are many, many psychotherapies out there in the world, waxing, waning, their popularity and so on. And many sort of therapeutic techniques. And the idea, I think ultimately would be to tell their specific techniques and approaches to specific high top presentations. Which I think is again, like intuitively, but a lot of clinicians do. It's kind of rare to encounter somebody who's very ideologically committed to a particular like three letter therapy where like all I do is DBT, that would be kind of odd. Right. It's more like, you have an armamentarium of different approaches and you can pull them out as you need to to work effectively with different aspects of a person's presentation, maybe even shifting midway through because something changes in the presentation and relationship. Right. So I think that people do that relatively intuitively and maybe what high top can contribute is a more systematic kind of like flow chart kind of approach or something like this. Right. The curious approach is the corresponding these kinds of things. And another thing, this is not directly related to high top, but that I've been kind of working on. There's this clinic that we have called the ARC Institute and I can give you the URL for that, but it's ARCS Institute. And that's a research and training clinic that I'm connected with here in Minnesota where the goal is really kind of to develop these approaches clinically. So that's an existing clinic, right. Like there's a group of clinicians who are part of this group practice who are also trying to implement these approaches clinically. The ARC Institute is all about trying to do this systematically. So that's something I'm personally involved in that isn't directly connected with the high top consortium, which is more of an academic endeavor, but ARCS came about because the idea was, could we create, you know, a group practice here in Minnesota in which, you know, we really try to take these ideas that are percolating in the academic literature and apply them clinically. And so all the clinicians that are connected with ARCS are trying to take this kind of approach and we have, you know, a group, you know, kind of group supervision thing. We have trainees, right. Like practical students who are connected with it. And that's the goal, right. To really kind of lay this stuff out clinically and try to apply it. Working with a diverse set of, you know, clients who are connected with that practice. So that's been really great. Like that's really is a very translational endeavor for me that I've enjoyed getting involved with where we're really trying to see if we can make this work clinically. And so we do a lot of personality profiling, right, as part of how we try to conduct that work. And again, the clinicians have, we spend at least an hour a week kind of a, you know, like a group supervision kind of said and talking about how, how is this going, how is this applied with this particular case and what are we learning from this approach, how can we tweak it. And so it's something we're trying to develop. And we're trying to develop things like a more formalized treatment manual type of approach, beginning to produce some materials like that, like getting some papers together, maybe trying to come up with something that looks more like a treatment manual, really. And we're calling that kind of personality-driven psychotherapy. Because really getting in my way of thinking, personalizing to the center of all of this, and that's what connects high-top the AMPD model with a lot of stuff that I've done academically. So yeah, that's a specific group practice. So if there are people listening who want to seek help, right, and the reimbursement stuff works out correctly in terms of their license and all of the practical things, but like, you know, that's a way to connect with this approach if it seems like it's something you're interested in as a client. Or as a practitioner, if you want to connect with us, that's a way to do that too. So again, in the academic realm, there's high-top per se, and it's clinical work group. And then in my, you know, sort of professional life, my specific professional life, I'm connected with this arts institute clinic where I'm, you know, I guess serving with scientific director and trying to, you know, have people working for us, right, like full-time clinicians and people like that who are really invested in this approach and trying to use it for. So those are two things that are separate, right, that I'm involved with. That might be an interest to, you know, listen to it. So how do you even begin to move forward with the idea of developing protocols, treatment protocols broadly defined for this profile, right, like, I think you and I and many, many people are very much on the same page that the idea of this treatment for this DSM category for this problem is flawed. So we can just sort of say that is, that is true. And even though fatal leaf, flawed often, the way one thinks about it is, I don't say straight forward because for those listening who have been involved in treatment, you know, intervention studies, RCTs, it's not straightforward. But, you know, the idea of this treatment for this problem, right, we have a, we have a treatment group in a placebo group or treatment group, some sort of control, whatever is like at least relatively ish straight forward, at least at the broad level, right, a person get their head wrapped around that. Where if I'm thinking about this profile, then it's like, man, that's not, that's not, you know, that's not even on a single dimension. I mean, that is, you know, so complex. So how do I even begin to think about a treatment for a profile and an attempt to standardize it? Yeah. No, a great question. It's something we're struggling with, right? I think my intuition about this, right, is that there's just a lot of stuff out there that we all learn how to do. And it's about being systematic about connecting different kinds of presentations with them, you know, kind of the personality and symptom profile with different techniques and approaches we have available. So I can try to be concrete about it, right? Like when people are kind of antagonistic or disengaged or they don't really, they don't really make me ready for like, they give it a stage of change kind of way, they're really ready. That's why people develop things like motivational intercourse. Sure. Right, that's the reason that kind of, you know, therapeutic approach has been articulated. So then, right, if that's in the profile, while you turn to those kinds of approaches and tools. So that's the essence of, I think, what we're trying to articulate within the arts institute is, okay, it's not that you mean like whole new, like another three letters psychotherapy, like I don't know if we need that, except in the sense that we made up a three letter for, we made a P, as you got it. It's the law, I'm pretty sure it's the law. It's the law that you need a three letter acronym. Yeah. So P-D-T, but like what that is is let's pay attention to personalities, the framework, and let's bring in psychotherapy to approaches that have been well articulated and tested because our kind of through our lens, right, what those things are doing is they're tapping into different aspects of the symptom and personality profile and coming up with techniques and strategies that are kind of key to different aspects of it. But we could be systematic about that. You could say like, oh, if this is present, right, try these things, right? And it gets a little tricky because you can't do the whole thing at once, which is I think what you're alluding to. Like you got to kind of pick and choose which things to focus on. But that's a collaborative discussion with the patient in the context of a therapeutic assessment. Does that make sense if I say that way? So there's a literature on therapeutic assessment, which I admire, right? Where the idea is to really use assessment because not a lot of people are using formal psychometric assessments in the way that I would like to. I find that simply useful in the clinic. So like the idea is we're going to do this collaboratively, right? It's not just for, you know, like some custody battle thing we have to take the MPI or whatever, right? It's we're going to, you're going to complete this questionnaire and we're going to interpret it together. Like this is what your questionnaire shows. Here's how your scores compare to, you know, norms. And let's talk about what you were trying to explain to make you decline by completing my questionnaire. Let's talk through what your personality profile means about you and kind of your thoughts and my thoughts about how we can, you know, prioritize, right? So there's a therapeutic assessment aspect of this too. Not just your share profile, but rather like here's what your profile suggests to me as, you know, like the treating professional. Talk to me about, you know, what's that like in your life, right? How these traits show up, you know, like is this seen consistent with your sense of yourself or if you've learned something new about yourself here? And can we work together to prioritize? Like what areas are really concerning to you? Right? Is it the perfectionism? Is it the turning depressivity? Right? Like is it that you, you know, said that you're kind of a manifolded person? And that's kind of interfering with your relationships, right? Like you have all this personality data if you do it this way. And you just try to talk with the person about how this stuff shows up in their lives and how we as a therapeutic team like me and the client want a kind of prioritized, right? Among those things. So that's kind of the essence of it. And then what do you do therapeutically? It's like you pull out the armamentarium of stuff that's connected with the areas that you and the client agree are areas of initial focus. And part of the idea here too is that like the that there are symptom clusters. I'm going to use DSM language. I apologize. I just don't have other language. But there are these, there are symptoms that are going to tend to cluster together. In other words, there are certain symptoms challenges that people are going to have that are going to correlate with other ones that they're typically elevated together or sort of pushed down together. And so you would start to see these, you know, I would imagine you would start to see these groupings of things. So that they're going to be related. So that you're going to attack sort of aspects of that person's life personality, whatever that are would sort of could potentially push all of them down or bunch of them down simultaneously. Yeah. Yeah. And you're looking for like points of interest too. And that's why the conversation with the client is so important. Because they've got to recognize that it's something they really want to work on. Or it's going to be harder. Of course, that's again, like when this works well, a conversation, right? It's not like you impose stuff on the case. It's rather you try to collaboratively do the assessment with the client and have the assessment data delivery back to the client. Hopefully have therapeutic aspects to it. Because they're learning something about themselves in that process. And then you kind of try to work together to decide, this is where you want to focus at least your initial efforts. Because these are the tendencies that are currently the most problematic for you to be client. I'm thinking, you know, as I was looking at the as I was preparing for this and I was looking at the sort of the primary figure that's everywhere regarding the high top, which I'll link. There's a lot going on in that figure. And it can be a little bit overwhelming trying to get your head wrapped around all of it. But what I'm as you're talking particularly clinically, but even in your discussion about this initially. So the last person I talked to a couple of weeks ago for the podcast was Dell Paulus, who's yeah, so dark tetrad. And so one of the things he said, and I'm going to get this wrong, one of the things he said was something like, you know, finding the level of the construct or sort of the sub levels that are of value and not sort of breaking apart more than that and not sort of clustering together, putting together higher than that. So for him, it was these dark personality traits. And so he said these four dark personality traits, that's where he sort of sits where, yeah, potentially you could break it down more than that, break those factors into sub factors. But you know, people have done, but it doesn't really seem to add very much, right? Or he said, you know, there are people who are looking at this sort of de-factor, sort of the dark factor. And he said, that's not, you know, to me, that's not very interesting either because any gave, no psychometric reasons as well as conceptual reasons as well or practical reasons as well. And I'm thinking about that as you're talking because like you have this model, which empirically and theoretically, you have all these different levels, what I'm hearing you sort of say is, yeah, there is all this stuff that's great. And I'm going to continue to look at it even, but practically, let's figure out sort of the levels that make sense for this patient or patients in general, with this patient and treatment. And let's use that. We don't have to use all of it. Let's just figure out what's helpful clinically right now. Yeah, and it's pretty rare to have everything all of you. Not, I mean, like a lot of people lot of different times problems, right? But it's at least in our experience at the arts and doing trying to kind of roll out this approach, people often have like a resettlement complain or current set of concerns thing that helps with this prioritization issue, even if they're lives in the first time I propose an opportunity. If that makes sense, and sometimes there's like a way of saying it's this mix, right? Like, right, like, this particular mix of things, because they're like our push and pull elements to different traits in people often, right? Like they, they might be very attention seeking, like they really want attention, but in addition to that, they're sort of, I'm not like shy and inhibited, something like this is a potential combination. You can see, it's in the combination that kind of reach the formulation and help to reach an understanding of the client, and that's kind of how you focus it. So it seems complicated, because there's lots of elements to people's personalities, but within a particular person, right? It often has this coherence, because that's how a personality works in a person. But in a person, it's that mix of traits in the population that's a variety of different dimensions, and so it was complicated at the population level. But within a person, that's who they are, and this mix of things. So yeah, I think that's where you're, you know, sort of driving at as the assessor and as the therapist, you're trying to get an integrated understanding of the person from the profile and help to convey it to them. And then that's kind of like what you work on. And yeah, that often, practically speaking, has what I want to call them like push and pull elements. Right? Like you want these things, but these traits interfere with getting, right? You'd like these things to happen to you, but you have trouble connecting with other people, right? And you want intimacy, but you are scared of it, like things like that, formulations along those things, are often sitting in the combination of traits. So one of the things I always ask everyone at the end of the conversation is if they've had, or what specific pushback that they've had toward their work? Well, my work, right? Like so, we want to conceptualize that as the work on high top, you know, specifically. I think, you know, the pushback is understandable and kind of comes from parts of the academic firmament, right? Where there's a lot of investment in free existing categorical notions. Right? If you've spent your whole career, right? Focused around some specific category. Well, then if I'm saying something like, that's kind of part of a bigger picture and we really shouldn't like devote ourselves to these categories in quite that way because presentations are more complicated. These things aren't really categories of nature. Well, that's a challenge, right? To your whole worldview, because you become the expert on categorical disorder X, right? You're known the world over as like the ADHD expert, like or whatever it is, and your whole career and professional identity are tied to these categories. So to the extent of this pushback, I think that's a place that it comes from and I think it's totally understandable. I've been fortunate that I've been able to build a career around the alternative to that, right? Kind of the high top style approach. But now I'm known as the dimensions guy or whatever, right? The high top kind of their guy or things like this, right? So that's my identity. So I don't have this problem of having been a comic disorder researcher or whatever, right? Who now takes a different approach, where I've got to somehow slough off the old identity to become connected with the multi-dimensional high top style approach. Rather, I'm the person who has been pretty consistent throughout my career and my writings in providing this alternative, right? So I totally get it, right? If you're the ADHD expert, the schizophrenia expert, right? The eating disorders expert, it's going to be a challenge, right? Just sort of personally and professionally to cope with the high top alternative. So I think that's often where the pushback comes from and it's easy to understand, and then, you know, like, how do you deal with that? If you're that person, well, you've seen people make these ships, right? I've seen people do this and say like, yeah, that's a really good point. Like, I'm trying to understand alcohol dependence or whatever, but I might be able to do a better job understanding if I think about it in this more multi-dimensional way. And that's when I think the ship does happen. It's when even if you have a prior investment in a particular, it's like we're saying those areas don't exist, that would be absurd. Nobody's saying like there aren't people without alcohol, and it's rather retaxing it within this multi-dimensional framework. And I think that if you could make that ship, then you become a little less antagonistic toward the enterprise. But yeah, to the extent that I've seen pushback, it's about investment in existing categorical concepts and how that's tied up in people's professional identities. And again, I want to be very sympathetic to that because I get it, right? People have invested years of their lives and careers in these concepts. So if we're going to move to a more, well, multi-dimensional and hopefully scientifically-based approach, we have to be sensitive to how those ships can happen in a way that recognizes those previous contributions and doesn't take on language like that was all dumb to begin with. So they don't think that's even true, right? That was the best we could do in the era. And many very good and useful things have been done under the umbrellas of those categorical concepts. So we got to recognize those contributions and now move forward without it the edifice that we're trying to do. So that language, that kind of diplomacy, as I think critical to do that. Yeah, it makes me as you were talking, I was thinking that, you know, I was thinking sort of from like a CUNY in like paradigmatic shift, you know, the idea of like a better idea is basically replacing worse ideas for without getting into it too much. But then sort of from what I understand the actual data on it is in science, it's not just better ideas don't just knock out worse ideas. It also has to do with the people who have the, I'm using the word worse and I'm being mindful of that's awfully critical. But that it has to do with folks who sort of ascribe to those other, those older ideas that aren't as empirically justifiable. It has to like them leaving the field eventually, you know, retiring and that sort of thing that these sort of paradigmatic shifts happen more on that timeline than just on the idea timeline. Yeah, no, that's fair. I mean, obviously that's I know it makes us salient, right? And that's why generativity is so important, right? I want to call that out too because I think that's the thing I believe deeply in and everything I try to do, right? Like the the junior people are the future, when they're hearts in mind. And hopefully like when if I win their hearts in mind, they don't mean in some sort of manipulative way, but like based on the evidence, right? That this will work better for what they're trying to achieve professionally. Then you then you have, well, generativity, right? And you have the ability to shift the field in the direction because they're the engine, right? Of what's going to happen next. So yeah, I think that's another way that I think about it, right? That's I think hopefully a positive spin on the coonion paradigm shift way of thinking about it's not just like the older generation tires, right? It's that it's that the younger generation is, becomes connected with a novel set of ideas because they're moving the other direction that they believe in. So Right. Yeah, yeah. And I think that was that was uh, uh, absolutely, right? And sort of the idea is that the these newer more, but you know, both, you know, right, both in the factor analyses, but also in the in the in the consulting room, right? Like both of those things are pointing to, oh yeah, this makes more sense that people who are coming up or people like me who aren't invested in the old school model, you know, I'm easily swayed by data and, you know, experience. Um, that then that happens and then yeah, that that will start to sort of slowly take over. So um, the last thing before I let you go. So we got uh, several resources that I will link in the show notes. Are there anything else? Any other resources or links or whatever? I think you guys, did you guys either you just have or just had a book come out, but other things you want me to link that you want people to know about who are interested in this? Yeah, I mentioned the arcs uh, institute, right? The clinic I connected with here, the clinical practice. I can give you the arts institute URL. I could just email that to you for the show. So that's one thing that might be helpful to people that occurs to me in that context. I top stuff. I think you pretty much have those links, but of course I'm happy to, you know, look over what you want to post and consult with him. Okay. Yeah. And if there's anything else, I just want to make sure to be able to because I'm sure there will be lots of people who are listening who want to learn more to give them resources. This has been fantastic. I can't tell you how much I appreciate it. Well, I appreciate the opportunity, right? It's fun for me to try to formulate my thoughts a little of this in a podcast kind of format. So I appreciate your time and you know inviting me to participate. Oh, you kidding? It's my pleasure. Ladies and gentlemen, Dr. Bob Krueger. That's a wrap on our conversation. As I noted at the top of the show, be much appreciated if you spread the word to anyone else who you think might enjoy it. Until next time.