The Enneagram: A Primer for Psychiatry Residents

The Enneagram is a personality theory that characterizes nine distinct strategies by which the human psyche develops a worldview and relates to the self and others. The theory proposes that by adulthood, individuals have developed a predominant personality strategy to cope with the external environment. Each of the nine core "types" described by the Enneagram has an associated basic fear, basic desire, and predictable pattern of behavior in times of stress and security. The Enneagram uses these basic fears and desires to describe the essential motivations underlying much of the resulting behavior. It thus captures a range of behavior for each type and is capable of providing a great deal of insight into an individual's underlying psychological wellness.

The exact origin of the Enneagram is difficult to trace, but the basic elements were synthesized by Oscar Ichazo, a South American philosopher, in the mid-20th century. The system was adapted and introduced in the United States in the early 1970s by psychiatrists Claudio Naranjo and John Lilly after they studied with Ichazo (1). Both physicians recognized the value of the Enneagram for describing personality and the immediate connections with their own psychoanalytic training. Naranjo wrote extensively about his applications of the Enneagram, most notably his theory that each of the nine Enneagram personality types under stress corresponds to a personality disorder as described by the DSM (2). Since then, many psychiatrists and psychologists have utilized the Enneagram in their own working theories of personality and in the practice of psychotherapy. The system has also been utilized by mental health professionals, religious communities, large business corporations, and leadership coaches in an effort to improve understanding of the self and others (the reference list to this article includes recommended reading). In recent years, the Enneagram has seen a surge in popularity, with numerous published books, podcasts, national conferences, and social media accounts emerging to discuss the system.

The Enneagram asserts that personality is by nature interconnected and multidimensional, qualities illustrated by the nine-point structure that serves as the symbol of the system. As such, individuals are thought to lead with one of the nine basic personality types, which does not change over time, but they will inevitably demonstrate characteristics associated with all nine types (Table 1). Self-identification after learning about the Enneagram is thought to be the best method for determining type, but there are several tests available to aid in the process, such as the Riso-Hudson Enneagram Type Indicator (RHETI) (1).

The types on either side of each numbered personality type have the potential to significantly influence the core type. These neighboring numbers are called "wings" and are traditionally identified with a w (e.g., type 4 with a 5 wing is notated as 4w5). Individuals are generally more influenced by one wing than the other, although traits from both wings may emerge in response to different environments. Although an individual's wing may determine many aspects of his or her personality, the core type describes the primary motivation driving behavior (3). For example, an individual with a 9w1 personality type would be more likely to pursue harmony and peace, similar to someone with a type 1 personality, because these goals relate to morality and may reflect a strong sense of right and wrong. Conversely, an individual with a 9w8 personality type would be more likely to pursue peace and harmony with a sense of energy and authority that would allow him or her to more readily take charge, similar to someone with a type 8 personality (Figure 1).

Each Enneagram type predictably takes on some characteristics of particular other numbers in times of stress or security. The directions of stress versus security for each personality type are indicated by the lines connecting the types. For example, an individual with a type 2 personality (intuitive, empathetic, people pleasing) takes on qualities of an individual with a type 8 personality when under stress (becoming more aggressive and controlling) and takes on type 4 personality traits (developing more personal insight and tolerance for pain) when experiencing security or integration of self. Knowing which qualities emerge during these times may be helpful as one learns to recognize which behaviors are associated with underlying stress or security (Figure 1).

Enneagram types are also affected by "instinctual variants." The Enneagram suggests that individuals tend toward instincts of self-preservation, social interaction, or sexual (i.e., one-to-one) bonding (Table 2). These instincts create nuance among each of the nine types by giving direction to the motivation of each type. For example, individuals with a type 4 personality are in tune with suffering, but each individual with an instinctual subtype demonstrates this in his or her own way: an individual with a self-preservation 4 personality is long-suffering and private about his or her pain, while an individual with a social 4 personality demonstrates pain as a means of garnering attention from others, and an individual with a sexual 4 personality projects his or her painful experiences onto those closest to him or her. Understanding how instinctual variants subtly affect the primary nine types provides additional insight and may aid in the process of identifying one's type (3).

Some authors suggest that the Enneagram could function as a single comprehensive model of personality (4–7). However, there are difficulties both with objective validation and with studying the Enneagram quantitatively, as is seen with other theories of personality. These include the subjective nature of personality and the quantity of studies available. Some researchers have correlated the Enneagram with other personality models, such as the Big Five or Myers-Briggs, and have found their validity comparable (8). Using the RHETI specifically as a test to identify an individual's type has been found to be statistically acceptable for research purposes (9). Despite limitations in objective studies, it appears to meet the three criteria used for personality inventories: predictive validity, demonstrated usefulness, and comprehensiveness (6). Inherent validity notwithstanding, we have found personal experience to be a valuable marker of utility, and the compelling insights gained into our own strengths, weaknesses, tendencies, and growth are evidence of the practical value.

Some have proposed that the Enneagram as a more comprehensive model for personality than what is currently adopted in the DSM-5. The alternative model of personality disorders included as an addendum in DSM-5 is similar to the Enneagram. It characterizes disorders by specific traits and notes healthy and unhealthy levels of each (10). In these proposed models, each personality type, when unhealthy, would correspond with one of the ten DSM-5 personality disorders. For example, an unhealthy individual with a type 3 personality may exhibit traits of narcissistic personality disorder. Many authors, including Naranjo (2), have suggested as much, but little research has been done to validate this concept. Furthermore, it is likely that certain personality types tend toward certain disorders, but the inverse may not necessarily be true. For example, an individual who meets criteria for narcissistic personality disorder may not necessarily identify as someone with a type 3 personality. This is an interesting area for further study, as it would allow treatment of personality disorders to expand with new ways of conceptualizing maladaptive coping mechanisms.

Although many leadership experts have used the Enneagram to promote personal development, some therapists have also used it in more traditional psychotherapy settings (11–13). For example, therapists have used it to help patients or clients understand their core motivations and resultant prominent defenses (14) or as a model for discussing object relations (15). Again, there is limited research on this specific utility, but existing studies suggest it can be a beneficial tool (5,11). At the very least, it seems likely to assist in formulating a case. The various aspects of each personality type and the dynamic relationships between types seem a natural avenue to guide questions about a patient's worldview, ego defenses, object relations, core beliefs, interpersonal dynamics, and self-awareness. Even if this is not brought into the room, it could help the therapist direct questions or consider nuanced patterns that fit within the Enneagram.

The Enneagram is a robust system that integrates all the concepts generally accepted to be necessary for a theory of personality, and its validity appears promising. The reference list includes recommended further reading. We advise caution in integrating these concepts too quickly, as the Enneagram is more complex than this brief overview suggests. We hope to expand on this overview in future papers targeted specifically at the practical value of the Enneagram for medical education and clinical psychotherapy.