Therapy and Treatment of Personality Disorders

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I. Introduction

The dogmatic schools of psychotherapy (such as psychoanalysis, psychodynamic therapies, and behaviorism) more or less failed in ameliorating, let alone curing or healing personality disorders. Disillusioned, most therapists now adhere to one or more of three modern methods: Brief Therapies, the Common Factors approach, and Eclectic techniques.

Conventionally, brief therapies, as their name implies, are short-term but effective. They involve a few rigidly structured sessions, directed by the therapist. The patient is expected to be active and responsive. Both parties sign a therapeutic contract (or alliance) in which they define the goals of the therapy and, consequently, its themes. As opposed to earlier treatment modalities, brief therapies actually encourage anxiety because they believe that it has a catalytic and cathartic effect on the patient. 

Supporters of the Common Factors approach point out that all psychotherapies are more or less equally efficient (or rather similarly inefficient) in treating personality disorders. As Garfield noted in 1957, the first step perforce involves a voluntary action: the subject seeks help because he or she experiences intolerable discomfort, ego-dystony, dysphoria, and dysfunction. This act is the first and indispensable factor associated with all therapeutic encounters, regardless of their origins.

Another common factor is the fact that all talk therapies revolve around disclosure and confidences. The patient confesses his or her problems, burdens, worries, anxieties, fears, wishes, intrusive thoughts, compulsions, difficulties, failures, delusions, and, generally invites the therapist into the recesses of his or her innermost mental landscape.

The therapist leverages this torrent of data and elaborates on it through a series of attentive comments and probing, thought-provoking queries and insights. This pattern of give and take should, in time, yield a relationship between patient and healer, based on mutual trust and respect. To many patients this may well be the first healthy relationship they experience and a model to build on in the future.

Good therapy empowers the client and enhances her ability to properly gauge reality (her reality test). It amount to a comprehensive rethink of oneself and one's life. With perspective comes a stable sense of self-worth, well-being, and competence (self-confidence).

In 1961, a scholar, Frank made a list of the important elements in all psychotherapies regardless of their intellectual provenance and technique:

1. The therapist should be trustworthy, competent, and caring.

2. The therapist should facilitate behavioral modification in the patient by fostering hope and "stimulating emotional arousal" (as Millon puts it). In other words, the patient should be re-introduced to his repressed or stunted emotions and thereby undergo a "corrective emotional experience."

3. The therapist should help the patient develop insight about herself - a new way of looking at herself and her world and of understanding who she is.

4. All therapies must weather the inevitable crises and demoralization that accompany the process of confronting oneself and one's shortcomings. Loss of self-esteem and devastating feelings of inadequacy, helplessness, hopelessness, alienation, and even despair are an integral, productive, and important part of the sessions if handled properly and competently.

II. Eclectic Psychotherapy

The early days of the emerging discipline of psychology were inevitably rigidly dogmatic. Clinicians belonged to well-demarcated schools and practiced in strict accordance with canons of writings by "masters" such as Freud, or Jung, or Adler, or Skinner. Psychology was less a science than an ideology or an art form. Freud's work, for instance, though incredibly insightful, is closer to literature and cultural studies than to proper, evidence-based, medicine.

Not so nowadays. Mental health practitioners freely borrow tools and techniques from a myriad therapeutic systems. They refuse to be labeled and boxed in. The only principle that guides modern therapists is "what works" - the effectiveness of treatment modalities, not their intellectual provenance. The therapy, insists these eclecticists, should be tailored to the patient, not the other way around.

This sounds self-evident but as Lazarus pointed out in a series of articles in the 1970s, it is nothing less than revolutionary. The therapist today is free to match techniques from any number of schools to presenting problems without committing himself to the theoretical apparatus (or baggage) that is associated with them. She can use psychoanalysis or behavioral methods while rejecting Freud's ideas and Skinner's theory, for instance.

Lazarus proposed that the appraisal of the efficacy and applicability of a treatment modality should be based on six data: BASIC IB (Behavior, Affect, Sensation, Imagery, Cognition, Interpersonal Relationships, and Biology). What are the patient's dysfunctional behavior patterns? How is her sensorium? In what ways does her imagery connect with her problems, presenting symptoms, and signs? Does he suffer from cognitive deficits and distortions? What is the extent and quality of the patient's interpersonal relationships? Does the subject suffer from any medical, genetic, or neurological problems that may affect his or her conduct and functioning?

Once the answers to these questions are collated, the therapist should judge which treatment options are likely to yield the fastest and most durable outcomes, based on empirical data. As Beutler and Chalkin noted in a groundbreaking article in 1990, therapists no longer harbor delusions of omnipotence. Whether a course of therapy succeeds or not depends on numerous factors such as the therapist's and the patient's personalities and past histories and the interactions between the various techniques used.

So what's the use of theorizing in psychology? Why not simply revert to trial and error and see what works?

Beutler, a staunch supporter and promoter of eclecticism, provides the answer:

Psychological theories of personality allow us to be more selective. They provide guidelines as to which treatment modalities we should consider in any given situation and for any given patient. Without these intellectual edifices we would be lost in a sea of "everything goes". In other words, psychological theories are organizing principles. They provide the practitioner with selection rules and criteria that he or she would do well to apply if they don't want to drown in a sea of ill-delineated treatment options.

This article appears in my book, "Malignant Self Love - Narcissism Revisited" 

next: Changes in the Diagnostic and Statistical Manual (DSM) IV