Major advances have been made in the theoretical constructs, classification, and treatment of personality disorders. Nevertheless, these disorders remain very challenging to treat and frustrating to many health care providers. Although we have witnessed a paradigmatic shift in the field of personology, there remains much more to do in this exciting field. A number of parallel trends have been made in diagnostic systems, models that make disorders of personality more understandable and more readily treated with both short-term and long-term psychotherapy. In fact, a number of issues in the field of personality disorders can be described as “breakthrough problems” for the field of psychotherapy and the mental health professions as a whole. This article presents the reader with a summary of these trends. © 1999 John Wiley & Sons, Inc.
Whereas the literature on borderline personality disorder (BPD) was once exclusively clinical and theoretical, today an accumulating body of research on the nature, etiology, prognosis, and treatment of BPD is of relevance to clinical practice. This article provides a “clinician's guide” to the empirical data on BPD. It begins with a discussion of the evolution of the borderline construct, from early descriptions of a type of patient on the border between psychosis and neurosis, through Kernberg's postulation of a level of disturbance called “borderline personality organization,” through the current DSM conceptualization. In the next section, we examine research on the etiology of BPD, focusing on genetic contributions, attachment histories, and physical and sexual abuse, after which we discuss prognosis, summarizing the results of longitudinal studies. Finally, we address treatment approaches, focusing on psychodynamic psychotherapy, dialectical behavior therapy, pharmacotherapy, and integrative treatment for BPD. © 1998 John Wiley & Sons, Inc.
This article presents a discussion and case illustration of using harm reduction as a model for treatment design for individuals presenting with multiple problems. Initial difficulties with engagement into treatment are discussed, as well as early strategies based on easing intake requirements and responding quickly to clients' stated needs. Some of these strategies include developing a needs hierarchy that clients participate in, not setting fixed rules for their behavior regarding their drug use, and a willingness to work with them on other pressing problems, such as housing despite active drug use. This strategy results in a working alliance based on mutual, honest exploration of clients' problems and creative solutions to them. In the case presented, shifting symptoms were addressed often without a diagnosis that could clarify whether the cause of the symptom was psychiatric, substance abuse, or medical in origin. Treatment team recommendations are given. © 1998 John Wiley & Sons, Inc.
This article presents an “anxiety-regulating” model of short-term dynamic psychotherapy that uses the behavioral principles of desensitization to treat psychodynamic conflict. In this model, psychodynamic conflict is reinterpreted as an “affect phobia.” In contrast to phobic stimuli that are external (bridges, snakes), intrapsychic phobias occur within us; the phobic stimuli are feelings. Within this framework, behavioral methods of exposure and the prevention of avoidance can be applied to avoided feelings to resolve the psychodynamic conflict. Clients who are afraid of anger, grief, or closeness are exposed to these feelings in imagery in doses they can bear. Defensive avoidance is prevented and the client experiences the conflicted feeling while learning to regulate the associated anxiety, guilt, shame, or pain. A case example with transcripted segments of sessions is presented to illustrate these principles. © 1999 John Wiley & Sons, Inc.
Harm reduction psychotherapy gives a name to a practice many therapists have quietly been conducting for years. Some of us have been doing psychotherapy with clients who present with both psychological and addictive behavior problems, despite the ideological barriers that have promulgated total separation of these two sets of problems in terms of treatment philosophies, interventions, and providers. This article chronicles the author's evolution from viewing addictions as distinct from psychological problems to understanding and treating them as a subset of human behaviors causing suffering that can and should be integrated into a more comprehensive psychotherapeutic framework. © 1998 John Wiley & Sons, Inc.
The personality disorders, having become officially recognized disorders separate from the symptom disorders with the arrival of DSM-III, are prevalent and debilitating conditions that require therapeutic intervention. However, research on the treatment of these disorders has been hampered by the multitude of complex and difficult issues of client heterogeneity, early dropout from treatment, length of treatment needed, manualization of therapies, and measurement of change. The existing research findings are reviewed, with an eye to the clinical implications in the treatment of these clients at this point in time. © 1999 John Wiley & Sons, Inc.
Dialectical Behavior Therapy (DBT) has been shown to be effective for adult, female borderline personality disordered patients and shows promise to be the treatment of choice for emotionally unstable patients in general. In this article we present an overview of the application of the DBT treatment to adolescent borderline clients, and illustrate the intervention in a 13-year-old male who presented for treatment with symptoms of identity disturbance, role confusion, frequent suicide ideation, and impulsive self-damaging behavior. Our intention is to illustrate the use of DBT with this population, and to explain by example some of the modifications we think are useful in using DBT with inner-city minority youth. © 1998 John Wiley & Sons, Inc.
Alcohol dependence not only affects the client but can have a devastating impact on the drinker's family as well. The reactions and attitudes of family members toward the drinker, especially those of spouses of alcoholics who may have endured their partner's problem drinking for many years, are often understandably negative and may hamper recovery efforts. This article describes some of the relationship dynamics common to couples struggling with one partner's alcoholism, and seeks to provide a better understanding of spousal manifestations of expressed emotion. Treatment strategies aimed at reducing high levels of expressed emotion in hopes of preventing drinker relapse are also discussed in the context of couples therapy. © 1998 John Wiley & Sons, Inc.
This article describes a group-treatment program that was developed and tested in a treatment-comparison study with clients who met criteria for tbe diagnosis of borderline personality disorder be etiologic and diagnostic factors that were selected for emphasis in the development of the treatment model are outlined; tbe specific structure, techniques, and therapeutic focus of the group method are described; and four phases of group development and focus are illustrated with the use of material from one of the groups. Therapist training and the use of subjective reactions for understanding and treating clients with borderline personality disorder are central features of this method be process of change within the context of group interaction is illustrated. Recommendations for selecting clients and guidelines for implementation of the treatment method are provided. (C) 1998 John Wiley & Sons, Inc.
Research on expressed emotion (EE) has shown that clients with depression, like those with schizophrenia, are more likely to relapse if they live with a partner or family members who express critical attitudes toward the client. This article describes a new treatment for major depression, based on systemic therapy we have called Partner Assisted Therapy. Specific interventions are discussed and illustrated with case material. Results at one and two years show partner-assisted therapy to be superior to pharmacological treatment. © 1998 John Wiley & Sons, Inc.
This article reviews the current comorbid clinical syndromes often present in the personality disordered client and offers both theoretical and practical guidelines based on research, theory, and clinical experience. A case of a client with a mixed dependent/avoidant personality disorder and comorbid anxiety disorder is presented, along with transcripts of the last phase of treatment, to demonstrate the process and technique of short-term restructuring psychotherapy, an integrative treatment approach based on psychodynamic principles and utilizing three methods of restructuring—defensive, affective, and cognitive. © 1999 John Wiley & Sons, Inc.
Because personality disorders are resistant to change and difficult to treat, powerful treatments are required. Group therapies are capable of mobilizing strong forces for change. Maladaptive behaviors are commonly demonstrated in the immediacy of the group situation; peer influence can be used to provide feedback and suggestions for change, and new adaptive behaviors can be practiced in the group. Group-oriented day treatment programs are intensive forms of group therapy, and this article describes a particular program that has treated clients with personality disorders for over 25 years. Its intensity is derived from the provision of many hours of group therapy per week to a large number of patients by multiple staff as part of a time-limited integrated system of diverse therapy groups. It is also derived from the implementation of modified principles of the therapeutic community. A case illustration demonstrates how the program is capable of bringing about change at the level of the individual client with a personality disorder. Given the number of clients who can be treated simultaneously, the program is also regarded as time efficient. © 1999 John Wiley & Sons, Inc.
This article provides an introduction to the construct of expressed emotion (EE), which comprises criticism, hostility, and emotional overinvolvement. The importance of EE as a predictor of treatment outcome and relapse in a number of psychiatric disorders is noted, as are the possible mechanisms of EE's impact on the patient and potential causes of EE. © 1998 John Wiley & Sons, Inc.
The traditional medical model of treatment for substance abuse has worked for some addicts. However, many have been unable to benefit from this paradigm because of comorbid psychiatric disorders that are not addressed, or due to individual characteristics or preferences that are not considered by the unitary approach of medical model treatment. A harm reduction approach, which combines principles of psychotherapy with substance use treatment, is described and illustrated with a case example of a woman treated for alcoholism and depression. This approach is nonauthoritarian, collaborative, and based on an integration of psychodynamic, cognitive-behavioral, and substance use treatment techniques. © 1998 John Wiley & Sons, Inc.
Expressed emotion (EE) is discussed in relation to bipolar affective disorder, a major psychiatric illness involving fluctuating periods of mania and depression. High levels of EE among relatives of bipolar clients are conceptualized as reactions to the stress of adjusting to the acute illness period and the post-episode aftercare period. EE has an associated cognitive component involving certain styles of attribution about illness in the client, and a behavioral component involving aversive interaction patterns between the bipolar client and his or her relatives. Family-focused psychoeducational treatment—consisting of psychoeducation about bipolar disorder, communication enhancement training, and problem-solving skills training—addresses high EE on the cognitive, affective, and behavioral levels. A case study illustrates the approach. © 1998 John Wiley & Sons, Inc.
Borderline personality disorder is a severe form of Axis II pathology characterized by disturbed interpersonal relationships. Widely regarded as being very difficult to treat, problematic family interactions are thought to be central to the etiology and maintenance of the disorder. Recently, empirical research has suggested that higher family levels of emotional overinvolvement might be associated with borderline clients doing better clinically and staying out of the hospital. This article describes a family-based approach to the treatment of borderline personality disorder based on the expressed emotion construct. © 1998 John Wiley & Sons, Inc.
A brief overview of transference-focused psychotherapy (TFP), developed by Otto F. Kernberg for the treatment of clients with severe personality disorders, is presented. The therapy begins with the development of a treatment contract, which consists of general guidelines that apply for all clients and with specific items developed from problem areas from the individual client's history that could interfere with the therapy process. The contract also contains therapist responsibilities. The client and therapist must agree to the content of the treatment contract for therapy to proceed. The client's affectively charged internal representations of previous relationships are consistently interpreted as the therapist becomes aware of them in the therapeutic relationship, that is, the transference. There are specific strategies and techniques used in TFP; however, more important are the guiding principles used throughout the treatment. A case is presented to illustrate aspects of this therapy as applied to a client with borderline personality disorder (BPD). © 1998 John Wiley & Sons, Inc.
Substance abuse occurs in approximately half of adults who have childhood-onset attention-deficit/hyperactivity disorder (ADHD), and in many individuals who exhibit symptoms of posttraumatic stress disorder (PTSD). This article provides clinical guidelines for working with this population. The case presented illustrates how a harm reduction approach to substance use and a “come-as-you-are” stance regarding both occasional use and characteristic ADHD symptoms may better serve the ADHD adult, and individuals with PTSD, than the traditional insistence on complete abstinence from substance use as a prerequisite to psychotherapy. © 1998 John Wiley & Sons, Inc.
The article describes the authors' approach to working with families of schizophrenic clients and attempts to give the reader an understanding of why it is important to take account of expressed emotion (EE) in planning and executing family interventions. To this end we include descriptions of the EE dimensions in the context of schizophrenia in a way that may be meaningful to clinicians (i.e., criticism, emotional overinvolvement, and hostility). Assessment techniques directed at general clinical use are outlined, and we describe methods of harnessing aspects of our understanding of EE to generate and guide family intervention goals. This is followed by a case example used to illustrate the assessments, before we examine the intervention framework and techniques with the help of further clinical material. We employ a case formulation framework to produce an individualized view of each family's problems (Barrowclough & Tarrier, 1992). © 1998 John Wiley & Sons, Inc.
Obsessive compulsive disorder (OCD) often has burdensome and debilitating effects on families. Family responses range from support and empathy to excessive accommodation and overinvolvement to hostility and rejection. Assessment of individual family members' responses in these arenas help determine psychoeducational content for family members and whether relatives should participate in behavioral treatment sessions and homework assignments. Research evidence indicates that families may be helpful in assisting with treatment, especially in a multifamily behavioral treatment (MFBT) format. Strategies for addressing problematic family behaviors and attitudes are illustrated with case examples. © 1998 John Wiley & Sons, Inc.
