Treating Personality Disorders in Children and Adolescents: A Relational Approach

Dr. Ludwik Fleck (1), a physician and microbiologist, proposed in 1935 that knowledge and scientific “facts” are relative rather than absolute and depend on the interpretive “thought styles” of the individuals in the particular “thought collective” of a field of research:

Contemporaneous psychiatric research about the theory of mind provides a striking illustration for the functioning of such a “thought collective” and of a neuroscientific-psychosocial soccer game. In a recent, remarkable neuroscientific positron emission tomography (PET) study, Calarge et al. (2) established that when volunteers silently imagined what might have led a total stranger to cry and then recounted their inventions (i.e., when the volunteers attributed a subjective mental state to another person and spoke, however, without having any relational basis to apprehend the stranger’s feelings), their mental task activated several regions of the medial frontal cortex—a region considered to maintain the representation of one’s own self—and the cerebellum, including the cerebellar vermis. Calarge et al. averred,

From a psychosocial perspective, mentalization, or reflective function, as studied in the neuroscientific report of Calarge et al., is the human capacity to make use of one’s apprehension of other people’s feelings, inclinations, intentions, moods, and wishes. Acquired developmentally, it functions unconsciously, leads to the structuring of the psychological self, and enables the individual to test reality, i.e., to distinguish internal from external reality (3). Peter Fonagy and Mary Target (4) argued that youngsters with “complex psychopathology” (severe disturbances in personality and behavior) lack this essential developmental achievement, either intermittently or pervasively.

The central contention of Dr. Efrain Bleiberg’s Treating Personality Disorders in Children and Adolescents is that children with severe personality disturbances have not developed, have lost, or have temporarily inhibited the reflective function, i.e., the ability “to interpret the behavior of…themselves as well as others, in terms of internal states” (p. 34). They lack the capacity to apprehend mental states; to attribute beliefs, feelings, or intentions to others; or to understand and to respond to other people’s behavior. They cannot “tune in” to, cannot “read,” other people’s minds or their own. They are “unable to preserve a psychologically grounded sense of self and others in the context of close human connections” (p. 20). Hence, their treatment has to focus methodically on the imaginative unfolding/restoration of this subtle and vital capacity rather than on their disordered and dramatic behavior.

According to Dr. Bleiberg, as well as Fonagy and Target (4), the development of reflective capacity results from the caregiver’s understanding of the infant’s internal state and her signaling to the infant that his behavior is intentional and understandable: “I get what you are feeling and I share your experience” (p 38). The infant can now internalize the attuned caregiver’s reflective response and begin to know: “So that is what I am feeling!” (p. 38). This alerts children to their primary affective arousal and allows them to label their psychological experiences.

Critically important for the caregiver is to maintain moment-to-moment reflective function—attunement—while struggling with the infant’s day-to-day dysregulation or hyperarousal, thus conveying that she can handle the infant’s internal state and behavior and restore him to homeostasis. Such myriad experiences of positive affect regulation following the infant’s signal of distress are crucial to the infant’s confident expectation that he can bring about a satisfying response from the caregiver. This person-specific, secure dyadic attachment subsequently leads to more generalized patterns of relatedness and organization of behaviors, feelings, and coping strategies; the development of defensive adaptations, symbolic capacities, and a sense of “I am me, the same that I was yesterday and am likely to be tomorrow” (p. 61); the maturation of a triangular reflective perspective; the unfolding of an ideal self-representation; and, in adolescence, satisfactory self-esteem regulation.

The introduction to reflective function in the first three chapters of this volume is followed by a sobering sketch of the disastrous developmental paths leading to severe personality disturbances. Traumatic experiences such as separation or perception of hatred from the caregiver, neglect, physical or sexual abuse, or care alternating with abuse create in infants and children increased arousal and trigger the autonomic fight-or-flight alarm system. Thus, when feeling cut off from their capacity to create an integrated representation of the caregiver and from their own coherent sense of self-agency, lacking the ability to fight or flee, infants and children will “escape” by inward flight, i.e., dissociation, and will detach threatening sensations from their other experiences, fragmenting their perceptions into nonintegrated components, and developing ultimately primitive psychological defense mechanisms such as splitting and projective identification. Biological vulnerabilities in children who are inhibited or have learning disabilities, reduced levels of D₂ dopamine receptors, attention deficit hyperactivity disorder, or mood disorders significantly increase the tendency toward dissociation for two reasons. First, anger, irritability, or an unstable mood give these children a fragmented sense of themselves and of others. Second, their ever-restless and changing behavior generates or exacerbates chaos in their environment: the parents are exhausted, and their severely challenged reflective function is compromised. To deal with mounting pressures to integrate contradictory perceptions of self and of others, these children become increasingly demanding and rigid as they seek to coerce parents, siblings, peers, and teachers to mirror their ever-changing fragmented internal states in an attempt to control their interpersonal relationships and regulate their affective experiences.

The following two chapters take up the plight of these children and adolescents as they become ruthless or grandiose, develop a false self, or victimize themselves and develop antisocial, narcissistic, histrionic, and borderline personality disturbances.

The second half of the book (five chapters) is devoted to the treatment of these severe developmental problems. Here Dr. Bleiberg proves to be a generous and eclectic psychoanalyst whose treatment efforts are focused on helping these children and adolescents regain reflective function in the face of circumstances that favor its inhibition/extinction. Thus, his goal is not to resolve intrapsychic conflicts or develop insight or correct a specific psychosocial deficit but to enhance broad perceptual capacities, interpersonal relations skills, and resilience in these vulnerable children and their unstable families. Because reflective function is at the crossroads of internal private personal experience and external interpersonal reality, Dr. Bleiberg advocates the use of an integrated treatment program that not only involves individual psychoanalytic psychotherapy but also targets specific maladaptive processes by more directive methods of cognitive behavior and interpersonal psychotherapies, together with family systems, psychoeducational, and psychopharmacological approaches. The goal is a comprehensive, individualized, long-term therapeutic process to enhance reflective function in all members of the family. Caregivers and treaters work collaboratively to achieve competence, consistency, and effectiveness in nurturing these children in all areas of their lives, to extricate them from the coercive roles they have assumed in their environment. Dr. Bleiberg notes that these children require two or more individual psychotherapy sessions per week to create secure attachment.

The last two chapters are devoted to residential treatment, to the continuum of services these youngsters need to profit from gains made during residential treatment, and to psychopharmacological treatments. The latter are summarized in three separate algorithms for patients in the spectrum of bipolar disorder/intermittent explosive aggression, affective dysregulation/depression, and attention deficit hyperactivity disorder.

I have referred to personality disturbances throughout this review to show preference, in an age group where personality structure is still fluid, first, for dimensional (a trait is more or less present) rather than categorical (a disorder is present or absent) diagnoses and, second, to avoid controversy about the presence or absence of a particular diagnostic criterion, when, in fact, psychiatric symptoms occur on a continuum. This is entirely within the spirit of Dr. Bleiberg’s concerns (p. 8). The use of DSM-IV-TR criteria defined for adults to diagnose personality disorders in children is controversial. For instance, Kestenbaum (5) pointed out that “the diagnostic label ‘borderline child’ embraces a heterogeneous group of overlapping syndromes that lead to a variety of psychiatric conditions in adult life.” This has been shown in children followed for 10–20 years (5, 6). No therapeutic purpose is served by squeezing children into nosological categories defined for adults, before validity and continuity of these children’s diagnoses into adulthood has been demonstrated. We need developmentally valid criteria for personality disorders in childhood and adolescence.

Dr. Bleiberg’s prose is felicitous in the clinical part of the book and can be elegant, as in his nimble summaries of the developmental theories of Margaret Mahler (p. 12) and Daniel Stern (pp. 45–46). He is less accessible, however, in the theoretical discussions titled “Psychological Organization and the World of Mental Representations” and “Trauma, Vulnerability, and the Development of Severe Personality Disorders.” These are unnecessarily complex, overinclusive, and reader-unfriendly. In numerous instances the author stumbles in not maintaining focus on his story line, going off on tangents that do not help comprehension and lose his reader.

But I have no wish to quibble. This significant and innovative work proposes entirely new and comprehensive strategies for the long-term psychiatric treatment of behaviorally disorganized children and adolescents and their families, a demanding and wearying task. In sum, the fundamental goal of the suggested treatment alliance is the enhancement of the children’s and caregivers’ reflectiveness by redirecting their attention from behavioral problems to concerns with internal states. To achieve his goals, Dr. Bleiberg, a practical training and supervising psychoanalyst, will see the child individually, will see the family together, and will see the caregiving couple by themselves whenever that is needed to maintain reflectiveness and consistency in the family.

In a review of 763 case records of children and adolescents in psychoanalysis or psychodynamic treatment at the Anna Freud Centre, Fonagy and Target (4) found that in a heterogeneous group of those children with complex psychopathology, including those with borderline disorder, 60% showed negative outcomes when followed in only once- or twice-weekly treatment. It became clear from an attempt to replicate these findings in a group of 18–25-year-old people in treatment either five times a week or once a week that “once-weekly treatment appears frequently to contribute to a deterioration of these young people’s condition.” Thus, Dr. Bleiberg’s delineation of a more eclectic and flexible treatment approach that specifically targets reflective function and mental states is particularly timely.

Of course, this treatment approach is action in progress. Empirical data will have to replace anecdotal evidence before a seasoned judgment can be rendered about this original, nuanced, and stimulating proposal. Consideration of a clinically controlled PET study before and after mentalization-based treatment is now possible. It is highly relevant, however, that in adult borderline personality disorder such mentalization-based treatment has had demonstrated effectiveness in randomized controlled clinical trials in reducing depression, self-injurious behavior, and hospitalization and in benefiting psychosocial functioning (7).

Dr. Bleiberg’s book is indispensable reading for anyone even remotely involved in treating children and adolescents with personality disturbances psychotherapeutically. Certainly my patients and I have profited from my reviewing this volume and from my becoming acquainted with Dr. Bleiberg’s creative ideas and urgent message.