Psychodynamic Psychotherapy for Personality Disorders: A Clinical Handbook

This clinical handbook has 16 chapters in three sections; and for the most part, the 25 authors are household names in psychotherapy research. Part I is dedicated to personality pathology, Part II to psychodynamic treatment approaches, and Part III to treatment research and future directions.

In the preface, the authors outline what is to come and raise the sensible question (previewing Gabbard's Chapter 8), “If psychodynamic therapies work, how do they work”? In this chapter, the question is sensibly answered as follows: “We don't know.”

The largest part of the book is indirectly aimed at this question. It briefiy outlines the theories that underlie object relationship and attachment as well as mentalization-based, transference-focused, psychodynamic, and dialectical behavior therapies, in addition to some others. In the section on treatment approaches, each author illustrates, mostly by vignettes (the best being by Svartberg and McCullough in Chapter 12), how a theory-derived therapy can be used to have the best effect in one of the personality disorders. So there are three chapters on borderline personality disorder, one on histrionic personality disorder, one on narcissistic personality disorder, and one on antisocial personality disorder as well as brief demonstrations of the other remaining diagnoses in the three clusters.

All the theories and their applications are made clear, and several of the chapters are outstanding. The chapters on mentalization-based treatment and transference-based therapy and the chapter by Gabbard on therapeutic action in psychoanalytic therapy are all crisp, to the point, and relatively free of jargon. The chapter by Shedler and Westen demonstrates well how the Shedler-Westen Assessment Procedure can enrich personality diagnosis. The authors feel that in several iterations of DSM, we may have gone too far, agglomerating symptoms as the basis of diagnosis without concern about how they fit together. The Shedler-Westen Assessment Procedure lists 200 descriptive statements similar to the diagnostic criteria in DSM-IV. The clinician endorses the symptoms observed in the patient but must also evaluate the intensity (on a 7-point scale) of each criterion present. The result is a graph, as in the Minnesota Multiphasic Personality Inventory, which reflects the mixture and degree of negativity of the patient's characteristics. Thus, the tool clarifies the diagnosis (categorical view),and further constructs the clinical picture in terms of the severity of symptoms both in and aside from the primary diagnosis (dimensional view).

It is interesting that while virtually all of the contributors note the difficulties in treating personality disorders, almost all maintain a positive attitude about what is possible. Only Stone, reminiscing on his close to 45 years of experience, illustrates precisely the extreme hardships of trying to treat patients with personality disorders, which include their high discontinuation rate, alarming sensitivity to affront, and the ease with which discontinuation can be precipitated. He classifies patients in the personality disorders group (and others) in terms of their being inhibited or not inhibited. Patients in the inhibited groups (e.g., obsessive-compulsive, avoidant, or dependent personalities) and patients with phobias or sexual inhibitions suffer from their symptoms and are therefore motivated to change. Patients in the noninhibited groups (narcissistic and psychopathic disorders) find their symptoms ego-syntonic. Thus, they are dismissive, self-centered, and impulsive and are concerned with others, if at all, only with extracting quickly what they want. Obviously, they are less likely to be amenable to psychotherapy. Stone's view on prognosis, generally, is also less sanguine (and perhaps more realistic) than those of the other contributors.

The representations of the several theories presented are clear and straightforward, and the authors elucidate a wide range of constructs that underlie the therapies. In accordance with the book's title, the chapters focus primarily on the treatment of personality disorders, but the techniques and tactics are also applicable to patients with other diagnoses for which psychotherapy is indicated. Readers can consider these tactics and their application in relation to their own practices and will find the book interesting and instructive, regardless of where they are in their progression from trainee to expert.

All of the therapies claim good results in a substantial number of cases, and there are randomized clinical trials and meta-analyses to substantiate the claims, although I am aware of none that strongly support the greater long-term success of one therapy over another. (In randomized clinical trials, it is typically the patients in the treatment-as-usual group that do poorer than patients in comparison therapies.) In addition, the therapist behaviors illustrated in the vignettes for any of the therapies discussed do not seem to differ substantially (except, to some extent, in transference-focused therapy, where the therapist focuses on behaviors and feelings as they occur between the therapist and patient). Similar claims of success, also supported by randomized clinical trials and meta-analyses, have recently been reported with complementary and alternative therapies (e.g., omega-3 fatty acids, S-adenosyl-L-methionine, exercise, and mindfulness-based cognitive therapy) (1).

So, what does the sum of these observations tell us? First, it would seem that the several psychotherapies, as practiced, are not as different as their theories would suggest. Second, it indicates that while the results of a therapy may be consistent with its theory, they do not affirm a causal role for it. And finally, it suggests that while we are not in total darkness, we are still in the shadows when trying to explain the question, “How do psychodynamic psychotherapies work?”

You will enjoy the book.