Practical Management of Personality Disorder

433 Pages·2003·2.68 MB·English

by  W. John Livesley MD

PRACTICAL MANAGEMENT
OF PERSONALITY DISORDER
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Practical Management
of Personality Disorder
W. John Livesley
THE GUILFORD PRESS
New York London
© 2003 The Guilford Press
A Division of Guilford Publications, Inc.
72 Spring Street, New York, NY 10012
All rights reserved
No part of this book may be reproduced, translated, stored in a
retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, microfilming, recording,
or otherwise, without written permission from the Publisher.
Printed in the United States of America
This book is printed on acid-free paper.
Last digit is print number: 9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data
Livesley, W. John.
Practical management of personality disorder / by W. John Livesley.
p. cm.
Includes bibliographical references and index.
ISBN 1-57230-889-3 (hardcover)
1. Personality disorders. I. Title.
RC554 .L585 2003
616.85′ 8—dc21
2002155225
To my family—
Ann, my wife,
and my children, Adrian, Nigel, and Dawn—
while not forgetting Flint and Cole
About the Author
About the Author
W. John Livesley, MD, PhD, is Professor and former Head of the
Department of Psychiatry at the University of British Columbia, Vancouver,
British Columbia, Canada. He is also Editor of the Journal of Personality
Disorders and has contributed extensively to the literature on personality
disorder. Dr. Livesley’s research focuses on the classification, assessment,
and origins of personality disorder, and his clinical interests center on an
integrated approach to treatment based on current empirical knowledge
about personality disorder and its treatment.
vi
Preface
Preface
This volume deals with the treatment of severe personality disor-
der. The intent is to describe a practical approach based on what we know
about personality disorder and interventions that work. A general frame-
work is presented that will be useful to practitioners and trainees from all
mental health disciplines working in such diverse settings as general hos-
pital inpatient units, outpatient departments, community mental health
services, managed care programs, and private offices. The approach pro-
vides guidelines for treating patients in therapies ranging from crisis inter-
vention to long-term treatment.
In organizing my ideas about personality disorder and its treatment, I
have attempted to address the questions posed by clinicians from all disci-
plines attending lectures and workshops that I have presented for more
than two decades. Typically, two kinds of questions are raised: general and
situation-specific. Questions of a general nature are usually variations on
such themes as: “What is personality disorder?”, “How do you treat per-
sonality disorder?”, and “Can personality disorder really be treated?” More
specific questions take the broad form of “What should I do when . . . ?”
followed by a variety of problems including suicide threats, crises develop-
ing during long-term treatment, attempts to change the treatment plan,
missing therapy sessions, attending sessions under the influence of alcohol,
refusing to leave at the end of a session, demanding more time, and so on.
Both types of questions suggest that (1) the questioners would have
benefited from a systematic account of personality disorder and a frame-
work for organizing treatment, and (2) many clinicians rely on tactical in-
terventions to deal with problems as they surface during treatment, rather
than use an overall treatment strategy based on an understanding of the
pathology involved. Although the clinicians were not inexperienced, un-
interested, or uninformed, they probably acted in this way because person-
vii
vi i i Preface
ality disorder is inordinately complex, and this complexity creates a gamut
of management problems. Patients typically present with multiple prob-
lems and complicated clinical pictures. Diagnosis is complicated by diffi-
culty untangling personality pathology from the symptoms of mental state
disorders. Even when the proper diagnosis is reached, it does not really
help: DSM-IV and ICD-10 personality diagnoses have limited value in
treatment planning. The multiple problems of a given patient are also
challenging because a combination of interventions is usually needed. Fur-
thermore, there is the challenge of managing the therapeutic relationship
when patients find it difficult to trust and collaborate with the clinician.
Personality disorder has a complex etiology; multiple biological, psy-
chological, and cultural factors contribute to its development, and the im-
plications of these multiple causes for treatment are rarely considered. This
complexity accounts for both interest in the disorder and frustration with
attempts to treat it. Few clinicians are not intrigued by personality disor-
der, the subtle ways it presents, the involved histories of many patients,
and the complex interaction between clinical course and outcome. Yet
there are few clinicians who have not also been frustrated in their at-
tempts to understand it and to treat it. For most clinicians, treatment pres-
ents a series of dilemmas, beginning with the problem of how to organize
information about the multiple problems and extensive psychopathology
into a coherent case formulation that facilitates treatment planning, and
continuing throughout the therapy in relation to which issues to address
and in what order, how to manage the inevitable relationship problems,
and how to select the appropriate intervention when faced with a variety
of alternatives.
Unfortunately, complexity is not only an inherent attribute of the
condition; professional reactions to personality disorder are also complex.
Like the old adage that psychotherapy supervision often mirrors the thera-
pist’s relationship with the patient, professional reactions to personality
disorder frequently seem to reflect the complexity of the disorder and the
confusion that often surrounds those who attract the diagnosis. Many cli-
nicians have difficulty approaching patients with personality disorder in
the same organized and consistent way that they approach patients with
other disorders. The problem is exacerbated by the complexity of some
treatments and theoretical models, which are described in language that
often obscures rather than clarifies. Many clinicians do not find current
theories to be of practical help in daily clinical practice. Most of these the-
ories have minimal empirical support, and there is no evidence that one
approach is better than another. There is, however, evidence showing that
some interventions are effective for some problems. This finding suggests
the need for an eclectic and pragmatic approach that applies interventions
on the basis of what works and a rational analysis of what is needed.
This volume attempts to provide a framework that clinicians can
Preface ix
adapt to their own style and the setting in which they work, and which
can also be modified as our understanding grows. The goal is not to de-
velop yet another treatment for the disorder but rather to define what we
need to achieve in treatment and then identify the best way to accomplish
these goals, based on the evidence. The approach presented here is eclec-
tic not in the sense that it provides a compendium of current ideas on
treatment—such is not my aim. Rather, Practical Management of Personality
Disorder presents “reasoned eclecticism,” to borrow a phrase from Gordon
Allport. I have borrowed extensively from the concepts and intervention
strategies of perspectives as diverse as self psychology, interpersonal therapy,
psychodynamic and psychoanalytic therapies, cognitive therapy, behavior
therapy, and constructivism, as well as combinations such as cognitive an-
alytic therapy and dialectical behavior therapy. These are combined with
medication, as necessary.
I had thought of giving the approach a name that could form a suit-
able acronym. It seems that an approach is nothing without an apt title
that can be referred to as a set of letters. However, to do so seems to vio-
late the spirit and intent of the exercise. If the study of personality disor-
der is to progress and treatment to become more effective, we need to
break away from one-dimensional approaches and adherence to theoretical
models that, despite their claims and even their elegance, are based on lit-
tle more than speculation. The framework offered is clearly not the last
word on the treatment of personality disorder; rather, it is a work in prog-
ress that will evolve as our knowledge about these conditions progresses
from our current somewhat scanty understanding to something more sys-
tematic and profound.
As I look over the final proofs, I feel tremendous gratitude toward the
patients with whom I have worked over the years. Their struggles with
personality disorder were a source of stimulation. At the same time, their
insightful descriptions of their problems and struggles, and the metaphors
they used to communicate their distress, transformed my understanding
and guided the development of an approach that could be tailored to their
needs.
I am grateful to Seymour Weingarten, Editor-in-Chief of The Guilford
Press, for patiently encouraging my efforts with this volume and for his
support over the years, and to Rochelle Serwator, who rather amazingly
managed to transform the original manuscript into something that might
be understood. My assistant, Roseann Larstone, provided much valued as-
sistance throughout.
Finally, I owe much to my family. I am deeply grateful to my wife,
Ann, who has not only patiently tolerated my absorption in the task of
writing in her uniquely loving and supportive way but also actively encour-
aged my efforts; and to my children, Adrian, Nigel, and Dawn, for their
support and benign tolerance and encouragement.